The situation of maternal health in the country has improved over the years.
The maternal mortality rate (MMR) has decreased to 89 in 2017 from 380 per 100,000 live births in 1994. This is according to a study on the situation of maternal health in Bhutan, published in the recent Bhutan Health Journal.
The study states that the overall cumulative efforts of the reproductive health programme in improving maternal health have gradually resulted in the reduction of the MMR.
Maternal mortality or death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.
Bhutan was one of the nine countries to have achieved the millennium development goal five in 2015 to reduce global maternal mortality by three-quarters between 1990 and 2015. “We still have a lot of work to reduce the preventable causes of maternal health,” the study states.
Findings from annual maternal death investigation review reports show a gradual decline in the number of mothers dying every year. “This is due to continued good policy and active intervention by the reproductive health programme,” it states.
Like in other regions, the number one cause of maternal death in Bhutan is primary postpartum haemorrhage at 43 percent, followed by other medical conditions at 24 percent. “Due to good antenatal care visits, pre-eclampsia and obstructed labour are far down the list.”
According to the study, the analysis of the cause of maternal deaths in Bhutan is based on the three-delay model. They are delay at home, which means patient and family members are not aware to seek care and delay in seeking care.
Delaying to reach a hospital due to lack of transportation, roadblock and long distance is the second delay. Delay at the hospital is the third that causes maternal mortality. This is due to shortage of staff, staff not in the station, medicine storage, equipment not working and sub-optimal late treatment.
According to the study, there is decline in delay one and two due to improvements in non-health sectors such as increasing literacy rate and improved communications system.
“Increasing female literacy rate from 33 percent in 2003 to 59 percent in 2017 has a huge invisible contribution towards the improvement of maternal health in Bhutan,” it states.
However, it states that the main challenge is now with third delay that is not receiving the appropriate treatment in time at the health facility due to human resource shortages and logistic deficiencies.
The study states that there is a new trend in Bhutan, which is the fourth delay that is deliberately not seeking care for social reasons.
“Some reasons of the fourth delay are pregnancy occurring out of wedlock and underage pregnancy where due to fear of being known by others, they deliberately don’t come for ANC and to deliver in health facilities,” it states.
Findings from an unpublished report of a community assessment of maternal health needs in 2005 revealed that many mothers had given birth at home because of reasons like lack of helpers to look after the children and cattle, lack of confidence in hospital and transport service and money.
With gradual improvements in creating patient-friendly policy and health facilities, the number of women delivering at home has also reduced from 86.1 percent in 1994 to three percent last year.
Accordingly, there has been a rising trend for delivery at health facilities. Improved road network and transport system also attributed to the increasing trend in institutional delivery.
In 2017, about 93.6 percent of the total deliveries took place at the health facilities, 83.2 percent more than in 1994 (10.40 percent).
Antenatal visits has increased from 18.9 percent with at least one visit in 2000 to 90.9 percent with more than four visits last year. Minimum recommended visit by the reproductive health programme in Bhutan is eight antenatal visits in each pregnancy since 2009.
According to the study, shortage of a gynaecologist to run emergency obstetric care centres is the main challenge. As the reproductive health programme is mostly funded by donor or partners, when priority for donors or partners change, the funding support also changes and this remains the main issue related to sustainability.
Meanwhile, it states that inadequate female health staff at the BHUs is an ongoing problem. “Human behavioural change is taking a long time for women to seek early health care.”
Since tracking every pregnant mother is important, it states that the reproductive health programme has introduced an online web-based mother and child health tracking system, which has been rolled out to more than 50 health facilities. It is planned to go nation wide by 2020.
Among others, improving the quality of service at health facilities improves the maternal health in the country. This includes training of trainers for the national standard guideline on primary postpartum haemorrhage (PPH) management.