UNFPAState of World Population 2004
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State of World Population
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Maternal Health

New Approaches
Causes and Consequences
Maternal Morbidity
Obstetric Fistula
Reducing Maternal Mortality and Morbidity
Difficulties in Measurement
Holistic Responses
Antenatal Care
Skilled Attendance
Emergency Obstetric Care
Post-abortion Care
Quality of Maternal Health
Men and Maternal Health
UNFPA and Safe Motherhood

Skilled Attendance

The majority of maternal deaths are due to unexpected complications. But attendants with the skills to respond are present at only about half of deliveries worldwide. Skilled attendance for all births is the only way to ensure emergency obstetric care for all those with complications. Skilled attendance during labour, delivery and the early post-partum period could reduce an estimated 16 to 33 per cent of deaths due to obstructed labour, haemorrhage, sepsis and eclampsia.(35)

A skilled attendant is a professionally trained health worker—usually a doctor, midwife(36) or nurse—with the skills to manage a normal labour and delivery, recognize complications early on and perform any essential interventions, start treatment and supervise the referral of mother and baby to the next level of care if necessary. Trained and untrained traditional birth attendants (TBAs) are not considered skilled attendants.(37)

A skilled attendant can influence maternal mortality by utilizing safe and hygienic techniques during delivery. However, these measures will not prevent most life-threatening infections, which are due to delayed treatment of complications such as prolonged labour, ruptured uterus or retained products.(38)

BACK-UP SYSTEMS AND TRAINING. Skilled attendants are limited to a narrow range of interventions when deliveries take place in the home. To be effective, skilled attendance requires adequate supplies, equipment and infrastructure as well as efficient and effective systems of communication and referral to emergency obstetric care facilities. Political support and appropriate policies—including pre- and inservice training, supervision and health system financing—are also critical.(39) There is a wide variation in how much skilled attendants are supported and supervised by health care systems.

A number of countries have taken steps since the ICPD to improve training of skilled attendants, and also to increase their numbers (and capacities) in rural and other underserved areas. In Iran, for example, rural midwives receive theoretical and practical training for six months and are required to have managed at least 20 deliveries before qualifying as midwives. In Panama, provision of training for midwives working in rural areas and with indigenous populations is a priority.(40)


To get from the village of Goudiry to the regional hospital in Tambacoumba, Senegal, women in labour had to travel 70 kilometres along a rough dirt road, often in donkey carts. Eight out of ten with complicated pregnancies didn’t get help in time, and many died.

That was before 2001, when with UNFPA support Goudiry’s tiny health clinic was expanded into an obstetric care centre with the equipment and personnel to handle blood transfusions and Caesarean sections. Already, the model clinic has saved more than 100 women.

An anaesthetist, 17 nurses and several trained community workers offer outreach services, including information about reproductive health issues. They also deliver contraceptive supplies to the surrounding areas.

Senegal’s maternal mortality ratio is nearly 700 deaths per 100,000 live births. It averages only one gynaecologist per 30,000 women of reproductive age, and most work in the capital. Rural women give birth to five or six children on average. Severe bleeding and eclampsia are the leading causes of maternal death. Early marriage, female genital cutting and sexually transmitted infections are additional factors that complicate childbirth for many women. See Sources

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