Accepted Article

Article type : Clinical Article

CLINICAL ARTICLE
Indications and factors associated with cesarean section in Bhutan: A hospital-based
study
Thinley Dorji1,*, Karma Wangmo2, Yeshey Dorjey3, Namkha Dorji4, Deep Kiran Chhetri5,
Sangay Tshering6, Passang Wangmo7, Tshokey Tshokey8
1 Kanglung Hospital, Trashigang, Bhutan
2 Regional Livestock Development Center, Khangma, Bhutan
3 Phuntsholing hospital, Phuntsholing, Bhutan
4 Central Regional Referral Hospital, Gelephu, Bhutan
5 Trashigang Hospital, Trashigang, Bhutan
6 Wangchuck National Referral Hospital, Thimphu, Bhutan
7 Faculty of Nursing and Public Heath, Thimphu, Bhutan
8 JDWNRH, Thimphu, Bhutan
*Correspondence
Thinley Dorji,
Email: thinleydorji2005@gmail.com

Keywords
Asia; Bhutan; Cesarean section; CS; Pregnancy
Synopsis
The common indications of cesarean section in Bhutan include previous cesarean section,
fetal distress, prolonged labor and failed induction.

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1002/IJGO.13506
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Accepted Article
ABSTRACT
Objective: To investigate the factors associated with Cesarean section (CS) in Bhutan.
Methods: This was a cross-sectional study, using the retrospective data from the birth
registers maintained in comprehensive EmOC (emergency obstetric care) centers for the
year 2018. The data was entered in excel 2013 and analyzed using STATA 13. Multiple
logistic regression was used to understand the factors associated with CS in Bhutan.
Results: The rate of CS in Bhutan was 18.7%. The indications of CS were previous CS,
fetal distress, prolonged labor and failed induction. The factors associated with CS were
maternal age > 25 years, male child, women with lesser number of living child, multiple
pregnancy and gestation period > 40 weeks. In addition, mothers delivering in Samtse
hospital and Central Regional Referral Hospital had higher odds of CS.
Conclusion: In Bhutan, the CS was commonly performed for mothers with previous CS,
fetal distress and prolonged labor. Increasing maternal age, multiple pregnancy and
postdated pregnancy and those with one or lesser number of live children were more likely
to undergo CS. To reduce the CS rate, Bhutan should focus on decreasing the primary CS
as well as prevent over diagnosis of prolonged labor by focusing on partograph.

1 INTRODUCTION
The Cesarean section (CS) is the most commonly performed surgery in the world. Currently,
the World Health Organization recommends a CS rate of 10-15% to achieve optimal
maternal care [1]. Although, the CS rates have increased in both developed and developing
countries, it varies from 19.5% in developed countries to 2% in developing countries [2].
The surgery is a lifesaving procedure for both the mother and baby if performed at right time
for compelling indications. In developing countries, the common causes of maternal deaths

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 are due to hemorrhage and obstructed labor [3] which can be decreased by as much as
Accepted Article
92% with timely surgical intervention [4]. The countries with CS below 10% had two times
the neonatal mortality and 5 times the maternal mortality due to loss of precious time
compared with countries whose CS rate was above 10% [5]. However, there is no difference
in maternal and neonatal mortality rate once the CS rate crosses the recommended rate [2].
Unintended CS has both long term and short-term complications for mother and the baby
[6–8]. Nevertheless, the judgment of CS should be made on case by case basis so as to
provide CS when medically indicated to provide best outcome and not to achieve the
optimum rate [9, 10].
In Bhutan, the institutional delivery was 94.5% [11] with 12.4% of them undergoing CS in
2012 [2]. The proportion of CS is one of the indicator of the access to maternal and neonatal
health services [1]. In Bhutan, the health system is divided into three tiers, with basic health
units and sub post at primary level, district hospitals at secondary level and regional referral
hospitals at tertiary level. Presently, the three regional referral hospitals of Central Regional
Referral Hospital (CRRH), Eastern Regional Referral Hospital (ERRH) and Jigme Dorji
Wangchuck National Referral Hospital (JDWNRH) along with the district hospitals of
Samtse, Phuntsholing and Trashigang provide comprehensive EmOC (emergency obstetric
care) services. All types of health services are provided free of cost by the Royal
Government of Bhutan. The antenatal care, deliveries and post-natal services are provided
at all levels of health facilities. However, the complicated cases requiring close monitoring
and surgical interventions are referred to the regional and comprehensive EmOC centers
that provide specialized obstetrical services.
Currently, there are no latest data rate of CS, indications and factors associated with it in
Bhutan. The main objective of this study was to determine the rate, indications and the
determinants for CS in Bhutan.

