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

evaluate population, health, and nutrition programs. Additional information about the 

MEASURE DHS project can be obtained by contacting ICF Macro, 11785 Beltsville Drive, 

Suite 300, Calverton, MD 20705 (telephone: 301-572-0200; fax: 301-572-0999; e-mail: 

reports@measuredhs.com; internet: www.measuredhs.com).

The main objectives of the MEASURE DHS project are: 

 to provide decisionmakers in survey countries with information useful for informed policy 

choices; 

 to expand the international population and health database; 

 to advance survey methodology; and 

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

demographic and health surveys. 
DHS Comparative Reports No. 26 

Levels and Trends in the Use of Maternal 

Health Services in Developing Countries 

Wenjuan Wang 

Soumya Alva 

Shanxiao Wang 

Alfredo Fort

ICF Macro 

Calverton, Maryland, USA 

June 2011 

Corresponding author: Wenjuan Wang, International Health and Development Division, ICF Macro, 11785 

Beltsville Drive, Suite 300, Calverton, MD 20705; Phone: 301-572-0398; Fax: 301-572-0999; Email: 

wwang@icfi.com 
Editor: Bryant Robey 

Document Production: Yuan Gu 

This study was carried out with support provided by the United States Agency for International 

Development (USAID) through the MEASURE DHS project (#GPO-C-00-08-00008-00). The views 

expressed are those of the authors and do not necessarily reflect the views of USAID or the United States 

Government. 

Recommended citation: 

Wang, Wenjuan, Soumya Alva, Shanxiao Wang, and Alfredo Fort. 2011. Levels and Trends in the Use of 

Maternal Health Services in Developing Countries. DHS Comparative Reports No. 26. Calverton, 

Maryland, USA: ICF Macro. 
iii 

Contents 

Tables........... ................................................................................................................................ v

Figures......................................................................................................................................... ix

Preface......................................................................................................................................... xi

Acknowledgements ...................................................................................................................... xiii

Executive Summary ...................................................................................................................... xv

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

2. Data and Analysis ....................................................................................................................... 3

2.1 Data ................................................................................................................................. 3

2.2 Analysis........................................................................................................................... 8

3. Results...... .................................................................................................................................. 9

3.1 Antenatal Care ................................................................................................................ 9

3.1.1 Current Use of Antenatal Care .............................................................................. 9

3.1.2 Timing of the First Antenatal Care Visit ............................................................. 11

3.1.3 Trends in Four or More Antenatal Care Visits .................................................... 13

3.1.4 Differentials in Four or More Antenatal Care Visits ........................................... 16

3.1.5 Providers of Antenatal Care ................................................................................ 20

3.1.6 Trends in Using Skilled Health Providers for Antenatal Care ............................ 23

3.1.7 Differentials in Use of Skilled Health Providers for Antenatal Care .................. 26

3.1.8 Content of Antenatal Care ................................................................................... 30

3.1.9 Use of Intermittent Preventive Treatment during Pregnancy for Malaria and 

HIV Testing During Antenatal Care ................................................................... 34

3.2 Delivery Care ................................................................................................................ 36

3.2.1 Place of Delivery ................................................................................................. 36

3.2.2 Trends in Births in Health Facilities ................................................................... 40

3.2.3 Differentials in Births in Health Facilities .......................................................... 43

3.2.4 Attendance during Delivery ................................................................................ 47

3.2.5 Trends in Use of Skilled Birth Attendants .......................................................... 50

3.2.6 Differentials in Use of Skilled Birth Attendants ................................................. 53
iv

3.3 Postnatal Care ............................................................................................................... 58

3.3.1 Current Use of Postnatal Care ............................................................................ 58

3.3.2 Timing of the First Postnatal Checkup ................................................................ 60

3.3.3 Provider of the First Postnatal Checkup .............................................................. 63

3.3.4 Differentials in Use of Postnatal Care ................................................................. 66

3.4 Relationships between Uses of Maternal Health Services ............................................ 69

3.4.1 Association between Using Antenatal Care and Skilled Birth Attendance ........ 69

3.4.2 Association between Using Antenatal Care and Postnatal Care ......................... 71

3.4.3 Association between Using Skilled Birth Attendance and Postnatal Care ......... 72

4 Summary and Discussion ........................................................................................................... 73

References.. ................................................................................................................................... 79

Appendix A: Trends in Caesarean Section Rates......................................................83
v

Tables 

Table 1. DHS surveys included in the analysis ......................................................................... 3

Table 2. Percent distribution of women who had a live birth in the five years preceding the 

survey by selected characteristics, the most recent DHS survey, 1990-2009 ............. 5

Table 3. Percent distribution of women who had a live birth in the five years preceding the 

survey by number of antenatal care visits for the most recent birth, the most recent 

DHS survey, 1990-2009 ............................................................................................ 10

Table 4. Percent distribution of women who had any antenatal care (ANC) for the most 

recent birth by timing of the first visit, the most recent DHS survey, 1990-2009 .... 12

Table 5. Percentage of women who received four or more antenatal care visits for the most 

recent live birth in the five years preceding the survey by selected characteristics, 

the most recent DHS survey, 1990-2009 ................................................................... 18

Table 6. Percent distribution of women who had a live birth in the five years preceding the 

survey by provider of antenatal care (ANC) for the most recent birth, the most 

recent DHS survey, 1990-2009 ................................................................................. 21

Table 7. Percentage of women who received antenatal care from a skilled health provider 

for the most recent birth in the five years preceding the survey by selected 

characteristics, the most recent survey, 1990-2009 ................................................... 28

Table 8. Among women receiving antenatal care (ANC) for the most recent birth in the 

five years preceding the survey, the percentage who reported specific antenatal 

services, the most recent survey, 1990-2009 ............................................................. 31

Table 9. Among women with a live birth in the five years preceding the survey, the 

percentage who received iron tablets or syrups and the percentage who received 

tetanus toxoid injections during the pregnancy of the most recent birth, the most 

recent survey, 1990-2009 .......................................................................................... 33

Table 10. Among women with a live birth in the two years preceding the survey, the 

percentage who received intermittent-preventive treatment (IPT) and the 

percentage who were offered and accepted an HIV test during an antenatal care 

(ANC) visit during the pregnancy of the most recent live birth, the most recent 

survey, 1990-2009 ..................................................................................................... 35

Table 11. Percent distribution of women who had a live birth in the five years preceding the 

survey by place of delivery for the most recent live birth, the most recent survey, 

1990-2009 .................................................................................................................. 38

Table 12. Percentage of women whose most recent live birth in the five years preceding the 

survey occurred in a health facility by selected characteristics, the most recent 

survey, 1990-2009 ..................................................................................................... 45
vi

Table 13. Percent distribution of women who had a live birth in the five years preceding the 

survey, by provider of assistance at birth for the most recent live birth, the most 

recent DHS survey, 1990-2009 ................................................................................. 48

Table 14. Percentage of women who had a skilled birth attendant at birth for the most 

recent birth in the five years preceding the survey by selected characteristics, the 

most recent survey 1990-2009 .................................................................................. 56

Table 15. Among women with a live birth in the five years preceding the survey, the 

percentage who received postnatal checkups (PNC) for the most recent birth 

according to place of delivery, the most recent survey, 1990-2009 .......................... 59

Table 16a. Percent distribution of women whose last live birth in the past five years 

occurred in a health facility and who received postnatal checkups (PNC) within 

41 days after delivery, by timing of mother's first postnatal checkup, the most 

recent survey, 1990-2009 .......................................................................................... 61

Table 16b. Percent distribution of women whose last live birth in the past five years 

occurred outside a health facility and who received postnatal checkups (PNC) 

within 41 days after delivery, by time of mother's first postnatal checkup, the 

most recent survey, 1990-2009 ................................................................................. 62

Table 17a. Percent distribution of women whose last live birth in the past five years 

occurred in a health facility and who received postnatal checkups (PNC) within 

41 days after delivery, by type of provider at the first checkup, the most recent 

survey, 1990-2009 ..................................................................................................... 64

Table 17b. Percent distribution of women whose last live birth in the past five years occurred 

outside a health facility and who received postnatal checkups (PNC) within 41 

days after delivery, by type of provider at the first checkup, the most recent 

survey, 1990-2009 ..................................................................................................... 65

Table 18a. Percentage of women whose last live birth in the past five years occurred in a 

health facility and who received postnatal checkups within 41 days after delivery 

by selected characteristics, the most recent survey, 1990-2009 ................................ 67

Table 18b. Percentage of women whose last live birth in the past five years occurred outside 

a health facility and who received postnatal checkups within 41 days after 

delivery by selected characteristics, the most recent survey, 1990-2009 .................. 68

Table19. Among women receiving different number of antenatal care visits for the most 

recent live birth in the five years preceding the survey, the percentage who had a 

skilled attendant at birth, the most recent survey, 1990-2009 ................................... 70
vii 

Table 20. Among women receiving different number of antenatal care visits for the most 

recent live birth in the five years preceding the survey, the percentage who had a 

postnatal checkup within 41 days after delivery, the most recent survey, 1990- 

2009 ........................................................................................................................... 71

Table 21. Among women receiving birth assistance from different providers for the most 

recent live birth in the five years preceding the survey, the percentage who had 

postnatal checkups within 41 days after delivery, the most recent survey, 1990- 

2009 ........................................................................................................................... 72

Appendix A. Percentage of women who had a caesarean section for the most recent live birth 

in the five years preceding the survey, 1990-2009 .................................................... 83

ix

Figures 

Figure 1. Trends in percentage of women having at least four antenatal care visits for the 

most recent birth in Western and Central Africa, 1990-2009 ................................... 14

Figure 2. Trends in percentage of women having at least four antenatal care visits for the 

most recent birth in Eastern and Southern Africa, 1990-2009 .................................. 14

Figure 3. Trends in percentage of women having at least four antenatal care visits for the 

most recent birth in South/Southeast Asia, 1990-2009 ............................................. 15

Figure 4. Trends in percentage of women having at least four antenatal care visits for the 

most recent birth in North Africa/West Asia/Europe, 1990-2009 ............................. 15

Figure 5. Trends in percentage of women having at least four antenatal care visits for the 

most recent birth in Latin America and the Caribbean, 1990-2009 .......................... 16

Figure 6. Trends in percentage of women receiving antenatal care from a skilled health 

provider for the most recent birth in Western and Central Africa, 1990-2009 ......... 24

Figure 7. Trends in percentage of women receiving antenatal care from a skilled health 

provider for the most recent live birth in Eastern and Southern Africa, 1990 

-2009 .......................................................................................................................... 24

Figure 8. Trends in percentage of women receiving antenatal care from a skilled health 

provider for the most recent live birth in South/Southeast Asia, 1990-2009 ............ 25

Figure 9. Trends in percentage of women receiving antenatal care from a skilled health 

provider for the most recent live birth in North Africa/West Asia/Europe, 1990 

-2009 .......................................................................................................................... 25

Figure 10. Trends in percentage of women receiving antenatal care from a skilled health 

provider for the most recent live birth in Latin America and the Caribbean, 1990 

-2009 .......................................................................................................................... 26

Figure 11. Trends in percentage of women whose most recent live birth occurred in a health 

facility in Western and Central Africa, 1990-2009 ................................................... 40

Figure 12. Trends in percentage of women whose most recent live birth occurred in a health 

facility in Eastern and Southern Africa, 1990-2009 .................................................. 41

Figure 13. Trends in percentage of women whose most recent live birth occurred in a health 

facility in South/Southeast Asia, 1990-2009 ............................................................. 41

Figure 14. Trends in percentage of women whose most recent live birth occurred in a health 

facility in North Africa/West Asia/Europe, 1990-2009 ............................................ 42

Figure 15. Trends in percentage of women whose most recent live birth occurred in a health 

facility in Latin America and the Caribbean, 1990-2009 .......................................... 42
x

Figure 16. Trends in percentage of women whose most recent live birth was attended by a 

skilled health provider in Western and Central Africa, 1990-2009 .......................... 51

Figure 17. Trends in percentage of women whose most recent live birth was attended by a 

skilled health provider in Eastern and Southern Africa, 1990-2009 ......................... 51

Figure 18. Trends in percentage of women whose most recent live birth was attended by a 

skilled health provider in South/Southeast Asia, 1990-2009 .................................... 52

Figure 19. Trends in percentage of women whose most recent live birth was attended by a 

skilled health provider in North Africa/West Asia/Europe, 1990-2009 .................... 52

Figure 20. Trends in percentage of women whose most recent live birth was attended by a 

skilled health provider in Latin America and the Caribbean, 1990-2009 ................. 53
xi 

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 Comparative Reports series examines these data across countries in a 

comparative framework. The DHS Analytical Studies series focuses 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 have a more 

analytical approach. The Comparative Reports series covers a variable number of countries, depending on 

the availability of data sets. Where possible, data from previous DHS surveys are used to evaluate trends 

over time. Each report provides detailed tables and graphs organized by region. Survey-related issues 

such as questionnaire comparability, survey procedures, data quality, and methodological approaches are 

addressed as needed. 

The topics covered in Comparative Reports are selected by MEASURE DHS staff in conjunction 

with the U.S. Agency for International Development. Some reports are updates of previously published 

reports. 

It is anticipated that the availability of comparable information for a large number of developing 

countries will enhance the understanding of important issues in the fields of international population and 

health by analysts and policymakers. 

Ann Way 

Project Director 

xiii 

Acknowledgements 

The authors would like to thank Sunita Kishor and Vinod Mishra who guided the research effort. 

Special thanks go to Marge Koblinsky and Joy Fishel for their review and helpful comments. In addition, 

we acknowledge the kind support from Stan Yoder who reviewed the report and provided valuable input. 

The authors also thank Bryant Robey for editing the report and Yuan Gu for formatting it. 

xv 

Executive Summary 

Many countries have made very limited or no progress in achieving the Millennium Development 

Goals (MDGs) 4 and 5 of reducing under-five mortality and maternal mortality. This study aims to 

contribute to the understanding of use of key maternal health services in the past two decades in 

developing countries. Such services are potentially important determinants of maternal and child 

mortality, and many other health outcomes of mothers and children. We analyze the current levels, trends 

and correlations in use of antenatal care, skilled birth attendance and postnatal care, along with 

differentials in use of these services by women’s demographic and socioeconomic characteristics. 

The study uses Demographic and Health Survey (DHS) data from 1990 to 2009 in 38 countries in 

four regions: sub-Saharan Africa; North Africa/West Asia/Europe; South/Southeast Asia; and Latin 

America and the Caribbean. We use the woman as the unit of analysis and focus on the most recent live 

birth in the past five years, or three years in surveys that asked only about births in three years prior to the 

interview. Based on the most recent DHS survey of each country, we report the level of each service use, 

as well as differences in use by individual and household characteristics. We also examine data from 

consecutive surveys in these countries to establish trends in use of antenatal care and skilled birth 

attendance. For postnatal care, the analysis covers only the most recent surveys in 18 countries with 

information available for both institutional births and non-institutional births. 

Our results indicate that the developing world as a whole has achieved great success in extending 

the reach of antenatal care. Over 80 percent of women in the majority of countries studied have at least 

one antenatal care visit during pregnancy, and in many countries the coverage reaches 90 percent. Despite 

progress in antenatal care coverage, many countries, particularly in sub-Saharan Africa and 

South/Southeast Asia, still have unsatisfactory levels of the recommended four or more antenatal care 

visits. Additionally, many women, particularly in sub-Saharan Africa, tend to wait to start antenatal care 

until the second or third trimester. Socioeconomic disparities in use of antenatal care are profound. 

Women are more likely to report four or more antenatal care visits if they reside in urban areas, have a 

higher education level or live in a richer household. The differentials are smaller in countries with overall 

high levels of antenatal care. The study shows that skilled health providers (doctor, nurse or midwife) are 

commonly reported as the sources of antenatal care in most of the countries studied. In all countries as a 

whole, women are more likely to get their blood pressure measured, but less likely to get urine and blood 

samples tested, particularly in South/Southeast Asia and sub-Saharan Africa. Countries in Latin America 

and the Caribbean perform better than those in other regions with regard to delivering a majority of the 

selected services. In sub-Saharan Africa, most countries have not taken advantage of antenatal care to 

offer women preventive medicines for malaria, despite the high prevalence of malaria. 

With regard to delivery care, there is a growing trend toward deliveries occurring in health 

facilities, both private and public. While in many countries the public sector contributes a major share of 

births that take place in an institutional setting, in some countries, particularly in North Africa/West 

Asia/Europe and South/Southeast Asia, the private sector for delivery care is much more developed. Use 

of health facilities for delivery varies by women’s socioeconomic status. There is a consistently positive 

association between use of health facilities for delivery and women’s education and household wealth. 

In most countries, skilled birth attendance for women at delivery follows a pattern very similar to 

their use of health facilities. These rates are considerably lower in sub-Saharan Africa and South Asia 

than in the other regions. Especially in sub-Saharan Africa, nurses and midwives rather than doctors are 

the main providers of skilled birth attendance. 

Women who delivered in a health facility, compared to those who did not, are more likely to 

report postnatal checkups, to have the first checkup within two days after delivery and to receive postnatal 
xvi 

care from a doctor, nurse or midwife. Combining institutional births and non-institutional births, in 8 of 

the 18 countries with data, 64 to 92 percent of women reported having a postnatal checkup within 41 days 

after giving birth. 

There is a strong positive correlation between number of antenatal visits, having skilled birth 

attendance, and receiving postnatal care. 

These findings provide valuable information for identifying intervention priorities for maternal 

and infant survival strategies and for developing policies and programs that can help to achieve MDGs 4 

and 5. 
1

1 Introduction 

Only five years are left to achieve the Millennium Development Goals (MDGs) 4 and 5 of 

reducing the under-five mortality rate by two-thirds and reducing the maternal mortality ratio by threequarters. However, many countries have made very limited or no progress in achieving these goals. 

Maternal mortality ratios remain high in many developing countries. The most recent estimates show that 

358,000 maternal deaths occurred worldwide in 2008, with 99 percent of maternal deaths occurring in 

developing countries as a whole, and 87 percent in sub-Saharan Africa and South Asia (WHO et al. 

2010). There has been encouraging achievement in reducing the global under-five mortality rate, which 

dropped from 89 per 1,000 in 1990 to 60 per 1,000 in 2009. Still, in 2009, 8.1 million children died before 

their fifth birthday. Neonatal mortality remains high and contributes to 40 percent of total under-five 

mortality (You, Jones, and Wardlaw 2010). 

The evidence shows that high maternal, neonatal and child mortality rates are associated with 

inadequate and poor-quality maternal health care, including antenatal care, skilled attendance at birth and 

postnatal care (Carroli, Rooney, and Villar 2001; Li et al. 1996; WHO 1999). With improved 

understanding of the need for women to prepare physically, mentally and even logistically for childbirth, 

antenatal care is recognized as a key maternal service in improving a wide range of health outcomes for 

women and children (McDonagh 1996; Carroli, Rooney, and Villar 2001; Chen et al. 2007). Antenatal 

care represents an opportunity to deliver interventions for improving maternal nutrition, providing health 

education, and encouraging skilled attendance at birth and use of facilities for emergency obstetric care 

(EMOC). All of these interventions could contribute to reducing maternal mortality and improving infant 

survival. With the spread of HIV in many countries of the world, antenatal care also serves as an 

important conduit for HIV testing and counseling and thus has potential for the prevention of HIV 

transmission from mother to child. The prevention and treatment of malaria among pregnant women can 

also significantly improve maternal health and fetal outcomes. 

The World Health Organization (WHO) recommends a minimum of four antenatal care visits, 

based on reviewing the effectiveness of different models of service delivery (Villar et al. 2001). WHO 

guidelines also specify the content of antenatal care visits, which should include blood pressure 

measurement, urine testing for bacteriuria and proteinuria, and blood testing to detect syphilis and severe 

anemia (WHO 2001). Some other services, including giving tetanus immunization, providing iron and 

folate tablets and teaching women about danger signs of pregnancy complications, are also important to 

improve both maternal and newborn health. 

Evidence suggests that skilled attendance at birth and access to emergency obstetric care are key 

factors in reducing the risk of maternal death, in both industrialized and developing countries (WHO, 

ICM, and FIGO 2004; Graham, Bell, and Bullough 2001; De Brouwere, Tonglet, and Van Lerberghe 

1998). WHO has defined a skilled attendant as ―an accredited health professional – such as a midwife, 

doctor or nurse – who has been educated and trained to proficiency in the skills needed to manage normal 

(uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, 

management and referral of complications in women and newborns‖ (WHO 1999). Providing skilled 

attendants for delivery care, along with the equipment, drugs and supplies necessary for effective 

prevention and management of obstetric complications, has been advocated as the most important 

intervention in preventing maternal deaths (WHO 1999). For this reason, the proportion of deliveries 

assisted by a skilled health provider is an intermediate indicator to monitor progress toward achieving 

MDG 5. 

Most studies on antenatal care and skilled birth attendance have been conducted in only one or a 

few countries, rather than more widely (Chen et al. 2007; Magoma et al. 2010; Mpembeni et al. 2007; 

Syed et al. 2008; Bhutta et al. 2011). However, one study of levels and trends of antenatal care conducted 
2

in the early 2000s based on household survey data in 49 countries showed that around 68 percent of 

women in developing countries had at least one antenatal care visit and that the use of antenatal care had 

increased by 20 percent in the developing world over the 1990 to 2000 decade (AbouZahr and Wardlaw 

2003). Another comparative study using DHS data in six countries examined trends in delivery care with 

a health professional and found that the proportion of deliveries with a health professional had increased 

between 1990 and 2000 in all six countries (Bell, Curtis, and Alayón 2003). 

A global analysis of maternal mortality trends also presented information on trends in skilled 

birth attendance and caesarean section delivery, based on data from the WHO/UNICEF databases and the 

DHS (AbouZahr and Wardlaw 2001). This study found modest improvement in use of skilled birth 

attendants, with an average annual increase of 1.7 percent in 53 countries examined in the decade 1989 to 

1999. The authors also found that caesarean delivery rates tended to be stable over the 1990s, with higher 

rates in countries of the Americas than in Africa and Asia. 

Compared to antenatal care and skilled attendance at birth, postnatal care has been largely 

neglected in safe motherhood programs. Postnatal care, especially within the first 48 hours after birth, is 

critical to the management of postpartum hemorrhage, an important cause of maternal deaths in 

developing countries. In developing countries, more than 60 percent of maternal deaths occur in the six 

weeks post-delivery and 80 percent of postpartum deaths are caused by obstetric factors occurring in the 

first week postpartum (Li et al. 1996). Postnatal care is also key to neonatal survival, through the 

prevention of neonatal sepsis and asphyxia/hypothermia, as well by promoting healthy behaviors such as 

exclusive breastfeeding and care of babies with low birth weight. Research on postnatal care, however, is 

limited in developing countries. One study using data from 30 DHS surveys conducted between 1999 and 

2004 found that seven of ten mothers delivering outside a health institution did not receive any postnatal 

care. However, this study was not able to find enough information on postnatal care among women 

delivering at a health facility; and the assumption that all women who delivered at a health facility would 

have received postnatal care may not be true in many cases (Fort, Kothari, and Noureddine 2006). 

Examining the use of maternal health services in developing countries can inform programs about 

where to focus interventions that can reduce maternal and newborn mortality and improve their health 

outcomes. For this purpose, our study provides up-to-date information on levels and trends in use of 

antenatal care, skilled birth attendance and postnatal care for mothers over the past two decades in 38 

developing countries. 

 
3

2 Data and Analysis 

2.1 Data 

This comparative report analyzes levels and trends in use of maternal health services: antenatal 

care, skilled birth attendance and postnatal care for the mother. The study uses Demographic and Health 

Surveys (DHS) data from 1990 to 2009 in 38 countries in four regions: 21 countries in sub-Saharan 

Africa; 4 countries in North Africa/West Asia/Europe; 8 countries in South/Southeast Asia; and 5 

countries in Latin America and the Caribbean. Each country included has at least two surveys and most 

have three or four completed during this period. For each country, we choose surveys in order to keep 

approximately five years' time difference between the two consecutive surveys, if surveys were conducted 

more frequently than every five years. To reflect a recent level of service use, we include only those 

countries in which the most recent survey was conducted after 2000. Table 1 lists the countries and 

surveys included in this analysis. 

Table 1. DHS surveys included in the analysis

Region and country Survey year

Sub-Saharan Africa

Benin 1996* 2001 2006

Burkina Faso 1993 1998-99 2003

Cameroon 1991 1998* 2004

Chad 1996-97 2004

Ethiopia 2000 2005

Ghana 1993* 1998 2003 2008

Guinea 1999 2005

Kenya 1993 1998* 2003 2008

Madagascar 1992 1997* 2003-04 2008-09

Malawi 1992 2000 2004

Mali 1995-96* 2001 2006

Mozambique 1997* 2003

Namibia 1992 2000 2006-07

Niger 1992 1998* 2006

Nigeria 1990 2003 2008

Rwanda 1992 2000 2007

Senegal 1992-93 1997 2005

Tanzania 1991-92 1996 1999 2004-05

Uganda 1995* 2000-01 2006

Zambia 1992 1996 2001-02 2007

Zimbabwe 1994* 1999 2005-06

North Africa/West Asia/Europe

Armenia 2000 2005

Egypt 1992 1995 2000 2005 2008

Jordan 1990 1997 2002 2007

Morocco 1992 2003-04

South/Southeast Asia

Bangladesh 1993-94* 1999-2000 2004 2007

Cambodia 2000 2005

(Cont’d)
4

Table 1. – cont’d

Region and country Survey year

India 1992-93* 1998-99* 2005-06

Indonesia 1991 1997 2002-03 2007

Nepal 1996* 2001 2007

Pakistan 1990-91 2006-07

Philippines 1993 1998 2003 2008

Vietnam 1997* 2002*

Latin America/Caribbean

Bolivia 1994* 1998 2003 2008

Colombia 1990 1995 2000 2005

Dominican Republic 1991 1996 2002 2007

Haiti 1994-95 2000 2005-06

Peru 1991-92 1996 2000 2005 2008

Note: Data for Peru 2005 and 2008 are obtained from the Peru 2004-2008 continuous DHS.

*Information was collected only for live births in the three years preceding the survey, so analyses focus on the 

most recent birth in the past three years.

In DHS surveys, women age 15-49 were asked to provide information about pregnancies 

resulting in a live birth during the five years prior to the interview. In some surveys conducted during the 

1990s, the reference period was three years prior to the interview. Since 1999, DHS resumed collecting 

antenatal and postnatal information for the last live birth in the past five years. Information on skilled 

birth attendance was collected for all live births in the past five years. Starting in 2005, DHS surveys have 

collected postnatal care information for both institutional and non-institutional births, whereas in previous 

surveys such information was collected only for non-institutional births. Therefore, we limit the analysis 

of postnatal care to surveys in which respondents were asked about postnatal care for all births (both 

institutional and non-institutional). As a result, only 18 of the 38 countries are included in our analysis of 

postnatal care. 

