|Year : 2018 | Volume
| Issue : 1 | Page : 36-42
Factors associated with delivery at home in Bhutan: findings from the National Health Survey 2012
Mongal Singh Gurung1, Dorji Pelzom2, Sonam Wangdi2, Tashi Tshomo3, Pema Lethro3, Tashi Dema1
1 Health Research and Epidemiology Unit, Maternal and Newborn Health Programme, Ministry of Health, Thimphu, Bhutan
2 Health Management Information System, Maternal and Newborn Health Programme, Ministry of Health, Thimphu, Bhutan
3 Reproductive, Maternal and Newborn Health Programme, Ministry of Health, Thimphu, Bhutan
|Date of Web Publication||27-Mar-2018|
Mongal Singh Gurung
Health Research and Epidemiology Unit, Maternal and Newborn Health Programme, Ministry of Health, Thimphu
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.
Keywords: Bhutan, childbirth, home delivery, institutional delivery, place of delivery
|How to cite this article:|
Gurung MS, Pelzom D, Wangdi S, Tshomo T, Lethro P, Dema T. Factors associated with delivery at home in Bhutan: findings from the National Health Survey 2012. WHO South-East Asia J Public Health 2018;7:36-42
|How to cite this URL:|
Gurung MS, Pelzom D, Wangdi S, Tshomo T, Lethro P, Dema T. Factors associated with delivery at home in Bhutan: findings from the National Health Survey 2012. WHO South-East Asia J Public Health [serial online] 2018 [cited 2019 Jul 18];7:36-42. Available from: http://www.who-seajph.org/text.asp?2018/7/1/36/228426
| Background|| |
Ensuring the presence of a skilled attendant at delivery for every birth was a key strategy for the Millennium Development Goals (MDGs) of reducing maternal as well as child mortality. As a result, there was a modest increase, at the global level, in the proportion of births assisted by skilled health personnel – it increased from 59% in 1990 to 71% in 2014. In Bhutan, coverage of institutional delivery in 2000 was 19.8%, while the infant mortality rate and maternal mortality ratio were 60.5 per 1000 live births and 255 per 100 000 live births respectively. Therefore, Bhutan started to promote institutional delivery as the key strategy towards improving maternal and child health. As a result, remarkable progress in the area of maternal and child health has been achieved over recent years. Despite this achievement, more than a quarter of deliveries still take place in homes, exposing mothers and neonates to a greater risk of morbidity and mortality. Furthermore, preventable causes, such as postpartum haemorrhage, continue to be a major cause of maternal death, especially among home deliveries. Over 70% of neonatal deaths occur during the first 3 days of life. All this evidence underscores the need to encourage institutional delivery to ensure proper medical care and attention during the birth of every child and critical periods after delivery. Therefore, the “proportion of births attended by skilled health personnel” is one of the two indicators adopted by the Royal Government of Bhutan for monitoring target 3.1 of the Sustainable Development Goals – “By 2030, reduce the global maternal mortality ratio to less than 70 per 100 000 live births”. Similarly, the “proportion of births attended by skilled health personnel” has a direct impact on target 3.2 – “By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births and under-5 mortality to at least 25 per 1000 live births”.
While institutional delivery or the presence of a skilled birth attendant at delivery is one of the critical interventions for safe motherhood and neonatal care, lack of satisfactory empirical studies in the Bhutanese context leads to difficulty in understanding the determinants of institutional delivery, which is needed to inform appropriate policy on intervention. According to a study from one of the districts of Bhutan, and studies from neighbouring or similar countries, the most common potential explanatory factors for pregnant women using a skilled birth attendant or institutional delivery were the place of residence (urban versus rural),,,,, the distance from a health centre,, socioeconomic status,,,,, the age of the mother,,, the education level of the mother,,,,,, the number of antenatal check-ups,,,,, religion,,, and obstetric history.,,, In this light, this study aimed to explore factors associated with home delivery in Bhutan. In this paper, home delivery is defined as delivery at home without a skilled birth attendant.
| Methods|| |
Bhutan, with an estimated population of 720 679 in 2012, is a small landlocked country nestled in the eastern Himalayas between India and China. Health-care services in the country are provided by the government, through its three-tiered health-care system comprising outreach clinics, sub-posts, and basic health units at the primary tier; hospitals at secondary level; and two regional referral hospitals and one national referral hospital at tertiary level at the apex of the system. All facilities, starting from basic health units, are equipped for institutional delivery. Lower-level health facilities refer cases to higher-level facilities through either ambulance or helicopter services, whenever necessary as per the referral guidelines. Given the paucity of skilled health-care providers in the country, all expectant mothers are encouraged to visit a health facility for delivery. A home visit by health-care providers for skilled birth attendance is discouraged by policy except in emergency situations. As a result, almost all home deliveries in Bhutan take place without a skilled birth attendant. Usually the elder women of the family are the traditional attendants during home deliveries. However, to the knowledge of the authors, there is no published study on practices related to traditional attendance and birth preparedness among women who deliver at home in Bhutan.
