Hypertensive disorder, unfavourable intrapartum, infection, chronic maternal illness, postmaturity, congenital malformation, and alcohol are some of the factors associated with stillbirth, according to a study the health ministry conducted.

The ministry conducted the study among women who had stillbirths in 2015.

Health officials say that all deliveries after 28 weeks of gestation in 2015 were included as  live birth and all outcome of pregnancy as a dead baby after 28 weeks of gestation were included as stillbirth.

The study observed that social factors like mother’s ignorance, poor family support, alcohol abuse, distance as a barrier, and unplanned pregnancy also contributed to stillbirth.

It also revealed that records of live and stillbirths with the maternal and child health (MCH), household survey and institutional delivery in the dzongkhags differ.

According to MCH record, the country had 11,122 live birth and 101 stillbirths in 2015, which is nine per 1,000 live births. Thimphu had the highest stillbirth with 17, followed by Samdrupjongkhar and Trashigang with 13 and 12.

Paro, Trongsa, Tsirang, and Wangdue had no stillbirth record in 2015, according to MCH.

The institutional delivery record shows the country’s stillbirth rate in 2015 was 8.4 per 1,000 live birth with 108 stillbirths and 11,126 live birth. Thimphu with 35 stillbirths is the highest among the dzongkhags. Chhukha and Mongar followed with 14 and 13 stillbirths.

Bumthang, Dagana, Gasa, Pemagatshel, Trashiyangtse, Tsirang, Wangdue and Zhemgang recorded zero stillbirth.

Annual household survey shows the country had 75 stillbirths in the same year with the highest stillbirth in Sarpang at 12. Samdrupjongkhar and Mongar had nine stillbirths each. Trashigang had eight.

With 8,902 live births, Bhutan’s stillbirth rate in 2015 according to the annual household survey was 8.4 per 1,000 live birth. Chukha, Dagana, Trongsa and Tsirang did not have any stillbirth.

About 49.6 percent of pregnant women delivered in referral hospitals; only 19.5 percent of them registered for antenatal care (ANC) in the referral hospitals.

Of 9.5 percent registering for ANC in BHU grade I, only 5 percent of them delivered in BHU I. Some 40 percent of the women registered for ANC in BHU grade II, of which only 9 percent delivered in BHU II.

The annual household survey information was unavailable for Thimphu and Phuentsholing, while some of the available information on other dzongkhags were incomplete. This is one of the limitations of the study.

A health official said MCH and institutional delivery records are maintained with the health centres while health staff conducts the survey, visiting households and questioning the household members. “There is the possibility of failure to capture all stillbirths.”

He said that there is a need for further study to validate the findings. “There seems to be underreporting, which should be validated by the study.”

A medical journal, Lancet Series estimated Bhutan’s stillbirth rate at 16 per 1,000 live births in 2015.

The study, the official said, is a part of Bhutan newborn action plan 2016 – 2023 during which the ministry aspires to reduce preventable stillbirth to 12.1 per 1,000 live births by 2023.

The official said that secondary data revealed a significant number of mothers drop out from the ANC. “Mothers were ignorant about early self-referral, which resulted in delayed help-seeking, especially following the decreased fetal movement, amniotic fluid leakage or commencement of labour.”

He said that some mothers visited ANC infrequently while others continued stressful physical activity even during late third trimester possibly due to poor family support and ignorance.

The study recommends maternal tracking and strengthening monthly reporting on live birth and stillbirth through institution of a surveillance system.

The health official said the ministry has initiated a web-based mother and child tracking system in a phased manner since last month. Over 150 healthcare providers have been trained in the country.

The ministry has also initiated the implementation of the newborn birth defects database surveillance system in Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) in Thimphu, and the regional hospitals in Gelephu and Mongar starting this month, which will include stillbirth and newborn in addition to birth defects surveillance.

The study recommended advocating risk of alcohol and smoking and its exposure to unborn, improving quality and coverage of ANC, promoting institutional delivery, strengthening MCH services monitoring and supervision both at central and district level, and rotating midwives posted at BHU grade II to hospitals to avoid loss of skills.

It used data from the annual household survey, MCH records and newborn delivery register in all health centres, and inpatient record of mothers who had stillbirth during her institutional delivery within 2015.

Dechen Tshomo