We use the woman as the unit of analysis and focus on the most recent live birth in the past five 

years, or three years in surveys that asked about births only in three years prior to the interview. Table 2 

presents characteristics of women who had a live birth in the five/three years preceding the most recent 

survey in each country. 
Table 2. Percent distribution of women who had a live birth in the five years preceding the survey by selected characteristics, the most recent DHS survey, 1990-2009

Age at the last birth Birth order Residence Education Wealth status (quintile)

Total number 

of women 

who had a live 

birth in the 

Country/Year <20 20 -34 35 -49 1 2 3 past 5 years

4 or 

more Urban Rural None

PrimarySecon 

-dary

High

-er

Low

-est

SecondMiddleFour

-th

High

-est

Sub-Saharan Africa

Benin 2006 11.0 73.6 15.4 17.6 17.9 16.1 15.4 35.6 64.4 73.1 18.5 7.9 0.5 21.0 19.8 20.7 20.7 17.8 10,521

Burkina Faso 2003 13.7 65.5 20.7 17.9 16.4 14.3 51.5 14.2 85.8 87.1 8.6 4.0 0.4 18.6 20.5 26.6 18.0 16.4 7,428

Cameroon 2004 21.2 65.5 13.3 22.9 18.3 14.5 44.3 46.2 53.8 28.0 41.7 29.0 1.3 23.8 19.6 20.4 19.2 17.0 5,303

Chad 2004 19.7 66.0 14.3 15.5 15.4 14.5 54.5 18.9 81.1 76.9 18.6 4.3 0.3 18.0 22.8 19.5 21.6 18.1 3,720

Ethiopia 2005 13.6 67.4 19.0 16.3 14.9 13.7 55.1 8.7 91.3 78.5 16.5 4.5 0.5 20.8 21.3 21.7 19.9 16.4 7,307

Ghana 2008 10.2 70.3 19.5 22.3 20.8 16.6 40.3 40.2 59.8 30.8 24.3 42.4 2.3 22.9 22.0 19.1 20.8 15.3 2,099

Guinea 2005 17.9 62.2 19.9 16.8 15.1 14.5 53.5 24.4 75.8 85.5 9.0 5.1 0.4 23.3 21.0 20.8 18.7 16.2 4,447

Kenya 2008 14.2 72.6 13.2 21.3 21.3 17.3 40.2 20.7 79.3 11.1 62.6 21.1 5.3 21.2 19.2 18.7 19.3 21.6 3,973

Madagascar 2008-09 19.6 62.7 17.7 21.4 19.2 15.7 43.7 12.4 87.6 23.2 54.6 20.9 1.2 23.4 21.4 20.1 18.5 16.6 8,662

Malawi 2004 17.8 68.5 13.7 20.9 20.3 16.3 42.6 14.3 85.7 24.9 63.0 11.8 0.3 19.0 21.7 22.1 19.7 17.5 7,271

Mali 2006 18.8 63.9 17.3 16.5 15.8 13.5 54.1 28.6 71.4 84.2 10.4 5.0 0.4 19.9 20.1 20.6 20.4 19.0 9,087

Mozambique 2003 20.4 64.4 15.2 20.3 17.9 15.6 46.3 31.2 68.8 44.3 51.1 4.5 0.2 25.5 19.0 20.5 17.2 17.9 7,179

Namibia 2006-07 15.1 69.3 15.6 31.4 25.7 16.6 26.4 43.9 56.1 9.5 27.9 57.3 5.3 20.2 18.2 21.9 22.0 17.6 3,898

Niger 2006 17.1 65.4 17.4 14.2 14.0 12.6 59.3 15.5 84.5 87.0 9.5 3.3 0.2 21.2 19.5 19.8 20.9 18.6 6,300

Nigeria 2008 13.4 68.1 18.5 17.3 16.6 15.3 50.8 30.2 69.8 45.5 22.8 25.8 6.0 23.1 22.2 19.0 18.2 17.5 17,635

Rwanda 2007 4.7 71.8 23.5 18.8 18.0 15.9 47.3 14.9 85.1 25.2 67.0 7.1 0.7 15.6 28.3 19.3 19.4 17.5 3,658

Senegal 2005 14.1 67.3 18.5 20.3 18.2 14.6 46.8 38.8 61.2 70.1 21.8 7.6 0.5 21.5 21.3 21.1 19.2 16.9 6,928

Tanzania 2004-05 15.7 69.5 14.8 20.4 20.2 16.1 43.3 22.1 77.9 25.4 69.4 4.0 1.3 21.2 20.6 20.2 19.5 18.5 5,772

Uganda 2006 15.4 68.1 16.5 16.3 14.1 13.5 56.2 13.3 86.7 21.6 62.7 12.9 2.8 21.3 21.6 19.6 19.1 18.4 5,035

Zambia 2007 15.5 68.6 15.9 18.7 17.2 15.5 48.6 32.6 67.4 13.0 61.0 22.9 3.1 22.3 20.9 20.2 20.6 16.0 4,136

Zimbabwe 2005-06 18.7 70.9 10.4 30.1 25.6 17.5 26.8 31.3 68.7 4.1 35.2 58.1 2.6 22.8 20.1 17.4 22.0 17.7 4,100

North Africa/West Asia/Europe

Armenia 2005 9.4 84.3 6.3 38.7 39.8 14.5 7.0 62.6 37.4 0.0 0.7 75.8 23.5 18.0 19.4 19.1 22.6 20.9 1,176

Egypt 2008 9.2 79.7 11.1 26.6 28.1 21.6 23.7 38.2 61.8 25.3 10.2 51.5 13.0 19.3 19.7 21.0 20.6 19.4 7,896

Jordan 2007 4.2 73.9 21.8 15.2 19.9 18.1 46.8 84.0 16.0 2.4 5.5 61.7 30.5 23.4 23.3 21.4 17.9 14.1 6,446

Morocco 2003-04 7.7 71.1 21.2 24.0 24.0 18.2 33.7 53.6 46.4 60.4 18.5 17.0 4.1 21.8 21.6 20.9 17.7 18.1 4,695

(Cont’d)

5
Table 2. – cont’d

Age at the last birth Birth order Residence Education Wealth status (quintile)

Total number 

of women 

who had a live 

birth in the 

Country/Year <20 20 -34 35 -49 1 2 3 past 5 years

4 or 

more Urban Rural None

PrimarySecon 

-dary

High

-er

Low

-est

SecondMiddleFour

-th

High

-est

South/Southeast Asia

Bangladesh 2007 30.8 63.2 6.0 31.9 26.8 16.9 24.4 21.2 78.8 26.1 30.9 36.2 6.7 21.8 21.3 19.0 19.5 18.4 4,905

Cambodia 2005 9.2 70.2 20.6 24.4 23.4 17.1 35.1 14.1 85.9 23.1 59.4 17.0 0.6 25.2 22.5 18.4 17.1 16.8 5,865

India 2005-06 17.3 77.4 5.2 26.4 28.7 17.2 27.8 26.8 73.2 47.4 14.0 32.7 6.0 24.1 21.7 19.6 18.3 16.3 39,677

Indonesia 2007 9.9 75.1 15.0 34.6 28.7 18.1 18.6 42.0 58.0 3.3 41.2 47.7 7.9 21.4 19.9 20.0 19.5 19.1 14,043

Nepal 2006 17.7 73.1 9.2 26.9 27.6 16.4 29.2 13.2 86.8 58.0 18.3 21.1 2.7 23.5 21.1 20.0 18.5 16.9 4,066

Pakistan 2006-07 8.1 75.8 16.1 17.0 18.2 15.5 49.2 30.2 69.8 64.6 15.0 14.3 6.0 22.7 21.0 19.4 18.8 18.1 5,677

Philippines 2008 9.3 72.2 18.5 27.9 22.6 17.1 32.3 49.7 50.3 1.5 23.1 47.9 27.5 24.0 22.0 19.7 18.8 15.5 4,590

Vietnam 2002 8.1 84.1 7.8 40.6 36.0 13.4 10.0 18.1 81.9 7.3 25.9 61.1 5.7 24.3 22.0 18.4 16.0 19.3 1,215

Latin America/Caribbean

Bolivia 2008 15.0 67.4 17.5 26.6 23.3 16.1 34.0 57.7 42.3 5.7 50.1 31.1 13.2 22.7 19.8 22.5 19.9 15.1 6,472

Colombia 2005 20.0 67.4 12.6 35.8 28.6 17.6 18.0 71.6 28.4 3.2 31.0 51.5 14.4 21.4 24.1 22.3 18.2 14.1 11,083

Dominican 

Republic 2007 21.2 70.5 8.3 32.7 26.0 21.4 19.9 68.5 31.5 3.7 38.6 39.2 18.4 22.7 22.9 20.7 18.4 15.2 8,203

Haiti 2005-06 14.6 65.4 20.0 27.5 18.6 13.1 40.8 37.0 63.0 31.6 42.1 24.5 1.8 22.4 19.3 20.3 21.4 16.6 4,074

Peru 2008 13.8 68.4 17.7 33.9 24.9 17.4 23.8 63.8 36.2 4.3 31.4 41.3 23.0 10.4 23.9 24.8 18.6 22.4 4,920

6
7

Reflecting the WHO definition, we define antenatal care as pregnancy-related health care 

checkups, which could occur either in a health facility or at home, and also use the WHO definition of a 

skilled health provider, which includes a doctor, midwife or nurse. Therefore, skilled birth attendance is 

defined as delivery assistance provided by a doctor, nurse or midwife (or in certain countries their 

professional equivalent, e.g., a nurse-midwife). It should be noted that in some countries other health 

personnel (e.g. auxiliary nurse or midwife) could be trained and equipped to provide maternal health care, 

although in the analysis we do not treat these providers as skilled health providers, for the purpose of 

consistency and comparability. We also use the WHO definition of postnatal care, which encompasses 

checkups by a health professional or others within 41 days or six weeks of childbirth. 

Indicators of care are derived based on the following questions in the DHS woman’s 

questionnaire. 

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? 

 As part of your antenatal care during this pregnancy, were any of the following done at least 

once? 

o Was your blood pressure measured? 

o Did you give a urine sample? 

o Did you give a blood sample? 

 During (any of) your antenatal care visit(s), were you told about the signs of pregnancy 

complications? 

 During this pregnancy, were you given an injection in the arm to prevent the baby from 

getting tetanus, that is, convulsions after birth? If YES, how many times did you get this 

tetanus injection during this pregnancy? 

 During this pregnancy, were you given or did you buy any iron tablets or iron syrup? 

 During this pregnancy, did you take any drugs to keep you from getting malaria? 

 How many times did you take (SP/Fansidar/Amalar/Maloxine) during this pregnancy? 

 Did you get the (SP/Fansidar/Amalar/Maloxine) during any antenatal care visit? 

 Were you offered a test for the AIDS virus as part of your antenatal care? 

 I don't want to know the results, but were you tested for the AIDS virus as part of your 

antenatal care? 

Delivery care: 

 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? 

Postnatal care: 

 Before you were discharged after (NAME OF CHILD) was born, did any health care provider 

check on your health? 

 How long after delivery did the first check take place? 

 Who checked on your health at that time? 
8

 After (NAME OF CHILD) was born, did a health professional or a traditional birth attendant 

check on your health? 

 How long after delivery did the first checkup take place? 

 Who checked on your health at that time? 

Variables of women’s characteristics, including age, birth order, urban/rural residence and level 

of education, are developed based on the relevant survey questions. Another characteristic, household 

wealth status, is a quintile index based on a number of indicators asked in the DHS related to household 

assets and housing characteristics (Rutstein and Johnson 2004). 

2.2 Analysis 

Based on the most recent DHS survey of each country, the analysis reports the level of use of 

each service, along with differentials by individual and household characteristics. We examine data from 

consecutive surveys to establish trends in use of antenatal care and skilled birth attendance. In the 18 

countries included for postnatal care analysis, only the most recent survey has collected postnatal care 

information for the last live birth; thus it is not possible to determine trends in using postnatal care. 

We analyze the data using Stata 10.0 Statistical Software. We apply sampling weights in all the 

analyses to enable us to generalize the results to the country’s population. The sample weight variable is 

the pre-existing individual sampling weight in the DHS datasets. 
9

3 Results 

3.1 Antenatal Care 

Having a sufficient number of antenatal care visits and receiving appropriate and timely care 

during the visits ensure that women prepare for the childbirth. This section presents the characteristics of 

antenatal care that women received for their most recent birth, including the number of antenatal care 

visits, timing of the first visit, content of care, provider of care and differentials in use. Trends are also 

presented in making four or more visits and using skilled health providers for antenatal care. 

3.1.1 Current Use of Antenatal Care 

Table 3 shows the number of antenatal care visits that women had for their most recent live birth 

in the five years preceding the most recent DHS survey in each country studied. Most countries show a 

fairly high level of antenatal care coverage. In 24 of the 38 countries, over 80 percent of women had at 

least one antenatal visit during their last pregnancy. In 18 countries, more than 90 percent had antenatal 

care. 

Women in Latin America and the Caribbean have higher levels of antenatal care than women in 

other regions. About 86 percent of pregnant women in Haiti, and more than 90 percent in the other four 

countries in this region, reported at least one antenatal care visit. In the Dominican Republic and Peru, 

almost all pregnant women had at least one antenatal care visit. 

In the North Africa/West Asia/Europe region, Jordan and Armenia show high rates of antenatal 

care coverage, at over 90 percent. But in Egypt and Morocco, coverage is lower, at 73 percent and 68 

percent, respectively. 

Large variations in use of antenatal care exist in sub-Saharan Africa. About half of the 21 subSaharan countries included in the analysis show over 90 percent coverage. However, levels in some 

countries are much lower. In Chad and Niger, for example, more than half of women did not receive any 

antenatal care. Ethiopia has the lowest level of antenatal care use among all countries included in this 

analysis, at only 28 percent. Antenatal care coverage in the other sub-Saharan African countries ranges 

from 55 percent to 87 percent, as of the most recent surveys. 

In South/Southeast Asia, antenatal care coverage is over 95 percent in Indonesia and the 

Philippines, and 87 percent in Vietnam, while the rates are lower than 80 percent in the other four 

countries. 

Having only one antenatal visit may not be enough to ensure that women prepare for and receive 

sufficient care for childbirth, and WHO recommends a minimum of four antenatal visits. Overall, most 

women who receive any antenatal care have at least four antenatal visits, but there is substantial variation 

among countries. In half the countries included in this analysis, more than 50 percent of all pregnant 

women surveyed reported four or more antenatal visits. Having four visits is most prevalent in Latin 

America and the Caribbean. With the exception of Haiti (54 percent), all other countries in the region 

have more than two-thirds of women reporting four or more antenatal care visits, and as many as 95 

percent in the Dominican Republic. 

In three of the four countries in the North Africa/West Asia/Europe region, at least two-thirds of 

women make four or more antenatal care visits. Levels are lower in the South/Southeast Asian region, 

except in Indonesia and the Philippines, where sizable proportions of women reported four or more 

antenatal visits. For example, only 21 percent of Bangladeshi women and 27 percent of Cambodian 
10 

women reported four or more visits. Although 87 percent of Vietnamese women reported having some 

antenatal care, only 30 percent had four or more visits. 

In sub-Saharan Africa, the proportion of women making four or more antenatal care visits ranges 

from 12 percent in Ethiopia to 78 percent in Ghana. Some countries with high antenatal coverage also 

show a high level of four or more visits—Ghana, Zimbabwe and Namibia, for example. In a few other 

countries—for example, Chad, Ethiopia and Niger—only a minority of women had any antenatal care at 

all, and very few made as many as four antenatal care visits. Even where antenatal coverage is high, the 

percentage reporting as many as four visits may be low. In Rwanda, for example, 96 percent of women 

reported at least one antenatal care visit, but only 24 percent reported four or more visits. 

Table 3. Percent distribution of women who had a live birth in the five years preceding the survey 

by number of antenatal care visits for the most recent birth, the most recent DHS survey, 1990-

2009

Number of visits

Percentage of 

women with

at least one 

visit

Number of women 

who had a live 

birth in the past 

Country/Year None 1 2-3 5 years

4 or 

more

Missing/

Don't know Total

Sub-Saharan Africa

Benin 2006 11.2 4.5 22.4 60.5 1.4 100.0 87.4 10,521

Burkina Faso 2003 26.2 9.5 45.3 17.6 1.4 100.0 72.4 7,428

Cameroon 2004 16.1 2.4 19.8 60.4 1.2 100.0 82.6 5,303

Chad 2004 56.3 3.8 20.9 17.8 1.2 100.0 42.5 3,720

Ethiopia 2005 71.5 4.6 11.3 12.2 0.4 100.0 28.1 7,307

Ghana 2008 3.5 2.8 13.3 78.2 2.3 100.0 94.3 2,099

Guinea 2005 16.5 5.5 24.2 48.8 5.0 100.0 78.5 4,447

Kenya 2008 7.3 4.3 39.2 47.1 2.0 100.0 90.6 3,973

Madagascar 2008-09 9.0 3.7 37.0 49.3 1.0 100.0 90.0 8,662

Malawi 2004 4.6 2.5 35.2 57.1 0.7 100.0 94.8 7,271

Mali 2006 28.7 6.3 27.6 35.4 2.1 100.0 69.3 9,087

Mozambique 2003 14.7 3.0 27.9 53.1 1.3 100.0 84.0 7,179

Namibia 2006-07 3.8 1.7 13.9 70.4 10.2 100.0 86.0 3,898

Niger 2006 52.9 5.5 26.6 14.9 0.2 100.0 47.0 6,300

Nigeria 2008 36.3 1.5 8.2 44.8 9.2 100.0 54.5 17,635

Rwanda 2007 2.7 5.9 66.0 23.9 1.5 100.0 95.8 3,658

Senegal 2005 6.6 3.8 47.5 39.8 2.3 100.0 91.1 6,928

Tanzania 2004-05 3.0 1.7 33.4 61.5 0.4 100.0 96.6 5,772

Uganda 2006 4.5 5.6 41.7 47.2 1.0 100.0 94.5 5,035

Zambia 2007 2.1 2.3 34.0 60.3 1.3 100.0 96.6 4,136

Zimbabwe 2005-06 5.0 2.0 20.7 71.1 1.2 100.0 93.8 4,100

North Africa/West Asia/Europe

Armenia 2005 6.3 2.9 18.1 70.9 1.7 100.0 91.9 1,176

Egypt 2008 25.8 0.4 6.5 66.5 0.8 100.0 73.4 7,896

Jordan 2007 1.2 0.6 3.9 94.1 0.1 100.0 98.6 6,446

Morocco 2003-04 32.0 8.0 29.1 30.5 0.5 100.0 67.6 4,695

(Cont’d)
11 

Table 3. – cont’d

Number of visits

Percentage of 

women with

at least one 

visit

Number of women 

who had a live 

birth in the past 

Country/Year None 1 2-3 5 years

4 or 

more

Missing/

Don't know Total

South/Southeast Asia

Bangladesh 2007 39.6 15.8 23.9 20.6 0.1 100.0 60.3 4,905

Cambodia 2005 28.2 11.2 33.2 27.0 0.3 100.0 71.4 5,865

India 2005-06 22.8 6.0 33.5 37.0 0.8 100.0 76.5 39,677

Indonesia 2007 4.2 2.6 11.1 81.5 0.7 100.0 95.2 14,043

Nepal 2006 26.2 8.5 35.8 29.4 0.0 100.0 73.7 4,066

Pakistan 2006-07 34.7 13.2 22.2 28.4 1.4 100.0 63.8 5,677

Philippines 2008 3.8 3.0 15.0 77.8 0.4 100.0 95.8 4,590

Vietnam 2002 12.8 9.8 47.2 30.1 0.0 100.0 87.1 1,215

Latin America/Caribbean

Bolivia 2008 9.6 3.3 14.7 72.1 0.4 100.0 90.1 6,472

Colombia 2005 6.4 1.4 7.7 83.0 1.5 100.0 92.1 11,083

Dominican 

Republic 2007 0.5 0.5 2.5 94.5 2.0 100.0 97.5 8,203

Haiti 2005-06 13.8 4.9 26.8 53.8 0.6 100.0 85.5 4,074

Peru 2008 2.5 1.0 4.5 92.0 0.1 100.0 97.5 4,920

3.1.2 Timing of the First Antenatal Care Visit 

To allow for sufficient time to identify and treat problems such as anemia and infections, women 

are recommended to start antenatal care early in pregnancy. Table 4 shows the timing of the first antenatal 

visit among women who report any antenatal care visits. 

In Latin America and the Caribbean and in North Africa/West Asia/Europe, among women who 

receive antenatal care, more than half receive care in the first trimester. In Jordan, nine in ten women start 

antenatal care in the first trimester. South/Southeast Asia has lower figures, however. In four countries—

India, Indonesia, the Philippines and Vietnam—more than half of women reported that the first antenatal 

care visit took place in the first trimester. Indonesia has the highest percentage; 79 percent of women 

reported that the first antenatal care visit was in the first trimester of pregnancy. In the other four 

countries of the region, however, less than half of women with any antenatal care reported starting care in 

the first trimester. 

Although in sub-Saharan Africa a majority of women receive antenatal care, most wait until the 

second or even the third trimester before making the first visit. The exception is Ghana, where 57 percent 

of women who reported antenatal care reported that their first visit occurred during the first trimester of 

pregnancy. In contrast, in Malawi, where 95 percent of women reported at least one antenatal care visit, 

less than 10 percent reported making the first visit in the first three months of pregnancy. In Senegal, the 

finding is even more striking. Although 91 percent of women make at least one antenatal care visit, 43 

percent of them wait until the third trimester to start care. Even where a high proportion of women 

reported four or more antenatal care visits, as in Namibia and Zimbabwe, at about 70 percent, only 34 

percent in Namibia and 29 percent in Zimbabwe reported making the first antenatal care visit in the first 

trimester. 
12 

Table 4. Percent distribution of women who had any antenatal care(ANC) for the most recent birth 

by timing of the first visit, the most recent DHS survey, 1990-2009

Timing of the first ANC visit among women receiving 

any ANC visit Number of women 

receiving ANC 

for their most 

Country/Year recent birth

<4 

months

4-6 

months

7 or more 

months

Missing/

Don't know Total

Sub-Saharan Africa

Benin 2006 47.0 43.7 8.6 0.8 100.0 9,286

Burkina Faso 2003 36.4 48.1 13.3 2.2 100.0 5,468

Cameroon 2004 41.4 52.3 5.5 0.8 100.0 4,436

Chad 2004 38.2 52.6 8.5 0.7 100.0 1,624

Ethiopia 2005 22.5 52.6 23.5 1.4 100.0 2,076

Ghana 2008 57.0 40.0 2.5 0.6 100.0 2,024

Guinea 2005 40.5 49.1 9.5 0.8 100.0 3,703

Kenya 2008 15.7 66.6 17.4 0.3 100.0 3,680

Madagascar 2008-09 30.1 62.5 6.2 1.2 100.0 7,869

Malawi 2004 8.1 75.6 16.0 0.3 100.0 6,930

Mali 2006 42.6 43.2 11.6 2.5 100.0 6,465

Mozambique 2003 20.9 70.2 8.0 0.9 100.0 6,098

Namibia 2006-07 33.9 55.7 8.4 2.1 100.0 3,734

Niger 2006 29.5 55.4 14.6 0.4 100.0 2,954

Nigeria 2008 25.4 60.8 10.8 2.8 100.0 11,158

Rwanda 2007 22.6 59.7 15.7 2.0 100.0 3,519

Senegal 2005 4.1 50.9 42.6 2.5 100.0 6,441

Tanzania 2004-05 14.5 73.5 11.8 0.1 100.0 5,593

Uganda 2006 17.4 65.2 17.2 0.2 100.0 4,809

Zambia 2007 19.6 72.3 7.7 0.4 100.0 4,044

Zimbabwe 2005-06 28.6 60.2 10.7 0.4 100.0 3,890

North Africa/West Asia/Europe

Armenia 2005 51.4 43.6 3.5 1.3 100.0 1,097

Egypt 2008 82.3 15.5 1.9 0.1 100.0 5,861

Jordan 2007 90.3 8.7 0.9 0.0 100.0 6,366

Morocco 2003-04 74.9 19.1 5.9 0.1 100.0 3,185

South/Southeast Asia

Bangladesh 2007 40.4 39.9 19.7 0.0 100.0 2,956

Cambodia 2005 32.2 48.5 18.8 0.7 100.0 4,213

India 2005-06 56.9 34.2 7.9 1.0 100.0 30,621

Indonesia 2007 78.6 18.2 2.8 0.5 100.0 13,457

Nepal 2006 37.5 53.4 8.9 0.1 100.0 3,000

Pakistan 2006-07 46.9 27.6 23.1 2.5 100.0 3,673

Philippines 2008 56.1 39.0 4.7 0.1 100.0 4,411

Vietnam 2002 65.0 26.8 8.0 0.1 100.0 1,059

Latin America/Caribbean

Bolivia 2008 68.4 26.8 4.4 0.4 100.0 5,841

Colombia 2005 75.3 21.8 2.8 0.2 100.0 10,379

Dominican Republic 2007 82.3 15.7 1.3 0.8 100.0 8,120

Haiti 2005-06 59.5 33.8 6.1 0.5 100.0 3,512

Peru 2008 74.1 23.6 2.3 0.1 100.0 4,796
13 

3.1.3 Trends in Four or More Antenatal Care Visits 

This section presents trends in making four or more antenatal care visits for the most recent birth. 

For this analysis we divide the sub-Saharan African region into two groups—the Western and Central 

African countries and the Eastern and Southern African countries—to provide a clearer picture of these 

trends within sub-Saharan Africa. 

Figure 1 shows the trends in Western and Central Africa in the proportion of women making at 

least four antenatal care visits. Eight of the 10 countries have experienced an increase in use of the 

recommended antenatal care, while two countries, Nigeria and Burkina Faso, show a slightly decreasing 

trend. Increases are large in Ghana and Senegal over the survey period (in Ghana, for example, the 

percentage of women making at least four antenatal visits increased from 60 percent in 1993 to 80 percent 

in 2008). In other countries, such as Niger and Chad, the increase is very small. 

Figure 2 presents the trends in Eastern and Southern Africa. Five countries—Namibia, 

Mozambique, Madagascar, Rwanda and Ethiopia—show increasing trends in the number of women 

making at least four antenatal visits, with varying degrees of increase. In the remaining six countries a 

decreasing trend is observed, most notably in Kenya and Tanzania, where the figure has dropped by over 

10 percentage points. 

Figure 3 shows a steady increase in all countries in South/Southeast Asia. Indonesia and the 

Philippines are the two countries in the region where the level of antenatal care is very high and also 

where the increase is greatest. For example, In Indonesia the percentage of women with four or more 

antenatal care visits rose from 58 percent in 1991 to 82 percent in 2007. 

Figure 4 shows that the four countries in North Africa/West Asia/Europe region have reached a 

fairly high proportion of women reporting four or more antenatal care visits. In little more than a decade, 

the level has more than doubled in Egypt, and there is an almost 60 percentage point increase in Morocco. 

For Jordan and Armenia, where the base level was higher, there is also a steady increase. 

Figure 5 shows that in Latin America and the Caribbean the percentage of women with four or 

more antenatal care visits has increased steadily in all countries, irrespective of their varying levels of 

antenatal care use. In general, the Dominican Republic has the highest level, rising from 86 percent in the 

1991 survey to 97 percent in 2007. Although Haiti shows the lowest level of antenatal care use, it has 

increased by over 20 percentage points over the survey period. Peru and Bolivia show the most 

encouraging trends. In Peru, the level was only 51 percent in 1991-92 but then increased considerably in 

the mid-1990s and reached 92 percent in 2008. In Bolivia, antenatal care use more than doubled from 

1994 to 2008, reaching 72 percent. 
14 

Figure 1. Trends in percentage of women having at least four antenatal care visits for the most 

recent birth in Western and Central Africa, 1990-2009 

Benin, 61

Burkina faso, 18

Cameroon, 61

Chad, 18

Ghana, 80

Guinea, 51

Mali, 36

Niger, 14

Nigeria, 49

Senegal, 41

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

100

1990 1995 2000 2005 2010

Percent

Year

Western and Central Africa

Figure 2. Trends in percentage of women having at least four antenatal care visits for the most 

recent birth in Eastern and Southern Africa, 1990-2009 

Ethiopia, 12

Kenya, 48

Madagascar, 50

Malawi, 57

Mozambique, 54

Namibia, 78

Rwanda, 24

Tanzania, 62

Uganda, 48

Zambia, 61

Zimbabwe, 72

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

100

1990 1995 2000 2005 2010

Percent

Year

Eastern and Southern Africa
15 

Figure 3. Trends in percentage of women having at least four antenatal care visits for the most 

recent birth in South/Southeast Asia, 1990-2009 

Bangladesh, 21

Cambodia, 27

India, 37

Indonesia, 82

Nepal, 30

Pakistan, 29

Philippines, 78

Vietnam, 30

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

100

1990 1995 2000 2005 2010

Percent

Year

South/Southeast Asia

Figure 4. Trends in percentage of women having at least four antenatal care visits for the most 

recent birth in North Africa/West Asia/Europe, 1990-2009

Amenia, 72

Egypt, 67

Jordan, 92

Morocco, 68

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

100

1990 1995 2000 2005 2010

Percent

Year

North Africa, West Asia, Europe
16 

Figure 5. Trends in percentage of women having at least four antenatal care visits for the most 

recent birth in Latin America and the Caribbean, 1990-2009 

Bolivia, 72

Colombia, 84

DR, 97

Haiti, 54

Peru, 92

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

100

1990 1995 2000 2005 2010

Percent

Year

Latin America/Caribbean

3.1.4 Differentials in Four or More Antenatal Care Visits 

Mother’s age at birth 

Table 5 shows percentage of women with four or more antenatal care visits for the most recent 

birth in the five years preceding the survey, by background characteristics—including mother’s age at 

birth, birth order, urban/rural residence, women’s education, and household wealth status. 

