Stillbirth – The Invisible Deaths in Perinatal Care- A Position Paper

Author: Dr Akshitha Panduranga, KREST Fellow in Fetal Radiology & Fetal Medicine, Delta Scans, Bengaluru

Maternal mortality rates and mortality rates in children less than 5 years have halved, most prominently for children < 5 years with an annual rate of reduction (ARR) improving globally from 1.2% between 1990 – 1995 to 4% between 2005 – 2013 [1,2]. The focus of maternal care programs is on reduction of maternal and neonatal mortality even in the Millenium Development Goal era. The global stillbirth rate was estimated as  21.4 stillbirths/ 1000 live births in the year 2000 and has steadily declined to 13.9 stillbirths/ 1000 live births.[3,4] Currently, India is a main contributor to the magnitude of global stillbirths.[3,4] Despite the high global and national stillbirth rates, focus on stillbirth reduction had not been addressed until recently, with the advent of ENAP (Every Newborn Action Plan). [4]

Stillbirths are often confused with or hidden and brushed off under a bracket term “neonatal death” (which is death occurring in the first 28 days of life after the birth of a baby).

International classification of Disease (ICD) and WHO recommendations are now widely accepted to define stillbirths. [4,5] ICD definition considers birthweight, and the WHO definition takes into account gestational age to define  stillbirths  

  • Late fetal death 1000g or more or 28 weeks or more or 35 cm or more.
  • Early fetal death 500g or more or 22 weeks or more or 25 cm or more.
  • Miscarriage as a pregnancy loss before 22 completed weeks of gestational age.

The lack of high-quality data is a major limitation to evaluate trends in stillbirth rates. There is a lack of awareness and action despite the staggering rates of stillbirth that are obviously present even with a lack of data from many regions.

Certain myths prevail like stillbirths are inevitable and are most likely due to non-preventable congenital abnormalities. A study conducted by Samrakshan showed that a larger focus only on congenital abnormalities in second trimester is a misplaced priority based on the magnitude of pre-eclampsia and fetal growth restriction in India. [6] Anemia and undernutrition/ malnutrition continues to be a major concern in Indian pregnant women. A recent study showed an increase in the number of C-sections in India from 8.5% in 2005-2006 to a 37.9% in 2021-2022. [7] Some of the C-sections maybe inappropriate leading to increase in the preterm birth rates. This could be attributed to the probable fear of “term still births” around 35-36 weeks and a presumed fetal distress. [8,9]

The INAP (India Newborn Action Plan) was launched in response to ENAP (Every Newborn Action Plan) and aspired to achieve the Global target of 12 or even lesser stillbirths per 1000 live births by 2030 and individually achieving the target for every state in India by the year 2035. The Samrakshan program of IRIA, launched in June 2019, reported a remarkable decline in stillbirth rate from 16.07/1000 live births to 5.99 stillbirths/1000 live births in the program areas.

India continues to strive for better reduction rates in stillbirths through various schemes and community awareness programs through educating public about family planning techniques like Antara programme, free distribution of OCP pills (Mala- N) and free distribution of condoms (NIRODH); by providing better nutrition to pregnant and lactating women under Poshan Abhiyan and increasing awareness regarding intimate partner violence. Data collection on stillbirths has improved from 2011, however, sufficient investments have to be made on data systems and skill building. [10] The recorded stillbirths must be routinely reviewed at both local and national levels. Creating synergy and linking the different schemes in India to each other to achieve a common goal must be optimized.

Nearly 21% of the government budgetary allocation in India remained unused because of poor planning, implementation, and monitoring. A collaborated effort involving pregnant women, men, mother in laws and other societal gate keepers is a need of the hour to bring a significant change.

Some of India’s neighboring countries have shown resilience in trying to reduce stillbirths by incorporating mandatory 4 antenatal care visits and presence of a skilled birth attendant. [11] We must consider what hindered India’s execution of plans when nations that are economically poorer than India showed a significant increase in the annual rate of reduction of stillbirths.

Credits: Lawn JE, Blencowe H, Waiswa P, et al ; Lancet Ending Preventable Stillbirths Series study group; Lancet Stillbirth Epidemiology investigator group. Stillbirths: rates, risk factors, and acceleration towards 2030. Lancet. 2016 Feb 6;387(10018):587-603.

The large population of India and diverse terrains and settings is a major challenge for India. Although urbanization continues to increase and urban healthcare provision has made significant strides, most of the stillbirths in India are from rural areas. Rural families have restricted access to midwifery care, family planning services and emergency obstetric care like C-section. A four-delay model has described the caregiving, social and economic barriers that exist to bring about a practical, achievable, immediate and sustainable change. [12] Addressing these delays through a sustained, systematic approach can help to further improve care to pregnant women, reduce stillbirths and maternal and neonatal deaths in India.

