Title: Paper Title: The unspoken grief of multiple stillbirths in rural Pakistan: an interpretative
phenomenological analysis
Version: 5 Date: 28 Oct 2021
Reviewer's report:
Abstract:
- The conclusion of the abstract states that “the health system should be responsive not only to
account for and prevent stillbirths,” but it unclear to me what is meant by them being responsive
to account for stillbirths?
Introduction:
- Thank you for your edits to the introduction. It still reads as though Pakistan has the highest
rate of stillbirths in the world. While Pakistan has one of the highest, it does not have the highest
rate, as Guinea-Bissau does. Please correct to be ‘one of the highest across the globe.’
- Thank you for including quotes around the phrase ‘child-killer.’ The first time ‘child-killer’
is mentioned, please provide more context for where this phrase is often used, where it comes
from, etc. as it is unclear.
- Please provide a citation for the following sentence: “Furthermore, young women also avoid
having social interaction with women who experienced stillbirth due to a perceived fear of
contracting adverse pregnancy outcomes.” This is certainly a finding from the study but it’s
unclear if this was something known prior to the study.
- The following sentence is concerning, “Stillbirth is the colloquial synonym of induced abortion
that is considered illegal and immoral in most countries,” as a spontaneous abortion is the term
for a miscarriage but a stillbirth is not a colloquial term for induced abortion that is widely
accepted (at least in the United States). I also strongly disagree with including the statement
that abortion is considered immoral. If it is illegal in Pakistan, please state that, but remove the
term immoral.
Methods:
- Study setting:
o Please provide a citation and/or statistics for the statement that women are only engaged in
the informal economy.
- Study participants:
o Please defined ‘unregistered health practitioners’
o Traditional Birth Attendants are mentioned as recruitment women in both phases 1 and 2, is
this correct?
o Was it required that husbands or heads of household give permission for women to participate
in the interviews?
- Interview guide:
o Can you provide examples of questions asked?
- Data collection process:
o Given the gender dynamics that you have mentioned being present, please justify why a male
graduate student conducted all interviews.
- Data Analysis:
o The emphasis on neutrality and the research team not having experienced stillbirths seems
misplaced. On the contrary, I would think that the researchers being able to relate to the women
would have been more appropriate.
o I don’t believe it’s necessary to refer to the degrees of the authors within the text.
o Please discuss how data saturation was reached within the data analysis section. It is mentioned
in an earlier section but seems more relevant here.
- Ethical considerations:
o The fact that verbal consent was given is stated here and in an earlier section. Please only
state this one time.
Results:
- Blaming the victims
o In the first sentence, I’m not sure how ‘spontaneous’ is relevant here or what it means.
o Please confirm that grandmothers typically refer to the paternal grandmother.
o Were there women that felt blamed after the first stillbirth as well? I wonder how this finding
would vary if looking at first stillbirth alone or separately.
- Perceived spiritual causes of stillbirths
o I find it problematic that the authors have linked women’s beliefs in spiritual causes to be
due to low socioeconomic status and not knowing the “real causes” of stillbirths. It is not clear
that this finding came from the data and seems to be the authors blaming the women for their
low socioeconomic status and lack of formal education. The rest of the section refers to cultural
beliefs, which seems to come more from the data. Furthermore, in a later section, one of the
quotes used clearly shows that the women want to learn about the biological cause of stillbirths
but doctors tell them to pray. This further indicates that blaming women’s low education is
incorrect but that doctors either 1) also believe these cultural beliefs or 2) are discriminating
against women due to their lack of formal education.
- Spousal relationship
o Given the poor relationship to others in the household, it is concerning that other household
members read off the consent rather than the study team. Can you please explain why this
occurred and if it felt like the decision to participate was truly the woman’s?
o There’s a discussion here about older vs. younger women, I’m interested in there was also a
difference by those that had other living children vs. those that did not.
- Coping strategies
o One of the quotes discusses women having support from others that have had stillbirths but this
is not discussed at all by the authors, which is concerning. I know the authors briefly mention
that women had other sources of support, but this should be highlighted much more as a strength
of the women.
- Lack of health system support
o This section should dig more deeply into whether the women felt that doctors did not listen
to them because of cultural superstitions around stillbirths, if they were discriminatory due to
their low socioeconomic status, etc.
o This section also mentions the health system broadly yet the study team mentioned earlier
the wide array of medical providers (e.g., lady health workers, traditional birth attendants,
unregistered providers). Please expand on these different types of providers’ reactions to
stillbirths.
- Discussion
o At the end of the discussion, the authors briefly mention a study in India on pregnancy loss –
it would be helpful to discuss this study’s findings in the context of other studies on pregnancy
loss more broadly in this region.
o There is a brief mention about doctors here, but no differentiation between women’s
relationships to lady health workers, traditional birth attendants, etc., please discuss women’s
experience with these other types of providers, that women may relate to better.
- Limitations
o Please state why the interviews were conducted by a male research team member and were
not conducted in the women’s native language – this seems problematic given the context.
- Conclusion
o The conclusion briefly mentions a referral to psychiatrists at the end, which is a relatively
unfeasible recommendation given the scarcity of psychiatrists in rural Pakistan. Rather, more
attention should be paid to potential interventions that would be feasible in this context.