MEASURE DHS+ assists countries worldwide in the collection and use of data to monitor and evaluate 

population, health, and nutrition programs. Funded by the U.S. Agency for International Development 

(USAID), MEASURE DHS+ is implemented by ORC Macro in Calverton, Maryland. 

 

The main objectives of the MEASURE DHS+ project are: 

1) to provide decisionmakers in survey countries with information useful for informed policy choices, 

2) to expand the international population and health database, 

3) to advance survey methodology, and 

4) to develop in participating countries the skills and resources necessary to conduct high-quality 

demographic and health surveys. 

 

Information about the MEASURE DHS+ project or the status of MEASURE DHS+ surveys is available on 

the Internet at http://www.measuredhs.com or by contacting: 

ORC Macro 

11785 Beltsville Drive, 

Suite 300 

Calverton, MD 20705 USA 

Telephone: 301-572-0200 

Fax: 301-572-0999 

E-mail: reports@orcmacro.com
DHS Analytical Studies No. 7 

Trends in Delivery Care in Six Countries 

Jacqueline Bell 

Siân L. Curtis 

Silvia Alayón 

September 2003 

ORC Macro 

Calverton, Maryland USA 

International Research Partnership for 

Skilled Attendance for Everyone (S.A.F.E.) 
Editor: Sidney Moore 

Recommended citation: 

Bell, Jacqueline, Siân L. Curtis, and Silvia Alayón. 2003. Trends in delivery care in six countries. DHS 

Analytical Studies No. 7. Calverton, Maryland: ORC Macro and International Research Partnership for 

Skilled Attendance for Everyone (SAFE).
iii 

Contents 

Page 

Preface ..................................................................................................................iv

Acknowledgments.................................................................................................. v

Executive Summary ..............................................................................................vi

1 Introduction ..................................................................................................... 1

2 Maternal Health Issues .................................................................................... 2

2.1 Measuring Maternal Health Outcomes................................................. 2

2.2 The Evolution of Process Indicators..................................................... 2

2.3 Delivery with a Health Professional, Skilled Attendants, and 

Skilled Attendance................................................................................ 3

2.4 The Focus on Skilled Attendance......................................................... 4

2.5 Issues of Equity in Delivery Care......................................................... 5

3 Sources of Data ............................................................................................... 7

3.1 Surveys Included in This Study............................................................ 7

3.2 Questions of Relevance to Delivery Care............................................. 7

3.3 Additional Information......................................................................... 8

3.4 Strengths and Limitations of the Data .................................................. 8

4 Methods......................................................................................................... 10

4.1 Delivery Care Indicators..................................................................... 10

4.2 Background Characteristics Associated with Delivery Care.............. 11

4.3 Sample Issues ..................................................................................... 12

5 Analysis and Results ..................................................................................... 16

5.1 General Patterns of Delivery Care...................................................... 16

5.2 Differentials in Delivery with a Health Professional.......................... 27

5.3 Use of Delivery Care and Antenatal Care .......................................... 33

5.4 Consistency of Delivery Care Use Between Pregnancies .................. 40

5.5 Professional Attendance at Delivery and Pregnancy Outcomes......... 43

6 Discussion ..................................................................................................... 46

6.1 Methodological Issues ........................................................................ 46

6.2 Substantive Findings .......................................................................... 46

References............................................................................................................ 51
iv 

Preface 

One of the most significant contributions of the MEASURE DHS+ program is the creation of an 

internationally comparable body of data on the demographic and health characteristics of populations in 

developing countries. The DHS Analytical Studies series and the DHS Comparative Reports series examine these data, focusing on specific topics. The principal objectives of both series are: to provide information for policy formulation at the international level, and to examine individual country results in an international context. Whereas Comparative Reports are primarily descriptive, Analytical Studies take a more 

analytical approach. 

The Analytical Studies series comprises in-depth, focused studies on a variety of substantive topics. The studies are based on a variable number of data sets, depending on the topic under study. A range 

of methodologies is used, including multivariate statistical techniques. The topics covered are selected by 

MEASURE DHS+ staff in conjunction with the MEASURE DHS+ Scientific Advisory Committee and 

USAID. 

It is anticipated that the Analytical Studies will enhance the understanding of significant issues in 

the fields of international population and health for analysts and policymakers. 

Martin Vaessen 

Project Director 
v 

Acknowledgments 

This study is a collaborative venture between the MEASURE DHS+ project at ORC Macro, USA 

and the SAFE (Skilled Attendance For Everyone) International Research Partnership coordinated by the 

Dugald Baird Centre for research on Women’s Health in Aberdeen, Scotland. Funding was provided by 

the U.S. Agency for International Development and the European Union. We wish to thank Julia Hussein, Cynthia Stanton, Wendy Graham, Nancy Fronczak, and Anja Giphardt, who read and commented on 

drafts of the report, and Christine Smith, who was involved in the early work on the report. 
vi 

Executive Summary 

Increasing the proportion of deliveries with skilled attendants present is being advocated as the 

most important step in preventing maternal deaths worldwide. The indicator most commonly used as a 

proxy for skilled attendance at delivery is the percentage of deliveries attended by a health professional, 

which has been selected as one of the Millennium Development Indicators for measuring reductions in 

maternal mortality. 

The objective of this study is to provide an in-depth understanding of trends in delivery with a 

health professional over the last decade, across a range of developing countries: Bangladesh, Bolivia, 

Ghana, Indonesia, Malawi, and the Philippines. In particular, the study analyzes trends in the types of professionals providing services, the place of delivery, and some composite indicators of skilled attendance. 

Throughout the report, emphasis has been placed on identifying subnational variation in trends by socioeconomic and obstetric characteristics of the women. 

The proportion of deliveries with a health professional has increased over the last decade in all six 

countries. The national trends were statistically significant in three countries—Bangladesh, Bolivia, and 

Indonesia—with the largest absolute increases in Bolivia and Indonesia. National trends, however, mask 

variations between different groups of women. Urban-rural residence, economic status (wealth index), 

parity, maternal education, and age were all associated with delivery with a health professional. The results suggest that inequities among women of different backgrounds may be increasing, emphasizing the 

importance of subnational analyses to ensure that the women least likely to seek care are not marginalized. 
1 

1 Introduction 

The purpose of this study is to provide a better understanding of trends in and the determinants of 

delivery care for women across a selected range of developing countries. It involves a detailed secondary 

analysis of data from Demographic Health Surveys (DHS). 

This is a collaborative venture between the MEASURE DHS+ project at ORC Macro, USA 

(ORC Macro, 2003) and the Skilled Attendance For Everyone (SAFE) International Research Partnership 

(SAFE, 2003), which is being coordinated by the Dugald Baird Centre for Women’s Health, Aberdeen, 

Scotland (University of Aberdeen). SAFE is a multicenter operations research study that aims to provide 

new knowledge to identify, implement and improve strategies designed to increase skilled attendance at 

delivery in developing countries. ORC Macro has been collecting survey data in developing countries 

since 1986 through the Demographic and Health Surveys (DHS) program. One of its most significant 

contributions is the creation of an internationally comparable body of data on the demographic and health 

characteristics of populations in developing countries. Among the maternal health indicators collected is 

information about individual deliveries—who attended them and where they took place—and it is this 

information that is the focus of this collaborative study. 

The study examines data from consecutive surveys in six countries to establish trends in delivery 

care and explore the use of process indicators. Established indicators “delivery with a health professional” 

(DHP) and “place of delivery” are examined; and alternative indicators—the partnership ratio between 

doctors and midwives, and composites of DHP and place of delivery—are introduced. The characteristics 

of women who use maternal health services are assessed as predictors of skilled attendance, with particular emphasis on the relationship between use of antenatal care and use of delivery care and on the consistency of use of delivery care across pregnancies. Finally, there is an examination of trends in early neonatal death and the relationship of early neonatal death to delivery care. We do not have data linking 

delivery care with individual maternal deaths. 

This analysis aims to provide new knowledge about ways of investigating levels of skilled attendance at delivery that can be used by health service providers to target those women who do not receive 

professional delivery care. Policymakers may also find the results helpful in developing policies targeting 

underserved women. 

In an overview of maternal health issues, Section 2 discusses the measurement of maternal health 

outcomes, the problems encountered, and the resulting use and limitations of process indicators. It explains the focus on skilled attendance and introduces some issues of equity in delivery care. Section 3 describes the DHS surveys and discusses their strengths and limitations. Section 4 introduces the methods 

used in the study and the indicators used in the report. It also discusses some key methodological issues 

such as the decision to use birth-based analysis in preference to woman-based analysis. Section 5 presents 

the main results of the analyses, and Section 6 is a discussion of the findings and their implications. 
2 

2 Maternal Health Issues 

2.1 Measuring Maternal Health Outcomes 

In the context of safe motherhood programs the outcome indicators refer to the health outcomes 

of maternal mortality and morbidity; they are the target of efforts at the program level (Campbell, 1999). 

Maternal health outcomes are measured in order to direct resources and monitor trends, to evaluate the 

effectiveness of interventions designed to improve outcomes, and to learn more about the causes of morbidity and mortality (Fortney and Smith, 1999). The most commonly quoted maternal health outcome 

indicator is the maternal mortality ratio (MMR).1

 There are three main sources of information on maternal 

deaths in developing countries: vital registration, health service statistics, and community-based surveys 

(AbouZahr, 1998). Countries with high levels of maternal mortality also tend to have poor statistical infrastructure. In 1989, the UN estimated that more than two-thirds of the world’s population live in areas 

that lack complete death registration (United Nations, 1991). Studies have shown that even countries with 

comprehensive vital registration regularly misclassify maternal deaths, and that in developing countries as 

many as 60 percent can be missed (Campbell and Graham, 1991). Health service figures may record maternal death with varying degrees of completeness and accuracy, but their main flaw is that they are usually not representative of the general population of pregnant women. They will tend to over-represent 

both complicated emergency cases and low-risk women from affluent backgrounds. To obtain accurate 

information on maternal deaths it is therefore important to use sources of data from reliable populationbased surveys. 

One method of obtaining information on maternal death uses household survey techniques and 

the sisterhood method (Graham, Brass, and Snow, 1989). DHS surveys use a modification of the sisterhood method by calculating the MMR from reports on the survival status and pregnancy status at death of 

respondents’ sisters (Stanton et al., 2001). In order to obtain precise current estimates this approach requires large sample sizes because maternal death is relatively rare even where the MMR is high. The size 

of the DHS surveys (typically including 4,000-8,000 women) is insufficient for this purpose and estimates 

obtained in this way tend to be imprecise. Also, the sisterhood method creates a retrospective estimate for 

the previous 10-12 years and not a current one. These limitations mean that most estimates of MMR cannot be used to monitor short-term trends and therefore are not helpful in assessing the impact of programs 

aimed at improving maternal health care. 

Problems of measurement and the current lack of a reliable, precise, and practical way of estimating maternal health outcomes have meant that safe motherhood program managers have found it difficult 

to demonstrate progress. This in turn has made funding difficult to obtain. The deadlock situation of limited information on maternal health indicators and low priority given to maternal health has been called 

the “measurement trap” (Graham and Campbell, 1992). 

The measurement of maternal morbidity was seen as a useful alternative to mortality because of 

its higher incidence, but studies have shown that the reliability and validity of women’s self-reports are 

often poor (Fortney and Smith, 1999; Filippi, Graham, and Campbell, 1990). It is also difficult to compare different morbidities and to standardize outcomes. 

2.2 The Evolution of Process Indicators 

The problems associated with measuring maternal health outcomes have led to an increasing reliance on process indicators; these measure the levels and changes in processes that are believed to influence the outcome of interest (Wardlaw and Maine, 1999). Process indicators are being recommended for 

 

1

 Maternal deaths per 100,000 live births 
3 

the measurement of levels and changes in the activities of a program to monitor progress toward the reduction of maternal mortality. Ideally, they should be closely correlated with mortality but have the advantage of being easier and cheaper to collect. They can often be derived from routinely-collected data or 

as part of program implementation and are more sensitive to change, permitting frequent measurement 

and short-term feedback on interventions (Wardlaw and Maine, 1999). Another benefit is that process 

indicators provide information on the deficits in a service, allowing policymakers to target interventions 

to reduce maternal mortality more effectively. These indicators can measure the provision of services—

e.g., the number of essential obstetric care facilities per 500,000 population or the percentage of hospitals 

with caesarean section facilities (Maine et al., 1997)—or service utilization such as the proportion of 

births attended by a health professional (Ronsmans, 2001). Such coverage statistics require populationbased data sources, but even with these it is difficult to establish a correlation between the indicator and 

maternal health outcomes. 

2.3 Delivery with a Health Professional, Skilled Attendants, and Skilled Attendance 

Providing skilled attendants for delivery care, along with the equipment, drugs and supplies necessary for effective management of obstetric complications, is now being advocated as the single most 

important factor in preventing maternal deaths (WHO, 1999). For this reason, the benchmark indicator 

”percentage of births attended by a skilled attendant” is currently used to monitor progress toward international goals for maternal mortality reduction (United Nations, 2002). At the General Assembly of the 

World Health Organization in 2001, it was stated that where maternal mortality rates are high, countries 

should strive to ensure that 60 percent of deliveries are assisted by a skilled attendant by the year 2015 

(WHO, 2001). 

The importance placed on this benchmark indicator has been debated by many international 

groups (Graham, Bell, and Bullough, 2001; Safe Motherhood Inter-Agency Group, 2000). The advantage 

of this indicator is that it is widely available for many developing countries from community health surveys such as the DHS. However, several aspects of its measurement have been challenged. The definition 

of a “skilled attendant” is not always clear. Until recently the term “trained attendant” was used and 

grouped both professional and nonprofessional health workers together. In 1999, the WHO/UNFPA/

UNICEF/World Bank statement recognized the skilled attendant as a “health professional” with midwifery or obstetric skills who can manage complications of delivery as well as normal deliveries. Health 

professionals include nurses, midwives, physicians, and other medical personnel (WHO, 1999). This can 

lead to differences in interpretation in many countries, particularly where intensive but shortened training 

has been provided to relieve the shortages of more traditionally trained doctors and nurse-midwives. Furthermore, the presence of a health professional does not necessarily imply competence or skills in conducting deliveries (Graham, Bell, and Bullough, 2001). 

It is generally agreed that to provide skilled attendance the attendant alone is not enough and that 

an enabling environment is also necessary. The Safe Motherhood Inter-Agency Group has defined skilled 

attendance as a process through which a woman is provided with adequate care during labor, delivery, 

and the postpartum period (Safe Motherhood Inter-Agency Group, 2000). The clarification of this concept 

is represented in Figure 2.1, which demonstrates that skilled attendance can only be provided when health 

professionals operate within a functioning health system or enabling environment, where drugs, equipment, supplies, and transport are all available. Skilled attendance therefore requires (i) a health professional with midwifery or obstetric skills; (ii) the availability of referral systems to facilities that provide 

basic obstetric care and comprehensive obstetric care; and (iii) the provision of the necessary supplies of 

drugs, equipment, and transport to deal with obstetric emergencies (Graham, Bell, and Bullough, 2001). 
4 

Figure 2.1 The concept of skilled attendance requires an enabling environment as well as health 

professionals who provide adequate care during labor, delivery, and the postpartum period 

Research being conducted by the SAFE International Research Partnership is addressing some of 

the complexities of measuring skilled attendance described above. Nevertheless, data currently available 

on skilled attendance is limited to the proportion of deliveries with different types of delivery attendants, 

whether health professionals, other health workers, traditional birth attendants (TBAs), or relatives. 

Whenever possible, differentiation will be made in appropriate sections on whether analysis refers to delivery with a health professional or otherwise. 

2.4 The Focus on Skilled Attendance 

One of the reasons for this focus on skilled attendance at delivery is that epidemiological data relating to maternal deaths in developing countries shows that about two-thirds of deaths occur at around 

the time of delivery (AbouZahr, 1998). During pregnancy, any woman can develop serious life threatening complications that require medical care. Because there is no reliable way to predict which women will 

develop these complications, it is essential that all women be treated with watchful expectancy during 

delivery, and that emergency obstetric care remains within reach of all pregnant women (Maine and 

Rosenfield, 1999). These situations require access to skilled care during delivery, with the implication 

that there will be benefits for care throughout the pregnancy for the mother as well as the neonate. Delivery with a health professional is at the center of this focus because there is no robust evidence to show 

that the training programs directed at TBAs have had any effect in lowering levels of maternal mortality 

(Ronsmans et al., 1997). 

An argument used for advocating skilled attendance is the existence of correlational evidence 

linking the proportion of deliveries with health professionals with maternal mortality (Figure 2.2). Historical data also points to the essential role played by the improvement of delivery care in reducing the 

incidence of maternal deaths (De Brouwere, Tonglet, and Van Lerberghe, 1998; Koblinsky, Campbell, 

Skills to promote 

utilization of delivery 

care, and to conduct 

normal deliveries 

Skills to provide basic 

emergency obstetric care 

Skills to provide 

comprehensive 

emergency obstetric 

care 

Referral

Enabling environment

Health professionals
5 

and Heichelheim, 1999; Loudon, 1992). It is important to point out that no sound epidemiological evidence exists for a causal connection between the two (Graham, Bell, and Bullough, 2001). 

