This presentation is all about the epidemiology of stillbirths, in India. It talks about the different challenges in controlling the stillbirths and the strategies of controlling it. The INAP guideline of Government of India, which is a stepping stone for controlling stillbirths in India, is also discussed here.

1. By: Sourav Goswami
Moderator: Dr Subodh S Gupta
MGIMS, Sevagram
EPIDEMIOLOGY OF STILLBIRTH

2. Framework
Introduction & definition
Facts and figures
The triad
Causes & Classification
Strategies to  SBR in India - INAP
Surveillance - Audit of stillbirth
Psycho-social impact
Conclusion
References

3. Introduction
Stillbirth is an important indicator of
- access to and quality of ANC and
delivery services
Perinatal deaths or stillborn ?
“Stillbirth rate” may be used as an
important developmental indicator.

4. Definition

5. Definition contd….
Stillbirth rate =
Number of babies born per year with no signs
of life weighing 1000 g and after 28≥
completed weeks of gestation / 1000 total
(live and stillborn) births

6. Facts and figures
WORLD (WHO)
Stillbirths are invisible in policy and
programs, yet constitute an enormous
burden of deaths, and disproportionately
affect the poor.
 2.6 million stillbirths annually (2015)
 1.3 million intrapartum stillbirths
Worldwide SBR is 18.4/1000 total births
 98% of the world’s stillbirths occur in
low- and middle-income countries

7. Facts and figures contd..
 In no of stillbirths by 19.4% from
2000 to 2015
ARR (globally) –
Stillbirths (2%)< MMR(3%) &
U5MR(4.5%)
10 nations of the world account for 2/3rd
of the global stillbirths
 India tops in that list !!!

8. Facts and figures contd..

9. Facts and figures contd..
In India, we have paucity of reliable
data regarding stillbirth.
Still birth rate of India is 22/1000 births
(Lancet stillbirth series,2009)

10. The epidemiological triad
Stillbirth
Agents
Host Environment
Infections
Pregnancy complications
Fetal complications
Congenital anomalies
 Maternal age
Addictions
Obesity
Preexisting condition-
DM, Epilepsy etc
 Infrastructure
Poverty
 Maternal education
 Surveillance/Reporting
Social stigma
Indoor air pollution
 Awareness

11. Causes of stillbirth
Developing countries
Obstructed/prolonged labor
and associated asphyxia,
infection and birth injury
(low availability of C-
section)
Congenitally acquired
infections especially syphilis
Hypertensive disease—
especially poor
management of
preeclampsia/eclampsia
Poor nutritional status
Previous stillbirth
Congenital anomalies
Malaria
Developed countries
Congenital/chrom
anomalies
Growth
restriction/placental
thrombosis
Medical diseases: DM,SLE,
kidney &, thyroid disorders,
thrombophilia, cholestasis
of pregnancy, Hypertensive
disease
Congenitally acquired
infections :Group B Strep
and parvovirus 19
Smoking

12. Classification of stillbirth
Why is classification required?
Different classifications
1. Causes of death and associated
conditions (Codac)
2. Wigglesworth classification
3. ICD-PM classification


13. CODAC system of classification
The CODAC classification system is
designed to retain information on the
main cause of death as well as up to two
associated conditions. It is a classification
system for perinatal deaths, recently
developed by an international group of
investigators events.

14. CODAC system of classification
It was developed with a basis of
incorporating:
Compatibility with the ICD.
Expandable main categories, when detailed
information is available, but possible to use
the main groups when information is limited.
Capture of intra-partum events.
Capture of placental conditions.
Ability to differentiate unknown and
unexplained

15. CODAC system of classification

17. Stillbirth: the “Delay model”
Most of the causes of still birth are preventable, &
can be hypothesized to occur due to delays in differ
levels.