Study design, population and sample
This study was a secondary analysis of the most recent data available, the National Health Survey (NHS) 2012 data set. The NHS 2012 covered 13 256 sampled households with urban–rural disaggregation and with representative samples from all 20 districts of Bhutan. The survey instruments consisted of five main questionnaires – the household questionnaire, the individual questionnaire, the women's questionnaire, the immunization questionnaire and the violence against women questionnaire. The women's module collected data related to reproductive and maternal health from children and women aged 10–49 years. The NHS 2012 reported that 2213 women aged 15–49 years had a live birth in the 2 years preceding the survey. All these women were included in this study.
Since the NHS 2012 involved multistage sampling, a weighted analysis of data sets was carried out to calculate proportions and to estimate the unadjusted and adjusted prevalence ratios. The sample weights were calculated and appended to all data sets by the NHS 2012 team. Details about the calculations of sample weights are provided in the NHS 2012 report. The analyses for the present study were performed by using these sample weights already appended to the data sets. The proportions of coverage of institutional delivery were calculated up to district level. The associations between place of delivery and the potential explanatory factors such as the age of the mother, wealth quintile, education, residence (urban/rural), region, distance from a health centre, parity, frequency of antenatal care, marital status, controlling behaviour of a husband, and intimate partner violence were examined. Further, a log-binomial regression was fitted, with home delivery as an outcome variable and the age of mothers, wealth quintile, education level of mothers and their husbands, residence, region, distance to the health facility, parity and having four or more antenatal care visits as the potential explanatory factors. Although it was planned that only those factors that were significant in a bivariate model at P < 0.1 would be included to calculate adjusted prevalence ratios (aPRs), all factors were significant in a bivariate model at P < 0.05. In the log-binomial regression model, all statistical associations were considered to be significant at P < 0.05; STATA/IC 15 (StataCorp. 2017. Stata Statistical Software: Release 15. College Station, TX: StataCorp LLC) was used for analysis.
The distance to health facilities was defined as the time taken to reach the nearest health facility, on foot, through another mode of transport or using a combination of both. The respondents were asked to give the time taken when household members usually go to health facility. The wealth index constructed and appended to data sets by the NHS 2012 team was used for the analyses in this paper. Details about the steps in the construction of the wealth index are provided in the NHS 2012 report.
Administrative clearance for conducting the study was provided by the Ministry of Health and ethical approval was obtained from the Ministry of Health Research Ethics Board of Health. All personal identifiers were removed to ensure confidentiality, and the need for informed consent was waived by the Research Ethics Board of Health, as the study involved only secondary analysis of a data set that had already been collected.
| 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.
Sociodemographic factors contributing to women's choice of place of delivery
About 59.6% of women did not have any formal schooling and 40.4% had formal education (see [Table 1]). Almost three quarters of the women resided in a rural area, and there was almost equal distribution of women in the three regions of the country. About 40.6% of women lived within half an hour's distance from the nearest health facility, while 26.1% lived more than an hour away from the nearest health facility. Of women who had a live birth in the 2 years preceding the survey, 33.7% had their first live birth, 29.6% had their second live birth, and 36.6% had their third or subsequent live birth.
|Table 1: Sociodemographic characteristics and place of delivery of women who had a live birth in the 2 years preceding the survey|
Click here to view
Only 4.5% of women in the richest quintile gave birth at home, while more than half of women in the poorest quintile did so (see [Table 1]). Similarly, women with a formal education level (primary and secondary or higher) were more likely to give birth at a health facility (86.8%) compared to women with no formal education/no education (65.2%). The older mothers aged 30–49 years were less likely (aPR: 0.79, 95% confidence interval [CI]: 0.70–0.88) to have a home delivery as compared to younger mothers aged 15–19 years; 95.4% of women living in urban areas and 66.1% of women living in rural areas gave birth at a health facility. While 86.7% of women living in western Bhutan gave birth at a health facility, only 56.6% gave birth at a health facility in the eastern part of the country. In addition to this, distance to the health facility also influenced where the women gave birth; 87.7% of women living within half an hour gave birth at a health facility, and this proportion decreased as the distance increased. Most women who gave birth for the first time chose a health facility (85.9%), while 75.4% of women with a second birth chose a health facility, and 59.9% of women delivering their third or subsequent child gave birth at a health facility.
