Skilled attendance at childbirth can make the difference between life and death.

Skilled attendance at birth remains drastically low in sub-Saharan Africa and southern Asia. Ethiopia has the lowest skilled birth attendance in the world, followed by Bangladesh and Afghanistan. Skilled attendance is also notably low in Haiti but generally high in the rest of the Caribbean.

Overall progress in increasing skilled attendance has been inhibited by failure to make advancements in rural areas, namely in sub-Saharan Africa and South and Southeast Asia. In the early 1990s, it was estimated that one in four women in developing countries gave birth alone or with only a relative or neighbor to assist; fifteen years later, this figure is still the same.⁵ In cases where women do receive skilled care at birth, their health may still be jeopardized by having not received the quality of care that they need or the full range of care from pregnancy to the end of the postpartum period.

As with most reproductive health indicators, country-level data masks disparities in access to care.⁶ In most countries and regions, delivery with the help of a skilled birth attendant is closely linked to wealth, with a few noteworthy countries, such as Sri Lanka, in which it is equitable across income groups.⁷ Researchers have recently classified areas with low rates of skilled care into two categories: areas of "marginal exclusion" where only the poorest lack access, versus areas of "massive deprivation" where only the very rich receive care.⁸ Where only the poorest lack access, use of services is inhibited by poor quality of care, cost, cultural barriers or lack of women's autonomy to seek professional care.

Where only the very rich receive care, barriers to service are due to delivery and the sheer absence of staff, facilities and reproductive health supplies. Progress in these locations will depend upon advancements in the training, adequate distribution and retention of health workers. The WHO estimates that to extend coverage of maternal and newborn care in the next 10 years, 75 countries need at least 334,000 additional midwives (or equivalent attendants), as well as additional training for 140,000 existing professionals providing first-level care and of 27,000 doctors who are not currently qualified to provide back-up care.⁹ Countries that have successfully reduced maternal mortality (including Zimbabwe, Egypt, Honduras and Jamaica), have included a strong focus on training, recruiting and supporting skilled attendants.¹⁰ Given the current resource shortages, strategic distribution of personnel is key to addressing skilled birth coverage in the short term.

Skilled attendance provides a snapshot of delivery care by indicating whether childbirth is attended by a trained health professional, but it does not reveal whether or not women have access to emergency obstetric care.¹¹ For example, cesarean rates among women in urban areas are roughly three times higher than among women in rural areas. More monitoring and research is needed to determine the unmet obstetric need, particularly in countries with high rates of maternal mortality and large disparities between rural and urban areas.¹² Moreover, access to emergency obstetric care is of particular importance to women who have undergone female genital mutilation/cutting (FGM).

The effects of female genital mutilation/cutting (FGM) are extreme during childbirth and often deadly for both the mother and child.¹³ FGM is the surgical removal of parts or all of the female genital organs and is traditionally practiced in 28 countries, mostly in Africa. It is estimated that more than 100 million girls and women are currently affected, with 3 million additional cases every year. Deliveries to women who have undergone FGM are significantly more likely to be complicated by caesarean section, postpartum hemorrhage and prolonged hospitalization. The severity of complications has been shown to increase according to the extent of the FGM. Furthermore, the infant death rate is 15 to 55 percent higher among those born to mothers who have FGM, depending upon its extent.¹⁴