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Epidemiology
Research
Stillbirth among women in nine states in India: rate and risk factors in study of 886,505 women from the annual health survey
  1. Noon Altijani1,
  2. Claire Carson2,
  3. Saswati Sanyal Choudhury3,
  4. Anjali Rani4,
  5. Umesh C Sarma5,
  6. Marian Knight2,
  7. Manisha Nair2
  1. 1 Nuffield Department of Population Health, University of Oxford, Oxford, UK
  2. 2 National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
  3. 3 Department of Obstetrics and Gynaecology, FAA Medical College and Hospital, Barpeta, Assam, India
  4. 4 Department of Obstetrics and Gynaecology, Institute of Medical Sciences, Banaras Hindu University, Ajagara, Banaras Hindu University, Varanasi, Uttar Pradesh, India
  5. 5 Srimanta Sankaradeva University of Health Sciences, Assam, Narkashur Hilltop, Christian Basti Bhangagarh, Guwahati, Assam, India
  1. Correspondence to Dr Manisha Nair; manisha.nair{at}npeu.ox.ac.uk

Abstract

Objectives To assess the rate of stillbirth and associated risk factors across nine states in India.

Design Secondary analysis of cross-sectional data from the Indian Annual Health Survey (2010–2013).

Setting Nine states in India: Madhya Pradesh, Chhattisgarh, Rajasthan, Uttarakhand, Jharkhand, Odisha, Bihar, Assam and Uttar Pradesh.

Participants 886 505 women, aged 15–49 years.

Main outcome measures Stillbirth rate with 95% CI. Adjusted OR to examine the associations between stillbirth and (1) socioeconomic, behavioural and biodemographic risk factors and (2) complications in pregnancy (anaemia, eclampsia, other hypertensive disorders, antepartum and intrapartum haemorrhage, obstructed labour, breech presentation, abnormal fetal position).

Results The overall rate of stillbirth was 10 per 1000 total births (95% CI 9.8 to 10.3). Indicators of socioeconomic deprivation were strongly associated with an increase in stillbirth: rural residence (adjusted OR (aOR) 1.27, 95% CI 1.16 to 1.39), female illiteracy (aOR 1.43, 95% CI 1.17 to 1.74), low socioeconomic status (aOR 2.42, 95% CI 1.82 to 3.21), schedule caste background (aOR 1.11, 95% CI 1.04 to 1.19) and woman not in paid employment (aOR 1.15, 95% CI 1.07 to 1.24). Women from minority religious groups were at higher risk than the Hindu majority (Muslim (aOR 1.33, 95% CI 1.25 to 1.43); Christian (aOR 1.42, 95% CI 1.19 to 1.70)). While a few women smoked (<1%), around 9% reported chewing tobacco, which was associated with an increased odds of stillbirth (aOR 1.11, 95% CI 1.02 to 1.21). Adverse pregnancy and birth characteristics were also associated with stillbirth: antenatal care visits <4 (aOR 1.08, 95% CI 1.01 to 1.15), maternal age <25 years (aOR 1.29, 95% CI 1.21 to 1.37) and ≥35 years (aOR 1.16, 95% CI 1.04 to 1.29), multigravida (aOR 3.06, 95% CI 2.42 to 3.86), multiple pregnancy (aOR 1.77, 95% CI 1.47 to 2.15), assisted delivery (aOR 3.45, 95% CI 3.02 to 3.93), caesarean section (aOR 1.73, 95% CI 1.58 to 1.89), as were pregnancy complications (aOR 1.42, 95% CI 1.33 to 1.51).

Conclusion India is an emerging market economy experiencing a rapid health transition, yet these findings demonstrate the marked disparity in risk of stillbirth by women’s socioeconomic status. Tobacco chewing and maternal and fetal complications were each found to be important modifiable risk factors. Targeting the ‘at-risk’ population identified here, improved recording of stillbirths and the introduction of local reviews would be important steps to reduce the high burden of stillbirths in India.

  • stillbirth
  • risk factors
  • pregnancy complications
  • India

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

http://dx.doi.org/10.1136/bmjopen-2018-022583

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    Footnotes

    • Contributors NA reviewed the literature, conducted the analysis and wrote the first draft of the paper; CC helped with the data analysis, and edited the paper; SSC helped in acquiring and interpreting the data, and edited the paper; AR and UCS edited the paper; MK contributed to the interpretation and discussion of the results, and edited the paper; MN developed the concept for the study, supervised the data analysis, interpretation and discussion of the results and edited the paper.

    • Funding The study was funded by a Medical Research Council Career Development Award to Manisha Nair (Grant Ref: MR/P022030/1).

    • Disclaimer The funder had no role in the study design, data analysis, data interpretation or writing of the manuscript. All authors, had full access to all of the data in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

    • Competing interests None declared.

    • Patient consent Not requried.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement The anonymised data are freely available through the Indian Government’s Data Sharing Portal.