Perceptions and practices regarding stillbirths in Thatta district, Sindh; a qualitative exploratory study
Date of Award
Master of Science in Health Policy & Management (MSc Health Policy & Mgmt)
Community Health Sciences
2.6 million stillbirths occur globally every year, 98% of which occur in low and middle-income countries(1). This high burden of stillbirths in developing countries indicates numerous socio-economic and health determinants that are adversely affecting the health of women of developing countries. Pakistan is ranked highest stillbirth rate of 43 per thousand births(2); with more than three forth of stillbirths occurring in rural areas of Pakistan(3). This could be an underestimate, as the home delivered stillbirths remain underreported. Thus, there is a need to understand stillbirths from the perspective of women and health care providers to identify factors, practices, and strategies for preventing stillbirths in low resource setting like Thatta. Study Objectives: The study aimed to explore the perceptions of rural women, birth attendants (including professional healthcare and traditional BA), and key informants to gain more in-depth information to address the high stillbirth rates in Thatta, rural Sindh. Methodology: This was an exploratory study design using qualitative methods for data collection. We conducted key-informants, in-depth interviews and focus group discussions with the participants using semi-structured interview guide. The FGDs were conducted with rural women and Traditional birth attendants who were permanent residents of Thatta. KIIs were conducted with women, who had experienced stillbirth and skilled birth attendants which included CMWs and LHVs. Furthermore, we approached Operational Manager of MERF, MNCH program officer in Thatta, Head of Obstetrics and Gynecology department of CHM and private practitioner (obstetrician) to get more in-depth views about reasons and prevention of stillbirths pertinent to low resource settings. Results: The findings are explained on the three levels of conceptual framework of the study. At micro level, women, shared concerns regarding difficulties and challenges to access quality of ANCs and delivery care during pregnancy and lack of post stillbirth counseling to prevent stillbirths in subsequent pregnancies. Moreover, women revealed certain high-risk behaviors during pregnancy such as non-compliance in supplements intake, consumption of Gutka (tobacco) in known anemic condition and ignoring warning signs of infection or headache leading to stillbirth. At meso level, health care providers, which included skilled and unskilled birth attendants; lacked assessment and monitoring expertise and related practices during ante partum and intra-partum period due to impending complications of childbirth, remained unidentified and resulted in stillbirth. Delayed reporting of pregnant woman at the facility after developing intra-partum complications were commonly observed in the rural setting. Further, unavailability of doctors at the hospitals, delay in receiving emergency obstetric care, lack of fetal heart monitoring practices at the time of delivery and no resuscitative measures taken for baby born without signs of life contribute to stillbirth. KIIs shared low coverage of deliveries by skilled birth attendants, lack of regulations on the delivery practices by untrained providers and compromises on the quality of standard ANC and delivery care as some contributing factors to stillbirth. Moreover, they identified loopholes in the MNCH program which is unable to sustain interventions at community levels to prevent stillbirth and lacks identification of targets and goals related to stillbirth. The majority of the respondents emphasized on improving quality of ANC during pregnancy for early detection of high-risk pregnancies and pregnancy complications, which could prevent stillbirth in low resource setting. Conclusion: In conclusion, most of the stillbirths are preventable. Findings explicitly highlight the needs of vigorous efforts to improve the quality of existing antenatal and intra-partum care through trained skilled birth attendants to prevent stillbirths. Further, public health policies need to constitute strategies for health system strengthening and implementing sustainable key interventions of MNCH and CMW programs at community level to target stillbirths in low recourse setting. Moreover, prevention of stillbirth requires holistic approach at all the levels of health system to achieve Every New born action goal of ending preventable stillbirths by 2030.
Zulfiqar, S. (2017). Perceptions and practices regarding stillbirths in Thatta district, Sindh; a qualitative exploratory study (Unpublished doctoral thesis). Aga Khan University, Karachi, Pakistan.