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Evidence has shown that quality skilled care during labor and delivery is essential to improve maternal and newborn health outcomes. Unfortunately, analyses of Demographic and Health Survey (DHS) data show that there are a substantial number of women around the world that not only do not have access to skilled care but also deliver alone with no one present (NOP). Among the 80 countries with data, we found the practice of delivering with NOP was concentrated in West and Central Africa and parts of East Africa. Across these countries, the prevalence of giving birth with NOP was higher among women who were poor, older, of higher parity, living in rural areas, and uneducated than among their counterparts. As women increased use of antenatal care services, the proportion giving birth with NOP declined. Using census data for each country from the US Census Bureau’s International Database and data on prevalence of delivering with NOP from the DHS among countries with surveys from 2005 onwards (n=59), we estimated the number of women who gave birth alone in each country, as well as each country’s contribution to the total burden. Our analysis indicates that between 2005 and 2015, an estimated 2.2 million women, who had given birth in the 3 years preceding each country survey, delivered with NOP. Nigeria, alone, accounted for 44% (nearly 1 million) of these deliveries. As countries work on reducing inequalities in access to health care, wealth, education, and family planning, concurrent efforts to change community norms that condone and facilitate the practice of women giving birth alone must also be implemented. Programmatic experience from Sokoto State in northern Nigeria suggests that the practice can be reduced markedly through grassroots community advocacy and education, even in poor and low-resource areas. It is time for leaders to act now to eradicate the practice of giving birth alone-one of many important steps needed to ensure no mother or newborn dies of a preventable death.
Since 1984, the Demographic and Health Surveys (DHS) have been conducted in at least 85 countries.9 DHS data have documented the association between skilled assistance at delivery and lower rates of mortality and morbidity among mothers and their newborns.10,11 In addition to quantifying the prevalence of skilled birth attendance, the DHS also explicitly collects data on women who gave birth with NOP. For our analysis, we used publicly available data from the DHS program’s STATcompiler database to profile the distribution of delivery with NOP across countries, as well as to identify which sub-populations within countries were most likely to engage in this risky practice.12 Data on women giving birth alone were available for 80 countries. The STATcompiler database also enabled us to stratify all live births that occurred with NOP in the 3 years preceding the most recent country DHS survey on several indicators. The variables available were urban/rural residence, wealth quintile, mother’s age, number of antenatal care (ANC) visits, birth order, and mother’s level of education. Although most countries had full data on these stratification variables, some disaggregated data were missing for Botswana, Ecuador, El Salvador, Mexico, Sri Lanka, Sudan, Thailand, and Trinidad and Tobago. We also sought to estimate each country’s contribution to the total burden of women who gave birth alone among surveyed countries. In doing this, we used the mid-year population of women between the ages of 15–49, as calculated by the US Census Bureau’s International Database, during the same year as each DHS, adjusted for the general fertility rates (as presented in STATcompiler) for the 3 years preceding each survey year. For these analyses, we found census data for the same year as the DHS data for 77 countries. (Census data were missing for Ecuador, Sudan, and Thailand and were excluded from the analysis because they did not have recent DHS surveys conducted after 2004; see below.)13 These numbers were used to calculate a rough estimate of the number of women who would have given birth alone, given the prevalence rates of delivery with NOP at the time of the most recent DHS survey after 2004. We excluded 18 countries in the final analyses (besides Ecuador, Sudan, and Thailand mentioned above) as they had no data available after 2004. These countries were Botswana, Brazil, Central African Republic, Chad, Eritrea, Guatemala, Mauritania, Mexico, Morocco, Nicaragua, Paraguay, South Africa, Sri Lanka, Trinidad and Tobago, Turkey, Turkmenistan, Uzbekistan, and Vietnam. This yielded a total of 59 countries with recent data that were used to assess the number of women giving birth alone. Data from the DHS and the US Census Bureau are both open access and publicly available. Additionally, as standard protocol, each DHS survey received in-country ethical clearance. As both of these data sources are anonymized, we did not seek any additional ethical approval for this work.
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