Frequency of antenatal and postnatal care
While 79.0% of pregnant women, who had had four or more antenatal care visits had an institutional delivery, only 51.4% of pregnant women who had not had four or more antenatal care visits gave birth at a health facility. On the other hand, 83.0% of women who had had an institutional delivery had received postnatal care; only 46.3% of women who had a home delivery had received postnatal care.
Impressively, 97.9% of women had received at least one antenatal care session from health-care providers during their most recent pregnancy. However, only 74.6% had received postnatal care.
Home delivery rate for 20 districts of Bhutan
Districts in the eastern and central regions of the country had a higher rate of home delivery compared to districts in the western side of the country (see [Figure 1]). The district with the highest rate of home delivery was Zhemgang with 50.6%, and the district with the lowest rate was Paro with 3.9%.
|Figure 1: Weighted percentage of women aged 15–49 years who had a home delivery in the 2 years preceding the survey, 2012a|
Click here to view
Log-binomial regression of determinants of home delivery
As shown in [Table 2], women in the poorest quintile were 7.35 times more likely to have a birth at home compared to women in the richest quintile (aPR: 7.35, 95% CI: 2.59–20.9).
|Table 2: Bivariate and multivariable log-binomial regression of potential factors associated with home delivery|
Click here to view
Another significant difference was between the locations of residence; women in rural areas were 2.87 times (aPR: 2.87, 95% CI: 1.42–5.77) more likely to give birth at home compared to women in urban areas. Similarly, women in the eastern region were 1.35 times (APR: 1.35, 95% CI: 1.17–1.55) more likely to have a home delivery compared to women living in the western region.
The other factors that seem to influence place of delivery are the parity and the number of antenatal care visits, especially four or more visits. The mothers giving birth for a third or sub–sequent time were 1.88 times (aPR: 1.88, 95% CI: 1.60–2.22) more likely to give birth at home compared to mothers giving birth for the first time. Women who had fewer than four antenatal care visits were 1.5 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 antenatal care visits.
| Discussion|| |
About one third of women in Bhutan still deliver at home, without a skilled birth attendant, despite the efforts of the Ministry of Health towards achieving an institutional delivery rate of 100%. In some districts, around half of women were found to be delivering at home. Nonetheless, the rate of institutional delivery in Bhutan is equivalent to the global rate of skilled birth attendance or institutional delivery, which was 78% in 2016. The rate was much higher than that of neighbouring countries. For example, the Bangladesh Demographic and Health Survey 2014 reports 37% institutional delivery and 42% of births with a skilled birth attendant and Nepal had 35% institutional delivery as per the Nepal Demographic and Health Survey data sets of 2011.
The analysis in this study showed that several factors were independently associated with women delivering at home. These were: the age of mothers, lower socioeconomic status, rural location, eastern location, non- first birth, and not having four or more antenatal visits.
The distance to a health facility was not significant in the final model; however, the unadjusted prevalence ratio shows that women living at a longer distance from a health facility are more likely to give birth at home. The insignificance in the final model may be because this variable “distance to health facility” in the NHS 2012 survey did not take into account the road accessibility and the mode of transportation the mothers have to use to get to the health facility.
The findings of the current study are similar to those of a district-level study carried out in Chukha, Bhutan, as well as the findings of other studies carried out elsewhere. For instance, the study from Chukha found that women from rural areas were 1.65 times more likely to deliver at home; the women who were delivering for the third or subsequent time were 2.42 times more likely to deliver at home. Similarly, studies from neighbouring as well as other developing countries show an association between the place of delivery and lower socioeconomic status,,,,, rural location,,,,, non- first birth,,,, and not having four or more antenatal visits.,,,,
The capital city of Bhutan is located in the western region of the country and the districts of the western region are generally more developed than the eastern and central regions. As a result, almost all the development indicators are much better in the western region. For instance, the prevalence of stunting in 2015 was highest (29.1%) in eastern Bhutan, as compared to 16.2% in western and 18.5% in central Bhutan. Therefore, the observation that more women from the eastern region have a home delivery is in line with the trends in other development indicators of the country. Hence, focusing on the eastern region needs to be one of the priorities for improving the coverage of institutional delivery in particular, and improving all other indicators in general.
The coverage of institutional delivery in Bhutan has increased from 19.8% in 2000 to 73.7% in 2012., This achievement in turn has resulted in achievement of the MDG targets 4 and 5, with infant mortality rate and maternal mortality ratio at 30 per 1000 live births and 86 per 100 000 live births respectively, against MDG targets of 30 per 1000 live births and 140 per 100 000 live births respectively.,, Thus, Bhutan has made remarkable progress in the area of maternal and child heath over recent years. With an increase in coverage of institutional delivery, further improvement in the area of maternal and child health is possible.
