Key Takeaway: Senegal enacted policies and programs aimed at reducing barriers to key components of reproductive and maternal care, especially contraception use, in-facility delivery, and cesarean section. Improvements in these indicators have translated directly to maternal and neonatal lives saved. |
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.


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.
Figure 10: Modern Contraceptive Prevalence by Method among Currently Married Women in Senegal from 1986 to 2019

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.
Figure 11: Age-Specific Fertility Rates in Senegal from 1986 to 2019

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.
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.
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.
Postabortion care has continued to advance in Senegal, as misoprostol was added to Senegal’s Essential Medicines List for post abortion care in 2013.
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.
Figure 12: ANC Coverage and Timing in Senegal from 1992 to 2019
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%.


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.
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.
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:
Oh yes, the audits had an impact on the reduction of the maternal mortality rate, especially the deaths that were linked to a problem with the organization of on-call duty, the availability of medicines, products, and the availability of blood. The audits made it possible to understand what the dysfunctions were, and the audits made it possible to understand what the corrective measures were.
- Interview respondent
Figure 13: Place of Delivery in Senegal from 1992 to 2019

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.
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.
Figure 14: C-Section Rate in Senegal from 1992 to 2019
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.


Newborns receiving care within a week increased substantially from 47.9% in 2012 to 82.1% in 2019.
Figure 15: Post-Natal Care Timing in Senegal from 2010-2019
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.
Our analysis, using Jain’s decomposition method,
Figure 16: Attributing Mortality Reductions to Fertility Decline and Improved Intervention Coverage
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.
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.
Figure 17: Maternal Lives Saved by Intervention in Senegal from 2000 to 2020

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.
Figure 18: Neonatal Lives Saved by Intervention in Senegal from 2000 to 2020

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.
Figure 19: Stillbirth Lives Saved by Intervention in Senegal from 2000 to 2020
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.
Figure 20: Hierarchical Drivers of Neonatal Mortality Reduction in Senegal from 2005 to 2019
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.
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.
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.
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.