WUNRN
Guttmacher Institute
http://www.guttmacher.org/pubs/journals/4017614.html
Volume 40, Number 4, December 2014
Young Women*s Access to & Use of
Contraceptives: Role of Providers* Restrictions in Urban Senegal
By
Estelle M. Sidze, Sol豕ne Lardoux, Ilene S. Speizer, Cheikh M. Faye, Michael M.
Mutua and Fanding Badji
CONTEXT: Contraceptive prevalence is very low in
Senegal, particularly among young women. Greater knowledge is needed about the
barriers young women face to using contraceptives, including barriers imposed
by health providers.
METHODS: Survey data collected in 2011 for the
evaluation of the Urban Reproductive Health Initiative in Senegal were used to
examine contraceptive use, method mix, unmet need and method sources among
urban women aged 15每29 who were either currently married or unmarried but
sexually active. Data from a sample of family planning providers were used to
examine the prevalence of contraceptive eligibility restrictions based on age and
marital status, and differences in such restrictions by method, facility type
and provider characteristics.
RESULTS: Modern contraceptive prevalence was 20%
among young married women and 27% among young sexually active unmarried women;
the levels of unmet need for contraception〞mostly for spacing〞were 19% and 11%,
respectively. Providers were most likely to set minimum age restrictions for
the pill and the injectable求two of the methods most often used by young women
in urban Senegal. The median minimum age for contraceptive provision was
typically 18. Restrictions based on marital status were less common than those
based on age.
CONCLUSIONS: Training and education
programs for health providers should aim to remove unnecessary barriers to
contraceptive access.
International Perspectives on Sexual and Reproductive Health, 2014, 40(4):176每183, doi: 10.1363/4017614
Family planning services
were introduced in Senegal in the early 1960s at the private Blue Cross Clinic
in Dakar, but it was only in 1981 that the government developed an
administrative structure capable of directing a national program and began to
provide information, education and counseling support and family planning
services. Wider provision of family planning prior to 1981 was prohibited by a
law passed during the 1920s, when Senegal was a French colony,1 and repealed only
in 1980. In 1988, a national population policy was issued, giving official and
political approval of the family planning program and paving the way for
progress in family planning in Senegal.
But despite changes in
Senegal*s legal and regulatory environment in regard to family planning,
contraceptive prevalence has been slow to increase. According to the 2010每2011
Senegalese Demographic and Health Survey (DHS), only 12% of currently married
women used a modern contraceptive method, compared with 8% in 1997 and 10% in
2005.2 This slow change can be attributed
to low demand for contraceptives, as well as to supply-side barriers. For
instance, most African countries have been providing oral contraceptives and
injectables through community-based distribution programs for decades; however,
Senegal pilot-tested such a program only in 2012每2013, a delay caused by
illogical restrictions on which types of providers can supply oral
contraceptives and injectables.3
Nearly 30% of currently
married Senegalese women have an unmet need for family planning〞that is, they
want to either postpone their next birth for at least two years or stop
childbearing altogether, but are not currently using a contraceptive method;2 the current level is slightly
lower than in 2005 (32%). The level of unmet need in Senegal〞especially for
spacing (29% among currently married women)〞is higher than in other West
African countries, such as Burkina Faso, Ghana, Mali and Nigeria.4
Factors contributing to
unmet need for family planning in developing countries include lack of
contraceptive knowledge; poor quality of and access to family planning
services; method cost; women*s concerns about side effects; and women*s,
husbands* or family members* objections to contraceptive use.4,5
According to a descriptive
analysis of Urban Reproductive Health Initiative data, women*s beliefs and
misconceptions about contraceptives, husbands* objections to contraceptive use
and the poor quality of family planning services are the most frequent reasons
deterring women in urban Senegal from practicing contraception.6
Youth constitute a key
target in reproductive health strategies and, in Senegal, appear to have
particularly low levels of contraceptive use. For example, in 2010每2011, only
2% of all 15每19-year-olds and 6% of all 20每24-year-olds reported using a modern
method;2 the proportions
among currently married women in those age-groups were slightly higher (5% and
8%, respectively). Access to reproductive health services remains an issue for
young women and men because of cultural, medical and financial barriers.7每9 For example, although there are
no legal restrictions to providing oral contraceptive pills to unmarried young
women, results from simulated client studies suggest that providers are
reluctant to do so and tend to promote abstinence instead.7,9 Consequences
among young women of lack of access to reproductive health services are
increased risk of unplanned pregnancy; unsafe abortion; STIs, including HIV;
and early school dropout due to pregnancy.7
Previous research has
stressed the importance of helping young people in developing countries to be
effective contraceptive users.10每12 As the
medical mediators between clients* knowledge and fears and their use of
contraceptives, health providers are also key to ensuring access to, and
adoption and continued use of, contraceptive methods among youth. Health
providers* knowledge and training influence access to specific contraceptives.13,14 In Tanzania, Speizer et al.