18. Surveillance & Still birth Audit
Why is surveillance essential?
Types of audit
Status in India

19. Strategies for  SBR
The Every Newborn Action Plan (ENAP) that
has been recently endorsed by the World
Health Assembly calls for a national SBR ≤
12/1000 births by 2030 & 10/1000 by 2035.≤
India has the potential to achieve the 2035
goals much earlier. But translating such
aspirations into deliverables would require long
term view, executional brilliance, intersectoral
synergy and, above all, political resolve.
The India Newborn Action Plan (INAP) being
launched by the Government of India indeed
incorporates these very principles.

20. INAP
Strategic goal for India:
Goal 1: Ending Preventable Newborn Deaths to
achieve “Single Digit NMR” by 2030, with all the
states to individually achieve this target by 2035
Goal 2: Ending Preventable Stillbirths to achieve
“Single Digit SBR” by 2030, with all the states to
individually achieve this target by 2035

21. INAP – National Targets
Target Current 2017 2020 2025 2030
Impact Targets
SBR 22 19 17 13 <10
Coverage targets
Safe
delivery
(%)
76 90 95 95 95

22. Projected Levels of SBR in India
2012-2030

23. Intervention packages(INAP)
1. Care during labour and child birth
2. Care of small and sick newborn
3. Care of healthy newborn
4. Immediate newborn care
5. Preconception and antenatal care

24. Preconception and antenatal care

25. Priority actions for Preconception
and antenatal care
Prioritize actions for delaying age at 1st pregnancy
with special focus on teenage pregnancy
Train an adequate number of service providers for
Family Planning Services and ensure availability of
commodities
Saturate high caseload facilities to provide PPIUCD
Train an adequate numbers of ANMs in SBA (including
ANC component)
“ Dakshata”

26. Priority actions for Preconception
and antenatal care contd…
Scale up nutritional interventions of peri-
conceptional folic acid, maternal calcium
supplementation, and iron folic acid
supplementation (NIPI/WIFS)
Strengthen convergence with related departments
for nutrition counseling
Screening of high-risk pregnancies and their
management as per protocols
Accelerate implementation of preventive measures
against malaria for pregnant women in endemic
area

27. Care during labour &
child birth

28. Priority action for care during
labour & child birth
Prioritize and strengthen public health facilities at
all levels (L1, L2, L3) for conducting safe delivery,
including provision of emergency obstetric care as
per the norms of MNH Toolkit
Provision of dedicated MCH wings in facilities with
high caseload, including functional WASH facilities
All delivery points to be saturated with adequately
trained health workers: Ensure trained and skilled
staff at all designated delivery points: L1 delivery
point should have SBA trained ANMs/SNs, L2
delivery point to have at least one BEmOC trained
MO, and L3 delivery point must have at least four
obstetrician & gynaecologist /CEmOC trained MOs
and four Anaesthetist/LSAS trained MOs

29. Priority action for care during
labour & child birth contd..
Expand the availability of SBA-trained birth
attendants. In addition to ANM, SBA training to
be rolled out for AYUSH doctors (as per state-
specific need)
Establish Quality Assurance mechanism at each
level, like- use of safe birth checklist and
regular quality audits including perinatal death
audits
Institutionalize referral mechanism to ensure to-
and-fro referral, including inter-facility referral,
as and where required

30. Priority action for care during
labour & child birth contd..
Accelerate scale-up of new policy decisions on
management of preterm labour through use of
antenatal corticosteroids and antibiotics for
premature rupture of membranes
Develop a mechanism of supportive supervision
through existing systems or through partnerships
(with professional organizations, medical colleges,
and private hospitals) at the regional and state level
Generate awareness on JSSK entitlements, promote
community participation, and demand for safe
institutional delivery
Establish a sound surveillance system for tracking
stillbirths

31. Name:
Laxmi Anil Belsare
Age: 25 years
Residence:
Zhingapur,
Tembusunda PHC,
Melghat

32. Psycho-social & financial impact
of Stillbirth
Stillbirth remains hidden from society, and
has wide-reaching consequences for parents,
care providers, communities, and society that
are frequently overlooked and
underappreciated.
The estimated direct financial cost of a
stillbirth is 10-70% greater than the cost of a
live birth (OOP)
Survey data show parents may only be
working at 26% of normal work productivity
30 days after the stillbirth of their baby,

33. Psycho-social impact of Stillbirth
Parents' grief after stillbirth is not
legitimized or accepted by health
professionals, family members, or
society.
An estimated 4.2 million women are
living with depression associated with
stillbirth
Care providers are also deeply affected
both personally and professionally,
experiencing guilt, anger, blame, anxiety,
and sadness, as well as fear of litigation
and disciplinary action.

