The boundaries and names shown and the designations used on this map do not imply official endorsement or acceptance by the United Nations. Final boundary between the Republic of Sudan and the Republic of South Sudan has not yet been determined. *Dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not yet been agreed upon by the parties.
Only 1 in 2 births in sub-Saharan Africa and South Asia are attended by a skilled provider
Live births (millions) and percentage and number of births attended and not attended by skilled health personnel, by region and world, 2009-2013
Note: The size of each pie chart represents the number of births in each region in 2013.
Estimates are based on a subset of 134 countries with available data for the period 2009–2013 covering 85% of births worldwide. Regional estimates represent data from countries covering at least 50% of each region. The sum of the regional births presented above does not add up to the world total, as there are additional countries outside of these regions that are not shown in the figure. These countries are primarily high- and upper-middle-income countries located in Australasia, Europe and North America.
Source: UNICEF global databases 2014 based on MICS, DHS, other national sources and UN Population Division.
Skilled care during childbirth and access to emergency obstetric care, when required, are the two most critical interventions needed to ensure safe motherhood. Worldwide, about one third of births take place without the assistance of skilled health personnel. In 2013 alone, this translated into more than 40 million unattended births, over 80 per cent of which were in South Asia and sub-Saharan Africa.
Sub-Saharan Africa and South Asia, which together represent over 85 per cent of all maternal deaths worldwide, also have the lowest levels of skilled attendance at birth. Regional averages range from about 50 per cent in South Asia and sub-Saharan Africa to a high of 99 per cent in Central and Eastern Europe and the Commonwealth of Independent States (CEE/CIS).
Despite substantial progress over the last two decades, inadequate or non-existent care during pregnancy and delivery is largely responsible for the annual deaths of an estimated 289,000 mothers and 2.8 million newborns in the first month of life. Indeed, roughly three quarters of all maternal deaths take place during delivery and in the immediate postpartum period.
To improve maternal and newborn survival, skilled health personnel (a doctor, nurse or midwife) should be capable of handling normal deliveries safely. They must also be able to recognize warning signs for complications and refer the mother to emergency care. Non-skilled attendants, including traditional birth attendants, whether trained or untrained, can neither predict nor cope with serious complications such as haemorrhage or sepsis, which are the leading killers of mothers during and after childbirth.
DISPARITIES IN COVERAGE
Globally, just over half of all births among rural mothers are attended by skilled health personnel, compared to 86 per cent among urban mothers. The largest gaps are observed in poor countries. Some of the greatest differentials are found in sub-Saharan Africa and South Asia, where women in urban areas are almost twice as likely as women in rural areas to deliver with help from skilled health personnel.
Large disparities in delivery care are also observed across wealth quintiles. Globally, women in the richest 20 per cent of the population are almost three times more likely than women in the poorest quintile to have a skilled birth attendant at delivery (85 per cent versus 33 per cent). Again, differences across wealth quintiles are largest in sub-Saharan Africa and South Asia.
DELIVERY IN HEALTH FACILITIES
In many countries, particularly middle- and high-income countries, a large proportion of babies are delivered in health facilities. Delivery in health facility increases access to appropriate equipment and supplies available on site or through immediate referral to a higher level facility. However it remains essential to ensure that the delivery is carried out by skilled health personnel, capable to anticipating or detecting signs and symptoms of complications. In East Asia and the Pacific as well as in Latin America and the Caribbean, about 9 in 10 births occur in health facilities. In contrast, in South Asia and sub-Saharan Africa where the burden of maternal and newborn deaths is highest, only about half of births (45 per cent and 46 per cent respectively) are delivered in a health facility.
DELIVERY BY CAESAREAN SECTION
Caesarean section (C-section) can be a life-saving intervention and is an essential part of comprehensive emergency obstetric care.