demonstrated examples of obstacles that prevent women from using modern
contraceptives, such as inappropriate contraindications, eligibility
restrictions, unnecessary process hurdles, overspecialization of providers,
bias and unnecessary regulations.13
This study examines the
role family planning providers* restrictions play in young women*s access to
and use of modern contraceptives in urban Senegal. Norms and policies have been
developed over the years in Senegal to ensure that all individuals receive
family planning services without any discrimination based on age, sex, marital
status, ethnic group or religious affiliation.15每18 With regard
to health services for young people in particular, the latest Senegalese
national health development plan (2009每2018) specifies that health
professionals should be able to counsel adolescents on pregnancy prevention, as
well as on prevention of and voluntary testing for STIs.17 These
responsibilities are clearly defined in training curricula for doctors, nurses,
midwives and social workers, and are to be carried out without any
stigmatization. Yet, very few studies have used provider data to assess the
prevalence of providers* restrictions for young people.13,14 We do so
here by facility type, method type, and providers* gender, age and
specialization.
DATA AND METHODS
The study draws on data on
women and health providers collected by the Measurement, Learning and
Evaluation (MLE) project in Senegal as part of the evaluation of the Senegal
Urban Reproductive Initiative, a five-year project (2010每2015) financed by the
Bill & Melinda Gates Foundation. The initiative*s goal is to implement
specific programs as part of a pilot project to show how using innovative
approaches based on high-quality health care delivery in the public and private
sectors〞as well as demand creation and advocacy efforts〞can significantly
increase the use of modern family planning methods in urban francophone Africa.
The MLE project received ethical approval from the National Ethics Committee of
Senegal and the institutional review board of the University of North Carolina
at Chapel Hill. Study participants were requested to sign a consent form and
had the right to withdraw at any time, without reprisal.
Survey of Women
As part of the MLE project,
a survey of women was conducted in 2011 using a two-stage stratified area
sampling procedure to obtain a representative sample of women aged 15每49 in six
urban sites (Dakar, Gu谷diawaye, Kaolack, Mbao, Mbour and Pikine). In the first
stage, 32每64 primary sampling units were selected with probability proportional
to population size of each site. In the second stage, a random sample of 21
households was chosen from each selected primary sampling unit, and all women
aged 15每49 in those households who were identified as habitual residents or
visitors were eligible for individual interviews.
Respondents answered
questions about their social and demographic characteristics, marital and
reproductive histories, fertility preferences, awareness and use of
contraceptives, sources of contraceptives, spousal communication about
contraceptive use and fertility preferences, migration history and exposure to
media. Information about women*s unmet need for spacing and limiting births was
also collected. Women were considered to have an unmet need for spacing if they
reported that their last or current pregnancy was mistimed or that they were
fertile, were not practicing contraception and wanted to wait at least two
years before having their next child. Women were considered to have an unmet
need for limiting if they reported that their last or current pregnancy was
unwanted or that they were fertile, were not practicing contraception and did not
want any more children. Currently pregnant women who became pregnant while
using a contraceptive method were excluded from determinations of unmet need.