By women’s age, in Latin America and the Caribbean and in North Africa/West Asia/Europe the 

differences in making four or more antenatal care visits are not substantial. In sub-Saharan Africa and in 

South/Southeast Asia, however, variations in antenatal care by age are more apparent. In more than half 

of the countries mothers age 20-34 are most likely to report four or more visits. Also, in the majority of 

countries in these two regions, mothers under age 20 are more likely to report four or more antenatal care 

visits than mothers age 35-49. Exceptions include Niger and Vietnam, where use of antenatal care 

increases by age, and also Zambia, Rwanda, Kenya and Ghana, where mothers age 35-49 have higher 

antenatal care use compared to mothers under age 20. 

Birth order 

Overall, mothers are more likely to make four or more antenatal visits for the first birth than for 

later births. This pattern holds in almost all countries studied, except in a few sub-Saharan African 

countries, including Burkina Faso, Kenya, Madagascar, Mali, Namibia and Senegal, where a similar 

proportion of women report at least four antenatal visits across the first three births. 
17 

In almost all countries, women are least likely to have four or more antenatal visits for birth 

orders 4 or higher. The differentials are smaller in sub-Saharan Africa and in Latin America and the 

Caribbean than in South/Southeast Asia or in North Africa/West Asia/Europe. In the latter two regions, 

use of at least four antenatal care visits drops as parity increases, in all countries except Jordan, where the 

level remains relatively flat after the second birth. 

Urban/rural residence 

In all countries, women who live in urban areas are more likely to make four or more antenatal 

care visits than women in rural areas. Urban-rural differentials are relatively larger in South/Southeast 

Asia than other regions. In five Asian countries—Bangladesh, India, Nepal, Pakistan and Vietnam—

urban women are at least twice as likely as rural women to report four or more antenatal care visits. The 

differentials are less marked in Latin America and the Caribbean. In the Dominican Republic, levels of 

use of four or more antenatal care visits are similar in urban and rural areas. 

Countries with overall low use of antenatal care generally have large urban-rural differences. For 

example, in Burkina Faso, Chad, Ethiopia and Niger, where less than 20 percent of women report four or 

more visits, women living in urban areas are two to six times more likely to have the recommended 

number of visits than women in rural areas. 

Women’s education 

In the surveyed countries as a whole, the likelihood of using antenatal care is associated with 

women’s educational attainment. In virtually every country, the more schooling a woman has the more 

likely she is to report four or more antenatal care visits. In most countries, over 80 percent of women with 

education beyond the secondary level, but fewer than half of women with no education, report the 

recommended four antenatal care visits. Across countries, there are striking differences in antenatal care 

use among women with the same level of education. For example, in sub-Saharan Africa the proportion of 

women with no education reporting four or more antenatal care visits ranges from 8 percent in Ethiopia to 

68 percent in Ghana, and in South/Southeast Asia from 5 percent in Vietnam to 44 percent in Indonesia. 

Such differences are less remarkable in Latin America and the Caribbean. 

Household wealth 

Use of antenatal care use is positively associated with level of household wealth. In all countries, 

use of four or more antenatal care visits is highest among women from the richest households. As with 

differentials by women’s education, wealth-related disparities in use of antenatal care are greater in 

countries with little use of antenatal care overall than in those with a high level of use. For example, in 

South/Southeast Asia, where in most countries less than one-third of women report four or more antenatal 

care visits, the disparity in use by wealth status is substantial. In Bangladesh, India, Nepal and Pakistan, 

women in the richest wealth quintile are at least six times more likely than women in the poorest quintile 

to report four or more visits. In Latin America and the Caribbean, where the overall level of use is high, 

the differences between the rich and the poor are less sizable. In the Dominican Republic use of four or 

more antenatal care visits is at least 90 percent across all wealth quintiles. 

In many sub-Saharan African countries, there is little difference in use of antenatal care among 

the bottom 60 percent of households by wealth status, while only in the top two wealth quintiles is there 

substantially higher use. This pattern is observed in Burkina Faso, Chad, Ethiopia, Kenya, Madagascar, 

Mali, Niger and Uganda. 
Table 5. Percentage of women who received four or more antenatal care visits for the most recent live birth in the five years preceding the survey by selected

characteristics, the most recent DHS survey, 1990-2009

Age at the last birth Birth order Residence Education Wealth status (quintile)

Country/Year <20 20 -34 35 -49 1 2 3

4 or 

more Urban Rural None

PrimarySecondaryHigh 

-er

Low

-est

SecondMiddleFour

-th

High

-est

Sub-Saharan Africa

Benin 2006 57.7 62.1 55.1 70.7 66.2 62.0 54.3 71.3 54.6 53.7 76.3 84.6 92.8 39.5 50.1 58.4 70.9 87.5

Burkina Faso 2003 18.3 18.1 15.6 20.2 21.0 18.2 15.5 33.4 15.0 15.3 28.8 39.4 * 11.9 12.1 16.4 18.7 31.8

Cameroon 2004 58.3 61.2 60.0 68.2 64.9 60.1 54.6 74.4 48.4 34.8 63.5 79.3 94.7 39.2 47.3 62.6 75.2 85.7

Chad 2004 19.7 18.1 13.5 22.3 19.0 18.9 15.8 43.7 11.7 13.2 27.1 54.9 * 2.2 11.7 11.9 20.6 43.7

Ethiopia 2005 13.1 13.3 7.6 19.0 18.9 13.5 8.0 54.5 8.1 7.9 16.9 61.1 79.2 4.0 6.1 8.5 8.7 39.3

Ghana 2008 70.8 79.5 77.3 82.6 81.1 78.7 73.9 88.1 71.5 68.4 72.0 87.6 * 62.9 73.2 77.6 89.1 93.8

Guinea 2005 52.9 49.7 42.3 55.0 52.4 50.8 45.3 65.7 43.4 45.8 66.5 64.1 * 36.6 39.3 47.1 58.4 69.8

Kenya 2008 39.6 49.2 43.9 50.3 50.0 53.9 41.0 59.9 43.8 34.6 42.4 59.6 80.5 36.0 38.8 41.1 55.3 63.4

Madagascar 2008-09 48.0 50.1 48.1 52.6 52.9 53.3 44.7 70.5 46.3 36.9 47.4 66.1 86.5 34.9 41.7 47.6 55.0 75.4

Malawi 2004 57.8 57.2 55.1 61.5 57.4 55.2 55.4 65.2 55.7 52.7 56.5 68.5 * 52.5 52.1 53.7 60.0 69.0

Mali 2006 33.5 36.4 33.6 37.7 38.8 37.5 33.2 54.8 27.6 31.2 51.3 68.7 (90.3) 22.9 27.3 28.4 36.0 63.8

Mozambique 2003 45.8 45.6 45.1 56.8 57.0 50.3 51.0 70.7 45.2 42.4 59.6 84.0 * 36.6 44.8 52.1 64.0 76.5

Namibia 2006-07 63.7 73.2 64.6 72.7 72.2 75.0 63.1 73.0 68.4 50.7 66.7 74.7 79.7 64.2 68.3 69.9 73.5 76.5

Niger 2006 13.5 14.9 16.2 17.9 14.9 15.6 14.0 35.3 11.1 12.3 24.2 53.1 * 8.6 10.3 9.4 13.1 34.6

Nigeria 2008 32.1 48.0 42.4 50.3 48.7 49.1 40.4 68.8 34.4 21.9 53.9 68.9 80.9 15.7 28.6 47.6 64.2 80.7

Rwanda 2007 18.0 24.8 22.3 30.0 24.3 22.0 22.0 26.5 23.5 20.3 23.4 38.5 (57.7) 22.3 19.9 23.2 25.9 30.4

Senegal 2005 37.2 41.9 34.3 45.0 44.3 46.5 33.8 50.6 33.0 35.6 45.2 60.8 * 28.4 30.5 37.9 47.3 60.2

Tanzania 2004-05 65.8 61.2 58.2 66.3 64.2 63.6 57.1 71.4 58.6 54.1 62.6 80.5 85.2 52.2 59.0 58.9 63.4 75.6

Uganda 2006 48.2 47.4 45.5 54.1 50.2 44.4 45.1 59.6 45.3 41.0 45.4 60.6 72.6 44.3 42.1 42.1 45.0 64.3

Zambia 2007 56.0 61.2 60.8 60.6 59.4 60.7 60.4 58.6 61.2 56.1 60.0 61.3 77.7 59.3 61.0 62.2 57.8 61.6

Zimbabwe 2005-06 69.2 72.4 65.1 74.7 70.9 72.1 66.5 75.7 68.9 59.6 65.7 74.4 87.9 64.9 68.4 72.3 71.5 80.3

North Africa/West Asia/Europe

Armenia 2005 63.9 72.1 64.9 79.2 69.8 64.0 45.8 81.6 53.0 na 93.2 66.9 83.1 47.2 59.6 78.0 78.8 86.9

Egypt 2008 67.0 67.2 61.1 79.5 68.6 63.7 52.1 80.5 57.9 45.7 59.2 72.5 89.2 41.7 55.9 64.5 80.5 89.4

Jordan 2007 96.4 94.4 92.7 98.5 94.3 94.9 92.3 94.8 90.7 75.9 85.0 94.5 96.3 90.0 93.8 95.4 94.9 98.4

Morocco 2003-04 30.7 30.4 30.8 42.8 33.1 31.6 19.2 44.0 14.9 19.6 34.5 53.4 78.2 10.6 19.6 27.9 40.8 60.4

(Cont’d)

18
Table 5. – cont’d

Age at the last birth Birth order Residence Education Wealth status (quintile)

Country/Year <20 20 -34 35 -49 1 2 3

4 or 

more Urban Rural None

PrimarySecondaryHigh 

-er

Low

-est

SecondMiddleFour

-th

High

-est

South/Southeast Asia

Bangladesh 2007 21.3 20.9 13.8 29.5 23.2 17.6 8.3 38.3 15.9 6.6 12.7 29.5 63.8 8.3 9.8 14.9 26.6 47.3

Cambodia 2005 28.4 29.4 18.3 39.4 31.1 26.6 15.8 43.2 24.4 15.6 24.6 49.1 (80.8) 15.1 19.0 22.5 30.6 56.8

India 2005-06 35.7 38.6 17.2 52.8 48.1 31.7 13.7 62.4 27.7 16.0 35.5 59.2 85.3 12.1 21.1 36.6 53.0 77.3

Indonesia 2007 77.2 83.3 75.4 87.2 84.0 81.0 67.7 89.9 75.5 44.1 73.3 88.7 96.8 61.1 78.3 83.4 90.6 96.4

Nepal 2006 36.8 30.3 8.2 47.0 34.1 23.5 12.1 51.9 26.0 16.1 35.6 53.5 87.2 10.5 20.1 27.6 38.0 60.3

Pakistan 2006-07 23.9 30.6 20.4 37.5 32.5 31.5 22.7 48.3 19.8 17.4 32.0 54.8 75.0 10.1 14.4 21.9 38.4 64.0

Philippines 2008 74.3 79.7 71.9 85.1 82.5 80.4 66.7 83.0 72.6 31.7 62.0 78.9 91.5 61.1 71.5 82.4 88.9 93.1

Vietnam 2002 25.9 30.2 33.3 38.7 28.1 19.8 16.4 56.5 24.3 4.8 18.6 33.6 77.6 13.8 19.9 25.6 33.8 63.7

Latin America/Caribbean

Bolivia 2008 70.0 74.5 64.5 79.3 78.3 73.8 61.3 81.3 59.5 49.0 63.5 81.4 92.7 50.3 66.9 76.0 83.2 90.9

Colombia 2005 79.6 84.6 80.4 88.0 86.0 83.4 68.3 86.9 73.3 55.2 73.9 87.0 94.6 67.0 81.3 87.5 89.9 94.5

Dominican Republic 2007 94.2 94.7 94.2 96.6 95.4 94.0 90.6 94.7 94.2 87.5 91.8 96.2 98.0 90.0 94.3 96.1 96.2 97.4

Haiti 2005-06 47.2 57.1 47.8 62.6 58.4 54.5 45.6 66.9 46.1 36.0 51.7 77.4 95.3 33.0 43.5 53.8 63.1 82.0

Peru 2008 88.7 93.3 89.2 93.8 94.2 93.3 86.0 94.3 87.8 84.5 87.3 92.8 98.1 84.7 87.0 92.1 96.1 97.0

Note: Figures in parentheses are based on 25-49 unweighted cases; an asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed.

19
20 

3.1.5 Providers of Antenatal Care 

Table 6 shows the providers of antenatal care that women receive for the most recent live birth—

whether a skilled provider or someone else, such as another health worker, traditional birth attendant or 

non-health person. Sources of antenatal care vary by region. In Latin America and the Caribbean and in 

North Africa/West Asia/Europe, 68 to 99 percent of women reported obtaining antenatal care from a 

skilled health provider, while other sources are rarely reported. Most women receive antenatal care from a 

doctor, except in Peru, Haiti and Morocco. Particularly in Jordan and the Dominican Republic, almost all 

women go to a doctor for antenatal care. 

In South/Southeast Asia, the proportion of women using a skilled health provider for antenatal 

care ranges from 44 percent in Bangladesh and Nepal to 93 percent in Indonesia. While doctors are the 

single largest source of antenatal care in Bangladesh, India, Pakistan and Vietnam, a nurse/midwife is 

more often reported as the provider in the other countries in the region. Indonesia makes the highest use 

of nurses or midwives, at about 80 percent. Antenatal care from non-skilled health providers is 

uncommon in this region, except in Nepal, where about 30 percent of women reported receiving antenatal 

care from other health providers, such as auxiliary health workers, maternal and child health workers, and 

village health workers. 

In sub-Saharan Africa, in seven countries over 90 percent of women obtain antenatal care from a 

doctor, nurse or midwife. The lowest use of skilled care is in Mali, at 37 percent, and Chad, at 39 percent. 

The general pattern in this region is that women heavily rely on nurses or midwives rather than doctors. 

For example, in Rwanda 92 percent of women reported a nurse/midwife and only 3 percent reported a 

doctor as their source of antenatal care. Kenya, Ghana, Madagascar and Nigeria have relatively higher use 

of doctors for antenatal care than other sub-Saharan African countries. 
Table 6. Percent distribution of women who had a live birth in the five years preceding the survey by provider of antenatal care(ANC)

for the most recent birth, the most recent DHS survey, 1990-2009

Country/Year Doctor

Nurse or 

midwife

Other 

health 

person

Traditional 

birth 

attendant

Other 

(not 

health 

workers) No one

Missing/

Don't 

know Total

Percentage of 

women who

received ANC 

from a skilled 

health provider

Total number of 

women who had 

a live birth in the 

past 5 years

Sub-Saharan Africa

Benin 2006 4.4 79.7 3.9 0.1 0.1 11.2 0.5 100.0 84.1 10,521

Burkina Faso 2003 2.5 70.3 0.0 0.7 0.1 26.2 0.2 100.0 72.8 7,428

Cameroon 2004 16.2 63.8 3.4 0.2 0.1 16.1 0.3 100.0 80.0 5,303

Chad 2004 2.6 36.3 4.7 0.1 0.0 56.3 0.0 100.0 38.9 3,720

Ghana 2008 23.5 63.2 8.8 0.3 0.7 3.5 0.1 100.0 86.7 2,099

Guinea 2005 13.2 39.4 29.6 1.1 0.0 16.5 0.2 100.0 52.6 4,447

Kenya 2008 28.9 62.6 0.2 0.8 0.1 7.3 0.1 100.0 91.5 3,973

Madagascar 2008-09 26.5 59.8 0.0 4.5 0.1 9.0 0.2 100.0 86.3 8,662

Malawi 2004 9.8 82.3 1.0 2.0 0.2 4.6 0.1 100.0 92.1 7,271

Mali 2006 1.4 35.8 0.0 33.8 0.1 28.7 0.2 100.0 37.2 9,087

Mozambique 2003 2.3 82.2 0.0 0.2 0.2 14.7 0.4 100.0 84.5 7,179

Namibia 2006-07 16.1 78.6 0.0 1.0 0.2 3.8 0.4 100.0 94.7 3,898

Niger 2006 0.7 45.4 0.0 0.8 0.0 52.9 0.3 100.0 46.1 6,300

Nigeria 2008 22.9 30.0 4.9 3.1 2.4 36.3 0.4 100.0 52.9 17,635

Rwanda 2007 3.4 92.4 0.0 0.4 0.0 2.7 1.1 100.0 95.8 3,658

Senegal 2005 4.6 55.2 27.6 5.5 0.1 6.6 0.5 100.0 59.8 6,928

Tanzania 2004-05 2.1 74.2 18.0 0.1 2.5 3.0 0.1 100.0 76.3 5,772

Uganda 2006 9.0 84.0 1.2 1.3 0.2 4.5 0.0 100.0 93.0 5,035

Zambia 2007 1.8 88.4 3.6 2.7 1.3 2.1 0.1 100.0 90.2 4,136

Zimbabwe 2005-06 10.0 84.2 0.0 0.4 0.2 5.0 0.1 100.0 94.2 4,100

North Africa/West Asia/Europe

Armenia 2005 89.8 3.2 0.2 0.0 0.0 6.3 0.4 100.0 93.0 1,176

Egypt 2008 73.9 0.3 0.0 0.0 0.0 25.8 0.0 100.0 74.2 7,896

Jordan 2007 96.1 2.7 0.0 0.0 0.0 1.2 0.0 100.0 98.8 6,446

Morocco 2003-04 40.2 27.6 0.0 0.1 0.0 32.0 0.2 100.0 67.8 4,695

(Cont’d)

21
Table 6. – cont’d

Country/Year Doctor

Nurse or 

midwife

Other 

health 

person

Traditional 

birth 

attendant

Other 

(not 

health 

workers) No one

Missing/

Don't 

know Total

Percentage of 

women who

received ANC 

from a skilled 

health provider

Total number of 

women who had 

a live birth in the 

past 5 years

South/Southeast Asia

Bangladesh 2007 35.5 8.2 8.0 0.2 8.4 39.6 0.1 100.0 43.7 4,905

Cambodia 2005 6.3 63.0 0.0 2.5 0.0 28.2 0.0 100.0 69.3 5,865

India 2005-06 50.2 23.0 2.7 1.1 0.1 22.8 0.1 100.0 73.2 39,677

Indonesia 2007 14.0 79.3 0.0 2.2 0.3 4.2 0.0 100.0 93.3 14,043

Nepal 2006 21.2 22.5 29.7 0.1 0.2 26.2 0.0 100.0 43.7 4,066

Pakistan 2006-07 56.0 4.9 1.4 2.4 0.0 34.7 0.6 100.0 60.9 5,677

Philippines 2008 39.1 52.0 0.0 5.0 0.1 3.8 0.1 100.0 91.1 4,590

Vietnam 2002 46.8 23.4 16.6 0.3 0.1 12.8 0.0 100.0 70.2 1,215

Latin America/Caribbean

Bolivia 2008 77.2 8.6 4.2 0.1 0.1 9.6 0.1 100.0 85.8 6,472

Colombia 2005 86.6 6.6 0.2 0.1 0.1 6.4 0.0 100.0 93.2 11,083

Dominican 

Republic 2007 98.7 0.1 0.0 0.0 0.1 0.5 0.5 100.0 98.8 8,203

Haiti 2005-06 48.6 27.8 9.1 0.5 0.2 13.8 0.0 100.0 76.4 4,074

Peru 2008 27.6 66.8 0.6 0.1 2.3 2.5 0.1 100.0 94.4 4,920

Note: If more than one source of antenatal care was mentioned, only the provider with the highest qualifications is considered in this table.

Ethiopia is excluded as doctors and nurses were not distinguished from other health professionals in the survey

22
23 

3.1.6 Trends in Using Skilled Health Providers for Antenatal Care 

Figure 6 shows trends in the proportion of women in Western and Central Africa who received 

antenatal care from a skilled health provider. Seven of the 10 countries have experienced an increase in 

the proportion of women receiving antenatal care from skilled providers. Ghana and Burkina Faso had the 

biggest increases in use of skilled providers. In the 2008 Ghana DHS, 87 percent of women reported 

using a skilled health provider compared to 61 percent in 1993–a 26 percentage point increase in 15 years 

(but with a small decline from 2003 to 2008). The increase is very small in Benin and Cameroon, where 

the baseline levels were already above 70 percent. Senegal, Guinea and Chad experienced a decreasing 

trend over the survey period. Guinea has the biggest drop, about 20 percentage points from 1999 to 2005. 

Figure 7 shows that in Eastern and Southern Africa 7 of the 10 countries have maintained high 

proportions (above 80 percent) of women receiving antenatal care from skilled providers and in the most 

recent surveys have reached over 90 percent. Among the other three countries, Tanzania, Madagascar and 

Mozambique, in Madagascar the level of antenatal use from skilled providers remained around 80 percent 

until 2003-04, then rose to 87 percent in the most recent survey in 2008-09. In Tanzania use of skilled 

providers for antenatal care decreased during the 1990s but increased substantially after 1999, reaching 76 

percent in 2004-05. And in Mozambique, use of skilled providers for antenatal care rose from 72 percent 

in 1997 to 85 percent in 2003. 

Figure 8 shows that in every country analyzed in South/Southeast Asia there has been a steady 

increase in antenatal care from skilled health providers. Indonesia and the Philippines have the highest 

level of service from a skilled provider across the years, with a slight increase, reaching over 90 percent in 

the most recent survey year. The increase is most rapid in Vietnam and Cambodia, where the level 

increased by about 30 percentage points within five years. 

Figure 9 shows an increase in the level of use of skilled health providers for antenatal care in all 

four countries in the North Africa/West Asia/Europe region. The increase is slight in Armenia and Jordan, 

where the level has been high over the survey years, but is substantial in Egypt and Morocco, where the 

levels rose from about 40 percent in the 1990s to about 70 percent in the most recent survey. 

Figure 10 shows that in all five countries analyzed in Latin America and the Caribbean, the 

percentage of women receiving antenatal care from a skilled provider was already high in the 1990s and 

has continued to rise. Peru and Bolivia show the most encouraging improvement. In Peru, only 69 percent 

of women in 1991-92 reported visiting a skilled health provider for antenatal care, rising to 95 percent in 

2008. 
24 

Figure 6. Trends in percentage of women receiving antenatal care from a skilled health provider 

for the most recent birth in Western and Central Africa, 1990-2009 

Benin, 85

Burkina Faso, 73

Cameroon, 80

Chad, 12

Guinea, 53

Mali, 37

Ghana, 87

Niger, 46

Nigeria, 53

Senegal, 60

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

100

1990 1995 2000 2005 2010

Percent

Year

Western and Central Africa

Figure 7. Trends in percentage of women receiving antenatal care from a skilled health provider 

for the most recent live birth in Eastern and Southern Africa, 1990-2009 

Kenya, 92 Malawi, 92

Namibia, 95

Rwanda, 97

Uganda, 93

Zambia, 90

Zimbabwe, 94

Madagascar, 87

Mozambique, 85

Tanzania, 76

4 0

5 0

6 0

7 0

8 0

9 0

100

1990 1995 2000 2005 2010

Percent

Year

Eastern and Southern Africa Note: Ethiopia is excluded as doctors and nurses were not distinguished from other health professionals in the survey
25 

Figure 8. Trends in percentage of women receiving antenatal care from a skilled health provider 

for the most recent live birth in South/Southeast Asia, 1990-2009 

Bangladesh, 44

Cambodia, 69

India, 73

Indonesia, 93

Nepal, 44

Pakistan, 61

Philippines, 91

Vietnam, 70

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

100

1990 1995 2000 2005 2010

Percent

Year

South/Southeast Asia

Figure 9. Trends in percentage of women receiving antenatal care from a skilled health provider 

for the most recent live birth in North Africa/West Asia/Europe, 1990-2009 

Armenia, 93

Egypt, 74

Jordan, 99

Morocco, 68

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

100

1990 1995 2000 2005 2010

Percent

Year

North Africa/West Asia/Europe
26 

Figure 10. Trends in percentage of women receiving antenatal care from a skilled health provider 

for the most recent live birth in Latin America and the Caribbean, 1990-2009 

Bolivia, 86

Colombia, 93

DR, 99

Haiti, 76

Peru, 95

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

100

1990 1995 2000 2005 2010

Percent

Year

Latin America/Caribbean

3.1.7 Differentials in Use of Skilled Health Providers for Antenatal Care 

Mother’s age at birth 

Table 7 shows the percentage of women who received antenatal care from a skilled health 

provider for the most recent birth in the five years preceding the survey, by women’s background 

characteristics. Overall, there is no marked relationship between level of skilled care use and mother’s age 

at birth. In general, all age groups show similar use of skilled providers, except in most South/Southeast 

Asian countries, where a decreased use is evident among women age 35-49. 

Birth order 

Mothers are most likely to receive antenatal care from a skilled provider for the first birth than for 

subsequent births. This pattern is observed in all but a few countries studied, including Kenya, Tanzania 

and Indonesia, where the difference in use across parity is negligible. In all countries in Latin America 

and the Caribbean, South/Southeast Asia and North Africa/West Asia/Europe, and in a majority of 

countries in sub-Saharan Africa, the proportion of women receiving skilled antenatal care decreases with 

each birth order. In the sub-Saharan African countries where this pattern is not consistent, there is a 

general decrease. Consistent decreased use of antenatal care with increase of parity is most pronounced in 

South/Southeast Asia and North Africa/West Asia/Europe, where the drop in antenatal care with increase 

in birth order is generally higher than 20 percentage points, whereas in most sub-Saharan African 

countries the decrease is very small. 
27 

Urban/rural residence 

In all countries, women living in urban areas have higher levels of use of skilled health providers 

for antenatal care than women in rural areas, and in almost all countries, across regions, this difference is 

considerable. For the sub-Saharan African region and the North Africa/West Asia/ Europe region, the 

countries with the most striking urban-rural gap are in North Africa and West Africa, including Guinea, 

Mali, Niger and Senegal, where the level of skilled provider use is at least twice as high in urban areas as

in rural areas, and sometimes three times as high, as in Mali. In all countries of South/Southeast Asia, 

there is a considerable gap as well, especially in Bangladesh and Nepal, where urban women are about 

twice as likely as rural women to receive antenatal care from a skilled provider. The difference, although 

still evident, is more moderate in Latin America and the Caribbean. In the Dominican Republic the level 

is almost the same for women in urban and rural areas. 

Women’s education 

Table 7 also shows that in developing countries as a whole the likelihood of using a skilled 

provider is positively associated with women’s level of educational attainment. In almost all countries 

with data, over 95 percent of women with education higher than the secondary level receive antenatal care 

from a skilled provider, while the percentage of women with no education receiving skilled care varies 

across countries, from 22 percent in Bangladesh to over 90 percent in the Dominican Republic, 

Zimbabwe and Rwanda. Since in almost all countries with available data nearly all women in the highest 

education group use skilled providers for antenatal care, the overall low level of skilled antenatal care use 

found in certain countries can be explained by the fact that less educated women, who receive very low 

levels of antenatal care, are a much greater share of all women needing antenatal care. As a result, there is 

also a greater gap by education status in countries with lower overall level of use. This observed barrier of 

education status is most pronounced in all countries in South/Southeast Asia and most countries in West 

Africa and North Africa. 

Household wealth 

As with women’s education, use of antenatal care from a skilled health provider is positively 

associated with household wealth. In all countries across regions, the level of use of skilled antenatal care 

is highest among women in the richest households. As before, wealth-related differences are larger in 

countries with a low level of antenatal care than those with a high level. For example, in Guinea, Mali, 

Niger, Nigeria, Senegal, Bangladesh, Nepal and Pakistan, where no more than half of women report use 

of antenatal care from a skilled provider, the disparity between rich and poor is substantial. Also in the 

same countries, wealth status does not seem to have an impact on skilled antenatal care use until the 

fourth wealth quintile. The level of use remains low for women in the bottom 60 percent of households, 

starts to increase for women in the fourth wealth quintile, and is highest for the richest 20 percent. 

