93556 Knowledge Brief Health, Nutrition and Population Global Practice BHUTAN: MATERNAL AND REPRODUCTIVE HEALTH AT A GLANCE Sameh El-Saharty, Naoko Ohno, Intissar Sarker, Federica Secci, and Somil Nagpal November 2014 Country Context KEY MESSAGES: Bhutan is a small landlocked country in the Himalayas • Bhutan has reduced poverty levels rapidly between China and India. Twenty-eight percent of the and improved human development population of 740,000 is younger than 15. Life expectancy is 67.8 years. Existing for centuries in isolation, Bhutan is outcomes in recent years, achieving slowly opening to outsiders. In 2012 its GDP was $2,399. gender parity in primary and secondary The economy is based on agriculture, forestry, and education. It is also slowly opening to hydropower exports.1, 2 outsiders. Poverty reduction has been rapid from about 23 percent • Bhutan has achieved MDG5 and its MMR in 2007 to 12-13 percent in 2012.3 Extreme poverty, is now 120 deaths per 100,000 live births. measured as less than $1.25 per day in purchasing power parity, is only 1.6 percent. The primary drivers of rapid • Fertility declined to 2.3, while poverty reduction are the increasing commercialization of contraceptive prevalence rate increased to agriculture, the accelerated development of rural infrastructure, including roads, health facilities, and schools, 66 percent. Ninety-seven percent of and spillovers from hydro-related construction projects.1, 2 women sought ANC from a qualified provider and nearly 65 percent of births Bhutan is progressing in improving human development outcomes. In education, net primary and secondary school were attended by qualified providers. enrollment is respectively 90 percent and 56 percent, with a • CPR is higher among the poorest quintile higher proportion of girls enrolled. The country is close to achieving MDG 4 on child survival. The U5MR and IMR have than the richest. Large disparities in fallen from 130 and 90 per 1,000 live births in 1990 to 44 and access to skilled birth attendant remain by 35 in 2012. Immunization coverage measured by DPT and geography and wealth quintile. measles is above 90 percent. Chronic malnutrition among children remains high: one in three children is stunted.1, 2 • Poor nutrition is a serious issue for pregnant mothers, since 55 percent of Gender equality and women’s empowerment are women are anemic. important determinants of reproductive health. Gender parity in primary and secondary schools has been achieved, • Bhutan would need to focus on increasing while tertiary education requires improvement. Female labor participation is about 90 percent. Bhutan ranks 92 of 148 the focus on quality along the continuum countries in the Gender Inequality Index.4 of care; improving access and equity; and ensuring sustainability of health financing. Page 1 HNPGP Knowledge Brief  currently married women. Injectables (28.9 percent), male sterilization (12.6 percent), the pill (7.5 percent) and female sterilization (7.1 percent) are the most commonly used form of modern methods. Traditional methods are used by only 0.2 percent of currently married women. 6 There is an unmet need of 11.7 percent. MDG Target 5a: Reduce the MMR by three-quarters, between 1990 and 2015 Bhutan has made excellent progress over the past two decades on maternal health resulting in its achievement of MDG 5. The MMR declined from 900 deaths per 100,000 live births in 1990 to 120 in 2013 (figure 1), reflecting an average annual decline of 8.4 5 percent. Early childbearing affects maternal health outcomes: 6.7 percent of women were married before age 15 and 30.8 percent before 18. The adolescent fertility rate is 40.9 births per 1,000 women age 15–19. The share of women age 15-19 that have begun childbearing is 16.7 percent; 1.6 percent of women had a live birth before 15 6 and 15.2 percent before 18. Pregnancy Outcomes Complete and timely antenatal care (ANC) is a necessary component for positive pregnancy outcomes. As of 2010, 97.3 percent of women had at least one ANC visit from a skilled sought provider; 77.3 percent of women received the recommended four or more ANC visits; 94.7 percent of women had their blood pressure measured (a component in a package of ANC 6 services). Skilled birth attendance (SBA) is critical reducing Fertility maternal deaths. SBA by a medically trained provider Fertility has been declining. Between 1990 and 2012, has increased from 14.9 percent in 1994 to 64.5 percent 1 the total fertility rate (TFR) fell from 5.6 to 2.3 (figure 2). 