Ensure that women have ready and affordable access to skilled attendance at delivery	Target 5.A: 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 360,000 maternal deaths and the more than 3 million deaths estimated to occur within the first month of life. Indeed, roughly three quarters of all maternal deaths take place during delivery and in the immediate post-partum period.

The two most critical interventions for safe motherhood are to ensure care during delivery by skilled health personnel and refer the mother for emergency care as needed. The personnel – a doctor, nurse or midwife – should be capable of handling normal deliveries safely and able 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 post-natal 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 there are complications, 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. This is vitally important.

Coverage in skilled attendance at delivery varies by region

Overall, 64 per cent of births in developing countries are attended by skilled health personnel. Africa and South Asia, which bear the greatest burden of maternal mortality, also have the lowest levels of skilled birth attendance. Regional averages range from a low of 37 per cent in Eastern and Southern Africa to a high of 97 per cent in Central and Eastern Europe/Commonwealth of Independent States (CEE/CIS). Skilled attendance at birth coverage is also high in East Asia and the Pacific and Latin America and the Caribbean, where 9 in 10 deliveries are assisted by skilled health personnel.

Coverage in skilled attendance at delivery must be accelerated in South Asia and Africa
Percentage of births attended by a doctor, nurse, midwife or auxiliary midwife, 2005-2009

Source:   UNICEF global databases 2010, from Multiple Indicator Cluster Surveys (MICS), Demographic and Health Surveys (DHS) and other nationally representative sources.  

It is important to note that in many countries, particularly in middle- and high-income countries, a large number of births occur in health facilities, and thus are attended by skilled health personnel with greater access to appropriate equipment and supplies. For example, almost all deliveries in CEE/CIS (93 per cent) and in Latin America and the Caribbean (87 per cent) take place in health facilities. In sub-Saharan Africa and South Asia, however, less than half of deliveries take place in health facilities.

Institutional delivery varies greatly by region
Percentage of births delivered in a health facility, 2005-2009

There are substantial disparities in delivery care. In developing countries, just 50 per cent of births in rural areas are attended by skilled health personnel compared with 82 per cent in urban areas. Some of the greatest differentials can be seen in South Asia and sub-Saharan Africa where women in urban areas are more than twice as likely as women in rural areas to deliver with a skilled health professional in attendance.

Large disparities are prevalent across household wealth quintiles in developing countries. Women in the wealthiest households (84 per cent) are almost three times as likely as women in the poorest households (30 per cent) to have a skilled birth attendant at delivery.

Women in rural areas and the poorest are less likely to deliver with a skilled health professional in attendance
Percentage of births attended by a doctor, nurse, midwife or auxiliary midwife, by urban-rural residence and wealth quintiles, 2005–2009

Source: UNICEF global databases 2010, from MICS, DHS and other nationally representative sources.

Increasing coverage in skilled attendance at delivery

Based on a subset of countries with trend data, all developing regions have increased their coverage of skilled delivery attendance since 1990, with a particularly marked increase in Latin America and the Caribbean, the Middle East and North Africa and South Asia, each with a nearly 20 percentage point increase.

Skilled attendance at delivery coverage has increased in all regions since 1990
Percentage of births attended by a doctor, nurse, midwife or auxiliary midwife, 1990–2009