Data Availability: Due to participant confidentiality concerns, the qualitative data cannot be made publicly available. The data can be requested from the corresponding author or from the institution that provided the authors with ethical approval: Adnan Khan, Assistant Registrar, Health Services Academy, Islamabad Pakistan, [email protected]: This work was supported by Postgraduate Research Support Scheme and حوامل Research Student Grant Scheme of the University of Sydney, Australia. CRG was funded by an NHMRC CDF #1086062, and a Robinson Fellowship, University of Sydney.
The burden of perinatal mortality comprising of stillbirths and early newborn deaths continues to be a challenge in low-income countries particularly in South Asia and Sub-Saharan Africa . Of the approximately 3.2 million global stillbirths, more than 98% occur in low and middle-income countries like Pakistan . Pakistan has the third highest stillbirth rate in the world, at 47 per 1000 births, resulting in ~242, 600 fetal deaths at 28 weeks of gestation in 2015. With ~244, 700 neonatal deaths within first week after birth in 2015, Pakistan ranks second in the list of countries with the highest neonatal mortality rate . To put this in perspective, most high-income countries have an average stillbirth rate of 3·5 per 1000 total births..Perinatal mortality is a highly sensitive indicator of the quality and accessibility of care received during pregnancy and at the time of birth . This suggests that some perinatal mortality is preventable through interventions . Countries like Bangladesh, Cambodia, and Rwanda outperformed other high burden countries, and achieved an annual reduction of more than 3.5% in stillbirths between 2000 and 2015, because they were able to improve women’s access to care during pregnancy and birth . In countries which lag behind, bottlenecks in intervention implementation continue to be a challenge to further reductions in perinatal mortality. For instance a bottleneck analysis for newborn survival identified wide gaps in almost all aspects of the implementation of intervention packages aimed at in-patient care of the small and sick newborns . In rural populations in Pakistan, despite improved access to primary healthcare services, the quality of care still lags behind best practice . Although the main risk factors  and interventions to prevent perinatal mortality have been identified , there still exist gaps in our understanding of how these interventions are integrated within community-based maternal and child healthcare services in countries with a high burden of perinatal mortality.
Understanding key healthcare system challenges experienced by women during pregnancy and birth is crucial to scale up available interventions and reduce perinatal mortality. A community perspective about preferences and experience of care during this period can be used to improve community-based programs to reduce perinatal mortality. Using a qualitative exploratory approach, we examined women’s experience of perinatal loss, aiming to understand the main factors, as perceived and experienced by women, leading to perinatal loss. Qualitative in-depth Interviews were conducted with 25 mothers with a recent perinatal loss, three family members, six healthcare officials, and two focus group discussions with 17 lady health workers. Data were analysed using inductive and deductive coding, by thematic analysis. Our findings revealed three distinct but interrelated themes, which include: 1) poor access to care during pregnancy and birth, 2) unavailability of appropriate healthcare services, and 3) poor quality of care during pregnancy and birth. Women frequently delayed seeking formal care around birth because of delays by themselves, their family members, or the local traditional birth attendants who frequently induced births at women’s homes without recognising the dangers to the mothers or their babies. Preference for private care was common, however they often could not bear the cost of care when they needed caesarean section or in-patient care for their sick newborns because these services were absent in public health facilities of the district. Referral to the regional tertiary care hospital was often not officially arranged leading to risky births in small and crowded private clinics. Women’s views about negative staff attitudes and the lack of attention given to them in public health facilities highlighted a lack of quality and respectful antenatal care. Improvement in women’s access to essential care during pregnancy and around birth, availability of emergency obstetric and newborn care, improving the quality of maternal and newborn care in both public and private health facilities at the district level might reduce perinatal mortality in Pakistan.