What did Senegal do?

Over the years, Senegal has made a concerted effort to prioritize reproductive, maternal, and newborn health. By improving access to the health system, coverage levels of key reproductive, maternal, newborn, and child health indicators have increased. Higher coverage of services critical in the antepartum, intrapartum, and postnatal periods have all played roles in reducing neonatal mortality rate (NMR) and maternal mortality ratio (MMR) in Senegal.

Improvements in reproductive, maternal, newborn and child health indicators

Contraception access

Senegal has prioritized the promotion of family planning in the past decade, especially after the National Family Planning Action Plan was launched in 2012 in response to the Ouagadougou Call to Action.¹ The action plan is centered around the “3 D’s,” aiming to democratize, demedicalize, and decentralize perspectives and administration of family planning in Senegal.¹

The compound annual growth rate of modern contraceptive prevalence among married women in Senegal was 2.9% per year from 1997 to 2011, before the National Family Planning Action Plan was launched in 2012.² Following the launch of the action plan, modern contraceptive prevalence began to increase sharply, with a compound annual growth rate of 9.8% per year from 2011 to 2019.² In 2019, seven years after the National Family Planning Action Plan, met need for family planning using modern methods reached 52.6%, which is a nearly 300% improvement since 1992 when met need was 13.2%.² This progress has also been linked to widespread public awareness campaigns—such as those by the Senegal Urban Reproductive Health Initiative—that reached women through mediums such as radio, newspaper, and television, with the intention of generating demand for family planning and reducing stigma around the topic.³ Restructured approaches to supply chain logistics have also helped reduce stockouts of contraceptive products, which is crucial as other components of the action plan steadily increase demand across the country.⁴ Professional logisticians, rather than providers, now oversee contraceptive stocks, using software to forecast demand in a system referred to as an “informed push model” versus the previous “pull model”.⁴ As seen in Figure 10, improvements in contraceptive use were mostly driven by increased use of implants and injections. In 2019, 9.7% of women used implants and 8.3% used injections, compared with 0% and 0.2% in 1992.²

As contraception use has increased in recent years, women in Senegal are having fewer children. The total fertility rate in Senegal declined from 6.0 births per woman in 1992 to 4.7 by 2019.² Shown in Figure 11, age-specific fertility declined for all age groups, most notably in the last decade, with especially sharp declines among women ages 15 to 19.² Lower fertility among younger women mirrors trends that show decreasing rates of marriages before age 15, as 8.5% of women reported being married before age 15 in 2019 compared with 21.7% in 1992.²

Post abortion care

Senegal’s abortion law is restrictive, prohibiting all pregnancy termination, but the Senegalese code of medical ethics allows abortion if doctors testify it is necessary to save the pregnant woman’s life.⁵

Despite the presence of restrictive abortion laws in Senegal, the Ministry of Health and Social Action identified a need for postabortion care in the 1990s, and in 1997 a post abortion care program was introduced that emphasizes health workers’ obligations to treat women experiencing complications linked to abortion.⁵ In the late 1990s, the Ministry of Health and Social Action piloted post abortion care services at several hospitals and determined from this assessment that both manual vacuum aspiration and misoprostol should be provided as components of post abortion care at all Senegalese health facility levels.⁵

From 2003 to 2005, post abortion care services were spread across all levels of health facilities in 23 districts that include more than half of Senegal’s population.⁶ In these districts in 2003, 0% of health posts and 39% of health centers had a provider trained in and offering post abortion care.⁶ By 2005, 100% of health centers had such a provider and by 2006 72% of health posts did as well.⁶

Postabortion care has continued to advance in Senegal, as misoprostol was added to Senegal’s Essential Medicines List for post abortion care in 2013.⁵ However, despite evidence that misoprostol can be effectively administered at the community level in Senegal, the medication remains underused and sometimes unavailable at smaller clinics.⁵

Antenatal care coverage

In recent decades, women in Senegal have generally attended more antenatal care visits during pregnancy and these visits have often occurred earlier in pregnancy. As seen in Figure 12, the percentage of women in Senegal attending at least one antenatal care visit with a skilled provider increased from 76% in 1992 to 97% in 2019, while the percentage of women attending at least four antenatal care visits with a skilled provider increased from 14% to 56% over the same time period.² From 1992 to 2019, the percentage of women attending their first antenatal care visit within four months of pregnancy increased from 38.4% to 61.3%.² In 2019, 94.2% of antenatal care visits were administered by nurses or midwives, highlighting the crucial role that various levels of providers beyond doctors play in the health care system.²

