Ensure that women have ready and affordable access to skilled attendance at delivery	Target: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio

The challenge

Insufficient maternal care during pregnancy and delivery is largely responsible for the staggering annual toll of more than half a million maternal deaths and the estimated 4 million newborn deaths that occur within the first month of life. Indeed, roughly three quarters of all maternal deaths occur during delivery and in the immediate postpartum period.

The single most critical intervention for safe motherhood is thus to ensure that women receive care during delivery by skilled health personnel - a doctor, nurse or midwife - with the necessary skills to handle normal deliveries safely, to recognize the onset of complications beyond their capacity and to refer the mother for emergency care as needed. Traditional birth attendants, whether trained or untrained, can neither predict nor cope with serious complications.

All women should have access to basic maternity care through a continuum of services offering quality antenatal care, clean and safe delivery, and postnatal care for mother and infant, with a functioning referral system linking the whole. The quality of care provided by health personnel is crucial. Particularly when complications occur, skilled personnel need access to essential drugs, supplies, equipment and emergency obstetric care. They should receive training on required competencies. And they need supervision that helps ensure high standards of care, which is vitally important.

Around 50 million births in the developing world, or about 4 in 10 of all births worldwide, are not attended by skilled health personnel. Just 10 countries account for slightly more than two thirds of unattended deliveries worldwide, with India alone responsible for more than one quarter.

Coverage in skilled attendance at delivery varies by region

Overall, 59 per cent of births in developing countries are attended by skilled health personnel.  Sub-Saharan Africa and South Asia, which bear the greatest burden of maternal mortality, also have the lowest levels of skilled birth attendance with less than half of births being delivered by a doctor, nurse or midwife. In contrast, 95 per cent of deliveries in CEE/CIS countries are attended by skilled personnel.

Sub-Saharan Africa and South Asia lag behind other regions on coverage of skilled attendance at delivery: Percentage of births attended by skilled health personnel, by region (2000–2006)

* Estimate for Latin America/Caribbean is based on institutional deliveries
Source: UNICEF, Progress for Children: A Report Card on Maternal Mortality, 2008

 It is important to note that many countries, particularly in middle- and high-income countries, a large number of births also occur in health facilities, and thus are attended by skilled health personnel. For example, most deliveries in CEE/CIS (89 per cent) and in Latin America and the Caribbean (86 per cent) occur in health facilities. In Sub-Saharan Africa and South Asia, however, only around one-third of deliveries occur in health facilities (36 per cent of deliveries in both regions).
 

Rates of skilled delivery attendance in CEE/CIS are among the highest in the world: Percentage of births attended by skilled health personnel (2000–2006)

Worldwide, births in urban areas are twice as likely to be attended by skilled health personnel as births in rural areas. Among countries with data, there is also a significant difference between rich and poor: In the developing world as a whole, women from the poorest households who give birth are broadly half as likely to benefit from skilled delivery attendants as those from the richest households.

Increase in coverage of skilled delivery care since 1995

Across the developing world, the proportion of births attended by skilled health personnel increased from 54 per cent in 1995 to 62 per cent in 2005, based on a subset of countries with trend data. Except for Eastern/Southern Africa, all developing regions have increased their coverage of skilled delivery attendance during the past decade, with a particularly marked increase in the Middle East/North Africa, which improved from 55 per cent in 1995 to 74 per cent in 2005. 
 

In all regions, coverage of skilled delivery attendance increased during the past decade:
Trends in the percentage of births attended by skilled health personnel, by region, based on a subset of 80 countries with trend data (around 1995 and around 2005)

References