New study reveals undercounting of stillbirths in India

A recent analysis of National Family Health Survey (NFHS) data reveals a significant undercounting of stillbirths in India. The data suggests that this issue is particularly prevalent for stillbirths occurring before 28 weeks of gestation.

Stillbirths occurring before 28 weeks of gestation are not captured in routine surveys, contributing to systematic underestimation and missed opportunities for targeted interventions, the study said.

The World Health Organization (WHO) definition for international reporting of stillbirths is foetal death at more than or equal to 28 completed weeks’ gestation or a birth weight greater than or equal to 1,000 g if gestational age is unknown.

The study, published in The Lancet Regional Health Southeast Asia, used three rounds of NFHS data (2005-06, 2015-16 and 2019-21) for burden, trend analysis of stillbirths. Data from 2019-21 was used for risk factor assessment. The researchers calculated the stillbirth rate (SBR) at more than equal to 28, 24 and 20 weeks of gestation.

Researchers led by Anuj Kumar Pandey from Mahidol University in Thailand reported that approximately 40 per cent of total stillbirths occur between more than equal to 20 weeks and less than equal to 28 weeks of gestation. This means that by considering only stillbirths occurring at more than equal to 28 weeks of gestation (in line with global standard for comparison), approximately two-fifths of total stillbirths are being excluded.

Analysis of 542,359 women from three survey rounds showed SBR of 12.8, 16.2, and 22 per 1,000 total births at more than or equal to 28, 24, and 20 weeks of gestation, respectively.

Trend analysis revealed that the SBR during 2019-21 was 11.7 per 1,000 total births at more than equal to 28 weeks' gestation, compared to 12.4 and 19.4 per 1,000 in 2005-06 and 2015-16, respectively.

Additionally, it was observed that approximately 40 per cent (42.5 per cent during 2019-21, 42.4 per cent during 2015-16 and 41.3 per cent during 2005-06) of all stillbirths in India are between 20 and 28 weeks of gestation.

Moreover, state/UT-wise assessment revealed that the contribution of SBR between more than equal to 20 weeks and less than equal to 28 weeks was higher than the national average in 38.9 per cent, 45.7 per cent, and 53.6 per cent of states during 2019-21, 2015-16 and 2005-06 respectively.

The relative reduction in stillbirths was highest (36.3 per cent) between 2005-06 and 2015-16, while it declined modestly (5.3 per cent) in the subsequent phase (2015-16 to 2019-21). A similar pattern of decline was observed across all selected gestational age thresholds.

During 2019-21, 19 out of 37 states/UTs (51.4 per cent) reported a single-digit SBR, whereas 18 out of 37 (48.6 per cent) and 6 out of 30 (20 per cent) had SBR in single digit in 2015-16 and 2005-06 respectively.

The decline could be attributed to various national programs aimed at improving the availability, accessibility, affordability and utilisation of healthcare services.

Results from multivariable analyses showed that women with high-risk fertility behaviour, height less than equal to 155 cm, delivery at private facilities, and those using unclean fuels, residing in urban areas had higher odds of stillbirths.

Global burden of disease (GBD) estimates highlight the stillbirth burden across gestational ages, revealing substantial numbers that remain underrecognised due to the predominant focus on reporting of stillbirth burden during late gestational age cut-offs (more than equal to 28 weeks). The study findings further align with the findings from GBD estimates with burden reported as 12.8 in contrast to 17.4 at more than equal to 28 gestational age.

Stillbirth remains a public health concern in India, marked by spatial disparities. Despite some progress, the persistently high stillbirth rates, particularly at earlier gestational ages underscore the need for strengthened maternal and newborn care.

District-level clustering suggests concentrated areas of vulnerability that require targeted interventions. Addressing preventable risk factors through comprehensive maternal and newborn care strategies is also critical for reducing the burden.

Global burden of disease (GBD) estimates highlight the stillbirth burden across gestational ages, revealing substantial numbers that remain under recognised due to the predominant focus on reporting stillbirth burden during late gestational age cut-offs (greater than or equal to 28 weeks). The study findings further align with the GBD estimates: the reported burden was 12.8, in contrast to 17.4 for gestational ages of 28 weeks or more. 

The WHO in 2014 launched the global Every Newborn Action Plan (ENAP) which provides a road map of strategic actions for ending preventable newborn mortality and stillbirth and contributing to reducing maternal mortality and morbidity.