Key findings
What is new?
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• What was known already: Many low- and middle-income countries rely on population-based surveys like the Demographic and Health Surveys to measure pregnancy and adverse pregnancy outcomes (APOs). However, there are challenges with their data quality, including misclassification and omission of events, as well as social norms that influence reporting of pregnancy and APOs. • What was done: 28 FGDs were conducted across five HDSS sites in five countries in sub-Saharan Africa and South Asia, involving 172 women and 82 survey interviewers (eight of these interviewers were supervisors from Matlab). Qualitative methods were used to explore barriers and enablers to reporting of pregnancy and multiple APOs, notably miscarriages, stillbirths and neonatal deaths. | |
What was found?
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• Barriers/enablers: o Methodological barriers to reporting pregnancies and APOs in surveys: these were mainly generic, such as challenges with survey tools and consistency in training, but context-specific too, including local understanding of constructs. Interviewer skills and knowledge are critical in accurate collection of data. o Sociocultural barriers to reporting pregnancy and APOs: these were remarkably similar across five different settings, especially religious and cultural beliefs and stigma. There are also women-specific barriers, notably for adolescents and younger women. o Psycho-social impact of APOs: grief associated with loss means that many mothers do not want to recount these negative experiences, especially for a purpose they do not understand. • Differences in reporting APOs o Variation in severity of reporting barriers by APO: The results suggest that there is a “dose response,” with higher barriers to reporting APOs at earlier gestations and those with more attached stigma, notably miscarriage, then stillbirth, with neonatal deaths more likely to be reported but still less likely than older child deaths. This is evident in the various burial and mourning practices. | |
What next in measurement and research?
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• Measurement improvement now: o Tools and local adaption: ensure translations of key terms are culturally and linguistically accurate and grounded in the local cultural context. o Interviewer soft skills: develop skills in rapport building, probing and empathy among survey interviewers through enhanced training with interactive and reciprocal exchanges. o Survey purpose and use of data: provide interviewers with adequate knowledge about the survey, and ensure this is well communicated to respondents, especially its benefits to their health and that of the broader community, with confidentiality emphasised. • Research needed: o Contextual adaptation guide: research is needed on how to improve tools for surveys on pregnancy and APOs, to ensure more accurate and consistent reporting in different cultures and languages. o Enhanced training module for interviewers: there is a need for development and evaluation of enhanced training materials on pregnancy and APOs to be included in survey fieldworker training, with prospective assessment to understand the effect of this enhanced training. |
Background
Methods
Study design
Participant selection
Data collection
Research team and reflexivity
Data analysis
Results
Overall
Major theme | Sub-theme | Barriers to reporting of pregnancy | Barriers to reporting of adverse outcomes |
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Socio-cultural and spiritual beliefs | Stigma | Unplanned pregnancy, fear of judgement | Blame for women for these APOs; fear of judgement and stigma from the community |
Religion | Religion discourages pregnancy before marriage | Fatalism about APOs or seen as punishment | |
Witchcraft and spiritual beliefs | People with ill intentions will harm the baby; evil spirits attracted by disclosure | Miscarriage and stillbirth caused by spiritual harm, or punishment; talking about it may cause a reoccurrence of APO | |
Variation in recognition of the baby’s value | Baby not considered human; value attached to a baby influences reaction to death | ||
Burial and mourning practices | Often different for APOs, especially miscarriages and stillbirths; secretive burials | ||
Descriptions/names of APOS | Names with negative meanings; same names used to mean different APOs | ||
Trust/privacy | Lack of trust, unsure of privacy and confidentiality of their information | ||
Gender & patriarchy | Men who do not want their wives to be interviewed; more barriers for interviewer of a particular sex | ||
Woman-specific | Age | Adolescent girls: secretive, scared and shy | |
Individual response to pregnancy | Woman unsure about pregnancy and considering if to terminate the pregnancy | ||
Psycho-social impact of APOs | Negative psychological and emotional impact | APOs cause grief and sadness. Talking about them resurrects bad memories | |
Survey interview tools and processes | Specific to these outcomes | Questions on APOs considered irrelevant, purpose and benefits not clear to women Questions are intrusive on a sensitive topic | |
General | Interviewer skills, strategies and knowledge Long interview tools with apparently repetitive questions Physical distance challenges in locating respondents High workload for interviewers Inconvenient time of interviews Multiple call-backs to a household to locate right respondent |
Barriers related to interview tools and processes
Sometimes when you go to the house, some of them will be in a hurry to go to work so they sometimes do not give us the right responses… (Interviewer, Kintampo, Ghana)
Barriers to reporting of pregnancy
Socio-cultural and spiritual beliefs
The problem may arise from some individuals who may label and say she gave birth while the previous child is an infant or she didn’t feed well the already born children but still she is getting another pregnancy. Or they may talk about whether you got the pregnancy from an unknown partner and this may bring another label to you, that the people may say that pregnancy (newborn) is called ‘diqala’ or ‘wofzerash’ meaning unknown source or from unknown father, which is very taboo and outlawed. Due to this and other social criticism we preferred to hide our pregnancy (Woman, Dabat, Ethiopia)
If she is pregnant for the first time, this is something that she was not expecting… you have this shame, this fear. For example, a woman like me who is not married to be pregnant, I am going to be embarrassed to tell people, for my colleagues to see me. Maybe those that have already been pregnant are not going to be embarrassed, but those that have never been pregnant before, I am going to be embarrassed to tell my boyfriend, I am going to say I have never been pregnant… (Woman, Bandim, Guinea Bissau)
Culturally, it’s not good to tell everyone about the pregnancy. When you tell one about your pregnancy age, culturally they can take your footstep soil and bewitch you and you get a miscarriage, have caesarean birth or you may die during labour process. Therefore, it is better to keep silent and they just see (Woman, IgangaMayuge, Uganda)
Sometimes when we arrive, the woman says her husband does not authorize her to speak with us (Interviewer, Bandim, Guinea-Bissau)
Woman-specific factors
…Also a woman will not tell you she is pregnant if she has not decided on whether to keep the pregnancy or not. So generally capturing early pregnancies is difficult (Interviewer, Kintampo, Ghana).
