Skilled attendance at delivery is one of the key indicators to reflect progress toward the Millennium Development Goal of improving maternal health. This paper assesses global progress in the use of skilled attendants at delivery and identifies factors that could assist in achieving Millennium Development Goals for maternal health. National data covering a substantial proportion of all developing country births were used for the estimation of trends and key differentials in skilled assistance at delivery. Between 1990 and 2000, the percentage of births with a skilled attendant increased from 45% to 54% in developing countries, primarily as a result of an increasing use of doctors. A substantial proportion of antenatal care users do not deliver with a skilled attendant. Delivery care use among antenatal care users is highly correlated with wealth. Women aged 35 and above, who are at greatest risk of maternal death, are the least likely to receive professional delivery care. Births in mid-level facilities appear to be a strategy that has been overlooked. More effective strategies are needed to promote skilled attendance at birth during antenatal care, particularly among poor women. Specific interventions are also needed to encourage older and high parity mothers to seek professional care at delivery.