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What the percentage of births in facilities does not measure: readiness for emergency obstetric care and referral in Senegal
  1. Francesca L Cavallaro1,2,
  2. Lenka Benova3,4,
  3. El Hadji Dioukhane5,
  4. Kerry Wong4,
  5. Paula Sheppard6,
  6. Adama Faye7,
  7. Emma Radovich4,
  8. Alexandre Dumont1,
  9. Abdou Salam Mbengue8,
  10. Carine Ronsmans4,
  11. Melisa Martinez-Alvarez9
  1. 1CEPED, Institut de Recherche Pour le Développement, Paris, France
  2. 2Institute of Child Health, University College London, London, UK
  3. 3Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
  4. 4Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
  5. 5Plan International Canada, Ottawa, Ontario, Canada
  6. 6Institute of Social and Cultural Anthropology, Oxford University, Oxford, UK
  7. 7Institut de Santé et Développement, Université Cheikh Anta Diop, Dakar, Senegal
  8. 8IRESSEF: Institut de Recherche en Santé, de Surveillance Epidémiologique et de Formations, Dakar, Senegal
  9. 9Medical Research Council Unit in The Gambia at the London School of Hygiene & Tropical Medicine, Fajara, The Gambia
  1. Correspondence to Dr Francesca L Cavallaro; f.cavallaro{at}


Introduction Increases in facility deliveries in sub-Saharan Africa have not yielded expected declines in maternal mortality, raising concerns about the quality of care provided in facilities. The readiness of facilities at different health system levels to provide both emergency obstetric and newborn care (EmONC) as well as referral is unknown. We describe this combined readiness by facility level and region in Senegal.

Methods For this cross-sectional study, we used data from nine Demographic and Health Surveys between 1992 and 2017 in Senegal to describe trends in location of births over time. We used data from the 2017 Service Provision Assessment to describe EmONC and emergency referral readiness across facility levels in the public system, where 94% of facility births occur. A national global positioning system facility census was used to map access from lower-level facilities to the nearest facility performing caesareans.

Results Births in facilities increased from 47% in 1992 to 80% in 2016, driven by births in lower-level health posts, where half of facility births now occur. Caesarean rates in rural areas more than doubled but only to 3.7%, indicating minor improvements in EmONC access. Only 9% of health posts had full readiness for basic EmONC, and 62% had adequate referral readiness (vehicle on-site or telephone and vehicle access elsewhere). Although public facilities accounted for three-quarters of all births in 2016, only 16% of such births occurred in facilities able to provide adequate combined readiness for EmONC and referral.

Conclusions Our findings imply that many lower-level public facilities—the most common place of birth in Senegal—are unable to treat or refer women with obstetric complications, especially in rural areas. In light of rising lower-level facility births in Senegal and elsewhere, improvements in EmONC and referral readiness are urgently needed to accelerate reductions in maternal and perinatal mortality.

  • maternal health
  • emergency obstetric care
  • referral
  • readiness
  • Senegal

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  • Handling editor Seye Abimbola

  • Twitter @dioukhane, @kerrylmwong

  • Contributors FLC, LB, MM-A and PS conceptualised the study, and designed the analyses with additional input from EHD and CR. KW, ER, LB and FLC prepared the databases. FLC, AF, EHD and AD compiled the list of facilities performing caesareans, and EHD and AF vetted data sources. FLC and KW conducted the data analysis, all authors including ASM contributed to the interpretation of results. FLC drafted the full manuscript, all authors edited the manuscript. All authors approved the final version of the manuscript.

  • Funding Some authors of this study were supported by funding from MSD, through its MSD for Mothers programme ( Funding was used for general financial support, including staff salaries, travel and overhead. MSD had no role in the design, collection, analysis and interpretation of data, in writing of the manuscript, or in the decision to submit the manuscript for publication. MSD for Mothers is an initiative of Merck & Co., Kenilworth, New Jersey, USA.

  • Disclaimer The content of this publication is solely the responsibility of the authors and does not represent the official views of MSD.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved by the Ethics Committee of the London School of Hygiene & Tropical Medicine.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data may be obtained from a third party and are not publicly available. Access to data from the Demographic and Health Surveys and Service Provision Assessments can be requested on the website