Stillbirth among women in nine states in India: rate and risk factors in study of 886,505 women from the annual health survey

Abstract

ObjectivesTo assess the rate of stillbirth and associated risk factors across nine states in India.DesignSecondary analysis of cross-sectional data from the Indian Annual Health Survey (2010–2013).SettingNine states in India: Madhya Pradesh, Chhattisgarh, Rajasthan, Uttarakhand, Jharkhand, Odisha, Bihar, Assam and Uttar Pradesh.Participants886 505 women, aged 15–49 years.Main outcome measuresStillbirth rate with 95% CI. Adjusted OR to examine the associations between stillbirth and (1) socioeconomic, behavioural and biodemographic risk factors and (2) complications in pregnancy (anaemia, eclampsia, other hypertensive disorders, antepartum and intrapartum haemorrhage, obstructed labour, breech presentation, abnormal fetal position).ResultsThe overall rate of stillbirth was 10 per 1000 total births (95% CI 9.8 to 10.3). Indicators of socioeconomic deprivation were strongly associated with an increase in stillbirth: rural residence (adjusted OR (aOR) 1.27, 95% CI 1.16 to 1.39), female illiteracy (aOR 1.43, 95% CI 1.17 to 1.74), low socioeconomic status (aOR 2.42, 95% CI 1.82 to 3.21), schedule caste background (aOR 1.11, 95% CI 1.04 to 1.19) and woman not in paid employment (aOR 1.15, 95% CI 1.07 to 1.24). Women from minority religious groups were at higher risk than the Hindu majority (Muslim (aOR 1.33, 95% CI 1.25 to 1.43); Christian (aOR 1.42, 95% CI 1.19 to 1.70)). While a few women smoked (<1%), around 9% reported chewing tobacco, which was associated with an increased odds of stillbirth (aOR 1.11, 95% CI 1.02 to 1.21). Adverse pregnancy and birth characteristics were also associated with stillbirth: antenatal care visits <4 (aOR 1.08, 95% CI 1.01 to 1.15), maternal age <25 years (aOR 1.29, 95% CI 1.21 to 1.37) and ≥35 years (aOR 1.16, 95% CI 1.04 to 1.29), multigravida (aOR 3.06, 95% CI 2.42 to 3.86), multiple pregnancy (aOR 1.77, 95% CI 1.47 to 2.15), assisted delivery (aOR 3.45, 95% CI 3.02 to 3.93), caesarean section (aOR 1.73, 95% CI 1.58 to 1.89), as were pregnancy complications (aOR 1.42, 95% CI 1.33 to 1.51).ConclusionIndia is an emerging market economy experiencing a rapid health transition, yet these findings demonstrate the marked disparity in risk of stillbirth by women’s socioeconomic status. Tobacco chewing and maternal and fetal complications were each found to be important modifiable risk factors. Targeting the ‘at-risk’ population identified here, improved recording of stillbirths and the introduction of local reviews would be important steps to reduce the high burden of stillbirths in India.

Burden of stillbirths and associated factors in Yirgalem Hospital, Southern Ethiopia: a facility based cross-sectional study

“…Thus, aforementioned studies were conducted in referral hospitals which have better obstetric care facilities and skilled health workforce; whereas our study setting was a general hospital with fewer obstetricians and majority of cases were referred from peripheral primary health care units with poor facilities, which provide obstetric services for a predominantly rural population. The proportion of stillbirths in our nding was also higher than the global estimates of stillbirth for Ethiopia (25,26), and other studies from developing countries such as Bangladeshi (27) and India (28). This variation could be partly explained by differences in study settings and methods because the present study was a hospital based study unlike other community based studies from developing countries.…”

“…Mothers in labour are often admitted and managed in the maternity ward of the hospital. Majority of mothers in labour are referred from the neighboring district hospitals and health centers for various obstetric and medical reasons (28).The total number of deliveries in one year period (from August 1, 2015-July 30, 2016) in the hospital was reported to be 3000.…”

Unsafe abortion and abortion-related death among 1.8 million women in India

“…The AHS is a population-based household survey in which self-reported data on maternal and child health, demographics, birth and access to health and family planning services were collected from 4.3 million households in nine less developed states of India (Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttar Pradesh, Uttarakhand and Assam), representing 50% of the country’s population, 61% of births and 62% of maternal deaths. 15 16 The AHS used a stratified simple random sampling (without replacement) to obtain a sample that was representative of and proportional to the size of the selected villages. Survey weights were developed to account for the sampling method.…”

“…All women who provided information on their pregnancy (91.3% most recent pregnancy and 8.7% on a previous pregnancy) were included. As in a previous study using the same dataset, women who had an abortion after 28 weeks were excluded as these were most likely to be stillbirths (according to the WHO definition for stillbirth) 15. A total of 1 876 462 women who reported being pregnant during the reference period 2007–2011 were included in the study.…”

Smoking and Tobacco Use: Ill Effects on Reproductive, Maternal, Newborn, Child Health, and Adolescent (RMNCHA) Program—A Review

“…43,64 A meta-analysis of risk factors in 886,505 women from nine states of India showed that tobacco chewing women (% of total) had higher odds of having stillbirth (OR: 1.1; 95% confidence interval [CI]: 1.02-1.21) after excluding other confounding factors. 65 Lessons learned from epidemiological and experimental animal model studies confirm these observations. 66 More than one-quarter of the risk of death due to SIDS is attributable to smoking during pregnancy and exposure to SHS, particularly in the home.…”