Overall, 9,614 women were
successfully interviewed; the response rate was 89%.19 Sample weights
were applied to adjust for the sample size at the different sites and for
nonresponse. For our analyses, we selected two weighted samples of young women
aged 15每29. One sample consisted of the 2,340 young women who reported being
currently married; the other sample consisted of the 237 who reported having
initiated sex, having been sexually active during the 12 months preceding the
survey and not being married to or living with a man at the time of the survey.
Descriptive analyses of young women*s modern contraceptive use, method choice
and method source were conducted using the svy command in Stata. Confidence
intervals were calculated to show the level of difference or similarity between
comparison proportions, and standard errors were adjusted for clustering.
Analyses were performed separately for the two samples to account for the
differences in contraceptive demand between the two groups.
Health Facility Survey
The MLE project also
collected data in 2011 from health facilities that supplied reproductive health
services and from providers who worked in such facilities. For the sampling
procedure, a list of operational health facilities providing reproductive
health services in survey sites was obtained from the Ministry of Health. This
list was updated using information from Dakar Medical Region, Mbour Health
District, Kaolack Health District, National Health Information System and
IntraHealth, and included 269 health facilities. Some 205 (76%) were
successfully located and surveyed, of which 153 were public facilities (eight
hospitals, 22 health centers, 111 health posts and 12 other public facilities
such as dispensaries and community health centers) and 52 were private (27 hospitals
or clinics, 10 faith-based facilities, five nongovernmental organization
clinics and 10 other private providers).
For each facility, 2每4
providers involved in the provision of reproductive health services (i.e.,
doctors, nurses, trained midwives, maternal and child health aides, medical
assistants and auxiliary staff) were randomly selected for interview from a
list of active, permanent facility personnel on duty when interviewers visited.
The number of providers selected depended on how many were involved in the
provision of reproductive health services at the facility. A total of 637
providers were interviewed: 516 from public facilities (32 from hospitals, 81
from health centers, 364 from health posts and 39 from other public facilities)
and 121 providers from private facilities.
All selected providers
answered questions about the reproductive services offered at their facility,
as well as their demographic characteristics and medical specialization.
Providers were asked about the two restrictions most likely to affect young
women*s access to contraceptive methods: minimum age and marital status. For
selected modern contraceptive methods (the pill, the injectable, the implant,
condoms and emergency contraception), providers were asked, ※What is the
minimum age you would offer the method to anyone?§ and ※Would you offer this
method to an unmarried person?§ Providers who did not report a minimum age were
considered as not restricting provision of contraceptive methods by age.
Providers who reported that they would not offer a given method to an unmarried
person were considered to restrict provision of that method based on marital
status.
For each of the selected
methods, we divided the number of providers applying minimal age and marital
status restrictions by the total number of providers who reported offering the
method at their facility at the time of interview. We present these estimated
percentages separately for public and private health facilities; although staff
at both types of facilities receive the same training and are required to
follow the same national guidelines for family planning service delivery,
differences in the prevalence of restrictions could be observed due to
differences in monitoring systems. In addition, we computed median ages below
which providers would not offer a specific method, as well as interquartile
ranges〞a measure of dispersion computed as the difference between the 75th
percentile (Q3) and the 25th percentile (Q1).
Finally, we conducted
chi-square analyses to examine the levels of minimum age and marital status
restrictions by providers* gender, age and specialization. We restrict the
results to the three methods found to be most commonly used by young women in
urban Senegal: the pill, the injectable and condoms.
RESULTS
Use and Sources of Contraceptives
The proportion of young
urban Senegalese women who reported using a modern contraceptive method was 20%
among those currently married and 27% among those who were unmarried and
sexually active (Table 1). The
greatest proportion of the married group relied on the injectable (43%),
followed by the pill (33%) and the condom (15%); this pattern was consistent
across age-groups. In contrast, the greatest proportion of the sexually active
unmarried group relied on the condom (56%), followed by the injectable (21%)
and the pill (14%). Overall, 19% of married women had an unmet need for
contraception, almost all for spacing; the highest level of unmet need for
spacing was among 20每24-year-olds (20%). Among sexually active unmarried women,
the level of unmet need for contraception〞all for spacing〞was 11%.