Similarly, countries with a higher overall level of skilled provider use have the least variance across 

wealth groups—namely Namibia, Nigeria, Zimbabwe, Uganda and most notably Jordan, Rwanda and the 

Dominican Republic, where the difference in use between the poorest and the richest is less than 4 

percentage points. 
Table 7. Percentage of women who received antenatal care from a skilled health provider for the most recent birth in the five years preceding the survey by selected 

characteristics, the most recent survey, 1990-2009

Age at the last birth Birth order Residence Education Wealth status (quintile)

Country/Year <20 20 -34 35 -49 1 2 3

4 or 

more Urban Rural None

PrimarySecon 

-dary

HigherLowestSecondMiddleFour

-th

High

-est

Sub-Saharan Africa

Benin 2006 81.0 85.2 81.3 89.2 86.9 85.9 80.6 90.9 80.4 79.8 94.6 98.4 98.1 68.4 78.6 85.0 93.0 97.5

Burkina Faso 2003 73.7 73.8 69.2 80.2 76.4 75.0 68.5 96.4 68.9 69.9 89.4 99.9 * 56.3 62.2 72.9 81.0 95.8

Cameroon 2004 80.4 80.3 77.9 87.3 83.1 80.9 74.7 91.5 70.1 55.1 85.8 94.9 100.0 60.6 71.4 85.9 92.2 96.2

Chad 2004 40.2 39.0 36.8 48.5 39.8 36.6 36.5 76.8 30.1 29.1 68.3 85.2 * 6.9 25.5 39.1 50.2 73.9

Ghana 2008 83.6 88.2 82.6 90.4 88.5 88.4 82.9 94.0 81.8 77.5 85.7 93.2 * 71.7 83.2 92.1 94.1 97.0

Guinea 2005 55.5 53.5 46.9 60.7 59.1 51.4 48.4 92.4 39.8 48.3 73.0 84.4 * 31.5 39.6 45.2 64.9 94.8

Kenya 2008 88.5 93.3 84.7 92.4 92.2 95.6 88.8 95.8 90.3 72.4 92.8 95.6 99.1 83.6 92.7 93.2 92.7 95.6

Madagascar 2008-09 82.8 87.4 86.3 88.6 87.3 88.1 84.1 94.7 85.1 71.2 88.8 95.8 100.0 72.9 82.8 89.2 94.5 97.2

Malawi 2004 92.5 92.4 90.7 93.8 93.5 92.1 90.8 97.6 91.3 86.3 93.5 97.3 * 88.7 89.8 91.1 94.9 97.2

Mali 2006 37.3 38.9 31.0 44.1 40.4 43.2 32.7 72.1 23.2 31.9 57.0 81.6 (93.7) 19.3 23.4 25.5 40.6 79.7

Mozambique 2003 87.2 84.0 83.6 89.9 86.6 82.5 82.2 97.1 78.9 75.0 91.5 98.7 * 67.0 82.5 86.1 96.9 98.3

Namibia 2006-07 79.5 80.3 75.9 62.7 62.7 61.1 58.8 96.1 93.4 79.0 94.4 97.1 97.2 90.3 93.2 95.7 97.0 96.6

Niger 2006 38.1 38.7 38.0 31.0 27.1 26.7 24.2 87.3 38.5 41.6 69.5 93.9 * 35.7 35.5 36.8 42.7 82.6

Nigeria 2008 38.2 56.3 50.8 32.9 31.5 31.7 26.7 78.8 41.6 27.6 62.0 79.9 93.6 20.3 35.8 56.8 75.2 89.8

Rwanda 2007 93.6 96.2 95.0 97.2 95.8 96.1 95.1 95.9 95.8 93.8 96.2 98.7 (100.0) 94.1 94.7 97.2 96.0 97.3

Senegal 2005 54.7 61.3 58.0 67.5 64.3 59.7 54.7 88.3 41.7 51.0 76.4 91.0 * 31.9 44.3 58.7 82.0 90.9

Tanzania 2004-05 73.6 77.1 75.2 76.6 78.7 78.7 74.1 83.2 74.3 67.1 79.4 77.6 86.2 66.0 75.2 80.2 78.0 83.2

Uganda 2006 93.9 93.1 91.2 96.0 93.1 92.9 92.0 97.1 92.3 89.5 93.3 95.7 98.5 92.5 91.4 92.0 92.9 96.3

Zambia 2007 90.7 90.2 89.5 92.7 91.6 90.1 88.7 98.2 86.3 82.5 89.5 95.0 99.2 85.1 83.7 88.5 97.6 98.2

Zimbabwe 2005-06 93.0 94.9 91.7 95.7 95.6 94.4 91.1 96.0 93.4 94.1 91.1 96.0 97.2 92.7 92.0 94.5 95.2 97.1

North Africa/West Asia/Europe

Armenia 2005 90.1 93.7 88.3 97.2 93.7 89.3 73.8 95.6 88.8 na 100.0 91.1 99.1 84.5 87.5 95.2 97.1 99.2

Egypt 2008 75.8 74.7 69.2 85.6 76.1 72.6 60.8 85.1 67.5 55.4 69.2 79.9 92.4 54.1 64.5 74.0 85.6 92.4

Jordan 2007 97.8 99.1 97.7 99.5 99.3 99.1 98.1 98.9 97.9 89.4 95.8 98.9 99.7 96.8 98.8 99.3 99.8 99.9

Morocco 2003-04 68.6 68.8 63.9 82.8 72.8 68.2 53.3 84.9 47.9 55.5 78.5 92.1 98.7 39.7 56.4 70.6 86.8 93.1

(Cont’d)

28
Table 7. – cont’d

Age at the last birth Birth order Residence Education Wealth status (quintile)

Country/Year <20 20 -34 35 -49 1 2 3

4 or 

more Urban Rural None

PrimarySecon 

-dary

HigherLowestSecondMiddleFour

-th

High

-est

South/Southeast Asia

Bangladesh 2007 45.7 44.1 29.3 58.1 45.1 37.9 27.3 67.1 37.4 21.6 36.0 58.0 87.8 22.4 27.7 37.4 56.8 79.8

Cambodia 2005 68.8 72.1 59.8 80.3 75.0 71.3 56.8 79.2 67.7 49.9 70.6 89.9 (100.0) 55.2 63.7 68.4 77.6 90.2

India 2005-06 76.5 74.1 50.1 85.5 82.7 71.1 53.1 89.0 67.4 56.8 78.4 90.3 98.1 52.0 64.5 76.4 87.7 96.2

Indonesia 2007 90.8 94.2 90.1 95.2 95.4 92.8 86.9 97.7 90.1 62.6 89.5 97.6 99.5 82.2 92.1 95.5 98.5 99.2

Nepal 2006 50.8 44.9 20.4 58.6 50.2 43.4 24.0 84.6 37.5 28.5 51.9 71.9 94.7 17.7 30.5 38.4 60.7 84.1

Pakistan 2006-07 59.0 63.7 48.9 73.4 67.3 65.4 52.8 78.1 53.5 50.1 70.1 85.4 96.1 36.9 48.3 61.4 73.7 91.9

Philippines 2008 90.9 91.8 88.7 95.2 93.1 93.6 84.8 94.2 88.1 44.0 80.6 94.2 97.1 77.1 91.4 95.9 97.6 98.3

Vietnam 2002 53.7 72.1 66.2 74.5 71.4 68.1 50.5 92.7 65.2 35.1 61.1 75.7 96.9 51.7 61.7 68.9 78.8 97.0

Latin America/Caribbean

Bolivia 2008 86.5 88.1 76.3 91.0 90.4 90.0 76.6 94.5 73.9 62.9 80.4 93.3 98.5 65.7 82.8 92.1 96.2 96.8

Colombia 2005 92.7 94.0 90.5 96.8 95.0 93.9 82.9 95.8 87.0 72.5 87.8 96.5 98.4 83.1 92.6 96.8 97.3 99.1

Dominican Republic 2007 99.0 98.8 98.9 99.5 99.1 98.3 98.2 99.0 98.5 94.6 98.8 99.2 99.4 97.8 99.2 99.1 99.4 99.1

Haiti 2005-06 77.9 78.1 69.7 84.8 80.1 77.3 68.7 85.7 70.9 60.8 78.1 91.8 99.4 57.6 71.3 80.1 83.7 93.6

Peru 2008 92.4 95.1 93.1 96.7 95.3 95.6 89.4 98.3 87.5 86.6 89.4 96.3 99.2 82.5 89.1 97.3 98.4 99.0

Note: Figures in parentheses are based on 25-49 unweighted cases; an asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed.

Ethiopia is excluded as doctors and nurses were not distinguished from other health professionals in the survey.

29
30 

3.1.8 Content of Antenatal Care 

Table 8 presents information on the percentage of women who were informed of signs of 

pregnancy complications, had blood pressure measured and urine and blood samples taken, for their most 

recent live birth in the last five years. The content of antenatal care provides an indication of its quality. 

Pregnancy complications are primary sources of maternal and child morbidity and mortality, and 

therefore teaching women about signs associated with pregnancy complications and the appropriate action 

to take, as well as having measurements and tests to identify any potential complications, are important 

components of antenatal care.

In most sub-Saharan African countries, less than half of women who received antenatal care were 

informed of signs of pregnancy complications. This percentage is extremely low in some countries, as in 

Rwanda, where less than 10 percent of women were taught about danger signs during pregnancy. Ghana 

and Zambia perform better than other countries, with more than two-thirds of women receiving such 

services, followed by Nigeria (61 percent) and Namibia (58 percent). In this region, most women who 

receive antenatal care had their blood pressure measured. The practice of taking urine and blood samples 

is less common except in a few countries, including Cameroon, Ghana, Kenya, Namibia, Nigeria and 

Zimbabwe. 

It is generally assumed that countries with higher levels of use of skilled health providers for 

antenatal care will also have higher percentages of women receiving essential services. However, this is 

not always the case. For example, in Uganda 93 percent of women reported using skilled health providers 

for antenatal care, but only 35 percent were informed of danger signs of pregnancy, 12 percent had their 

urine samples taken, and 28 percent had blood samples taken, while a little more than half were measured 

for blood pressure. A similar pattern is observed in Rwanda and Malawi. In these countries, the main 

source of antenatal care is a nurse or midwife, rather than a doctor.

Similarly, in the South/Southeast Asia region most women had their blood pressure measured 

during antenatal care visits, but less than half were informed of signs of pregnancy complications. Even 

fewer women had their urine or blood samples taken. Countries in the region perform differently with 

respect to the various components of care. For example, India has the highest percentage of women whose 

urine and blood samples were collected in antenatal care but the smallest percentage who were informed 

of signs of pregnancy complications. Cambodia demonstrates the opposite pattern. 

Countries in North Africa/Central Asia/Europe and particularly in Latin America and the 

Caribbean generally have a high proportion of women reporting provision of the selected services. 

Nevertheless, in all countries of both regions relatively fewer women reported being informed about signs 

of pregnancy complications than reported the other three types of services (measurement of blood 

pressure and taking urine and blood samples). 
31 

Table 8. Among women receiving antenatal care (ANC) for the most recent birth in the five years 

preceding the survey, the percentage who reported specific antenatal services, the most recent 

survey, 1990-2009

Country/Year

Informed of 

signs of 

pregnancy 

complications

Blood 

pressure 

measured

Urine 

sample 

taken

Blood 

sample 

taken

Number of women 

receiving ANC 

for their most 

recent birth

Sub-Saharan Africa

Benin 2006 39.0 98.7 91.6 39.6 9,286

Burkina Faso 2003 19.2 95.5 78.9 36.0 5,468

Cameroon 2004 38.4 93.9 83.8 82.3 4,436

Chad 2004 18.0 74.0 42.1 39.1 1,624

Ethiopia 2005 31.4 61.9 26.5 26.2 2,076

Ghana 2008 68.4 97.1 90.3 90.4 2,024

Guinea 2005 26.8 87.0 59.9 42.5 3,703

Kenya 2008 43.4 84.7 67.7 82.1 3,680

Madagascar 2008-09 48.7 80.6 29.5 30.6 7,869

Malawi 2004 70.3 77.9 20.7 35.9 6,930

Mali 2006 29.1 88.1 45.4 35.3 6,465

Mozambique 2003 51.8 72.8 37.7 50.4 6,098

Namibia 2006-07 58.2 97.3 93.7 97.4 3,734

Niger 2006 26.2 87.1 37.9 36.2 2,954

Nigeria 2008 61.3 85.1 74.5 73.6 11,158

Rwanda 2007 7.7 86.9 18.0 70.8 3,519

Senegal 2005 34.0 97.6 82.6 56.5 6,441

Tanzania 2004-05 47.3 66.0 41.9 54.2 5,593

Uganda 2006 35.3 52.5 12.4 28.1 4,809

Zambia 2007 73.3 80.4 23.0 59.0 4,044

Zimbabwe 2005-06 49.6 92.6 68.6 67.8 3,890

North Africa/West Asia/Europe

Armenia 2005 46.2 98.5 98.4 98.5 1,097

Egypt 2008 39.8 93.2 76.8 78.7 5,861

Jordan 2007 49.9 98.3 94.1 94.6 6,366

Morocco 2003-04 39.1 90.9 54.0 52.3 3,185

South/Southeast Asia

Bangladesh 2007 37.5 86.4 54.2 36.8 2,956

Cambodia 2005 60.3 80.6 23.8 18.1 4,213

India 2005-06 24.6 63.8 58.1 59.5 30,621

Indonesia 2007 38.8 91.9 40.1 29.2 13,457

Nepal 2006 57.3 78.5 31.6 27.9 3,000

Pakistan 2006-07 25.0 79.6 49.2 43.7 3,673

Philippines 2008 68.8 92.9 54.3 46.6 4,411

Vietnam 2002 na na na na

Latin America/Caribbean

Bolivia 2008 66.6 97.2 72.1 69.8 5,841

Colombia 2005 63.6 99.3 92.2 93.0 10,379

Dominican 

Republic 2007 69.1 99.5 97.2 99.1 8,120

Haiti 2005-06 43.8 95.4 66.7 68.9 3,512

Peru 2008 85.0 99.4 84.3 83.3 4,796
32 

Table 9 shows information about other components of antenatal care, including women’s receipt 

of iron tablets/syrups and tetanus injections during pregnancy. While both services could be obtained 

outside of antenatal care, an antenatal visit serves as an important channel to distribute them to pregnant 

women. Administration of iron tablets/syrup is very important to meet women’s increased iron needs 

during pregnancy, and it also affects the iron status of the children after birth. In Latin America and the 

Caribbean, the majority of women were given or bought iron supplements during pregnancy of their last 

birth. In South/Southeast Asia the figures also are higher than 50 percent, except in Pakistan (43 percent). 

In the four countries in North Africa/West Asia/Europe, the percentage of women receiving iron 

supplementation during antenatal care is highest in Jordan, at 81 percent. It is lowest in Armenia, at 18 

percent, and is 38 percent in Morocco and 42 percent in Egypt. 

A large variation in iron supplementation is found among countries in sub-Saharan Africa. In 

Senegal, Zambia, Ghana, Benin and Namibia, at least 8 in 10 pregnant women reported receiving iron 

tablets or syrups. Among most other countries, the level ranges from 29 percent in Chad to 79 percent in 

Malawi. However, in Ethiopia only 10 percent of women reported receiving iron supplements during 

pregnancy. 

Neonatal or maternal tetanus could occur in deliveries conducted at home or other places where 

the hygienic environment is poor. Tetanus toxoid injections are given to pregnant women primarily for 

the prevention of neonatal tetanus, a leading cause of infant mortality, but it also prevents tetanus in the 

women. If a woman did not previously receive injections, she should receive at least two doses during the 

pregnancy in order to be fully protected. 

Table 9 also shows the percentage of women who reported one, two or more doses of tetanus 

toxoid injections during pregnancy for their most recent live birth. In most countries in Latin America and 

the Caribbean, South/Southeast Asia and 11 countries in sub-Saharan Africa, more than half of women 

reported receiving two or more injections during pregnancy. However, in North Africa/West Asia/Europe, 

much smaller percentages reported two or more doses of tetanus toxoid injections—38 percent in Egypt, 

13 percent in Morocco and 6 percent in Jordan. 
33 

Table 9. Among women with a live birth in the five years preceding the survey, the percentage 

who received iron tablets or syrups and the percentage who received tetanus toxoid injections 

during the pregnancy of the most recent birth, the most recent survey, 1990-2009

Country/Year

Iron tablets 

or syrup

Tetanus toxoid injections Number of women with a 

One Two or more live birth the past 5 years

Sub-Saharan Africa

Benin 2006 86.1 19.3 56.3 10,521

Burkina Faso 2003 69.3 24.4 40.2 7,428

Cameroon 2004 73.3 19.1 53.3 5,303

Chad 2004 28.7 12.5 29.3 3,720

Ethiopia 2005 10.4 8.7 28.0 7,307

Ghana 2008 86.5 31.5 56.2 2,099

Guinea 2005 75.0 9.9 65.7 4,447

Kenya 2008 68.7 32.5 55.0 3,973

Madagascar 2008-09 41.1 15.0 47.4 8,662

Malawi 2004 79.4 18.4 66.2 7,271

Mali 2006 60.8 14.4 47.9 9,087

Mozambique 2003 60.2 18.5 57.2 7,179

Namibia 2006-07 79.8 21.0 32.9 3,898

Niger 2006 45.3 18.4 23.0 6,300

Nigeria 2008 54.3 9.1 45.3 17,635

Rwanda 2007 41.0 39.4 30.7 3,658

Senegal 2005 90.5 21.8 66.1 6,928

Tanzania 2004-05 38.9 23.8 55.9 5,772

Uganda 2006 63.1 25.9 50.8 5,035

Zambia 2007 90.4 49.2 30.3 4,136

Zimbabwe 2005-06 42.9 25.2 54.5 4,100

North Africa/West Asia/Europe

Armenia 2005 17.9 na na 1,176

Egypt 2008 41.5 42.1 37.7 7,896

Jordan 2007 80.5 25.3 6.2 6,446

Morocco 2003-04 38.3 15.1 12.6 4,695

South/Southeast Asia

Bangladesh 2007 54.8 22.9 59.7 4,905

Cambodia 2005 62.8 21.4 54.2 5,865

India 2005-06 65.1 6.7 76.3 39,677

Indonesia 2007 77.3 21.8 49.7 14,043

Nepal 2006 59.3 10.2 63.2 4,066

Pakistan 2006-07 43.3 4.9 53.4 5,677

Philippines 2008 82.4 30.4 47.7 4,590

Vietnam 2002 na 14.2 71.3 1,215

Latin America/Caribbean

Bolivia 2008 76.8 27.7 40.1 6,472

Colombia 2005 75.9 24.0 61.5 11,083

Dominican Republic 2007 92.8 9.0 84.1 8,203

Haiti 2005-06 64.7 13.8 60.2 4,074

Peru 2008 77.4 19.2 54.6 4,920

na=not available; information was not collected in the survey.
34 

3.1.9 Use of Intermittent Preventive Treatment during Pregnancy for Malaria and HIV Testing 

During Antenatal Care 

Due to the relatively high prevalence of HIV and malaria in sub-Saharan Africa, we examine use 

of intermittent preventive treatment (IPT) for malaria during pregnancy and HIV testing during antenatal 

care among women in this region. IPT during pregnancy is defined as preventive treatment for malaria 

with two or more doses of sulfadoxine/pyrimethamine (SP/Fansidar) given to pregnant women. In high 

malaria-endemic areas, it is recommended that pregnant women receive SP/Fansidar once in the second 

trimester of pregnancy and once in the third trimester, preferably during antenatal care visits. 

As table 10 shows, in certain countries—Burkina Faso, Cameroon, Chad, Ethiopia and Niger—

almost none of the pregnant women receive two doses of SP/Fansidar during pregnancy for their most 

recent birth in the two years prior to the survey. Zambia, Malawi and Ghana have the highest use of IPT, 

with 66 percent, 47 percent and 46 percent of women, respectively, receiving at least two doses of 

SP/Fansidar during the pregnancy. They are followed by Tanzania (22 percent), Rwanda (18 percent) and 

Uganda (18 percent). In most of countries, a majority of women who took at least two doses of 

SP/Fansidar received at least one dose during an antenatal care visit. 

Antenatal care is also an important conduit for HIV screening. Table 10 indicates that in most of 

the sub-Saharan African countries studied a very small proportion of women were offered and accepted 

HIV testing during their antenatal care visits, except in Namibia and Kenya (73 percent each). 
35 

Table 10. Among women with a live birth in the two years preceding the survey, the percentage 

who received intermittent-preventive treatment (IPT) and the percentage who were offered and 

accepted an HIV test during an antenatal care (ANC) visit during the pregnancy of the most 

recent live birth, the most recent survey, 1990-2009

Country/Year

Intermittent-preventive 

treatment (IPT)1

Were offered and accepted 

an HIV test during 

antenatal care2

Number of 

women with 

a live birth 

in the 2 years 

prior to the 

survey3

Took two 

or more 

doses of 

SP/Fansidar 

Took two 

or more 

doses of 

SP/Fansidar, 

and received 

at least one 

during an 

ANC visit

Received 

results

Did not 

receive 

results

Sub-Saharan Africa

Benin 2006 3.0 0.1 15.8 2.3 6,380

Burkina Faso 2003 0.0 0.0 na na 4,201

Cameroon 2004 0.0 0.0 8.9 1.1 3,173

Chad 2004 0.0 0.0 0.6 0.0 2,251

Ethiopia 2005 1.2 0.5 0.4 0.1 4,321

Ghana 2008 45.5 43.7 28.0 7.3 1,178

Guinea 2005 3.6 2.5 1.5 0.5 2,614

Kenya 2008 15.1 14.0 72.7 1.8 2,264

Madagascar 2008-09 6.7 6.4 6.2 1.2 4,807

Malawi 2004 46.5 42.9 3.7 0.6 4,604

Mali 2006 11.2 4.0 6.8 0.7 5,663

Namibia 2006-07 10.6 10.0 72.5 4.1 2,054

Niger 2006 0.5 0.4 1.9 0.2 3,918

Nigeria 2008 6.5 4.9 16.0 3.1 11,027

Rwanda 2007 17.7 17.3 na na 2,267

Senegal 2005 13.2 11.9 6.2 0.8 4,391

Tanzania 2004-05 22.3 21.7 12.9 2.3 3,500

Uganda 2006 17.6 16.2 21.2 4.8 3,247

Zambia 2007 65.7 62.5 39.5 5.0 2,631

Zimbabwe 2005-06 6.8 6.3 27.5 7.2 2,144

1

Intermittent Preventive Treatment during pregnancy is preventive treatment with two or more doses of 

SP/Fansidar. 

2Only women who were offered the test are included here; women who were either required or asked for the test 

are excluded from the numerator of this measure.

3

This includes women who did not receive antenatal care for their last birth in the past 2 years

na=not available.
36 

3.2 Delivery Care 

Delivery care through access to health facilities and skilled health personnel are two important 

interventions for safe motherhood. Historically, increasing women's access to health facilities with the 

capacity to provide emergency obstetric care has been responsible for large drops in maternal mortality 

(Post 1997; Wildman and Bouvier-Colle 2004; Maine 1991). This section provides information on the 

patterns for both indicators in the countries studied. 

3.2.1 Place of Delivery 

Table 11 presents the distribution of place of delivery for women whose most recent birth was in 

the five years preceding the survey. In half of the 38 countries analyzed, the majority of women delivered 

their last child in an institutional setting. In North Africa/West Asia/Europe and in Latin America and the 

Caribbean, women are more likely to give birth in a health facility than are women in sub-Saharan Africa 

or South/Southeast Asia. In Jordan and Armenia, over 95 percent of women had their most recent birth in 

a health facility, whether public or private. In the Latin American and Caribbean countries, except for 

Haiti (at 27 percent), over 70 percent of women delivered their most recent birth in an institutional 

setting, including 92 percent in Colombia and 98 percent in the Dominican Republic. 

In contrast, the situation in sub-Saharan Africa is mixed. The use of institutional facilities is 

greatest in Namibia (82 percent), Benin (81 percent), and Zimbabwe (70 percent). In about half of the 

countries, most births take place in a health facility, but the percentage is around 50 percent in several 

countries, including Mozambique, Rwanda, Tanzania and Zambia. The region’s countries with the lowest 

levels of births in health facilities are Ethiopia (6 percent), Chad (13 percent) and Niger (18 percent). 

In South and Southeast Asia, very few women deliver in health facilities. As table 11 shows, 

women who did not deliver in public or private birth facilities primarily delivered at home. Other than 

Vietnam, in no country in this region were a majority of last births delivered in facilities. Instead, home 

births were predominant. Particularly low levels of institutional births are in Bangladesh (16 percent), 

Nepal (20 percent), and Cambodia (23 percent). 

Overall, the public sector contributes a major share of births that take place in an institutional 

setting—particularly in Namibia, Armenia, Vietnam, Colombia, the Dominican Republic and Peru, where 

over 70 percent of women’s births are in a public health facility. Other countries with widespread access 

to public sector childbirth facilities include Benin (66 percent), Jordan (63 percent), Senegal (60 percent) 

and Bolivia (60 percent). In a few countries, however, particularly in North Africa/West Asia/Europe and 

South Asia/Southeast Asia, private sector provision of delivery care plays a relatively important role. For 

example, in Egypt 46 percent of women, and in Jordan 36 percent, delivered their most recent birth in a 

private sector facility. The pattern is similar in Indonesia (38 percent) and Pakistan (26 percent), with 

India not far behind (23 percent). In sub-Saharan Africa, the highest use of private sector delivery care is 

in Malawi, at 27 percent. 

Table 11 also presents information on the rates of caesarean section among all births. 

A higher caesarean section percentage suggests the availability of obstetric care, which is offered 

primarily in institutional facilities. It is well recognized that very low and or very high levels of caesarean 

section are dangerous. WHO has proposed that in a country a rate of 5-15 percent of births undergoing a 

caesarean section is optimal, and a rate above 15 percent in a country is not recommended (WHO 2009). 

Among the regions, caesarean section rates are lowest in sub-Saharan Africa, exceeding 5 percent 

only in Namibia (14 percent) and Ghana and Kenya (7 percent each). In contrast, the rates of caesarean 
37 

section deliveries in Egypt, Jordan and all countries in Latin America and Caribbean studied except Haiti 

are much higher than 15 percent. Particularly high rates are seen in Egypt and Colombia (29 percent each) 

and the Dominican Republic (44 percent). 

Overall, the countries with the highest caesarean section rates, all above 20 percent (Egypt, 

Jordan, Bolivia, Colombia, the Dominican Republic and Peru), are also among the countries with the 

highest institutional birth rates (Benin, Namibia, Armenia, Egypt, Jordan, Vietnam, Bolivia, Colombia, 

the Dominican Republic and Peru). In some of these countries, the high rate of caesarean section 

deliveries is associated with a high percentage of births taking place in public health facilities. Data not 

presented here indicate that, particularly in Latin American and Caribbean countries with caesarean 

section rates above 20 percent (Bolivia, Colombia, the Dominican Republic and Peru), more than 60 

percent of caesarean section deliveries occur in public facilities, and as many as 95 percent in Colombia 

and 79 percent in Peru. However, comparing caesarean sections in public and private facilities, the rate is 

much higher in private facilities than in public facilities in a number of countries, including Mozambique, 

Namibia, Armenia, Morocco, Bangladesh, Bolivia, the Dominican Republic and Peru (data not shown 

here). 

