Increased Caesarean delivery rates among Bhutanese refugee community in Eastern Nepal since 2009: A causal analysis and mitigation strategies

Lakruwan Dassanayake, Hervé Isambert, Nadine Cornier, United Nations High Commissioner for Refugees

Background Information

1.

The enforcement of restrictive citizenship laws in Bhutan 2.

Over 100,000 Bhutanese refugees with Nepalese ethnic origin fled to Nepal in early 1990s.

3.

The refugees from Bhutan settled in seven refugee camps in south-eastern Nepal 4.

Failing the negotiation between Nepal and Bhutan for repatriation.

5.

Third country resettlement commenced in the year 2007.

6.

By the year 2012 some 65,325 refugees have been resettled in third countries 7.

Current population 38,000.

Population Trend of Bhutanese Refugee Camps

74 299 85 078 86 117 89 740 91 801 93 674 95 651 97 571 98 897 100 780 102 263 103 650 104 915 106 248 107 803 107 810 102 087 85 908 72 242 54 995 40 971 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Table 3: Population trend of the Bhutanese refugee camps 1992-2012

Introduction:

1. Caesarean section (CS) rates have increased both in developed and developing countries.

2. In Nepal it varies between 10-30 %.

3. In the Bhutanese refugee camps of Eastern Nepal, the CS rate was around 15 % until 2009. In 2010, it increased to 23% and then to 31%(Table:1).

Table 1: Caesarean delivery rates of Bhutanese refugee community from 2008 to 2012

Methodology:

1. Formal and informal key informant interviews. 2. MCH data review.

3. Camp field assessment of MCH units (both management and equipment).

Findings:

1. Four maternal deaths occurred in 2009

( Table 2).

2. Only one of them (pre-eclampsia) could have been saved by a faster CS 3. CS and referral of obstetrics cases from camp MCH units to Referral Hospital (RH) increased starting the following year with significant reduction of camp PHCC deliveries

( Table 2).

4. Despite registries showing obvious indications justifying transfers, some health care workers attribute the observed changes in practices to this traumatic experience.

4 Maternal Deaths Table 2: Percentage of deliveries carried out in camp PHCCs from 2008 to 2012

Findings ctd;

1. The rapid turnover of MCH staff with the departure of experienced refugee midwives for third country resettlement

(Table 3).

2. Replacement of resettled staff was at times delayed 3. Newly recruited staff has found it difficult adapting to limitations of the camp working environment.

4. The CS rate among refugees referred to the primary level referral hospital has increased post-2009: from 29% to 32.6% and to 42% by

2011 (Table 4).

5. Those observations coincide with the nationwide “safe delivery incentive programme”.

Safe Motherhood Programme Table 4: Caesarean section rates among the cases referred to higher center obstetrics care 2008-2012

Challenges:

1.

Confronting demanding clients in an economically enabling environment supported by safe delivery incentive projects 2. While emphasis has been put on developing access to hospital delivery, the increasing trend of CS rates may result in long term adverse consequences, especially on young women willing to have more babies.

Key approaches:

1. From camp all the identified factors have been carefully addressed.

a. Pro-active identification of staff who leave and timely replacement.

b. Continuous staff capacity building.

c. Upgrade of MCH facilities.

d. Ad-hoc CS case-file review in RH. 2. The client factor effect on choosing CS remains to be further investigated and addressed in culturally sensitive ways.

a. Effect of client factor survey is going on.

3. Advocacy with the referral hospital for safe rational use of CS as a mode of delivery is going on.

Staff Capacity Building

Upgrade MCH facilities

Ad-hoc CS case-file review in RH

References:

1.

Nira S. Shrestha, Sumita Pradhan. On demand caesarean section what’s women’s attitude? N. J. Obstet. Gynaecol 2007 Nov-Dec; 2 (2): 12 – 15 2.

Monitoring Emergency Obstetric Care: a handbook. World Health Organization 2009 ISBN978 9241547734 http://whqlibdoc.who.int/publications/2009/9789241547734_eng.pdf

3.

Method of delivery and pregnancy outcomes in Asia :the WHO global survey on maternal and perinatal health 2007-08.

4.

Annual summary statistics 2008,2009,2010,2011,2012.Health Information System ,UNHCR, Nepal 5.

Caesarean section: its rates and indications at a tertiary referral center in Eastern Nepal. S Chhetri, U Singh. Health Renaissance. Vol 9, No 3 (2011)