There is currently no evidence to indicate that improvement of skilled attendance at delivery, nor 

of any other safe motherhood intervention strategy, will necessarily lead to a reduction in maternal mortality (Graham, 2002). However, if it is taken that improvement in the quality of care is in itself a step 

forward, then the emphasis being placed on ensuring skilled attendance is worthwhile. If the potential of 

increasing skilled attendance to reduce maternal and perinatal mortality is realized, its effects will reach 

far beyond those related only to maternal health—6.9 million perinatal deaths every year are related to 

maternal complications (Koblinsky et al., 2000)—and have far-reaching consequences for family life, 

stability of the family unit, and economic status. 

2.5 Issues of Equity in Delivery Care 

In the richest and most developed countries, almost all women deliver with a health professional, 

while in the sub-Saharan countries the proportion ranges from 15 to 70 percent (Stewart, Stanton, and 

Ahmed, 1997) and can fall as low as 12 percent (NIPORT, Mitra and Associates, and ORC Macro, 2001). 

Apart from the inequities between richer and poorer countries, the national figures quoted can disguise 

internal inequities in the provision and use of maternal health services between different groups of 

women. 

Access to skilled attendance at delivery is still limited for many women especially in rural areas 

(Le Bacq and Rietsema, 1997). In many African countries where there may be difficulties with transportation, women from rural areas may have to walk long distances to reach the nearest health services 

(Gwatkin et al., 2000; Rose et al., 2001; Starrs, 1997; UNICEF, 1999). Women who live in urban areas 

are often three times as likely to have delivery care as their rural counterparts (Stewart, Stanton, and Ahmed, 1997). 
6 

As well as urban-rural differences, economic differentials in access to delivery care have also 

been demonstrated (Gwatkin et al., 2000). Figure 2.3 shows that differences in the percentage of attended 

deliveries vary by as much as 50 percentage points between women in the richest and poorest households. 

The inequity is far more pronounced for delivery care than for other services such as care for acute respiratory infection (ARI) in children. 

Women’s use of antenatal care (ANC) may give some indication of service coverage (Bulatao 

and Ross, 2000). However the generally higher uptake of ANC seen in most countries (compared with 

delivery care) could be due to the greater availability of antenatal services through lower level health facilities and mobile services, which may be due to the lower cost of providing ANC compared with delivery care. In addition, unlike ANC, the precise timing of a delivery is unpredictable, making it more difficult for women without access to transportation to reach delivery care. It is also the case that user charges 

are levied less frequently for ANC than for delivery care. It is clear that socioeconomic disadvantage can 

have a detrimental effect on maternal health and that indicators such as level of household wealth and 

level of education are associated with women’s utilization of all maternal health care services (Kunst and 

Houweling, 2001). For many women the cost of using formal health services is prohibitive (Graham and 

Murray, 1997). Other factors influencing women’s use of skilled attendance are cultural beliefs about 

where a woman should deliver. There may be restrictions on women’s movement outside the home and 

lack of decision-making rights regarding health care. 

The causal pathways between maternal mortality and process indicators remain uncertain. Until 

the validity of this association can be determined, the use of process indicators to improve the understanding of trends and determinants is justified, theoretically at least. This report uses existing DHS data related to maternal health care to highlight the issues of who attends deliveries and where they take place. 
7 

3 Sources of Data 

Demographic and Health Survey (DHS) data have been collected from over 70 countries since 

1986. Surveys are typically repeated every three to five years, allowing analysis of trends in key indicators for many countries. Data from these surveys are now available on the web. 

3.1 Surveys Included in This Study 

In this study data were obtained from six countries where at least two DHS surveys have been 

conducted. The number of countries was limited to six because two recent DHS reports (Rose et al., 2001; 

Stewart, Stanton, and Ahmed, 1997) already provide comparisons of a wide range of countries, and this 

study aims to look at the same subject matter in greater depth. The original intention was to study countries that were participating in the SAFE study (Bangladesh, Ghana, Jamaica, Malawi, and Mexico). 

These countries represent a broad spectrum from very low to relatively high proportions of delivery with 

a health professional (DHP) and a good geographical spread. However, no DHS surveys have been conducted in Jamaica, and there is only one survey available for Mexico. Alternatives were chosen on the 

basis of levels of DHP and global representation. The countries finally selected were Bangladesh, Bolivia, 

Ghana, Indonesia, Malawi, and the Philippines. There have been three surveys in Bangladesh (1994, 

1997, 2000), three in Bolivia (1989, 1994, 1997), three in Ghana (1988, 1993, 1998), four in Indonesia 

(1987, 1991, 1994, 1997), two in Malawi (1992, 2000), and two in the Philippines (1993, 1998). 

3.2 Questions of Relevance to Delivery Care 

DHS surveys typically interview all women age 15-49 in selected households.2

 Women are asked 

a series of questions on pregnancy and delivery care for each live birth they report occurred in the past 

five (or three) years. The specific questions on delivery care (ORC Macro, 2001a; ORC Macro, 2001b) 

are:3

 

• Who assisted with the delivery of (NAME OF CHILD)? Anyone else? 

• Where did you give birth to (NAME OF CHILD)? 

• Was (NAME OF CHILD) delivered by caesarean section? 

In addition, respondents were asked the following questions on antenatal care: 

• When you were pregnant with (NAME OF CHILD), did you see anyone for antenatal care for 

this pregnancy? IF YES: Whom did you see? Anyone else? 

• How many months pregnant were you when you first received antenatal care? 

• How many times did you receive antenatal care during this pregnancy? 

The DHS questions allow for multiple responses to be recorded for the person assisting with delivery and the person providing antenatal care. 

The questionnaire includes a complete live birth history from which neonatal deaths can be identified. Information is also collected on background characteristics of the woman such as socioeconomic 

characteristics, level of education, and place of residence. 

 

2

 In Indonesia and Bangladesh only ever-married women were interviewed. 

3

 Exact question wording can vary slightly by survey. See individual survey reports for the exact wording used in a 

particular survey. 
8 

3.3 Additional Information 

Economic status levels have recently been described by using DHS data to classify women into 

quintile groups according to household wealth. Wealth is measured by means of an asset score that is 

based on principal component analysis on more than 40 asset variables—these include durable consumer 

goods, housing facilities, and housing materials (Gwatkin et al., 2000). These asset scores were added to 

several of the recent surveys, thus enabling exploration of the relationship between poverty and women’s 

use of delivery care. 

3.4 Strengths and Limitations of the Data 

DHS data have a number of strengths and limitations that it is important to be aware of when interpreting the results of this analysis. 

Strengths: 

1. The data are population-based and so are representative of the experience of women in the 

general population. 

2. DHS surveys employ standardized, well-tested procedures to maximize data quality, 

including rigorous interviewer training, field supervision, and data processing procedures. 

3. DHS survey questions have been used in over 100 surveys and so are well tested in the field. 

4. The data have been collected in a consistent manner allowing comparisons across countries 

and across time. 

5. DHS surveys contain substantial background information on the women interviewed. 

6. The questions are simple, making them relatively easy to collect, and the indicators based on 

these questions are widely used internationally. 

Limitations: 

1. Information about attendant at delivery and place of delivery is only recorded for live births. 

This means that it is not possible to calculate perinatal mortality rates by type of attendant 

because information on attendants involved in stillbirth deliveries is not available. 

2. It is not known how accurately women are able to identify their attendants. Different 

categories of attendants may appear similar, and it is not known to what extent women can 

distinguish, for example, between trained TBAs and midwives and between midwives and 

doctors. Also, there is no way of knowing the level of skill of individual practitioners. We 

have only the professional labels reported by the women. 

3. The level of involvement of attendants reported by the women is not clear. It is assumed that 

the attendants recorded have had significant involvement in the delivery, but this is not 

certain. 

4. The health facility indicator includes a wide range of care, and there is insufficient 

information about the health facilities recorded to enable stratification by level of obstetric 

care available (basic or comprehensive). 
9 

5. It is not possible to control effectively for complications of pregnancy or delivery. Some DHS 

surveys do collect information on women’s self-reported complications, but such data in 

household surveys has been shown to be unreliable. 

Most of these limitations are unavoidable in surveys of this type and they do not detract from the 

utility of either the surveys or this report. DHS surveys give us the best estimates of many reproductive 

indicators and remain the main source of international information in the area of safe motherhood. Although a wide range of data can be collected, the scope of the surveys necessitates a sacrifice in terms of 

the depth of information available. 
10 

4 Methods 

4.1 Delivery Care Indicators 

It is not possible to determine from the available data whether a delivery had skilled attendance 

according to the definition in Figure 2.1 because there is neither information about the environment nor 

the actual skills of the health professionals. For this reason, the following indicators were chosen for 

analysis. 

Delivery with a Health Professional (DHP) 

The percentage of (live) deliveries that are attended by a health professional 

This is a standard international indicator of delivery care. The term “health professional” rather 

than “skilled attendant” is used here because the surveys record the professional label used by the women 

to identify their attendants and provide no indication of the individual’s level of practical skill. As noted 

above, DHS surveys record all the attendants named by the woman, but for the purposes of this analysis 

the indicator is defined by the most qualified attendant mentioned. For example if a woman reported a 

midwife and a doctor in attendance, the delivery will be classified as attended by a doctor for the analysis. 

Not all health professionals are qualified to attend deliveries, as defined by the World Health Organization (WHO, 1999). For the purposes of this analysis we define health professionals as midwives, doctors, 

and nurses. The complete listing of categories that we have chosen to define as health professionals are 

shown in Table 4.1 for the selected countries. 

Table 4.1 Categorization of health professionals by country 

 Country Health professional Non-health professional 

 Bangladesh Doctor, nurse or midwife Family welfare visitor, TBA (trained and 

untrained), relative, other, none 

 Bolivia Doctor, nurse or midwife Auxiliary midwife, TBA, relative, other, none 

 Ghana Doctor, nurse or midwife TBA (trained and untrained), relative, other, 

none 

 Indonesia Doctor, nurse or midwife Auxiliary midwife, relative, other, none 

 Malawi Doctor, nurse or midwife, clinical 

officer/medical assistant1

TBA (trained and untrained), relative, other, 

none 

 Philippines Doctor, nurse or midwife TBA (trained and untrained), relative, other, 

none 

 TBA = Traditional birth attendant 

1

 In the 2000 survey clinical officers were coded in the same category as doctors. In the 1992 survey they 

were coded with medical assistants in a separate category (for most qualified attendant at delivery n=7). 

For comparability between surveys, the 1992 clinical officer/medical assistant category was coded as 

health professional. 

Delivery in a Health Facility4

The percentage of (live) deliveries that occur in a health facility 

All health facilities were included in this indicator—hospitals, clinics, health centers, and maternity homes. However, the data do not indicate anything about the enabling environment (described in 

Section 2.4) available in these facilities. 

 

4

 Information on place of delivery was not collected for Bolivia 1989, Ghana 1988, and Indonesia 1987, so only 

Bangladesh and Indonesia will have three points in any trend analysis of a composite indicator. 
11 

Composite Indicators 

We also examine three composite indicators. These represent an attempt to get closer to the concept of skilled attendance described in Section 2.4 by combining attendant and place of delivery, or combining types of attendants. 

(i) The percentage of (live) deliveries attended by a health professional in a health facility.

This may give a better approximation of the real level of skilled attendance, although it still 

contains no information about the environment of care and the availability of referral systems, which are an integral part of the concept. 

(ii) The percentage of (live) deliveries attended by a health professional outside of a health 

facility.

(iii) The partnership ratio (PR). This has been used as an indicator to emphasize the importance 

of different health professionals with complementary skills working together (Graham, Bell, 

and Bullough, 2001). It is expressed as two mutually exclusive figures: the proportion of deliveries where a doctor is the most qualified attendant and the proportion of deliveries where 

the most qualified attendant is a midwife—for example PR (10,55)—with the sum indicating 

the total proportion of deliveries with a health professional. If the goal of 100 percent of deliveries with professional attendants is accepted, along with the need for doctors to attend at 

least 15 percent of these (this being the usual estimate of the percentage of births with lifethreatening complications) then an optimum point can be plotted at PR (15,85).

4.2 Background Characteristics Associated with Delivery Care 

Table 4.2 summarizes the independent variables used in the bivariate and multivariate analyses of 

the determinants of delivery care. This is not an exhaustive list of factors that are expected to be associated with delivery care. For example, biomedical risk factors such as history of complications during index and previous pregnancies are expected to influence use of delivery care but are not available in the 

DHS surveys. Similarly, direct measures of access to delivery services are not available in these surveys. 

However, this list covers basic characteristics that are theoretically expected to be associated with delivery care. The variables are grouped into three categories: utilization of other maternal health services, obstetric characteristics, and socioeconomic factors. 

Table 4.2 Summary of independent variables 

Variable Definition

Utilization of other maternal 

health services 

 Number of ANC visits Number of ANC visits for index pregnancy: none, 1-3 or 4 plus 

 Timing of first ANC visit Timing of the first ANC visit for index pregnancy: early (before 5 months), 

late (after 5 months) or no visits 

Obstetric characteristics 

 Parity during index pregnancy 0, 1-2, 3-5 and 6+ (based on live births only) 

 Age at time of index birth <19, 19-34, 35+ 

 Multiple birth Single or multiple 

Socioeconomic factors

 Maternal education level None, primary or secondary plus (categorized by DHS) 

 Area of residence Urban or rural (based on DHS definition) 

 Poverty quintile Quintiles based on asset factor scores (Gwatkin et al., 2000) 
12 

Utilization of other maternal health services. We include two variables to measure use of ANC 

services by the mother during the index pregnancy: the number of visits made and the timing of the first 

visit. Utilization of ANC during the pregnancy is expected to reflect several things including the mother’s 

access to, knowledge of, and attitude toward antenatal services, and her awareness of the potential problems of pregnancy. In addition, women who receive ANC may be encouraged to use professional delivery 

services during their antenatal visits. We therefore expect women who seek ANC more frequently and at 

an earlier point in their pregnancy to be the most likely to use delivery care, and those who do not receive 

ANC at all to be the least likely to use delivery care. 

Obstetric characteristics. DHS collects data on certain obstetric characteristics such as parity 

(the number of viable births a woman has experienced), maternal age, and past obstetric history. While 

individual obstetric characteristics have been associated with various types of unfavorable obstetric and 

infant outcomes, they are poor predictors of obstetric risk because they are not direct causes of poor outcome (Rooney, 1992). Nevertheless, characteristics such as youngest and oldest women and women experiencing first births and high order births continue to be used as clinical markers for identifying individual women who need referral or extra care in pregnancy. The validity and usefulness of risk 

assessment for reducing maternal mortality is not fully understood. 

Socioeconomic characteristics. Use of delivery care is expected to be strongly associated with 

socioeconomics status. Maternal education is consistently and strongly associated with all types of health 

behavior and we expect use of delivery care to be higher among more educated mothers. The service and 

social environments are typically very different in urban and rural areas, so strong urban-rural differentials in use of delivery care are expected. Several analyses are presented separately for urban and rural 

areas because of the large differences in access to delivery care. Finally, economic status is an indicator of 

access to delivery care, and use of delivery care is expected to be substantially higher among mothers in 

the upper quintiles of the wealth index. 

4.3 Sample Issues 

Before proceeding with the analysis, there are two related issues to be resolved concerning which 

deliveries to include in the analysis sample. The first issue concerns the choice between birth-based or 

woman-based analysis. The second issue concerns the choice between a three-year or five-year reference 

period. 

4.3.1 Birth-based Analysis 

Birth-based analysis uses all the deliveries recorded for a representative sample of women over a 

set period. DHS reports present birth-based estimates, using all births that occurred in either the preceding 

five years or the preceding three years, depending on the period used for the delivery questions in that 

particular survey. 

Advantages and disadvantages of the birth-based approach 

The advantages of birth-based analysis are: 

• Statistically representative of all births in a given period (John, Menken, and Trussell, 1988); 

• Simple to calculate because it does not involve random selection of a birth for women with 

multiple births; 

• Provides a larger sample size and thus smaller sampling errors than a woman-based analysis. 
13 

The disadvantage of a birth-based analysis is that individual women may contribute more than 

one birth to the sample. Thus, while the sample is representative of all births in a given period, it overrepresents women who deliver more than once in the period. These women are not representative of the 

total population of women. They tend for example to be less educated and more rural. They also tend to 

be less likely to have a professional attendant or facility delivery. Thus, estimates of the percentage of 

deliveries occurring with a health professional or in a health facility will typically be lower than for a corresponding woman-based analysis. The size of this difference will depend on the proportion of women 

contributing multiple births to the sample and how different the delivery care behavior of those women is 

compared with women who contribute only one birth to the sample. 

