In 2015, nearly 300,000 women over the world died due to complications affected by pregnancy and childbirth.1 It is well known that antenatal care (ANC) plays a pivotal role to decrease maternal mortality caused by perinatal complications through early detection, prompt treatment, and appropriate referral to upper level of care.1

The World Health Organization (WHO) has specified the purposes of ANC as following: providing psychological support for pregnancy, newborn delivery, breast-feeding, and child rearing; providing psychological and social support for newborn delivery, and increasing awareness on relevant matters among family members; monitoring pregnancies for the health and well-being of the mother and the newborn; monitoring signs of obstetric difficulties through diagnostic tests and paying close personal attention to pregnant mothers; and giving advice and encouragement to pregnant mothers by establishing relationships with family members or relatives who have experienced pregnancies.2

In light of this, WHO recommends a minimum of 4 ANC visits during pregnancy.3 The United Nations Development Programme (UNDP) reported that, though the ratio of pregnant mothers who have received ANC 4 or more times increased from 37% in 1990 to 52% in 2012, African countries continued to report rates of 50% or lower.4 A study on the ratio of pregnant mothers receiving ANC 4 or more times in Senegal in 2015 reported that the national average was 47.0%, that in urban areas was 57.0%, and that in rural areas was 40.0%.5 Sub-Saharan African countries, including Senegal, are considered to have a high maternal mortality ratio (MMR), and they have low rates of access to ANC.67

With the global efforts to reduce the MMR of Senegal was reduced by 41.7% from 1990 to 2015, yet the number of maternal deaths per 100,000 live births in 2015 was 315, which is still higher than the global average of 216 and the average of 239 among developing countries.67 Furthermore, a report of the WHO, which studied the ratio of pregnant mothers receiving ANC 4 or more times from 2000 to 2013, indicated that Senegal's participation in ANC ranked 23rd among the 32 African countries.7

The objective of this study was to improve maternal health services by identifying bottleneck affecting the ANC uptake using Tanahashi model. Several previous studies aimed to understand the barriers to ANC among pregnant mothers in Senegal, but have limitations in that they applied qualitative and quantitative analyses separately. Thus, this paper applied a mixed model (combining qualitative and quantitative methods) to examine the barriers to ANC with respect to the availability, accessibility, acceptability, and effectiveness coverage.

Sub-Saharan African countries, including Senegal, are considered to have a high MMR, and they have low rates of access to ANC.67 The present analysis on the effectiveness (increase rates) of health facilities in the same quarters during a year, before and after the KOICA and Better World implemented the Maternal and Newborn Health Services Program, showed that the 15% usage rate in the first and second quarters in 2015 increased to 21% during the first and second quarters of 2017. Despite these improvements, the overall use of ANC is still considered low.

In light of such low usage rates despite an increase in the awareness of the importance of ANC, the following bottlenecks and barriers were identified in the present study from the factors affecting the utilization of maternal and newborn healthcare.

The analysis of the availability of ANC indicated that only 65.0% of all Posts de Santé were capable of providing BEmONC, while no Posts de Santé were capable of providing CEmONC. Further, 79.5% of the Posts de Santé were capable of providing ANC. WHO recommends the establishment of 5 Posts de Santé (including at least 1 Post de Santé capable of CEmONC) capable of providing BEmONC per 500,000 people.13 Despite the need to provide infrastructural support to make comprehensive facility functions available in Senegal, be difficult, the provision of support for district hospitals to fulfill comprehensive facility functions could be an option.

The present results on accessibility revealed that most women of childbearing age who participated in the FGDs did not experience any physical difficulties in visiting Posts de Santé to receive maternal and newborn healthcare. Previous research on accessibility reports a significant relationship between waiting time and ANC use,1415 and a significant relationship between ANC use and transportation conditions.1516 However, though most FGD participants in the present study responded that they “were not burdened” by transportation and exam expenses related to the utilization of maternal and newborn healthcare, some economically disenfranchised communes reported that economic burdens were a barrier to use. Specifically, the expenses for ultrasonic (approximately XOF franc 14,000) and for the purchase of additional drugs during childbirth were viewed as economic burdens. In the case of Ghana, although free maternal healthcare services were provided to alleviate the economic burdens related to ANC utilization, most pregnant mothers still reported that they were economically burdened by the indirect expenses associated with visiting clinics, including the purchase of clothing and hair dressing activities.17 The opportunity costs associated with not being able to prepare meals for family members or to tend to crops were also considered as a part of the economic burden.18

