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 includes 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. Reflecting its importance in reducing maternal morbidity and mortality, skilled birth attendance was included as indicator 3.1.2 under goal 3 and target 3.1 of the Sustainable Development Goals.
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.
Globally in 2016, about one in five births (22 per cent) take place without the assistance of a skilled birth attendant as coverage of skilled health attendant at birth rose from just over 60% in 2000 to nearly 80% in 2016. In 2016, this translated into nearly 31 million unattended births worldwide. Coverage of skilled birth attendance across regions ranges from 99 per cent in Eastern Europe and Central Asia and Western Europe to 52 per cent in West and Central Africa.
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.
Adolescent mothers
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, approximately 67 per cent of births among rural mothers are attended by skilled health personnel, compared to about 90 percent of births among urban mothers. The urban rural gap remains at over 20 percentage points despite progress in the past 15 years.
Large disparities in delivery care are also observed across wealth quintiles. Globally, women in the richest 20 per cent of their countries’ population are about 2 times more likely than women in the poorest quintile to have a skilled birth attendant at delivery (90 per cent versus 46 per cent). Differences across wealth quintiles are largest in sub-Saharan Africa with the richest being 2.5 times more likely to deliver with the help of a skilled health provider than the poorest. This is especially in true in West and Central Africa where the richest 20 per cent of mothers are 3 times as likely to have a skilled birth attendance at delivery.
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 Eastern Europe and Central Asia (97 per cent), Western Europe (99 per cent), Latin America and the Caribbean (94 per cent) as well as East Asia and the Pacific (90 per cent) over 9 in 10 births occur in health facilities. In contrast, in sub-Saharan Africa where the burden of maternal and newborn deaths is highest, just over half of all births (56 per cent) are delivered in a health facility and the urban-rural gap is over 30 percentage points (78% vs. 46%) and the gap between women from the richest and poorest quintiles of their national populations is a staggering 51 percentage points (86% vs. 35%).
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. Globally, approximately 1 in 5 births are delivered via caesarean section. However, there are significant regional differences with rates ranging from only 3 per cent in West and Central Africa up to 43 per cent in Latin America and the Caribbean. 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, many countries have coverage exceeding 15 per cent, which suggests potential overuse of this procedure, exposing women to unnecessary risks associated with major surgery.
There are also substantial disparities within countries in rates of caesarean section for women in urban and rural areas (28% vs. 12%). Similarly, women from the richest 20% of households in a country utilized caesarean section delivery at a rate 3.5 times higher than women from the poorest 20% of households (25% vs. 7%).
References
UNICEF, The State of the World’s Children 2016, UNICEF, New York, 2016.
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.
