Clinical, logistic, and geographic factors in ensuring adequate access to implant removals: A cross-sectional survey of public facilities and GIS modeling of geographic access in two districts of Senegal

Abstract

IntroductionEnsuring adequate access to contraceptive implant removal services requires an understanding of potential clinical, logistical, and geographic challenges.MethodsWe conducted a cross-sectional survey of 39 public health facilities in two districts of Senegal. To assess facility readiness, we reported the proportion of facilities meeting all minimum conditions for regular and difficult implant removals. We then describe characteristics of referral networks. Geographic access modeling was conducted in a geographic information system to estimate the proportion of women of reproductive age living within specific travel times of facilities ready for regular and difficult removals.Results72% of facilities met all conditions for regular removals, and 8% for difficult removals. In both cases, the main gaps related to equipment availability (79% of facilities had the minimum equipment for regular removals and 8% for difficult removals). 72% of facilities organized in three referral networks sent clients to other facilities for cases they could not manage. Of 11 receiving or single-network facilities, seven were ready for regular removals and one for difficult removals. Altogether, 36% of women in Dakar Centre and 99% of women in Kolda lived within two hours of a facility that was equipped to handle regular removals, compared to 15% and 69%, respectively, for difficult removals.ConclusionData such as those provided in this assessment are important to provide a realistic picture of the state of readiness of the health system and its ability to meet the inevitable demand for implant removals. Referral networks should be considered as an emerging strategy to avail sufficient capacity at the systems level, including for managing difficult removals. However, careful thought should be given to the location of facilities that are ready to receive cases in order to target upgrades.

What is needed to improve quality of implant removal services in Nigeria? results of a landscape assessment

“…Of particular concern in this Nigerian study context is the scarcity of specialized equipment needed to manage difficult removals, including ultrasound and x-ray, and the fact that no facilities had modified vasectomy forceps. Similar deficiencies have been noted in studies in other sub-Saharan African countries: only 8 percent of facilities assessed in Senegal were fully equipped to manage difficult removals (23). Stockouts also have adverse impact on providers' ability to perform quality removals, but despite national commitment to offer free FP services, a lack of formal policy and regulation relating to the private sector stymies effective public-private partnerships needed to sustain robust supply chains (44).…”

“…Howett et al describe an essentially identical context in Botswana, finding that nine of ten providers reported having experienced barriers to providing implant removal, including inadequate training, insufficient equipment, insufficient time, and lack of a referral pathway for difficult removals ( 45 ). Organized referral networks may offer a means for clients with difficult removals to obtain quality services in health systems with limited capacity: in Senegal, 72 percent of facilities in organized referral networks referred clients with difficult removals to other facilities, much higher than in this Nigeria landscape assessment where referral out was uncommon ( 23 ).…”

“…However, emerging data indicate that service delivery capacity for implant removals has not kept pace with that for insertion in FP2020 countries, and numerous barriers hinder access to quality implant removals. Clinical challenges can result in failed removal services, supply chain issues can limit availability of needed consumables, and geographic challenges can adversely affect clients seeking removal (facilities offering removals may be farther away than those offering insertions ( 23 ). Several studies describe users seeking implant removal from providers but failing to obtain them when desired ( 3 , 16 , 24 ) Where removal services are readily available, studies have found that up to 20 percent of implant users request removals during the first year of use ( 25 , 26 ).…”