The present findings on access to information showed that 68.5% of the participants watched television, and most participants of the FGDs reported that they sourced information regarding maternal and newborn healthcare from television programs. Previous studies report a 2.11 times higher chance that pregnant mothers who own radio or television set will receive ANC within 12 weeks of pregnancy, as compared to pregnant mothers who do not own the same.19 The FGDs conducted in the present study revealed that the media campaigns for maternal and newborn healthcare in Senegal had a positive effect on the perceptions of mothers-in-law and husbands of pregnant women regarding ANC. A mix of community-based interventions (media campaigns, education initiatives, and incentives for pregnant mothers) and system-related interventions (home visits for pregnant women and provision of equipment to clinics) is known to improve ANC coverage (at least one visit), and to reduce perinatal mortality and the occurrence of low birth weight.20 Additionally, women of high income backgrounds were found to present higher accessibility as compared to women of lower income backgrounds.21 For low income families who reside in communities and have low access to media, the utilization of community health workers to relay information is considered efficient. This study confirmed that, in addition to media campaigns, the maternal and newborn healthcare activities of Badiene gokhs have an extremely large effect on the improvement of perceptions regarding maternal and newborn healthcare. The National Agency of Statistics and Demography (NASD) of Senegal conducted studies on access to media content (once per week) among women of childbearing age, and found differences in the rates of accessing media content among urban and rural areas.22 Specifically, the access to television programs in urban and rural areas was 85% and 35.9%, respectively, and that to radio programs in urban and rural areas was 61.2% and 51.4%, respectively. Considering the low accessibility of television programs in rural areas, it may be necessary to undertake public campaigning activities through radio programs.22

The present findings on acceptability showed that long waiting times to receive maternal and newborn healthcare, increasing numbers of unmarried mothers within local communities, fears and social stigmas associated with miscarriages, language barriers of minority ethnic groups, and high illiteracy rates among women acted as barriers to the use of ANC services. It was found that, due to the fear of being stigmatized in case of a miscarriage, pregnant mothers often hide their pregnancy until a later stage of their pregnancy. According to FGDs, unmarried mothers were especially found to display high levels of fear of being pregnant and it led to late or no ANC. Magadi revealed that greater delays on the first ANC visit resulted in a reduction in the number of women who undertake 4 or more ANC visits.23 Women who have previously miscarried were also reported to contribute to lowering the adequate frequency of ANC attendance.24

According to the World Bank, in 2013, the illiteracy rate of Senegalese women (15 years or older) was 66.4%. This rate is higher than the average illiteracy rate of 47% among sub-Saharan African women in 2010.25 In addition, in 2013, the ratio of women aged over 25 years who have completed primary school education in Senegal was 21.7%, which is considered extremely low.26 The completion of 4 ANC visits is known to be linked with the level of education of women.2728 Further, women of childbearing age in Senegal comprise several ethnic groups that speak different languages, including Wolof (39.8%), Pular (26.5%), and Serer (15.0%).22 Language barriers are known to deter the utilization of maternal and newborn healthcare and ANC.29 A method of minimizing the language barriers experienced by some minority ethnic groups during the utilization of maternal and newborn healthcare includes the utilization of community health workers who are capable of communicating with such minorities. The use of images to provide maternal and newborn healthcare for illiterate women is another method that should be considered.

An interesting finding of the present study was that the role of mothers-in-law, who previously acted as a barrier to the use of maternal and newborn healthcare, had changed. In most cases, the ability of women to make decisions on the use of medical services in developing countries is limited by family members.30 This was also the case in Senegal. As the husbands of pregnant mothers typically found it difficult to care for their spouses due to their livelihood responsibilities, mothers-in-law typically had higher levels of responsibility and authority. Although, in the past, mothers-in-law generally viewed ANC as unnecessary,31 the present study confirmed that the perception of mothers-in-law on the use of maternal and newborn healthcare had undergone gradual changes. Considering that mothers-in-law, who are highly knowledgeable, presented a tendency to support ANC,32 it is necessary to continue promoting and educating mothers-in-law on the use of maternal and newborn healthcare.

