Deferred and referred deliveries contribute to stillbirths in the Indian state of Bihar: results from a population-based survey of all births

Abstract

BackgroundThe India Newborn Action Plan (INAP) aims for < 10 stillbirths per 1000 births by 2030. 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.MethodsDetailed interviews were conducted in a representative sample of all births between January and December 2016 from 182,486 households (96.2% participation) in 1657 clusters in the Indian state of Bihar. A stillbirth was defined as foetal death with gestation period of ≥ 7 months wherein the foetus did not show any sign of life. The association of stillbirth was investigated with a variety of risk factors among all births using a hierarchical logistic regression model approach.ResultsA 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 1000 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 1000 births, respectively. Detailed interview was available for 20,152 (84.2% participation) births including 275 stillbirths (81.4% participation). In the final regression model, significantly higher odds of stillbirth were documented for deliveries with gestation period of ≤ 8 months (OR 11.36, 95% CI 8.13–15.88), for first born (OR 5.79, 95% CI 4.06–8.26), deferred deliveries wherein a woman was sent back home and asked to come later for delivery by a health provider (OR 5.51, 95% CI 2.81–10.78), and in those with forceful push/pull during the delivery by the health provider (OR 4.85, 95% CI 3.39–6.95). The other significant risk factors were maternal age ≥ 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 (OR 1.75, 95% CI 1.19–2.56) and home (OR 2.60, 95% CI 1.87–3.62). Varied risk factors were associated with antepartum and intrapartum stillbirths. Birth weight was available only for 40 (14.5%) stillborns. Among the facility deliveries, the women who were referred from one facility to another for delivery had significantly high odds of stillbirth (OR 3.32, 95% CI 2.03–5.43).ConclusionsWe found an increased risk of stillbirths in deferred and referred deliveries in addition to demographic and clinical risk factors for antepartum and intrapartum stillbirths, highlighting aspects of health care that need attention in addition to improving skills of health providers to reduce stillbirths. The INAP could utilise these findings to further strengthen its approach to meet the stillbirth reduction target by 2030.Electronic supplementary materialThe online version of this article (10.1186/s12916-019-1265-1) contains supplementary material, which is available to authorized users.

Distinct mortality patterns at 0–2 days versus the remaining neonatal period: results from population-based assessment in the Indian state of Bihar

“…The methods of this survey are detailed elsewhere, and those relevant to this paper are presented [8]. For this current survey, a sample size of 23,200 live births was estimated to detect a change of 17.5% in neonatal mortality rate in Bihar from 2011 to 2016 with 80% power.…”

Enhancing the National Family Health Survey-5 for policy making

“…In NFHS-4, there were no questions to confirm stillbirth or to differentiate it from neonatal death immediately after delivery. 5 NFHS-4 found a propor tion of stillbirths of 9•7 per 1000 births for India, which is much See Online for appendix Biju Boro/Getty Images have the power to investigate full-term stillbirths 2 was subject to consultation until June 18, 2019, and we hope all those with an interest in this field to responded accordingly. Feedback is expected in September, 2019.…”

“…2 However, many of these data could be collected in population-based surveys. 5 Furthermore, in NFHS-4, the pregnancy, labour, and delivery details were documented only for livebirths. Excluding such details for stillbirths restricts the under standing of risk factors for these events.…”

“…The risk factors for antepartum and intrapartum stillbirths are not necessarily the same as those for neonatal deaths, with deferred and referred deliveries standing out as important contributors to stillbirths. 5 Second, more robust prevalence estimates are needed for stillbirths so changes over time can be monitored. In NFHS-4, there were no questions to confirm stillbirth or to differentiate it from neonatal death immediately after delivery.…”

“…2 Robust antepartum and intrapartum stillbirth estimates in large-scale household surveys are possible, as shown in the Indian state of Bihar. 5 Given these limitations, NFHS-4 data were insufficient to inform policy making and programme planning to reduce neonatal mortality and the pro portion of stillbirths in India. To not address these important data issues in NFHS-5 would be a missed opportunity to maximise relevant data for policy making in one of the largest surveys of its kind.…”