Sixty-seven percent of all
young women currently using a modern method of contraception reported obtaining
that method from the public sector (2% from hospitals, 17% from health centers,
43% from health posts and 4% from other public health facilities; Table 2). Health posts were the facility
type most commonly cited by women as their public source for the pill (39%) and
the injectable (64%); health centers were the most common public source for the
implant (60%). Twenty-six percent of young women obtained their contraceptive
method from the private sector. Young women mostly turned to private- sector
health facilities for condoms (61%); however, 34% of condom users obtained the
method from NGOs or other facilities.
Minimum Age and Marital Status Restrictions
Public-sector providers
commonly apply a minimum age restriction for provision of contraceptives,
including the pill and the injectable〞two of the most commonly used methods
among young women (Table 3).
Overall, 57% of public-sector providers reported that they would not provide a
client below a certain age with the pill; that proportion was 59% in hospitals,
47% in health centers and in other public facilities, and 46% in health posts.
For the injectable, 44% of public-sector providers applied a minimum age
restriction; that proportion was 52% in hospitals, 43% in health centers, 40%
in health posts and 37% in other public facilities. In addition, 45% of
public-sector providers applied an age restriction for the implant, 25% for the
condom and 24% for emergency contraception. In private facilities, the
proportion of providers who required clients to be above a certain age to
receive a contraceptive method was 49% for the pill, 41% for the injectable,
38% for the implant, 20% for the condom and 21% for emergency contraception.
Overall, the median minimum
age required by public providers who reported having an age restriction for
contraceptives was 17 for the pill and 18 for the injectable, the implant, the
condom and emergency contraception; the median minimum age was as high as 20
for provision of the implant in public hospitals and health centers. In the
private sector, the median minimum age was 18 for all methods studied.
In general, restrictions on
contraceptive provision because of marital status were less common than those
because of age. Overall, 12每14% of providers in public health facilities
reported requiring that a woman be married to receive the pill, the injectable
or the implant, and 8每9% applied a marital status restriction for condoms and
emergency contraception. In private health facilities, 21每30% of providers
reported refusing to offer unmarried women the pill, the injectable, the
implant or emergency contraception; 12% imposed a marital status restriction
for condoms.
Restrictions by Providers* Characteristics
Contraceptive restrictions
varied among providers depending on their characteristics. For instance, among
public-sector providers, a greater proportion of men than of women reported
applying a minimum age restriction for provision of the injectable (54% vs.
39%; Table 4); male providers at public
facilities were also more likely than their female peers to restrict young
clients* access to at least one of the three methods studied (58% vs. 45%). In
the private sector, male providers were generally more likely than female
providers to apply minimum age restrictions to contraceptive method provision,
although no significant differences by gender were found. It is important to
note that few public- or private-sector providers of the pill, the injectable
or condoms were male.
The proportion of public
and private providers who reported applying minimum age restrictions to
contraceptive method provision were generally consistent across provider
age-groups. In regard to provider type, in the public sector, greater
proportions of nurses than of other providers reported having a minimum age restriction
for the pill (62% vs. 33每43%) or for at least one of the three methods (57% vs.
39每44%); the pattern by provider type in the private sector seemed to follow
that seen in the public sector, but no differences were significant.
In our analyses of
providers* restrictions based on marital status, we found only one significant
finding: the proportion of public staff who would not provide the pill to
unmarried women increased with provider*s age (from 5% among those younger than
30 to 9% among those 30每39 and 16% among those 40 or older; Table 5). The pattern by age seemed to
also apply to provision of the injectable and condoms at public facilities, but
was opposite for pill and injectable provision at private facilities; however,
the differences were not significant. In general, female providers were
slightly more likely than male providers to require clients to be married to
receive contraceptives; female providers in private facilities were generally
more restrictive than their counterparts in public facilities. In regard to
provider type, in the public sector, restrictions by marital status generally
were more common among nurses than among other providers; in the private
sector, midwives appeared to be the provider type most likely to restrict
unmarried women*s access to contraceptives.
