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‘Who assisted with the delivery of (NAME)?’ Issues in estimating skilled birth attendant coverage through population-based surveys and implications for improving global tracking
  1. Emma Radovich1,
  2. Lenka Benova1,2,
  3. Loveday Penn-Kekana1,
  4. Kerry Wong1,
  5. Oona Maeve Renee Campbell1
  1. 1Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
  2. 2Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
  1. Correspondence to Ms Emma Radovich; emma.radovich{at}


The percentage of live births attended by a skilled birth attendant (SBA) is a key global indicator and proxy for monitoring progress in maternal and newborn health. Yet, the discrepancy between rising SBA coverage and non-commensurate declines in maternal and neonatal mortality in many low-income and middle-income countries has brought increasing attention to the challenge of what the indicator of SBA coverage actually measures, and whether the indicator can be improved. In response to the 2018 revised definition of SBA and the push for improved measurement of progress in maternal and newborn health, this paper examines the evidence on what women can tell us about who assisted them during childbirth and methodological issues in estimating SBA coverage via population-based surveys. We present analyses based on Demographic and Health Surveys and Multiple Indicator Cluster Surveys conducted since 2015 for 23 countries. Our findings show SBA coverage can be reasonably estimated from population-based surveys in settings of high coverage, though women have difficulty reporting specific cadres. We propose improvements in how skilled cadres are classified and documented, how linkages can be made to facility-based data to examine the enabling environment and further ways data can be disaggregated to understand the complexity of delivery care. We also reflect on the limitations of what SBA coverage reveals about the quality and circumstances of childbirth care. While improvements to the indicator are possible, we call for the use of multiple indicators to inform local efforts to improve the health of women and newborns.

  • maternal health
  • skilled birth attendant
  • maternal mortality
  • demographic & health surveys
  • multiple indicator cluster surveys
  • population-based surveys
  • measurement

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  • Handling editor Seye Abimbola

  • Contributors ER designed the research question, analysed data and prepared the manuscript. LB, LPK and OC conceptualised the paper and focus of analysis. ER conducted the search, title and abstract screen, full-text screen and data extraction for the systematic review; LB conducted a 10% double screen of titles and abstracts. KW conducted the secondary data analyses. All authors read and approved the final manuscript.

  • Funding Some of the research in this publication was supported via funding from MSD, through its MSD for Mothers program. MSD for Mothers is an initiative of Merck & Co., Kenilworth, New Jersey, USA.

  • Disclaimer MSD and its MSD for Mothers program had no role in the design, collection, analysis and interpretation of data, in writing of the manuscript or in the decision to submit the manuscript for publication. The content of this publication is solely the responsibility of the authors and does not represent the official views of MSD.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The DHS and MICS receive government permission and follow ethical practices including informed consent and assurance of confidentiality. The authors requested and received approval to download and use the data from the DHS and MICS websites as detailed under Data sharing. The Research Ethics Committee of the London School of Hygiene and Tropical Medicine approved our secondary-data analysis.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement The data that support some of the findings of this analysis are held by the Demographic and Health Surveys (DHS) Program, operated by ICF International, and Multiple Indicator Cluster Surveys (MICS), operated by Unicef. Restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are available for free from the DHS Program and Unicef websites, respectively, or by request from country statistical offices and available for researchers who apply for and meet the criteria for access. Legal access agreements do not allow the sharing of datasets to unregistered researchers.