Table 3 Social norms and taboos affecting the reporting of stillbirths

NUMERATOR – Stillbirths and early neonatal deaths are often hidden

• Loss of "not-yet-human" babies is attributed to spiritual possession and sorcery in many traditional cultures. Hence social norms suppress grieving or even discussion for fear of the spirits causing a recurrence.

• In societies where fertility is prized, having a stillbirth may constitute failure as a wife and may result in divorce, adding a layer of shame to having had a stillbirth.

• Lack of societal recognition of a stillbirth as a loss (e.g. compared to a child death) also results in suppressed grieving and lengthened time for grief resolution.

• Women may fear being accused of having an induced abortion or not wanting the baby.

• Some cultures believe a stillbirth occurs because the woman was unfaithful during pregnancy, so the event may be concealed to prevent gossip.

DENOMINATOR – Pregnancy is concealed in many cultures

• Pregnant women are believed to be more vulnerable to sorcery, spirit possession, injury, and disease. Hence pregnancies are not publicly acknowledged until they "show" and may even be denied when very apparent (e.g., an Ashanti in Ghana when asked if pregnant is expected to say "No I am only drinking too much water"). In many cultures, disclosure is limited to one's partner and one or two trusted females to secure support.

• In societies with high fertility and high rates of breastfeeding, women may not be menstruating regularly and may be several months pregnant before they are aware of the pregnancy.

DATA IMPLICATIONS

• Underreporting of stillbirths and pregnancies is common in many settings. Sensitivity may be heightened where induced abortion is illegal or socially unacceptable.

• Mortality data collection techniques are required that are more confidential and woman-sensitive.

• An objective scoring system for stillbirth data quality is required so that falsely low rates are not used for programme priority setting and tracking of programme effectiveness.

• Analysis suggests that existing data collections systems underestimate stillbirth rates (Vital Registration systems by 34% and Demographic and Health Surveys by at least 30%). Current data in many settings may need to be adjusted using modelling techniques.

SOCIETAL IMPLICATIONS

• Social taboos mean that open mourning, public discussion and also media coverage is rare, and this affects the policy priority given to stillbirths by the media and by politicians.