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. 2019 Feb 7;17(1):28.
doi: 10.1186/s12916-019-1265-1.

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

Rakhi Dandona  1   2 , G Anil Kumar  3 , Md Akbar  3 , Debarshi Bhattacharya  4 , Priya Nanda  4 , Lalit Dandona  3   5
Affiliations

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

Rakhi Dandona et al. BMC Med. .

Abstract

Background: The 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.

Methods: Detailed 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.

Results: 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 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).

Conclusions: We 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.

Keywords: Antepartum; Deferred delivery; India; Intrapartum; Rate; Stillbirth.

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Conflict of interest statement

Ethics approval and consent to participate

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.

Consent for publication

Not applicable.

Competing interests

PN and DB are employees of the Bill & Melinda Gates Foundation, India Country Office, New Delhi. The other authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Referral pattern for 827 births where the women had gone to another facility for delivery but then delivered in a different facility in the Indian state of Bihar. Data missing on 9 births
Fig. 2
Fig. 2
Classification process used to identify antepartum and intrapartum deaths for the stillbirths in the Indian state of Bihar
Fig. 3
Fig. 3
Key recommendations for the India National Action Plan (INAP) to strengthen surveillance mechanism for stillbirths in addition to those proposed in the INAP
See this image and copyright information in PMC

References

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