A C-section rate below 5 per cent suggests that some women who need the procedure do not have access to it, which endangers their lives and those of their babies. Country estimates suggest that women in high burden countries especially in rural areas, lack access to this critical intervention at delivery. On the other hand, some countries have coverage exceeding 15 per cent, which suggests potential overuse of this procedure, exposing women to unnecessary risks associated with major surgery.
Countries with highest neonatal mortality rate and available data on Caesarean section for the period 2009–2013. Countries with less than 10,000 births are not included.
Caesarean section rate is a proxy for access to comprehensive emergency obstetric care.
* Although a panel of experts at a meeting organized by WHO in 1985 concluded “there is no justification for any region to have a Caesarean section rate higher than 10-15 per cent”, there is no empirical evidence for an optimum percentage or range of percentages. It should be noted that the proposed upper limit of 15 per cent is not a target to be achieved but rather a threshold not to be exceeded and that this recommendation refers to rates at population level. To enforce it at facility level would not be appropriate due to differences in the obstetric populations (WHO 2014).
Source: UNICEF global databases, 2014, from MICS, DHS and other nationally representative sources.
UNICEF, Committing to child survival: A Promise Renewed – Progress Report 2014, UNICEF, New York, 2014.
UNICEF, The State of the World's Children 2011: Adolescence – An age of opportunity, UNICEF, New York, 2011.
United Nations Inter-agency Group for Child Mortality Estimation (IGME), Levels and Trends in Child Mortality: Report 2013, UNICEF, New York, 2013.
WHO, UNFPA, UNICEF, AMDD, Monitoring Emergency Obstetric Care – A handbook, 2009 revision, WHO, Geneva 2009.
WHO, UNICEF, UNFPA and The World Bank, Trends in Maternal Mortality: 1990 to 2010, WHO, Geneva, 2012.
WHO, UNICEF, UNFPA and The World Bank, Trends in Maternal Mortality: 1990 to 2013, WHO, Geneva, 2014.
This report presents new estimates of maternal mortality produced by the Maternal Mortality Estimation Inter-Agency Group (MMEIG) as part of global and country monitoring of the Millennium Development Goal five. The estimates are the seventh in a series of analyses carried out by MMEIG. The report describes estimates of levels and trends in maternal mortality ratio between 1990 and 2013, associated number of maternal deaths and lifetime risk of maternal deaths.
This report looks at causes of death and coverage of key interventions for mother and newborn and highlights initiatives by governments, civil society and the private sector to accelerate progress on child survival.
UNICEF – in collaboration with WHO – is the UN organization responsible for monitoring and reporting the indicator ‘Births attended by skilled health personnel’, which is one of the official indicators for MDG 5: Improve maternal health.
Millennium Development Goal
5.2 Births attended by skilled health personnel, percentage
Goal 5. Improve maternal health
Target 5.A: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio
DEFINITION OF INDICATOR
Births attended by skilled health personnel (doctor, nurse or midwife) is the percentage of births attended by health personnel trained in providing life-saving obstetric care, including giving the necessary supervision, care and advice to women during pregnancy, labour and the postpartum period; conducting deliveries on their own; and caring for newborns. Traditional birth attendants, even if they receive a short training course, are not included.
Computation: The number of live births to women aged 15 to 49 in a defined recent period attended by skilled health personnel (doctor, nurse or midwife), expressed as a percentage of live births to women aged 15 to 49 in the same period.
Measurement limitations: The indicator is a measure of a health system’s ability to provide adequate care for pregnant women. Concerns have been expressed that the presence of a skilled attendant may not adequately capture women’s access to good-quality care, particularly when complications arise, and that information on the supplies and equipment a skilled attendant may or may not have is lacking.
In addition, standardization of the definition of skilled health personnel is sometimes difficult because of differences in training of health personnel in different countries. Although efforts have been made to standardize the definitions of doctors, nurses, midwives (and in some cases, auxiliary midwives) used in most household surveys, it is likely that the abilities of many skilled attendants to provide appropriate care in an emergency depends on the environment in which they work.