Summary of the stakeholders’ meeting during the mid-term review of the
SOCIALAB study
Background
Despite recent progress on coverage and quality of antenatal care in the last years, the maternal
mortality remains high in Senegal and jeopardizes the achievement of MDG5. The maternal mortality
ratio per 100,000 live births is targeted to be 168 in 2015, but still was at 392 in DHS 2011 (down from
500 in 2000). Antenatal screening tests can help identify curable illnesses and contribute to the
reduction of maternal morbidity and mortality. It is therefore crucial that laboratory services play their
part in the process of antenatal care.
What is SOCIALAB?
SOCIALAB is the study of social, cultural and historical factors limiting the contribution of clinical
laboratories to antenatal services in Francophone West Africa. The study was launched in Senegal on
November 12th 2012, under the auspices of the Ministry of Health and Social Affairs (MHSA).
SOCIALAB is the collaboration between the Amsterdam Institute for Global Health and Development
(AIGHD, Netherlands), the Direction de Laboratoires (DL, Senegal), Fondation Mérieux (France), Charles
Mérieux Infectious Diseases Centre of Bamako (CICM, Mali), Direction de Laboratoires (Burkina Faso),
the Center for Social Science and Global Health (SSGH, Netherlands) and the Institut Pasteur (Senegal).
This project is built around the West Africa Network for Strengthening Laboratory (RESAOLAB), whose
main stakeholder is the Fondation Mérieux.
SOCIALAB uses an interdisciplinary approach combining biomedical sciences (data collection led by
Postdoc Dr Aicha Marceline Sarr, pharmacist-biologist, DL) and socio–anthropology (data collection led
by Dr. Winny Koster, medical anthropologist, AIGHD) with the following objectives:
1) Identify the barriers to the utilization of laboratory testing during antenatal care in Senegal;
2) Search their causes and consequences;
3) Make recommendations to improve the utilization of screening tests during ANC.
The study targets the three levels of 1) health policy, 2) service providers (ANC and laboratory) and 3)
clients (pregnant women and their entourage). The study at the level of service providers and clients is
conducted in Senegal only. Sixteen health facilities were sampled for data collection in biomedical part
(4 hospitals, 12 health centers), 11 for the socio-anthropology part (3 hospitals, 8 health centers).
Selection out of the 96 health facilities with laboratories in Senegal was based on regional
representation. The socio-historical study at the level of health policy will be conducted in Senegal, Mali
and Burkina Faso.
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Midterm review
A midterm review commissioned by the funder (NWO/WOTRO, the Netherlands Organization for
Scientific Research) was held in Dakar on 2-4 June 2014. A one-day meeting with stakeholders involved
in the study was part of this; the goal was to share and discuss the preliminary research findings The
Knowledge Translation Network (KTNET) Africa from Makerere University, Uganda (also funded by
NWO/WOTRO) provided its assistance for the effective dissemination of results.
Stakeholders present were representatives from: health facilities covered by the research (medical
doctors, midwives, biologists, laboratory technicians); national HIV/AIDS program; the Ethics
Committee; the associations of laboratory technicians and private biologists.
Preliminary findings
When presenting the preliminary findings, the researchers stressed that they were only half-way
through data collection (the biomedical part had collected data in 8 health facilities, the anthropology
part had done 5 health facilities) and that only very crude analysis had been done (for the purpose of
this meeting). Still, preliminary findings allowed the identification of some likely bottlenecks and barriers
to the utilization of ANC tests at the levels of clients and health services in Senegal. By ‘utilization’, we
mean: the test request, the access to the lab, the execution of tests, and the utilization of test results for
treatment.
1. Laboratory level
The price of the recommended laboratory tests package varies from 8,500 to 14,300 CFA, which
represents 20 to 34 of an average monthly income. Other hidden costs have to be added to this initial
price, such as for the often multiple travels between the ANC consultation, the laboratory and home.
The infrastructure and expertise required to perform the prenatal screening tests are generally good
(despite temporarily stock-out of reagents or broken down machines). However, the organization of the
laboratory and in particular the desynchronization of working hours between the laboratories and the
antenatal consultations are possible barriers for women to access the lab services. Moreover the poor
communication between lab and ANC staff does not facilitate the quick access to laboratory results for
the antenatal care staff. Constraints identified at the laboratory level are linked to the heavy hierarchy
based on seniority rather than on expertise.
2. ANC level
The study found a lack of clarity on the prenatal tests 'required', 'recommended' and 'optional'. Indeed,
there are discrepancies between: 1) the national recommendations from the Division of Reproductive
Health (Policy Standards and Protocols); 2) the tests mentioned in the ANC register and; 3) the tests
listed in the woman’s ‘health card’. The consequence of this situation is that midwives’ requests for
number of tests vary.
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Analysis of the health facility register of The Prevention of Mother to Child Transmission of HIV Program
(PMTCT) showed that there is a 10% attrition rate at each step of the cascade between the midwife’s
proposal of an HIV test (to be done either during ANC consultation or in the lab), the woman’s
acceptance of this test, the execution of the test and the withdrawal of the results. This attrition is
attributed to various factors including the shortage of the (rapid) test packages and confidentiality
issues. Consequently, 30% of pregnant women do not know their HIV status after the first antenatal
visit.
Major problems were reported and observed in the midwives’ execution of rapid tests for the
determination of protein and glucose in the urine. This test is recommended during every ANC
consultation. One of the reasons was a shortage of urine dipsticks. These observations are made in a
context of high workload, poor working conditions and job insecurity for midwives (as for many other
health workers).
3. Community (client) level
One third of the 81 pregnant women interviewed in the community have not done for different reasons:
they had no money; the midwife did not give them a test request; they did not realize the importance of
the tests. Some women were absolutely poor; others had difficulties to get the money from their
husbands who are normatively to pay for expenses; others had other priorities such as family expenses
or other investigations such as ultrasound.
Feedback from the stakeholders
The stakeholders generally validated the preliminary results and were of the opinion that the findings
were very interesting. They said to be eagerly waiting for more data and in-depth analysis. For instance
they wanted in-depth analysis of: the pricing of tests; the reasons for shortage of reagents and rapid
tests; the shortage of ANC staff; the inaccessibility of guidelines for recommended tests.
They already proposed some interventions that could increase utilization of ANC tests: Better
organization and supervision of rapid tests during ANC consultations; health facilities looking in different
possibilities to reduce the tests price; creating more awareness in communities among women and men
about the importance of ANC tests; clarity on the recommended test package; aligning lab and ANC
opening hours. Professor Iyane Sow, co-principal investigator of SOCIALAB and Director of Laboratories
in Senegal solicited for the support and close collaboration with stakeholders and he reminded the key
role of the Division of Reproductive Health (who unfortunately could not be present).
After the mid-term
In the SOCIALAB second phase, the two post-docs will complete the data collection in all health facilities
and at the policy level. After analysis of all data, the complete team will invite a wider range of
stakeholders for a first stakeholder consultation workshop. This workshop, planned in the first trimester
of 2015, is intended to start identifying and developing strategies and interventions aimed at increasing
the utilization of ANC lab tests.
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Participants in the midterm stakeholder workshop
Authors: Dr. Aicha Marceline Sarr and Dr. Winny Koster (contact persons for KTNET)
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