National, state and district-level estimates of stillbirth in India at 20 weeks’ gestation or longer using national family health survey data (2005–21)

Background: India contributes a substantial share to the global stillbirth burden. However, stillbirths occurring before 28 weeks of gestation are not captured in routine surveys, contributing to systematic underestimation and missed opportunities for targeted interventions. This study estimated stillbirth burden at different gestational age cutoffs across national, state/union territories, and district levels, and assessed associated risk-factors. Methods: This study used three rounds of National Family Health Survey (NFHS) data (2005-06, 2015-16 and 2019-21) for burden, trend analysis of stillbirths and data from 2019 to 21 was used for risk factor assessment. We calculated the stillbirth rate (SBR) at more than equal to 28, 24 and 20 weeks of gestation using vcal (reproductive calendar) variable from NFHS, which provides information from all sampled women about history of birth (B), termination (T), pregnancy (P) and contraception usage (C). We leveraged multivariable analysis and propensity score matching methods for risk factor assessment for stillbirths at more than equal to 28-week gestation. Findings: Analysis of 542,359 women from three survey rounds showed SBR of 12.8 (95% CI 10.7, 13.1), 16.2 (95% CI 13.6, 16.8), and 22.0 (95% CI 19.4, 22.7) per 1000 total births at more than equal to 28, 24, and 20 weeks of gestation, respectively. Largest decline (36.3%) in SBR was noted between 2005 and 06 and 2015-16. 51.4% of states and 51.9% of districts achieved single digit SBR during 2019-21. During 2019-21, an estimated 42% of stillbirths were reported between more than equal to 20 and less than equal to 28 weeks gestation. District wise spatial analysis indicated moderate clustering (crude v/s smoothed global Moran's I: 0.134 v/s 0.168 in 2019-21). Stillbirth was associated with illiteracy, short maternal stature, anaemia, use of unclean cooking-fuel, rural residence, and belonging to scheduled caste category. Lower risks were observed among women wanting delayed pregnancies and residing in joint families. Interpretation: Stillbirth remains a key public health concern in India. Counting only late-gestation stillbirths could result in missing approximately two-fifths of all stillbirths. This study reiterates the need for high-quality, standardised data systems till district level with accurate gestational age reporting that must be made more accessible for evidence-based decision-making. Funding: None.