Determinants of Neonatal Mortality in Bhutan: A Case-Control Study.

More than half of Bhutan's under-five mortality is attributed to neonatal deaths. Despite this, there is a lack of local evidence on determinants of neonatal mortality. It is critical to generate new evidence to accelerate interventions to achieve sufficient reduction of neonatal mortality rate in line to sustainable development goal target 3.2. Thus, this study was aimed at exploring determinants of neonatal mortality in Bhutan. A case-control study was performed with reported neonatal deaths from hospitals and primary health centers between 2018 and 2019. A total of 181 neonatal deaths were included as cases along with three corresponding controls. Epidata and STATA were used for data management and analysis, respectively. A multivariable model was fitted to identify determinants of neonatal mortality. History of obstetric complications (odds ratio [OR] = 3.53; 95% confidence interval [CI] = 1.48-8.42), intrapartum complications (OR = 3.86; 95% CI = 1.71-8.74) gestational age (OR = 8.07; 95% CI = 2.89-22.52), and Apgar 1 minute (OR = 4.40; 95% CI =1.83-10.59) were associated with neonatal death. Therefore, quality of care during pregnancy and childbirth besides promoting supportive family environment is essential to reduce neonatal mortality.

Barriers to Institutional Delivery Services in Districts With the Lowest Institutional Delivery Coverage in Bhutan.

Bhutan aims to achieve 100% institutional delivery coverage. While evidence indicates improved institutional delivery coverage over the years, coverage in some of the districts is only 49%. This study was aimed at exploring barriers to institutional delivery in three low-coverage districts. In-depth qualitative interviews and six focus group discussions were conducted in December 2015. The analysis was done as per the Braun and Clarke's 6-phase guide to doing thematic analysis. This study sheds light on 15 barriers for institutional deliveries, which include hesitancy to seek health care when the pregnancy is out of wedlock, the restriction of alcohol consumption at health centers, fear of hypothermia in cold places, pastoralism, health care providers shortage, lack of maternity waiting home and food, distance, difficult terrain, lack of transportation services, and financial constraints. Some of these barriers could be unique to Bhutan. The coverage could be improved considerably if the recommendations in this article are implemented.

Factors associated with delivery at home in Bhutan: findings from the National Health Survey 2012.

Background: Despite Bhutan's remarkable progress in the area of maternal and child health during the era of the Millennium Development Goals, a large proportion of pregnant women are still delivering at home with no skilled attendant. Limited empirical studies have been carried out to understand the factors associated with delivery at home in Bhutan. Methods: This cross-sectional analytical study used secondary data collected in the nationally representative National Health Survey 2012. The survey included a total of 2213 women aged 15-49 years who had a live birth in the 2 years preceding the survey and were selected using multistage stratified cluster sampling. Weighted analysis was done to evaluate determinants for the place of delivery. Unadjusted and adjusted prevalence ratios with 95% confidence intervals (CIs) were calculated to assess the possible association of factors with home delivery. Results: Out of 2213 women aged 15-49 years who had a live birth in the 2 years preceding the survey, 73.7% had an institutional delivery. Coverage of institutional delivery ranged from 49.4% in Zhemgang district to 96.1% in Paro district. Women in the poorest wealth quintile were 7.35 times more likely to have a birth at home compared to women in the richest quintile (adjusted prevalence ratio [aPR]: 7.35, 95% CI: 2.59-20.9). The older mothers aged 30-49 years were 0.79 times (aPR: 0.79, 95% CI: 0.70-0.88) less likely to have a home delivery than mothers aged 15-19 years. Women who had fewer than four antenatal care visits were 1.50 times (aPR: 1.50, 95% CI: 1.35-1.66) more likely to give birth at home compared to those who had four or more visits. The mothers giving birth for a third or more time were 1.88 times (aPR: 1.88, 95% CI: 1.60-2.22) more likely to give birth at home compared to those giving birth for the first time. Women living in rural areas were 2.87 times (aPR: 2.87, 95% CI: 1.42-5.77) more likely to deliver at home compared to those living in urban areas and women living in the eastern region of the country were 1.35 times (aPR: 1.35, 95% CI: 1.17-1.55) more likely to have a home delivery compared to those living in the western region. Conclusion: Lower socioeconomic status, rural location, eastern location, non- first birth, and having fewer than four antenatal visits were significant factors associated with home delivery. These findings should inform further research and policy to build on Bhutan's progress in promoting institutional delivery as the key strategy towards improving maternal and child health and achieving the relevant targets of Sustainable Development Goal 3.