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causes of under-five Mortality in Bhutan

causes of under-five Mortality in Bhutan . Dr. Subodh S Gupta Public Health Specialist. Specific objectives. The objective of the consultancy are: To identify the causes of under-five mortality of the country* To identify contributing factors associated with these deaths.

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causes of under-five Mortality in Bhutan

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  1. causes of under-five Mortality in Bhutan Dr. Subodh S Gupta Public Health Specialist

  2. Specific objectives The objective of the consultancy are: • To identify the causes of under-five mortality of the country* • To identify contributing factors associated with these deaths * As per the TOR, it had been decided that the assessment will be done based on data for 5 years from 2006-10. Interaction with the Medical Superintendants of the hospitals revealed that the case records of the patients admitted are well kept for 2009 onwards in most of the hospitals. Therefore, in consultation with Ministry of Health, Bhutan and UNICEF, Bhutan, it was decided to restrict the analysis for the period 2009-11.

  3. Sources of information available • Neonatal death investigation report and review reports: for deaths happening both in the health facilities and home settings • Hospital records for under-five deaths happening in the hospitals

  4. Methodology (contd.) • Desk review of available neonatal death investigation reports and other relevant documents • Visits to health care facilities • Analysis of records • Observation of health facilities • Meeting with important stakeholders At most of the facilities, case records before 2009 were not available. Therefore, cause of death analysis was done for 2009-11.

  5. Analysis of cause of death 0-27 days deaths • Sepsis or Meningitis • Pneumonia • Diarrhea • Preterm birth complications • Intrapartum-related complications • Congenital abnormalities • Tetanus • Other disorders 1-59 months deaths • Pneumonia • Diarrhea • Meningitis • Measles • Malaria • AIDS • Injury • Others Based on Classification followed by Child Health Epidemiology Reference Group (CHERG) of WHO and UNICEF

  6. Cause of death categories and ICD-10 codes (based on CHERG classification)

  7. Cause of death categories and ICD-10 codes (based on CHERG classification)

  8. Facilities visited Facilities visited

  9. Facilities visited

  10. Qualitative information • Meeting with Health care providers at all health facilities visited: a) Regional Hospitals; b) District Hospitals; c) Basic Health Units • Meeting with District Health Officers • Meeting with Tshogpa and VHW • Meeting with Community members • Observation of Community initiative at Chaskhar

  11. Assumptions & Limitations • Analysis based on deaths happening in hospitals • Two-third under-reporting of newborn and child deaths • Most of deaths not reported would occur at home • Variable quality of records available at different levels of service delivery The result presented here are preliminary finding. The work of data collection is not complete yet. Moreover, some of the figures shown here may change after triangulation of data.

  12. Desk Review

  13. Trend of U-5 MR in Bhutan 295 56.1 Source: UN Inter-agency Group for Child Mortality Estimation

  14. Trend of IMR in Bhutan 200 43.7 Source: UN Inter-agency Group for Child Mortality Estimation

  15. Inequity: U-5 MR

  16. Perinatal/Neonatal Death Review

  17. Under-five out-patient consultations (2010) Out of a total of 1,82,031 under-5 consultations in year 2010, approx half were for Acute Respiratory Infections and approx three-fourths were for four categories of illnesses.

  18. Under-five Hospital Admissions (2010) Out of a total of 9,116 under-five hospital admissions in year 2010, approx half were for Acute Respiratory Infections and three-fourths were for four categories of illnesses.

  19. Deliveries conducted in 2010 Out of total 13,700 deliveries expected in year 2010, more than two-thirds were either conducted in institutions or were attended by health professionals (BHW/ HA). In the same year 13,258 doses of BCGs were given to the newborn children.

  20. Summary indicators (MICS 2010)

  21. Beyond the numbers reported Estimates for year 2010 • Total population: 695,822 • Expected births: 13,700 (CBR: 19.7) • Expected newborn deaths: 350 (NMR: 26) • Expected infant deaths: 600 (IMR: 43.7) • Expected U-5 deaths: 770 (U-5 MR: 56.1) • Newborn death reporting: 114/350 (approx: 33%) Value for Population & CBR is based on Census 2010 Values for child mortality rates are based on the UN Inter-agency group on child mortality estimation (Ref: Child Mortality Report 2011)

  22. Analysis of case records

  23. Under-five deaths recorded

  24. Causes of Newborn Deaths (0-27 days): Weighted proportion

  25. Comparison with SE Asia causes of neonatal deaths (0-27 d) Current Analysis SE Asia distribution

  26. Distribution of neonatal deaths (0-27 days)

  27. Causes of Child Deaths (1-59 months): Weighted proportion

  28. Comparison with SE Asia distribution of causes of death Current Analysis SE Asia distribution

  29. Duration between hospital admission & deaths (for children 11-59 months)

  30. Case Study 1 Yeshi, 34 yr/F, is a resident of and interior village in District Tashiyangtse. When she became pregnant the fourth time, her husband decided to get the delivery done at the District Hospital. She delivered a baby boy weighing 3.3 Kg at full term. Doctor informed her that the baby is normal. She was discharged the third day from hospital. On the first night after she returned home, she found her baby dead. Cause ???

