Late gestation stillbirth epidemiology: findings from a nationally representative mortality survey of one million population sample in India

We report on late gestation stillbirth rate (SBR) and impact of COVID-19 pandemic in a nationally representative mortality survey in nine Indian states. Detailed verbal autopsy (VA) interviews using PHMRC VA tool were undertaken for stillbirths reported between 2019 and 2022 from the adult most knowledgeable about the circumstances in a nationally representative population sample of one million. Late gestation stillbirth was defined as a fetal death with gestation period of ≥ 7 months where the fetus did not show any sign of life. We estimated overall SBR, and pre-, during and post-COVID-19 periods per 1000 births for India. We also report on stillbirth registration, last rites, and whether the mother was able to see and hold her baby. We identified 878 stillbirths in 59,639 births from 240,975 households (87.1% participation) covering an average population of 1,002,098. The annualised SBR between 2019 and 2022 was 14.7 (95% CI 13.8–15.7) per 1,000 births. The SBR in post-COVID-19 period (18.3; 95% CI 16.1–20.8) was significantly higher than pre-COVID-19 period (12.7; 95% CI 11.2–14.4) and COVID-19 period (14.4; 95% CI 13.0-15.9). The annualised antepartum SBR was estimated at 6.1 (95% CI 5.5–6.7) and intrapartum SBR at 5.0 (95% CI 4.5–5.6) per 1,000 births. Stillbirth certificate was available for only 8 stillbirths; last rites were performed for nearly all stillbirths (98.9%) and burial was the most commonly reported practice (90.9%). Only 187 (25.5%) mothers had seen and held their stillborn baby, 194 (26.4%) had only seen their baby, and 353 (48.1%) had neither seen nor held their baby. This study documents an increase in SBR post COVID-19 pandemic as compared with the pre- and pandemic periods in India. Findings could contribute to monitoring of SBR, development of bereavement guidelines, and strengthening of stillbirth registration to address the burden of stillbirths in India.