Rates and indications of caesarean section deliveries in Bhutan 2015–2019: a national review

Abstract

Background Bhutan 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. Methods This 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. Results For 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%). Conclusion Bhutan’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.

Health inequities in Bhutan's free healthcare system: a health policy dialogue summary

“…It must also be noted that bypassing the referral system may be counterproductive in terms of patient outcomes. For example, all institutional deliveries in Bhutan are attended by skilled professionals—health assistants, midwives and doctors at the primary and second‐tier hospitals, and by obstetricians at the seven obstetric centres [18]. Many women with no high‐risk pregnancy bypass the referral channel and present to these obstetric centres for delivery.…”

“…In the absence of national standards and guidelines on making decisions on caesarean deliveries, these women end up with more likelihood of delivering babies by caesarean section at centres where an obstetrician is available. Bhutan has an increasing rate of caesarean deliveries which may be counterproductive towards the 2030 Sustainable Development Goal agenda [18].…”

Post-cesarean severe sepsis and uterine wound disruption presenting as abdominal wound abscess and peritonitis: A case report

“…In Bhutan, the rate of cesarean section (CS) is around 18.7%. 3 The most common indications for CS were previous CS, fetal distress, prolonged labor, and failed induction. 3 Complications of cesarean delivery can be immediate and late with commonest complication being postpartum hemorrhage, sepsis, and wound infection.…”

“… 3 The most common indications for CS were previous CS, fetal distress, prolonged labor, and failed induction. 3 Complications of cesarean delivery can be immediate and late with commonest complication being postpartum hemorrhage, sepsis, and wound infection. 1 , 4 Uterine scar dehiscence following lower segment cesarean section (LSCS) is rare with incidence of 0.6%.…”

FIGO good practice recommendations for cesarean delivery on maternal request: Challenges for medical staff and families

“…[1][2][3][4][5][6] Cesarean delivery rates are increasing worldwide. [7][8][9][10][11] Published data from 154 countries covering 94.5% of the world's live births found that 21.1% of women gave birth by cesarean globally. 12 Cesarean delivery rates varied among countries, with average rates ranging from 5% in Sub-Saharan Africa to 42.8% in Latin America and the Caribbean.Moreover, projections for 2030 are alarming.…”