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Lost from sight - why women in Senegal miss 30% of their family planning appointments

In a small health post in south-east Senegal, midwife Awa is reviewing her family planning client folders. She has set one pile aside: women who had an appointment this month but didn’t come – those ‘lost from sight’. In this health post, they are trying hard to reach out to these women to get them back in the clinic, as these delays can have important health implications in Senegal, where abortion is heavily criminalised.
Caption: Senegalese mother and baby. Caption: Flickr/Leocadio Sebastian

The Guttmacher Institute estimates more than 50,000 induced abortions occurred in Senegal in 2012, the vast majority of which were clandestine and unsafe. So why are Senegalese women missing their family planning appointments?

Our recent study indicates that this is in fact common throughout Senegal. Almost one-third (30%) of appointments for pills or injectables were delayed in nine regions, meaning that women using these methods to avoid getting pregnant were nonetheless exposed to pregnancy once-twice per year, on average.

When asked why, women and health providers often first reply that women ‘forget’. Dig a little deeper, however, and a much more complex picture emerges - not all women, in fact, know their next appointment date. Midwives like Awa give contraceptive users a reminder card for their next appointment, however 60% of women are thought to be illiterate in Senegal, making them dependent on others to know when to return to the clinic.

Even when women know their next appointment date, they aren’t always able to go at the right time. Across the country, many women use contraception without their husbands’ or families’ knowledge, since family planning is not widely accepted. This covert use restricts when they are able to get their injections or pill packs: women reported pretending to be sick or waiting until their husbands travelled before returning to the clinic.

Cost is also a barrier. Women pay up to US$3.65 for each appointment, a large sum in Senegal where 38% of the population lives on less than US$1.90 per day, leading many to delay appointments when cash flow is low. Many clinics have restricted operating hours, making it especially difficult for women to attend their appointments during the harvest season, when they are working in the fields.

So what can be done to support women using contraception in Senegal?

In many clinics, nurses and midwives like Awa have spontaneously developed strategies to help women using covertly, for example keeping appointment reminder cards at the clinic for discretion, and using mobile phones or outreach workers to remind them of their next appointment date. Additional innovative reminder strategies are needed. Providers could identify women at risk of missing appointments (such as those unable to read or using covertly) to offer them this additional support.

However, focusing on individual women will only ever amount to a ‘band aid’ solution. The Senegalese government and reproductive health partners need to address contextual barriers to ensure that all women are able to use contraception continuously and effectively. Family planning services need to be affordable and accessible at convenient times. Universal education for women is needed for informed choice and returning to the clinic on time.

Most importantly, the need to make contraception acceptable among men and communities in general is clear – but the way to achieve it is not. More research is needed to understand reasons for low acceptability and design more effective communication campaigns.

Universal access to contraception is fundamental to upholding the human rights of autonomy and bodily integrity. It can also help achieve the Sustainable Development Goals of maintaining good health, eliminating poverty and mitigating climate change.

These rights will only be achieved when all women in Senegal can use contraception freely, without needing to hide their clinic visits or pill packs, and when no more women who want to use contraception are ‘lost from sight.’

Publication

Francesca L. Cavallaro, Diane Duclos, Jenny A. Cresswell, Sylvain Faye, David Macleod, Adama Faye, Caroline Lynch. Understanding “missed appointments” for pills and injectables: a mixed methods study in Senegal. DOI:10.1136/bmjgh-2018-000975.