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5.2 Proportion of births attended by skilled health personnel

Modified on 2012/03/05 16:08 by MDG Wiki Handbook Categorized as Goal 5


Goal 5. Improve maternal health
Target 5.A: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio


The proportion of births attended by skilled health personnel is the proportion of total live births that are attended by a skilled birth attendant trained in providing life saving obstetric care.

The indicator is expressed as a percentage.

Alive birth is the complete expulsion or extraction, from its mother, of a product of conception, irrespective of the duration of the pregnancy, which, after such separation, breathes or shows any other evidence of life—such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles—whether or not the umbilical cord has been cut or the placenta is attached. Each product of such a birth is considered a live birth.

A skilled birth attendant is an accredited health professional—such as a midwife, doctor or nurse—who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period; and in the identification, management and referral of complications in women and newborns. Traditional birth attendants either trained or not, are excluded from the category of skilled health workers.

Traditional birth attendants are traditional, independent (of the health system), non-formally trained and community-based providers of care during pregnancy, childbirth and the postnatal period.

Method of computation
The indicator is calculated as the number of births attended by skilled health personnel (doctors, nurses or midwives) divided by the total number of births in the same period and multiplied by 100.



Measuring maternal mortality accurately is notoriously difficult, except where there is comprehensive registration of deaths and causes of death. Several process indicators have been proposed for tracking progress toward improving maternal health, such as attendance of professional care during pregnancy and childbirth, which is particularly important for the management of complications. Assistance by properly trained health personnel is key to lowering maternal deaths. The proportion of women who give birth with the assistance of a medically trained health care provider is one of the most widely used of these process indicators.

Indicator values are close to 100 where skilled birth assistance is provided to all women, as is the case in most of the developed regions. Values of less than 20 per cent are found in settings where health care is very poor and maternal mortality is a major public health problem. The proportion of births attended by skilled health personnel should be closely followed together with a set of related indicators disaggregated by socio-economic characteristics to identify target populations and plan policy measures accordingly.


Data are collected through national-level household surveys, including Multiple Indicator Cluster Surveys (MICS) and Demographic Health Surveys (DHS). These surveys are generally conducted every 3–5 years by national statistical offices or ministries of health.

In order to facilitate interpretation of trends and differentials based on survey data, it is useful to report confidence intervals together with estimates.

In the absence of survey data, some countries may have health facility data. However, it should be noted that these data may overestimate the proportion of deliveries attended by a skilled professional because the denominator presumably excludes women who give birth outside of health facilities.


The disaggregation of this indicator by urban and rural areas, age of mother, and by levels of social and economic status would help assess the basis of different degrees of access to reproductive health care and inform the necessary policies and interventions.


This indicator is a measure of a health system’s ability to provide adequate care during birth, a period of elevated mortality risk for both mothers and newborns. However, this indicator may not adequately capture women’s access to good quality care, particularly when complications arise. In order to effectively reduce maternal deaths skilled health personnel should have the necessary equipment and adequate referral options.

In addition, standardization of the definition of skilled health personnel is sometimes difficult because of differences in training of health personnel in different countries. Although efforts have been made to standardize the definitions of doctors, nurses, midwives and auxiliary midwives used in most household surveys, it is probable that many skilled attendants’ abilities to provide appropriate care in an emergency depends on the environment in which they work.

Recall error is another potential source of bias in the data. In household surveys, the respondent is asked to recall each live birth for a period of up to five years before the interview. The respondent may or may not know or remember the qualifications of the attendants at delivery during the reference period.

As mentioned above, facility data, if used, would exclude women who give birth at home and thus would overestimate the true proportion of deliveries with a skilled attendant.


The low social status of women in some countries limits their access to economic resources and basic education and thus their ability to make decisions related to health and nutrition. Some women are denied access to care when it is needed either because of cultural practices of seclusion or because decision-making is the responsibility of other family members. Lack of access to or use of essential obstetric services is a crucial factor contributing to high maternal mortality.


Data for global monitoring are reported by the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO). These agencies obtain the data from national sources; both survey and registry data.

Before data can be included in the global databases, UNICEF and WHO undertake a process of data verification that includes correspondence with field offices to clarify any questions.

Discrepancies between international and national estimates are possible if national figures are compiled at the health facility level. These would differ from international figures which are based on survey data collected at the household level.

In terms of the limitations of survey data, some survey reports may present a total percentage of births attended that includes a type of provider that does not conform to the definition provided above (e.g., providers that are not considered skilled, such as a community health worker). In those cases, the percentage of births attended by a physician, nurse, or midwife are totalled and entered into the global database as the estimate for this indicator.

Regional and global estimates are then calculated based on averages of country data weighted by the total number of births in each country. The regional and sub-regional aggregates are presented only if available data cover at least 50 per cent of total births in the regional grouping.




United Nations Children’s Fund. Childinfo – Monitoring the Situation of Children and Women. New York. Internet site http://www.childinfo.org/.

United Nations Population Fund (annual). State of World Population. New York. Available from http://www.unfpa.org/swp/swpmain.htm.

World Health Organization. WHO Statistical Information System (WHOSIS) . Internet site http://www.who.int/whosis.

World Health Organization (2006). Reproductive Health Indicators - Guidelines for their Generation, Interpretation and Analysis for Global Monitoring. Geneva. Available from http://whqlibdoc.who.int/publications/2006/924156315X_eng.pdf.

World Health Organization (2008). Proportion of births attended by a skilled attendant: 2008 updates. Department of Reproductive Health and Research Factsheet. Geneva. Available from http://www.searo.who.int/LinkFiles/Publications_skilled_attendant_at_birth_2008.pdf .

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