2 METHODOLOGY
Study design and site: This was a cross-sectional study with retrospective data collection
from the birth records maintained in the hospital birth register. The study included three

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 regional hospitals (CRRH, ERRH and JDWNRH) and Samtse General Hospital (Figure 1).
Accepted Article
The study included all the deliveries conducted in above hospitals for period of one year
(January to December 2018). The ERRH caters to complicated obstetric cases in the
Eastern Bhutan, CRRH caters to patients in the Central part of Bhutan. Samtse General
Hospital provides to patients in the South Western region and JDWNRH serves as the apex
hospital catering to patients of Western Bhutan as well as to the regional referral hospitals.
Variables
All the pregnant women admitted in these hospitals and registered in birth record for delivery
were considered for the study. The birth register contains information on mother’s age,
gravida, parity, gestational age and type of delivery along with indications if patient
undergoes CS. The dependent variable was divided into “1” for patients undergoing CS and
“0” for vaginal delivery. The indications for CS was grouped as following; previous CS, fetal
distress (fetal heart rate < 110/min or > 160/ min), prolonged labor (second stage lasting for
> 2 hours in nulliparous women and >1 hour in multiparous women), failed induction
(inability to achieve active phase of labor), mal-presentation/mal position (breech
presentation), cephalo-pelvic disproportion, amniotic fluid disorders (polyhydramnios &
oligohydramnios), hypertensive disorders (PIH, eclampsia & HELLP syndrome), antepartum
hemorrhage (placenta previa & abruptio placenta), multiple gestations, premature rupture of
membrane, maternal conditions (Rh negative, HIV positive, chorioamnionitis & medical
conditions), fetal conditions (congenital anomaly baby & fetal growth restriction) and others
(cord prolapse). Those women who underwent CS but indications of surgery not mentioned
was labelled as missing data.
Inclusion and exclusion criteria
All the deliveries that occurred in the year 2018 in the study hospitals were included for the
study. However, women admitted for miscarriages with period of gestation below viable
period (<24 weeks) were excluded for the study.

Data collection and analysis

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 The data was collected using a questionnaire and entered in Excel sheet 2013. The data
Accepted Article
was cleaned and analyzed using Stata 13 (Stata Corporation, College Station, TX, USA).
The descriptive analysis was presented in percentages and figures. Multiple logistic
regression was used to control for the confounders.

Ethical clearance
The ethical clearance was obtained from Research Ethics Board of Health Ministry of Health
(Ref. No. REBH/Approval/2019/042) and permissions from the respective health centers
were taken for the data collection. The informed consent was deemed not necessary as the
study didn’t involve face to face interview with the patient. To ensure and protect the privacy
of the patients, the personal identifiers like names of the patients were replaced by
alternative unique ID number and not included in data analysis. The extracted database will
be safeguarded to protect the study participant’s identification by keeping in a password
encrypted folder authorized computer only.

3 Results
The socio-demographic characteristics are summarized in Table 1. During the study period,
a total of 6466 women delivered in these four hospitals. The majority of the delivery was
conducted in the JDWNRH [n=4129 (63%)] followed by ERRH [n=973 (15.1%)] and CRRH
[n=940 (14.5%)]. The mean age of the expectant mother was 27.5 ± 5.3 years (Range 15-49
years) with mean age for nulliparous 24.5±4.09 years and mean age of multiparous women
29.6±4.97 years. More than one-third [n=2425 (37.5%)] of mothers were in the age-groups
of 25-29 years. Teenage pregnancy (<20 years) comprised of 4.3% (n=276) of the total
deliveries. The parity of the mothers ranged from zero to 12 (mean: 2.05± 1.22). Of the total
deliveries, 41.5% (n=2684) were nulliparous and 4.5% (n=292) were grand multipara.
Almost one-fifth (n=1259) of the babies born were overweight (>4 kg at birth) and 6%
(n=388) had low birthweight (<2.5 kg). In terms of maturity, 18.5% (n=1197) were born
preterm (<37 weeks of pregnancy) while 13.8% (n=889) were born late-term (>41 weeks).