4.3.2 Woman-based Analysis 

Woman-based analysis addresses these issues by using only one delivery per woman. One approach is to select only the woman’s most recent birth in the last five (or three) years. However, Grummer-Strawn (Grummer-Strawn and Stupp, 1996) shows that this can lead to biased results, although the 

bias was less for pregnancy and delivery-related indicators than for other child health indicators examined. An alternative is to randomly select one birth per woman if the woman has multiple deliveries during the analysis period. 

4.3.3 Time-period for Analysis 

As mentioned in Section 3, DHS collects information on delivery care for all live births that occurred in either the five years preceding the survey or the three years preceding the survey. This leads to 

the second, related sample issue—the choice of a five-year or a three-year reference period. Most of the 

surveys included in this analysis collected data for births in the five years preceding the survey. The exceptions are Bangladesh 1994 and Ghana 1993, which used a three-year reference period. The three-year 

reference period provides a more current estimate than the five-year period and should therefore be less 

prone to recall error by women. It will also provide greater consistency between the birth-based and 

woman-based samples because fewer women will contribute multiple births to the sample than with a 

five-year reference period. However, it will yield a smaller sample size and thus greater standard errors 

for the indicators. 

4.3.4 Comparison of Approaches 

Table 4.3 illustrates these issues for our data by presenting the indicator “percentage of deliveries 

attended by a health professional” based on different sample options. Standard errors are presented in parentheses.5

Woman versus birth-based estimates 

As expected, levels of professional attendance obtained from birth-based estimates tend to be 

lower than those obtained from woman-based estimates over the same reference period. For the three-year 

reference period the differences are small, with most less than one percentage point (range: 0-2.0 percentage points). The differences between birth-based and woman-based estimates are substantially larger for 

the five-year reference period, with most differences greater than one percentage point (range: 0-6.3 percentage points). The larger difference for the five-year period reflects the fact that more women contribute 

 

5

 The sample errors are calculated taking into account the complex sample designs in the DHS surveys and, when 

applicable, the correlation between births to the same woman. Because of data limitations, the standard errors 

presented for Bolivia 1989, Ghana 1988, and Indonesia 1987 have not been adjusted for the survey design. 

However, the estimates for these are weighted to be representative at the national level. 
14 

multiple births to the five-year birth-based sample and therefore there is a greater difference between the 

woman-based and birth-based samples. 

Five-year versus three-year reference period 

For birth-based samples, estimates of professional attendance for five-year periods tend to be 

lower than those for three-year periods (range: 0.5-2.9 percentage points) except in Malawi. The differences probably reflect a trend toward increasing use of professional delivery care because, on average, the 

five-year estimate refers to a point in time approximately a year earlier than the three-year estimate. However, the differences are small. 

In contrast, in the woman-based samples estimates of professional attendance tend to be slightly 

higher for the five-year reference period than for the three-year period (range: 0.1-2.4 percentage points). 

This probably reflects that women of higher socioeconomic status tend to have lower fertility and are 

therefore less likely to have had a birth in the last three years than women of lower socioeconomic status. 

Random versus last birth 

Using different methods to obtain woman-based estimates of professional attendance, i.e., random birth and last birth, appears to have little effect on the estimates. Differences are small for the threeyear period because most women contribute only one birth, so the random birth is often the last birth. For 

the five-year period, differences are also small—0.5 percentage points or less in all countries except Malawi, where the differences are larger at around 1.5 percentage points. 

Table 4.3 Percentage of births attended by a health professional (and standard errors) based on different sample 

options, Demographic and Health Surveys, 1987-2000 

 Sampling option and reference period 

Woman-based sample 

Birth-based sample Random birth Last birth 

 Survey 3 years 5 years 3 years 5 years 3 years 5 years 

Bangladesh 

1994 9.1 (0.5) u 9.3 (0.5) u 9.1 (0.6) u 

1997 8.1 (0.6) 7.6 (0.5) 8.7 (0.6) 9.1 (0.6) 8.6 (0.6) 9.0 (0.5) 

2000 12.1 (0.7) 11.5 (0.6) 12.5 (0.8) 12.6 (0.7) 12.3 (0.8) 12.4 (0.7) 

Bolivia 

1989 43.1 (1.0) 42.0 (0.8) 44.1 (1.1) 45.8 (1.0) 44.2 (1.1) 46.2 (1.0) 

1994 45.7 (1.5) u 46.6 (1.5) u 46.8 (1.5) u 

1998 58.2 (1.2) 55.3 (1.1) 59.9 (1.1) 60.3 (1.0) 60.2 (1.1) 61.6 (1.0) 

Ghana 

1988 40.6 (1.0) 39.8 (0.8) 41.0 (1.0) 41.3 (0.9) 40.6 (1.0) 41.2 (0.9) 

1993 43.4 (1.6) u 43.8 (1.5) u 43.8 (1.5) u 

1998 44.7 (1.5) 44.1 (1.4) 45.1 (1.5) 46.5 (1.3) 45.2 (1.5) 46.1 (1.4) 

Indonesia 

1987 37.6 (0.8) 36.2 (0.6) 37.3 (0.9) 36.2 (0.7) 37.2 (0.9) 36.2 (0.7) 

1991 35.7 (1.0) 35.1 (0.9) 35.9 (1.0) 35.9 (1.0) 36.0 (1.0) 35.9 (1.0) 

1994 41.5 (1.1) 39.7 (1.1) 41.7 (1.2) 40.6 (1.1) 41.7 (1.2) 40.6 (1.1) 

1997 50.9 (1.2) 49.0 (1.1) 51.1 (1.2) 50.1 (1.1) 51.1 (1.2) 50.1 (1.1) 

Malawi 

1992 52.5 (1.9) 54.5 (1.8) 53.2 (1.9) 55.2 (1.9) 52.7 (2.0) 53.6 (1.8) 

2000 52.9 (1.2) 54.1 (1.1) 53.7 (1.2) 56.1 (1.2) 53.4 (1.2) 54.7 (1.2) 

Philippines 

1993 53.9 (1.1) 52.8 (1.1) 54.4 (1.1) 55.4 (1.0) 54.6 (1.1) 55.5 (1.0) 

1998 57.5 (1.1) 56.4 (1.0) 59.0 (1.1) 59.7 (1.0) 58.9 (1.1) 59.3 (1.0) 

Note: Standard errors presented here are adjusted for the sample design. Due to data limitations, the standard errors 

presented for the following surveys were not adjusted for the complex survey design: Bolivia 1989, Ghana 1988, 

Indonesia 1987. However, the estimates for these are weighted to be representative at the national level. 

u = Unknown (not available) 
15 

Sample sizes and sampling errors 

Considerable gains in sample size can be made when considering a birth-based rather than a 

woman-based sample: 7 to 24 percent for a three-year reference period and 26 to 58 percent for a fiveyear reference period. Comparing reference periods reveals larger differences; woman-based samples 

from a five-year period are 19 to 46 percent larger than those from a three-year period, and birth-based 

samples show a 57 to 77 percent gain. However, the gains in sample size had relatively little effect on the 

estimated sampling errors. 

4.3.5 Choice of Approach: Birth-based Analysis Using a Three-year Reference Period 

The selection of the unit of analysis should be influenced by the question under study (Filippi, 

Graham, and Campbell, 1990). Delivery care programs typically target women, so it could be argued that 

woman-based estimates are the more relevant. However, because the objective of safe motherhood programs is that every woman should have a skilled attendant for every delivery, there is also a strong case 

for using a birth-based indicator as an approximation to a delivery-based indicator, given that we don’t 

have information for non-live deliveries. In addition, if we want to consider delivery care in the context of 

neonatal outcomes, the analysis should be birth-based. 

Taking into consideration these factors, we chose to use a birth-based sample with a three-year 

reference period for most of the analyses in this report.6

 The main reasons for this decision are: 

• It allows a consistent reference period to be used across all surveys. 

• It provides a more recent estimate. 

• There is little difference between the woman-based and birth-based samples, so results are 

relevant to either situation. 

The one exception is the analysis of consistency in use of delivery care, which is woman-based 

and uses as much information as is available to maximize the sample size. 

 

6

 Multiple births are only included once in the sample because they represent only one delivery. 
16 

5 Analysis and Results 

5.1 General Patterns of Delivery Care 

The first analysis examines trends in selected indicators of delivery care in six countries to obtain 

a picture of the changes that have occurred in delivery care between the late 1980s and the late 1990s. 

National trends are presented first. We then look at urban and rural trends to determine what changes have 

occurred in these two very different environments. 

5.1.1 Delivery with a Health Professional 

Table 5.1.1 shows the percentage of deliveries that were attended by a health professional, by 

type of attendant.7

 Figure 5.1 summarizes these results by showing trends in delivery with a health professional. According to the most recent surveys, the percentage of deliveries attended by a health professional ranges between 44 and 58 percent in five of the six countries. The exception is Bangladesh where 

only 12.1 percent of deliveries were attended by a health professional. The percentage of deliveries attended by a qualified health professional has increased in all six countries. The largest absolute increases 

are observed in Bolivia and Indonesia (16.4 and 13.3 percentage points, respectively) and the lowest increase is observed in Malawi (0.2 percentage points). The increases are statistically significant at the 5 

percent level in three of the six countries (Bangladesh, Bolivia, and Indonesia). 

Table 5.1.1 Trends in percentage of deliveries attended by a health professional: National level

 Health professional Non-health professional 

Survey Doctor 

Nurse or 

midwife 

Total 

HP Trained TBA TBA1 Other 

HW 

Total 

Non-HP 

No 

attendant 

Number of 

deliveries 

(weighted) 

 Bangladesh 

 1993 4.2 4.9 9.1 4.1 60.5 0.3 89.3 1.4 3,898 

 1997 5.6 2.4 8.1 7.7 64.7 0.5 90.6 1.3 3,637 

 2000 7.6* 4.5 12.1* 10.4* 63.4 0.7 86.3* 1.5 4,180 

 Bolivia 

 1989 38.8 3.0 41.8 u 12.7 1.4 53.2 4.8 3,531 

 1994 42.5 3.2 45.7 u 10.3 1.3 52.1 2.1 3,588 

 1997 55.4* 2.8 58.2* u 7.1* 1.0 40.3* 1.3* 4,080 

 Ghana 

 1988 6.3 34.2 40.6 u 27.7 u 53.1 5.9 2,507 

 1993 6.4 37.0 43.4 15.7 30.8 u 51.7 4.7 2,152 

 1998 7.4 37.4 44.7 24.2* 41.6* u 50.2 4.7 1,888 

 Indonesia 

 1987 3.8 33.8 37.6 u 59.9 u 61.8 0.2 4,617 

 1991 4.8 30.9 35.7 u 59.6 u 64.0 0.3 8,613 

 1994 6.7 34.8 41.5 u 54.5 u 58.1 0.4 10,052 

 1997 7.4* 43.6* 50.9* u 46.1* u 48.8 0.3 9,685 

 Malawi 

 1992 4.6 48.2 52.7 11.1 18.9 u 41.9 5.1 2,789 

 2000 5.2 47.8 52.9 u 23.9* 1.4 44.6 2.4* 7,590 

 Philippines 

 1993 26.9 27.0 53.9 39.9 43.3 u 45.9 0.2 5,356 

 1998 32.7* 24.8 57.5 u 40.4 u 42.3 0.2 4,530 

 Note: If respondent mentioned more than one person attending the delivery, only the most qualified person is considered. 

*Indicates a significant difference (at the .05 level) between the first and last survey in the country. 1

 Includes trained and untrained TBAs as well as those whose training status was unknown. 

HP = Health professional 

HW = Health worker 

TBA = Traditional birth attendant 

u = Unknown (not available) 

 

7

 If the respondent mentioned more than one person attending the delivery, only the most qualified person is 

considered. 
17 

While all of the countries show an increase in attendance at delivery by a health professional, the 

dynamics of the changes vary across countries. In Bangladesh, the small upward trend has occurred primarily because of a small increase in deliveries by doctors, but overall, professional attendance at delivery remains extremely low. Bolivia exhibits a medical model of delivery care with the large recent increase in professional attendance driven entirely by greater use of doctors, while use of nurses or 

midwives appears to have declined slightly and is very low. Ghana and Indonesia show very different 

rates of change but in both cases trends are related to a greater use of nurses and midwives, accompanied 

by much smaller increases in the use of doctors. Malawi has experienced little change in professional attendance at delivery while the Philippines has experienced a slight shift from nurses/midwives and nonprofessional attendants to doctors. 

In all countries, delivery with a nonprofessional attendant or no attendant has correspondingly decreased as professional attendance has increased. However, there are a couple of interesting patterns regarding the use of TBAs. In Bangladesh, there has been a large relative increase in the use of trained 

TBAs alongside the smaller increase in professional attendance. Ghana has also experienced a large increase in the percentage of deliveries attended by TBAs, particularly trained TBAs, alongside the more 

modest increases in the percentage of deliveries attended by doctors, nurses, and midwives. In contrast, 

Indonesia has seen a marked shift away from TBAs; the percentage of deliveries attended by TBAs there 

has declined from 60 percent in 1987 to 46 percent in 1997. 

Women are about twice as likely to deliver with a health professional if they live in an urban area 

compared with a rural area in all countries except Bangladesh, where they are four times more likely to do 

so (see Table 5.1.2, Figure 5.2). According to the most recent surveys, over 75 percent of urban deliveries 

were attended by a health professional in every country except Bangladesh, where the figure was only 33 

percent. In all countries, deliveries in urban areas were two to five times more likely to be attended by a 

doctor than deliveries in rural areas. The differences between the likelihood of delivery by a nurse or 

midwife in urban and rural areas were less marked with ratios in the range of 1.4 to 3. 
18 

Table 5.1.2 Trends in percentage of deliveries attended by a health professional by urban-rural residence

 Health professional Non-health professional 

Survey Doctor 

Nurse or 

midwife 

Total 

HP 

Trained 

TBA TBA1

Other 

HW 

Total 

Non-HP 

No 

attendant 

Number of 

deliveries 

(weighted) 

URBAN 

Bangladesh 

 1993 17.9 16.1 34.0 4.7 49.2 0.4 65.4 0.5 392 

 1997 25.6 10.3 35.9 10.6 50.0 0.0 63.8 0.4 328 

 2000 22.3 10.5 32.8 9.5* 49.9 1.2 66.1 1.0 687 

 Bolivia 

 1989 58.8 3.0 61.8 u 11.9 1.0 35.2 2.9 1,712 

 1994 61.4 3.8 65.2 u 8.2 0.6 33.1 1.4 1,882 

 1997 75.7* 2.1 77.9* u 5.4* 0.2* 21.2* 0.5* 2,327 

 Ghana 

 1988 10.8 58.0 68.9 u 14.2 u 26.2 4.4 684 

 1993 15.7 64.7 80.4 4.9 10.2 u 16.7 2.5 598 

 1998 17.0* 59.3 76.3 10.3 17.7 u 20.9 2.3 471 

 Indonesia 

 1987 10.4 60.9 71.3 u 27.9 u 28.3 0.1 1,239 

 1991 12.8 55.4 68.2 u 30.4 u 31.8 0.0 2,495 

 1994 16.0 62.3 78.2 u 20.5 u 21.7 0.1 2,798 

 1997 16.0* 63.8 78.8 u 19.6 u 20.0 0.1 2,693 

 Malawi 

 1992 15.5 70.4 85.9 3.0 5.8 u 11.9 2.0 315 

 2000 8.6* 71.5 80.1 u 11.0 0.9 18.5 1.3 951 

 Philippines 

 1993 41.3 30.5 71.8 25.2 27.3 u 28.1 0.1 2,618 

 1998 50.2* 29.1 79.2* u 20.1* u 20.6* 0 2,089 

RURAL 

 Bangladesh 

 1993 2.6 3.7 6.3 4.0 61.8 0.3 92.0 1.5 3,507 

 1997 3.7 1.7 5.3 7.4 66.2 0.5 93.2 1.4 3,309 

 2000 4.7* 3.4 8.1 10.6* 66.0 0.6 90.2 1.6 3,493 

 Bolivia 

 1989 19.9 3.0 22.9 u 13.5 1.7 70.2 6.6 1,819 

 1994 21.6 2.5 24.1 u 12.6 2.0 73.0 2.8 1,706 

 1997 28.4* 3.7 32.1* u 9.4* 2.1 65.6 2.2* 1,753 

 Ghana 

 1988 4.7 25.3 30.0 u 32.8 u 63.2 6.5 1,823 

 1993 2.8 26.3 29.1 19.8 38.7 u 65.2 5.5 1,554 

 1998 4.2 30.1 34.3 28.8* 49.5* u 59.9 5.5 1,418 

 Indonesia 

 1987 1.4 23.8 25.3 u 71.7 u 74.1 0.2 3,378 

 1991 1.5 20.9 22.4 u 71.5 u 77.1 0.4 6,118 

 1994 3.1 24.2 27.3 u 67.5 u 72.2 0.5 7,254 

 1997 4.0* 35.8* 39.8* u 56.4* u 59.9* 0.3 6,992 

 Malawi 

 1992 3.2 45.3 48.5 12.2 20.5 u 45.7 5.5 2,484 

 2000 4.7 44.4 49.0 u 25.8 1.4 48.4 2.6* 6,639 

 Philippines 

 1993 13.2 23.6 36.8 53.9 60.6 u 62.9 0.2 2,738 

 1998 17.7* 21.1 38.8 u 57.8 u 60.8 0.3 2,441 

Note: If respondent mentioned more than one person attending the delivery, only the most qualified person is considered. 

