Abstract
BackgroundBhutan has made much efforts to provide timely access to health services during pregnancy and increase institutional deliveries. However, as specialist obstetric services became available in seven hospitals in the country, there has been a steady increase in the rates of caesarean deliveries. This article describes the national rates and indications of caesarean section deliveries in Bhutan.MethodsThis is a review of hospital records and a qualitative analysis of peer-reviewed articles on caesarean deliveries in Bhutan. Data on the volume of all deliveries that happened in the country from 2015 to 2019 were retrieved from the Annual Health Bulletins published by the Ministry of Health. The volume of deliveries and caesarean deliveries were extracted from the Annual Report of the National Referral Hospital 2015–2019 and the data were collected from hospital records of six other obstetric centres. A national rate of caesarean section was calculated as a proportion out of the total institutional deliveries at all hospitals combined. At the hospital level, the proportion of caesarean deliveries are presented as a proportion out of total institutional deliveries conducted in that hospital.ResultsFor the period 2015–2019, the average national rate of caesarean section was 20.1% with a statistically significant increase from 18.1 to 21.5%. The average rate at the six obstetric centres was 29.9% with Phuentsholing Hospital (37.2%), Eastern Regional Referral Hospital (34.2%) and Samtse General Hospital (32.0%) reporting rates higher than that of the National Referral Hospital (28.1%). Except for the Eastern Regional Referral and Trashigang Hospitals, the other three centres showed significant increase in the proportion of caesarean deliveries during the study period. The proportion of emergency caesarean section at National Referral Hospital, Central Regional Referral Hospital and the Phuentsholing General Hospital was 58.8%. The National Referral Hospital (71.6%) and Phuentsholing General Hospital reported higher proportions of emergency caesarean sections (64.4%) while the Central Regional Referral Hospital reported higher proportions of elective sections (59.5%). The common indications were ‘past caesarean section’ (27.5%), foetal distress and non-reassuring cardiotocograph (14.3%), failed progress of labour (13.2%), cephalo-pelvic disproportion or shoulder dystocia (12.0%), and malpresentation including breech (8.8%).ConclusionBhutan’s caesarean section rates are high and on the rise despite a shortage of obstetricians. This trend may be counterproductive to Bhutan’s efforts towards 2030 Sustainable Development Goal agendas and calls for a review of obstetric standards and practices to reduce primary caesarean sections.
Highlights
Bhutan has made much efforts to provide timely access to health services during pregnancy and increase institutional deliveries
The Jigme Dorji Wangchuck (JDW) National Referral Hospital published annual reports; the first report for the year 2015 contained only the total number of deliveries and the number born via caesarean section [26]
The indications for caesarean section were available from only two hospitals: JDW National Referral Hospital in 2016 and 2018 [15, 27] and the Eastern Regional Referral Hospital in 2016–2018 [17]; data from the JDW National Referral Hospital for 2017 were omitted because of gross inconsistencies [28]
Summary
Bhutan has made much efforts to provide timely access to health services during pregnancy and increase institutional deliveries. As specialist obstetric services became available in seven hospitals in the country, there has been a steady increase in the rates of caesarean deliveries. This article describes the national rates and indications of caesarean section deliveries in Bhutan. Low- and middle-income countries with poor maternal and neonatal indicators are recommended to increase access to caesarean section through the establishment of surgical centres and training of human resources [1]. Bhutan is a small country with a population of 0.76 million situated in the eastern Himalayas that has made steady progress in maternal and child health indicators over the last three decades [5]. The rate of stillbirths in 2015 among institutional deliveries, which covered 86% of all births in the country, was 10 per 1000 live births, much lower than the global estimate of 18.4 per 1000 live births [8, 9]
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