Pre-Term, Deferred and Referred Deliveries Contribute to Stillbirths in the Indian State of Bihar: Results from a Population-Based Survey of All Births

Abstract

Background: The Indian government has adopted a target of <10 stillbirths per 1,000 births by 2030 through the India Newborn Action Plan (INAP). A population-based understanding of risk factors for stillbirths compared with live births that could assist with reduction of stillbirths is not readily available for the Indian population. Methods: Detailed interviews were conducted in a representative sample of all births irrespective of the birth outcome between January to December 2016 from 182,486 households (96.2% participation) in 1,657 clusters in the India state of Bihar. A stillbirth was defined as fetal death with gestation period of >28 weeks wherein the fetus did not show any sign of life. We investigated the association of stillbirth with a variety of socio-demographic, maternal, pregnancy, labour and delivery related risk factors among all births using a hierarchical logistic regression model approach. Findings: A total of 23,940 births including 338 stillbirths were identified giving the state stillbirth rate (SBR) of 15.4 (95% CI 13.2-17.9) per 1,000 births, with no difference in SBR by sex. Antepartum and intrapartum SBR was 5.6 (95% CI 4.3-7.2) and 4.5 (95% CI 3.3-6.1) per 1,000 births, respectively. In the final logistic regression model, significantly higher odds of stillbirth were documented for deliveries with gestation period of 30 years (OR 3.20, 95% CI 1.52-6.74), pregnancies with multiple foetuses (OR 2.82, 95% CI 1.49-5.33), breech presentation of the baby (OR 2.70, 95% CI 1.75-4.18), and births in private facilities and home (OR 2.23, 95% CI 1.67-2.99). Varied risk factors were associated with antepartum and intrapartum stillbirths. Among the facility deliveries, the referred deliveries had significantly high odds of stillbirth (OR 3.32, 95% CI 2.03-5.43). Interpretation: This study finds increased risk of stillbirths in deferred and referred deliveries in addition to identifying demographic and clinical risk factors for antepartum and intrapartum stillbirths from population-based data, highlighting aspects of health care that need attention in addition to improving skills of health providers to reduce stillbirths. The INAP could utilise the findings of this study to further strengthen its approach to meet the stillbirth reduction target by 2030. Funding Statement: This work was supported by the Bill & Melinda Gates Foundation. Declaration of Interests: PN and DB are employees of the Bill & Melinda Gates Foundation, India Country Office, New Delhi. The other authors have no conflict of interest. Ethics Approval Statement: This study was approved by the Institutional Ethics Committee of the Public Health Foundation of India. All participants provided written informed consent, and for those who could not read or write, the participant information sheet and consent form were explained by the trained interviewer and a thumb impression obtained.