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Most stillbirths in 2019 happened in India, estimates UN report


Commenting on the recently released fifth round of National Family Health Survey (NFHS-5) data for 17 states and five Union Territories (UTs) in an article published in The Indian Express (dated 6th January, 2021), Arvind Subramanian and his co-authors have stated that India has made progress on certain outcomes, including infant mortality rate (IMR), under-five mortality rate (U5MR) and neonatal mortality rate (NNMR). Relying on various rounds of NFHS data, the authors have stated that the country has been able to reduce child deaths (i.e. neonatal, infants and under-5), among other outcomes related to children’s health and nutrition, over the years. It should be noted here that the NFHS does not provide data on stillbirths.

Although data on stillbirth rate is officially reported by the Sample Registration System of the Office of the Registrar General & Census Commissioner, there are serious concerns about the quality of stillbirth data that is collected in low- and lower-middle income countries (we will discuss this elaborately in the next section). Officially, India has been able to reduce its stillbirth rate (i.e. the number of stillbirths per 1,000 total births) from 6.0 in 2011 to 4.0 in 2018. However, a recent report published by the United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) shows that India's stillbirth rates (i.e. stillbirths per 1,000 total births) were 29.6 in 2000, 20.2 in 2010 and 13.9 in 2019 – much higher than what is reported officially.

A Neglected Tragedy: The global burden of stillbirths -- Report of the UN Inter-agency Group for Child Mortality Estimation, 2020 (released in October 2020) shows that 173 out of 1,000 stillbirths in the world took place in India during 2019. Prepared jointly by the United Nations Children’s Fund (UNICEF), World Health Organisation (WHO), World Bank Group and United Nations, Department of Economic and Social Affairs, Population Division, the report has estimated that nearly 0.34 million of the 1.97 million stillbirths globally in 2019 occurred in our country.

In comparison to 2019, India bore a higher global burden of stillbirths in the past years. About 296 out of 1,000 stillbirths of the world happened in India during 2000, which fell to nearly 227 out of 1,000 stillbirths in 2010. For more information, kindly consult table-1.  

Table 1: Global burden of stillbirths

Source: A Neglected Tragedy: The global burden of stillbirths -- Report of the UN Inter-agency Group for Child Mortality Estimation, 2020 (released in October 2020), please click here to read more

Note: Please click here to access the data in google spreadsheet
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According to the UN IGME report, six countries bore the burden of half of all stillbirths of the world (i.e. nearly 50.05 percent of total global stillbirths in 2019) – India, Pakistan, Nigeria, the Democratic Republic of the Congo, China and Ethiopia.

In the year 2019, India, Pakistan and Nigeria together accounted for around one-third of the total burden of stillbirths (i.e. 35.73 percent of the global total) and 27 percent of live births. Please consult table-1.

The same report also says that the top 15 countries with the greatest percentage decline in the stillbirth rate during 2000–2019 were China (63 percent), Turkey (63 percent), Georgia (62 percent), North Macedonia (62 percent), Belarus (60 percent), Mongolia (57 percent), Netherlands (55 percent), Azerbaijan (53 percent), Estonia (53 percent), India (53 percent), Kazakhstan (52 percent), Romania (52 percent), El Salvador (50 percent), Peru (48 percent) and Latvia (46 percent).

Table-2 shows that the percentage decline in India's stillbirth rate during 2000-2019 was -53.0 percent. The annual rate of reduction (ARR) in stillbirth rate during 2000-2019 was -4.0 percent. The total number of stillbirths in the country was 8.52 lakh in 2000, 5.36 lakh in 2010 and 3.41 lakh in 2019. The percentage decline in stillbirths for India during 2000-2019 was -60.0 percent. The annual rate of reduction (ARR) in total number of stillbirths during 2000-2019 was -4.8 percent. India witnessed 2.41 crore livebirths and 2.45 crore total births in 2019.

Table 2: Stillbirth situation in South Asia in 2000, 2010 and 2019

Source: A Neglected Tragedy: The global burden of stillbirths -- Report of the UN Inter-agency Group for Child Mortality Estimation, 2020 (released in October 2020), please click here to read more

Note: Please click here to access the data in google spreadsheet
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In 2019, stillbirth rate per 1,000 total births in Afghanistan was 28.4 (total stillbirth in 2019: 35,384), Bangladesh was 24.3 (total stillbirth in 2019: 72,508), Bhutan was 9.7 (total stillbirth in 2019: 127), China was 5.5 (total stillbirth in 2019: 92,170), India was 13.9 (total stillbirth in 2019: 340,622), Maldives was 5.8 (total stillbirth in 2019: 41), Myanmar was 14.1 (total stillbirth in 2019: 13,493), Nepal was 17.5 (total stillbirth in 2019: 9,997), Pakistan was 30.6 (total stillbirth in 2019: 190,483) and Sri Lanka was 5.8 (total stillbirth in 2019: 1,943). Please see table-2.

