Health: The number of caesarean section (c-section) deliveries in the country has been on the rise over the past few years along with an increase in childbirths.

Records show that from 444 c-section deliveries or surgical childbirths in 2000 it increased to 2,179 in 2015. In 2010, it stood at 1,759.

In 2015, the Thimphu referral hospital performed 4,035 deliveries of which 27.7 percent were through c-section. Similarly, in 2013, about 25.9 percent of the deliveries were done through c-section, which increased to 27.3 percent in 2014.

JDWNRH records

Records with the hospital show that the top indicators of emergency c-section delivery in 2015 were fetal distress at about 18 percent, past caesarean at about 17 percent and failed progress at about 16 percent followed by other causes.

As for elective c-section deliveries, the top five indications were previous caesarean at about 66 percent followed by non-reactive CTG, breech at term and failed induced labour and delivery of twins.

Thimphu referral hospital’s medical superintendent Dr Gosar Pemba said on an average about 25 percent of deliveries constitute of c-section deliveries, which is acceptable for now.

Dr Gosar Pemba said unless it was higher than 25 percent, which usually happens globally in private healthcare centres as it means more money, it is not an issue. “The increase is not much considering the increasing childbirth annually,” he said. “With increasing deliveries, c-section delivery is likely to increase as well.”

Dr Gosar Pemba said in Bhutan a woman cannot have more than three deliveries through c-section as the surgery tends to leave scars on the uterus making it difficult as the baby grows in the womb. Most women opt to deliver two babies through c-section but some opt for three and four in rare cases provided that there are no complications at all.

“We don’t encourage women who have had caesarean previously to opt for normal delivery, as it requires good monitoring, as chances of complication are high,” he said.

Although the hospital has not studied the cost implications of c-section deliveries yet, Dr Gosar Pemba said it could range between Nu 70,000 to Nu 80,000 per delivery.

The Thimphu referral hospital alone recorded 16,405 deliveries from 2012 to 2015. The highest was in 2013 with 4,248 babies. In 2015, 4,035 babies were delivered. Of the total birth in 2015, 3,991 were live births, 44 were intrauterine fetal deaths and 44 were early neonatal deaths which means the perinatal mortality rate per 1,000 births stood at 21.80 percent

Similarly, of the 4,248 births in 2013, 4,195 were live births, 53 were intrauterine fetal deaths and 35 were early neonatal deaths. The perinatal mortality rate per 1,000 births stood at 20.70 percent.

Of the total deliveries at the Thimphu referral hospital, less than half of the women (43 percent) came from other dzongkhags. Among the total deliveries in 2015, about 67 percent were housewives followed by 24.1 percent who were employed and the rest (4.5 percent) were into business. Less than one percent of the women who delivered in 2015 were students.

Among women who delivered in 2015, women aged 20 to 25 years were the highest at about 39.5 percent followed by 26 to 30 years at about 34 percent and 15 percent were aged 31 to 35 years.

WHO’s accepted rate

World Health Organisation (WHO) country office’s technical officer for Reproductive, Maternal, Newborn, Child and Adolescent Health Dr Egmond Evers said there is a lot of information that simply “naked” c-section rates do not tell us.

For instance, a seemingly acceptable national c-section rate can mask over-utilisation among urban middle class and under-utilisation among poor rural populations.

The annual health bulletin 2016 has noted 16,192 deliveries as per the 2015 household survey. With 2,179 c-section deliveries in 2015, it stands at about 13.5 percent that is within the 10-15 percent range, which WHO has considered acceptable since 1985.

In general, WHO assumes less than 10 percent to be under-utilisation where progress can be made in terms of outcomes for mothers and newborns. More than 15 percent is considered to be over-utilisation, whereby there is no added value in terms of health outcomes for mothers and children. Therefore, these are unnecessary, expensive, invasive procedures, which in turn, as all operations, have associated health risks.

For tertiary facilities, such as JDWNRH, the percentage is accepted to be higher than 10-15 percent. “This could be because complicated cases are referred to such facilities, thereby “skewing” the numbers towards more c-sections,” Dr Egmond Evers said. “For tertiary facilities the acceptable percentage is highly dependent on hospital, population and country characteristics, and requires in-depth analysis.”

Dr Egmond Evers also said that keeping in mind the “naked” rates not telling the full story, the number in Bhutan in general as well as at JDWNRH, are not reason for concern as of yet.

He added that on a global level, however, it was true that excess caesarian sections not only exposes women and newborn babies to unnecessary risks, but also poses challenges to keeping healthcare affordable and can have negative consequences for health equity both within and across countries.

WHO’s statement on c-section rates 2015 states that c-sections are effective in saving maternal and infant lives, but only when they are required for medically indicated reasons.

“At the population level, c-section rates higher than 10 percent are not associated with reductions in maternal and newborn mortality rates,” the statement reads. “C-sections can cause significant and sometimes permanent complications, disability or death particularly in settings that lack facilities or capacity to properly conduct safe surgery and treat surgical complications.”

Every effort should be made to provide c-sections to women in need, rather than striving to achieve a specific rate.

The effects of c-section rates on other outcomes, such as maternal and perinatal morbidity, paediatric outcomes, and psychological or social well-being are still unclear, according to the statement. Therefore, more research is required to understand the health effects of c-section on immediate and future outcomes.

Kinga Dema