Further analyses (not
shown) indicated no correlation between minimum age restrictions and parity
restrictions.
DISCUSSION
As unmet need remains high
in Senegal,2,4 family planning
programs face challenges in removing barriers to family planning access and
use. Young people have particularly low levels of contraceptive use, despite
being knowledgeable of contraceptive methods.3 In this study, we
found that in urban Senegal, only about one-fifth of married young women and one-fourth
of unmarried, sexually active young women reported current use of a modern
contraceptive method. In addition, one in five married young women and one in
10 unmarried, sexually active young women had an unmet need for contraception.
These levels of contraceptive use and unmet need suggest a need for improvement
in family planning services for youth in urban Senegal.
An important goal of this
study was to investigate the role providers* restrictions play in young women*s
access to contraceptives. Providers are key to ensuring young people*s access
to, and adoption and continued use of, contraceptive methods; thus, provider
biases and restrictions may hamper young people*s access and use.
According to our findings,
providers in Senegal seem generally more likely to impose restrictions based on
age than on marital status; this pattern has been reported in previous
research.14 More than half of
providers in the public sector and almost half of those in the private sector
reported applying a minimum age for provision of the pill. Minimum age
restrictions for the pill and the injectable are particularly troubling,
because these are the two methods most used by young married women. Minimum age
restrictions for emergency contraception and the condom were relatively less
common in both the private and the public sectors; however, restricting young
women*s access to these methods is still problematic. Emergency contraception
is an effective way of preventing unwanted pregnancies among young women after
unprotected sex, and the condom〞the method used by the greatest proportion of
unmarried, sexually active young women〞is the only method that prevents against
STIs (including HIV) as well as pregnancy.
On average, providers in
both the public and the private sectors required clients to be at least 18 for
most of the contraceptive methods studied, which presents a major barrier to
contraceptive access not only for young adolescents, but for most teenagers and
some young adults as well. It does not appear that providers consider parity
when making decisions to restrict methods by minimum age.
We found that male
providers〞particularly in the public sector〞were more likely than female providers
to impose restrictions by minimum age for the pill, the injectable and condoms.
Also in the public sector, nurses were more likely than other staff to impose
minimum age restrictions for those methods. The context must be considered,
however, when interpreting these results: In Senegal, few public providers of
these methods are male, and different types of providers play different roles
in service provision.
Previous studies have
demonstrated that provider restrictions reflect the social norms and values of
providers.20每22 For
example, according to Batieno, the choice of methods providers offer their
female patients may perpetuate norms and values of the society.21 In Senegal,
provider-imposed restrictions are most likely a reflection of the country*s
long history of restrictive family planning practices and a generally socially
conservative environment.1,3 Strong norms
exist against premarital sexuality, especially for women, and health providers
may tend to promote abstinence for young women, while restricting unmarried women*s
access to the pill.9 Providers may also
be reluctant to offer contraceptives (including condoms) to young people out of
fear that youth might be stigmatized by parents or other community members.
In the provision of family
planning services, concerns defined by the state of medical knowledge and
scientific advances should prevail over social norms. According to the World
Health Organization*s report on medical eligibility criteria, even the medical
concerns expressed regarding the use of certain methods must be balanced
against the advantages of avoiding unintended pregnancies, particularly when it
comes to youth.23 Clients* approach
to choosing a contraceptive may vary according to individual social issues,
such as frequency of intercourse among young adults, for example, as well as
the economic activities and educational aspirations of women. In the absence of
a clear regulatory framework for service provision to young people, health
providers may refer to their own perspectives to determine how and when to
offer youth services and methods. Proper provider training is essential to
prevent providers from limiting the options available for young women. In
addition, family planning programs should organize more regular follow-up and
updates on contraception via forums and seminars for providers. Health
providers currently may not have enough knowledge about methods, or about the
potential health consequences and side effects of contraceptives. In Kenya and
Ethiopia, for instance, counseling on and provision of emergency contraception
was positively associated with providers* greater level of knowledge of the
method.24 Thus, an increase
in provider knowledge may allow clients better contraceptive access.