The stillbirth rate (SBR) is defined as the number of babies born with no signs of life at 28 weeks or more of gestation, per 1,000 total births. The stillbirth rate is calculated as: SBR = 1000 * {sb/(sb+lb)}, where 'sb' refers to the number of stillbirths = 28 weeks or more of gestational age; and 'lb' refers to the number of live births regardless of gestational age or birthweight.

The UN IGME report mentions that there are a variety of reasons behind the slow reduction in stillbirth rates: absence of or poor quality of care during pregnancy and birth; lack of investment in preventative interventions and the health workforce (i.e. nurses and midwives); inadequate social recognition of stillbirths as a burden on families; measurement challenges and major data gaps; absence of global and national leadership; and no established global targets, such as the Sustainable Development Goals (SDGs). Even before the pandemic disrupted health services, few women in low- and middle-income countries had received timely and high-quality care to prevent stillbirths. The report warns that the COVID-19 pandemic could further worsen the global number of stillbirths.

Sample Registration System and stillbirth data

The Sample Registration System Statistical Report 2018 (released in June 2020) shows that the stillbirth rate for the country has been estimated to be 4.0 stillbirths per 1,000 total births in 2018. In 2018, the highest SBR, among the bigger states/ UTs, has been estimated for Odisha (10.0) and lowest has been estimated for Jammu and Kashmir and Jharkhand (i.e. 1.0 each). Kindly check table-3. The SRS Statistical Report 2018 mentions that stillbirths are extremely difficult to capture and there is a room for considerable improvement in netting the events.

Table 3: Stillbirth rates by residence, India and bigger states/ UTs, 2018

Source: Sample Registration System Statistical Report 2018 (released in June 2020), published by the Office of the Registrar General & Census Commissioner, please click here to read more
Note: *Based on three-year period 2016-18
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It has been stated by the report A Neglected Tragedy: The global burden of stillbirths that the UN IGME estimates are not necessarily the official statistics of the United Nations Member States. The Sample Registration System is the preferred source for estimates of stillbirth rates, which are the endorsed official estimates of stillbirth in India. The Sample Registration System is a nationally representative data collection system that records both stillbirths and live births.

Aside from reducing stillbirth rate to 12 or fewer third trimester (late) stillbirths per 1,000 total births in every country by 2030, the UN IGME report has asked for addressing the gaps in counting and reporting of stillbirths.

The report has mentioned that poor availability and quality of stillbirth data pose a major challenge to estimate stillbirth rates. For some countries, vital and medical registration systems, health management information system (HMIS), or household surveys may not record stillbirths at all. In cases where stillbirth data are captured, non-standard definitions, underreporting or misclassification of stillbirths, and other data quality issues may render the data unusable. The UN IGME measures data quality by using criteria such as the ratio of the stillbirth rate to the neonatal mortality rate. Among the 195 countries for which stillbirth estimates are generated, 24 countries have no stillbirth data, and an additional 38 countries lack quality stillbirth data. For 62 countries, the UN IGME stillbirth estimates are derived using covariates without empirical stillbirth data included in the model.

Data availability and quality is uneven among regions. Due to concerns about data quality, 46 percent of data points on stillbirths are excluded from the UN IGME model. While in the group of high-income countries less than 20 percent of the national data on stillbirths are excluded in the modelling, in low- or lower-middle income countries over 70 percent are excluded due to data quality issues. Only 18 percent of the national stillbirth data informing the estimates are from low- and lower-middle income countries. Over 40 percent of low- and lower-middle income countries do not produce usable stillbirth data, according to the report of the UN IGME. So, it is possible that the official data collected in India has not been taken into account in the UN IGME model to estimate stillbirth rate.

Data availability also varies by region. Apart from the Europe, Northern America, Australia and New Zealand region, around one-third of countries in the remaining regions have no quality stillbirth data. The proportion increases to 44 percent in sub-Saharan Africa and 86 percent in Oceania (excluding Australia and New Zealand). In sub-Saharan Africa, an additional 23 percent of countries have less than five data points over the past two decades, and only 8 percent have more than 10 data points.

