An in-depth investigation of perinatal mortality, and newborn survival policies in Pakistan

Background The global burden of perinatal mortality includes ~2.6 million stillbirths and 2 million early neonatal deaths, mostly occurring in the low-and-middle-income countries of South Asia and sub-Sahran Africa. Most perinatal mortality is preventable through interventions focussing on care during pregnancy and around birth. Yet progress has been dismal in countries like Pakistan, where the perinatal mortality rate is currently ten times that of high-income countries. Pakistan’s current stillbirth rate of 47 per 1000 births is the third highest in the world, resulting in ~242, 600 stillbirths annually. Pakistan ranked second in the world with respect to neonatal mortality in 2015, when ~244, 700 neonates died in the country, most during the first week of life. Perinatal mortality continues to pose a challenge and Pakistan is yet to fully recognise the need for a focus on relevant interventions and research. Previous studies have identified the main risk factors for perinatal mortality, however, healthcare system and policy challenges for the prevention of perinatal mortality have not been comprehensively analysed in the context of Pakistan. Aims and objectives The broad aim of this research was to examine perinatal mortality in the context of the culture and healthcare system of Sindh province in Pakistan. The first objective was to determine, via an analysis of the data from a demographic and health survey (DHS) 2011-12 , the key factors associated with perinatal mortality in Pakistan, with particular focus on women’s access to healthcare services during pregnancy and birth. The second objective was to understand the perceptions, cultural practices and healthcare experiences of women who had a recent perinatal death (within a year preceding data collection) in a rural district in Sindh, Pakistan. The last objective was to analyse newborn survival strategies in Pakistan’s most recent health policies and to identify current policy gaps and contextual barriers to improved newborn health. Methods A mixed methods approach was used to achieve the aims of this research. In the first study, data from the DHS 2011-12 on singleton births in the preceding five years were analysed to determine the risk factors associated with perinatal mortality in Pakistan using multivariate logistic regression analysis. In the second and third studies, qualitative, in-depth interviews were conducted with women who had experienced a perinatal death within the previous year, family members and healthcare officials, and focus group discussions were conducted with female health workers. The women were purposively selected through local female health workers. Data were analysed by thematic analysis. The fourth study involved a content analysis of federal level policies addressing newborn mortality from 2001 to 2019 a p, followed by a case study analysis of policy and program responses in Sindh province of Pakistan with a comparison of the findings with successful policies and programs in other countries in the region. Results In the first study, women whose family elders made their healthcare decisions had higher odds of stillbirth compared with women who made their own decisions (aOR=2.04, 95% CI: 1.05-3.99). Among women who had never used any form of contraception, compared to those using a modern method, the odds of stillbirth increased by 1.47 times (aOR=1.47, 95% CI: 1.06-2.04). Higher odds of stillbirth were also found among women who performed manual labour compared to those who did not (aOR=1.55, 95% CI: 1.09-2.21), and among those whose husbands were manual labourers (aOR=1.45, 95% CI: 1.01-2.06). Higher odds of early neonatal mortality were also associated with women who faced financial hardship in accessing healthcare (aOR=1.67, 95% CI: 1.06-2.63), babies who were not weighed at birth (aOR=4.39, 95% CI: 1.00-19.33), undernutrition in women (body mass index