Current Status + Progress
Despite accelerated recent progress, millions of births occur annually without any assistance from a 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 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 (21 per cent) take place without the assistance of a skilled birth attendant. In 2016, this translated into nearly 31 million unattended births worldwide. Coverage of skilled birth attendance across regions ranges from  99 per cent in Central and Eastern Europe and the Commonwealth of Independent States (CEE/CIS) to 51 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.

While in 2000 globally just over 60% of births were delivered with the assistance of a skilled health attendant the coverage of this important intervention rose to nearly 80 per cent by 2016. Least developed countries saw an increase in coverage from 29 per cent to 55 per cent over the same period, with the largest increase in South Asia where coverage grew from 35 per cent to 72 per cent between 2000 and 2016.

Global progress in skilled attendance at birth has remained steady since 2000
Percentage of births attended by a skilled health professional, by region, 2000-2016

Source: Joint UNICEF/WHO database 2016 of skilled health personnel, based on population-based national household survey data and routine health systems.

Note: Includes data on institutional births for countries in which data on skilled attendance at birth were not available.

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, 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.

Large and stagnating urban-rural equity gaps are observed across regions
Percentage of births attended by skilled health personnel, by urban-rural residence, 2015 (2010-2015)

* 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.

Largest disparities are observed in South Asia and sub-Saharan African regions, where women in the richest quintile are 3 times more likely to have a skilled attendant at birth than the poorest women
Percentage of births attended by skilled health personnel, by the richest and poorest quintiles, 2015 (2010-2015 period)

* 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.

About half of all deliveries in sub-Saharan Africa take place in health facilities
Percentage of births taking place in a health facility, 2015 (2010-2015 period)

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.

Very low Cesarean section rates, particularly in rural areas, suggest inadequate emergency obstetric care in countries with high neonatal mortality
Percentage of births delivered by Cesarean section, by residence, countries with highest neonatal mortality rate and available data on c-section, 2015 (2010-2015)

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.

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.

Access The Data
Delivery Care
Caesarian section (Dec 2016)Download Data
Place of delivery (Dec 2016)Download Data
Births by age 18 (Dec 2016)Download Data
UNICEF/WHO joint database on skilled attendance at birth (Feb 2017)Download Data
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Notes on the Data

UNICEF – in collaboration with WHO – is the UN organization responsible for monitoring and reporting “Proportion of births attended by skilled health personnel”, an official indicator for Goal 3 of the Sustainable Development Goals.

SDG indicator Sustainable Development Goal Target
3.1.2: Proportion of births attended by skilled health personnel (doctors, nurses, midwives)

Goal 3: Ensure healthy lives and promote well-being for all at all ages

Target 3.1: By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births

DEFINITION

Definition:

The proportion of births attended by skilled health personnel as defined as the percentage of live births attended by skilled health personnel (doctors, nurses, midwives) during a specified time period, generally up to the past five years.

Computation:

The indicator is computed as the number of live births attended by skilled health personnel (generally doctors, nurses or midwives) out of total number of live births in a specified reference period.

Limitations:

Standardization of the definition of skilled health personnel can be challenging on account of differences in training of health personnel across 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. Additionally, this indicator is a measure of a health system’s ability to provide adequate care for pregnant women; however, 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.

Database:

Since 2015, UNICEF and WHO have maintained a joint database on skilled attendant at birth. Joint estimates are published annually, released simultaneously in May by UNICEF and WHO in the State of the World’s Children report, and are available at www.data.unicef.org and World Health Statistics (http://www.who.int/whosis/whostat/en/), respectively. As skilled attendance at delivery is an SDG indicator (3.1.2), databases and regional estimates are also provided for SDG data releases on an annual basis.