Underreporting of stillbirths in Pakistan: perspectives of the parents, community and healthcare providers

Abstract

BackgroundPakistan has the highest rate of stillbirths globally. Not much attention has been given so far to exploring the sociocultural factors hindering the reportage of stillbirths and the causes of death. Therefore, the aim of this study was to assess the perspectives of parents, communities and healthcare providers regarding the sociocultural practices and health system-related factors contributing to stillbirths and their underreporting.MethodsThis study used a qualitative approach including in-depth interviews and 14 focus group discussions to collect data from four districts of Pakistan. We conducted 285 in-depth interviews and 14 focus group discussions with health professionals – mainly active in the areas of maternal and child health – and parents who had experienced stillbirth. Constant comparative method and analytical induction method were performed to analyze the data.ResultsThe results of this study show that stillbirth is frequently misclassified and, therefore, an underreported phenomenon in Pakistan. It is an outcome of sociocultural practices, such as the social meaning of stillbirth and their understanding about the conflict between cultural and medical anatomy. In addition to grief and psychological distress, it endangers the maternal identity and worth in society in contrast to the mothers of live-born children.ConclusionThe misclassification of stillbirth, especially by healthcare providers, is a significant impediment to designing preventive strategies for stillbirth. We recommend that the reporting system for stillbirth should be aligned with the WHO definition of stillbirth to avoid its underreporting. Reporting procedures at a more administrative level need to be made uniform and simplified.

Barriers and enablers to reporting pregnancy and adverse pregnancy outcomes in population-based surveys: EN-INDEPTH study

“…This was especially so for stigma, witchcraft, religion and spiritual beliefs. Studies in South Africa, Ethiopia, Gambia, Uganda and Cameroon identified similar barriers to reporting APOs, as well as grief and patriarchy [6,21,22,25,[29][30][31][32][33][34]. Consistently across all sites in our study, cultural factors played a role in encouraging silence around pregnancy and APOs.…”

Community-level interventions for pre-eclampsia (CLIP) in Mozambique: A cluster randomised controlled trial

“…Our incidence of stillbirth (per 1000 livebirths) of 24·3 is slightly higher than the 2015 national estimate of 20·7, despite use of the same definition [24] . This may reflect underreporting in other datasets due to cultural norms and beliefs prohibiting disclosure of stillbirths [25] , [26] . Of note, misclassification of stillbirths as neonatal deaths is unlikely, as our estimate of neonatal mortality (26·4 per 1000 livebirths) is similar to the 2015 national, population-level estimate (25·5), and to 2011 regional rates (population-level demographic health survey (34–37)) [24] , [27] .…”

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