Antenatal care quality

Several indicators of antenatal care quality have shown substantial progress in recent years. From 2005 to 2019, the percentage of women having blood samples taken at antenatal care visits increased from 57% to 86%, the proportion informed about signs of pregnancy complications increased from 34% to 70%, and the percentage receiving intermittent preventive treatment for malaria via sulfadoxine-pyrimethamine increased from 21% to 88%.² Over 95% of women who reported using this antimalarial drug during pregnancy received it from an antenatal care visit, as opposed to other community programs or pathways.² Other crucial components of antenatal care such as iron supplementation, blood pressure measurement, and urine sample collection have progressed closer to universal coverage, with 96.3%, 99.6%, and 96.4% coverage, respectively, in 2019.² Administration of tetanus toxoid vaccinations at antenatal care visits has also increased in recent years, from 68.6% in 2010 to 87.2% in 2019.²

In-facility delivery

In-facility births increased from 46.8% in 1992 to 80.4% in 2019, with 76.6% of births in 2019 occurring in public facilities.² The proportion of births occurring in public hospitals declined slightly from 13% to 8.8% over this time period, indicating a shift from higher-level to lower-level facilities alongside the growth in facility-based delivery.² To this end, births in public health posts—the lowest level of facility that routinely offers delivery care—nearly tripled from 16.8% of all births in 1992 to 48.9% of all births in 2019.² Whereas only 35.9% of facility-based deliveries occurred at public health posts in 1992, by 2019 60.8% of facility-based births occurred at health posts.²

The 2005 National Free Delivery and Caesarean Policy has been linked to increased rates of in-facility delivery, reflected in higher rates of facility-based delivery between 2005 and 2010 in Figure 13.⁷   This program removed all user fees for normal delivery in health posts and health centers, as well as cesarean sections at the hospital level.⁷ In the five regions that first implemented this policy, the number of deliveries at health posts and health centers was almost twice as high in 2006 than in 2004, while in regions without this policy, the number of births in health posts and health centers was only 1.19 times higher in 2006 than in 2004.⁸

Lower-level facilities have increasingly been trained to identify signs of pregnancy emergencies throughout antenatal care and closer to delivery that would necessitate referral to a higher-level health facility. In particular, a strong network of trained community health workers ensures that women experiencing complications are directed to more advanced facilities. Higher-level facilities reported that they conducted maternal death reviews in which they assessed stocks of emergency supplies, availability of trained staff, and communication proficiency to audit potential sources of problems and avoid repeating past mistakes. One interview respondent spoke to the influence of these audits, saying:

Skilled birth attendants

From 1992 to 2019, the percentage of deliveries attended by skilled providers increased from 47% to 75%, with 12% of all births in 2019 attended by traditional birth attendants such as matrones.² While matrones are not intended to be the primary source of delivery care, they are trained to do so in case of emergencies—most often in cases of unexpected deliveries in rural, isolated areas. In 1992, 27.4% of births were attended by traditional birth attendants, decreasing to 11.4% by 2019.² In 2019, 48.5% of births supervised by traditional birth attendants occurred in facilities, compared with 9.5% in 1992.² The most common type of skilled birth attendants in 2019 were nurses and midwives who collectively supervised 67.1% of all births, compared with 45.2% of births in 1992.²

Cesarean section

In 2005, Senegal introduced the National Free Delivery and Caesarean Policy to reduce financial barriers to delivery care in the five poorest regions of the country (Kolda, Ziguinchor, Tambacounda, Matam, and Fatick), expanding to all other regions besides Dakar in 2006, and later Dakar in 2012.⁹ After seeing stagnant C-section rates in previous years, the C-section rate in the five original regions saw a statistically significant annual increase from 4.2% in 2004 to 5.6% in 2005.⁷ This policy provided a sustained boost to C-section rates, which reached 6.9% nationally in 2019, a notable increase since 1992 when coverage was 2.2%.²

Maternal postnatal and neonatal care

Coverage of postnatal care for mothers within a week of birth increased from 68.5% in 2012 to 80.8% in 2019.² Mothers are receiving postnatal care earlier, with 75.9% receiving care within four hours of delivery in 2019 compared with 48.6% in 2012.² The length of stay in facilities after birth—often an indicator related to provision of maternal postnatal care—has also increased slightly; from 2012 to 2019, the percentage of women who delivered vaginally and stayed in facilities for more than one day increased slightly from 42.1% to 47.6%.² Longer monitoring periods after delivery are similarly reflected; from 2017 to 2019 the percentage of women who stayed in facilities for less than six hours declined from 20.6% to 13.2%.² The proportion staying at least three days after a C-section remained fairly constant, near 90%.²