Trend data on caesarean section deliveries (see Appendix A) indicate a mixed pattern in subSaharan Africa. While steady increases are evident in Namibia, Ghana and Benin, a majority of countries 

in the region display little change, and in some instances a small decline. Elsewhere, increases in 

caesarean section rates between the early 1990s and 2010 exceeded five percentage points in Egypt and 

Jordan in the North Africa/West Asia/Europe region, India, Indonesia and Pakistan in South/Southeast 

Asia, and Bolivia, Columbia, the Dominican Republic and Peru in Latin America and the Caribbean. 
Table 11. Percent distribution of women who had a live birth in the five years preceding the survey by place of delivery for the most 

recent live birth, the most recent survey, 1990-2009

Institutional delivery

Home

Other 

places

Missing/

Don't know Total

Percentage

who delivered 

in a health 

facility

Percentage 

who 

received 

caesarean

section

Total number of 

women with a 

live birth in the 5 

years preceding 

Country/Year the survey

Public 

sector

Private 

sector

Sub-Saharan Africa

Benin 2006 65.9 14.6 19.3 0.2 0.1 100.0 80.5 4.0 10,521

Burkina Faso 2003 39.7 0.8 59.4 0.1 0.0 100.0 40.5 0.7 7,428

Cameroon 2004 42.9 18.9 37.4 0.6 0.2 100.0 61.8 2.3 5,303

Chad 2004 11.4 1.9 86.1 0.6 0.0 100.0 13.3 0.5 3,720

Ethiopia 2005 5.8 0.6 93.1 0.4 0.1 100.0 6.4 1.2 7,307

Ghana 2008 50.7 9.4 39.3 0.5 0.0 100.0 60.1 7.2 2,099

Guinea 2005 30.0 1.8 68.0 0.0 0.1 100.0 31.8 1.9 4,447

Kenya 2008 34.9 11.9 53.1 0.2 0.0 100.0 46.8 7.2 3,973

Madagascar 2008-09 34.4 3.2 61.7 0.7 0.0 100.0 37.6 1.7 8,662

Malawi 2004 42.4 27.3 29.0 1.2 0.0 100.0 69.7 3.3 7,272

Mali 2006 45.1 2.4 52.1 0.2 0.1 100.0 47.5 2.0 9,087

Mozambique 2003 49.9 0.3 48.2 1.6 0.1 100.0 50.2 2.4 7,179

Namibia 2006-07 77.2 5.1 17.3 0.2 0.2 100.0 82.3 13.6 3,898

Niger 2006 17.6 0.5 81.5 0.4 0.0 100.0 18.1 1.2 6,300

Nigeria 2008 21.3 15.2 61.2 2.3 0.0 100.0 36.5 2.1 17,635

Rwanda 2007 48.7 0.9 47.2 3.2 0.0 100.0 49.6 na 3,658

Senegal 2005 59.8 4.3 35.2 0.5 0.2 100.0 64.1 3.9 6,928

Tanzania 2004-05 40.5 9.7 49.6 0.1 0.0 100.0 50.2 4.0 5,772

Uganda 2006 32.0 13.3 54.5 0.1 0.0 100.0 45.3 3.6 5,035

Zambia 2007 45.6 4.9 49.0 0.4 0.1 100.0 50.5 3.5 4,136

Zimbabwe 2005-06 56.6 12.9 29.5 0.9 0.2 100.0 69.5 5.4 4,100

North Africa/West Asia/Europe

Armenia 2005 96.7 0.7 2.0 0.3 0.3 100.0 97.4 9.8 1,176

Egypt 2007 26.8 45.6 27.6 0.1 0.0 100.0 72.4 29.2 7,896

Jordan 2007 62.6 36.3 1.1 0.0 0.0 100.0 98.9 20.0 6,446

Morocco 2003-04 55.1 8.5 36.0 0.3 0.1 100.0 63.6 5.8 4,695

(Cont’d)

38
Table 11. – cont’d

Institutional delivery

Home

Other 

places

Missing/

Don't know Total

Percentage of 

women who 

delivered in a 

health facility

Percentage 

who 

received 

caesarean

section

Total number of 

women with a 

live birth in the 5 

years preceding 

Country/Year the survey

Public 

sector

Private 

sector

South/Southeast Asia

Bangladesh 2007 7.5 8.6 83.6 0.3 0.0 100.0 16.1 8.6 4,905

Cambodia 2005 18.1 5.1 76.7 0.1 0.0 100.0 23.2 2.2 5,865

India 2005-06 19.0 22.5 58.3 0.2 0.0 100.0 41.5 9.8 39,677

Indonesia 2007 9.9 37.5 51.6 0.7 0.3 100.0 47.4 7.3 14,043

Nepal 2006 14.4 5.1 79.2 1.3 0.0 100.0 19.5 3.3 4,066

Pakistan 2006-07 11.5 25.5 62.4 0.0 0.5 100.0 37.0 8.5 5,677

Philippines 2008 27.8 19.0 53.1 0.1 0.0 100.0 46.8 11.4 4,590

Vietnam 2002 75.8 3.6 20.3 0.2 0.1 100.0 79.4 10.2 1,215

Latin America/Caribbean

Bolivia 2008 59.6 12.1 27.9 0.4 0.0 100.0 71.7 21.1 6,472

Colombia 2005 88.0 4.0 7.8 0.2 0.0 100.0 92.0 28.8 11,084

Dominican Republic 2007 76.0 21.9 1.0 0.6 0.4 100.0 97.9 44.4 8,203

Haiti 2005-06 15.9 11.5 72.0 0.5 0.1 100.0 27.4 3.5 4,074

Peru 2008 73.3 7.4 18.4 0.9 0.0 100.0 80.7 20.3 4,920

39
40 

3.2.2 Trends in Births in Health Facilities 

Figures 11-15 show trends in institutional births, including both public and private health 

facilities. Overall, in almost all countries the percentage of births taking place in health facilities has 

increased since the early 1990s. Among the West and Central African countries (Figure 11), the increases 

are most prominent in Benin, Ghana, Mali and Senegal, at 10-18 percentage points between the early/mid 

1990s and the mid/late 2000s. But in Chad, Guinea, Niger and Nigeria, the percentage of births in 

institutional facilities has increased very little and remains quite low. 

In East and Southern Africa (Figure 12), the most significant increase in institutional births is in 

Rwanda, at 24 percentage points between 2000 and 2007. Other countries with increases over 10 

percentage points between the early 1990s and mid 2000s are Malawi, Namibia and Uganda. However, a 

few countries in this sub-region (Madagascar, Tanzania and Zambia) display a decrease in the percentage 

of institutional births over the survey period. 

In South/Southeast Asia (Figure 13), all countries show steady increases in institutional deliveries 

in the past two decades. India, Indonesia and Pakistan, in particular, have had the highest levels of growth 

(24-31 percentage points). As Figures 14 and 15 indicate, there is a strong upward trend in institutional 

births in North Africa and West Asia and in Latin America and Caribbean, except for Haiti. In all of these 

countries with increases, a high percentage of births now take place in a health facility. In some of the 

countries, as in Jordan, the increase seems small, but only because the level of institutional births has been 

consistently high, approaching 100 percent. 

Figure 11. Trends in percentage of women whose most recent live birth occurred in a health 

facility in Western and Central Africa, 1990-2009 

Benin, 81

Burkina Faso, 41

Cameroon, 62

Chad, 13

Ghana, 60

Guinea, 32

Mali, 48

Niger, 18

Nigeria, 35

Senegal, 64

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

100

1990 1995 2000 2005 2010

Percent

Year

Western and Central Africa
41 

Figure 12. Trends in percentage of women whose most recent live birth occurred in a health 

facility in Eastern and Southern Africa, 1990-2009 

Ethiopia, 6

Kenya, 47

Madagascar, 38

Malawi, 70

Mozambique, 50

Namibia, 82

Rwanda, 50

Tanzania, 50

Uganda, 45

Zambia, 51

Zimbabwe, 70

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

100

1990 1995 2000 2005 2010

Percent

Year

Eastern and Southern Africa

Figure 13. Trends in percentage of women whose most recent live birth occurred in a health 

facility in South/Southeast Asia, 1990-2009 

Bangladesh, 16

Cambodia, 23

India, 41

Indonesia, 48

Nepal, 19

Pakistan, 37

Philippines, 47

Vietnam, 80

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

100

1990 1995 2000 2005 2010

Percent

Year

South/Southeast Asia
42 

Figure 14. Trends in percentage of women whose most recent live birth occurred in a health 

facility in North Africa/West Asia/Europe, 1990-2009 

Amenia, 97

Egypt, 72

Jordan, 99

Morocco, 64

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

100

1990 1995 2000 2005 2010

Percent

Year

North Africa, West Asia, Europe

Figure 15. Trends in percentage of women whose most recent live birth occurred in a health 

facility in Latin America and the Caribbean, 1990-2009 

Bolivia, 72

Colombia, 92

DR, 98

Haiti, 27

Peru, 81

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

100

1990 1995 2000 2005 2010

Percent

Year

Latin America/Caribbean
43 

3.2.3 Differentials in Births in Health Facilities 

Mother’s age at birth 

Table 12 shows the characteristics of women whose last birth was at a health facility. In general, 

the younger the mother is, the more likely she is to use a health facility. That is, the age of the mother at 

last birth is inversely related to the use of a health facility for birth. This pattern is most prominent in subSaharan Africa, where in a majority of countries the percentage of women under age 20 who gave birth in 

an institutional setting is greater than the percentage among women age 35-49. 

The relationship between mother’s age and use of health facilities for delivery is somewhat nonlinear in some sub-Saharan African countries (Benin, Cameroon, Ghana, Nigeria and Zimbabwe) and in 

South/Southeast Asia (all countries except Nepal and Vietnam), where a larger proportion of women age 

20-34 had their last birth at a health facility compared to other age groups. In Indonesia, the Philippines 

and Vietnam, the proportion of women age 20-34 who delivered in a health facility is 10 percentage 

points higher than among women under age 20. 

Birth order 

As Table 12 shows, birth order has a strong inverse relationship with use of a health facility for 

delivery. Consistently across all four regions in this study, the proportion of births delivered in a health 

facility declines with birth order. A larger proportion of women with just one birth deliver at a health 

facility compared to women with four or more births. This difference is less prominent in sub-Saharan 

Africa than the other three regions, where most countries show a 20 percentage point difference between 

the two groups. Exceptions are Jordan and the Dominican Republic, where the percentage of institutional 

births is consistently high, over 97 percent irrespective of birth order. 

Urban/rural residence 

Overall, births in a health facility are more common in urban than rural areas. This difference is 

most apparent in sub-Saharan Africa and South/Southeast Asia, where in a majority of countries the 

proportion of health facility births in urban areas is double the proportion in rural areas. Countries where 

health facility use is significantly low in rural areas are Chad, Ethiopia and Niger, where less than 10 

percent of women in rural areas delivered their most recent child in a health facility. Other countries with 

percentages between 10 and 20 percent are Bangladesh, Cambodia, Nepal and Haiti. In contrast, in 

Armenia, Jordan and the Dominican Republic, rates in rural areas, as in urban areas, are close to 100 

percent. Benin and Vietnam also display a high rate of institutional births in rural areas (over 75 percent). 

Women’s education 

In all countries examined, there is a strong positive association between mother’s education and 

use of a health facility for delivery. In most countries, over 90 percent of women educated beyond the 

secondary level had their last birth at a health facility. Some exceptions are in sub-Saharan Africa and 

South/Southeast Asia, with the lowest percentages in Bangladesh and the Philippines. This pattern 

persists among women with secondary education. Among women with a primary education or no 

education, the proportion of women using a health facility for delivery is lowest in sub-Saharan Africa 

and South/Southeast Asia, although there is considerable variation across countries. 
44 

Household wealth 

Overall, the relationship between household wealth status and health facility use for delivery is 

positive, as with mother’s education. However, there is some variation between countries within regions. 

For example, in Chad and Ethiopia in sub-Saharan Africa, and Bangladesh in South Asia, countries where 

the use of institutional facilities for childbirth is low, less than half of women in the wealthiest quintile 

had their last birth in a health facility. This percentage is lowest in Ethiopia (28 percent). Among the 

poorest groups in these countries, the use of health facilities for delivery is minimal. Other countries with 

very low use of health facilities among the poorest groups but moderate to high use among women in the 

wealthiest quintile include Guinea, Niger and Nigeria. A similar pattern is evident in Haiti and several 

South/Southeast Asian countries, except Vietnam, where less inequity exists than elsewhere in the region. 

In Vietnam even among the poorest group, over 50 percent of women had their last birth in a health 

facility. In all four counties in the North Africa/West Asia/Europe region, the use of health facilities 

ranges between 80 and 100 percent for the two richest groups, and over 90 percent for the richest group 

alone, while only in Egypt and Morocco is it below 50 percent for the poorest group. 
Table 12. Percentage of women whose most recent live birth in the five years preceding the survey occurred in a health facility by selected characteristics, the most 

recent survey, 1990-2009

Age at birth Birth order Residence Education Wealth status (quintile)

Country/Year <20 20 -34 35 -49 1 2 3

4 or 

more Urban Rural None

PrimarySecondaryHigh 

-er

LowestSecondMiddleFour

-th

High

-est

Sub-Saharan Africa

Benin 2006 77.9 81.6 76.6 88.7 84.1 83.4 75.1 87.7 76.4 75.0 93.9 98.7 97.0 59.1 72.7 82.1 92.8 97.9

Burkina Faso 2003 44.4 41.0 36.1 53.2 43.0 42.0 34.8 88.8 32.5 34.8 70.9 94.6 * 19.1 26.8 34.0 46.1 86.2

Cameroon 2004 61.7 62.5 58.7 75.1 68.0 59.8 53.1 82.8 43.8 22.3 68.2 89.4 95.4 28.7 44.1 69.5 85.9 92.1

Chad 2004 16.4 12.6 12.2 22.0 13.3 11.9 11.2 47.1 5.4 8.5 22.6 54.6 * 1.4 5.6 7.0 10.8 44.7

Ethiopia 2005 8.0 6.8 3.8 16.0 9.8 5.7 2.8 45.8 2.6 2.6 10.0 50.9 80.6 0.7 1.3 1.9 4.5 28.4

Ghana 2008 56.5 62.3 54.6 71.7 66.5 61.4 50.0 83.4 44.6 37.6 56.7 76.5 * 23.6 51.6 64.9 81.4 92.2

Guinea 2005 36.7 31.9 27.3 43.3 32.3 32.4 28.0 64.4 21.5 27.1 52.3 71.0 * 12.0 17.7 26.9 46.0 68.7

Kenya 2008 52.9 47.3 37.1 66.3 53.0 49.4 32.0 75.8 39.2 17.2 40.8 69.6 89.4 18.9 32.3 45.2 55.1 80.9

Madagascar 2008-09 35.6 38.4 37.1 46.6 39.7 41.5 31.0 62.8 34.1 17.9 36.7 59.0 87.1 18.4 25.2 37.7 49.3 67.8

Malawi 2004 70.7 70.8 63.3 77.5 71.7 68.3 65.6 87.8 66.7 55.2 71.7 89.7 * 56.9 63.0 66.1 75.9 89.9

Mali 2006 51.6 47.5 42.9 58.1 49.1 49.3 43.3 79.8 34.5 41.6 73.4 90.0 (86.5) 31.6 34.2 35.4 53.4 84.8

Mozambique 2003 57.0 49.2 44.8 62.7 54.8 46.9 43.9 82.0 35.7 32.1 61.6 95.4 * 25.2 34.1 44.4 70.3 90.0

Namibia 2006-07 83.3 83.6 75.3 90.3 84.6 83.3 69.9 93.6 73.4 49.4 72.7 90.8 99.6 59.6 74.6 86.4 93.5 97.0

Niger 2006 18.4 17.9 18.9 27.8 20.7 19.4 15.0 71.6 8.4 13.2 40.0 81.0 * 4.4 7.0 9.1 13.5 60.5

Nigeria 2008 23.5 39.6 34.8 46.5 42.1 41.2 29.9 61.4 25.8 10.7 40.5 66.3 90.1 7.7 16.5 34.5 57.7 80.4

Rwanda 2007 65.5 52.7 37.0 74.8 54.7 48.4 38.0 68.1 46.4 35.1 51.4 80.1 (91.59) 40.4 44.6 47.3 48.9 69.2

Senegal 2005 64.3 65.3 59.8 79.4 68.2 61.8 56.6 88.6 48.6 54.7 83.0 94.6 * 30.5 44.8 71.0 89.3 94.1

Tanzania 2004-05 55.1 51.1 41.0 67.3 54.0 53.5 39.2 82.8 41.0 32.8 53.9 81.7 99.4 31.7 38.4 42.3 56.1 87.2

Uganda 2006 54.3 45.9 34.8 65.2 50.7 47.2 37.8 82.0 39.8 27.9 42.9 77.2 87.8 29.8 34.7 37.4 50.8 78.6

Zambia 2007 59.7 51.6 36.8 69.0 58.3 48.5 41.3 84.9 34.0 26.3 44.8 73.1 99.0 29.3 30.2 38.1 73.4 92.9

Zimbabwe 2005-06 69.1 71.2 58.1 79.7 73.7 67.8 55.0 93.4 58.6 36.0 52.2 80.9 99.1 46.0 55.8 71.2 84.3 95.0

North Africa/West Asia/Europe

Armenia 2005 98.9 97.6 95.2 100.0 98.4 95.9 82.8 99.7 93.9 na 100.0 96.8 100.0 88.4 98.7 100.0 99.6 100.0

Egypt 2007 73.0 72.1 73.6 83.4 74.7 70.9 58.6 86.0 64.0 52.6 65.5 78.4 92.5 46.2 61.3 74.4 84.6 94.6

Jordan 2007 98.4 98.9 98.7 99.6 99.3 98.3 98.7 98.9 98.5 95.1 96.7 98.8 99.7 97.5 98.6 99.5 99.4 99.9

Morocco 2003-04 69.7 63.2 62.7 83.3 68.1 62.7 46.9 83.9 40.2 49.6 76.3 91.5 98.2 29.6 49.6 70.3 83.9 93.7

(Cont’d)

45
Table 12. – cont’d

Age at birth Birth order Residence Education Wealth status (quintile)

Country/Year <20 20 -34 35 -49 1 2 3

4 or 

more Urban Rural None

PrimarySecondaryHigh 

-er

LowestSecondMiddleFour

-th

High

-est

South/Southeast Asia

Bangladesh 2007 15.7 16.7 11.6 26.7 16.4 11.3 5.1 33.1 11.5 3.0 7.4 24.6 60.8 5.1 5.5 9.4 19.3 44.9

Cambodia 2005 23.7 24.4 18.8 33.9 26.3 22.0 14.2 53.6 18.2 10.7 20.5 47.2 (88.0) 7.1 11.1 15.2 27.0 68.0

India 2005-06 40.8 42.8 24.0 61.1 50.9 32.9 18.4 70.5 30.9 19.5 39.0 64.9 93.1 13.2 24.3 41.1 60.2 85.6

Indonesia 2007 37.9 48.7 47.6 56.0 48.9 43.5 33.3 71.0 30.4 15.7 29.9 58.7 84.4 14.1 32.4 48.6 62.7 83.6

Nepal 2006 24.1 19.3 11.6 36.5 20.4 11.3 7.3 51.6 14.6 8.5 19.5 41.7 79.9 5.0 9.3 11.7 23.3 57.1

Pakistan 2006-07 35.6 39.3 26.8 51.4 45.5 40.9 27.7 59.1 27.5 24.7 42.7 66.5 85.3 14.4 22.3 32.8 48.6 74.8

Philippines 2008 38.0 48.4 44.7 61.6 52.8 47.8 29.2 62.0 31.7 7.8 18.6 45.5 74.8 13.0 34.3 49.2 70.2 85.3

Vietnam 2002 67.0 80.2 83.8 86.7 80.8 71.0 56.0 99.1 75.1 38.8 69.8 86.4 100.0 50.5 78.3 86.6 93.4 98.7

Latin America/Caribbean

Bolivia 2008 75.5 74.1 59.3 84.7 80.7 74.3 54.0 89.1 48.0 37.3 58.5 87.7 99.0 32.9 62.6 81.5 92.9 99.0

Colombia 2005 92.6 92.1 90.3 97.0 94.0 92.8 78.2 97.5 78.1 71.0 83.8 96.2 99.3 73.0 94.0 97.6 99.1 99.2

Dominican 

Republic 2007 98.7 97.8 97.5 98.7 98.2 97.5 97.0 98.4 97.1 90.4 97.9 98.4 98.5 95.5 99.1 98.8 98.7 97.8

Haiti 2005-06 30.2 29.6 18.1 46.0 30.8 24.1 14.4 45.6 16.7 9.1 21.8 56.1 90.3 6.8 10.8 20.7 39.4 67.3

Peru 2008 82.5 81.4 76.5 90.3 84.0 79.6 64.4 93.7 57.8 49.1 61.3 89.2 97.9 41.7 64.3 85.7 96.6 97.5

Note: Figures in parentheses are based on 25-49 unweighted cases; an asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed.

46
47 

3.2.4 Attendance during Delivery 

Table 13 presents information on skilled birth attendance for women’s last birth in the five years 

preceding the survey. The proportion of births attended by skilled health personnel is one of the two key 

indicators of progress toward the reduction of maternal mortality, as part of Millennium Development 

Goal 5. In the DHS, women who had a live birth in the five years preceding the survey in a country were 

asked who assisted with the delivery. 

Overall, the pattern of birth attendance for women at delivery is similar to their use of health 

facilities for births. Except for a few countries (Benin, Namibia, Zimbabwe and Vietnam), the use of 

skilled care for delivery is considerably lower in sub-Saharan Africa and South/Southeast Asia than in the 

other regions. In sub-Saharan Africa, only 8 of the 21 countries examined have skilled birth attendance 

rates higher than 50 percent. Within the region, the Southern African countries perform better, 

particularly Zimbabwe and Namibia, with rates of skilled birth attendance higher than 70 percent. In 

Western Africa, Cameroon (62 percent) and Benin (76 percent) had much higher percentages of skilled 

birth attendance than other countries in the sub-region. In all sub-Saharan countries, the predominant type 

of skilled provider is a nurse/midwife. 

In the South/Southeast Asian region, the use of skilled attendants at birth is lower in South Asia 

than Southeast Asia. The lowest rates are in Bangladesh (19 percent) and Nepal (21 percent). The highest 

rates are in the Philippines (65 percent) and Vietnam (78 percent). Within South Asia, the highest rates 

are in India (49 percent) and Pakistan (42 percent). In all countries in the region except Indonesia and 

Cambodia, doctors constitute the major portion of skilled delivery assistance, although, especially in 

India, there are large disparities within country (data not shown). 

Although skilled birth attendants typically provide delivery care in institutional facilities, this is 

not always the case. In Egypt, for example, 28 percent of women deliver at home (see Table 11), while 

about 28 percent of home births had a skilled attendant at birth (data not shown). In Indonesia as well, 

where home births account for 52 percent of deliveries, 28 percent of home births had a skilled attendant. 

Madagascar is another example, where 16 percent of the 62 percent of women who delivered at home had 

a skilled birth attendant. 

Outside sub-Saharan Africa, in most countries doctors are the main providers of skilled birth 

assistance, and especially In North Africa/West Asia/Europe, except for Morocco, where nurses/midwives 

outnumber doctors as skilled providers of delivery assistance. The Latin American and the Caribbean 

countries follow the pattern of high levels of health facility use for deliveries, alongside very high levels 

of skilled birth attendance, except for Haiti. Doctors play a key role in deliveries in Bolivia, Colombia and 

the Dominican Republic, and to a smaller extent in Peru. 

Among births delivered without skilled birth attendance, traditional birth attendants form the 

major group in most countries. Some exceptions are Chad, Ethiopia and Senegal in sub-Saharan Africa, 

and Nepal in South Asia, where relatives and other individuals are also important in providing birth 

assistance. 

In several sub-Saharan African countries, over 10 percent of women reported not receiving any 

assistance for their last birth. The lack of assistance during delivery reaches nearly 20 percent in Niger 

and Nigeria, and 13 percent in Mali and Rwanda. 
Table 13. Percent distribution of women who had a live birth in the five years preceding the survey by provider of assistance at 

birth for the most recent live birth, the most recent DHS survey, 1990-2009

Person providing assistance during delivery Percentage 

of women 

who had a 

skilled birth 

attendant

Total number of 

women with 

a live birth in the 

5 years 

preceding the 

Country/Year Doctor survey

Nurse/

Midwife

Other 

health 

personnel

Traditional 

birth 

attendant

Relative/

Other

No 

one

Missing/

Don't 

know Total

Sub-Saharan Africa

Benin 2006 6.0 70.2 3.9 4.8 10.8 4.0 0.2 100.0 76.2 10,521

Burkina Faso 2003 1.7 38.0 0.0 32.5 21.9 6.0 0.0 100.0 39.7 7,428

Cameroon 2004 9.0 52.9 2.7 11.0 19.0 5.3 0.1 100.0 61.9 5,303

Chad 2004 0.8 1.8 11.9 34.0 47.6 3.9 0.0 100.0 2.6 3,720

Ghana 2008 11.5 46.3 3.9 27.5 8.0 2.8 0.0 100.0 57.8 2,096

Guinea 2005 5.3 25.2 9.3 22.5 28.1 9.5 0.2 100.0 30.5 4,447

Kenya 2008 18.0 30.0 0.6 24.3 20.7 6.4 0.0 100.0 48.0 3,972

Madagascar 2008-09 15.7 31.5 0.0 46.1 5.9 0.8 0.0 100.0 47.2 8,651

Malawi 2004 6.3 50.5 1.0 25.1 14.4 2.6 0.1 100.0 56.8 7,272

Mali 2006 1.7 27.1 0.0 44.3 13.6

12.

9 0.3 100.0 28.8 9,087

Mozambique 2003 3.5 46.7 0.0 10.7 36.0 3.0 0.2 100.0 50.2 7,179

Namibia 2006-07 19.5 63.2 0.0 5.8 10.7 0.7 0.1 100.0 82.7 3,898

Niger 2006 0.5 18.2 0.0 63.6 0.1

17.

6 0.0 100.0 18.7 6,273

Nigeria 2008 9.9 26.2 4.8 21.4 18.7

19.

1 0.0 100.0 36.1 17,537

Rwanda 2007 6.8 43.9 6.1 1.4 29.0

12.

8 0.0 100.0 50.7 3,617

Senegal 2005 4.1 43.1 7.4 6.9 34.1 4.2 0.2 100.0 47.2 6,928

Tanzania 2004-05 4.6 40.9 4.0 18.1 29.1 3.1 0.2 100.0 45.5 5,772

Uganda 2006 5.4 39.8 0.7 21.8 23.2 9.1 0.0 100.0 45.2 5,035

Zambia 2007 3.9 44.1 1.1 22.6 23.3 4.9 0.0 100.0 48.0 4,136

Zimbabwe 2005-06 10.0 60.1 0.0 26.0 1.6 2.1 0.2 100.0 70.1 4,100

North Africa/West Asia/Europe

Armenia 2005 94.3 4.1 0.7 0.0 0.4 0.0 0.5 100.0 98.4 1,176

Egypt 2007 75.4 4.5 0.0 18.9 0.7 0.5 0.0 100.0 79.9 7,891

Jordan 2007 74.4 24.8 0.0 0.0 0.5 0.3 0.0 100.0 99.2 6,446

Morocco 2003-04 16.9 48.6 0.0 19.3 14.0 1.0 0.2 100.0 65.5 4,695

(Cont’d)

48
Table 13. – cont’d

Person providing assistance during delivery Percentage 

of women 

who had a 

skilled birth 

attendant

Total number of 

women with 

a live birth in the 

5 years 

preceding the 

Country/Year Doctor survey

Nurse/

Midwife

Other 

health 

personnel

Traditional 

birth 

attendant

Relative/

Other

No 

one

Missing/

Don't 

know Total

South/Southeast Asia

Bangladesh 2007 14.0 4.9 0.7 72.1 6.2 2.2 0.0 100.0 18.9 4,902

Cambodia 2005 7.4 39.0 0.0 52.7 0.6 0.3 0.0 100.0 46.4 5,865

India 2005-06 38.1 10.5 1.2 34.5 15.2 0.5 0.1 100.0 48.6 39,677

Indonesia 2007 14.0 43.7 16.5 23.4 2.0 0.4 0.0 100.0 57.7 14,043

Nepal 2006 11.7 8.9 4.0 19.1 49.9 6.4 0.0 100.0 20.6 4,066

Pakistan 2006-07 35.8 5.9 0.0 49.3 7.7 0.8 0.6 100.0 41.7 5,677

Philippines 2008 37.5 27.9 0.0 33.5 1.0 0.2 0.0 100.0 65.4 4,587

Vietnam 2002 50.3 27.5 8.0 5.4 8.7 0.1 0.0 100.0 77.8 1,215

Latin America/Caribbean

Bolivia 2008 69.9 3.8 1.3 3.6 20.5 0.9 0.0 100.0 73.7 6,469

Colombia 2005 89.5 2.7 0.4 4.5 2.6 0.3 0.0 100.0 92.2 11,084

Dominican 

Republic 2007 97.9 0.6 0.0 0.5 0.4 0.0 0.6 100.0 98.5 8,203

Haiti 2005-06 17.8 9.8 1.5 62.9 4.7 3.4 0.0 100.0 27.6 4,074

Peru 2008 50.8 32.3 0.5 8.2 7.8 0.4 0.0 100.0 83.0 4,920

Note: Ethiopia is excluded as doctors and nurses were not distinguished from other health professionals in the survey.

