In this blog, we will focus on a neglected component of antenatal care (ANC) and point at figures and facts usually not highlighted by the National Demographic Household Surveys (DHS) based on results from the Addressing social, cultural and historical factors limiting the contribution of medical laboratory services to antenatal care in West Africa (SociaLab) project Senegal. SociaLab has a biomedical and a socio-anthropology research component; this blog concerns the socio-anthropology component, which is led by Dr. Winny Koster a medical anthropologist post-doctoral scientist.

During a standard ANC, the midwife takes a woman’s reproductive history, measures vital signs and proceeds to physical examination. A number of biological investigations are also supposed to take place during the ANC consultation. The presence of glucose and protein in the urine or HIV infection can be detected by the midwife herself using rapid tests. All additional blood tests not feasible at the ANC site are then requested to be done in the laboratory.

DHS report the coverage of ANC by professional health providers, including the coverage of blood testing. DHS 2010-2011 data for Senegal reports 93% coverage of one ANC visit at the national level. Among women who had at least one ANC visit, 76% received a blood test. Variations in ANC coverage are huge between the 14 regions of Senegal. The regional range for coverage of first visit is between 79% and 99% and for full ANC of 4 visits between 42% and 62%. The regional coverage of blood testing ranges from 61% to 93% (DHS 2011). The capital Dakar shows the highest coverage of all ANC components.

With this background and statistics in mind, the SociaLab project set out to study the barriers to laboratory diagnostic testing during ANC. Data were collected in 16 health facilities and surrounding communities across Senegal.

Our project looked further than the DHS statistics on blood tests, because these do not say which tests and whether the full set of recommended tests were done. In Senegal the Division of Reproductive Health of the Ministry of Health and Social Welfare recommends 5 ‘’compulsory’’ and one ‘advised’’ blood tests. Blood should be tested for: Blood group/Rhesus factor; sickle cell anemia; HIV antibodies; syphilis; haemoglobin level; Hepatitis B active infection (advised).

Testing of protein and glucose in urine.  Image courtesy of google images

The preliminary data analysis showed that up to 41% of 81 women interviewed in the community had no tests in the laboratory at all during pregnancy. The coverage of ANC visits including the full set of laboratory screening turns out to be dramatically lower than the figure provided by the DHS statistics. Only 22% of 81 women interviewed in the community and 39% of 283 women who were interviewed when visiting the laboratory had undergone a complete set of tests.

So, what are the reasons for this low uptake of ANC testing? Let us look at different levels to find the answers: the woman in the community, the midwife who request the tests and the laboratory staff who execute the tests.

Summarizing the main reasons and showing the interconnections, we start with the midwives who are the gatekeepers to the lab. Without the midwives’ request, pregnant women do not access the lab. Midwives reported intentional incomplete or no test request because they anticipated women’s financial problems (in this way they ‘’help’’ women). Alternatively, they also reported to rely on clinical diagnosis and routine prevention, or to know that testing reagents were not available in the lab. Importantly, midwives mentioned that they have no access to guidelines about ANC testing or simply forget to request test – understandably so because of harsh working conditions and heavy workload for the health staff.

The main barrier limiting women’s access to the laboratory once they have received a test request was financial. Many families in Senegal live under the threshold of poverty and struggle for their daily upkeep.  Thirty percent of women interviewed in the community were absolutely poor. The Plan National de Développement Sanitaire du Sénégal (PNDS) 2009- 2018 data show that 61% of people in Senegal have to live from less than 2 US$ a day. Laboratory tests are expensive – the mean of 9,454CFA (15 Euro) would represent a week’s work for a cleaning lady in Dakar or 2.5 day work for someone with a good salary. Very few Senegalese women in both urban and rural areas are able to raise the money for tests on their own and the gender script dictates that wives depend on their husbands in terms of financial support. Getting financial support to pay for ANC screening test depends on husbands and mother-in-laws to understand the importance of laboratory testing for the pregnant woman. However, since women themselves do not know the reasons for testing and are hardly educated on this by the midwives, they cannot use this information to motivate their family to release money. Mothers-in-law were found to refer to their own pregnancies and safe deliveries without any laboratory investigation, to plead against paying for ANC screening tests.

At the level of laboratories, the reagents and equipment for ANC testing are available most of the time. A major problem is the prohibitive price of lab tests for most Senegalese households. In each health facility prices are set by the management team based on discrete criteria, within maximum and minimum limits fixed by the Ministry of Health. The large range in test prices, up to three times as much for the complete set, was surprising and suggests that tests do not have to be that expensive.

Collectively, our data provide a worrisome picture of the utilization of laboratory testing during ANC in Senegal, which contrasts with the figures reported by the DHS. The large coverage of ANC visits and the overall availability of infrastructures and reagents for ANC testing in Senegal provide a unique opportunity to improve the quality of ANC, by increasing the uptake of laboratory testing. Most if not all the clinical conditions identified by ANC screening test are preventable or curable provided a timely detection.

Our data provide useful context-specific indications on the nature of barriers limiting the utilization of laboratory testing in ANC. Multilevel interventions can be designed to reduce these barriers, which will contribute to increase evidence-based ANC and reduce maternal and child mortality.

The authors are KTNet Africa contact persons for SociaLab project Senegal

Contact the authors at: [email protected] and [email protected]