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Four out of five unattended births worldwide take place in sub-Saharan Africa and South Asia

Worldwide, about one third of births take place without the assistance of skilled health personnel. In 2012 alone, this translated into about 44 million unattended births, 80 per cent of which were in South Asia and sub-Saharan Africa.

Despite substantial progress over the last two decades, inadequate or non-existent care during pregnancy and delivery is largely responsible for the annuals deaths of an estimated 289,000 mothers and almost 3 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. Skilled care during childbirth and access to emergency obstetric care, when required, are the two most critical interventions needed to ensure safe motherhood.

To contribute to 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

Sub-Saharan Africa and South Asia, which together represent 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 97 per cent in Central and Eastern Europe and the Commonwealth of Independent States (CEE/CIS).

Coverage of skilled attendance at birth ranges from 46 per cent in least developed countries to over 90 per cent in three regions
Percentage of births attended by skilled health personnel (doctor, nurse or midwife), 2008─2012

* CEE/CIS: Central and Eastern Europe and the Commonwealth of Independent States.

Notes: Global estimates are based on a subset of 125 countries, covering 86 per cent of births worldwide. Regional estimates represent data from countries covering at least 50 per cent of regional births.

Source:  UNICEF global databases, 2014, based on MICS, DHS and other nationally representative sources.  

Globally, just over half of all births among rural mothers are attended by skilled health personnel, compared to 87 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.

Urban mothers are far more likely than their rural counterparts to deliver with assistance from skilled health personnel
Percentage of births attended by skilled health personnel (doctor, nurse or midwife), by urban or rural residence, 2008─2012

Notes: Global estimates are based on a subset of 88 countries covering 72 per cent of urban births and 90 per cent of rural births. Regional estimates represent data from countries covering at least 50 per cent of regional births. Data coverage was insufficient to calculate regional averages for CEE/CIS.  

Source: UNICEF global databases, 2014, from MICS, DHS and other nationally representative sources.

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 (86 per cent versus 32 per cent). Again, differences across wealth quintiles are largest in sub-Saharan Africa and South Asia.

In South Asia, women in the richest quintile are nearly four times more likely to have skilled attendance at birth than the poorest women
Percentage of births attended by skilled health personnel (doctor, nurse or midwife), by the richest and poorest quintiles, 2008─2012

* Excludes China.

Notes: Global estimates are based on a subset of 69 countries covering 56 per cent of births (excluding China, for which comparable data are not available). Regional estimates represent data from countries covering at least 50 per cent of regional births. Data coverage was insufficient to calculate regional averages for CEE/CIS, Latin America and the Caribbean, and the Middle East and North Africa.

Source: UNICEF global databases, 2014, based on DHS, MICS and other nationally representative sources.

DELIVERY IN HEALTH FACILITIES

In many countries, particularly middle- and high-income countries, a large proportion of babies are delivered in health facilities. These births take place with assistance from skilled health personnel, who presumably have access to appropriate equipment and supplies. 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, the share is less than 50 per cent in sub-Saharan Africa and South Asia.

Less than half of all deliveries in South Asia and sub-Saharan Africa take place in health facilities
Percentage of births taking place in a health facility, 2008─2012

Notes: Global estimates are based on a subset of 108 countries, covering 82 per cent of births in the developing world. Regional estimates represent data from countries covering at least 50 per cent of regional births. Data coverage was insufficient to calculate the regional average for CEE/CIS.

Source: UNICEF global databases, 2014, from MICS, DHS and other nationally representative sources. 

DELIVERY BY CAESAREAN SECTION

Caesarean section (‘C-section’) can be a life-saving intervention and is an essential part of comprehensive emergency obstetric care. It is estimated that 5 per cent to 15 per cent of births require C-sections.[1]

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. Regional estimates suggest that women in South Asia and sub-Saharan Africa, especially in rural areas, lack access to this critical intervention at delivery. On the other hand, some developing regions have coverage exceeding 15 per cent, which suggests overuse of this procedure, exposing women to unnecessary risks associated with surgery.
 

Data suggest both lack of access to potentially life-saving Caesarean sections as well as overuse of this procedure
Percentage of births delivered via Caesarean section, 2008─2012

* Both very low and very high rates of Caesarean section can signal a problem, but the optimum rate is unknown. 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. Although WHO has recommended since 1985 that the rate should not exceed 10 per cent to 15 per cent, there is no empirical evidence for an optimum percentage or range of percentages, despite a growing body of research that shows the negative effects of high rates.

Notes: Global estimates are based on a subset of 76 countries, covering 64 per cent of births worldwide. Regional estimates represent data from countries covering at least 50 per cent of regional births. Data coverage was insufficient to calculate the regional average for CEE/CIS as well as Latin America and the Caribbean. 

Source: UNICEF global databases, 2014, from MICS, DHS and other nationally representative sources.

REFERENCES


UNICEF, The State of the World's Children 2011: Adolescence – An age of opportunity, UNICEF, New York, 2011.

UNICEF, The State of the World’s Children 2014, UNICEF, New York, 2014.

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.



[1] Both very low and very high rates of Caesarean section can signal a problem, but the optimum rate is unknown. 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. Although WHO has recommended since 1985 that the rate should not exceed 10 per cent to 15 per cent, there is no empirical evidence for an optimum percentage or range of percentages, despite a growing body of research that shows the negative effects of high rates.

 

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Trends in Maternal Mortality: 1990 to 2013

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. 

 

Notes on the Data

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.

 

MDG indicator

Millennium Development Goal

Target

 

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.