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 Spontaneous vaginal delivery comprised of 78.5% (n=5076) of total deliveries and
Accepted Article
instrumental delivery (vacuum/forceps) at 2.8% (n=178). The overall rate of CS in this study
was 18.7% (n=1212) (Table 2).
Of the total 1212 CS, the common indication of CS was previous CS [n=255 (23%)], fetal
distress [n=172 (15.5%)], prolonged labor [n=168 (15.1%)], failed induction [n=121 (10.9%)]
and mal presentation/mal position [n=101 (9.1%)] (Figure 2). However, indications of CS
were missing for 101 cases.

Factors associated with CS

Binary logistic regression
The binary logistic regression shows that women delivering in Samtse Hospital (OR-3.00;
95% CI- 2.38-3.78), CRRH (OR-3.14; 95% CI-2.65-3.73) and ERRH (OR-4.03; 95% CI-3.42-
4.74) were more likely to undergo CS. In addition, women in the age group of 35-39 years of
age (OR-2.20; 95% CI-1.52-3.25) had higher chances of CS (Table 3). Women having
singleton pregnancy (OR-0.02; 95% CI-0.01-0.08) and term pregnancy (OR-0.48; 95% CI-
0.41-0.56) were less likely to undergo CS.
Multiple logistic regression
Table 4 describes the multiple logistic regression constructed using the full model fits on
factors associated with the CS. Compared to JDWNRH, the odds of CS was higher in
Samtse Hospital (AOR 3.29; 95% CI 2.59-4.18; p-value <.001) and CRRH (AOR 3.72; 95%
CI 3.10-4.48; p-value <.001). The mothers in the age group 25–29 years (AOR 1.68; 95% CI
1.11-2.57; p-value 0.015), 30–34 years (AOR 2.20; 95% CI 1.41-3.44; p-value .001), 35–39
years (AOR 3.79; 95% CI 2.32-6.19; p-value <0.001) and ≥40 years (AOR 3.07; 95% CI
1.52-6.21;p-value 0.002) were more likely to undergo CS than mothers under 20 years of
age. The mothers who delivered male child had 1.26 times (95% CI 1.08-1.47; p-value
0.003) more odds of CS. Women with no live child (AOR 2.26; 95% CI 1.23-4.14; p-value
0.009) and those with one live child (AOR 1.56; 95% CI 1.22-1.99; p-value <.001) had more
odds of CS than women who had two or more live child. Mothers who had singleton
pregnancy had 80% lower risk of CS (AOR 0.02; 95% CI 0.01-0.08; p-value <.001)

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 compared to mothers with twin baby. Compared to term pregnancy, mothers with gestation >
Accepted Article
40 weeks were 1.25 times more likely to undergo CS (95% CI 1.01-1.56; p-value 0.044).

4 Discussion
The CS rates have increased in developing countries due to improvement in the health
system. The aim of this study was to understand the indications of CS and factors
associated with it in Bhutan.
The average CS rate in our study was 18.7%, which varied from 11.6% to 34.6% among the
health centers. The CS rate in this study was lower than facility based studies in Egypt
(53%) [12] and Vietnam (58.6%) [13]. The high rates of CS in the above studies were found
to be due to non-medical indications like social preference. In Bhutan, the decision for CS is
made by treating obstetricians based on the indications. Although, the CS rate in our study is
higher than the WHO recommended rate of 10-15% [1], it is not representative of the
national CS rate. The study could not include two more comprehensive EmOC centers and
home deliveries. Moreover, the uncomplicated deliveries are conducted in other health
facilities and these hospitals serve as the referral point for the complicated and high-risk
cases for CS.
The common indication of CS in our study were previous CS (23%), fetal distress (15.5%),
prolonged labor (15.1%), failed induction (10.9%) and mal presentation/mal position (9.1%).
The indications in our study were similar to a facility-based study conducted by World Health
Organization in nine Asian countries [10].
Previous CS was the most common indications of CS in this study and is consistent with
other studies [12–14]. Repeat CS is not indicated for all women with previous CS in the
subsequent pregnancies and vaginal birth after CS (VBAC) can be encouraged especially in
centers equipped with obstetricians. Studies in some countries have shown that VBAC had
success rate of 91.3% [15] especially in women who underwent vaginal birth before CS and
fetal mal-presentation as indications of previous CS. Usually VBAC is associated with lower
morbidity compared to repeat CS. However, VBAC is not usually practiced in Bhutan due to