*Indicates a significant difference (at the .05 level) between the first and last survey in the country. 1

 Includes trained and untrained TBAs as well as those whose training status was unknown. 

HP = Health professional 

HW = Health worker 

TBA = Traditional birth attendant 

u = Unknown (not available) 
19 

Trends in delivery with a health professional in rural areas largely mirror those observed at the 

national level. The percentage of rural deliveries attended by a health professional increased in every 

country, with Indonesia demonstrating the most substantial increase (14.5 percentage points). The increase was statistically significant only in Bolivia and Indonesia. The trends in the type of professional 

attending deliveries in rural areas also mirror the trends seen at the national level. For example, the increase in professional attendance in rural Bolivia is due to increased use of doctors, accompanied by a 

slight increase in the use of midwives; while in rural Indonesia, the increase in professional attendance is 

mainly due to increased use of midwives and nurses. 

In Bolivia, Ghana, and the Philippines, the absolute increase in the percentage of deliveries attended by a health professional was higher in urban areas than in rural areas. In contrast, the increase was 

higher in rural areas than in urban areas in Indonesia, while delivery with a health professional decreased 

slightly in urban Bangladesh and Malawi. In urban areas, increases in professional attendance are driven 

mainly by increased use of doctors. The urban use of midwives and nurses has generally changed very 

little except for a slight decline in Bangladesh and a slight increase in Indonesia. 

5.1.2 Partnership Ratio 

Figures 5.3 and 5.4 show the information from Tables 5.1.1 and 5.1.2 for the most recent surveys 

in the form of partnership ratio graphs. In these graphs, the percentage of deliveries with nurses or midwives is plotted against the percentage of deliveries with doctors, and the optimal point (15,85) is indicated (Graham, Bell, and Bullough, 2001). The vertical dotted line represents 15 percent of deliveries attended by doctors whereas the horizontal line marks 80 percent of deliveries with nurses/midwives. The 

intersection of the two dotted lines represents universal delivery care where 15 percent of deliveries are 

attended by doctors and 85 percent by nurses/midwives. The partnership ratio graphs enable us to see 

where countries fall with respect to this optimal point. 
20 

The plotted national figures for the partnership ratio fall far short of the optimal value of (15,85). 

Ghana, Indonesia, and Malawi lie about halfway to the optimum values on both components, while Bangladesh stands out as very low on both. In contrast, the percentage of deliveries with doctors exceeds the 

optimal point in Bolivia and the Philippines, while deliveries with midwives are well below the optimum. 
21 

Bolivia in particular stands out as having almost exclusive reliance on doctors for professional delivery 

care. When stratified by urban-rural residence however, the urban partnership ratios in Ghana, Indonesia, 

and Malawi all approach the ideal. In Bolivia and the Philippines the urban figures approach the diagonal 

indicating close to 100 percent attendance, but with a heavy reliance on doctors, particularly in Bolivia. 

5.1.3 Place of Delivery 

Table 5.2.1 and Figure 5.5 show trends in the distribution of deliveries by place of delivery. According to the most recent surveys, the percentage of deliveries in health facilities is highest in Bolivia 

and Malawi (55.9 percent and 54.0 percent, respectively) and lowest in Bangladesh (8.6 percent). The 

majority of deliveries in health facilities take place in government hospitals or health centers in all countries except Indonesia, where the private sector dominates. 

 Table 5.2.1 Trends in place of delivery over time: National level 

Survey 

Government 

hospital 

Government 

health center 

Private 

hospital/health 

center 

Other health 

facility 

All health 

facilities Domiciliary 

Number of 

deliveries 

(weighted) 

Bangladesh 

1993 1.7 0.3 1.4 u 3.4 96.2 3,898 

1997 2.2 0.5 1.9 u 4.6 94.4 3,637 

2000 4.0* 0.7 3.0* 0.9 8.6* 91.1* 4,180 

 Bolivia 

1989 u u u u u u u 

1994 20.1 4.6 10.9 6.5 42.1 57.4 3,588 

1997 28.4* 7.6* 12.7 7.2 55.9* 43.5* 4,080 

 Ghana 

1988 u u u u u u u 

1993 24.4 4.7 5.1 7.6 41.7 57.4 2,152 

1998 26.6 5.6 5.4 6.6 44.1 54.8 1,888 

 Indonesia 

1987 u u u u u u u 

1991 5.2 1.6 12.1 2.2 21.0 78.5 8,613 

1994 6.1 2.0 9.7 0.3 18.1 81.7 10,052 

1997 6.5 2.5 12.1 0.6* 21.7 78.3 9,685 

 Malawi 

1992 19.3 11.7 10.5 11.7 53.2 44.9 2,798 

2000 18.8 20.6* 10.5 4.1* 54.0 45.2 7,590 

 Philippines 

1993 16.4 1.8 10.9 0.3 29.4 70.5 5,356 

1998 18.5 1.4 16.0* 0.1 36.0* 63.8* 4,530 

*Indicates a significant difference (at the .05 level) between the first and last survey in the country. 

u = Unknown (not available) 

The percentage of deliveries occurring in health facilities increased in each country over time, 

with the largest absolute increase observed in Bolivia (13.8 percentage points). However, the increases 

were less than three percentage points in Ghana, Indonesia, and Malawi, and were statistically significant 

only in Bangladesh, Bolivia, and the Philippines. Although the absolute rise in institutional deliveries in 

Bangladesh was small (5 percentage points) this represented a relative increase of over 150 percent between 1993 and 2000. The largest increase was generally observed in use of government hospitals except 

in Malawi where the main increase was seen in government health centers, and in the Philippines where 

use of private hospitals and health centers increased more than use of government hospitals. In most 

cases, the increased use of government hospitals for delivery is associated with decreased home births. 

However, in Malawi the increased use of government health centers is associated with a shift away from 

deliveries in other types of facilities (government health posts, maternity facilities, private health centers) 

rather than deliveries at home. 
22 

As expected, a much higher percentage of deliveries occur in health facilities in urban areas than 

in rural areas (Table 5.2.2 and Figure 5.6). Urban-rural differences are most striking in Bangladesh where 

a delivery in an urban area is more than five times as likely to occur in a health facility as a delivery in a 

rural area. In Indonesia, the urban-rural ratio in the percentage of deliveries occurring in a health facility 

is about 3 and in the other countries it is approximately 2. 

In Ghana, Indonesia, and Malawi the percentage of deliveries that took place in a health facility 

declined by between 2 and 6 percentage points in urban areas (all non-significant). In Malawi, the decline 

was related to a decrease in deliveries in government hospitals and other health facilities that was only 

partly compensated for by an increase in deliveries in government health centers; in Indonesia, the decline 

was mainly because of a decrease in deliveries in other health facilities; and in Ghana it occurred because 

of a combination of declines in deliveries in government health centers and in other health facilities. Urban areas in Bangladesh, Bolivia, and the Philippines showed increases of between 7 and 14 percentage 

points in the percentage of deliveries occurring in health facilities (this trend was not significant in Bangladesh). 

All countries demonstrated an increase in institutional deliveries in rural areas, which was significant in Bangladesh, Bolivia, Indonesia, and the Philippines. In rural Bangladesh the percentage of deliveries occurring in health facilities tripled between 1993 and 2000, although this represents an absolute rise 

of only 3.4 percentage points. Most of the increases are attributable to increased use of government sector 

delivery care; the only notable private sector increase in rural areas was in the Philippines where the share 

of rural deliveries in private health facilities doubled from 3 percent to nearly 7 percent. In Indonesia a 

national increase in deliveries in health facilities of 0.6 percentage points masks an increase of nearly 4 

percentage points in rural areas and a decline of nearly 6 percentage points in urban areas. 
23 

 Table 5.2.2 Trends in place of delivery over time by urban-rural residence 

Survey 

Government 

hospital 

Government 

health center 

Private 

hospital/health 

center 

Other health 

facility 

All health 

facilities Domiciliary 

Number of 

deliveries 

(weighted) 

 URBAN

 Bangladesh 

 1993 9.5 1.3 8.9 u 19.7 79.2 392 

 1997 11.0 0.9 12.8 u 25.7 72.2 328 

 2000 12.6 0.4 10.3 3.6 26.8 72.7 687 

 Bolivia 

 1989 u u u u u u u 

 1994 27.5 7.0 16.8 10.0 61.3 38.3 1,882 

 1997 35.2* 10.1 18.9 11.2 75.4* 24.0* 2,327 

 Ghana 

 1988 u u u u u u u 

 1993 53.0 4.7 10.2 10.9 78.8 20.9 598 

 1998 53.9 2.7 10.5 9.1 76.2 21.9 470 

 Indonesia 

 1987 u u u u u u u 

 1991 11.8 3.2 29.0 6.3 50.3 49.1 2,495 

 1994 13.6 3.7 26.2 0.5 44.1 55.8 2,798 

 1997 11.6 3.8 28.4 0.8* 44.5 55.5 2,693 

 Malawi 

 1992 56.4 6.4 13.8 9.2 85.8 13.5 315 

 2000 49.5 16.7* 14.8 0.8* 81.7 18.1 951 

 Philippines 

 1993 22.8 3.3 18.8 0.5 45.4 54.4 2,618 

 1998 25.4 2.3 26.6* 0.1 54.3* 45.5* 2,089 

 RURAL

 Bangladesh 

 1993 0.8 0.2 0.6 0 1.6 98.1 3,507 

 1997 1.3 0.5 0.8 0 2.5 96.6 3,309 

 2000 2.3* 0.7* 1.6* 0.4 5.0* 94.7* 3,493 

 Bolivia 

 1989 u u u u u u u 

 1994 12.0 1.9 4.4 2.6 20.9 78.5 1,706 

 1997 19.4* 4.3 4.5 1.8 29.9* 69.4* 1,753 

 Ghana 

 1988 u u u u u u u 

 1993 13.4 4.6 3.1 6.3 27.4 71.4 1,554 

 1998 17.5 6.5 3.7 5.8 33.4 65.7 1,418 

 Indonesia 

 1987 u u u u u u u 

 1991 2.4 1.0 5.1 0.5 9.1 90.5 6,118 

 1994 3.2 1.4 3.3 0.2 8.1 91.7 7,254 

 1997 4.5* 2.0* 5.8 0.5 12.9* 87.2* 6,992 

 Malawi 

 1992 14.6 12.3 10.1 12.0 49.1 48.8 2,484 

 2000 14.4 21.2* 9.9 4.6* 50.1 49.1 6,639 

 Philippines 

 1993 10.3 0.4 3.2 <0.1 14.0 85.8 2,738 

 1998 12.6 0.7 6.9* 0.2 20.3* 79.4* 2,441 

*Indicates a significant difference (at the .05 level) between the first and last survey in the country. 

u = Unknown (not available) 
24 

5.1.4 Deliveries by Health Professionals in Health Facilities and Homes 

The indicators for attendant at delivery and place of delivery were combined to give two composite indicators; the percentage of deliveries attended by health professionals in health facilities, and the 

percentage of deliveries attended by health professionals in homes. These indicators are shown in Table 

5.3.1 and Figure 5.7. 

The trends in these two composite indicators vary across countries, reflecting different models of 

delivery care. In Bolivia and Ghana, the recent increases in the percentage of deliveries attended by health 

professionals documented earlier are associated with an increase in institutional professional deliveries. 

This trend reflects a delivery care model in which virtually all births attended by health professionals occur in health facilities. In Malawi, virtually all professionally attended deliveries also occur in health facilities but there was essentially no change in use of delivery care between 1992 and 2000. In Bangladesh 

the recent increase in professionally attended deliveries reflects a move toward professional delivery in a 

health facility, while professional delivery at home actually declined slightly between 1993 and 1997 

(both these changes are significant). The Philippines has also experienced a shift away from professional 

delivery at home toward professional delivery in a health facility, but professional home delivery remains 

a common form of delivery care there (about one in five deliveries). Indonesia is the only country that has 

seen an increase in professional attendance at delivery driven by an increase in professionally attended 

home births. The percentage of deliveries attended by a health professional in a health facility remained 

fairly constant during the 1990s at around 20 percent, while the percentage of deliveries attended by a 

health professional at home doubled from 15 to 30 percent. 
25 

Table 5.3.1 Delivery care indicators: partnership ratio, health professional in health facility, health professional at home: 

National level 

 Partnership ratio 

Survey Doctor 

Nurse or 

midwife 

Health 

professional in 

health facility 

Health 

professional 

at home 

Number of 

deliveries 

(weighted) 

Bangladesh 

 1993 4.2 4.9 3.4 5.5 3,898 

 1997 5.6 2.4 4.4 3.2 3,637 

 2000 7.6* 4.5 8.3* 3.8* 4,180 

 Bolivia 

 1989 38.8 3.0 u u 3,531 

 1994 42.5 3.2 42.0 3.7 3,588 

 1998 55.4* 2.8 55.5* 2.5 4,080 

 Ghana 

 1988 6.3 34.2 u u 2,507 

 1993 6.4 37.0 41.1 2.1 2,152 

 1998 7.4 37.4 43.5 1.2 1,888 

 Indonesia 

 1987 33.8 37.6 u u 4,617 

 1991 30.9 35.7 20.9 14.7 8,613 

 1994 34.8 41.5 17.9 23.5 10,052 

 1997 43.6* 50.9* 21.4 29.5* 9,685 

 Malawi 

 1992 4.6 48.2 52.4 0.4 2,789 

 2000 5.2 47.8 52.4 0.5 7,590 

 Philippines 

 1993 26.9 27.0 29.3 24.6 5,356 

 1998 32.7* 24.8 35.8* 21.6 4,530 

 *Indicates a significant difference (at the .05 level) between the first and last survey in the country. 

u = Unknown (not available) 
26 

Births are much more likely to be attended by health professionals in health facilities in urban areas than in rural areas (Table 5.3.2). In the three countries in which professionally attended home deliveries make up a significant proportion of all deliveries (Bangladesh, Indonesia, and the Philippines), urban 

births are also more likely than rural births to be attended by a health professional at home, although the 

differential is less pronounced than for institutional births. Trends are generally similar in urban and rural 

Table 5.3.2 Delivery care indicators: partnership ratio, health professional in health facility, health professional at home, by urban-rural 

residence 

 Partnership ratio 

 Survey Doctor 

Nurse or 

midwife 

Health 

professional in 

health facility 

Health 

professional 

at home 

Number of 

deliveries 

(weighted) 

URBAN 

 Bangladesh 

 1993 17.9 16.1 19.5 13.4 392 

 1997 25.6 10.3 25.2 9.0 328 

 2000 22.3 10.5 25.8 6.9* 687 

 Bolivia 

 1989 58.8 3.0 u u 1,712 

 1994 61.4 3.8 61.2 3.9 1,882 

 1998 75.7* 2.1 75.2* 2.6 2,327 

 Ghana 

 1988 10.8 58.0 u u 684 

 1993 15.7 64.7 78.4 2.0 598 

 1998 17.0* 59.3 75.6 0.5 471 

 Indonesia 

 1987 10.4 60.9 u u 1,239 

 1991 12.8 55.4 50.0 18.0 2,495 

 1994 16.0 62.3 44.0 34.2 2,798 

 1997 16.0* 63.8 44.3 35.5* 2,693 

 Malawi 

 1992 15.5 70.4 85.4 0.4 315 

 2000 8.6* 71.5 80.1 0.1 951 

 Philippines 

 1993 41.3 30.5 45.3 26.4 2,618 

 1998 50.2* 29.1 54.0* 25.2 2,089 

 RURAL 

 Bangladesh 

 1993 2.6 3.7 1.6 4.7 3,507 

 1997 3.7 1.7 2.4 2.7 3,309 

 2000 4.7* 3.4 4.8* 3.1 3,493 

 Bolivia 

 1989 19.9 3.0 u u 1,819 

 1994 21.6 2.5 20.7 3.3 1,706 

 1998 28.4* 3.7 29.4* 2.5 1,753 

 Ghana 

 1988 4.7 25.3 u u 1,823 

 1993 2.8 26.3 26.8 2.2 1,554 

 1998 4.2 30.1 32.8 1.5 1,418 

 Indonesia 

 1987 1.4 23.8 u u 3,378 

 1991 1.5 20.9 9.0 13.4 6,118 

 1994 3.1 24.2 7.9 19.4 7,254 

 1997 4.0* 35.8* 12.6* 27.2* 6,992 

 Malawi 

 1992 3.2 45.3 48.2 0.4 2,484 

 2000 4.7 44.4 48.4 0.5 6,639 

 Philippines 

 1993 13.2 23.6 13.9 22.8 2,738 

 1998 17.7* 21.1 20.2* 18.5 2,441 

*Indicates a significant difference (at the .05 level) between the first and last survey in the country. 

u = Unknown (not available) 
27 

areas and reflect the national trends described above. Indonesia is again an interesting case. In urban areas 

there has been a decline in the percentage of deliveries attended by a health professional in a health facility, accompanied by an large increase in the percentage attended by a health professional at home. In rural 

areas, however, there has been an increase in both institutional and domiciliary professionally attended 

deliveries, although the increase has been much larger for professionally attended home births. 

