Ensuring that all births are assisted by skilled health personnel is critical for reducing maternal and newborn deaths. Skilled health professionals assisted 83 per cent of births globally in 2020, but coverage continues to be uneven around the world with significant discrepancies between regions. While regions like Central Asia, Eastern Asia, Western Asia, Northern America and Europe have achieved universal or nearly universal coverage, only 64 per cent of births are attended by a medical doctor, nurse or midwife in sub-Saharan Africa. According to projections, sub-Saharan Africa will experience a 15 per cent increase in the number of annual births by 2030. If current coverage of births by skilled health personnel stays the same, in 2030 approximately 16 million births in sub-Saharan Africa will occur without the assistance of skilled health personnel. Taking into account the projected population changes in regions like sub-Saharan Africa, substantially more resources will be required to increase intervention coverage levels and provide skilled care to women and their newborns during childbirth.
Skilled health personnel, including medical doctors, nurses and midwives, are trained to handle normal deliveries safely. They are also able to recognize warning signs for complications and refer mothers to emergency care in case of complications like haemorrhage or sepsis, which are the leading killers of mothers during and after childbirth. Reflecting its importance in reducing maternal morbidity and mortality, the proportion of births attended by skilled health personnel was included as indicator 3.1.2 under Goal 3 and Target 3.1 of the Sustainable Development Goals.
Despite facing challenges in increasing skilled care at birth, sub-Saharan Africa and Southern Asia are the regions with the greatest progress globally in increasing coverage of births assisted by health professionals. Over the last two decades, coverage births by skilled birth attendants in the sub-Saharan African regions has grown by almost 30 percentage points while that in Southern Asia has grown by almost 40 percentage points.
Adolescent mothers
Currently, the highest rates of early childbearing are found in sub-Saharan African countries, where birth rates among adolescents in 2019 reached over 100 births per 1,000 girls aged 15-19, compared to lower rates in other regions. It is important that girls in this vulnerable group receive an education on family planning as well as the necessary care during pregnancy and childbirth to ensure their wellbeing and the wellebing of their babies.
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Disparities in coverage
Despite progress made in the past decade, large equity gaps remain, with rural and poor populations often left behind. Globally, in 2020, approximately 70 per cent of births among rural mothers were attended by skilled health personnel, compared to 90 per cent of births among urban mothers.
Large disparities in care during childbirth are also observed across wealth quintiles. Globally, women in the richest 20 per cent of the population for their country are almost 2 times more likely than women in the poorest quintile to have a skilled birth attendant at delivery (94 per cent versus 56 per cent). Differences across wealth quintiles are largest in West and Central Africa with the richest being 2.4 times more likely to deliver with the help of a skilled health provider than the poorest (91 per cent versus 38 per cent).
Institutional deliveries
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. Giving birth in a health facility can increase survival prospects for mother and baby given 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 addition, it is critical that water, sanitation and hygiene services are available in health care facilities. This is key for infection prevention and control, patient safety and child and maternal health, in particular during the time around child delivery.
In Eastern Europe and Central Asia (98 per cent), East Asia and the Pacific (92 per cent) and Latin America and the Caribbean (91 per cent), over 9 in 10 births occurred in health facilities. In contrast, in West and Central Africa and Eastern and Southern Africa, where the burden of maternal and newborn deaths is highest, 55 and 66 per cent of births respectively were delivered in health facilities, with an urban-rural gap of over 20 percentage points (81 per cent vs 58 per cent) and a staggering 46 percentage point gap between women in the richest (91 per cent) wealth quintiles and those in the poorest (45 per cent) wealth quintiles.
Caesarean section
A caesarean section, or C-section, can be a life-saving intervention and is an essential part of comprehensive emergency obstetric care, preventing maternal and perinatal mortality and morbidity when medically justified. Globally, approximately 17 per cent of newborns are delivered by C-section. In Latin America and the Caribbean, C-sections accounted for 43 per cent of all deliveries, more than 10 times higher than in West and Central Africa (4 per cent). Latin America and the Caribbean’s high coverage of C-sections may suggest over-medicalization of childbirth; conversely, the low percentage of C-sections in sub-Saharan Africa (5 per cent) is alarming, suggesting a dire lack of access to this potentially lifesaving intervention.
Globally, the proportion of babies delivered by C-section in urban areas is twice that of those in rural areas (23 per cent and 11 per cent, respectively), although the disparities are relatively small in sub-Saharan Africa (5 per cent) where overall C-section deliveries are the lowest.
References
United Nations Inter-agency Group for Child Mortality Estimation (IGME), Levels and Trends in Child Mortality, UNICEF, New York, 2020.
WHO/UNICEF JMP, Water, Sanitation and Hygiene in Health Care Facilities: Global baseline report 2019, UNICEF, New York, 2019.
UNICEF, The State of the World’s Children 2019, UNICEF, New York, 2019.
UNICEF, Healthy Mothers, Healthy Newborns: Taking Stock of Maternal Health. UNICEF, New York, 2019.
UNICEF, Committing to Child Survival: A Promise Renewed – 2015, UNICEF, New York, 2015.
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: 2000 to 2017, WHO, Geneva, 2019.