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 shortage of human resources. So, all women with previous CS undergo CS in the
Accepted Article
subsequent pregnancies.
Fetal distress is a common contributor to increasing CS rates [14]. One method of
decreasing fetal distress could be intrauterine fetal resuscitation and fetal blood sampling to
confirm the diagnosis of fetal distress [16]. However due to the absence of facilities for fetal
blood sampling in Bhutan, high risk pregnant women with persistent variable deceleration or
prolonged deceleration undergo CS to avoid fetal complications.
Prolonged labor, defined as second stage of labor lasting for more than one hour in
multiparous and more than two hours in nulliparous women [17] was a common indication of
CS as in Bangladesh [14]. Partograph is a widely used tool to monitor the progress of labor
and the well-being of both the mother and fetus [18]. However, studies have shown that
health workers have poor knowledge on partograph [19] which could led to overdiagnosis of
prolonged labor. Moreover, the American College of Obstetricians and Gynecologists and
the Society for Maternal-Fetal Medicine recommends increasing the threshold time for
definition of the prolonged labor by an hour as one means of decreasing primary CS [17].
In our study, type of health facility was one of the factors associated with CS. It was seen
that women delivering in Samtse Hospital and CRRH had higher odds of CS than JDWNRH.
One of the reasons could be due to presence of advanced facility in JDWNRH, which is fully
equipped to deal with all types of complications arising in both the mother and neonate.
Studies in other countries also showed that CS rate differed from one facility to another [13].
Consistent with other studies, women having one or no child at all were more likely to
undergo CS [14, 20, 21]. The reason could be unwillingness of the obstetrician to take risk of
intrapartum complications of normal delivery that could endanger the health of baby
especially in elderly nulliparous women. Nowadays, women tend to marry late and conceive
late and therefore pregnancy becomes valuable.
Increasing maternal age was found to be one of the factors associated with CS. This is
consistent with studies from Ghana [20], Vietnam [13], Ethiopia [22] and Oman [21]. This
was due to increase in age related complications like pre-eclampsia, gestational diabetes,
obesity and fetal malformations [6, 23]. Similar to a study in Vietnam, the mothers carrying

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 male child were more likely to undergo CS [13]. This was thought to be due to high
Accepted Article
incidence of shoulder dystocia and unreassuringly fetal heart rate among male child [24].
Although CS is life-saving surgery, unwarranted surgery can lead to untoward complications.
Apart from the surgical and anesthetic complications, it can lead to peripartum hysterectomy,
persistent pain, infections in mother and thromboembolic complications [6]. In addition,
babies born by CS tend to have altered immunological development, asthma, atopy and
reduced gut flora [7]. Moreover, long term complications of CS include placenta previa, still
births, abortions, preterm births and uterine ruptures in subsequent pregnancy [6]. CS can
also lead to delayed initiation of breastfeeding for the newborn due to inability of mother to
room in the newborn [8]. Moreover CS are associated with longer hospital stay and higher
cost to the health system compared to the vaginal delivery [25].
This study has its limitations since it was a retrospective data review. Other variables known
to influence CS such as body mass index [21], education level and income could not be
assessed in this study. Moreover, data for the indications of CS were missing for some
cases. In addition, two others comprehensive EmOC centers could not be involved in this
study.

5 Conclusion
The most common indications of Cesarean deliveries were previous CS, fetal distress,
prolonged labor, failed induction and mal presentation. Women with age more than 25 years,
those with one or less living child, male child, twins and those with postdated pregnancies
were associated with Cesarean deliveries. To reduce the CS rate, Bhutan can focus on
mitigating the indications of CS especially primary CS to prevent CS in subsequent
pregnancies. The CS has to be conducted after a judicious judgment to prevent un-
necessary surgery but at the same time achieve the optimal care.

Author contribution
TD contributed to design of study, data collection, analysis and finalization of manuscript.
KW contributed to data collection, cleaning, analysis and results and finalization of

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 manuscript. YD contributed to study design, drafting and finalization of manuscript. ND
Accepted Article
contributed in study design and finalization of manuscript. DC contributed to design of study,
data collection and finalization of manuscript. ST contributed to study design, data collection,
drafting and finalization of manuscript. PW contributed to data collection and finalization of
manuscript. TT contributed to study design, analysis, drafting and finalization of manuscript.

