WHO Bhutan

Health Information

Reproductive Health

Milestones in Reproductive Health in Bhutan

1971 Introduction of family planning in the health care delivery system via resolution adopted in the 34th National Assembly.

1974 Introduction of Family Planning Services albeit with a limited coverage in geographic area and with a narrow range of contraceptive methods.

1979 Adoption of Primary Health Care approach and integration of family planning in general health care system.

1981 Establishment of National Institute of Family Health (NIFH) and family planning expanded throughout the country as an integrated PHC service. Introduction of improved methods of vasectomy for males and tubal ligation for females (mid-line incision vasectomy and minilaparotomy method for tubal ligation).

1987 Field study conducted for the introduction of DMPA in two Dzongkhags.

1988 Introduction of DMPA throughout the country as an additional choice for contraception.

1990 Introduction of non-scalpel method of vasectomy throughout the country.

1993 Expansion of IUD insertion services to BHUs following training of Health Workers.

1994 Nation-wide health survey indicates Bhutan's population growth rate at 3.1%.

Bhutan attends International Conference on Population Development (ICPD) held in Cairo, shifts emphasis in family planning from the contraceptive to the broader reproductive health approach, and introduces the following health initiatives:

     Safe Motherhood

     Prevention and Management of complication of abortion

     Child Survival including care of the new born

     Management and prevention of RTI, STDs and HIV

     Prevention and management of Infertility and Re- canalization

     Adolescent Reproductive health.

     Cancer of reproductive tract and Breast

1995 Royal decree on population planning is issued, followed by intensification and strengthening of the Family Planning and Reproductive Health Programme.

1996 The use of low dose oral contraceptives begins (Norgestrol 0.15mg and Ethynyl oestratiol 0.03 mg).

His Holiness Je Khenpo endorses the book "Buddhist Perspective on Family Planning".

1997 Based on the royal decree, national campaign on population planning begins.

1998 High level advocacy campaign is launched by the Hon'ble Minister for Health and Education in the Armed Forces and in previously uncovered areas.

1999 Construction of 9 BHUs and boys and girls hostel at RIHS is initiated to increase the infrastructural capacity to deliver services in the distant corners of the country and to increase the intake of trainees to meet the human resource requirements.

Her Majesty the Queen Ashi Sangay Choden Wangchuck accepts the UNFPA Goodwill Ambassadorship and begins high level advocacy in the Armed Forces and schools on population issues and reproductive heath.

Introduction of cervical and breast cancer screening.

Development of standards for midwifery and safe motherhood is completed.

1999 Comprehensive and Basic EmOC centres are established in the country.

In-service training conducted and implementation of midwifery standard practices begins.

In-service training of Health Workers on reproductive health issues is conducted.

Figure 1: Knowledge and practice of family planning by age group (%)

Contraceptives are widely available with the different methods offered including oral pills, Cu-T, condoms and Depo-Provera injections. A graphical break up of the different methods in use can be seen in Figure 2. The decline in the birth rate can clearly be credited to the increased contraceptive use.

Figure 2: Contraception methods in use

Teenage pregnancy and its consequences

A preliminary study was conducted in June 2000 by the Youth Guidance and Counselling Division to gain perspective on youth views and attitudes towards teenage sex, pregnancy and early marriage . While the sample is very small and the findings of the study do not fully represent the views of youth across the nation, it nonetheless presented some information.

The study involved a total of 185 students in the capital Thimphu. Of the respondents 59.5% were female and 40.5% male, ranging between the ages of 14 and 23. Of this number, 72% were adolescents (14-19 years of age). It showed that in general Bhutanese youth hold a more conservative attitude on adolescent sexual activity. However, like young people all over the world, the Bhutanese youth are no strangers to sexual activity, some of them starting in the adolescence period. The study also found that males were more sexually aware than females.

Some of the reasons identified for early marriage were lack of awareness, poverty, family problems, and lack of guidance from parents on matters of romance and love. In rural areas the lack of awareness was pointed out as one of the main reasons for early adolescent pregnancy while unplanned sex, lack of precaution and guidance were other reasons cited.

On the practice of safe sex, 34.2% of respondents said they used condoms and other contraceptives while a significant number, 26.2%, did so only sometimes and 20.2% did not use any form of contraceptive. Many of the respondents were unaware of the legal age for marriage in Bhutan.

Child labour

Bhutan prohibits the employment of minors although the use of child labour is known to exist. Children, mostly boys, can be seen working for a living in and around urban areas. Girls are mostly found in homes working as domestic help and as baby sitters. The commercial exploitation of child labour including child prostitution is not known in Bhutan .