  31. Case Study 2 Choden, 34 yr/ F, was pregnant the fourth time. She did not visit a doctor during early part of her pregnancy. During 7th month of pregnancy, she felt pain abdomen and visited the district hospital. She was sent for Ultrasound to assess the gestation. When she returned from the ultrasound room, the Chief Nurse found that the baby is already half out. Immediately, she was taken to the labour room. A baby boy weighing 1.5 Kg was born. The baby was cyanosed at birth and the doctor had difficulty resuscitating the baby. The staff at district hospital decided to refer her immediately. A nurse escorted her to the regional hospital. The baby was kept in newborn ward for 3 weeks. The Chief Nurse at the District Hospital was excited to see the child at 4 months when he was brought for immunization. He weighs 5 Kg and is full healthy.

  32. More stories • Death during transport (Home to BHU, BHU to District Hospitals, District Hospitals to Regional Hospitals) • Death of babies at home when they waited for next day for taking the child to hospital (Lack of knowledge on urgency) • Sick children being taken to home for performing Puja • Babies being abandoned and child abuse

  33. Visits to health care facilities Meeting with stakeholders

  34. What Bhutan is doing well? • Commitment at the highest level\ Vision for the future • Universal health coverage • Health infrastructure and equipments • Primary Health Care: Utilization of health assistants and Assistant Clinical Officers for provision of curative health care • An excellent system of referral and referral transport • Telemedicine through use of mobile • Toll-free number 112 for health information • High coverage with essential services to mother and children

  35. What Bhutan is doing well? • Operationalization of IMNCI/ C-IMNCI/ H-IMNCI • Use of partograph in each delivery • Use of ICD Code at each level for reporting of morbidity and mortality • Maternal & Neonatal Death Review

  36. Health System in Bhutan

  37. Social Factors Distal Proximal

  38. Harmful traditional practices • Butter being given as pre-lacteal feed and continued together with breastmilk • Early initiation of complementary feeding • Giving bath to newborn babies several times (2-3 times usually) a day even in winter months • Modern medicine is delayed as the community has over-reliance on traditional healers

  39. Home & Community level services • Out-reach Clinics • Village Health Workers Issues identified • Less activities of community mobilization • Health education mostly restricted to outreach sessions using individual approach • Deaths among children – not being reported

  40. Catchment area of a VHW Area for VHW 2 Area for VHW 1 - The farthest village which the VHW need to cover is at a distance of 3 hours walk from the village he is located. - Several villages are not covered by VHWs. They are considered to be directly under the BHU catchment area

  41. Issues: health facilities Basic Health Units • Interaction with the community mostly restricted to Outreach Clinics • Manpower not as per norm at several BHU District Hospitals • Manpower not as per norm, shortage of doctors/ specialists • No separate ward for neonates/ children • Hygiene practices

  42. Issues: health facilities Regional Referral Hospitals • Shortage of health manpower • Training of staff in intensive care • No separate ward for Newborn and children • Adequate equipments, but problems with maintenance • Microbiology

  43. Issues: health facilities National Referral Hospitals • Shortage of health manpower • Training of staff in intensive care • Requirement of separate Pediatric Intensive Care Unit • Adequate equipments, but problems with maintenance • Measures required to reduce burden on specialist services

  44. Interpretation & Recommendations

  45. Three Delays Model Source: Operational Guidelines on Maternal and Newborn Health, NRHM, MoH & FW In Bhutan, the delays are mostly at the first two levels

  46. Continuum of care Bhutan has created an excellent network of health facilities, family and community care may be the weakest link in the system.

  47. What Bhutan further needs to do? • Stronger presence at community level • Expanding role of VHW • Behaviour change communication • New interventions • Availability of antibiotics with VHW • Post-natal visits (Ref: Joint statement by WHO/UNICEF) • Vaccines against organisms causing pneumonia • Improved management of premature babies at referral level • Initiate Under-five Death Reviews on line of Maternal and Child Death Reviews • Strengthening of child health services at every level • Strengthen MIS • Strengthen Research capacity

  48. Recommendations: Home and Community Level • Strong community mobilization • For changing community norms • Reaching the unreached • Orientation/ engagement of local religious leaders • Universalization of VHW and expansion of their role

  49. Lessons from local initiatives Chaskhar BHU; Chewog; Brabang; MNH Tshogpa (Domo) and her family members with HA, SangayChoden

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