1 in 2010 (figure 3). Of all births, 63.1 percent are delivered in a health facility (63.0 percent in public sector facilities 6 The contraceptive prevalence rate (CPR) has been and 0.1 percent in private sector facilities). 1 increasing over the past 20 years. The CPR (any method) increased from 18.8 percent in 1994 to 65.6 percent in 2010 (Figure 2). Modern methods are the main choice of contraceptives and are used by 65.4 percent of Page 2 HNPGP Knowledge Brief  Larger disparities are found in SBA across residence: 89.5 percent of urban women are assisted during delivery by a medically qualified professional compared with only 6 Equity in Access to Maternal Health 54.3 percent of rural women (figure 6). Services Inequity in access to maternal health services is a barrier toward MDG 5. Little variation in CPR is observed across residence in Bhutan. The CPR is slightly higher in 6 rural than urban area (figure 4). Considerable variations in SBA also exist among wealth quintiles. Women in the richest quintile were The CPR pattern across wealth quintiles is unusual. three times more likely than women in the poorest quintile The CPR is higher among the poorest wealth quintile (69 to have SBA. Only 34.3 percent of women in the poorest 6 percent) than the richest (62.3 percent) (figure 5). quintile received SBA compared with 95.1 percent in the 6 richest quintile (figure 7). Page 3 HNPGP Knowledge Brief  Key Strategies to Improve Maternal and Reproductive Health Outcomes Increasing the focus on quality along the continuum of care by implementing an evidence- based revision of National Standards and Guidelines; retaining healthcare providers’ skills; and monitoring and supervising effectively to track very mother and child during the critical first 1,000 days of life, known as the “golden days,” and beyond. Improving access and equity by implementing focused interventions to reach the unreached, e.g., the poor, adolescents, and malnourished, particularly focusing on stunting, and neonates. Ensuring sustainability of health financing by exploring mechanisms to manage the limited fiscal Nutrition space in the health sector, for example by considering Poor nutrition is a serious issue for pregnant mothers alternative measures such as social marketing for in Bhutan: Fifty five percent of Bhutanese women are contraceptives and cost sharing mechanisms, e.g., anemic. The country has undergone a nutrition transition public-private partnerships; strengthening collaboration with a shift from traditional diets that included fruits and and coordination at all stakeholder levels, including vegetables to diets that are processed involving more development partners, the Ministry of Health, the sugar, salt and fats. Migration to cities has also led to Ministries of Education and Agriculture, for example, more sedentary lifestyles. Underlying factors that and with nongovernmental organizations and civil contribute to undernutrition are diarrheal diseases and society organizations; and enhancing human resource parasitic infections as well as food insecurities in remote capacity at all levels to do more with less, with a special areas. Remoteness of villages also affects crop focus on public health, research, and epidemiology. production. Lack of knowledge also contributes to 7 undernutrition. References: 1 World Bank. World Development Indicators 2014: Accessed 19 May 2014 2 Bhutan:Country Program Snapshot. March 2014, the World Bank 3 National Statistics Bureau. 2012. Bhutan Poverty Analysis 4 UNDP. 2013 Human Development Report Gender Inequality Index 5 WHO, UNICEF, UNFPA and The World Bank. 2014. Trends in Maternal Mortality: 1990 to 2013: World Health Organization 6 Bhutan Multiple Indicator Survey, May 2011, National Statistics Bureau, Thimphu, Bhutan 7 World Bank. 2014. Bhutan - Development update. The World Bank Group South Asia region poverty reduction and economic management. Washington, DC ; World Bank Group. http://documents.worldbank.org/curated/en/2014/04/19455214/bhutan- development-update For more information on this topic, go to: www.worldbank.org/health. Page 4