5.2 Differentials in Delivery with a Health Professional 

The analysis in Section 5.1 used several different indicators of delivery care to obtain a comprehensive picture of delivery care patterns and trends in the six selected countries. With that context established, we focus on one indicator of delivery care, the percentage of deliveries attended by a health professional, for the remainder of the report. This indicator is selected for more in-depth analysis because it 

is the most commonly used indicator of delivery care, is featured among the United Nations’ Millennium 

Development Goals (United Nations, 2002), and is used internationally as a proxy for monitoring skilled 

attendance at delivery. In this section we examine demographic and socioeconomic differentials in delivery with a health professional and examine the extent to which trends in delivery with a health professional vary among demographic and socioeconomic groups. Figures showing selected results are presented below; the actual percentages and confidence intervals are presented in Table 5.4. 

5.2.1 Parity 

Figure 5.8 shows the percentage of deliveries that were attended by a health professional by the 

number of live births the mother had experienced at the time of the most recent survey. Primiparous 

women are consistently more likely to deliver with a health professional than any other parity group; the 

percentage of first births attended by a health professional ranges from 18 percent in Bangladesh to 76 

percent in Bolivia, in the most recent surveys, and exceeded 58 percent in the other four countries. Highparity women (6+ births) are the least likely to deliver with a health professional; Malawi has the highest 
28 

 Table 5.4 Trends in the percentage of deliveries with a health professional (DHP), by background characteristics 

 Parity Age 

 0 1-2 3-5 6+ Less than 20 20-34 35 and over 

Survey % DHP n % DHP n % DHP n % DHP n % DHP n % DHP n % DHP n 

 Bangladesh 

 1993 13.7 1,007 9.1 1,515 5.9 1,020 5.4 357 8.8 792 9.4 2,866 6.6 240 

 1997 15.1 1,023 6.9 1,451 3.4 868 3.0 295 6.6 924 8.6 2,538 8.1 176 

 2000 18.1* 1,263 11.9 1,786 6.8 875 2.5 256 9.7 1,061 13.4* 2,897 7.2 222 

 Bolivia 

 1989 55.4 722 48.3 1,212 34.3 1,048 23.9 549 44.3 315 43.7 2,633 32.0 583 

 1994 62.8 820 53.0 1,216 33.8 951 26.2 601 49.6 326 47.7 2,682 34.1 580 

 1998 76.4* 1,001 63.1* 1,450 47.1* 1,062 34.3* 567 66.7* 394 59.1* 2,993 49.5* 693 

 Ghana 

 1988 52.5 488 40.1 843 36.5 797 34.8 379 46.9 162 41.6 1,784 35.5 561 

 1993 56.2 447 44.2 792 38.7 653 30.4 260 48.3 149 44.4 1,555 38.2 448 

 1998 58.2 459 47.7 670 35.4 536 30.6 223 50.7 106 46.2 1,334 39.1 448 

 Indonesia 

 1987 45.8 1,200 36.7 1,791 32.1 1,154 33.7 472 25.1 379 39.3 3,776 34.0 463 

 1991 42.7 2,415 35.7 3,382 31.2 2,146 24.8 670 24.9 778 37.3 6,901 32.8 934 

 1994 50.7 3,032 42.8 3,995 33.6 2,176 22.6 849 26.1 831 44.3 7,974 33.7 1,248 

 1997 61.4* 3,237 51.8* 3,982 37.3 1,936 30.5 529 40.1* 858 53.4* 7,579 43.7* 1,248 

 Malawi 

 1992 57.4 524 53.6 808 53.2 889 46.5 577 52.8 355 54.2 1,947 46.8 496 

 2000 61.3 1,810 51.9 2,712 50.3 2,072 46.2 996 56.7 1,005 53.2 5,618 47.5 967 

 Philippines 

 1993 67.0 1,212 57.9 1,964 45.6 1,478 37.4 702 44.9 234 54.9 4,253 51.5 868 

 1998 72.3 1,161 63.1 1,720 47.2 1,166 26.5 483 49.7 219 59.7* 3,587 48.8 724 

 Education Wealth index (quintile) 

 No education Primary Secondary+ Poorest Second Third Fourth Richest 

% DHP n % DHP n % DHP n % DHP n % DHP n % DHP n % DHP n % DHP n 

 Bangladesh 

 1993 4.5 2,241 6.5 1,059 31.2 598 u u u u u u u u u u 

 1997 2.6 2,051 7.3 972 27.6 614 1.6 803 2.2 848 3.8 735 9.2 675 29.7 576

 2000 5.4 1,919 8.0 1,199 28.8 1,062 3.8* 1,093 5.4* 921 6.8 842 13.2 681 41.8* 643

 Bolivia 

 1989 11.5 709 32.4 1,817 80.1 1,006 u u u u u u u u u u 

 1994 11.5 511 33.1 1,751 75.4 1,326 9.8 850 28.7 791 48.5 769 74.2 673 90.2 504

 1998 21.8* 454 42.1* 1,951 86.8* 1,676 19.7* 1,074 48.1* 868 67.1* 879 88.1* 770 97.7* 489

 Ghana 

 1988 24.8 1,076 49.9 1,306 79.2 125 u u u u u u u u u u 

 1993 23.4 862 53.9 1,171 84.0 119 24.5 428 24.2 484 31.0 451 62.0 431 84.9 358

 1998 26.7 694 51.8 1,079 87.3 116 17.5 510 30.2 394 48.7* 377 64.9 350 87.7 258

 Indonesia 

 1987 12.0 779 32.3 2,957 78.2 881 u u u u u u u u u u 

 1991 14.9 1,167 26.7 5,417 71.7 2,030 9.6 2,075 17.0 1,858 32.7 1,626 51.2 1,658 84.3 1,396

 1994 11.7 1,077 30.2 5,978 74.7 2,997 14.9 2,425 21.8 2,140 41.4 1,896 56.6 1,626 88.1 1,666

 1997 20.3* 817 38.4* 5,521 79.2 3,346 21.8* 2,177 36.7* 1,999 50.5* 1,933 66.6* 1,933 89.3 1,625

 Malawi 

 1992 42.7 1,409 60.9 1,303 93.9 86 u u u u u u u u u u 

 2000 42.9 2,323 54.3 4,741 85.1 525 44.6 1,620 45.3 1,497 48.0 1,763 49.6 1,352 81.1 1,357

 Philippines 

 1993 10.7 140 35.4 2,154 68.9 3,061 u u u u u u u u u u 

 1998 12.4 95 30.6 1,479 72.4 2,956 22.3 1,267 47.0 1,037 73.1 862 84.7 758 92.6 606



*Indicates a significant difference (at the .05 level) between the first and last survey in the country. 

u = Unknown (not available) 

percentage of births of order six or higher attended by a health professional (46 percent) and Bangladesh 

has the lowest (2.5 percent). Bangladesh also shows the largest relative difference between the highest 

and lowest parity groups (a ratio of 7.2) while Malawi has the smallest difference, with primiparous 

women only 1.3 times more likely to have DHP than the high-parity group. 
29 

In all six countries the percentage of deliveries attended by a health professional has increased for 

most parity categories (Table 5.4). The largest increases have occurred among women in the low-parity 

groups. Among high-parity women the percentage of deliveries attended by a health professional has increased only in Bolivia (a significant increase of 10 percentage points). In Indonesia, the percentage of 

deliveries to high-parity women that were attended by a health professional declined between 1987 and 

1994 but has increased again more recently. In the other four countries delivery with a health professional 

among high-parity women has declined, most notably in the Philippines, where an 11 percentage point 

decline has occurred. These patterns have resulted in widening parity differentials over time. 

5.2.2 Age 

Figure 5.9 and Table 5.4 show the percentage of births attended by a health professional by 

mother’s age at the time of the birth. The differentials in DHP by age are not consistent across countries. 

The most common pattern observed is for lower use of DHP among mothers over the age of 35 (Bolivia, 

Ghana, Malawi, Bangladesh except in 1997, and the Philippines in 1998). In these countries there is generally little difference in DHP between mothers under 19 and mothers age 19-34. In Indonesia and the 

Philippines in 1993, DHP was lowest among mothers under 19 and highest among mothers age 19-34. 

National trends in the use of DHP are fairly similar across age groups. In Bolivia and Indonesia 

there is evidence that DHP has increased most rapidly among mothers under 19 in the most recent period, 

so that by the most recent survey there is relatively little difference between the youngest and oldest age 

groups. In Malawi there is also some suggestion of a more rapid increase in DHP among mothers under 

19 and in Bangladesh trends in DHP use among women age 35 and older are the opposite of those observed among younger women. 
30 

5.2.3 Maternal Education 

Maternal education is strongly associated with delivery by a health professional (Figure 5.10 and 

Table 5.4). At the time of the most recent survey, over 70 percent of deliveries to mothers with at least a 

secondary education were attended by a health professional in every country except Bangladesh. In contrast, the highest percentage of deliveries with a health professional among women with no education was 

43 percent in Malawi. Women with secondary education were two to six times more likely to deliver with 

a health professional than those with no education. Countries with the most difference between education 

groups were Bangladesh and the Philippines (which had ratios of over 5). Malawi showed the least difference in this respect: women with secondary education were just two times more likely than women with 

no education to have professional assistance at delivery. 

In general, trends in delivery with a health professional are similar among women at each level of 

education, so differentials between levels have remained fairly constant over time. Education differentials 

appear to have narrowed in Indonesia and Malawi. In Indonesia this is because there has been a significant increase in the use of health professionals at delivery among women who have not gone beyond primary education; in Malawi it is because of declining use of professional attendants among mothers with 

primary and secondary education. By contrast, in the Philippines differentials may have widened because 

of a larger increase in the use of professional attendants among women with secondary education than 

among women with no education, and a slight decline in the use of professional attendants among mothers with primary education (these differences are not statistically significant). 

5.2.4 Wealth Index 

Lastly, Table 5.4 shows the percentage of deliveries that were attended by a health professional 

by wealth quintile and year for Bangladesh, Bolivia, Ghana, and Indonesia. The wealth index cannot be 

calculated in a comparable way for many of the earlier DHS surveys because the list of assets collected in 
31 

the earlier surveys was less detailed than in later surveys. Therefore, trends in the use of professional delivery care by wealth quintile are not available for Malawi and the Philippines, and are available only for 

a small number of data points in the other four countries. Trends in delivery care by wealth quintile have 

to be interpreted carefully because the quintiles measure relative wealth, not absolute wealth. This means 

that the poorest quintile represents the poorest 20 percent of households in each survey. However, the 

poorest 20 percent in one survey could be richer (or poorer) in absolute terms than the poorest 20 percent 

in the previous survey. 

There are marked differentials in use of health professionals at delivery by wealth quintile. Figure 

5.11 shows that in the most recent surveys, the percentage of births in the highest (richest) quintile that 

were attended by a health professional ranged from 42 percent in Bangladesh to 98 percent in Bolivia, and 

exceeded 80 percent in all countries except Bangladesh. In the lowest (poorest) quintile, the percentage of 

deliveries attended by a health professional was highest in Malawi (45 percent) and lowest in Bangladesh 

(4 percent). Malawi was the only country in which more than 22 percent of deliveries in the lowest quintile were attended by a health professional. Bangladesh again fared the worst in terms of relative inequity 

with a ratio of 11 between the use of professional delivery care in the highest and the lowest quintiles, 

while Bolivia had the largest absolute difference (78 percentage points). Malawi had the lowest relative 

difference (ratio of 1.8) and absolute difference (36.5 percentage points). Malawi is also unusual in that it 

shows very little difference in professional attendance at delivery between the first four quintiles. 

The trends in use of professional delivery care by wealth quintile vary across countries. In Bangladesh, the percentage of deliveries attended by a health professional has increased most in the highest 

quintile and has changed little in the others, resulting in widening economic differentials over time. In 

Bolivia, the smallest increases were seen in the highest quintile—where there is little room for improvement—and in the lowest quintile. The middle three quintiles show fairly similar rates of increase. Thus, 

there is a narrowing of the differentials between the four highest quintiles while the lowest quintile, which 

includes the poorest sections of society, is falling further behind. Ghana has seen very little increase in the 
32 

use of professional attendants in the top two quintiles, larger increases in the second and middle quintiles, 

particularly the middle quintile, and a decline in use in the lowest quintile (although none of these trends 

are significant). This again results in an overall widening of economic differentials. Finally, in Indonesia, 

increases in professional attendance at delivery have been smallest in the highest quintile, where delivery 

care was already close to universal in 1991, compared with the four lower quintiles. However, the lowest 

quintile has seen smaller increases than the next three quintiles. 

5.2.5 Multivariate Analysis 

The last part of this section uses logistic regression models to examine these basic determinants 

of delivery care as a group. The analysis has two objectives. The first objective is to examine the extent to 

which the national trends in DHP in these six countries are associated with changes in basic socioeconomic and obstetric characteristics. To do this we first fitted a simple logistic regression model containing 

only the survey year dummy variable to estimate the crude trend in DHP. This is presented in Model 1 of 

Table 5.5 for each country and is equivalent to the initial trend analysis in Table 5.1.1. We then added the 

other variables to the model to estimate the trend after controlling for age, parity, education, and urbanrural residence (Model 2, Table 5.5). The change in the parameter estimate for the survey year variable 

indicates the extent to which the observed change in DHP is explained by changes in the basic socioeconomic and obstetric characteristics of the population.8

 The second objective is to estimate the association 

between each socioeconomic and obstetric determinant and DHP after controlling for the other variables. 

This will enable us to gauge the relative importance of each determinant as well as the consistency in the 

relationships across the six countries.9

 Wealth index is not included in any of the multivariate analyses. 

Although the bivariate analysis found wealth quintile to be strongly associated with use of professional 

delivery care, the wealth index variable is not available in the earliest surveys. Therefore, including it in 

the multivariate analysis would mean that we would have to drop a number of surveys from the analysis. 

The results of the logistic analysis are presented in Table 5.5. As expected, given the earlier 

bivariate analysis, the crude increase in DHP is only significant in Bangladesh, Bolivia, and Indonesia. 

Even in these countries, the odds ratio is only significant for the most recent survey. In Bangladesh, the 

significant increase in DHP becomes an insignificant decrease when the other factors in the model are 

controlled. Additional exploratory analysis (not shown) suggests that it is socioeconomic factors rather 

than obstetric factors that drive this change. Therefore, it appears that the recent increase in DHP in Bangladesh is primarily associated with favorable changes in maternal education and the urban-rural distribution of births. In Bolivia and Indonesia the increase in DHP is reduced by controlling for the other variables in the model but remains significant. Again, the decline in the odds ratio for the trend is primarily 

associated with controlling for education and urban-rural residence, particularly in Indonesia (data not 

shown), rather than with controlling for obstetric characteristics. In the remaining three countries the 

crude trend in DHP is not significant and is not affected much by controlling for other variables. 

The odds ratios in the second model largely confirm the patterns observed in the bivariate analyses. The largest effects are consistently observed for education; the odds of DHP are between 5 (Malawi) 

and 14 (Bolivia) times higher among births to women with secondary or higher education than among 

births to women with no education. The odds ratios for births to women with primary education are more 

 

8

 The logistic regression models are weighted to control for the different sample designs used in each year. This is 

particularly important in the crude model to ensure that it is consistent with the bivariate analysis and because we are 

not able to control for sample stratification effects in such a simple model. We ran the full main effects model both 

weighted and unweighted and the parameter estimates were very similar in both models with the exception of the 

trend parameter. The trend parameter will pick up any uncontrolled sample design effects in the unweighted model 

(e.g., due to changing regional stratification over time) so is expected to differ slightly. 

9

 Note that this model includes only a limited set of the variables that are likely to be associated with use of 

professional delivery care. Therefore, the parameter estimates should not be interpreted causally. 
33 

modest in size (1.6 to 3.8) but are still highly significant. Rural residence is also strongly and consistently 

associated with lower use of DHP; odds ratios range from 0.18 in Ghana and Indonesia to 0.29 in Bolivia.10

The multivariate analysis shows consistently lower odds for use of DHP with increasing parity in 

all six countries. The association is particularly strong in Bangladesh and the Philippines and is somewhat 

weaker in Malawi. Interestingly, the multivariate analysis also shows consistently higher odds of use of 

DHP with increasing age. This relationship is significant in every country except Malawi. The odds of 

DHP are between 1.2 (Malawi) and 3.5 (Bangladesh) times higher for births to women age 35 and older 

than for births to women under 19, after controlling for other variables in the model. This contrasts with 

the bivariate results discussed above, which found much less consistency. Age is highly correlated with 

both parity and education. The results suggest that the lower levels of DHP often observed among births 

to mothers over age 35 in the bivariate analysis are likely to be associated with the higher parity and 

lower maternal education of older mothers rather than to age per se. 