Newborns receiving care within a week increased substantially from 47.9% in 2012 to 82.1% in 2019.² Similar to maternal postnatal care, newborns are receiving care earlier, with 71.5% of newborns receiving care within the first hour of life in 2019 compared with 15.2% in 2012.² The quality of neonatal care has improved, with 45.1% of parents receiving counseling about potential danger signs for their child’s health in 2019 compared with 39.6% in 2017.² In 2019, 38.5% of newborns underwent observed breastfeeding by a trained healthcare worker to aid with initiation, an increase from 29.1% in 2017.² Reflecting the earlier onset of neonatal care visits, the percentage of children who started breastfeeding within one hour of birth has increased from 22.6% in 2005 to 31.5% in 2019.²

Connecting reproductive, maternal, newborn and child health indicators to mortality reductions

Fertility decline as a contributor to NMR/MMR improvements

There have been substantial decreases in fertility in Senegal in recent decades—from 1992 to 2019, the total fertility rate decreased from 6.0 to 4.17 births per woman.² Declines in fertility translate to fewer high-risk pregnancies by way of longer birth intervals, lower birth parity, and decreased birth rates among teen girls and older women.

Our analysis, using Jain’s decomposition method,¹⁰ isolates the impact of fertility decline on maternal and neonatal mortality. Fertility decline alone in Senegal was found to explain 6% of the MMR reduction and 8% of the NMR reduction. These mortality reductions translate to 109 fewer maternal deaths in 2017 and 1,121 fewer neonatal deaths in 2019 than would have been expected if fertility levels had remained constant since 2000. This decomposition approach attributes other improvements to “safe motherhood” initiatives, a term used to collectively refer to improving intervention coverage and services such as antenatal care, in-facility delivery, skilled birth attendance, and emergency care services. Together, fertility decline and improved safe motherhood initiative coverage led to 1,482 maternal lives saved in 2017 and 10,732 neonatal lives saved in 2019, compared with what would have been expected if fertility rate and coverage levels had remained constant since 2000. This result, illustrated in Figure 16, highlights the impact of fertility decline as a key driver of MMR and NMR decline, in tandem with other health care indicators commonly associated with MMR and NMR decreases. In Senegal, the impact of fertility decline on MMR and NMR has emerged in recent years as fertility has declined and contraception use has increased. This trend suggests that fertility decline could play a growing role in furthering Senegal’s progress in years to come if contraception use continues to rise.

Lives saved by intervention analysis

An analysis using the Lives Saved Tool was conducted for Senegal, incorporating 32 maternal, 67 neonatal, and 26 stillbirth interventions, to quantify the impact of increased intervention coverage from 2000 to 2020. The Lives Saved Tool uses estimates of intervention coverage, effectiveness of interventions, and estimates of NMR, MMR, and stillbirth rate to model the contribution of each intervention on mortality reductions.¹¹ The interventions included in this analysis were able to collectively explain 52% of the MMR reduction, 60% of the NMR reduction, and 69% of the stillbirth reduction over this time period.

Interventions near the time of delivery were often the most influential for saving maternal lives, with parenteral administration of uterotonics, C-section, and magnesium sulfate administration emerging as key interventions, respectively saving 1,484, 1,378, and 1,045 maternal lives cumulatively from 2000 to 2020. Other key interventions at the time of delivery include antibiotics for maternal sepsis and the presence of a clean birth environment, as shown in Figure 17. Use of contraception was found to have saved 880 maternal lives during this time span, with most of this impact in the most recent decade since the implementation of the National Family Planning Action Plan, which has bolstered rates of contraception use. Similarly, the number of lives saved from C-sections dramatically increased after the 2005 National Free Delivery and Caesarean Policy was enacted.

Interventions immediately after birth were among the most influential for saving neonatal lives, including case management of neonatal sepsis/pneumonia, thermal protection, and neonatal resuscitation, which respectively saved 13,761, 6,029, and 5,937 cumulative neonatal lives from 2000 to 2020. Other key interventions at the time of delivery include C-section, clean cord care, immediate drying/stimulation, and the presence of a clean birth environment. Key components of antenatal care also saved numerous neonatal lives, with 4,203 neonatal lives saved by malaria prevention in pregnancy and 4,537 lives saved as a result of vaccinations against tetanus toxoid. Similar to the observed trend for maternal lives saved, the impact of many facility-based interventions, including C-section, increased dramatically following the 2005 National Free Delivery and Caesarean Policy.