Barriers to reporting of adverse pregnancy outcomes
…but musawo [doctor] you have asked a number of times but now look at such questions. The children died and you won’t bring them back. Just ask for the ones who are still alive but the dead, miscarriages, stillbirths, how are you going to help us? It is useless and just time wasting to ask those questions (Interviewer, IgangaMayuge, Uganda)
Variation in recognition of the baby’s value
One child of mine has been miscarried. I have seen, it was like a piece of meat. So, what was [there] to love about that piece of meat? (Woman, Matlab, Bangladesh)
With regard to a miscarriage, it’s not yet developed into a human and you don’t see the face but the one I have given birth to and have seen the face and cared for, when he/she dies it will pain me more than the miscarriage. It could be that the miscarriage didn’t even last for three or four months compared to the one I will carry for nine months, care and breastfeed. So I will value him or her more than the miscarriage (Woman, Kintampo, Ghana).
Descriptions/names of adverse pregnancy outcome
Psycho-social impact of APOs
As I have told you before, acquiring information is difficult on adverse pregnancy outcomes. Talking about the dead child is uncommon in the community. It is worse when it is neonatal death or when children get older as compared to the miscarriages, abortion and stillbirth because they remember the characteristics that they have seen. Therefore, women will be even tearing when you talk about a newly lost newborn. This makes the data collection difficult in the case of neonatal deaths (Interviewer, Dabat, Ethiopia)
Enablers to reporting of pregnancy and APOs
Interview process
We conduct a one-on-one interview and there is privacy, so if you read out the informed consent and the person is told why you have visited her, the woman will be sure of confidentiality since the consent brings out all that message. It makes them free and gives us the information… (Interviewer, IgangaMayuge, Uganda)
Interviewer skills and strategies
In my perspective the question about the abortion, stillbirth or dead infant may be very important to link the causes of death. But the way of asking such sensitive questions must take a friendly approach and care must be taken not to disappoint the women who have suffered. If you approach the woman kindly, share condolence and give her time to talk about her worries you can get the right information and these women will be treated well and they will give credit to you. The problem is most data collectors are very speedy and without conscious understanding of the women’s grief they started to ask directly about this sensitive issue. Consequently, we end up with the wrong information or a quarrel may be raised (Woman, Dabat, Ethiopia).
Respondents’ understanding and perceived benefits from the interview
Discussion
Discussion of findings
Area | Potential solutions |
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Interview process | Guaranteeing privacy and confidentiality |
Detailed and comprehensive consent | |
Using language respondent is comfortable with and the interviewer is fluent in (most commonly used language) | |
Realistic number of interviews per interviewer each day | |
Interviewer training | Development of enhanced training module for interviewers, with prospective assessment to understand its effect |
Interactive and reciprocal training that involves the experienced interviewers sharing their strategies to make respondents more comfortable and open up | |
Classroom and field practice interviews | |
Thorough training of interviewers to ensure in-depth understanding of the study and ability to explain its purpose to others | |
Interviewer skills, strategies and knowledge | Interviewer sensitivity to cultural semantics and taboos |
Building rapport | |
Probing skills | |
Empathy | |
Sensitivity | |
Understanding of psycho-social impact of grief | |
Skills in interviewing adolescents | |
Selecting interviewers from the same jurisdiction (though not the actual villages in which they will work) | |
Tools | Translation of tools using accurate and culturally recognised definitions e.g. of the different APOs |
Contextual adaptation guide to ensure more accurate and consistent reporting in different cultures and languages | |
Shorter tools | |
Respondents and community | Conducting sensitisation before the study begins, including a clear explanation on purpose, benefits and any incentives to be given |
Consent from different gate keepers | |
Provision of feedback on the study |