Acknowledgments
The authors would like to thank the Medical Superintendents of CRRH, ERRH and
JDWNRH for giving consent for data collection. Moreover, we are also grateful to Dr. Dinesh
Pradhan of CRRH for his help in data collection and Dr. Tsheten for his help in making map.

Conflict of interest
The authors have no conflicts of interest.

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TABLE 1 Socio-demographic characteristic of pregnant women in Bhutan.

Characteristic Number (%)

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 Hospital
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CRRH, Gelephu 940 (14.5%)
Samtse Hospital 424 (6.6%)
ERRH, Mongar 973 (15.1%)
JDWNRH, Thimphu 4129 (63.9%)
Age groups
< 20 years 276 (4.3%)
20- 24 years 1713 (26.5%)
25-29 years 2425 (37.5%)
30-34 years 1387 (21.5%)
35-39 years 533 (8.2%)
≥ 40 years 132 (2%)
Gravida
Primigravida 2684 (41.5%)
2-4 3490 (54%)
≥5 292 (4.5%)
Abortion
No abortion 6103 (94.4%)
1 abortion 318 (4.9%)
≥ 2 abortion 45 (.7%)
Live children
No live child 2831 (43.8%)
1 live child 2129 (32.9%)
>=2 live child 1506 (23.29%)
Type of delivery
SVD 5076 (78.5%)
Instrument delivery 178 (2.7%)
Cesarean-section 1212 (18.7%)
Sex of baby
Male 3311 (51.4%)
Female 3134 (48.6%)
Weight of baby
<2.5 kg 388 (6%)

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 2.5- 4 kg 4819 (74.5%)
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> 4 kg
Baby
1259 (19.5%)

Single 6355 (98.3%)

Twins 31 (.5%)
stillborn 80 (1.2%)
Apgar at birth (n=5500)
<7 Apgar 316 (5.8%)
>=7 Apgar 5184 (94.2%)
Gestational age at birth
< 37 weeks 1197 (18.5%)
37-40 weeks 4380 (67.7%)
> 40 weeks 889 (13.8)
ERRH-Eastern Regional Referral Hospital
CRRH-Central Regional Referral Hospital
JDWNRH-Jigme Dorji Wangchuck National Referral Hospital
SVD-Spontaneous vaginal delivery

TABLE 2 Mode of delivery in different health centers in Bhutan.

Mode of delivery
spontaneous Instrumental
Place of delivery vaginal delivery delivery Cesarean section
Samtse hospital 291 (68.6%) 13 (3.1%) 120 (28.3%)
JDWNRH 3501 (84.8%) 148 (3.6%) 480 (11.6%)
CRRH 653 (69.5%) 12 (1.3%) 275 (29.3%)
ERRH 631 (64.9%) 5 (0.5%) 337 (34.6%)
Total 5076 (78.5%) 178 (2.8%) 1212 (18.7%)
ERRH-Eastern Regional Referral Hospital; CRRH-Central Regional Referral Hospital; JDWNRH-Jigme Dorji
Wangchuck National Referral Hospital.

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 TABLE 3 Crude odds ratio for binary logistic regression for factors associated with
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Cesarean section in Bhutan
Type of delivery
Characteristic Non- Cesarean COR (95% CI) p-value
Cesarean section
Hospital
3.00 (2.38-
Samtse 304(5.8%) 120 (9.9%) <0.001
3.78)
3649
JDWNRH 480 (39.6%) Ref
(69.4%)
3.14 (2.65-
CRRH 665 (12.7%) 275 (22.7%) <0.001
3.73)
4.03 (3.42-
ERRH 636 (12.1%) 337 (27.8%) <0.001
4.74)
Age groups
< 20 years 234 (4.5%) 42 (3.5%) Ref
1440 1.06 (0.74-
20- 24 years 273 (22.6%) 0.761
(27.4%) 1.50)
1982 1.25 (0.88-
25-29 years 443 (36.5%) 0.212
(37.7%) 1.76)
1114 1.37 (0.96-
30-34 years 273 (22.5%) 0.085
(21.2%) 1.95)
2.20 (1.52-
35-39 years 381 (7.3%) 152 (12.5%) <0.001
3.25)
1.57 (0.93-
≥ 40 years 103 (2%) 29 (2.4%) 0.094
2.66)
Gravida
2164 0.78 (0.58-
Primi 520 (42.9%) 0.084
(41.2%) 1.03)
2867 0.70 (0.53-
2-4. 623 (51.4%) 0.015
(54.6%) 0.93)
≥5 223 (4.2%) 69 (5.7%) Ref
Abortion

