Title: Paper Title: The unspoken grief of multiple stillbirths in rural Pakistan: an interpretative
phenomenological analysis
Version: 3 Date: 27 Jun 2021
Reviewer's report:
Abstract:
- Does Pakistan have the highest rate of stillbirths in the world? The abstract makes it sound like
the highest in the world. I recommend revising this sentence.
- I would recommend putting words such as “child-killer” in quotation marks.
- The claim that healthcare providers “totally ignore the psycho-social and medical needs” seems
like a generalization beyond the research.
Introduction:
- What is the stillbirth rate in Asia? You all say that Pakistan has the highest but it’s only
compared to the global estimate.
- The first paragraph jumps between global estimates, discussing LMIC settings, and Pakistan
specifically. I would recommend starting with global estimates and becoming increasingly more
focused.
- Can you expand on the mental, physical, and social costs of stillbirth beyond the single
sentence?
- Can you discuss more about the rate, determinants, and causes of stillbirths in the introduction?
This seems like relevant contextual information that is briefly referenced.
- Have studies in other regions studied multiple stillbirths that you could reference?
Methods:
- I’m not sure what “the qualitative method” is that you refer to. Do you mean “a qualitative
methodology, specifically a phenomenological approach”?
- Study Setting: Can you compare percentages such as literacy with those of the country as a
whole for context? Also, please state the stillbirth rate in this region.
- Study participants:
o Please expand on the role of community health workers, traditional birth attendants, and quaks.
o What are the local cultural values and norms that were followed?
- Data Collection: Please revise table one to summarize demographic information rather than
having a row for each woman separate (e.g., present age groups and how many women fall
within each age group).
- Data Collection: You said that you stopped collection when data saturation was reached but
how was data saturation decided on? Did you begin analysis while data collection was still
ongoing?
Results:
- Please provide more interpretation of the quotes or a summary of the theme after they are
presented rather than quickly moving onto the next sub-section. Each theme seemed quite brief.
- Please connect the themes in the results as you move between them.
- Coping seemed to be mostly about avoidance and pre-occupation, which could be drawn out
more.
Discussion:
- Was there any difference in experience between the women that had other live children versus
those that did not? This is not discussed at all but seems highly important given women’s identity
as mothers.
- Did anyone have positive sources of support (such as a supportive spouse or friends)? This
isn’t explored either but seems important even if it was not a recurring experience.
- Can you discuss the role of rurality in your findings, if at all? The rurality of the region was
mentioned as important but wasn’t discussed much in the results or discussion.
Conclusion:
- The conclusion is the first time that solutions or next steps are introduced. Can those be
expanded on earlier? For example, you all recommend that the health system should provide
support. But, is that something the women want and discussed? Should this be something done
by lady health workers, traditional birth attendants, etc.?