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

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          Pakistan 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.


          This 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.


          The 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.


          The 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.

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          Most cited references 18

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          A purposeful approach to the constant comparative method in the analysis of qualitative interviews

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            Stillbirths: ending preventable deaths by 2030.

            Efforts to achieve the new worldwide goals for maternal and child survival will also prevent stillbirth and improve health and developmental outcomes. However, the number of annual stillbirths remains unchanged since 2011 and is unacceptably high: an estimated 2.6 million in 2015. Failure to consistently include global targets or indicators for stillbirth in post-2015 initiatives shows that stillbirths are hidden in the worldwide agenda. This Series paper summarises findings from previous papers in this Series, presents new analyses, and proposes specific criteria for successful integration of stillbirths into post-2015 initiatives for women's and children's health. Five priority areas to change the stillbirth trend include intentional leadership; increased voice, especially of women; implementation of integrated interventions with commensurate investment; indicators to measure effect of interventions and especially to monitor progress; and investigation into crucial knowledge gaps. The post-2015 agenda represents opportunities for all stakeholders to act together to end all preventable deaths, including stillbirths.
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              Stillbirth in developing countries: a review of causes, risk factors and prevention strategies.

              To understand the rates, causes and risk factors for stillbirth in developing countries as well as the strategies that have been evaluated to reduce stillbirth. We searched the English literature for 2003-2008 for all articles related to stillbirth and perinatal mortality in developing countries and reviewed all related publications. Despite the large number of stillbirths worldwide, the topic of stillbirths in developing countries has received very little research, programmatic or policy attention. In many developing countries, almost half of the deliveries occur at home, and under-reporting of stillbirths is a significant problem. Reliable data about rates and causes are unavailable in many areas of the world. Nevertheless, of the estimated 3.2 million stillbirths that occur yearly world-wide, the vast majority occur in developing countries. Rates in many developing countries are 10-fold greater or more than in developed countries. There is not a standard international classification system that defines cause of death, nor is there agreement about the lower limits of birthweight or gestational age that define stillbirth, making comparisons of causes of stillbirth or rates over time or between sites problematic. From available data, prolonged and obstructed labour, pre-eclampsia and various infections, all without adequate treatment, appear to account for the majority of stillbirths in developing countries. Identification and treatment of maternal syphilis has been effective in reducing stillbirth risk, as has improvements in access to emergency obstetrical services and particularly caesarean section. Further research is needed to understand the causes and the best preventive strategies for stillbirth specific to geographic areas. However, based on current data, better access to appropriate obstetric care, particularly during labour and delivery and better screening and treatment of syphilis should reduce developing country stillbirth rates dramatically.

                Author and article information

                BMC Pregnancy Childbirth
                BMC Pregnancy Childbirth
                BMC Pregnancy and Childbirth
                BioMed Central (London )
                16 July 2018
                16 July 2018
                : 18
                [1 ]ISNI 0000 0001 0670 519X, GRID grid.11173.35, Department of Sociology, Institute of Social and Cultural Studies, , University of the Punjab, ; Lahore, Pakistan
                [2 ]ISNI 0000 0001 0670 519X, GRID grid.11173.35, Department of Public Health, Institute of Social and Cultural Studies, , University of the Punjab, ; Lahore, Pakistan
                [3 ]ISNI 0000 0001 0944 9128, GRID grid.7491.b, Department of Public Health Medicine, School of Public Health, , Bielefeld University, ; Bielefeld, Germany
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

                Funded by: Care International
                Research Article
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                © The Author(s) 2018

                Obstetrics & Gynecology

                underreporting, stillbirths, pakistan, gestational health, cause of death


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