Identification of factors associated with stillbirth in the Indian state of Bihar using verbal autopsy: A population-based study.

BACKGROUND: India was estimated to have the largest numbers of stillbirths globally in 2015 and the Indian government has adopted a target 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 1000 births with it being higher in the rural areas. A total of 1132 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 6161 (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.