Limitations
We must acknowledge our
study*s limitations. Data on providers* characteristics were limited; thus,
multivariate analyses examining associations between providers* characteristics
and age or marital restrictions were not possible. Because only 2每4 providers
were interviewed per health facility, the data may not represent all providers
at the facility level; nonetheless, we believe that the data collection
procedure was suitable for our study given that all facilities located in study
sites were eligible for inclusion, rather than a random sample〞often used in
situation analyses.25Reported
age-heaping occurred in our data on the service provider minimum age
restriction, particularly at age 18 and at all ages with ※0§ and ※5§ digits
beyond 15 years of age; this would speak to the quality of data on age
restrictions reported by service providers. Finally, the women*s survey data
about reasons for nonuse (among women not using contraceptives) does not fully
capture the extent to which providers* restrictions could have accounted for
the nonuse.
CONCLUSIONS
Findings from this study
suggest several programmatic recommendations. First, training and education
programs for medical staff in Senegal should aim to reduce unnecessary
provider-implemented barriers to contraceptive access, such as restrictions by
age or marital status. All staff of both public and private facilities should
receive training and education; however, targeted training for male providers,
nurses and older staff may be warranted, given evidence that those groups may
be more likely to apply restrictions by age and marital status. Such programs
could contribute to increased access to and use of contraceptives among young women,
lower unmet need and improved health outcomes in urban Senegal and beyond.
Second, all family planning
service delivery protocols or policies should make clear that young people are
eligible for services. Currently, the documents related to the norms and
protocols in Senegal specify no regulatory restrictions against youth*s access
to family planning services; however, they also do not include a clear official
statement that adolescents and young people should have unrestricted access. In
the absence of a clear message, providers in Senegal can define their
restriction criteria based on their own opinions and values regarding sexuality
and contraception.
REFERENCES
1. Wilson E, Reproductive Health Case Study, Senegal, Washington,
DC: Futures Group International, 1998, <http://www.policyproject.com/pubs/countryreports/sendbl.pdf>,
accessed Aug. 21, 2013.
2. Agence Nationale de la Statistique et de la D谷mographie (ANSD) S谷n谷gal and
ICF International, Enqu那te D谷mographique et de Sant谷 角 Indicateurs Multiples
au S谷n谷gal (EDS-MICS) 2010每2011, Calverton, MD, USA: ANSD and ICF
International, 2012.
3. FHI 360, Senegal: Community Health Workers Successfully Provide
Intramuscular Injectable Contraception, Dakar, 2013, <http://www.fhi360.org/sites/default/files/media/documents/community-health-workers-intramuscular-depo-senegal.pdf>,
accessed July 8, 2014.
4. Sedgh G et al., Women with an unmet need for contraception in developing
countries and their reasons for not using a method, Occasional Report,
New York: Guttmacher Institute, 2007, No. 37.
5. Cleland J et al., Family planning: the unfinished agenda, Lancet,
2006, 368(9549):1810每1827.
6. Measurement, Learning and Evaluation (MLE) Project, 2011 Baseline
Survey for the Senegal Urban Health Initiative (ISSU) Service Delivery Site
Survey: Final Report, Chapel Hill, NC, USA: IntraHealth International,
2012, <http://www.urbanreproductivehealth.org/sites/mle/files/issu_service_delivery_site_baseline_survey_english.pdf>,
accessed May 12, 2013.
7. Katz K and Nar谷 C, Reproductive health knowledge and use of services among
young adults in Dakar, Senegal, Journal of Biosocial Science, 2002,
34(2):215每231.