5.3 Use of Delivery Care and Antenatal Care 

Delivery care and antenatal care (ANC) are two key components of maternity care, so the relationship between them is of particular interest. One might expect that women who are motivated to attend 

antenatal services during pregnancy would also be motivated to use delivery services. However, use of 

 

10 We also ran models including an interaction between the survey variable and urban-rural residence to test for 

significant differences in the trends in urban and rural areas after controlling for other factors in the model. The 

interaction was only significant in Ghana and had little effect on the other parameter estimates in any of the 

countries. Therefore, we decided not to include it in the final model. 

Table 5.5 Odds ratios for delivery with a health professional (DHP) by trends over time and background characteristics, simple logistic regression 

model (Model 1) and regression model plus other variables (Model 2) 

Bangladesh 

(n=11553) 

 Bolivia 

(n=11423)

Ghana 

(n=6565)

Indonesia 

(n=35047)

Malawi 

(n=10170) 

Philippines 

(n=10354) Background 

characteristic Model 1 Model 2 Model 1 Model 2 Model 1 Model 2 Model 1 Model 2 Model 1 Model 2 Model 1 Model 2

Survey 

 First survey 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 

 Second survey 0.87 0.83 1.17 0.94 1.12 1.10 0.92 0.75* 1.02 0.87 1.16 1.09 

 Third survey 1.38** 0.95 1.94*** 1.62*** 1.19 1.17 1.17 0.93 na na na na 

 Fourth survey na na na na na na 1.71*** 1.39* na na na na 

 Residence 

 Urban na 1.00 na 1.00 na 1.00 na 1.00 na 1.00 na 1.00 

 Rural na 0.19*** na 0.29*** na 0.18*** na 0.18*** na 0.28*** na 0.26***

 Education 

 No education na 1.00 na 1.00 na 1.00 na 1.00 na 1.00 na 1.00 

 Primary na 1.65*** na 2.77*** na 2.72*** na 2.36*** na 1.59*** na 3.79***

 Secondary na 6.13*** na 13.50*** na 8.10*** na 10.77*** na 5.36*** na 11.91***

 Mother’s age 

 Less than 20 na 1.00 na 1.00 na 1.00 na 1.00 na 1.00 na 1.00 

 20-34 na 2.20*** na 1.26 na 1.34* na 1.97*** na 1.09 na 2.00***

 35+ na 3.50*** na 2.13*** na 1.56** na 2.56*** na 1.15 na 3.38***

 Parity 

 0 na 1.00 na 1.00 na 1.00 na 1.00 na 1.00 na 1.00 

 1-2 na 0.49*** na 0.65*** na 0.61*** na 0.68*** na 0.79*** na 0.63***

 3-4 na 0.34*** na 0.52*** na 0.53*** na 0.59*** na 0.85 na 0.42***

 5+ na 0.26*** na 0.40*** na 0.53*** na 0.48*** na 0.74** na 0.27***

 Note: Model 1 presents the crude trend in DHP. Model 2 presents the trend in DHP adjusted for background characteristics of the mother. 

*p<0.05; **p<0.01; ***p<0.001 

na = Not applicable
34 

antenatal care is consistently higher than use of delivery care in the six countries reviewed here (Figure 

5.12). In this section we examine the association between use of ANC and use of delivery care. 

5.3.1 Patterns of Use of Delivery Care and Antenatal Care 

Figure 5.13 shows the patterns of use of delivery care and antenatal care observed in the most recent surveys. Women received DHP and ANC for about half of births in Bolivia, Indonesia, Malawi, and 

the Philippines, making that service combination the most common in these countries. In Ghana, the percentage of women that received both services was only slightly less than the percentage that received 

ANC only (44 percent versus 46 percent). In Bangladesh the situation is completely different; women 

received neither DHP nor ANC for 62 percent of births, and only 10 percent received both. The percentage of women without DHP or ANC is also substantial in Bolivia (25 percent), but for the remaining 

countries this category accounts for less than 9 percent of women with births. Women receiving only 

ANC make up a notable proportion in every country (ranging from 16 percent in Bolivia to 46 percent in 

Ghana). The DHP only category is the smallest in every country, ranging from 5 percent in Bolivia down 

to 0.7 percent in Indonesia. 

Table 5.6.1 shows that the percentage of births for which women receive both DHP and ANC has 

increased in every country, most notably in Bolivia and Indonesia (13 percentage points). The increase 

was minimal in Ghana and Malawi, and although the absolute change was small in Bangladesh (3 percentage points) this represents a relative increase of over 50 percent. The percentage of births for which 

women received neither DHP nor ANC fell in all countries except the Philippines; again the greatest improvement was seen in Bolivia and Indonesia (14 and 12 percentage points, respectively). There has been 

little change in the proportion of women receiving only DHP. The percentage of births for which women 

received only ANC has risen in some countries and fallen in others, but the changes were small (not more 

than 4 percentage points in either direction). 
35 

Table 5.6.1 Women's use of health professionals for delivery care and antenatal care: National level 

 Survey DHP and ANC DHP only ANC only No DHP or ANC 

Number of 

deliveries 

Bangladesh 

 1993 5.8 3.3 21.5 69.1 3,898 

 1997 6.3 1.8 24.5 67.3 3,637 

 2000 9.6* 3.2 25.6* 61.6* 4,180 

 Bolivia 

 1989 u u u u u 

 1994 37.8 7.6 15.1 39.0 3,588 

 1998 52.5* 5.4* 16.4 25.0* 4,080 

 Ghana 

 1988 u u u u u 

 1993 41.9 1.3 44.5 11.5 2,152 

 1998 43.6 1.1 46.4 8.4 1,888 

 Indonesia 

 1987 u u u u u 

 1991 34.3 1.3 46.1 17.9 8,613 

 1994 40.4 0.9 47.7 10.5 10,052 

 1997 49.9* 0.7* 43.1 5.7* 9,685 

 Malawi 

 1992 51.3 0.4 40.1 6.4 2,798 

 2000 52.2 0.5 42.1 4.1 6,604 

 Philippines

 1993 51.4 2.2 40.4 5.1 5,356 

 1998 55.5 1.8 36.4 5.7 4,530 

 *Indicates a significant difference (at the .05 level) between the first and last survey in the country. 

u = Unknown (not available) 
36 

In urban areas more than 70 percent of women received both DHP and ANC in all countries except Bangladesh (29 percent) (Table 5.6.2). In contrast, in rural areas the percentage of women that received both services was much lower, ranging from 6 percent in Bangladesh to 48 percent in Malawi. 

Correspondingly, the percentage of women that received neither DHP nor ANC was higher in rural than 

in urban areas for all the countries, and was the most common service combination in rural Bangladesh 

and rural Bolivia. The percentage of women that received DHP only was larger in urban areas than in ru-

 Table 5.6.2 Women's use of health professionals for delivery care and antenatal care, by urban-rural 

residence 

 Survey DC & ANC DC only ANC only No DC or ANC 

Number of 

women 

(weighted) 

URBAN

Bangladesh 

 1993 28.9 5.1 27.1 38.6 392 

 1997 33.5 2.4 31.8 32.3 328 

 2000 29.1 4.8 30.0 36.0 687 

 Bolivia 

 1989 u u u u u 

 1994 55.6 9.4 12.4 22.1 1,882 

 1998 71.3* 6.3* 9.8 11.9* 2,327 

 Ghana 

 1988 u u u u u 

 1993 79.4 0.8 16.6 2.5 598 

 1998 75.0 1.3 19.4 3.8 471 

 Indonesia 

 1987 u u u u u 

 1991 66.7 1.4 27.3 4.4 2,495 

 1994 77.3 0.7 19.5 2.1 2,798 

 1997 79.1* 0.3* 18.9 1.2* 2,696 

 Malawi 

 1992 81.0 0.5 12.4 1.6 315 

 2000 79.7 0.3 18.3 1.0 854 

 Philippines

 1993 68.2 2.8 25.1 2.9 2,618 

 1998 76.7* 2.4 18.5* 2.0 2,089 

RURAL 

Bangladesh 

 1993 3.2 3.1 20.9 72.5 3,507 

 1997 3.6 1.7 23.7 70.8 3,309 

 2000 5.7* 2.9 24.7 66.7* 3,493 

 Bolivia 

 1989 u u u u u 

 1994 18.1 5.7 18.1 57.5 1,706 

 1998 27.5* 4.3 25.2* 42.4* 1,753 

 Ghana 

 1988 u u u u u 

 1993 27.5 1.4 55.2 15.0 1,554 

 1998 33.2 1.1 55.3 10.0* 1,418 

 Indonesia 

 1987 u u u u u 

 1991 21.0 1.3 53.8 23.5 6,118 

 1994 26.2 1.0 58.5 13.8 7,254 

 1997 38.7* 0.9 52.3 7.5* 6,992 

 Malawi 

 1992 47.6 0.4 43.6 7.0 2,484 

 2000 48.1 0.6 45.7 4.6 5,750 

 Philippines 

 1993 35.2 1.5 55.1 7.2 2,738 

 1998 37.3 1.3 51.7 8.9 2,441 

 *Indicates a significant difference (at the .05 level) between the first and last survey in the country. 

u = Unknown (not available) 
37 

ral areas for all countries except Indonesia and Malawi, where ANC is virtually universal. The higher percentage of women receiving DHP only in urban areas than in rural areas may reflect better access to 

emergency services in urban areas. 

Bangladesh was the only country where women in urban areas were more likely to receive ANC 

only than women in rural areas (where the majority of women reported no DHP or ANC). In all other 

countries the ANC only group was at least twice as large in rural areas as in urban areas (where the majority of women received both DHP and ANC). The largest urban-rural differences were in Bangladesh, 

where women in urban areas were five times as likely to receive both DHP and ANC as women in rural 

areas, and in Indonesia, Malawi, and the Philippines, where women in rural areas were four to six times as 

likely to receive no DHP or ANC compared with their urban counterparts. 

The percentage of women receiving DHP and ANC has generally increased over time in both urban and rural areas. The main exceptions to this pattern are Ghana and Malawi, where the percentage of 

women receiving both services in urban areas fell slightly. The percentage of women that received ANC 

only declined in urban areas of Bolivia, Indonesia, and the Philippines, but it generally increased or was 

fairly stable in rural areas. This pattern reflects the different points that urban and rural areas are at in 

terms of use of maternity services. In urban areas ANC is close to universal in most of the countries, so 

improvements come from a shift from ANC only to use of both services. In rural areas, there are still 

many women that do not receive either service, so there are shifts from use of no services to use of ANC 

only. With a couple of exceptions (urban Ghana, rural Philippines) the percentage of women that received 

neither service has declined in both urban and rural areas. The differences between urban and rural areas 

in women’s use of maternity services has been decreasing over time except in Malawi where the disparity 

has remained constant between surveys. 

5.3.2 Relationship Between ANC Use and Delivery with a Health Professional 

Table 5.7.1 examines the percentage of deliveries that were attended by a health professional by 

the level of ANC care they received. Two aspects of ANC use are examined; the timing of the first visit 

and the total number of visits. As expected, the percentage of deliveries that were attended by a health 

professional was consistently lower for births to mothers who had not received ANC than for births to 

mothers who had received ANC. In each of the countries, births to mothers who received ANC before 

they were five months pregnant were more likely to delivery with a health professional than those who 

were not seen until later in their pregnancy. At the time of the most recent survey the early ANC attendees had rates of DHP ranging from 35 percent in Bangladesh to 81 percent in Bolivia, while the late

ANC attendees had rates from 19 to 64 percent (also Bangladesh and Bolivia). Similarly, there is a clear 

positive association between the number of antenatal visits and DHP (see Figure 5.14). Women who 

made 4 or more ANC visits were generally about five times as likely to have DHP as those who had no 

ANC visits at all. The exceptions were Bangladesh (11 times as likely) and the Philippines (three times as 

likely). 

At the national level, DHP generally increased over time in all categories of antenatal care. The 

main exceptions were among women with no ANC in the Philippines and women who attended 1-3 times 

in Ghana. The magnitude of increase varied across countries and level of ANC use. For example, in Malawi there was virtually no change in the use of health professionals for delivery among users of ANC 

services, but there was a small nonsignificant increase among those who did not receive ANC. In Indonesia, there were relatively large increases in use of health professionals for delivery in all categories of 

ANC use; these increases were significant among women who received antenatal care. 

The relationships between ANC and DHP observed at the national level are also observed in urban and rural areas; i.e., use of DHP is highest among women who received ANC early and often, and 

 
38 

Table 5.7.1 Percentage of deliveries with a health professional (DHP), by use of antenatal care services: National level 

 Timing of first antenatal visit Number of antenatal visits 

 Early Late None 1-3 4+ 

Survey % DHP n % DHP n % DHP n % DHP n % DHP n 

 Bangladesh 

 1993 27.3 536 15.1 532 4.6 2,823 13.8 850 50.1 217 

 1997 26.4 548 14.6 570 2.6 2,512 12.9 884 48.9 233 

 2000 35.4 608 19.1 858 4.7 2,711 15.1 1,055 53.3 414 

 Bolivia 

 1989 u u u u u u u u u u 

 1994 78.1 1,320 56.0 579 16.3 1,678 50.6 762 85.4 1,136 

 1997 80.5 2,100 63.8 712 17.7 1,251 55.5 849 85.1 1,962 

 Ghana 

 1988 u u u u u u u u u u 

 1993 54.8 1,130 38.8 711 9.8 275 26.3 574 58.4 1,286 

 1998 54.1 1,114 37.2 576 11.8 182 21.3 509 60.0 1,192 

 Indonesia 

 1987 u u u u u u u u u u 

 1991 47.8 5,223 26.7 1,679 6.9 1,660 20.0 2,127 52.6 4,797 

 1994 50.8 6,776 30.3 2,090 7.9 1,145 23.2 2,413 54.4 6,441 

 1997 57.9* 7,298 35.8* 1,726 11.4 625 31.3* 2,093 60.5* 6,911 

 Malawi 

 1992 59.1 666 55.4 1,927 6.3 192 50.9 823 58.5 1,739 

 2000 58.7 1,446 54.3 4,835 11.4 308 51.0 2,564 58.4 3,664 

 Philippines 

 1993 62.9 2,966 45.7 1,964 29.8 389 38.2 2,087 69.1 2,829 

 1998 67.2 2,705 47.5 1,462 23.9 341 39.8 1,385 70.6 2,776 

 Note: During the Malawi 2000 and Bangladesh 2002 surveys, information about the timing and number of ANC visits was only 

asked relative to the most recent live birth in the 3-year reference period, whereas in all the other surveys, the data represent all 

live births in the 3-year reference period. 

*Indicates a significant difference (at the .05 level) between the first and last survey in the country. 

u = Unknown (not available) 
39 

lowest among those who received no ANC (Table 5.7.2). For every category of ANC use, women in urban areas have higher levels of DHP than women in rural areas. The difference in DHP levels between 

women with four or more ANC visits and those with no visits is always higher in rural areas than urban 

 Table 5.7.2 Percentage of deliveries with a health professional by use of antenatal care services and urban-rural residence 

Timing of first antenatal visit Number of antenatal visits 

 Early Late None 1-3 4+ 

Survey % DHP n % DHP n % DHP n % DHP n % DHP n 

 URBAN

Bangladesh 

 1993 60.6 137 36.3 84 11.6 171 34.8 113 69.2 107 

 1997 63.1 140 28.9 74 6.9 114 30.3 108 72.7 106 

 2000 60.3 214 33.2 191 11.4 281 26.8 211 70.1 195 

 Bolivia 

 1989 u u u u u u u u u u 

 1994 86.5 936 68.9 348 29.7 598 63.2 371 89.4 908 

 1997 90.2 1,493 79.5* 400 34.0 431 74.4* 419 91.7 1,469 

 Ghana 

 1988 u u u u u u u u u u 

 1993 85.7 384 76.6 188 a 20 63.4 82 86.0 492 

 1998 79.9 328 77.3 116 a 24 47.8 65 84.6 380 

 Indonesia 

 1987 u u u u u u u u u u 

 1991 73.9 1,974 54.8 367 23.8 145 39.4 369 76.9 1,976 

 1994 82.2 2,340 65.4 373 24.6 76 57.9 300 82.6 2,409 

 1997 82.1 2,351 69.8 294 18.3 39 57.3 277 83.4 2,361 

 Malawi 

 1992 91.8 75 86.0 230 a 7 81.7 72 88.4 222 

 2000 82.4 250 80.6 592 a 11 80.6 251 81.7 586 

 Philippines 

 1993 77.0 1,611 66.0 846 49.9 149 55.0 803 82.0 1,640 

 1998 84.7* 1,429 69.9 558 54.9 92 63.6 437 85.3 1,551 

RURAL

Bangladesh 

 1993 15.9 339 11.1 448 4.1 2,652 10.6 737 31.7 111 

 1997 13.8 408 12.5 496 2.4 2,399 10.4 775 29.1 127 

 2000 21.9 394 15.0 667 3.9 2,430 12.1 844 38.4 219 

 Bolivia 

 1989 u u u u u u u u u u 

 1994 57.6 384 36.6 231 8.9 1,080 38.6 391 69.5 228 

 1997 56.5 607 43.8 313 9.1 820 37.0 431 65.5 493 

 Ghana 

 1988 u u u u u u u u u u 

 1993 38.9 746 25.2 523 8.6 255 20.1 492 41.3 794 

 1998 43.3 786 27.1 459 9.8 158 17.4 444 48.4* 812 

 Indonesia 

 1987 u u u u u u u u u u 

 1991 32.0 3,249 18.9 1,312 5.3 1,515 16.0 1,758 35.7 2,821 

 1994 34.2 4,436 22.7 1,718 6.7 1,069 18.3 2,114 37.5 4,032 

 1997 46.5* 4,947 28.9* 1,432 10.9* 585 27.3* 1,816 48.6* 4,549 

 Malawi 

 1992 55.0 591 51.2 1,697 5.6 185 48.0 752 54.2 1,517 

 2000 53.8 1,195 50.7 4,244 10.7 297 47.8 2,313 53.9 3,078 

 Philippines 

 1993 46.2 1,355 30.3 1,119 17.4 240 27.7 1,284 51.2 1,189 

 1998 47.7 1,277 33.7 905 12.6 249 28.8 948 52.0 1,225 

Note: During the Malawi 2000 and Bangladesh 2002 surveys, information about the timing and number of ANC visits was 

only asked relative to the most recent live birth in the 3-year reference period, whereas in all the other surveys, the data 

represent all live births in the 3-year reference period. 