49
50 

3.2.5 Trends in Use of Skilled Birth Attendants 

Figures 16-20 show trends in skilled birth attendance for the countries studied, by region. In 

almost all countries in Western and Central Africa (Figure 16), use of skilled birth attendants increased 

over the survey period, although the increases are small. Ghana and Benin show the steepest increase in 

the region. Chad has the lowest rate and there appears to be a decline in the use of skilled birth attendants 

between the surveys in 1996-97 and 2004. 

Among the Eastern and Southern African countries (Figure 17), in Uganda use of skilled birth 

attendants decreased from 34 percent in 1995 to 20 percent in 2000-01, but then rose sharply to 45 

percent in 2006, mainly because of the large role played by nurses and midwives in recent years. Steep 

rises in skilled birth attendance occurred in Rwanda between 1992 and 2007, from 25 to 50 percent, and 

in Namibia, from 70 to 83 percent between 1992 and 2006-07. In Madagascar, however, use of skilled 

birth attendants has declined since 1992. 

Improvements in skilled birth attendance were seen in all countries in South/Southeast Asia 

(Figure 18). Vietnam showed the steepest increase, from 57 percent in 1997 to 78 percent in 2002, 

followed by Cambodia, from 34 percent in 2000 to 46 percent in 2005. Elsewhere in the region, Pakistan 

had a steady increase in use of skilled birth attendants, from 17 percent in 1990-91 to 42 percent in 2006-

07. 

All four of the North African/West Asian/European countries saw an increase in use of skilled 

birth attendants (Figure 19). The two countries with the highest initial levels, Jordan and Armenia, 

showed a very small increase, while Morocco and Egypt, which had low levels in the early 1990s, 

increased substantially. 

The countries studied in Latin America and the Caribbean (Figure 20) follow a pattern similar to 

North Africa/West Asia/Europe. Increases in the Dominican Republic and Colombia have been small, 

partly because the levels were already quite high, while Peru and Bolivia show larger increases. Haiti, 

which has a much lower rate of skilled birth attendance than the other four countries, also displays an 

increase, but at a much slower rate. 
51 

Figure 16. Trends in percentage of women whose most recent live birth was attended by a skilled 

health provider in Western and Central Africa, 1990-2009 

Benin, 76

Burkina Faso, 40

Cameroon, 62

Chad, 3

Ghana, 58

Guinea 31

Mali, 29

Niger, 19

Nigeria, 36

Senegal, 47

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

100

1990 1995 2000 2005 2010

Percent

Year

Western and Central Africa

Figure 17. Trends in percentage of women whose most recent live birth was attended by a skilled 

health provider in Eastern and Southern Africa, 1990-2009 

Kenya, 48

Madagascar, 47

Malawi, 57

Mozambique, 50

Namibia, 83

Rwanda, 50

Tanzania, 46

Uganda, 45

Zambia, 48

Zimbabwe, 70

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

100

1990 1995 2000 2005 2010

Percent

Year

Eastern and Southern Africa Note: Ethiopia is excluded as doctors and nurses were not distinguished from other health professionals in the survey
52

Figure 18. Trends in percentage of women whose most recent live birth was attended by a skilled 

health provider in South/Southeast Asia, 1990-2009 

Bangladesh, 19

Cambodia, 46

India, 49

Indonesia, 58

Nepal, 21

Pakistan, 42

Philippines, 65

Vietnam, 78

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

100

1990 1995 2000 2005 2010

Percent

Year

South/Southeast Asia

Figure 19. Trends in percentage of women whose most recent live birth was attended by a skilled 

health provider in North Africa/West Asia/Europe, 1990-2009 

Amenia, 98

Egypt, 80

Jordan, 99

Morocco, 66

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

100

1990 1995 2000 2005 2010

Percent

Year

North Africa, West Asia, Europe
53 

Figure 20. Trends in percentage of women whose most recent live birth was attended by a skilled 

health provider in Latin America and the Caribbean, 1990-2009 

Bolivia, 74

Colombia, 92

DR, 99

Haiti, 28

Peru, 83

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

100

1990 1995 2000 2005 2010

Percent

Year

Latin America/Caribbean

3.2.6 Differentials in Use of Skilled Birth Attendants 

Mother’s age at birth 

Table 14 presents the characteristics of women whose last birth was attended by a skilled health 

provider. In a majority of countries, there is a negative relationship between mother’s age at last birth and 

use of a skilled attendant. Typically, younger women are more likely to use skilled birth attendants. This 

inverse relationship is strongest between women age 20-34 and women age 35-49, at greater than 10 

percentage points in several sub-Saharan African countries (Kenya, Rwanda, Uganda, Zambia and 

Zimbabwe), and in India (over 20 percentage points), Pakistan, Bolivia and Haiti. 

In a substantial number of countries, however, a non-linear relationship is observed, although the 

differences are small. In these countries women age 20-34 are most likely to use skilled birth attendants. 

Among countries following this pattern, the difference in use of skilled birth attendants between women 

under age 20 and women age 20-34 is largest in Nigeria (16 percentage points), Indonesia (14 percentage 

points). 

Birth order 

In all countries, higher levels of use of skilled attendants are associated with lower birth order. In 

most sub-Saharan African countries, women with one child (birth order 1) are substantially more likely to 

use a skilled health provider for their last delivery than women with four or more children. In several subSaharan African countries with skilled birth attendance rates over 60 percent for women with one child, 
54 

the decline in skilled birth assistance between birth order 1 and birth orders 4 or more is 30-50 percentage 

points (Rwanda, Tanzania and Zambia). 

This pattern is also evident in South/Southeast Asia. In India, for example, the rate of skilled 

attendance decreases from 68 percent for birth order 1 to 25 percent for birth orders 4 or more. The 

pattern is also evident in countries with low levels of skilled birth attendance, such as Bangladesh and 

Nepal in South/Southeast Asia and Haiti in the Caribbean. 

In most countries of Latin America and the Caribbean and North Africa/West Asia/Europe, the 

use of skilled birth attendants is relatively widespread, and in these countries use of skilled birth 

attendants also decreases as birth order increases. 

Urban/rural residence 

Women in urban areas use skilled birth attendants to a much greater extent than women in rural 

areas. In over half of sub-Saharan African countries and in several countries in South/Southeast Asia, the 

use of skilled birth attendants among urban women is double that of rural women. Only in two 

countries—Chad and Bangladesh—do less than half of urban women use skilled birth attendants. In 

Namibia and Vietnam, use of skilled birth care is over 90 percent in urban areas and is almost 75 percent 

in rural areas. However, in many countries in these two regions, less than 25 percent of rural women 

receive skilled assistance. In North Africa/West Asia/Europe and Latin America and the Caribbean, 

differences between urban and rural areas in skilled attendance at delivery are minimal, except in Haiti 

and Morocco, where they are significant, for example, in Morocco at 86 percent of urban women 

compared with 42 percent of rural women. 

Women’s education 

Mother’s education is consistently positively related to the use of skilled birth attendants at 

delivery. Skilled birth attendance among the most educated women is high. Chad and Bangladesh are the 

few countries where less than 80 percent of women with the highest education level had a skilled birth 

attendant at last delivery. In a majority of countries, outside of South/Southeast Asia, this percentage is 

well over 90 percent. As mentioned, in many countries studied very few women have more than a 

secondary education. 

Although the use of skilled birth attendants increases with education, there is large variation 

across countries among women at the same education level. For example, in Benin over 70 percent of 

women with no education had skilled attendance at their last birth, while this percentage rises among 

women who have primary and secondary levels of education. In most other countries in the region, skilled 

birth care among women with no education ranges between 20 and 40 percent. Other countries with high 

levels of skilled birth assistance among uneducated women or women with primary only education are 

Armenia, Jordan and the Dominican Republic. 

Household wealth 

A strong positive relationship is evident between household wealth status and use of skilled birth 

care at delivery. The greatest inequality in use of skilled birth care is in South Asia. Very low levels of 

care (below 10 percent) are observed among women in the poorest wealth quintile in Bangladesh and 

Nepal, with India and Pakistan performing only slightly better (18-19 percent). Such low levels of care 

among the poorest group are also observed in sub-Saharan Africa, in Burkina Faso, Chad, Guinea, Mali, 

Niger, Nigeria and Senegal. However, several countries in sub-Saharan Africa –Namibia, Benin, 

Zimbabwe, Malawi and Rwanda—and Vietnam in Southeast Asia are reasonably good performers even 
55 

among women in the poorest wealth quintile. In these countries, over 40 percent of women in the poorest 

group use skilled birth care. 

The use of the skilled birth care is highest among the wealthiest group in almost all of the 

countries studied. In sub-Saharan Africa, over 90 percent of women in the highest wealth quintile in 

Benin, Cameroon, Ghana, Madagascar, Namibia, Zambia and Zimbabwe received skilled birth assistance 

for their last birth. Skilled birth attendance is high among the wealthiest group in some South/Southeast 

countries as well. In Cambodia, India, the Philippines and Vietnam, more than 90 percent of women in 

the wealthiest group reporting having a skilled birth attendant.

In North Africa/West Asia/Europe and Latin America and the Caribbean, over 95 percent of 

women in the highest wealth quintile had a skilled birth attendant at delivery, in all countries except Haiti. 

These high percentages prevail even among the poorest group in Armenia, Jordan and the Dominican 

Republic.
Table 14. Percentage of women who had a skilled birth attendant at birth for the most recent birth in the five years preceding the survey by selected characteristics, the 

most recent survey 1990-2009

Age at birth Birth order Residence Education Wealth status (quintile)

Country/Year <20 20 -34 35 -49 1 2 3

4 or 

more Urban Rural None

PrimarySecondary HigherLowestSecondMiddleFourthHighest

Sub-Saharan Africa

Benin 2006 72.1 77.4 73.5 83.6 80.4 79.0 71.0 85.8 70.9 70.4 90.1 96.2 98.1 54.1 68.5 76.7 88.4 96.1

Burkina Faso 2003 44.0 40.3 34.9 52.5 43.1 41.2 33.7 89.1 31.5 34.0 69.9 93.6 * 18.0 25.8 32.9 45.8 85.8

Cameroon 2004 62.1 62.7 58.1 75.8 67.5 59.8 53.1 83.6 43.4 22.6 67.7 90.1 98.2 28.3 43.3 70.2 85.4 93.9

Chad 2004 4.2 2.3 2.2 5.7 3.2 2.4 1.7 10.0 0.9 1.6 4.0 14.5 * 0.0 0.7 2.0 2.0 9.1

Ghana 2008 52.7 60.0 51.9 68.6 63.8 57.7 48.4 82.2 41.1 35.2 52.2 74.7 * 21.7 44.8 63.5 79.4 93.0

Guinea 2005 34.8 31.5 23.5 42.7 35.7 29.3 25.5 80.1 14.7 25.2 54.7 70.9 * 8.3 13.5 19.8 41.6 85.4

Kenya 2008 54.0 48.6 38.3 67.5 53.6 50.3 33.6 75.8 40.7 22.0 41.4 70.3 91.9 21.4 33.5 45.4 56.7 81.3

Madagascar 2008-09 44.1 48.6 45.3 57.8 51.5 52.5 38.1 83.8 42.0 23.4 44.6 77.3 97.0 23.0 29.2 44.2 62.4 91.1

Malawi 2004 58.0 57.6 50.9 65.3 59.6 54.1 52.2 83.9 52.2 40.8 57.9 83.5 * 44.1 46.6 50.3 62.3 84.9

Mali 2006 30.5 30.1 22.5 38.2 32.0 32.6 24.2 69.2 12.7 22.7 52.6 78.9 (91.3) 8.9 13.4 16.2 32.0 76.4

Mozambique 2003 56.4 49.4 45.1 62.0 55.5 46.7 44.2 81.9 35.8 32.5 61.4 95.2 * 24.9 34.6 44.9 70.7 89.3

Namibia 2006-07 83.6 84.2 75.0 90.4 85.0 83.7 70.7 94.1 73.8 50.3 73.0 91.3 99.3 61.0 74.4 86.5 94.0 97.5

Niger 2006 18.7 18.4 19.7 28.5 20.7 19.4 15.7 72.6 8.8 13.7 40.6 82.0 * 4.6 7.9 9.1 13.8 61.6

Nigeria 2008 22.8 38.9 34.1 46.2 41.9 39.9 29.1 61.9 24.6 10.7 39.3 65.0 88.0 7.3 16.1 32.4 57.0 80.2

Rwanda 2007 64.4 53.1 38.1 75.4 55.1 48.8 38.6 68.8 46.9 35.4 52.0 80.5 (91.6) 41.0 44.9 47.9 49.5 70.0

Senegal 2005 45.8 48.3 44.1 61.6 51.4 46.7 39.4 82.1 25.0 35.9 69.0 85.4 * 14.4 22.4 45.1 77.4 88.3

Tanzania 2004-05 50.0 46.4 36.7 62.2 49.8 48.1 34.7 81.2 35.4 26.8 49.4 79.6 99.6 24.6 32.6 37.1 52.3 86.1

Uganda 2006 54.3 45.6 35.1 64.8 50.6 47.1 37.7 83.1 39.4 28.1 42.9 75.2 89.2 29.7 34.6 37.0 50.6 78.7

Zambia 2007 56.2 49.1 35.3 65.4 55.2 45.6 39.6 83.7 30.8 24.2 42.0 71.1 95.2 26.4 26.6 35.0 71.7 92.1

Zimbabwe 2005-06 69.8 71.7 59.3 80.2 74.2 68.3 55.9 93.9 59.2 36.0 52.7 81.7 99.1 46.4 56.5 71.5 85.3 95.6

North Africa/West Asia/Europe

Armenia 2005 100.0 98.3 97.2 99.5 99.2 98.5 87.5 99.6 96.4 na 97.9 99.9 98.4 92.9 99.2 100.0 99.2 100.0

Egypt 2007 79.3 79.8 80.5 89.2 81.7 78.8 68.1 90.7 73.2 61.3 75.6 85.7 96.1 56.7 70.4 83.7 90.7 96.9

Jordan 2007 97.7 99.3 99.2 99.3 99.5 99.0 99.1 99.3 98.7 95.4 97.1 99.3 99.6 98.4 99.0 99.2 100.0 100.0

Morocco 2003-04 71.6 65.1 64.7 84.9 69.9 65.4 48.7 86.0 41.8 51.5 77.9 93.7 99.4 30.7 51.6 73.0 85.9 95.5

 (Cont’d)

56
Table 14. – cont’d

Age at birth Birth order Residence Education Wealth status (quintile)

Country/Year <20 20 -34 35 -49 1 2 3

4 or 

more Urban Rural None

PrimarySecondary HigherLowestSecondMiddleFourthHighest

South/Southeast Asia

Bangladesh 2007 18.9 19.5 12.7 30.5 19.3 14.0 6.7 38.5 13.7 4.7 9.0 29.3 63.8 5.2 6.3 12.2 24.1 51.2

Cambodia 2005 47.8 47.8 41.0 57.0 52.2 46.9 35.0 74.0 41.9 24.0 44.9 80.8 (95.0) 21.6 30.6 42.4 64.3 91.0

India 2005-06 48.9 49.8 29.4 68.2 58.2 40.8 25.0 76.0 38.6 26.4 47.3 72.6 96.4 19.2 31.7 49.8 69.1 90.1

Indonesia 2007 45.8 59.3 57.7 63.3 59.3 56.9 45.6 80.1 41.5 22.6 39.7 69.8 93.0 25.4 44.4 58.3 74.5 89.9

Nepal 2006 25.1 20.5 12.3 38.0 21.6 12.8 7.9 54.3 15.5 8.9 21.0 44.1 84.5 5.7 10.3 12.1 24.5 59.8

Pakistan 2006-07 41.7 43.8 31.6 56.4 50.0 46.8 31.8 63.4 32.3 29.3 49.2 70.4 87.2 18.3 27.1 38.5 54.3 78.2

Philippines 2008 60.9 67.2 60.5 77.3 71.3 68.6 49.2 80.6 50.3 13.7 36.6 67.7 88.2 26.8 57.5 77.0 87.0 95.3

Vietnam 2002 66.1 78.5 82.4 84.4 78.0 71.4 58.8 97.5 73.4 39.1 68.9 84.1 100.0 51.6 72.6 84.3 91.6 99.1

Latin America/Caribbean

Bolivia 2008 77.9 75.7 62.3 86.5 82.1 76.7 56.4 89.3 52.3 39.9 61.6 88.9 98.4 38.2 66.8 81.8 93.0 98.2

Colombia 2005 93.3 92.0 91.1 97.3 94.2 92.4 78.5 97.5 78.9 71.2 84.3 96.2 99.2 74.1 94.2 97.3 98.9 99.4

Dominican 

Republic 2007 98.9 98.3 98.6 99.0 99.2 98.1 97.0 98.8 97.7 92.1 98.2 99.1 99.0 96.2 99.4 98.6 99.5 99.0

Haiti 2005-06 31.1 29.5 18.3 45.8 30.5 24.2 14.9 45.9 16.7 9.7 21.6 55.9 91.4 6.8 9.9 21.0 40.2 67.6

Peru 2008 84.6 83.7 79.3 92.1 85.1 84.2 67.2 95.2 61.6 52.6 64.9 91.5 98.4 45.8 68.2 88.1 97.3 98.7

Note: Figures in parentheses are based on 25-49 unweighted cases; an asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed.

Ethiopia is excluded as doctors and nurses were not distinguished from other health professionals in the survey.

57
58 

3.3 Postnatal Care 

Postnatal care, especially within the first 48 hours after birth, is critical to the management of 

postpartum hemorrhage, an important cause of maternal deaths in developing countries. DHS surveys ask 

women whether they received a health checkup after the delivery of their most recent live birth, the 

timing of the checkup and the type of health provider performing the services. As might be expected, use 

of postnatal care, its timing and type of provider vary according to whether or not women delivered at a 

health facility. This section presents findings on the use of postnatal care by separating women who 

delivered in a health facility and women who delivered outside a health facility. 

3.3.1 Current Use of Postnatal Care 

The survey results (Table 15) show substantial differences in receiving postnatal care between 

women who delivered at a health facility and women who did not. Overall, at least two-thirds of women 

who delivered at a health facility reported postnatal checkups within 41 days after delivery. This is true in 

all countries except Uganda and Zimbabwe, where less than half of the women reported postnatal 

checkups. In contrast, women who delivered in non-institutional settings are much less likely to report 

receiving postnatal care within 41 days of delivery. 

In South/Southeast Asia, in four countries (Bangladesh, India, Nepal and Pakistan), only 15-28 

percent of women who did not give the birth at a health facility received postnatal care. Cambodia and the 

Philippines are exceptions, with a high proportion of women who did not give the birth at a health facility 

reporting postnatal care (up to 88 percent in the Philippines), although these figures do not provide 

information on the content and providers of services. 

In sub-Saharan Africa, very low proportions of women who did not deliver at a health facility had 

a postnatal checkup, except in Ghana and Madagascar, where little over half of such women had a 

postnatal checkup during this period. 

In three of the four Latin America and the Caribbean countries studied (Bolivia, the Dominican 

Republic and Peru), although more than half of women who did not deliver at a health facility reported 

postnatal checkups, women who delivered at a health facility were far more likely to report postnatal 

checkups, at 90 percent or more. 

Combining women who delivered in a health facility and those who did not, in 8 of the 18 

countries with data, 64-92 percent of women reported a postnatal checkup within 41 days after delivery. 

The level of postnatal service use is low in most of countries studied in South/Southeast Asia and subSaharan Africa. 
Table 15. Among women with a live birth in the five years preceding the survey, the percentage who received postnatal checkups 

(PNC) for the most recent birth according to place of delivery, the most recent survey, 1990-2009

Women who delivered in 

a health facility

Women who did NOT deliver in 

a health facility All women

Country/Year

No 

PNC

Received 

PNC 

within 41 

days after 

delivery

Received 

PNC 

after 41 

days/

Missing/

Don't 

know

Total 

number 

of 

women

No 

PNC

Received 

PNC 

within 41 

days of 

delivery

Received 

PNC 

after 41 

days/

Missing/

Don't 

know

Total 

number 

of 

women

No 

PNC

Received 

PNC 

within 41 

days of 

delivery

Received 

PNC 

after 41 

days/

Missing/

Don't 

know

Total 

number 

of 

women

Sub-Saharan Africa

Ghana 2008 6.3 91.5 2.2 1,263 46.8 51.9 1.3 835 22.5 75.7 1.8 2,099

Kenya 2008 30.1 66.8 3.1 1,858 71.3 28.1 0.6 2,113 52.1 46.2 1.8 3,973

Madagascar

2008-09 9.4 85.8 4.8 3,256 47.4 50.7 1.8 5,394 33.2 63.9 2.9 8,662

Namibia 2006-07 14.1 79.2 6.7 3,207 56.0 42.1 1.9 684 21.6 72.5 5.9 3,898

Nigeria 2008 14.9 77.7 7.5 6,431 78.2 20.9 0.9 11,157 55.2 41.5 3.3 17,635

Uganda 2006 57.8 41.2 0.9 2,245 87.2 12.7 0.1 2,789 74.1 25.4 0.5 5,035

Zambia 2007 27.8 69.2 3.0 2,090 72.3 26.2 1.5 2,043 49.8 48.0 2.2 4,136

Zimbabwe 2005-06 34.7 46.7 18.7 2,849 67.6 25.1 7.3 1,244 44.8 40.0 15.2 4,100

South/Southeast Asia

Bangladesh 2007 5.3 92.8 1.9 732 80.5 19.1 0.4 4,171 69.3 30.1 0.6 4,905

Cambodia 2005 9.0 89.4 1.6 1,358 36.5 62.9 0.6 4,507 30.1 69.1 0.9 5,865

India 2005-06 19.0 78.5 2.4 16,267 83.8 15.3 0.9 23,396 57.2 41.2 1.5 39,677

Nepal 2006 13.2 83.8 2.9 745 79.0 20.9 0.1 3,320 67.0 32.4 0.6 4,065

Pakistan 2006-07 31.7 65.6 2.7 2,101 71.5 28.3 0.2 3,548 56.9 42.0 1.1 5,677

Philippines 2008 5.8 93.3 1.0 2,145 11.4 88.0 0.6 2,442 8.8 90.4 0.8 4,590

Latin America/Caribbean

Bolivia 2008 2.0 97.7 0.3 4,638 44.2 53.5 2.2 1,832 13.9 85.2 0.9 6,472

Dominican 

Republic 2007 8.3 89.5 2.3 8,036 34.2 63.1 2.7 132 9.1 88.7 2.3 8,203

Haiti 2005-06 22.1 75.3 2.6 991 78.0 21.5 0.5 3,080 64.4 34.6 1.0 4,074

Peru 2008 1.5 98.3 0.3 3,970 36.4 63.3 0.3 950 8.2 91.5 0.3 4,920

Note: The total number of women does not always equal the sum of the number of women who did and did not deliver in a health facility since information on 

place of delivery is missing for some births.

59
60 

3.3.2 Timing of the First Postnatal Checkup 

Tables 16a and 16b show the timing of the first postnatal checkup for women who received 

postnatal checkups within 41 days after delivery. The data show that the timing of the first postnatal 

checkup is very different between women who delivered at a health facility and women who delivered in 

other places. In all countries except Madagascar and Zimbabwe, over 90 percent of women who gave 

birth in a health facility received postnatal care within two days of delivery, and many of them (63-97 

percent) reported having the first checkup within 24 hours after delivery. 

Among women who delivered in a non-institutional setting, in most countries more than 70 

percent reported receiving postnatal care within two days, except in Zambia (38 percent), Zimbabwe (42 

percent), India (65 percent), Bolivia (52 percent) and Peru (65 percent). In many countries, although 

women who deliver at health facilities are more likely to report receiving postnatal care in the first 24 

hours than those who delivered elsewhere, there is little difference between these two groups in reporting 

a postnatal checkup within one hour after delivery. This pattern is observed in Ghana, Kenya, 

Madagascar, Namibia, Uganda and all South/Southeast Asian countries except Bangladesh. While the 

current survey data cannot explain this finding, it is possible that some women who delivered at home 

may report checkups given by the birth attendants before they leave following the childbirth, which 

should be considered as intra-partum care, not postnatal care. 
Table 16a. Percent distribution of women whose last live birth in the past five years occurred in a health facility and who received 

postnatal checkups (PNC) within 41 days after delivery, by timing of mother's first postnatal checkup, the most recent survey, 1990-

2009

Women who delivered in a health facility and received postnatal 

checkups within 41 days after delivery

Percentage 

who 

received 

PNC within 

24 hrs after 

delivery

Percentage 

who 

received 

PNC within 

2 days after 

delivery

Total 

number 

of 

Country/Year women

Within 

1 hour

1-3 

hours

4-23 

hours

1-2 

days

3-6 

days

7-41 

days Total

Sub-Saharan Africa

Ghana 2008 24.3 42.6 16.8 11.9 1.2 3.2 100.0 83.7 95.6 1,156

Kenya 2008 14.5 47.4 18.7 15.2 1.3 2.9 100.0 80.6 95.8 1,241

Madagascar 2008-09 13.5 17.1 11.4 28.1 11.5 18.4 100.0 42.0 70.1 2,793

Namibia 2006-07 8.1 39.7 15.7 27.5 2.5 6.6 100.0 63.5 91.0 2,539

Nigeria 2008 12.7 57.4 14.2 12.0 1.9 1.9 100.0 84.3 96.3 4,994

Uganda 2006 9.5 33.1 30.7 19.9 4.7 2.2 100.0 73.3 93.2 926

Zambia 2007 21.2 43.5 25.5 6.3 0.8 2.7 100.0 90.2 96.5 1,447

Zimbabwe 2005-06 19.4 18.6 25.2 20.2 2.9 13.7 100.0 63.2 83.4 1,330

South/Southeast Asia

Bangladesh 2007 58.1 27.1 11.0 2.4 0.4 1.0 100.0 96.2 98.6 679

Cambodia 2005 4.3 53.0 19.0 21.8 1.2 0.8 100.0 76.3 98.1 1,378

India 2005-06 12.7 61.0 13.5 10.5 1.1 1.2 100.0 87.2 97.7 12,777

Nepal 2006 17.7 48.6 27.3 5.3 0.6 0.5 100.0 93.6 98.9 625

Pakistan 2006-07 22.2 45.8 18.0 9.4 2.1 2.4 100.0 86.0 95.4 1,378

Philippines 2008 8.5 43.0 23.0 17.6 2.6 5.2 100.0 74.5 92.1 2,001

Latin America/Caribbean

Bolivia 2008 12.0 47.9 26.7 11.9 0.5 0.9 100.0 86.6 98.5 4,533

Dominican Republic 2007 7.1 48.4 19.1 18.3 2.6 4.6 100.0 74.6 92.9 7,190

Haiti 2005-06 10.5 47.9 17.8 21.1 2.4 0.3 100.0 76.2 97.3 747

Peru 2008 17.4 59.4 20.5 2.0 0.2 0.6 100.0 97.3 99.3 3,901

61
Table 16b. Percent distribution of women whose last live birth in the past five years occurred outside a health facility and who received 

postnatal checkups (PNC) within 41 days after delivery, by time of mother's first postnatal checkup, the most recent survey, 1990-2009

Women who did not deliver in a health facility and received 

postnatal checkups within 41 days after delivery

Total

Percentage 

who 

received 

PNC within 

24 hrs after 

delivery

Percentage 

who 

received 

PNC within 2 

days after 

delivery

Total 

number 

of 

Country/Year women

Within 

1 hour

1-3 

hours

4-23 

hours

1-2 

days

3-6 

days

7-41 

days

Sub-Saharan Africa

Ghana 2008 20.4 26.5 8.1 21.3 9.7 14.0 100.0 55.0 76.3 433

Kenya 2008 15.1 41.5 10.5 14.5 2.7 15.7 100.0 67.1 81.6 594

Madagascar 2008-09 14.0 15.7 8.7 36.6 12.4 12.6 100.0 38.4 75.0 2,736

Namibia 2006-07 8.7 33.4 7.5 29.4 8.1 12.9 100.0 49.6 79.0 288

Nigeria 2008 20.5 43.9 5.5 13.9 4.8 11.3 100.0 69.9 83.8 2,329

Uganda 2006 10.8 37.0 18.6 17.4 7.5 8.7 100.0 66.4 83.8 354

Zambia 2007 5.4 12.1 6.5 14.1 10.4 51.5 100.0 24.0 38.1 536

Zimbabwe 2005-06 6.3 7.4 6.9 21.7 18.3 39.4 100.0 20.6 42.3 313

South/Southeast Asia

Bangladesh 2007 31.3 24.6 13.0 13.3 6.3 11.5 100.0 68.9 82.2 795

Cambodia 2005 5.9 36.1 14.0 34.2 8.6 1.3 100.1 56.0 90.2 1,004

India 2005-06 12.0 27.5 5.9 19.1 10.2 25.3 100.0 45.4 64.5 3,585

Nepal 2006 21.5 34.2 18.3 20.9 3.8 1.3 100.0 74.0 94.9 693

Pakistan 2006-07 28.7 28.1 9.3 25.8 4.5 3.5 100.0 66.1 91.9 1,004

Philippines 2008 10.3 28.7 10.4 29.0 11.5 10.1 100.0 49.4 78.4 2,150

Latin America/Caribbean

Bolivia 2008 9.1 16.7 6.0 20.4 12.6 35.1 100.0 31.8 52.2 981

Dominican Republic 2007 12.6 28.2 10.4 20.5 10.1 18.3 100.0 51.2 71.7 84

Haiti 2005-06 4.3 23.5 6.8 37.4 17.2 10.8 100.0 34.6 72.0 661

Peru 2008 11.4 26.2 13.4 14.2 6.2 28.5 100.0 51.0 65.2 601

62
63 

3.3.3 Provider of the First Postnatal Checkup 

Tables 17a and 17b present information on the provider of the mother’s first postnatal checkup, 

among women who received a postnatal checkup within 41 days after delivery. Almost all women who 

delivered at health facilities (Table 17a) received the first checkup from a doctor, nurse or midwife. In the 

majority of sub-Saharan African countries, women are more likely to report a nurse or midwife than a 

doctor. In the other two regions, however, in countries with data doctors are the main providers of 

postnatal care, except in Cambodia and Peru, where fewer women reported doctors than nurses or 

midwives. 