Delay in danger sign recognition.
Delay in care seeking due to economic /social barriers or lack of transport.
Delay in receiving high quality health care facility.
Taking responsibility for maternal mortality.


India has made significant progress towards achieving better perinatal health despite the challenges posed by its large population size, vast regions and diversity of terrains and settings. Concerted efforts that focus on better data collection and data and evidence driven approaches can help to substantially improve perinatal care results. These approaches should balance information on the magnitude, risk factors, solutions and evaluation of outcomes, improved understanding of social and economic barriers and strategies to redress those, and integrate with the various schemes that currently exist to improve antenatal care. Although the magnitude of stillbirths is high, an interdisciplinary team effort can help to rapidly reduce the absolute numbers of stillbirths in India. The first step, however, is to acknowledge we have a problem and to encourage communication and discussion around it.


  1. WHO, UNICEF, UNFPA, World Bank Group, UN Population Division. Trends in maternal mortality: 1990 to 2015.
  2. You D, Hug L, Ejdemyr S, et al ; United Nations Inter-agency Group for Child Mortality Estimation (UN IGME). Global, regional, and national levels and trends in under-5 mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Inter-agency Group for Child Mortality Estimation. Lancet. 2015 Dec 5;386(10010):2275-86. doi: 10.1016/S0140-6736(15)00120-8.
  3. Lawn JE, Blencowe H, Waiswa P, et al ; Lancet Ending Preventable Stillbirths Series study group; Lancet Stillbirth Epidemiology investigator group. Stillbirths: rates, risk factors, and acceleration towards 2030. Lancet. 2016 Feb 6;387(10018):587-603. doi: 10.1016/S0140-6736(15)00837-5.
  4. Blencowe H, Cousens S, Jassir FB, et al; Lancet Stillbirth Epidemiology Investigator Group. National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysis. Lancet Glob Health. 2016 Feb;4(2):e98-e108. doi: 10.1016/S2214-109X(15)00275-2.
  5. WHO International Classification of Diseases 10th revision (ICD-10). Date: 2010.
  6. Choorakuttil RM, Satarkar SR, Sharma LK, et al. Prioritizing Fetal Structural Abnormalities Over Risk for Pre-Eclampsia and Fetal Growth Restriction in the 20-24 Gestation Week Assessment in India: Missing the Woods for the Trees? Indian J Radiol Imaging. 2022 Dec 11;33(1):107-109. doi: 10.1055/s-0042-1758875. PMID: 36855730; PMCID: PMC9968549.
  7. Pandey AK, Raushan MR, Gautam D, Neogi SB. Alarming Trends of Cesarean Section-Time to Rethink: Evidence From a Large-Scale Cross-sectional Sample Survey in India. J Med Internet Res. 2023 Feb 13;25:e41892. doi: 10.2196/41892. PMID: 36780228; PMCID: PMC9972201.
  8. Betran AP, Torloni MR, Zhang J, et al. What is the optimal rate of caesarean section at population level? A systematic review of ecologic studies. Reprod Health. 2015 Jun 21;12:57. doi: 10.1186/s12978-015-0043-6. PMID: 26093498; PMCID: PMC4496821.
  9. Chang HH, Larson J, Blencowe H, et al; Born Too Soon preterm prevention analysis group. Preventing preterm births: analysis of trends and potential reductions with interventions in 39 countries with very high human development index. Lancet. 2013 Jan 19;381(9862):223-34. doi: 10.1016/S0140-6736(12)61856-X. Epub 2012 Nov 16. PMID: 23158883; PMCID: PMC3572865.
  10. de Bernis L, Kinney MV, Stones W, et al; Lancet Ending Preventable Stillbirths Series study group; Lancet Ending Preventable Stillbirths Series Advisory Group. Stillbirths: ending preventable deaths by 2030. Lancet. 2016 Feb 13;387(10019):703-716. doi: 10.1016/S0140-6736(15)00954-X. Epub 2016 Jan 19. PMID: 26794079.
  11. El Arifeen S, Hill K, Ahsan KZ, et al. Maternal mortality in Bangladesh: a Countdown to 2015 country case study. Lancet. 2014 Oct 11;384(9951):1366-74. doi: 10.1016/S0140-6736(14)60955-7. Epub 2014 Jun 29. PMID: 24990814.
  12. MacDonald T, Jackson S, Charles MC, et al. The fourth delay and community-driven solutions to reduce maternal mortality in rural Haiti: a community-based action research study. BMC Pregnancy Childbirth. 2018 Jun 20;18(1):254. doi: 10.1186/s12884-018-1881-3. PMID: 29925327; PMCID: PMC6011389.

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