There are some limitations to this study. Only data on factors assessed in the NHS 2012 survey were available for analysis. Thus, this study was not able to capture and assess other factors, such as language and cultural group, which may be important. Nonetheless, the data are nationally representative and robust data analysis was carried out. Therefore, it is hoped that the findings will be useful for changes of policy and practice, both within and beyond Bhutan.
The study has several implications. First, considering that the overall rate of home delivery of 26.3% is still high for a country that has been aiming for 100% institutional delivery ever since 2005, targeted interventions should be initiated and strengthened. The interventions should be focused on women of low socioeconomic status, the eastern region of the country, rural areas, and those delivering for the third or subsequent time. Second, the public or high-risk groups identified by this study should be educated on institutional delivery through conventional and folk media. Third, efforts should also be made to ensure that every pregnant woman receives at least four antenatal visits. Fourth, given that almost all women attend a health-care centre for at least one antenatal care visit, health-care providers should make extra efforts at the first antenatal contact to convince women of the advisability of institutional delivery, as well as subsequent antenatal care visits. Finally, considering that the coverage of postnatal care was found to be low in Bhutan and the majority of maternal and neonatal deaths occur within 48 hours of delivery, efforts need to be strengthened for coverage of postnatal care.
Source of support: Financial support for this secondary data analysis was provided by the United Nations Population Fund Country Office for Bhutan.
Conflict of interest: None declared.
Authorship: MSG contributed to the conception and design, acquisition, analysis and interpretation of data, and drafting and revision of the manuscript. DP contributed to acquisition, analysis and interpretation of data, and critical revision of the manuscript. SW contributed to the conception and design, interpretation of data, and critical revision of the manuscript. TT contributed to interpretation of data, and critical revision of the manuscript. PL contributed to interpretation of data, and critical revision of the manuscript. TD contributed to interpretation of data, and revision of the manuscript.
| References|| |
Maternal and Neonatal Death Review report 2014. Thimphu: Ministry of Health; 2014.
Wangdi K, Gurung MS, Pelzom D, Dema T, Wangdi S. Preference of place of delivery and its determinants: a cross-sectional study in Chukha District, Bhutan. Bhutan Health J. 2015;1(1):23–9.
Kamal SMM, Hassan CH, Alam GM. Determinants of institutional delivery among women in Bangladesh. Asia Pac J Public Health. 2015;27(2):1372–88. doi:10.1177/1010539513486178.
Tadele N, Lamaro T. Utilization of institutional delivery service and associated factors in Bench Maji zone, Southwest Ethiopia: community based, cross sectional study. BMC Health Serv Res. 2017;17(1):101. doi:10.1186/s12913-017-2057-y.
Yaya S, Bishwajit G, Ekholuenetale M, Seydou I, HlmWang MF, He Z. Factors associated with the utilization of institutional delivery services in Bangladesh. PLoS One. 2017;12(2):e0171573. doi:10.1371/journal.pone.0171573.
Shahabuddin A, De Brouwere V, Adhikari R, Delamou A, Bardaj A, Delvaux T. Determinants of institutional delivery among young married women in Nepal: evidence from the Nepal Demographic and Health Survey, 2011. BMJ Open. 2017;7(4):e012446. doi:10.1136/bmjopen-2016-012446.
Shah R, Rehfuess EA, Maskey MK, Fischer R, Bhandari PB, Delius M. Factors affecting institutional delivery in rural Chitwan district of Nepal: a community-based cross-sectional study. BMC Pregnancy Childbirth. 2015;15:27. doi:10.1186/s12884-015-0454-y.
Exavery A, Kanté AM, Njozi M, Tani K, Doctor HV, Hingora A et al. Access to institutional delivery care and reasons for home delivery in three districts of Tanzania. Int J Equity Health. 2014;13:48. doi:10.1186/1475-9276-13-48.
Kebede A, Hassen K, Nigussie Teklehaymanot A. Factors associated with institutional delivery service utilization in Ethiopia. Int J Womens Health. 2016;8:463–75. doi:10.2147/IJWH.S109498.
Agha S, Carton TW. Determinants of institutional delivery in rural Jhang, Pakistan. Int J Equity Health. 2011;10:31. doi:10.1186/1475-9276-10-31.
Bangladesh Demographic and Health Survey 2014. Dhaka, Bangladesh and Rockville: National Institute of Population Research and Training (NIPORT), Mitra and Associates, and ICF International; 2016 (https://dhsprogram.com/pubs/pdf/FR311/FR311.pdf
, accessed 18 January 2018).
Dorji T, Dzed L, Yangchen P, Pelzom D, Gurung MS, Pem D et al. National Nutrition Survey 2015. Thimphu: Nutrition Programme, Department of Public Health, Ministry of Health; 2015.
[Table 1], [Table 2]