Background: The World Health Organization (WHO) defines perinatal mortality (PNM) as the "death of a baby between 28 weeks of gestation onwards till the first 7 days of life." PNM is a key indicator of the quality of care for newborns and directly reflects the category of prenatal, intrapartum, and postpartum care given to a newborn. According to a report published by the WHO, 2.3 million children died within their first 20 days of life in 2022. Approximately 6500 newborn deaths occur every day, accounting for 47% of all child deaths under the age of five years. PNM is a public health concern in low and middle-income countries. According to the Pakistan Health and Demographic Survey 2017-18, the PNM rate has remained consistently high in Pakistan (75 per 1000 births) during the last decade. Aims: To observe the frequency of PNM and early neonatal mortality (ENM) among the Pakistani population within the last decade and to identify additional risk factors for PNM and ENM. Methods: Published studies were searched using keywords comprising PNM, ENM, stillbirths, risk rate, perinatal period, and their combinations with search engines such as Science Direct, SCOPUS, PubMed, and Google Scholar. We followed Preferred Reporting Items for Systematic review and Meta-Analyses (PRISMA) guidelines to filter articles and selected 18 relevant articles for systematic review. All studies reported either the PNM, ENM, stillbirth, or live birth rate. Results: Systematic review showed that the PNM rate in Pakistan remained high from 2013 to 2022. Hypertensive disorders, antepartum hemorrhage, and neonatal infections increased the overall risk of PNM and ENM. Other factors that contributed to the high PNM rate were advanced maternal age, low birth weight, congenital abnormalities, multigravida, poor socioeconomic conditions, and other medical problems such as gestational diabetes. Conclusion: The PNM rate in Pakistan was found to be high according to the systematic review, but discrepancies were observed when compared with the WHO figures for PNM. We recommend conducting more original research to accurately assess the PNM rate in Pakistan, which is essential for informed and effective policy making.

OBJECTIVE: We conducted a systematic review and meta-analysis to examine the relationship between stillbirth and various perinatal outcomes in subsequent pregnancy. DATA SOURCES: PubMed, the Cochrane Library, Embase, Web of Science, and CNKI databases were searched up to July 2023. STUDY ELIGIBILITY CRITERIA: Cohort studies that reported the association between stillbirth and perinatal outcomes in subsequent pregnancies were included. METHODS: We conducted this systematic review and meta-analysis in accordance with the PRISMA guidelines. Statistical analysis was performed using Rand Stata software. We used random-effects models to pool each outcome of interest. We performed a meta-regression analysis to explore the potential heterogeneity. The certainty (quality) of evidence assessment was performed using the GRADE approach. RESULTS: Nineteen cohort studies were included, involving 4,855,153 participants. From these studies, we identified 28,322 individuals with previous stillbirths who met the eligibility criteria. After adjusting for confounders, evidence of low to moderate certainty indicated that compared with women with previous live births, women with previous stillbirths had higher risks of recurrent stillbirth (odds ratio, 2.68; 95% confidence interval, 2.01-3.56), preterm birth (odds ratio, 3.15; 95% confidence interval, 2.07-4.80), neonatal death (odds ratio, 4.24; 95% confidence interval, 2.65-6.79), small for gestational age/intrauterine growth restriction (odds ratio, 1.3; 95% confidence interval, 1.0-1.8), low birthweight (odds ratio, 3.32; 95% confidence interval, 1.46-7.52), placental abruption (odds ratio, 3.01; 95% confidence interval, 1.01-8.98), instrumental delivery (odds ratio, 2.29; 95% confidence interval, 1.68-3.11), labor induction (odds ratio, 4.09; 95% confidence interval, 1.88-8.88), cesarean delivery (odds ratio, 2.38; 95% confidence interval, 1.20-4.73), elective cesarean delivery (odds ratio, 2.42; 95% confidence interval, 1.82-3.23), and emergency cesarean delivery (odds ratio, 2.35; 95% confidence interval, 1.81-3.06) in subsequent pregnancies, but had a lower rate of spontaneous labor (odds ratio, 0.22; 95% confidence interval, 0.13-0.36). However, there was no association between previous stillbirth and preeclampsia (odds ratio, 1.72; 95% confidence interval, 0.63-4.70) in subsequent pregnancies. CONCLUSION: Our systematic review and meta-analysis provide a more comprehensive understanding of adverse pregnancy outcomes associated with previous stillbirth. These findings could be used to inform counseling for couples who are considering pregnancy after a previous stillbirth.

Inadequate attendance to antenatal care has been associated with negative maternal and fetal outcomes, including stillbirth. This study aimed to identify facilitators and barriers to antenatal care attendance. A systematic search was conducted in March 2019 and updated in January 2021. Qualitative studies involving pregnant or post-partum women up to 12 months from high-income countries that provided data about facilitators and barriers to antenatal care attendance were sought. Meta-ethnography was used to inform this meta-synthesis. Fifteen studies were included in the analysis. Findings indicate that inadequate antenatal care attendance is influenced at different levels. Aspects like sociodemographic factors, difficulties navigating the health system, administrative delays, lack of flexibility and tailored care, constant change of carer and communication issues also act as barriers. These issues affect women's access to knowledge and the formation of women's beliefs and feelings towards seeking care. On the contrary, having a positive attitude towards the pregnancy, encountering empathetic healthcare professionals and availing of social support acted as facilitators. The reasons why women seek or delay attending antenatal care are multifactorial and can be explained using the Social Determinants of Health Framework. Any response needs to be taken across all levels of influence and not just focused on the individual. A better understanding of the barriers and facilitators to antenatal care might contribute to informing intervention or policy development addressing this issue.