*Indicates a significant difference (at the .05 level) between the first and last survey in the country. 

a = Figure is based on fewer than 25 unweighted cases and has been suppressed 

u = Unknown (not available) 
40 

areas. Trends in DHP by ANC-utilization group are less consistent in urban and rural areas than at the 

national level—in part because of the small sample size for some subgroups—and no general conclusions 

can be drawn. 

5.4 Consistency of Delivery Care Use Between Pregnancies 

Another aspect of delivery care that is of particular interest is the extent to which women repeat 

the same delivery care across different pregnancies. For example, do women who choose to have a health 

professional deliver their first child continue to use delivery care for subsequent births, or do they stop 

using delivery care for later births as their familiarity and confidence in the birthing process increases. 

Literature from other areas of health behavior research suggests that past behavior is a very strong predictor of subsequent behavior (Nuwaha et al., 2001; Sutton, 1994) so we would expect a strong correlation in 

the use of health professionals at delivery for births to the same woman. 

To examine this issue for the six countries in this study, we begin by summarizing the delivery 

care behavior of women who had more than one birth in the five years preceding each survey. Note that 

this analysis is based on women, not births. In order to maximize the number of women with more than 

one birth in the reference period, we use only those surveys that collected information on delivery care for 

the five calendar years before the survey. However, even with the longer reference period there are relatively few women with multiple live births in the reference period and it is important to remember that 

this group of women is a relatively select group because it represents women who tend to have higher 

fertility and shorter birth intervals. These women are typically of lower socioeconomic status and, as 

noted earlier, are less likely to use delivery care. In addition, given the short reference period, most 

women with multiple deliveries have only two deliveries in the period. This feature of the sample means 

we will underestimate the percentage of women who change their delivery care behavior over their lifetime because we are only observing a limited part of their reproductive experience. 

In Tables 5.8.1 and 5.8.2 women with multiple deliveries are classified according to whether they 

reported DHP for all, some, or none of their deliveries. In all surveys except the most recent surveys in 

Malawi and the Philippines, women who did not receive professional delivery care for any of their deliveries were the largest proportion, ranging from 36 percent in Malawi to 89 percent in Bangladesh. The 

percentage of women who reported having DHP for all their deliveries ranged from 5 percent in Bangladesh to 44 percent in the Philippines. Although most women were consistent in their use or nonuse of 

DHP, a significant minority of women did change their delivery care behavior between pregnancies in the 

last five years; the percentage of women with multiple deliveries who reported delivery with a health professional for some, but not all, of their births ranged from 7 percent in Bangladesh to 27 percent in Malawi. 

The percentage of women who had DHP for all of their deliveries increased in each of the countries except Malawi where it fell by 2 percentage points. The largest increases were seen in Bolivia and 

Indonesia (9 percentage points). These increases were largely achieved through declines in the percentage 

of women who reported delivery care for none of their deliveries; the percentage of women reporting inconsistent delivery care behavior remained fairly constant over time in all countries except Bangladesh 

and Bolivia, where it increased by about 3 percentage points. 

As with other indicators, the national-level data on consistency of delivery care mask differences 

by urban-rural residence. The shift toward more consistent use of delivery care was more marked in urban areas than in rural areas in Bangladesh, Bolivia, Ghana, and Indonesia. In each of these countries the 

percentage of women who used delivery care for successive births increased sharply in urban areas. The 

gains were statistically significant in Bolivia, Ghana, and Indonesia, but not Bangladesh, where the urban 

sample was smaller. In rural areas, the increases were significant only in Bangladesh and Indonesia. 

These gains were accompanied by declines in the percentage of women who did not receive delivery care 
41 

for any of their births. These declines were also larger in urban areas than rural areas, and were significant 

in Bolivia and rural Bangladesh and Indonesia. 

Differences by urban-rural residence for women who received delivery care for some, but not all 

their births, varied by country, and the Philippines and Malawi showed distinct patterns. In the Philippines, the national shift toward more consistent delivery care was driven almost entirely by changes in 

behavior among urban women. In urban areas in the Philippines, the percentage of women receiving delivery care for all births increased significantly while the percentage of women receiving no delivery care 

for any births declined significantly. At the same time, there were no significant changes in behavior 

among rural women. Malawi was the only country that experienced a shift away from consistent delivery 

care—a shift that was most evident in urban areas. While the decline in the percentage of women in Malawi receiving delivery care for all their births was not significant in either urban or rural areas, the percentage of women in that country who reported no delivery care for any of their births increased significantly in urban areas and showed a smaller, nonsignificant increase in rural areas. 

Another way of looking at this issue is to estimate the effect of whether or not the previous child 

received DHP on the probability of the index child receiving DHP. This is best done in a multivariate 

framework. The sample for this analysis consists of all children born in the past five years who had an 

older sibling born in the same five-year period. Again, a five-year reference period is used for this analysis to maximize the sample of births for the model. As with the previous woman-based analysis, it is important to remember that this subsample of births is selective because it will tend to include higher order 

births with shorter preceding birth intervals. However, for this analysis our interest is in the odds ratio for 

the effect of the delivery care received for the preceding birth and not on the overall level of use of DHP. 

Table 5.8.1 Consistency of use of health professionals for delivery services among women with more 

than one delivery over a five-year period: National level 

 

Use of health professionals by women with 

more than one delivery 

Survey All deliveries Some deliveries No deliveries 

Number of 

women 

(weighted) 

Bangladesh 

 1993 u u u u 

 1997 1.8 3.7 94.5 2,979 

 2000 4.8* 6.7* 88.5* 3,164 

 Bolivia 

 1989 28.9 10.9 60.2 3,750 

 1994 u u u u 

 1997 38.1* 13.9* 48.1* 4,109 

 Ghana 

 1988 27.6 17.7 54.7 2,573 

 1993 u u u u 

 1998 29.6 16.5 54.0 1,594 

 Indonesia 

 1987 31.5 9.6 58.9 4,184 

 1991 28.1 9.2 62.7 6,327 

 1994 31.9 10.0 58.2 6,692 

 1997 40.1* 9.2 50.7* 5,644 

 Malawi 

 1992 40.0 28.1 31.9 3,072 

 2000 37.7 26.8 35.6* 7,539 

 Philippines 

 1993 41.8 13.5 44.6 5,747 

 1998 43.9 14.1 41.7* 4,657 

*Indicates a significant difference (at the 0.05 level) between the first and last survey in the country. 

u = Unknown (not available) 
42 

Table 5.8.2 Consistency of use of health professionals for delivery services among women with more 

than one delivery over a five-year period, by urban-rural residence 

 Health professional in attendance 

Survey All deliveries Some deliveries No deliveries 

Number of 

women 

(weighted) 

URBAN 

Bangladesh 

 1993 u u u u 

 1997 13.4 10.5 76.2 203 

 2000 17.3 15.8 66.9 435 

 Bolivia 

 1989 46.4 13.2 40.4 1,636 

 1994 u u u u 

 1997 60.5* 14.1 25.4* 1,967 

 Ghana 

 1988 54.0 21.2 24.8 633 

 1993 u u u u 

 1998 65.2* 14.2 20.7 308 

 Indonesia 

 1987 63.3 10.6 26.2 1,147 

 1991 58.5 11.6 29.9 1,822 

 1994 69.7 12.8 17.5 1,647 

 1997 72.6* 6.6* 20.8 1,434 

 Malawi 

 1992 76.9 15.7 7.4 320 

 2000 69.3 18.3 12.5* 786 

 Philippines 

 1993 60.0 14.4 25.4 2,661 

 1998 68.4* 12.9 18.5* 1,960 

RURAL 

 Bangladesh 

 1993 u u u u 

 1997 1.0 3.2 95.8 2,776 

 2000 2.8* 5.3* 91.9* 2,729 

 Bolivia 

 1989 15.3 9.1 75.6 2,115 

 1994 u u u u 

 1997 17.5 13.6* 68.9* 2,142 

 Ghana 

 1988 19.0 16.6 64.4 1,940 

 1993 u u u u 

 1998 21.0 17.0 62.0 1,285 

 Indonesia 

 1987 19.5 9.3 71.2 3,037 

 1991 15.8 8.2 76.0 4,505 

 1994 19.5 9.1 71.5 5,046 

 1997 29.1* 10.1 60.8* 4,211 

 Malawi 

 1992 35.7 29.5 34.8 2,753 

 2000 34.0 27.8 38.3 6,753 

 Philippines 

 1993 26.1 12.7 61.1 3,086 

 1998 26.1 15.0 58.6 2,696 

 *Indicates a significant difference (at the 0.05 level) between the first and last survey in the country. 

u = Unknown (not available) 

Table 5.9 shows the odds ratios from a logistic regression model that includes DHP for a previous 

child as a predictor of the index child being delivered by a health professional. We also include interactions between parity and the delivery care of the previous child to investigate whether women become 

less inclined to repeat use of professional delivery care for higher order births. The results demonstrate 

that a preceding delivery with a health professional was by far the strongest predictor of DHP in the index 

pregnancy. The association between DHP and education level or urban-rural residence is small in com-
43 

parison. The interaction between delivery care for the preceding child and parity is significant in Bangladesh and the Philippines, and suggests that the effect of use of professional delivery care for the preceding 

child is even stronger for births of parity 3-4 than for births of parity 2. 

5.5 Professional Attendance at Delivery and Pregnancy Outcomes 

In this final section we briefly explore the relationship between use of professional attendants for 

delivery and selected outcomes of pregnancy. However, the types of outcomes that we are able to look at 

with DHS data and the way we can look at the association between delivery care and outcomes are very 

limited. As discussed in the introduction, it is extremely difficult to measure maternal mortality and, even 

when maternal mortality data are available, they are not sufficiently precise to allow us to look at trends 

over the same periods that we are looking at for use of professional attendants. Therefore, we do not include any analysis of maternal mortality here. There are also no data on maternal morbidity in the DHS 

that can be used here. Therefore, we focus only on caesarean section rates and early neonatal mortality 

rates (ENMR). 

Table 5.10 presents trends in the percentage of births that were attended by a doctor and by a health professional alongside trends in the percentage of births that were delivered by caesarean section and the 

early neonatal mortality rate. This analysis provides a simple comparison of trends in different maternal 

health outcomes and enables us to see whether the patterns fit with our expectations. We cannot infer causality from this type of comparison. 

Table 5.9 Odds ratios for delivery with a health professional for previous child as a predictor of delivery with a health professional for subsequent 

child, by background characteristics, simple logistic regression model (Model 1) and regression model plus other variables (Model 2)

Bangladesh 

(n=3098) 

Bolivia 

(n=2312) 

Ghana 

(n=2078) 

Indonesia 

(n=6631) 

Malawi 

(n=2343) 

Philippines 

(n=3208) Background 

characteristics Model 1 Model 2 Model 1 Model 2 Model 1 Model 2 Model 1 Model 2 Model 1 Model 2 Model 1 Model 2

Delivery care for 

previous child 

 No 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 

Yes 25.59*** 18.33*** 38.99*** 39.99*** 18.79*** 16.22*** 50.64*** 42.82*** 7.29*** 7.63*** 33.85*** 24.40***

 Survey 

 First survey 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 

 Second survey 0.92 0.93 0.89 0.89 1.18 1.17 1.03 1.03 0.85 0.84 0.94 0.94 

 Third survey 0.97 0.97 1.82*** 1.81*** 1.04 1.04 1.14 1.13 u u u u 

 Fourth survey u u u u u u 1.16 1.15 u u u u 

 Residence 

 Urban 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 

 Rural 0.27*** 0.26*** 0.50*** 0.50*** 0.40*** 0.40*** 0.27*** 0.27*** 0.31*** 0.31*** 0.51*** 0.51***

 Education 

 No education 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 

 Primary 1.36 1.38 1.78** 1.79** 1.60** 1.60** 1.81*** 1.80*** 1.30* 1.30* 1.40 1.32 

 Secondary 4.12*** 4.25*** 4.03*** 4.03*** 3.89*** 3.87*** 3.23*** 3.24*** 4.77*** 4.71*** 2.57** 2.47** 

 Parity 

 1-2 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 

 3-4 1.32 0.88 1.21 1.23 1.07 0.94 1.16 0.99 1.21 1.32 1.00 0.75 

 5+ 1.14 0.85 0.88 0.90 0.95 0.77 1.05 0.86 1.22 1.22 0.89 0.59* 

 Interactions 

Parity 3-4 *delivery care 

for previous child u 4.05* u 0.96 u 1.25 u 1.43 u 0.87 u 1.77* 

Parity 5 +*delivery care 

for previous child u 2.48 u 0.95 u 1.48 u 1.66 u 1.00 u 2.57* 

P-value for likelihood 

ration test u 0.01 u 0.99 u 0.49 u 0.07 u 0.79 u 0.01 

*p<0.05; **p<0.01; ***p<0.001 

u = Unknown (not available) 
44 

Table 5.10 Trends in percentage of deliveries attended by a doctor, percentage of deliveries attended by a health professional,

percentage of deliveries by caesarean section, and percentage of early neonatal deaths 

Delivery attended by: 

Survey Doctor 

Health 

professional 

Caesarean 

section 

Number of 

deliveries 

Early 

neonatal deaths 

(0-6 days) 

Number of 

births 

(weighted)1

Bangladesh 

 1993 4.2 9.1 u 3,898 3.3 3,926 

 1997 5.6 8.1 u 3,637 2.4 3,665 

 2000 7.6* 12.1* 2.8 4,180 2.9 4,212 

 Bolivia 

 1989 38.8 41.8 u 3,531 2.3 3,548 

 1994 42.5 45.7 10.3 3,588 2.0 3,615 

 1997 55.4* 58.2* 14.6* 4,080 2.1 4,106 

 Ghana 

 1988 6.3 40.6 u 2,507 3.4 2,565 

 1993 6.7 43.4 4.5 2,152 2.9 2,204 

 1998 7.4 44.7 4.0 1,888 2.4 1,927 

 Indonesia 

 1987 3.8 37.6 u 4,617 1.3 4,652 

 1991 4.8 35.7 1.2 8,613 2.0 8,697 

 1994 6.7 41.5 2.8 10,052 2.2 10,131 

 1997 7.4* 50.9* 4.2* 9,685 1.6 9,768 

 Malawi 

 1992 4.6 52.7 3.4 2,798 3.5 2,854 

 2000 5.2 52.9 2.6 7,590 3.0 7,758 

 Philippines 

 1993 26.9 53.9 6.4 5,356 1.3 5,393 

 1998 32.7* 57.5 6.1 4,530 1.5 4,566 

 *Indicates a significant difference (at the 0.05 level) between the first and last survey in the country. 

u = Unknown (not available) 

1

 Includes multiple births 

As discussed throughout this report, the percentage of births attended by a health professional has 

increased in all six countries as has the percentage of births attended by a doctor. However, the percentage of births delivered by caesarean section has only increased in Bolivia and Indonesia, the countries that 

saw the largest increases in professional attendance. It appears that the increases observed in the percentage of deliveries attended by a health professional is not large enough in the other countries to have a significant impact on use of C-sections. The World Health Organization recommends that national caesarean 

section rates should not be lower than 5 percent or higher than 15 percent (Maine et al., 1997), and a recent study estimated that a caesarean section rate of 3.6 to 6.5 percent is needed to address obstetric complications in West Africa (Dumont et al., 2001). C-section rates are below 5 percent in four of the six 

countries, and of these only Indonesia has seen significant improvement. This raises concerns about the 

adequacy of access to C-sections in these countries. In Bolivia and Indonesia the increase in the use of Csections has been associated with a significant increase in the use of doctors for delivery care. These data 

do not allow an assessment of the proportion of these C-sections that were necessary nor the proportion of 

women for whom a C-section was indicated, but not performed. 