This trend is particularly stark when assessing the impact of interventions aimed at preventing stillbirths. An estimated 18,751 stillbirth deaths were prevented from 2000 to 2020 due to C-section rates that improved after 2000, with the influence of this intervention dramatically increasing after 2005. Other interventions similarly reflect this trend, including the second most influential intervention, malaria prevention during pregnancy, which prevented 3,952 stillbirth deaths from 2000 to 2020. Since 2005, there has been a steady increase in intervention coverage compared with 2000 baselines, with nearly 2,000 additional stillbirth lives saved in 2020 compared with about 1,000 in 2005.

Hierarchical neonatal mortality decomposition analysis

The rapid reduction in neonatal and maternal mortality seen in Senegal is driven by interconnected distal, intermediate, and proximal factors. Distal factors reflect “upstream” social, political, and economic influences. Intermediate factors include programs and services that influence people’s ability to access high-quality health care as well as household and individual contextual factors that influence health-seeking behavior. Proximal factors include variables immediately relevant to the point of care, playing more direct roles in influencing health outcomes.

Using these distinct categories, a multivariable hierarchical decomposition analysis was conducted for the period 2005 to 2018 in Senegal. Through this analysis, we aimed to produce findings that could yield more granular insights than the fertility-based Jain’s decomposition analysis presented earlier, while also reflecting the influence of broader factors that cannot be captured in an intervention-based Lives Saved Tool analysis. This approach was only conducted for NMR—and not MMR—due to the relative rarity of maternal mortality compared with neonatal mortality, resulting in scarce individual-level MMR data.

In this analysis, the proximal drivers of modern contraceptive use and ANC4+ (at least four antenatal care visits) coverage were identified as the largest contributors to NMR reduction in Senegal, respectively accounting for 19% and 18% of the observed reduction in neonatal mortality. There was a 192% increase in modern contraceptive use between 2005 and 2018 and a 41% increase in ANC4+ coverage over the same period.² This finding aligns with other evidence suggesting that the 2012 National Family Planning Action Plan has been successful in improving met demand for contraception, and importantly, that this has translated to mortality reductions.^3,4 The impact of ANC4+ reflects not only higher levels of ANC coverage but also improved quality of care.

The intermediate factors generally play a lesser role in explaining NMR reduction compared with proximal variables. In this analysis, findings on C-section rates should be interpreted with caution considering biases such as endogeneity that exist when studying a procedure often performed in instances that are inherently higher risk for mortality. To potentially mitigate the effect of this bias in individual level data, C-section was also considered at the community level, but was not statistically significant as it was at the individual level. As such, the finding that an increasing C-section rate is associated with a negative contribution to NMR progress should not be interpreted to suggest that C-section is causing these deaths. Instead, this finding reflects that C-sections are likely occurring in high-risk scenarios and indicates that the procedure has not become common in lower-risk instances without medical need. C-section rates in Senegal increased from 3.3% to 5.9% over the period of this analysis, and as this rate continues to increase, we would expect the relationship between C-section and NMR to evolve as the risk profile of the patient population changes over time with expanded access to care.²

Other intermediate factors, such as wealth index and paternal education, also contributed to the observed neonatal mortality reduction, respectively accounting for 6% and 2% of the decline. Change in wealth over time was based on an index that included seven components: ownership of a radio, a television, a bicycle, a refrigerator, a motorbike, a car, and improved flooring material in the home . Components of this wealth index could directly result in health care being more accessible to household members, or in health information being disseminated via communications channels, which have been shown to empower individuals facing obstacles in accessing care.¹² Although in this analysis paternal education was identified as a significant contributor to NMR reduction, the link between maternal education and neonatal health is widely documented in the literature and should not be overlooked.¹³

The risk profiles of prospective mothers have also evolved over the study period, explaining some of the change in neonatal mortality over time. There has been a 9% decrease in the rate of births that are categorized as falling into “multiple high-risk categories” (including more than one of the following categories: short birth interval, high birth parity, younger or older maternal age) and an 18% increase in the rate of births categorized as “unavoidable risk” (none of the aforementioned risk categories).

The distal driver of electricity access was also found to be a strong contributor to neonatal mortality reduction, accounting for 15% of the observed decline. While related to wealth, this variable is considered distinctly as it is dependent on a larger electric grid beyond the individual household. Other distal factors—such as urbanicity, broader governance, and national programs—are difficult to quantify in a way that links to individual mortality outcomes and are thus not quantified in this analysis, but their impact should not be discounted.