In contrast, among women who delivered at home or places other than a health facility (Table 

17b), in only a few countries do more than half receive postnatal care from a skilled health provider. 

These countries include Namibia, Zambia, Zimbabwe, India, Bolivia, the Dominican Republic and Peru. 

In Zimbabwe, among women who received postnatal care, 94 percent received a checkup from a skilled 

health provider. In other countries, the majority of women received postnatal care from non-skilled health 

providers (e.g. traditional birth attendants). 

Combining institutional and non-institutional births, the overall use of skilled health providers for 

postnatal care is high (data not shown). In countries both in sub-Saharan Africa and Latin America and 

the Caribbean, more than two-thirds of women reported postnatal checkups from a skilled health provider. 

In South/Southeast Asia, this level is slightly lower except in India, at 91 percent, which is probably due 

to the much higher level of use of skilled health providers in India than elsewhere in this region, even 

among women who did not deliver at health facilities. 
Table 17a. Percent distribution of women whose last live birth in the past five years occurred in a health facility and who received 

postnatal checkups (PNC) within 41 days after delivery, by type of provider at the first checkup, the most recent survey, 1990-2009

Women who delivered in a health facility and received postnatal checkups 

within 41 days after delivery

Total

Percentage 

who 

received 

PNC from a 

skilled 

health 

provider

Total 

number 

Country/Year Doctor of women

Nurse/ 

Midwife

Other 

health 

personnel

Traditional 

birth 

attendant Other

Missing/

Don't know

Sub-Saharan Africa

Ghana 2008 34.4 59.0 5.8 0.4 0.3 0.1 100.0 93.4 1,156

Kenya 2008 50.9 48.6 0.1 0.4 0.0 0.0 100.0 99.5 1,241

Madagascar 2008-09 39.4 60.0 0.1 0.4 0.0 0.1 100.0 99.4 2,793

Namibia 2006-07 47.9 51.7 0.0 0.0 0.0 0.3 100.0 99.6 2,539

Nigeria 2008 48.4 43.2 8.0 0.4 0.1 0.0 100.0 91.6 4,994

Uganda 2006 27.0 70.6 1.5 0.9 0.0 0.0 100.0 97.6 926

Zambia 2007 12.9 82.0 3.4 1.1 0.6 0.0 100.0 94.9 1,447

Zimbabwe 2005-06 26.0 73.9 0.0 0.0 0.0 0.1 100.0 99.9 1,330

South/Southeast Asia

Bangladesh 2007 89.6 9.3 0.8 0.0 0.2 0.0 100.0 98.9 679

Cambodia 2005 29.7 69.8 0.0 0.5 0.0 0.0 100.0 99.5 1,378

India 2005-06 84.1 15.5 0.2 0.1 0.0 0.0 100.0 99.6 12,777

Nepal 2006 51.2 47.3 1.1 0.5 0.0 0.0 100.0 98.5 625

Pakistan 2006-07 86.4 10.5 0.5 2.5 0.0 0.0 100.0 96.9 1,378

Philippines 2008 75.6 23.6 0.0 0.8 0.0 0.0 100.0 99.2 2,001

Latin America/Caribbean

Bolivia 2008 84.5 14.4 0.7 0.0 0.4 0.0 100.0 98.9 4,533

Dominican Republic 2007 87.7 11.8 0.0 0.0 0.2 0.2 100.0 99.5 7,190

Haiti 2005-06 58.5 39.3 2.1 0.0 0.0 0.0 100.0 97.8 747

Peru 2008 47.3 51.3 0.1 0.0 1.2 0.0 100.0 98.6 3,901

64
Table 17b. Percent distribution of women whose last live birth in the past five years occurred outside a health facility and who 

received postnatal checkups within 41 days after delivery, by type of provider at the first checkup, the most recent survey, 1990-

2009

Women who did not deliver in a health facility and received postnatal 

checkups within 41 days after delivery

Total

Percentage 

who 

received 

PNC from 

a skilled 

health 

provider

Total 

number 

Country/year Doctor of women

Nurse/ 

Midwife

Other 

health 

personnel

Traditional 

birth 

attendant Other

Missing/

Don't 

know

Sub-Saharan Africa

Ghana 2008 2.3 23.6 7.8 55.0 11.3 0.0 100.0 25.9 433

Kenya 2008 13.6 17.6 1.7 66.1 1.0 0.0 100.0 31.2 594

Madagascar 2008-09 12.7 20.9 42.9 22.7 0.6 0.1 100.0 33.6 2,736

Namibia 2006-07 9.3 51.8 0.0 35.2 3.0 0.6 100.0 61.1 288

Nigeria 2008 7.3 27.2 10.8 53.8 0.5 0.4 100.0 34.5 2,329

Uganda 2006 4.7 26.7 1.0 65.8 1.2 0.6 100.0 31.4 354

Zambia 2007 0.6 60.7 8.3 29.3 1.1 0.0 100.0 61.3 536

Zimbabwe 2005-06 6.0 87.9 0.0 5.0 0.9 0.1 100.0 93.9 313

South/Southeast Asia

Bangladesh 2007 0.1 29.7 13.9 2.7 4.2 49.4 100.0 29.8 795

Cambodia 2005 1.8 39.0 0.0 58.7 0.5 0.0 100.0 40.8 1,004

India 2005-06 27.0 31.6 6.9 34.2 0.3 0.0 100.0 58.6 3,585

Nepal 2006 5.6 11.3 17.4 64.1 1.6 0.0 100.0 16.9 693

Pakistan 2006-07 8.1 4.9 1.2 83.9 1.9 0.1 100.0 13.0 1,004

Philippines 2008 1.4 33.3 0.7 64.1 0.5 0.0 100.0 34.7 2,150

Latin America/Caribbean

Bolivia 2008 50.0 27.4 21.2 0.0 1.4 0.0 100.0 77.4 981

Dominican Republic 2007 73.6 6.7 0.0 19.1 0.6 0.0 100.0 80.3 84

Haiti 2005-06 14.0 19.8 47.4 17.9 0.1 0.9 100.0 33.8 661

Peru 2008 17.9 68.2 2.4 5.5 5.7 0.2 100.0 86.1 601

65
66 

3.3.4 Differentials in Use of Postnatal Care 

Mother’s age at birth 

Tables 18a and 18b show percentages of women who received postnatal care for the most recent 

birth, by women’s characteristics. In most countries in sub-Saharan Africa, the percentage of women who 

delivered at a health facility (Table 18a) and who reported postnatal care tends to increase as mother’s age 

at birth increases; mothers under age 20 are least likely to report postnatal care. In South/Southeast Asia, 

Bangladesh and the Philippines show increasing use of postnatal care among mothers who are older at 

birth, while in the other four countries in the region use is greatest among women age 20-34. In the Latin 

America and the Caribbean region, differentials associated with age are not apparent, with women 

reporting similar levels of postnatal care across all age groups. 

In contrast, the pattern of receiving postnatal care associated with mother’s age at birth is unclear 

among women who did not deliver in health facilities (Table 18b). In 12 countries, however, women age 

20-34 reported the highest levels of use of postnatal care. 

Birth order 

Receipt of postnatal care does not appear to be associated with birth order for institutional births, 

although a slightly lower level is seen for birth orders 4 or higher. For non-institutional births, higher 

births orders are generally less likely to receive postnatal care. In Nigeria, Bangladesh, Cambodia, Nepal 

and Haiti, a consistent pattern is observed—that is, as birth order increases, the proportion of women 

receiving postnatal checkups decreases. 

Urban/rural residence 

In most countries, for both institutional and non-institutional births, women in urban areas are 

more likely to report postnatal care than women in rural areas. The Philippines is an exception, where the 

opposite relationship is observed. In six countries, including Ghana, Bangladesh, Nepal, Bolivia, the 

Dominican Republic and Peru, among women who delivered at a health facility, women in rural areas 

reported about the same level of postnatal care as women in urban areas. 

Women’s education 

In general, regardless of whether the delivery was in an institution or not, women with more 

education are more likely to report postnatal care, although in some countries the association starts from 

the secondary or higher levels of education. For non-institutional births, due to small number of cases, 

data for women with higher than secondary level education are suppressed in several countries. 

Household wealth 

Among women whose last birth was delivered at a health facility, a consistent association 

between wealth and postnatal care is observed in most countries—that is, women from richer households 

are more likely to report postnatal care. In contrast, among women who did not deliver at a health facility, 

the association between postnatal care and household wealth is consistent only in a few countries—

Namibia, Nigeria, Zimbabwe and India, where a pattern of increasing use of postnatal care with wealth is 

observed. In the Philippines, Bolivia and Peru, the level of postnatal care is similar across wealth groups. 
Table 18a. Percentage of women whose last live birth in the past five years occurred in a health facility and who received postnatal checkups within 41 days after delivery

by selected characteristics, the most recent survey, 1990-2009

Age at birth Birth order Residence Education Wealth status (quintile)

Country/Year <20 20-34 35-49 1 2 3

4 or 

more Urban Rural None

PrimarySecondary HigherLowestSecondMiddleFourthHighest

Sub-Saharan Africa

Ghana 2008 85.9 92.3 91.4 92.8 91.1 92.0 90.6 91.8 91.2 89.8 86.8 93.9 (95.2) 90.8 88.4 91.4 90.5 95.7

Kenya 2008 62.3 66.8 73.9 66.9 68.4 68.3 64.2 75.4 62.5 60.4 64.5 69.1 74.8 60.8 58.9 61.1 65.0 74.8

Madagascar 2008-09 84.8 86.4 84.6 85.6 87.1 85.1 85.5 89.5 84.8 82.9 85.0 87.3 93.8 79.3 86.3 84.5 86.1 88.6

Namibia 2006-07 77.4 79.2 81.0 78.0 80.6 83.5 76.0 81.9 76.5 72.4 73.6 81.3 86.1 71.0 73.1 79.3 82.7 85.3

Nigeria 2008 73.0 78.2 77.7 78.1 81.9 77.3 75.7 82.4 72.7 77.4 74.7 76.6 86.5 65.1 72.2 72.1 75.7 84.7

Uganda 2006 40.5 40.7 45.5 43.6 45.4 39.8 39.1 45.9 39.7 39.3 36.7 47.6 68.9 39.6 36.6 36.8 37.1 49.2

Zambia 2007 64.7 70.1 71.4 67.8 71.1 70.0 69.0 73.0 64.8 63.2 67.0 69.8 93.0 61.6 68.2 65.0 67.2 77.3

Zimbabwe 2005-06 43.3 46.5 55.6 44.5 45.9 47.9 50.1 57.1 39.1 20.8 13.8 28.7 26.0 33.4 39.7 42.3 47.3 62.1

South/Southeast Asia

Bangladesh 2007 91.5 93.2 (94.5) 93.2 92.7 93.0 90.4 92.9 92.7 (92.6) 86.2 93.2 95.9 (85.0) (93.7) 87.0 92.3 95.2

Cambodia 2005 84.9 90.4 87.7 89.7 92.0 90.9 84.7 91.8 88.3 83.9 86.8 94.9 * 81.8 87.3 89.4 88.5 91.5

India 2005-06 73.8 79.9 70.3 79.1 82.2 76.2 68.7 82.6 75.2 68.8 74.1 81.1 89.6 65.1 71.6 75.0 78.9 86.1

Nepal 2006 82.1 85.5 (69.1) 83.0 88.7 78.2 79.5 83.4 84.1 81.8 76.4 86.1 92.6 (85.7) 79.0 86.8 76.9 86.9

Pakistan 2006-07 64.1 67.0 57.0 66.1 68.7 68.9 61.9 70.7 60.8 59.8 64.3 71.2 74.9 57.0 57.8 57.3 67.6 72.9

Philippines 2008 91.1 93.2 94.3 92.9 92.0 95.9 93.2 91.7 96.3 * 93.4 91.9 94.7 94.7 93.4 91.5 92.7 94.8

Latin America/Caribbean

Bolivia 2008 97.2 97.8 98.1 97.7 97.4 97.6 98.2 97.7 97.8 95.6 97.5 97.8 98.4 97.5 97.5 97.0 97.3 99.4

Dominican Republic 2007 87.5 89.9 90.8 89.9 90.5 89.6 87.3 89.7 89.0 84.8 86.9 90.3 93.8 85.6 89.0 88.3 94.8 91.0

Haiti 2005-06 75.6 74.4 79.7 75.2 75.5 78.2 73.9 77.3 71.9 63.8 72.6 77.9 87.4 (67.3) 66.5 71.8 74.9 79.4

Peru 2008 98.3 98.7 96.6 98.5 98.5 98.4 97.4 98.4 97.9 98.5 97.0 98.6 98.7 96.8 97.6 98.8 97.5 99.2

Note: Figures in parentheses are based on 25-49 unweighted cases; an asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed.

67
Table 18b. Percentage of women whose last live birth in the past five years occurred outside a health facility and who received postnatal checkups within 41 days after 

delivery by selected characteristics, the most recent survey, 1990-2009

Age at birth Birth order Residence Education Wealth status (quintile)

Country/Year <20 20-34 35-49 1 2 3

4 or 

more Urban Rural None

PrimarySecondary HigherLowestSecondMiddleFour

-th

High

-est

Sub-Saharan Africa

Ghana 2008 51.4 53.3 47.9 55.5 55.9 50.3 49.8 60.9 50.0 45.4 53.2 63.0 * 47.8 45.4 60.0 66.8 *

Kenya 2008 26.3 29.5 23.2 29.4 29.4 27.3 27.5 36.3 27.2 26.6 27.5 30.8 * 29.4 23.8 28.4 30.0 31.7

Madagascar 2008-09 49.9 51.2 49.9 52.8 54.5 49.7 48.8 64.1 49.7 41.4 52.9 62.6 * 42.9 48.2 52.4 60.5 65.2

Namibia 2006-07 30.1 46.6 36.6 38.9 47.1 46.5 39.3 53.7 40.0 27.7 43.9 53.0 * 30.0 44.2 56.3 70.8 *

Nigeria 2008 18.7 22.0 18.8 26.3 22.7 21.7 18.8 31.5 18.5 13.3 27.9 42.9 58.3 12.5 15.6 25.0 36.5 51.7

Uganda 2006 11.1 12.6 14.0 14.7 10.4 12.2 12.9 24.0 12.2 12.6 12.4 14.0 * 15.1 10.2 9.6 14.3 18.5

Zambia 2007 22.5 26.7 27.0 24.1 29.3 27.6 25.5 39.2 24.8 23.7 26.6 28.3 * 25.8 26.1 22.5 31.8 (49.4)

Zimbabwe 2005-06 20.1 25.2 31.3 21.0 21.5 27.2 28.3 32.9 24.6 35.0 23.0 26.0 * 20.4 24.7 31.5 31.5 (35.3)

South/Southeast Asia

Bangladesh 2007 19.2 19.6 13.1 24.6 19.8 17.9 13.4 23.9 18.0 11.5 16.6 25.5 47.5 11.5 16.1 18.9 26.5 28.3

Cambodia 2005 61.2 63.4 62.0 65.2 63.2 62.9 61.6 64.4 62.8 57.9 62.2 77.9 * 57.0 59.2 65.5 70.3 77.4

India 2005-06 14.7 15.8 11.1 18.0 19.2 16.3 11.2 20.9 14.4 11.9 17.3 24.2 37.1 11.9 12.9 18.9 20.4 28.2

Nepal 2006 23.4 21.3 13.4 23.1 21.9 20.3 18.9 22.9 20.7 20.1 15.8 26.4 (80.4) 9.2 20.0 27.3 26.8 30.9

Pakistan 2006-07 24.0 30.3 22.5 28.8 28.5 30.3 27.6 33.9 26.9 25.7 35.2 39.3 46.1 26.7 23.0 30.8 34.0 35.0

Philippines 2008 87.4 88.1 87.9 87.9 88.9 88.4 87.5 87.5 88.3 79.3 86.4 88.7 91.6 87.5 86.9 88.3 92.0 88.0

Latin America/Caribbean

Bolivia 2008 49.9 54.8 52.3 52.9 58.8 55.1 51.8 44.5 56.2 53.1 52.9 57.1 * 54.7 57.0 47.8 46.2 *

Dominican Republic 2007 (61.0) 61.7 (75.1) 79.4 (59.9) (45.6) (67.6) 69.9 56.8 54.7 61.4 (66.9) * 58.6 * * * *

Haiti 2005-06 23.3 21.6 20.0 29.5 22.7 19.3 17.9 26.0 19.7 14.2 22.3 36.0 * 15.2 19.5 21.3 28.6 32.6

Peru 2008 54.7 65.2 62.5 66.9 61.7 72.0 59.0 73.5 60.6 59.5 58.0 78.2 (77.6) 55.4 65.3 66.8 (78.4) (78.9)

Note: Figures in parentheses are based on 25-49 unweighted cases; an asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed.

68
69 

3.4 Relationships between Uses of Maternal Health Services 

With regard to maternal health care, it is also important to explore associations between care 

received by women during pregnancy, delivery and post-delivery. In this section, we analyze bivariate 

associations between these maternal health care indicators to show their relationships and the patterns 

across countries. 

3.4.1 Association between Using Antenatal Care and Skilled Birth Attendance 

Table 19 presents the percentage of women who received skilled birth attendance for their last 

birth based on the number of antenatal care visits they reported. Overall, there is a strong positive 

association between the number of antenatal visits and the use of skilled birth assistance. In 11 of the 20 

sub-Saharan African countries studied (with Ethiopia excluded), over 60 percent of women who had four 

or more antenatal care visits also had skilled assistance at their last birth. Benin, Cameroon, Namibia and 

Zimbabwe, in particular, display this pattern. Benin is a good example of a maternal health program in 

West Africa where nurses and midwives play an important role. In Benin, 80 percent of women reported 

receiving antenatal care from a nurse or midwife, and 70 percent reported nurses/midwives attending their 

last birth. Almost 90 percent of women in Benin who had four or more antenatal care visits also reported 

skilled birth assistance. 

Countries in Latin America and the Caribbean (except Haiti), as well as countries in the North 

Africa/West Asia/Europe region, show the results of strong maternal health care programs. Among 

countries in these two regions, over 80 percent of women in Armenia, Jordan and the Dominican 

Republic reported skilled assistance at delivery, despite receiving no antenatal care. 

Other than India (81 percent), Cambodia (70 percent), Pakistan (73 percent), the Philippines (73 

percent) and Vietnam (91 percent), continuity in maternal health care in other South/Southeast Asian 

countries (Bangladesh, Indonesia and Nepal) has not been as successful, at least based on data for women 

who reported four or more antenatal care visits. Other than Indonesia and the Philippines, where over 75 

percent of women received four or more antenatal care visits, the other countries in South/Southeast Asia 

performed relatively poorly. 
70 

Table19. Among women receiving different number of antenatal care visits for the most recent 

live birth in the five years preceding the survey, the percentage who had a skilled attendant at 

birth, the most recent survey, 1990-2009

Number of antenatal care visits

Country/Year No visits 1-3 4 or more

Sub-Saharan Africa

Benin 2006 11.4 73.6 89.3

Burkina Faso 2003 3.1 49.1 63.4

Cameroon 2004 10.5 56.2 78.0

Chad 2004 0.4 4.0 7.8

Ghana 2008 10.0 29.5 65.8

Guinea 2005 2.5 22.5 42.7

Kenya 2008 11.6 39.3 61.7

Madagascar 2008-09 5.8 39.0 61.4

Malawi 2004 23.6 50.3 63.8

Mali 2006 5.1 26.6 48.7

Mozambique 2003 4.7 45.5 65.2

Namibia 2006-07 39.8 70.9 87.7

Niger 2006 3.0 31.0 47.9

Nigeria 2008 3.7 28.8 59.5

Rwanda 2007 9.3 47.3 65.3

Senegal 2005 6.3 42.8 59.3

Tanzania 2004-05 19.2 38.1 51.2

Uganda 2006 15.7 36.4 56.3

Zambia 2007 4.0 45.2 51.0

Zimbabwe 2005-06 28.9 62.0 75.5

North Africa/West Asia/Europe

Armenia 2005 84.9 99.4 99.7

Egypt 2007 58.9 72.5 88.7

Jordan 2007 89.7 97.7 99.4

Morocco 2003-04 37.4 71.8 87.2

South/Southeast Asia

Bangladesh 2007 4.2 17.6 49.7

Cambodia 2005 23.0 47.1 69.6

India 2005-06 15.1 37.6 80.9

Indonesia 2007 5.5 6.3 24.4

Nepal 2006 4.1 15.5 42.9

Pakistan 2006-07 15.6 42.6 73.0

Philippines 2008 34.6 41.6 72.5

Vietnam 2002 50.0 77.0 91.2

Latin America/Caribbean

Bolivia 2008 24.5 55.5 84.7

Colombia 2005 56.6 83.6 95.8

Dominican Republic 2007 80.8 96.6 99.0

Haiti 2005-06 4.4 15.0 40.5

Peru 2008 36.7 60.8 85.6

Note: Ethiopia is excluded as doctors and nurses were not distinguished from other health professionals in the 

survey.
71 

3.4.2 Association between Using Antenatal Care and Postnatal Care 

Table 20 presents the association between receiving antenatal care and receiving postnatal care. 

In all countries studied except Uganda, Zimbabwe and Haiti, a majority of women who reported four or 

more antenatal care visits also received postnatal care. In Ghana, Madagascar, Namibia, Cambodia, the 

Philippines and all Latin American and Caribbean countries except Haiti, this association also holds true 

among women who received 1-3 antenatal care visits for their last birth. In fact, in countries where 

postnatal care levels are extremely high, as in the Philippines, even women who received no antenatal 

care received postnatal care. In the Philippines, however, the percentage of women who did not receive 

antenatal care for their last birth is very small (see Table 3). A similar pattern is found in Cambodia, the 

Dominican Republic and Peru, where more than 50 percent of women with no antenatal care received 

postnatal care. Although in the Dominican Republic and Peru the percentage of women not receiving any 

antenatal care is very small, as Table 3 indicates, the same is not true of Cambodia. 

Table 20. Among women receiving different number of antenatal care visits for the most 

recent live birth in the five years preceding the survey, the percentage who had a postnatal 

checkup within 41 days after delivery, the most recent survey, 1990-2009

Number of antenatal care visits

Country/Year No visits 1-3 4 or more

Sub-Saharan Africa

Ghana 2008 41.6 57.8 81.1

Kenya 2008 24.8 38.7 56.6

Madagascar 2008-09 31.0 60.4 72.8

Namibia 2006-07 46.4 70.2 76.0

Nigeria 2008 13.8 40.3 63.3

Uganda 2006 8.5 19.7 32.7

Zambia 2007 10.5 44.7 51.2

Zimbabwe 2005-06 15.0 35.2 43.4

South/Southeast Asia

Bangladesh 2007 12.7 31.5 60.6

Cambodia 2005 56.3 69.7 81.4

India 2005-06 10.5 30.0 72.3

Nepal 2006 18.0 29.1 50.2

Pakistan 2006-07 23.9 41.8 64.6

Philippines 2008 80.3 87.7 91.6

Latin America/Caribbean

Bolivia 2008 45.4 76.7 92.6

Dominican Republic 2007 56.5 82.4 89.5

Haiti 2005-06 12.2 24.4 46.2

Peru 2008 55.8 77.7 93.3
72 

3.4.3 Association between Using Skilled Birth Attendance and Postnatal Care 

Table 21 shows the association between having a skilled attendant at last birth and receiving 

postnatal care. Overall, in a majority of countries there is a strong association between having skilled birth 

attendance and receiving postnatal care. Only in Uganda and Zimbabwe do less than 50 percent of women 

who had a skilled birth attendant also receive postnatal care. In several countries (Cambodia, the 

Philippines, the Dominican Republic and Peru), over 60 percent of women who had someone other than a 

skilled birth attendant help with the birth nonetheless receive postnatal care. 

Table 21. Among women receiving birth assistance from different providers for the most recent 

live birth in the five years preceding the survey, the percentage who had postnatal checkups 

within 41 days after delivery, the most recent survey, 1990-2009

Person providing assistance during delivery

Country/Year Doctor/Nurse/Midwife Others No one

Sub-Saharan Africa

Ghana 2008 91.6 55.7 33.7

Kenya 2008 66.1 29.8 14.5

Madagascar 2008-09 82.4 47.8 17.4

Namibia 2006-07 79.0 42.4 15.8

Nigeria 2008 77.5 27.1 8.6

Uganda 2006 41.0 13.5 8.1

Zambia 2007 69.8 27.9 25.8

Zimbabwe 2005-06 46.6 22.8 49.0

South/Southeast Asia

Bangladesh 2007 89.4 16.3 11.8

Cambodia 2005 93.2 66.9 57.4

India 2005-06 71.1 13.1 11.1

Nepal 2006 82.6 20.8 3.3

Pakistan 2006-07 61.8 28.2 14.0

Philippines 2008 92.1 87.6 35.1

Latin America/Caribbean

Bolivia 2008 97.6 50.6 52.2

Dominican Republic 2007 89.2 64.8 38.2

Haiti 2005-06 75.7 19.1 16.8

Peru 2008 98.3 76.5 48.3
73 

4 Summary and Discussion 

Analyzing data from nationally representative household surveys in 38 countries between 1990 

and 2009, our study contributes to an understanding of the use of essential maternal health services in the 

past two decades and has important policy and program implications in improving health outcomes for 

mothers and children, particularly in developing countries. 

Antenatal care 

The developing world as a whole has achieved great success in extending the reach of antenatal 

care. Over 80 percent of women in the majority of countries studied have at least one antenatal care visit 

during pregnancy, and the coverage reaches 90 percent in many countries. 