0 4947 1156 (95.4%) Ref

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 (94.2%)
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1 271 (5.2%) 47 (3.9%)
0.74 (0.54-
0.065
.1.02)
1.07 (0.51-
≥2 36 (0.7%) 9 (.7%) 0.857
2.23)
Live child
2282 1.12 (0.95-
No live child 549 (45.3%) 0.165
(43.4%) 1.32)
1.07 (0.90-
1 live child 1732 (33%) 397 (32.8%) 0.449
1.27)
1240
≥2 live child 266 (22%) Ref
(23.6%)
Baby
5179
Singleton 1176 (97%) 0.02 (.01-.08) <0.001
(98.6%)
Twins 3 (0.1%) 28 (2.3%) Ref
0.01 (0.002-
Stillbirth 72 (1.4%) 8 (0.7%) <0.001
0.05)
Sex of baby
2649
Male 662 (55%) 1.2 (1.05-1.36) 0.005
(50.5%)
2593
Female 541 (45%) Ref
(49.5%)
Weight of baby
< 2.5 kg 306 (5.8%) 82 (6.8%) Ref
4082 0.67 (0.52-
2.5- 4 kg 737 (60.8%) 0.003
(77.7%) 0.87)
1.69 (1.29-
> 4 kg 866 (16.5%) 393 (32.4%) <0.001
2.22)
APGAR score at birth
(n=5500)
0.92 (0.67-
<7 269 (5.8%) 47 (5.4%) 0.598
1.26)

≥7 4355 829 (94.6%) Ref

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 (94.2%)
Accepted Article
Maturity
3651 0.48 (0.41-
Term 729 (60.2%)
(69.5%) 0.56) <0.001
Pre-term 845 (16.1%) 352 (29%) Ref
0.42 (0.37-
Post dated 758 (14.4%) 131 (10.8%)
0.47) <0.001

ERRH-Eastern Regional Referral Hospital; CRRH-Central Regional Referral Hospital;

JDWNRH-Jigme Dorji Wangchuck National Referral Hospital; COR-crude odds ratio

TABLE 4 Adjusted odds ratio for multiple logistic regression for factors associated with
Cesarean section in Bhutan.

Characteristic AOR (95% CI) p-value

Hospital

Samtse 3.29 (2.59-4.18) <.001

JDWNRH Ref

CRRH 3.72 (3.10-4.48) <.001

ERRH 3.72 (0.58-23.71) 0.165

Age groups
< 20 years Ref

20- 24 years 1.17 (0.77-1.79) 0.466

25-29 years 1.68 (1.11-2.57) 0.015

30-34 years 2.20 (1.41-3.44) 0.001

35-39 years 3.82 (2.33-6.24) <0.001

≥ 40 years 3.07 (1.52-6.21) 0.002

Gravida

Primi 1.47 (0.67-3.22) 0.339

2-4. 1.23 (0.77-1.95) 0.389

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 ≥5 Ref
Accepted Article
Abortion
0 Ref

1 1.25 (0.84-1.86) 0.265

≥2 1.78 (0.81-3.92) 0.151

Live child

No live child 2.26 (1.23-4.14) 0.009

1 live child 1.56 (1.22-1.99) <0.001

≥2 live child Ref
Baby

Singleton 0.02 (0.007-.081) <0.001

Twins Ref

Stillbirth 0.01(0.002-0.04) <0.001

Sex of baby

Male 1.26 (1.08-1.47) 0.003

Female Ref
Weight of baby
< 2.5 kg

2.5- 4 kg 0.73 (0.51-1.02) 0.067

> 4 kg 1.08 (0.69-1.70) 0.737

APGAR score at birth (n=5500)

<7 0.85 (0.59-1.23) 0.386

≥7 Ref
Maturity
Term Ref
Pre-term 1.12 (0.74-1.69) 0.593
Post dated 1.25 (1.01-1.56) 0.044
ERRH-Eastern Regional Referral Hospital; CRRH-Central Regional Referral Hospital; JDWNRH-Jigme Dorji
Wangchuck National Referral Hospital; AOR-Adjusted odds ratio

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Accepted Article

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Accepted Article

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