Violence against women and children

Domestic violence is common in Bhutan but the magnitude cannot be assessed as there are no studies or data available. A summary of crimes committed against women is provided below in Table 1.

Table 1: Crime against women

Age at marriage by sex

Age at marriage by sex

In 1994 the expected age at first marriage for 55% of women was less than 20 years. While the age at first marriage was not covered in the 2000 survey, it would appear that on the basis of age specific marital status the average age at first marriage is increasing. The legal age for marriage is 18 years.

Table 2: Age specific marital status in percentage

Maternal mortality

In Bhutan the number of deliveries attended by health personnel increased from 15% in 1994 to 23% in 2000. This progress, together with other initiatives such as the implementation of the Safe Motherhood Initiative and the training of health workers in midwifery standards, has led to the reduction of the maternal mortality rate from 7.7/1000 live births in 1984 to 2.5/1000 live births in 2000, a span of less than two decades. Even so, and while such improvements are indeed commendable, it is sobering to note that Bhutan's MMR is still among the highest in the region.

To assess some of the possible causes of maternal death in the country a needs assessment survey in 1999 identified 10 maternal deaths associated with data available on reported obstetric complications in 31 health facilities. The most common obstetric complications and associated maternal death were as given in Table 3.

Table 3: Obstetric complications and maternal death

Table 4: Complications during pregnancy, delivery and pueperium

Anaemia was the most common cause of complication during pregnancy in 1995 and 1996 and increased to an alarmingly high 88.2% in 2001. Iron deficiency anaemia has adverse health consequences for all age groups but is especially harmful for pregnant women. Maternal anaemia aggravates the effects of haemorrhage and sepsis during child birth and is a major contributing cause of maternal mortality. Maternal anaemia also increases the incidence of low birth weight, anaemia and protein-energy malnutrition in infants.

Nutritional anaemia and malaria in pregnancy

A UNICEF study by Dr. Sood, in 1985 found 59% of pregnant women were anaemic based on haemoglobin examination (less than 11g/dl). In the same study, anaemia was higher (78%) in the southern zone and lower (50%) in Thimphu. The higher anaemic rated in the south is probably related to the high incidence of malaria, but dietary habits could also be a factor. The same study also suggests that the most dominating factor in the causation of anaemia is iron deficiency.

Reported HIV cases in Bhutan, 1993-2003 (click here)

Reported cases of STDs

Figure 3: Cervical biopsy results for 1999 (405 samples)

In elderly women

The percentage of the population above 60 is around 7.2% . There are no special institutional homes for the elderly and they usually live with their children. Relatives and other family members care for those who do not have children. While there are no special services aimed at the elderly and there are no geriatric wards, there is an increasing awareness that attention must be focussed on the care of the elderly. World wide, osteoporosis, a disease of calcium depletion normally occurring after menopause, affects a large section of women over the age of 60. A few baseline studies to assess the health problems of the elderly population especially women suffering from arthritis and osteoporosis are needed. At present there are no data or any studies on the health conditions of the elderly population.

Table 5: Country Status v. ICPD Goals

Objectives for reproductive health in 9FYP

The Reproductive Health Program has set a range of specific goals to be achieved by the end of the 9th Five Year Plan in 2007. These objectives include the following:

     To reduce maternal mortality ratio from 2.55 in the year 2000 to 1.63/1000 live births by the end of 2007

     To increase family planning knowledge from 94% to 100% among women of child bearing age

     To reduce anaemia in pregnant women from 60% to 30%.

     To increase contraceptive prevalence rate from 30.7 to 60 %.

     To reduce infant mortality from 50/1000 Live birth to 30/1000 live births.

     To reduce neonatal mortality.

     To reduce growth rate from 2.6 to 2% 0r less.

     Adequate (4 visits) antenatal visits from 51% to 100%.

     Increase trained birth attendance from 24% to 50%.

     Increase postnatal clinic attendance from 48% to 100%.

     Reduce total fertility rate from 4.7 to 3 or less.

     Cervical cancer screening facilities extended to 50% of target population (currently at 40%).

     To have one basic EmOC facility for every 60,000 population.

     To have one Comprehensive EmOC facility for every 150,000 population.

     To substantially increase the proportion of birth in basic and comprehensive EmOC facilities.

     To substantially increase the number of women with obstetric complication treated in an EmOC facility (currently at 37%).