Ameer Muhammad ( Vital Pakistan Trust, Karachi, )
Yasir Shafiq ( Department of Pediatrics, Aga Khan University, Karachi, Pakistan. )
Madam, worldwide, around 2 million births annually ended in stillbirths.1 Sub-Saharan Africa and South Asia are sharing 80% of the burden, with 44% of events being contributed by only six countries i.e., India, Pakistan, Nigeria, the Democratic Republic of the Congo, China, and Ethiopia.1 Considering the public health burden of significance, even now stillbirths are the most neglected in country-level attention and low priority is given to mitigate the risk factors of stillbirths.2
The consequence of stillbirth is huge, both systemwide as well at the level of the household. The impact is grossly linked with both economic broadly and psychological and physical well-being at the individual level.3 Furthermore, at the individual level, the social and cultural taboo attached with stillbirth as an outcome is severe and hinders correct reporting at the country level.3 The problem of under or misreporting is grossly an issue in low-and middle-income countries (LMICs); socio-cultural barriers are most prevalent in these countries.3
Nearly 40% of stillbirths are attributable to preventable causes, usually happening during the intrapartum period, which can easily be averted through better health interventions and quality of care.1 Further, the rest of the leading causes are pertaining to antepartum complications.1 The distribution of causes of stillbirths are continuing to remain stagnant since last few years, and remedial interventions so far at the country level are not on track to gain the reduction in stillbirth rates as per criteria for the count down 2030.4,5
To track the country-level progress, a robust mechanism of reporting and identifying stillbirth events and accuracy is needed to assign the cause of stillbirth, which is currently deficient in LMICs.4 Every Newborn Action plan was endorsed by 194 countries at the World Health Assembly asked every country to develop and implement a plan to improve maternal, neonatal and child survival programmes in 2014 to end preventable stillbirths, after strenuous efforts, only 29 out of 90 countries implemented and set reduction of stillbirth less than 10 stillbirths per 1000 total births by 2030.4,5
Pakistan is the second most contributor to the global burden of stillbirths; at the highest stillbirth rate of 43 per 1000 births, translating into 0.25 million stillbirths are annually.6 Pakistan's pledge to stillbirth countdown 2030, the country is lagging far behind. The slow progress is stemmed from many factors, which exist both at the community level as well as related to the overall health system approach. At the community level, the socio-cultural aspects are hindering the accurate reporting on the burden and poor health-seeking behaviours. From the health system viewpoint, the system is still not able to avert the preventable causes and the system failed to provide optimal care to those who need it the most. Lack of innovation in the care and poor services in low resource settings is a huge problem.7 Besides, stillbirths are not reported accurately to hide the errors in a health care setting. Unfortunately, Pakistan is one of the states where no population-based surveillance exists, leading to under-studied, underreported, and poorly implemented initiatives.7 Political commitment to address the issue of the burden of stillbirths is not visible; many country-led reports missed out on the stillbirth rate as a key indicator, and even if added, the targets are missing. Therefore, Pakistan is not fully ready for stillbirths count down 2030.
There are a lot of actions required in Pakistan to move in a positive direction. The solution is embedded in integrated approaches to address the root causes both community-related as well as health system-related, data accuracy, and continuous tracking of the progress. Applying new tools to deliver better care to pregnant women in vulnerable communities in Pakistan is crucial. This may involve digital innovation in care during antenatal care and intrapartum care, better decision support to the health worker, strengthening community-based midwifery system and better use of data is integral. Further, continuous sensitization of the community is also needed to create better awareness of the issue is also important. This pathway if chosen has great potential for Pakistan to set a better trajectory to reduce the number of stillbirths by 2030.
Disclaimer: None to declare.
Conflict of Interest: None to declare.
Funding Sources: None to declare.
1. Hug L, Mishra A, Lee S, You D, Moran A, Strong KL, et al. A neglected tragedy the global burden of stillbirths. Estimates developed by the UN Inter-agency group for child mortality estimation. UNICEF; 2020.
2. De Bernis L, Kinney MV, Stones W, Ten Hoope-Bender P, Vivio D, Leisher SH, et al. Stillbirths: ending preventable deaths by 2030. Lancet. 2016; 387:703-16.
3. Heazell AE, Siassakos D, Blencowe H, Burden C, Bhutta ZA, Cacciatore J, et al. Stillbirths: economic and psychosocial consequences. Lancet. 2016; 387:604-16.
4. Wang H, Bhutta ZA, Coates MM, Coggeshall M, Dandona L, Diallo K, et al. Global, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016; 388:1725-74.
5. Reinebrant HE, Leisher SH, Coory M, Henry S, Wojcieszek AM, Gardener G. Making stillbirths visible: a systematic review of globally reported causes of stillbirth. BJOG. 2018; 125:212-24.
6. National Institute of Population Studies (NIPS) Pakistan and ICF. Pakistan demographic and health survey 2017-18.
7. Aziz S, Pradhan NA, Roujani S, Ali A, Abbsai Z, Hussain S, et al. A Situational Analysis on Stillbirths, Newborn Deaths and Small and Sick Newborn Care Findings from Pakistan. Islamabad, Pakistan: Department of Community Health Sciences, Aga Khan University, UNICEF and Ministry of National Health Services Regulation and Coordination, 2019.