Ensuring that all births are assisted by skilled birth attendants is a critical strategy for reducing maternal and newborn morbidity and mortality. 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.
Globally in 2019, 81 per cent of births were assisted by skilled health professionals, which generally includes a medical doctor, nurse or midwife. However, population growth poses an impending challenge for the coverage of essential maternal and newborn health care services. While most regions are projected to experience a decline in the number of annual births between 2019 and 2030, Africa will see a 14 per cent increase. Based on this projection in the number of births and assuming current coverage levels of skilled birth attendants will stay the same, an estimated 19 million births in Africa will not be attended by a skilled provider in 2030. This future prospect means that substantially more resources will be required to increase intervention coverage levels and to stay apace with population changes happening in the continent.
While coverage of skilled birth attendant is 60 per cent in sub-Saharan Africa and 77 per cent in Southern Asia, other regions like Central Asia, Eastern Asia, Western Asia, Northern America and Europe, have achieved universal coverage.
Despite these challenges, Southern Asia and sub-Saharan Africa were regions with the greatest progress in increasing coverage of births assisted by health professionals by 2019.
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.
Despite substantial progress over the last two decades, inadequate or non-existent care during pregnancy and delivery was largely responsible for the annual death of an estimated 295,000 mothers in 2017 and 2.4 million newborns in the first month of life in 2019. 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 in 2019 birth rates among adolescents 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 the necessary care during antenatal period and delivery to ensure their wellbeing and that of their babies as well as education on family planning.
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Disparities in coverage
Despite the progress made, large equity gaps remain, with the rural or the poorest population often left behind. Globally in 2019, approximately 72 per cent of births among rural mothers are attended by skilled health personnel, compared to 90 per cent of births among urban mothers. The urban-rural gap remains at about 20 per cent 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 were 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 (38 per cent versus 91 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. Delivery in a health facility can increase 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 the time around child delivery. In Western Europe (99 per cent), Latin America and the Caribbean (94 per cent) and East Asia and the Pacific (92 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, 54 and 60 per cent of births respectively were delivered in a health facility, with an urban-rural gap of 20 percentage points (75 per cent vs 55 per cent) and a staggering 50 percentage point gap between women in the richest (88 per cent) and poorest (38 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 18 per cent of newborns are delivered by C-section. In Latin America and the Caribbean, C-sections accounted for 44 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 excessively high average suggests 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 (24 per cent and 12 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.
