India was estimated to have the largest numbers of
stillbirths globally in 2015, and the Indian government has adopted a target of <10
stillbirths per 1,000 births by 2030 through the India Newborn Action Plan (
INAP). The objective of this study was to use verbal autopsy interviews to examine factors associated with
stillbirth in the Indian state of Bihar and make recommendations for the
INAP to better inform the setting of priorities and actions to reduce
stillbirths.
METHODS AND FINDINGS: Verbal autopsy interviews were conducted for deaths including
stillbirths that occurred from January 2011 to March 2014 in a sample of 109,689 households (87.1% participation) in 1,017 clusters representative of the state of Bihar. The Population Health Metrics Research Consortium shortened verbal autopsy questionnaire was used for each interview, and cause of death was assigned using the SmartVA automated algorithm. A
stillbirth was defined as a foetal death with a gestation period of ≥28 weeks wherein the foetus did not show any sign of life. We report on the
stillbirth epidemiology and present case studies from the qualitative data on the health provider interface that can be used to improve success of improved, skilled care at birth and delivery interventions. The annualised
stillbirth incidence was 21.2 (95% CI 19.7 to 22.6) per 1,000 births, with it being higher in the rural areas. A total of 1,132
stillbirths were identified; 686 (62.2%) were boys, 327 (29.7%) were firstborn, and 760 (68.9%) were delivered at a health facility. Of all the
stillbirths, 54.5% were estimated to be antepartum. Only 6,161 (55.9%) of the women reported at least 1
antenatal care visit, and 33% of the women reported not consuming the
iron folic acid tablets during pregnancy. Significant differences were seen in delivery-related variables and associated maternal conditions based on the place of delivery and type of
stillbirth. Only 6.1% of the women reported having undergone a test to rule out
syphilis. For 34.2% of the
stillbirths, the possible risk factor for
stillbirth was unexplained. For the remaining 65.8% of the women who reported at least 1 complication during the last 3 months of pregnancy, maternal conditions including anaemia,
fever during labour, and
hypertension accounted for most of the complications. Of importance to note is that the maternal conditions overlapped quite significantly with the other possible underlying risk factors for
stillbirth. Obstetrics complications and excessive
bleeding during delivery contributed to nearly 30% of the cases as a possible risk factor for
stillbirth, highlighting the need for better skilled care during delivery. Of the 5 major themes identified in open narratives, 3 were related to healthcare providers-lack of timely attention, poor skills (knowledge or implementation), and reluctance to deliver a dead baby. The case studies document the circumstances that highlight breakdowns in clinical care around the delivery or missed opportunities that can be used for improving the provision of quality skilled care. The main limitation of these data is that
stillbirth is defined based on the gestation period and not based on
birth weight; however, this is done in several studies from developing country settings in which
birthweight is either not available or accurate.
CONCLUSIONS: To our knowledge, this study is among the few large, population-based assessments of
stillbirths using verbal autopsy at the state level in India. These findings provide detailed insight into investigating the possible risk factors for
stillbirths, as well as insight into the ground-level changes that are needed within the health system to design and implement effective preventive and intervention policies to reduce the burden of
stillbirths. As most of the
stillbirths are preventable with high-quality, evidence-based interventions delivered before and during pregnancy and during labour and childbirth, it is imperative that with
INAP in place, India aspires to document
stillbirths in a systematic and standardised manner to bridge the knowledge gap for appropriate actions to reduce
stillbirths. We have made several recommendations based on our study that could further strengthen the
INAP approach to improve the quality and quantity of
stillbirth data to avoid this needless loss of lives.