Understanding stillbirths and maternal deaths in Pakistan: evidence from a national household survey.

Background: The global impact of stillbirths and maternal deaths is enormous, with over two million deaths occurring each year, affecting public health outcomes and global development practices. Despite Pakistan's commitment to the Sustainable Development Goals, the country faces a substantial burden of stillbirths and maternal deaths. However, data on cause-specific mortality and the timing of deaths remains limited. In this context, we aimed to estimate the cause distribution and proportion of stillbirths (antepartum and intrapartum) and maternal deaths among married women aged 12-49 years in Pakistan. Methods: We conducted a cross-sectional household survey with retrospective ascertainment in urban and rural households from all four provinces of Pakistan (Sindh, Punjab, Balochistan, and Khyber Pakhtunkhwa) and three administrative regions (Gilgit Baltistan, Azad Jammu and Kashmir, and the Islamabad Capital Territory) using the sampling frame of the Pakistan National Nutrition Survey 2018. For the cause of death estimation, we calculated a target sample size of 2,100 stillbirths, allocated to provinces and regions in proportion to the population. Maternal deaths were ascertained using the same household enumeration and selection process. The mortality survey questionnaire collected information on births, stillbirths, and maternal deaths, while a Verbal and Social Autopsy questionnaire was used to assess causes of death. Following extensive training, the study teams conducted fieldwork to interview households with identified deaths. Data were captured electronically in the field to enable continuous quality control and remote monitoring. Causes of death were assigned both by trained physicians (physician-certified verbal autopsy) and by two computer-coded methods (InterVA-5 and InSilicoVA). Results: We recorded 2,076 stillbirths and 848 maternal deaths from the identified households during the 2017-2018 study period. The overall rate of stillbirth at the country level was 30.5 per 1,000 total births, while the maternal mortality ratio was 176.2 per 100,000 live births, with higher rates observed in rural areas. The leading causes of death for both stillbirths and maternal deaths were generally similar, including pregnancy-induced hypertension, obstetric haemorrhage, sepsis, and obstructed labour. Delays in seeking and accessing care, both for stillbirths and maternal deaths, resulted from issues in the identification of illness severity, decision-making, transportation issues, and delayed provision of health care once reaching a provider. Conclusions: The high stillbirth (30.5 per 1,000 births) and maternal mortality (176 per 100,000 live births) rates we observed exceed Pakistan's national targets and the Sustainable Development Goals 2030 targets. Persistent inequities, particularly in rural Balochistan and Khyber Pakhtunkhwa, are driven by delays in recognising illness, deciding to seek care, reaching facilities, and receiving timely facility-based care. Closing these gaps will require provincial investment in emergency obstetric and newborn care, scale-up of skilled birth attendance, and community awareness of danger signs.