Despite progress in extending antenatal care coverage, many countries, particularly in subSaharan Africa and South/Southeast Asia, still have unsatisfactory levels of the WHO-recommended four 

or more antenatal care visits. However, it is encouraging that the data on trends in having at least four 

antenatal care visits show improvements since 1990 in most countries. This trend could be the result of 

program efforts based on better understanding of antenatal care in improving health outcomes for women 

and children. Steady increases are found in Latin America and the Caribbean, North Africa/West 

Asia/Europe and South/Southeast Asia, while the former two regions already had relatively high levels of 

use in the 1990s. Sub-Saharan Africa presents a mixed picture, with increases more evident in Western 

and Central Africa than elsewhere in the region. 

WHO recommends that pregnant women start antenatal care in the first trimester to have enough 

time for diagnosis and treatment of problems and diseases. The majority of women surveyed in Latin 

America and the Caribbean and in North Africa/West Asia/Europe have the first antenatal care visit in 

their first trimester of pregnancy. In contrast, women in sub-Saharan Africa tend to start antenatal care 

only in the second trimester, and even as late as the third trimester. 

Socioeconomic disparities in use of antenatal care are profound. In developing countries as a 

whole, women are more likely to report four or more antenatal care visits if they reside in urban rather 

than rural areas, have a higher education level or live in a richer household. These differentials are smaller 

in countries with overall high levels of antenatal care. 

Antenatal care provided by a skilled health provider—that is, a doctor, nurse or midwife—can be 

effective in identifying problems and pregnancy complications, given that such providers have been 

educated and trained to be proficient in the skills of diagnosing, managing and referring complicated 

pregnancies. Use of skilled health providers for antenatal care has been increasing in most of countries 

studied, although the degree of increase varies by country. The most recent surveys show that skilled 

health providers are commonly reported as the providers of antenatal care in most countries, except for a 

few in Western and Central Africa. 

Doctors are the main providers of antenatal care, particularly in Latin America and the Caribbean 

and North Africa/West Asia/Europe. In contrast, in sub-Saharan Africa women rely primarily on nurses or 

midwives for antenatal care. Traditional birth attendants and other health personnel other than a doctor, 

nurse or midwife are rarely reported as providers of antenatal care, except in a very few countries. 

The likelihood of a woman receiving antenatal care from a skilled health provider appears to be 

highly associated with residence in an urban rather than rural area, having a higher education level and 

belonging to a richer household. Furthermore, the socioeconomic gap in antenatal care is considerably 

larger in countries where overall use of skilled health providers is low. 
74 

Essential examinations and tests, such as measuring blood pressure and testing urine and blood 

samples for certain diseases, should be performed during antenatal care visits. Overall, and particularly in 

South/Southeast Asia and sub-Saharan Africa, women are more likely to have their blood pressure 

measured than to have urine and blood samples tested. Countries in Latin America and the Caribbean 

perform better than those in other regions with regard to delivering a majority of the selected services, but 

more efforts in teaching women about signs of pregnancy complications are needed. 

Results also show that receiving antenatal care from a skilled health provider does not in itself 

ensure the delivery of essential services. For example, in Uganda, although over 90 percent of women 

receive antenatal care from a skilled health provider, most women do not get their blood and urine 

samples tested. However, in many countries in Latin America and the Caribbean, North Africa/West 

Asia/Europe, and some sub-Saharan countries, where a high proportion of women report a doctor as their 

source of antenatal care, a high proportion of women also receive the essential services. 

This finding may reflect the quality of care provided by different health providers, although we 

are unable to directly examine the quality of service provided to women, due to lack of data. Another 

reason could be related to availability of testing supplies in the facility. In facilities where testing supplies 

are not available, women may not get blood or urine samples drawn and tested regardless of which 

providers they see. 

The receipt of iron supplements during pregnancy is common in Latin America and the Caribbean 

and in South/Southeast Asia, but is generally less common in sub-Saharan Africa. The high proportion of 

pregnant women who are given or who purchase iron supplements in some sub-Saharan countries, 

including Senegal and Ghana, may reflect program efforts to address high levels of anemia among women 

and children (Seck and Jackson 2010; MacDonald et al. 2007). 

Antenatal care visits also represent an important opportunity to address other key health issues 

such as malaria and HIV/AIDS. Study results in sub-Saharan Africa show that many countries with high 

malaria prevalence have not taken advantage of antenatal care to offer women preventive medicines for 

malaria. For example, in Cameroon and Chad none of the pregnant women took two or more doses of 

SP/Fansidar during the pregnancy, despite the high prevalence of malaria. In Zambia and Malawi, 

however, a high proportion of women receive IPT during pregnancy, which reflects the extensive 

program efforts to address the problem of malaria infections in these two countries. Similarly, despite the 

extremely high prevalence of HIV in many sub-Saharan countries, including Malawi, Zambia and 

Zimbabwe, women are rarely offered and accept HIV testing during antenatal care visits. 

Delivery care 

Delivery care—including giving birth in health facilities and receiving skilled attendance at 

birth—has a strong positive influence on the health of mothers and their children. Globally, there is a 

growing trend for women to give birth in health facilities, both private and public. A strong upward trend 

is clearly evident in North Africa/West Asia/Europe and in Latin America and the Caribbean, except 

Haiti. Countries in these regions show a high percentage of births in health facilities, rather than at home 

or elsewhere. In half of the 38 countries analyzed, the majority of women delivered their last child in an 

institutional setting. Despite this progress, the situation in sub-Saharan Africa is mixed, with levels of 

institutional births over 70 percent in Benin, Namibia and Zimbabwe, but below 20 percent in Ethiopia, 

Chad and Niger. The South/Southeast Asia region also lags behind in the percentage of women who 

deliver in health facilities. 

In all but a handful of countries, the public sector contributes the major share of births that take 

place in an institutional setting. In Namibia, Vietnam and Peru, for example, over 60 percent of women’s 
75 

births take place in a public health facility. However, in some countries, particularly in North Africa/West 

Asia/Europe and South/Southeast Asia, the private sector for delivery care is much more developed. 

Other studies also see an increasing trend of privatization of delivery (Pomeroy, Koblinsky, and Alva 

2010). 

Countries where the private sector plays a large role in deliveries include Egypt (46 percent) and 

Jordan (36 percent), and Indonesia, Pakistan and Malawi (each over 25 percent). In contrast, the 

percentage of home births continues to remain high in all South/Southeast Asian countries except 

Vietnam, with Bangladesh, Cambodia and Nepal having the highest levels. Recently, however, in 

Bangladesh, India and Indonesia much of the recent increase in facilities for births has been in the private 

sector (Pomeroy, Koblinsky, and Alva 2010). 

In some countries studied, a high rate of caesarean section deliveries is associated with a high 

percentage of births in public health facilities. Particularly in the Latin America countries studied 

(Bolivia, Colombia, the Dominican Republic and Peru), which have caesarean section rates above 20 

percent, more than 60 percent of caesarean section deliveries occur in public facilities. The highest rates 

in the region are in Colombia (95 percent) and Peru (79 percent). Vietnam is another example where, with 

a caesarean section rate of 10 percent, almost all caesarean section deliveries are in public health facilities 

(98 percent). 

Use of health facilities for delivery varies by women’s socioeconomic status. A negative 

relationship between maternal age and institutional births is most prominent in sub-Saharan Africa. 

Moreover, in all four regions, the proportion of births delivered in a health facility declines with birth 

order, although the decline is smaller in sub-Saharan Africa than elsewhere. Both findings might indicate 

that the increase in use of health facilities for delivery is a recent trend. Furthermore, as expected, births 

in health facilities are more common than home births in urban areas than rural areas. This difference is 

most apparent in sub-Saharan Africa and South/Southeast Asia, where in a majority of countries studied 

the proportion of births in health facilities in urban areas is double the proportion in rural areas. The 

higher levels in urban areas are also associated with such factors as women’s education and wealth, as 

well as a higher density of facilities in urban areas, resulting in easier access. 

Overall, skilled birth attendance and use of health facilities for births follow similar patterns, with 

rates considerably lower in sub-Saharan Africa and South Asia compared to the other regions. 

Nurses/midwives are the great majority of skilled birth attendants in sub-Saharan Africa, while doctors 

dominate in other regions. In a few countries, including Chad, Guinea and Indonesia, other health 

personnel also play a role in delivery. Among births delivered without skilled birth attendants, traditional 

birth attendants are the primary care providers in most countries. 

Overall, the majority of countries show an increase in rates of skilled birth attendance in recent 

years, although the increase is small in most countries. This includes countries where skilled birth 

attendance for delivery has been the norm, as in Armenia, Jordan, the Dominican Republic and Colombia, 

and many sub-Saharan African countries, where skilled assistance is not widely available. In other subSaharan countries, including Benin, Ghana, Namibia, Rwanda and Uganda, increases in skilled 

attendance have been substantial in the past decade. 

With regard to demographic and socioeconomic differences in use of delivery care, in most 

countries there is a negative relationship between the mother’s age at last birth and the use of skilled 

attendants. But in many countries there is a non-linear relationship, although weak. Birth order is also 

negatively related to skilled birth attendance, and substantially higher levels of skilled attendance are seen 

with lower birth orders in many countries, including those with low levels of skilled birth attendance—

Bangladesh, Nepal, Indonesia and Haiti. The majority of women in urban areas use skilled birth 
76 

attendants for delivery. Furthermore, in a majority of countries in sub-Saharan Africa and 

South/Southeast Asia, the use of skilled birth attendants among urban women is double that among rural 

women. Although there are differences in the level of use of skilled birth care, mother’s levels of 

education and household wealth are consistently and positively related to the use of skilled birth 

attendants at delivery in all countries. 

Postnatal care 

Postnatal care, especially within the first few days following delivery, is critical to reducing 

maternal mortality and improving newborn survival. Although there is consensus on this point, no 

globally accepted guidelines exist that address the provision and standardize the content of postnatal care 

to mothers. WHO and Save the Children are two organizations working to define aspects of care and to 

develop evidence-based guidelines for postnatal care (WHO 2010). 

As expected, women who deliver in a health facility are more likely than women who deliver at 

home or other places to report postnatal checkups, have the first checkup within two days after delivery 

and receive postnatal care from a skilled health provider. 

Among all women regardless of place of delivery, whether in a health facility or elsewhere, in 8 

of the 18 countries with data, more than half of the women have a postnatal checkup within 41 days after 

delivery. In sub-Saharan Africa and Latin American and the Caribbean, more than two-thirds of women 

who receive postnatal care have a postnatal checkup from a skilled health provider (doctor, nurse or 

midwife). In South/Southeast Asia the proportion is lower. 

Relationships between uses of maternal health services 

Given the association between lack of appropriate care at all stages (pregnancy, birth and postdelivery) and poor maternal and newborn health outcomes, a concept of ―continuum of care‖ for maternal 

and newborn health has been developed, focusing on the continuity of care for every woman and child 

(AbouZahr and Wardlaw 2003; Kerber et al. 2007; Tinker et al. 2005; de Graft-Johnson, Kerber, and 

Tinker 2006). Overall, our study shows that there is a strong positive correlation between the number of 

antenatal visits and the use of skilled birth attendants. Women who receive antenatal care are more likely 

to use skilled birth attendants for delivery. 

However, in some countries there is no clear pattern in relation to maternal mortality. For 

instance, although maternal mortality ratios continue to remain high in Benin (410 per 100,000 live 

births) and Cameroon (600 per 100,000 live births), according to recent WHO estimates (WHO et al. 

2010), both countries have high levels of antenatal care and skilled birth attendance. The percentage of 

four or more antenatal care visits as well as skilled birth attendance is greater than 60 percent in both 

countries, and over three-fourths of women with four or more antenatal care visits also receive skilled 

birth assistance. Nevertheless, it is important to note that in these countries the major providers of such 

care are nurses and midwives, whose roles in caesarean sections and other life-saving procedures are 

more limited. Most countries in Latin America and the Caribbean, as well as North Africa/West 

Asia/Europe, display a similar pattern. Interestingly, in a few countries (Armenia, Jordan and the 

Dominican Republic) women report having skilled birth attendance at delivery despite receiving no 

antenatal care. 

In almost all countries, a majority of women who have four or more antenatal care visits also 

receive postnatal care. A strong association between having a skilled attendant at birth and receiving 

postnatal care is also observed. However, in several countries a significant percentage of women who 
77 

receive no antenatal care or use a non-skilled birth attendant or other person at delivery also receive 

postnatal care. 

Limitations of the study 

There are several limitations in this study that should be acknowledged. First is recall bias. 

Information collected in the DHS for maternal health services such as antenatal care, skilled birth 

attendance and postnatal checkups are based on women’s recall of events, which can be affected by the 

period of recall as well as the women’s situation at the time of the event. We focus on the last birth in the 

five years prior to the survey and expect that women are more likely to misreport or misclassify events the 

earlier the birth occurred. A woman in a critical situation, for example, shortly after delivery or a 

caesarean section, may be prone to misinterpret or not realize whether a contact with a health provider 

after birth was ―postnatal care‖ or some other type of care. A woman may also not correctly identify the 

category or skill level of the care provider. This may occur because of poor recall, nonstandard provider 

uniform (or no uniform), or lack of knowledge of the types of provider offering these services. Similarly, 

women may not know whether the facility they visit is public or private, although this may be less likely 

to be a problem than knowing the provider type. DHS makes every effort to construct survey questions 

adequately to provide reliable information, but because women’s answers to these questions are selfreported, the resulting data are open to the potential for self-reporting bias. 

While the DHS provides information on the use of antenatal care, including timing, number of 

visits and components of antenatal care, there is limited information on the specific contents of services 

offered in skilled birth attendance and postnatal care. Although the surveys give information on caesarean 

section delivery, only in a few surveys are there details about obstetric care and complications. As a 

result, the surveys do not provide data on the quality of care received by women. 

The third limitation is related to the design of DHS surveys. In most DHS surveys, women age 

15-49 are asked to provide information about pregnancies resulting in live births during the five years 

prior to the interview. In some surveys conducted in 1990s, the reference period was reduced to three 

years prior to the interview. Since 1999, surveys have resumed collecting antenatal and postnatal 

information for the reference period of five years, but only for the last birth in the reference period. 

Information on skilled birth attendance continues to be collected for all live births in the past five years. 

Thus, in our trend analysis, data from a number of surveys (noted in Table 1) conducted during the 1990s 

were only based on the last birth in the three-year reference period. However, we do not expect 

substantial differences resulting from using reference periods of three years versus five years, based on a 

recent study that examined such differences using DHS data (Bell, Curtis, and Alayón 2003). 

79 

References 

AbouZahr, C., and T. Wardlaw. 2001. Maternal mortality at the end of a decade: signs of progress? 

Bullution of the World Health Organization 79 (6):561-8. 

AbouZahr, C., and T. Wardlaw. 2003. Antenatal care in developing countries: promises, achievements 

and missed opportunities. Geneva: World Health Organization. 

Bell, J., S. Curtis, and S. Alayón. 2003. Trends in delivery care in six countries. In DHS analytical studies 

N0.7. Calverton, Maryland USA: ICF Macro and International Research Partnership for Skilled 

Attendance for Everyone (SAFE). 

Bhutta, Z. A., S. Soofi, S. Cousens, S. Mohammad, Z. A. Memon, I. Ali, A. Feroze, F. Raza, A. Khan, S. 

Wall, and J. Martines. 2011. Improvement of perinatal and newborn care in rural Pakistan 

through community-based strategies: a cluster-randomised effectiveness trial. Lancet 377(9763): 

403-412. 

Carroli, G., C. Rooney, and J. Villar. 2001. How effective is antenatal care in preventing maternal 

mortality and serious morbidity? An overview of the evidence. Paediatr Perinat Epidemiol 15 

Suppl 1:1-42. 

Chen, X. K., S. W. Wen, Q. Yang, and M. C. Walker. 2007. Adequacy of prenatal care and neonatal 

mortality in infants born to mothers with and without antenatal high-risk conditions. Aust N Z J 

Obstet Gynaecol 47 (2):122-7. 

De Brouwere, V., R. Tonglet, and W. Van Lerberghe. 1998. Strategies for reducing maternal mortality in 

developing countries: what can we learn from the history of the industrialized West? Trop Med 

Int Health 3 (10):771-82. 

de Graft-Johnson, J, K Kerber, and A Tinker. 2006. The maternal, newborn and child health continuum of 

care. In Opportunities for Africa’s newborns, edited by Lawn J and Kerber K. Cape Town, South 

Africa: Partnership for Maternal, Newborn and Child Health. 

Fort, A., M. Kothari, and A. Noureddine. 2006. Postpartum Care: Levels and Determinants in Developing 

Countries. Calverton, Maryland USA: ICF Macro. 

Graham, W.J., J.S. Bell, and C.H.W. Bullough. 2001. Can skilled attendance at delivery reduce maternal 

mortality in developing countries? In Studies in health service organisation and policy, edited by 

V. D. Brouwere, V. Lerberghe and B. I. P. Antwerp. Antwerp, Belgium: TIG Press. 

Kerber, K. J., J. E. de Graft-Johnson, Z. A. Bhutta, P. Okong, A. Starrs, and J. E. Lawn. 2007. Continuum 

of care for maternal, newborn, and child health: from slogan to service delivery. Lancet 370 

(9595):1358-69. 

Li, X. F., J. A. Fortney, M. Kotelchuck, and L. H. Glover. 1996. The postpartum period: the key to 

maternal mortality. Int J Gynaecol Obstet 54 (1):1-10. 

MacDonald, C;, B; Main, R; Namarika, M; Neequaye, and K Siekmans. 2007. Effectiveness of a largescale multiple-sector program to reduce anemia in Ghanaian and Malawian women. In 

Micronutrient Forum. Istanbul, Turkey. 
80 

Magoma, M., J. Requejo, O. M. Campbell, S. Cousens, and V. Filippi. 2010. High ANC coverage and 

low skilled attendance in a rural Tanzanian district: a case for implementing a birth plan 

intervention. BMC Pregnancy Childbirth 10:13. 

Maine, D. 1991. Safe motherhood programs: options and issues. New York: Center for Population and 

Family Health, Columbia University. 

McDonagh, M. 1996. Is antenatal care effective in reducing maternal morbidity and mortality? Health 

Policy Plan 11 (1):1-15. 

Mpembeni, R. N., J. Z. Killewo, M. T. Leshabari, S. N. Massawe, A. Jahn, D. Mushi, and H. Mwakipa. 

2007. Use pattern of maternal health services and determinants of skilled care during delivery in 

Southern Tanzania: implications for achievement of MDG-5 targets. BMC Pregnancy Childbirth

7:29. 

Pomeroy, A., M. Koblinsky, and S. Alva. 2010. Private delivery care in developing countries: Trends and 

determinants. In DHS working paper series. Calverton, Maryland USA: ICF Macro. 

Post, M. 1997. Preventing Maternal Mortality through Emergency Obstetric Care. In SARA Issues Paper. 

Washington DC: Academy for Educational Development. 

Rutstein, S.O., and K. Johnson. 2004. The DHS Wealth Index. In DHS Comparative Reports No. 6.

Calverton, Maryland USA: ICF Macro. 

Seck, B. C., and R. T. Jackson. 2010. Multiple contributors to iron deficiency and anemia in Senegal. Int 

J Food Sci Nutr 61 (2):204-16. 

Syed, U., N. Khadka, A. Khan, and S. Wall. 2008. Care-seeking practices in South Asia: using formative 

research to design program interventions to save newborn lives. J Perinatol 28 Suppl 2:S9-13. 

Tinker, A., P. ten Hoope-Bender, S. Azfar, F. Bustreo, and R. Bell. 2005. A continuum of care to save 

newborn lives. Lancet 365 (9462):822-5. 

Villar, J., H. Ba'aqeel, G. Piaggio, P. Lumbiganon, J. Miguel Belizan, U. Farnot, Y. Al-Mazrou, G. 

Carroli, A. Pinol, A. Donner, A. Langer, G. Nigenda, M. Mugford, J. Fox-Rushby, G. Hutton, P. 

Bergsjo, L. Bakketeig, H. Berendes, and J. Garcia. 2001. WHO antenatal care randomised trial 

for the evaluation of a new model of routine antenatal care. Lancet 357 (9268):1551-64. 

WHO. 1999. Reduction of maternal mortality: A joint WHO/UNFPA/UNICEF/World Bank statement. 

Geneva: World Health Organization. 

———. 2001. Antenatal care randomized trial: manual for the implementation of the new model. In 

WHO/RHR/01.30. Geneva: World Health Organization. 

———. 2009. Monitoring emergency obstetric care: a handbook. Geneva: World Health Organization. 

———. 2010. WHO technical consultation on postpartum and postnatal care. Geneva: Department of 

Making Pregnancy Safer, WHO. 

WHO, ICM, and FIGO. 2004. Making pregnancy safer: the critical role of the skilled attendant. A joint 

statement by WHO, ICM and FIGO. Geneva: World Health Organization. 
81 

WHO, UNICEF, UNFPA, and World Bank. 2010. Trends in maternal mortality: 1990-2008. Estimates 

developed by WHO, UNICEF, UNFPA and the World Bank. . Geneva: WHO. 

Wildman, K., and M. H. Bouvier-Colle. 2004. Maternal mortality as an indicator of obstetric care in 

Europe. BJOG 111 (2):164-9. 

You, D., G. Jones, and T. Wardlaw. 2010. Levels and trends in child mortality. New York: the United 

Nations Children’s Fund. 

83 

Appendix A: Percentage of women who had a caesarean section for the most recent live birth in 

the five years preceding the survey, 1990-2009

Country Survey year Percentage with a caesarean section

Sub-Saharan Africa

Western and Central Africa

Benin 1996* 2.3

2001 3.9

2006 4.0

Burkina Faso 1993 1.6

1998-99 1.1

2003 0.7

Cameroon 1991 2.8

1998* 2.7

2004 2.3

Chad 1996-97 0.5

2004 0.5

Ghana 1993* 4.8

1998 4.0

2003 4.4

2008 7.2

Guinea 1999 2.2

2005 1.9

Mali 1995-96* 0.9

2001 1.1

2006 2.0

Niger 1992 1.0

1998* 0.6

2006 1.2

Nigeria 1990 2.5

2003 1.9

2008 2.1

Senegal 1992/93 2.5

1997 na

2005 3.9

Eastern and Southern Africa

Ethiopia 2000 0.7

2005 1.2

Kenya 1993 6.0

1998* 7.0

2003 4.9

2008 7.2

Madagascar 1992 1.1

1997* 0.7

2003-04 1.0

2008-09 1.7

Malawi 1992 3.9

2000 3.0

2004 3.3

Mozambique 1997* 2.3

2003 2.4

Namibia 1992 7.2

2000 na

2006-07 13.6

Rwanda 1992 1.7

2000 2.2

2007 na

 (Cont’d)
84 

Appendix A. – cont’d

Country Survey year Percentage with a caesarean section

Tanzania 1991-92 2.9

1996 2.3

1999 3.7

2004-05 4.0

Uganda 1995* 2.7

2000-01 3.1

2006 3.6

Zambia 1992 3.0

1996 2.1

2001-02 2.4

2007 3.5

Zimbabwe 1994* 6.0

1999 7.5

2005-06 5.4

North Africa/West Asia/Europe

Armenia 2000 7.3

2005 9.8

Egypt 1992 5.6

1995 7.6

2000 11.3

2005 21.5

2008 29.2

Jordan 1990 7.0

1997 12.2

2002 17.3

2007 20.0

Morocco 1992 2.7

2003-04 5.8

South/Southeast Asia

Bangladesh 1993-94* na

1999-2000 2.9

2004 4.0

2007 8.6

Cambodia 2000 1.0

2005 2.2

India 1992-93* 2.8

1998-99* 7.3

2005-06 9.8

Indonesia 1991 1.6

1997 4.6

2002-03 4.1

2007 7.3

Nepal 1996* 0.8

2001 1.1

2007 3.3

Pakistan 1990-91 2.7

2006-07 8.5

Philippines 1993 7.0

1998 6.7

2003 8.6

2008 11.4

Vietnam 1997* 3.6

2002* 10.2

 (Cont’d)
85 

Appendix A. – cont’d

Country Survey year Percentage with a caesarean section

Latin America/Caribbean

Bolivia 1994* 11.1

1998 16.5

2003 17.2

2008 21.1

Colombia 1990 16.8

1995 18.8

2000 25.8

2005 28.8

Dominican Republic 1991 24.4

1996 28.3

2002 34.3

2007 44.4

Haiti 1994-95 2.0

2000 2.0

2005-06 3.5

Peru 1991-92 11.1

1996 10.3

2000 14.0

2005 16.4

2008 20.3

*Information was collected only for live births in the three years preceding the survey, so analyses focus on the 

most recent birth in the past three years.

na=not available

DHS Comparative Reports Series 

1. Westoff, Charles F. 2001. Unmet Need at the End of the Century. 

2. Westoff, Charles F., and Akinrinola Bankole. 2002. Reproductive Preferences in Developing 

Countries at the Turn of the Century.

3. Rutstein, Shea O. 2002. Fertility Levels, Trends, and Differentials 1995-1999.

4. Mahy, Mary. 2003. Childhood Mortality in the Developing World: A Review of Evidence from the 

Demographic and Health Surveys.

5. Westoff, Charles F. 2003. Trends in Marriage and Early Childbearing in Developing Countries.

6. Rutstein, Shea O., and Kiersten Johnson. 2004. The DHS Wealth Index.

7. Yoder, P. Stanley, Noureddine Abderrahim, and Arlinda Zhuzhuni. 2004. Female Genital Cutting in 

the Demographic and Health Surveys: A Critical and Comparative Analysis. 

8. Stallings, Rebecca. 2004. Child Morbidity and Treatment Patterns.

9. Rutstein, Shea O., and Iqbal H. Shah. 2004. Infecundity, Infertility, and Childlessness in 

Developing Countries. 

10. Mukuria, Altrena, Jeanne Cushing, and Jasbir Sangha. 2005. Nutritional Status of Children: Results 

from the Demographic and Health Surveys, 1994–2001. 

11. Mukuria, Altrena, Casey Aboulafia, and Albert Themme. 2005. The Context of Women’s Health: 

Results from the Demographic and Health Surveys, 1994-2001. 

12. Yoder, P. Stanley, Noureddine Abderrahim, and Arlinda Zhuzhini. 2005. L’excision dans les Enquêtes 

Démographiques et de Santé: Une Analyse Comparative.

13. Garenne, Michel, and Julien Zwang. 2006. Premarital Fertility and Ethnicity in Africa.

14. Westoff, Charles F. 2006. New Estimates of Unmet Need and the Demand for Family Planning. 

15. Fort, Alfredo L., Monica T. Kothari, and Noureddine Abderrahim. 2006. Postpartum Care: Levels and 

Determinants in Developing Countries. 

16. Khan, Shane, Vinod Mishra, Fred Arnold, and Noureddine Abderrahim. 2007. Contraceptive Trends 

in Developing Countries. 

17. Johnson, Kiersten, and Yuan Gu. 2009. Men’s Reproductive Health: Findings from Demographic and 

Health Surveys, 1995-2005. 

18. Garenne, M. Michel. 2008. Fertility Changes in Sub-Saharan Africa.

19. Khan, Shane, and Vinod Mishra. 2008. Youth Reproductive and Sexual Health.

20. Kishor, Sunita, and Lekha Subaiya. 2008. Understanding Women’s Empowerment: A Comparative 

Analysis of Demographic and Health Surveys (DHS) Data. 

21. Mishra, Vinod, Shane Khan, Li Liu, and Benny Kottiri. 2008. Medical Injection Use and HIV in SubSaharan Africa. 

22. Mishra, Vinod, Amy Medley, Rathavuth Hong, Yuan Gu, and Bryant Robey. 2009. Levels and Spread 

of HIV Seroprevalence and Associated Factors: Evidence from National Household Surveys. 

23. Sneeringer, Stacy E. 2009. Fertility Transition in Sub-Saharan Africa: A Comparative Analysis of 

Cohort Trends in 30 Countries. 

24. Mishra, Vinod, Praween Agrawal, Soumya Alva, Yuan Gu, and Shanxiao Wang. 2009. Changes in 

HIV-Related Knowledge and Behaviors in Sub-Saharan Africa.

25. Westoff, Charles F. 2010. Desired Number of Children: 2000-2008.

26. Wang, Wenjuan, Soumya Alva, Shanxiao Wang, and Alfredo Fort. 2011. Levels and Trends in the

Use of Maternal Health Services in Developing Countries.