8. International Youth Foundation (IYF), Youth Map Senegal, Youth
Assessment: The Road Ahead, Vol. 1: Main Report, Baltimore, MD, USA: IYF,
2011, <http://www.iyfnet.org/sites/default/files/YouthMap_Senegal_Vol.1_Report.pdf>,
accessed May 12, 2013.
9. Nar谷 C, Katz K and Tolley E, Adolescents* access to reproductive health
and family planning services in Dakar (Senegal), African Journal of
Reproductive Health, 1997, 1(2):15每25.
10. Blanc AK et al., Patterns and trends in adolescents* contraceptive use and
discontinuation in developing countries and comparisons with adult women, International
Perspectives on Sexual and Reproductive Health, 2009, 35(2):63每71.
11. Biddlecom AE et al., Adolescents* views of and preferences for sexual and
reproductive health services in Burkina Faso, Ghana, Malawi and Uganda, African
Journal of Reproductive Health, 2007, 11(3):99每110.
12. Bankole A et al., Knowledge of correct condom use and consistency of use
among adolescents in four countries in Sub-Saharan Africa, African Journal
of Reproductive Health, 2007, 11(3):197每220.
13. Speizer IS et al., Do service providers in Tanzania unnecessarily restrict
clients* access to contraceptive methods? International Family Planning
Perspectives, 2000, 26(1):13每20 & 42.
14. Miller K et al., How providers restrict access to family planning methods:
results from five African countries, in: Miller K et al., eds., Clinic-Based
Family Planning and Reproductive Health Services in Africa: Findings from
Situation Analysis Studies, New York: Population Council, 1998, pp.
159每180.
15. Republic of Senegal, loi no. 2005每18, relative 角 la sant谷 de la
reproduction, Aug. 5, 2005, Chapter IV, Article 10.
16. Republic of Senegal, Politiques et Normes de Services de SR, S谷n谷gal,
Dakar, Senegal: Division de la Sant谷 de la Reproduction, 2007.
17. Republic of Senegal, Plan National du D谷veloppement Sanitaire du
S谷n谷gal (PNDS 2009每2018), Dakar, Senegal: Minist豕re de la Sant谷 et de la
Pr谷vention, 2009.
18. Republic of Senegal, Plan d*Action National de Planification Familiale
2012每2015, Dakar, Senegal: Division de la Sant谷 de la Reproduction, 2012.
19. Measurement, Learning and Evaluation (MLE) Project, 2011 Baseline Survey
for the Senegal Urban Health Initiative (ISSU) Household Survey: Final Report,
2012, <https://www.urbanreproductivehealth.org/sites/mle/files/Final_Household_Baseline_Report_ISSU_April%2026%202012%20F.pdf>,
accessed Dec. 15, 2013.
20. Quesnel A and Samuel O, Mexico: Women between husband and doctor, Histoires
de D谷veloppement, 1993, <http://horizon.documentation.ird.fr/exl-doc/pleins_textes/pleins_textes_6/b_fdi_33-34/38840.pdf>,
accessed Nov. 23, 2012 (in French).
21. Bationo BF, The relationship between health workers and young girls in
Burkina Faso, Agora D谷bats/Jeunesses, 2012, <www.cairn.info/revue-agora-debats-jeunesses-2012-2-page-21.htm>,
accessed Nov. 23, 2012 (in French).
22. Stanback J and Twum-Baah K, Why do family planning providers restrict
access to services? An examination in Ghana, International Family Planning
Perspectives, 2001, 27(1):37每41.
23. World Health Organization (WHO), Medical Eligibility Criteria for
Contraceptive Use, fourth ed., Geneva: WHO, 2009, <http://www.who.int/reproductivehealth/publications/family_planning/9789241563888/en/index.html>,
accessed Nov 23, 2012.
24. Judge S, Peterman A and Keesbury J, Provider determinants of emergency
contraceptive counseling and provision in Kenya and Ethiopia, Contraception,
2011, 83(5):486每490.
25. Miller R et al., The Situation Analysis Approach to Assessing Family
Planning and Reproductive Health Services: A Handbook, New York: Population
Council, 1997.