Early neonatal mortality rates have declined slightly in four of the six countries but the declines 

are small and not statistically significant. The changes do not seem to be associated with increases in professional attendance at delivery. For example, Indonesia has seen large increases in professional attendance at delivery but early neonatal mortality rates have fluctuated between 1.3 percent of live births in 

1987 and 2.2 percent of live births in 1994. One problem with this type of analysis is that the sample sizes 

are small for detecting change in early neonatal mortality rates so the rates tend to fluctuate due to sampling noise. In addition, the quality of reporting of early neonatal deaths can be poor (Curtis, 1995) so 

variations in the quality of data between surveys could also contribute to fluctuations in the early neonatal 

mortality rate. 
45 

Table 5.11 presents the early neonatal mortality rates for births that were attended by a health 

professional and those that were not. According to the most recent surveys in Bangladesh, the ENMR is 

slightly higher among births attended by a health professional than those not attended by a health professional. Given the very low level of delivery with a health professional in Bangladesh, this finding probably represents selection effects whereby the deliveries that occur with a health professional are more 

likely to be those with complications and therefore at higher risk of early neonatal death. Another possible 

type of selection is that delivery with a health professional is more common among more educated and 

economically advantaged mothers, who also report early neonatal deaths more completely. In the remaining countries, the ENMR is either similar among births attended and not attended by a health professional 

(Ghana, Indonesia, the Philippines) or it is slightly higher among births not attended by a health professional (Bolivia, Malawi). Differences are small though and should be interpreted with caution given the 

potential for selection effects to operate as described for Bangladesh. 

Trends in the ENMR for the two groups of births vary across countries and there are no consistent 

patterns. The ENMR for deliveries by nonprofessionals decreased in Bangladesh but increased for deliveries by a health professional. The reverse was true in Bolivia. In Ghana, there was a decline in both 

groups, and in Indonesia both groups increased in surveys 2 and 3 and then declined in survey 4. Changes 

in the ENMR were very small in Malawi and the Philippines. 

Table 5.11 Trends in early neonatal death (0-6 days) by attendance of a health professional at 

delivery 

Early neonatal deaths (0-6 days) 

Survey 

Health 

professional 

in attendance 

Number of

births 

(weighted) 

No health 

professional 

In attendance 

Number of 

births 

(weighted)1

 

Bangladesh 

 1993 1.6 362 3.4 3,557 

 1997 4.0 296 2.2 3,365 

 2000 4.5 516 2.6 3,692 

 Bolivia 

 1989 2.0 1,486 2.6 2,055 

 1994 1.5 1,656 2.3 1,952 

 1998 1.4 2,395 3.0 1,701 

 Ghana 

 1988 3.9 1,049 2.8 1,506 

 1993 2.8 964 2.9 1,235 

 1998 2.1 864 2.2 1,056 

 Indonesia 

 1987 0.7 1,757 1.6 2,875 

 1991 1.6 3,101 2.2 5,575 

 1994 2.1 4,206 2.2 5,924 

 1997 1.6 4,982 1.5 4,786 

 Malawi 

 1992 3.0 1,501 4.0 1,346 

 2000 2.3 4,113 3.7 3,642 

 Philippines 

 1993 1.3 2,911 1.1 2,479 

 1998 1.5 2,627 1.5 1,933 

1

 Includes multiple births 
46 

6 Discussion 

6.1 Methodological Issues 

One of the key methodological issues highlighted in this comparative study is related to sampling. 

Our choice to use a birth-based analysis of deliveries in the past three years is explained in Section 4. The 

results identified the merits and weaknesses of different approaches, and made clear the pitfalls of comparing surveys that have different data collection periods or different approaches (woman-based analysis 

versus birth-based analysis). Researchers examining the data should be aware that comparison of heterogeneous data sets can lead to biases in results and the identification of trends where there are none, or no 

trends where they do in fact exist. 

Another important methodological consideration is related to the statistical significance of differences observed in levels of DHP over time and between subgroups of women. Sometimes these differences may appear large but are based on small numbers of women and, therefore, can easily be due to 

random fluctuation and not to any real difference in use of delivery care. 

In addition, a variety of methods for investigating the levels and characteristics of delivery care 

are presented in this study, using both new and established indicators. Various processes of analyses are 

used including bivariate analysis, multivariate analysis, and stratification of indicators by women’s use of 

ANC and demographic and obstetric characteristics. We used this wide range of methods in pursuit of our 

aim to increase the depth of understanding of delivery care indicators and to identify the degree of information that can be extracted from existing data. 

The value of stratification is demonstrated by the differences observed in use of delivery care by 

urban-rural residence. These were substantial throughout the analysis, in both levels and rates of change. 

For example, in Indonesia a national increase in deliveries in health facilities of 0.5 percent masks an increase of nearly 4 percent in rural areas and a decline of nearly 6 percent in urban areas. In each of the 

countries DHP levels were at least twice as high in urban areas as in rural areas. This stratification demonstrates how national figures can mask differences at the subnational level and the importance of separate analysis. 

This comparative study has provided the opportunity to use DHS data to create composites of 

more than one variable. It was noted earlier that the proportion of deliveries with a health professional is 

only a crude indicator of skilled attendance, and measures only one of its components. The composite 

indicators used in this study combine attendant and place of delivery, or types of attendants, in an attempt 

to capture the complexity of skilled attendance. 

6.2 Substantive Findings 

National trends in delivery with a health professional over the past decade show an increased use 

of delivery care in the countries analyzed here, although the increase was negligible in Malawi. In three of 

the countries this trend was statistically significant at the 5 percent level but the magnitude of the trends 

was reduced after controlling for socioeconomic factors, and became nonsignificant in Bangladesh. The 

change in the estimated trend when controlling for other factors indicates the extent to which the observed 

change in DHP is explained by changes in the basic socioeconomic and obstetric characteristics of the 

population. In each of the countries the prevalence of factors associated with favorable levels of DHP are 

increasing; there is a shift toward urban residence, lower parity, and improved levels of maternal education. In Bangladesh, these changes have been relatively large—between 1993 and 2000, for example, the 

proportion of women with at least a secondary education rose from 15 percent to 25 percent and urban 

residence increased from 10 percent to 16 percent. These shifts in the characteristics of the population 
47 

completely explained the observed trend in DHP, which is an important factor to consider in any assessment of the effectiveness of national safe motherhood programs. 

The increase in DHP was lowest in Malawi, where there was essentially no change. There may be 

several reasons for this lack of progress. Despite reasonably good access to health facilities where health 

professionals are based, Malawi has had to face the challenge of one of the most severe HIV/AIDS epidemics in sub-Saharan Africa, with a national prevalence of 15 percent documented at sentinel surveillance sites (MOHP, 1999). In addition to the stigma associated with positive HIV status among seekers of 

delivery care, the HIV/AIDS epidemic has also affected the human resource pool of professionals. Malawi is also the seventh poorest country in the world according to recent World Bank estimates (World 

Bank, 2002). 

As noted earlier, the proportion of deliveries with a health professional measures only one component of skilled attendance. Considering attendant and place of delivery together is an attempt to capture 

a little more of the complexity of skilled attendance, and it reveals an additional dimension hidden by 

considering the two components separately. The investigation of national trends using these composite 

indicators illustrates the existence of two main models of care used by the six countries. One approach—

the medical model where women travel to health facilities to be attended by a professional during delivery—has resulted in the establishment of provision of care by health professionals in health facilities (Bolivia, Ghana, and Malawi), with the vast majority of deliveries with a health professional occurring in facilities. The other approach—the community or domiciliary model where professionals in the community 

are available to attend home-based deliveries—adopted in Indonesia, brings the services of health professionals into the community and has strengthened the domiciliary model (Ronsmans et al., 2001). In Bangladesh and the Philippines, a transition between the two models is taking place, with a move toward 

institutional care. 

It is generally agreed that skilled attendance can only be provided when health professionals operate within a functioning health system (or enabling environment) where drugs, equipment, supplies, and 

transport are all available. The definition of skilled attendance does not preclude domiciliary deliveries, 

but if these deliveries are to be included in the total of those receiving skilled care, consideration must be 

given to the enabling environment. If this is judged to be inadequate (for all or a substantial part of a 

country) then DHP would provide a poor approximation of skilled attendance in places where professional domiciliary deliveries account for a non-negligible proportion of total deliveries. For example, in 

Indonesia the exclusion of professionally attended home births would reduce the level of skilled attendance by more than half, and translate an apparent substantial improvement in delivery care into a trivial 

one. A related question is whether institutional deliveries are necessary for skilled attendance. It is crucial 

to clarify this issue, as advocating the institutionalization of all deliveries would have profound resource 

and logistical implications as well as raising concerns over the risks of over-intervention and iatrogenicity. Even deliveries with a health professional in a health facility cannot be assumed to meet the criteria 

for skilled attendance, and some of them certainly will not. The adequacy of an enabling environment in 

either facility or domiciliary settings cannot be captured by the simple indicator used in this analysis and 

is best assessed at the local level. 

The partnership ratio, another composite indicator used in this analysis, provides another approach to examining delivery care data. It is a good visual aid and is easier to interpret than tables of figures, while providing a perspective on skilled attendance related to the type of delivery attendant. Furthermore, it is a good advocacy tool for reinforcing the sense of partnership between doctors and nurses or 

midwives. It does not generate new information, but presents what we already have in a different way. 

The partnership ratio also incorporates a widely used statistic that 15 percent of deliveries can be expected 

to require medical attention (Maine et al., 1997), although the evidence for this appears to be based on a 

limited number of sources. 
48 

Plotting the partnership ratio by urban-rural residence produces the interesting finding that in urban areas the ratio nearly attains the optimum level of (15,85). It would be interesting to be able to look at 

MMR by urban-rural residence to see how the two correlate, but such a breakdown of the mortality data is 

not available at present. 

Not surprisingly, the increased use of DHP seen in all countries corresponds to a decline in the 

use of nonprofessional delivery attendants. However, analysis of deliveries with no professional present 

reveals differences between countries and emphasizes the importance of considering trends among nonprofessionals. Bangladesh and Ghana both show significant increases in the use of trained TBAs, while 

delivery care in Indonesia has shifted away from TBAs. As noted earlier, strategic approaches being advocated in these countries differ, and this could explain the differential use of nonprofessionals. Indonesia 

has been pursuing a policy of posting a trained midwife in every village (Ronsmans et al., 2001), making 

health professionals more geographically accessible to women. Ghana, on the other hand, has pursued a 

strategy of training TBAs (MOHG, 1997), while nurse midwives continue to practice almost exclusively 

in health facilities. In addition, user fees in Ghana for health facility care were only removed in 1998, a 

policy that had previously made the services of a health professional less accessible to women because of 

the cost (Asenso-Okyere, 1998). The findings suggest that a demand for better trained delivery attendants 

is likely to exist no matter what the programmatic strategy, and approaches that improve access to delivery care will be taken up. 

A significant finding of this study is that even in countries where national trends in DHP show 

improvement, large differentials remain. The associations observed between delivery care and maternal 

education, urban-rural residence, economic level, and parity were consistent with previous work (Stewart, 

Stanton, and Ahmed, 1997). An interesting new finding is that parity differentials are increasing in most 

of the countries. Urban-rural differentials also increased in three of the countries, educational differentials 

increased in Ghana and the Philippines, and wealth differentials increased to some extent in Bangladesh 

and Ghana. It is important to remember that these countries are currently experiencing changes in the 

characteristics of their populations that may explain all or part of this effect. For example, the proportion 

of births to high-parity women is declining in these countries as a result of a general decline in fertility. 

As this fertility decline becomes established, the women who progress to very high parities will increasingly be women with the least physical, social, or economic access to health services. These selection effects may in part explain the decline in the use of health professionals for delivery care among high-parity 

women. Similar patterns are observed for maternal education—with the proportion of women receiving 

no education declining—and for residence, as people continue to move to urban areas. These changes 

may mean that women in rural areas, those with no education, and high-parity women become an increasingly poorly-served but also a declining proportion of the population, in which overall levels of DHP may 

continue to rise due to these same changes in the characteristics associated with delivery care. 

Multivariate analysis also shows that education and urban-rural residence are the strongest predictors of DHP, controlling for year, parity, and maternal age. These findings are consistent with other studies that focus on predictors of professional delivery care (Thaddeus and Maine, 1994). 

Despite the clear association between DHP and use of ANC, sizeable percentages of women receive ANC only (e.g., in rural Bangladesh three times the number of those that receive DHP). This means 

that there are a substantial number of women able to access services who could be encouraged to use 

DHP at the time of their antenatal visits. The substantially higher levels of ANC compared with DHP 

suggests a disparity in the access to these two related services. For example, in some countries ANC is 

more likely to be free of charge than DHP, or it may be provided in a way that makes it more likely to be 

locally available to women than DHP (e.g., mobile clinics). The inability to predict the precise timing of a 

delivery may also make DHP less accessible to women compared with ANC. 
49 

We have also shown that women tend to be consistent in their use or nonuse of professional delivery care for successive births. This could be interpreted as showing that it is important to recruit 

women for professional delivery care early in their reproductive lives, because they tend to continue with 

the type of care with which they are familiar. 

It is difficult to assess the relationship between perinatal outcomes and professional attendance at 

delivery because of the bias that inevitably comes from our ability to consider only live births. Until more 

information is available, it is only possible to anticipate that the presence of a skilled health professional 

will increase the likelihood of improved perinatal outcomes. 

It is important to recognize that the indicator of DHP used in this analysis is very simple. While 

in many ways its simplicity is one of its strengths, it also gives rise to a number of limitations. The definition of a skilled attendant has not always been clear. Until recently, the term trained attendant was used 

and grouped both professional and nonprofessional health workers together. Only in 1999, were skilled 

attendants recognized as “health professionals with midwifery skills who have been trained to proficiency 

in the skills necessary to manage normal deliveries and diagnose or refer obstetric complications” (WHO, 

1999). These changes can cause confusion and may lead to differences in interpretation in many countries, particularly where intensive but shortened training has been provided to relieve the shortages of 

more traditionally trained doctors and nurse-midwives. Furthermore, the presence of a health professional 

does not necessarily imply competence or skills in conducting deliveries as there is no way of knowing 

the level of midwifery or obstetric skill of individual practitioners. 

Another limitation of DHP as used here is the reliance on women’s self-reports of the type of attendant present at delivery. It is not known how accurately women are able to identify the category of 

their attendant, nor do we know the extent of involvement of the health care provider in the delivery. In 

addition, the DHS information about deliveries is only recorded for live births, which misses a notinsignificant number of deliveries involving stillbirth. The biases resulting from these limitations are impossible to identify without further work. 

While it is important to recognize these inherent limitations when interpreting findings, it is also 

important to recognize the strengths of these data. The data are population-based so are representative of 

the experience of women in the general population; they contain large amounts of background information on the women; the surveys employ standardized, well-tested procedures to maximize data quality, 

and data have been collected in a consistent manner allowing comparisons across time. DHS surveys provide the best estimates currently available of many reproductive indicators including DHP in many countries, and remain the main source of international information in the area of safe motherhood. 

Future research in this area might include the development of population-based surveys that include: (i) validation work on the accuracy of women’s reports when asked about delivery attendants, e.g., 

their ability to identify the type of attendants present at delivery, and the level/timing of involvement of 

the attendants reported; (ii) the collection of data for all deliveries rather than only live births; and (iii) 

improved links with health facility information so that these can be classified into facilities providing basic and comprehensive emergency obstetric care. Other suggestions include improving countries abilities 

to perform data analysis similar to that described in this report for themselves; and increasing the availability of indicators for skilled attendance at delivery. These latter suggestions are partially addressed in 

the SAFE Strategy Development Tool (SAFE, 2003b), which provides guidelines on the secondary analysis of DHS data and a module on creating a skilled attendance index based on data collected from delivery 

records. 

Although national levels of professional attendance are increasing by varying degrees in the six 

countries included in the study, national trends mask substantial subnational variation in levels and trends 

in delivery care, and inequity in service use is increasing in some cases. Changes in the socioeconomic 
50 

profile of populations bode well for the uptake of delivery care at the national level. However, even when 

progress is being made at the national level, it is important to look deeper into the distribution of service 

utilization. Care must be taken not to neglect the disadvantaged women in society whose needs may be 

masked by the aggregated figures, and to be aware that although their numbers may be falling, they still 

make up a substantial proportion of the population. 
51 

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