34. Psycho-social impact of
Stillbirth
Mullan et al. describe consequence of a
stillbirth as: ‘The grief of a stillbirth is
unlike any other form of grief: the months
of excitement and expectation, planning,
eager questions and the drama of labor —
all magnifying the devastating
incomprehension of giving birth to a baby
bearing no signs of life.’

35. Conclusion
The stillbirth rate is an important indicator
of quality of care in pregnancy and
childbirth, as well as a sensitive marker of
health systems’ strength, measuring not
only progress in achieving SDG targets for
reduction of neonatal, maternal, and under
5 mortality, but also progress on other
targets aimed at reducing poverty and
increasing equity and access to healthcare.
Extra and directed efforts will be necessary
in overcoming barriers at service-
community interfaces in achieving our

36. Conclusion contd…
Barriers crossing will need awareness,
health education & demand creation in
community; socioeconomic upliftment of
population and physical (roads etc) &
communication infrastructure development
on one hand and manpower development
and their effective deployment in health
sector on the other.
Women's empowerment plays an important
part in reducing stillbirth
Unavailability of reliable data

37. References
Blencowe, Hannah et al. National, regional, and
worldwide estimates of stillbirth rates in 2015, with
trends from 2000: a systematic analysis. The Lancet
Global Health , Volume 4 , Issue 2 , e98 - e108
Lawn, JE, Blencowe, H, Oza, S et al. Every Newborn:
progress, priorities, and potential beyond survival.
Lancet. 2014; 384: 189–205
WHO and UNICEF. Every Newborn: an action plan to
end preventable deaths. World Health Organization,
Geneva; 2014
http://wwweverynewbornorg/Every%20Newborn%20Actio
. (accessed Dec 03, 2016).
Cunningham F G et al. Williams Obstetrics. 23rd
edition.
New York : McGraw-Hill Medical; 334-335
Horton, Richard et al. Stillbirths: ending an epidemic of
grief. The Lancet , Feb 2016. Volume 387 , Issue
10018 , 515 – 516

38. References contd..
Lawn, Joy E et al. Stillbirths: rates, risk factors, and
acceleration towards 2030. Feb 2016. The Lancet ,
Volume 387 , Issue 10018 , 587 – 603
WHO. Making every baby count: Audit and review of
stillbirths and neonatal deaths. World Health
Organization, Geneva;2016
Roberts LR, Anderson BA, Lee JW, Montgomery SB. Grief
and Women: Stillbirth in the Social Context of India.
International journal of childbirth. 2012;2(3):187-198.
Bharti DK. Stillbirths: A high magnitude public health
issue in India. South East Asia Journal Of Public Health .
http://www.banglajol.info/index.php/SEAJPH/article/viewFil
(accessed Dec 04,2016)
Census of India. Estimates of mortality indicators 2010.
http://www.censusindia.gov.in/
vital_statistics/srs/Chap_4_2010.pdf (accessed November
2016)

39. References contd…
Mullan Z, Horton R. Bringing stillbirths out of the
shadows. Lancet 2011; 377: 9774:1291-2.
McClure EM, Dudley DJ, Reddy U, Goldenberg RL.
Infectious Causes of Stillbirth: A Clinical Perspective.
Clinical obstetrics and gynecology. 2010;53(3):635-
645.
Silver RM et al.Stillbirth: A review of the evidence.
American journal of obstetrics and gynecology.
2007;196(5):433-444.
Kochar PS, Dandona R, Kumar GA, Dandona L.
Population-based estimates of still birth, induced
abortion and miscarriage in the Indian state of Bihar.
BMC Pregnancy and Childbirth. 2014;14:413

40. Thank you