SKILLED ATTENDANT AT BIRTH
One critical strategy for reducing maternal morbidity and mortality is ensuring that every baby is delivered with the assistance of a skilled birth attendant which generally include a medical doctor, nurse or midwife. Experts agree that the risk of stillbirth or death due to intrapartum–related complication can be reduced by about 20 percent with the presence of a skilled birth attendant.
To improve maternal and newborn survival across all ages, skilled health personnel should be capable of handling normal deliveries safely. They must also be able to recognize warning signs for complications and refer mothers to emergency care. Non-skilled attendants, including traditional birth attendants, can neither predict nor appropriately manage serious complications such as haemorrhage or sepsis, which are the leading killers of mothers during and after childbirth.
Worldwide, about one in four births (25 per cent) take place without the assistance of a skilled birth attendant. In 2015 alone, this translated into more than 40 million unattended births in low- and middle-incomecountries, about 90 per cent of which were in South Asia and sub-Saharan Africa. Regional average proportions of births without skilled birth attendant range from about 50 per cent in sub-Saharan Africa to 2 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 was largely responsible for the annual deaths of an estimated 303,000 mothers and 2.7 million newborns in the first month of life in 2015. Indeed, roughly three quarters of all maternal deaths take place during delivery and in the immediate postpartum period.
In early 1990, about two thirds of births were delivered with the assistance of a skilled health attendant, while over the 2010-2015 period, this coverage rose to 75 per cent. The least developed countries saw the largest increase over this period, going from 29 per cent to 54 per cent, almost doubling coverage. Furthermore, South Asia and the Middle East and North Africa region are among the regions which saw the largest increases. South Asia presented the highest increase from 29 per cent to 62 per cent between 1990 and 2015.
* Excludes India
Source: UNICEF global databases 2015 based on MICS, DHS and other nationally representative sources.
Note: Global estimates are based on a subset of 103 countries, covering 76 per cent of births in 2015. Regional estimates represent data from countries covering at least 50 per cent of regional births.
Currently, the highest rates of early childbearing are found in sub-Saharan African countries, where birth rates among adolescents reach over 200 births per 1000 girls aged 15-19, compared to lower rates in other regions. It is important that girls in this vulnerable group receive the necessary care during antenatal period and delivery to ensure their wellbeing and that of their babies as well as education on family planning. See more
DISPARITIES IN COVERAGE
Despite progress made, large equity gaps remain, with the rural or the poorest population often left behind. Globally, 6 in 10 (60 per cent) of all births among rural mothers are attended by skilled health personnel, compared to 89 per cent of births among urban mothers. The urban rural gap remains at about 30 percentage points despite progress in the past 15 years.
* Excludes India
Source: UNICEF global databases 2015 based on from MICS, DHS and other nationally representative sources.
Note: Global estimates are based on a subset of 96 countries covering 65 per cent of urban births and 86 per cent of rural births. Regional estimates represent data from countries covering at least 50 per cent of regional births. for CEE/CIS region and Latin America and the Caribbean region.
Large disparities in delivery care are also observed across wealth quintiles. Globally, women in the richest 20 per cent of the population are 2 times more likely than women in the poorest quintile to have a skilled birth attendant at delivery (89 per cent versus 43 per cent). Differences across wealth quintiles are largest in sub-Saharan Africa and South Asia with the richest being about 3 times more likely to deliver with the help of a skilled health provider than the poorest.
* Excludes India
** Excludes China
*** Excludes China, India and high and upper-middle-income countries located in Australasia, Europe and North America
Source: UNICEF global databases 2015 based on DHS, MICS and other nationally representative sources.
Note: Global estimates are based on subset of 89 countries covering 69 per cent of births (excluding China, India as well as countries in high- and upper-middle-income countries located in Australasia, Europe and North America 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 and Latin America and Caribbean.
DELIVERY IN HEALTH FACILITIES
Monitoring deliveries in health facilities is essential to ensuring that women receive quality care and deliver in an environment that is prepared for an emergency. In many countries, particularly middle- and high-income countries, a large proportion of babies are delivered in health facilities. Delivery in a 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 also ensure that the delivery is carried out by skilled health personnel, capable of anticipating or detecting signs and symptoms of complications. In CEE/CIS, 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 sub-Saharan Africa where the burden of maternal and newborn deaths is highest, only half of all births (50 per cent) are delivered in a health facility and the urban-rural gap is over 30 percentage points.
Source: UNICEF global databases 2015, from MICS, DHS and other nationally representative sources.
Note: Global estimates are based on a subset of 115 countries, covering 85% of births. Regional estimates represent data from countries covering at least 50% of regional births.
DELIVERY BY CAESAREAN SECTION
Caesarean section (C-section) can be a life-saving intervention and is an essential part of comprehensive emergency obstetric care. In places with no data on access to emergency case, C-section rates are generally considered as proxy for access to emergency obstetric care.
A C-section rate below 5 per cent suggests that some women who require this emergency 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 in 2015 and available data on Caesarean section for the period 2010-2015. 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, 2015, from MICS, DHS and other nationally representative sources.
UNICEF, Committing to Child Survival: A Promise Renewed – 2015, UNICEF, New York, 2015.
UNICEF, The State of the World’s Children 2011: Adolescence – An age of opportunity, UNICEF, New York, 2011.
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 2015, WHO, Geneva, 2012.
This summary 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 for 1990 to 2015 presented in this summary are the eighth in a series of analyses by the MMEIG to examine global, regional and country progress in reducing maternal mortality.
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.
|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.