Another interesting result of the present study was that husbands had the decision-making authority on women's use of maternal and newborn healthcare. Considering that this decision-making authority has been shifting from mothers-in-law to husbands, it is necessary to provide training and education on the benefits of early ANC as well as the expected complications of pregnancies through newly-formed husband-centered communities.

Based on the results of this study, the following recommendations are made for implementation in future programs to increase the rate of utilization of ANC and maternal and newborn healthcare 4 or more times in Rufisque, Senegal. First, considering that the long wait time experienced by pregnant mothers in Posts de Santé was a barrier to the use of ANC, efforts to minimize waiting times and the provision of waiting areas that are equipped with adequate ventilation systems are necessary.33 In addition, it may be appropriate to consider the provision of education by community health workers during waiting times, to increase awareness among pregnant mothers on maternal and newborn health.

Second, since the social stigmas and fears associated with early pregnancies and miscarriages were barriers to ANC utilization during the initial period of the pregnancy, and because it had an effect on the ratio of pregnant mothers receiving ANC 4 or more times during their pregnancy, the importance of initial ANC visits needs to be conveyed to the husbands and mothers-in-law as well as pregnant mothers. Such attempts would increase pregnant mothers' utilization of ANC services during the early phases of pregnancy.

Third, the increasing number of unmarried mothers in Senegal has resulted in increased MMR and reduced use of ANC. Thus, it is important for Badiene gokhs in the community to find out the mothers in the early stage of pregnancy and cooperate with health facility staffs at the facility. Besides, further awareness-raising education on the use of condoms needs to be undertaken in cooperation with the Direction de la Santé de Rufisque.

Fourth, husbands are getting the most influential decision-maker on the utilization of maternal and newborn healthcare among family members. Further, the social supporter for pregnant women with reference to their utilization of maternal and newborn healthcare was also husbands. Therefore, it is necessary to implement programs to train and educate husbands on the importance of ANC to improve their perceptions.

Fifth, in order to implement effective education, programs for women visiting maternal and newborn healthcare facilities (Post de Santé, Centre de Santé, etc.) need to be developed, and information regarding the use of maternal and newborn healthcare needs to be broadcasted through different media (e.g., radio and television programs). In addition, the need for ANC should be promoted through radio and television programs that are regularly accessed by local communities. A means of communicating information that accounts for the low literacy rates in developing countries also needs to be developed.

Sixth, community health workers (Badiene gokhs), the providers of maternal care in Senegal, are known to serve as a source of information on maternal health, and they are known to be supporters of maternal health. By strengthening the capacities of Badiene gokhs, a system in which they play a central role in maternal and newborn healthcare within local communities needs to be established.

This study had some limitations with analysis of availability coverage and sampling. First, “satisfaction rates regarding the use of public health facilities,” and “the capacities of health practitioners,” which are known to be related to the utilization of ANC and the services offered at Posts de Santé, were not assessed. Additionally, the quantitative surveys were conducted with women who visited Posts de Santé, a group considered to already present a high rate of utilization of medical services. Considering this limitation, FGDs with Badiene gokhs were arranged so that they would represent the status of non-respondents who do not use ANC services. Lastly, this study sampled only a few key Posts de Santé from the 5 selected communes due to a lack of public health statistics in Senegal. To apply these findings to community level, further study with greater number of participants including needs to be followed.

Despite these limitations, the present study explored the bottlenecks and barriers to the utilization of ANC healthcare services through the FGDs that included women of childbearing age as well as other interested parties such as mothers-in-law, husbands, and Badiene gokhs. Therefore, this study is considered significant in that it analyzed the barriers from a socio-cultural standpoint through the FGDs that included multiple stakeholders, which would otherwise have been difficult to derive from a purely quantitative study. Further, this study is significant in that the survey included illiterate women by conducting interviews via trained interviewers.

In conclusion, the present study identified the bottlenecks and barriers associated with the utilization of maternal and newborn healthcare by pregnant women in Rufisque District, Dakar, Senegal. Several methods to improve the rate of utilization of ANC among pregnant women were analyzed through the FGDs that included different stakeholders (women of childbearing age, husbands, mothers-in-law, health facility staff, and community health workers). The present results confirmed that, in Senegal, husbands and mothers-in-law were becoming more supportive of maternal and newborn healthcare. However, the fear of miscarriages among pregnant women delayed their initial ANC visit. These results are expected to serve as basic materials for the development of methods to improve the utilization of ANC services in Senegal.