Perinatal Mortality: A Dissection of Social Myths, Socioeconomic Taboos and Psychosocial Stress

Perinatal mortality is a global challenge. However, developing countries have to bear the brunt of it, accounting for 98% of perinatal deaths [1]. World Health Organization (WHO) defines perinatal mortality as deaths occurring during late pregnancy (>22 weeks of gestation), during birth and within seven days after delivery [1,2]. The perinatal period is considered the most critical phase of Life [2-4]. Globally there are about 130 million babies born every year of which 4 million die in the first 4 Weeks and 3.3 million are still births [1,5]. In Pakistan, about 5.3 million births occur yearly out of which 2,70,000 new borns die. This high perinatal mortality is 10 times higher than that in Unites States [5,6].


Introduction
Perinatal mortality is a global challenge. However, developing countries have to bear the brunt of it, accounting for 98% of perinatal deaths [1]. World Health Organization (WHO) defines perinatal mortality as deaths occurring during late pregnancy (>22 weeks of gestation), during birth and within seven days after delivery [1,2]. The perinatal period is considered the most critical phase of Life [2][3][4]. Globally there are about 130 million babies born every year of which 4 million die in the first 4 Weeks and 3.3 million are still births [1,5]. In Pakistan, about 5.3 million births occur yearly out of which 2,70,000 new borns die. This high perinatal mortality is 10 times higher than that in Unites States [5,6].
It would be difficult to achieve The Millennium Development goal of reducing child mortality by two thirds by 2015 without reducing perinatal death [2,7]. The Perinatal mortality rates reported for Pakistan are between 61-81/1,000 [5,8]. A demographic survey in Karachi reported 54/1000 [5,9]. Rural and per urban survey from Lahore reported 67/1000 [5,10].
Surveys previously conducted were largely hospital based focusing on socio-biological determinants. The importance of this research lies in unfolding community practised social myths, socioeconomic and psychosocial stresses contributing in high perinatal mortality.

Objective
To lay out in open, various community based social myths, socioeconomic and psychosocial taboos causing an increase in PNM.

Methodology
A small scale, community based, retro-grade, cross sectional survey was conducted by a learning researcher in the month of June, 2012. Study was conducted in an urban squarter, Rehri Goth, a coastal fishing village in Pakistan, located on Arabian Sea coast, comprising of the community of fishermen and laborers [11]. Included in the survey were a total of 55 married women of reproductive age (15-49 years) having a history of perinatal mortality (still births and early neonatal deaths). They were conveniently surveyed by a structured questionnaire preceded by informed consent, filled by researcher. It inquired about various dimensions affecting PNM.
2) Biological and Psychological Determinants (no. of pregnancies experienced, hours of work daily during pregnancy, no of full term, premature, still births, neonatal deaths experienced, antenatal care if taken, vaccination history, if pressured for giving birth to sons, antenatal, postnatal complications and psychosocial stress faced in each pregnancy).
3) Details of New Born (sex, congenital anomaly, birth weight if known, history of birth asphyxia, umbilical cord anomaly).

Results
Outcome of the study showed that out of 55 surveyed women with a history of perinatal mortality, 38.2% were pressurized for sons; rate of drug and tobacco addiction was high amongst them. Generally, 67.3% were addicted to betel nuts and gutka, 50.9% to tobacco and 25.5% to drug intake. Psychological stress was faced by 40% (confirmed through emotional and behavioral symptoms) during pregnancy. Majority of surveyed females 63.6% did not take antenatal care, 40.9% of them due to some myth while 22.7% had no access to antenatal care (Table 1).

Psychosocial Factors
During our survey, 38.2% females reported that they were pressurized for giving birth to sons while 61.8% were not. Addiction to betel nuts and gutka, tobacco and drug intake were 67.3%, 50.9%, 25.5%, respectively. Psychological stress was experienced by 40%  Normal birth weight of 2.5 Kgs were 29.1% (n=16) and those with birth weight >2.5 Kgs were 5.5% (n=3). Since, it was retrospective survey exact weight of the neonate was not determined, had to rely over hospital records and mother's memory.

Discussion
Pakistan has rich heritage of social myths, spanning several decades, diffusing through linguistic, racial, geographical and socioeconomic barriers. However, with better conditioning of mind through education many of these detrimental myths have washed away in upper and middle socioeconomic setups. Unfortunately, in orphanage areas like rural and outskirts of urban it still persists as a plague. Underlying rationale behind endemicity of social myths is being deserted from basic education. More than 60% of men and 90% of women have received no formal schooling or education (IUCN, 2003). Among many myths, stories, or old wives' tales, is the belief that is passed arduously in Rehri Goth and directly implicated in perinatal mortality was the probability of acquiring 'infertility' with antenatal care taken. The majority of surveyed females (63.6%) did not take antenatal care during their pregnancy, 40.9% of them due to 'infertility' myth while 22.7% had no access to antenatal care.
Another myth that was found among Rehri Goth women was that by eating less the child will be born easier through the normal vaginal delivery. The consequence of this myth often leads to malnourishment and low birth weight for the child sometimes resulting in death. There is also a belief that home delivery is a better option than that of a hospital. These decisions create barriers to the delivery of a healthy child.
Perinatal mortality itself is governed by many factors including the 'myth' factor which is largely over-looked and yet is a significant contributor in many developing nations. Any stigma to form and prosper requires several culture influenced factors. To overcome them requires multi-dimensional prolong efforts in various sectors. Perinatal mortality jeopardizes maternal health and life accounting for high maternal morbidity and mortality in Pakistan. It is important not only to make ante-natal care accessible but also to make it acceptable and available. Proper education regarding benefits of antenatal care and surveillance programs can help in reducing PNM.
Another significant culprit present in Rehri Goth particularly and largely in developing nations like Pakistan is the pressure inflicted on pregnant females for bearing sons. Survey results showed (38.2%) females were pressurized for sons. Higher rate of drug usage, tobacco in the form of shisha and gutka, betel nuts were seen among these pressurized females. Study has shown that perinatal mortality increases directly with the level of maternal smoking during pregnancy. Increases in smoking level are associated with increases in the frequency of early fetal deaths and of neonatal deaths [12].
Psychological stress was reported by 40% during their pregnancy. Factors causing such stress were intense house hold work for 6-8 (34.5%) hours per day, economic instability (76.4% men had temporary earning of less than 5,000/month <52.97 USD/month), poverty, pressure for sons, and unbalanced diet (50.9%). Along with malnutrition, maternal health is affected by manual labor (getting water and fuel for their households). Moreover, the fertility rates among such women are high. The high energy demands on poor women from their combined productive and reproductive roles together with malnutrition thus have a substantial impact on their health. This is further compounded by poor health care. Children born to underweight and stunted women are also likely to be underweight and stunted which affect their future potential at the individual and community level [13].
Illiteracy, unskilled labor, poor living conditions, disparity among kids, preference for male child results as malnutrition, poor maternal health, antenatal and postnatal complications and eventually an increase in perinatal mortality.  Figure 3: According to mothers, 29.1% (n=16) deaths were due to her own disease out of which vast majority were due to Pre-eclampsia. Of significance here was 14.5% (n=8) reported that neonatal death was either due to God's will or supernatural powers. A study has reported 64/1000 PNDs due to eclampsia and 56% of severe perinatal complications [5,11].