Canada ranks 20th out of 146 countries in a survey of the best and worst places to live for mothers and children, according to U.S.-based humanitarian organization Save the Children.

The group issued its ninth annual State of the World's Mothers report Tuesday, ranking countries according to mothers' and children's health, education and economic status.

Canada's ranking slipped to 20 from 15 last year, but not because of changes within Canada, says Susan Rooks, spokeswoman for Save the Children Canada.

"It's because a number of other countries improved spending on early childhood education and secondary education," Rooks told CBC.

Nordic countries came out on top while countries in sub-Saharan Africa dominated the bottom tier. Sweden tops the list, followed by Norway, Iceland and New Zealand while Niger ranks last among countries surveyed, just ahead of Chad, Yemen and Sierra Leone.

Survey criteria included:

• Lifetime risk of maternal mortality.
• Percentage of women using modern contraception.
• Skilled attendant at delivery.
• Female life expectancy.
• Expected number of years of formal schooling for females.
• Ratio of estimated female-to-male earned income.
• Maternity leave benefits.
• Participation of women in national government .
• Mortality rate for children under 5.
• Percentage of children under age 5 moderately or severely underweight.
• School enrolment ratios.
• Ratio of girls to boys enrolled in primary school.
• Percentage of population with access to safe water.

The gap in availability of maternal and child health services is especially striking when comparing Sweden, at the top of the list, and Niger, at the bottom. Skilled health personnel are present at virtually every birth in Sweden while only 33 per cent of births are attended in Niger.

A typical Swedish woman has almost 17 years of formal education and will live to be 83. Modern methods of contraception are used by 72 per cent of Swedish women, and only 1 in 185 women will lose a child before the child's fifth birthday.

In Niger, a typical woman has less than three years of education, and the life expectancy of a girl born today is only 45. Only four per cent of Nigerian women use modern contraception, and one child in four never reaches the age of 5. At this rate, every mother is likely to suffer the loss of a child during her lifetime.

200 million children without basic health care

In a separate survey, the group also ranked 55 developing countries according to children's access to health care.

It found more than 200 million children lack basic health care according to a recent survey of developing countries that estimates six million of those who die every year could be saved if they had access to such services.

The children and health care survey found the Philippines ranks first and Ethiopia ranks last, with more than 80 per cent of Ethiopian children under age five not receiving basic lifesaving care.

The group defines basic health care as a package of lifesaving interventions that includes prenatal care, skilled care at childbirth, immunizations and treatment for diarrhea and pneumonia.

"A child's chance of celebrating a fifth birthday should not largely depend on the country or community where he or she is born," Charles MacCormack, president of Save the Children, said in a release.

Although some countries are doing a good job of reaching all children with basic health care, a closer look shows disparities. The poorest Filipino children, for example, are 3.2 times more likely than those from wealthier families to go without basic health measures, according to the report.

In 12 of the 55 countries, the poorest children are three or more times more likely to die than the richest children. These countries include Azerbaijan, Brazil, Bolivia, Cambodia, Egypt, India, Indonesia, Morocco, Nigeria, South Africa and the Philippines.

Peru has the widest gap in child death rates between the rich and poor. The poorest Peruvian children are 7.4 times more likely to die than the richest Peruvian children.

The report calls on governments around the world to close the child survival gap by stepping up commitments to deliver basic health care, especially to the poorest children in developing countries.