The UN IGME report states that there is an immediate need to increase the reporting of stillbirths and improve data quality for planning and programming. Strengthening data collection and improving data quality in HMIS and household surveys is key to fill the enormous data gaps.

KEY FINDINGS

According to the report entitled A Neglected Tragedy: The global burden of stillbirths -- Report of the UN Inter-agency Group for Child Mortality Estimation, 2020 (released in October 2020):

• About one stillbirth occurs every 16 seconds, which means that every year, about 2 million babies are stillborn i.e. showing no signs of life at birth. It means every day, almost 5,400 babies are stillborn. Globally, one in 72 babies is stillborn.

• In the past two decades, 48 million babies were stillborn. Three-in-four stillbirths occur in sub-Saharan Africa or Southern Asia. Low and lower-middle income countries account for 84 percent of all stillbirths but only 62 percent of all live births.

• Stillbirths are largely absent in worldwide data tracking, rendering the true extent of the problem hidden. They are invisible in policies and programmes and underfinanced as an area requiring intervention. Targets specific to stillbirths were absent from the Millennium Development Goals (MDGs) and are still missing in the 2030 Agenda for Sustainable Development.

• There are a variety of reasons behind the slow reduction in stillbirth rates: absence of or poor quality of care during pregnancy and birth; lack of investment in preventative interventions and the health workforce; inadequate social recognition of stillbirths as a burden on families; measurement challenges and major data gaps; absence of global and national leadership; and no established global targets, such as the Sustainable Development Goals (SDGs).

• Globally, an estimated 42 percent of all stillbirths are intrapartum (i.e., the baby died during labour); almost all of these 832,000 stillborn deaths that occurred in 2019 could have been prevented with access to high-quality care during childbirth, including ongoing intrapartum monitoring and timely intervention in case of complications. An intrapartum stillbirth is a death that occurs after the onset of labor but before birth.

• Around 20 million babies are projected to be stillborn in the next decade, if trends observed between 2000 and 2019 in reducing the stillbirth rate continue. Among the 20 million, 2.9 million stillbirths could be prevented by accelerating progress to meet the ENAP target in the 56 countries at risk to miss the goal. Every Newborn Action Plan (ENAP) calls for each country to achieve a rate of 12 stillbirths or fewer per 1,000 total births by 2030 and to close equity gaps.

• In the first two decades of this century (i.e. 2000-2019), the annual rate of reduction (ARR) in the stillbirth rate was just -2.3 percent, compared to a -2.9 percent reduction in neonatal mortality and -4.3 percent among children aged 1–59 months. Meanwhile, between 2000 and 2017, maternal mortality decreased by -2.9 percent.

• In the year 2000, the ratio of the number of stillbirths to the number of under-five deaths was 0.30; by 2019, it had increased to 0.38. So, stillbirths are an increasingly critical global health problem.

• National stillbirth rates around the globe ranged from 1.4 to 32.2 stillbirths per 1,000 total births in 2019. Sub-Saharan Africa, followed by Southern Asia, had the highest stillbirth rate and the greatest number of stillbirths.

• Six countries bore the burden of half of all stillbirths of the world – India, Pakistan, Nigeria, the Democratic Republic of the Congo, China and Ethiopia, in order of burden (highest to lowest).

• Nearly 3,40,622 of the 19,66,000  stillbirths globally in 2019 were in India, making it the country with the largest such burden (i.e. 17.33 percent).

• In 2019, India, Pakistan and Nigeria alone accounted for one-third of the total burden of stillbirths and 27 percent of live births.

• Stillbirth rate is defined as the ratio of the number of stillbirths per 1,000 live births and stillbirths taken together (i.e. total births).

• Some progress has been made in preventing stillbirths. Globally, the stillbirth rate declined by 35 percent since 2000. Since 2000, the stillbirth rate declined by 44 percent in Central and Southern Asia, 53 percent in India, 52 percent in Kazakhstan and 44 percent in Nepal.

• Among the lower-middle income countries, the stillbirth rate fell by 39 percent since 2000. Since the year 2000, stillbirth rate in lower-middle income countries like Mongolia, India and El Salvador declined by 57 percent, 53 percent and 50 percent, respectively.

• A total of 14 countries – including three low- and lower middle income countries (Cambodia, India, Mongolia) – slashed the stillbirth rate by more than half during 2000-2019.

• The top 15 countries with the greatest percentage decline in the stillbirth rate during 2000–2019 are China (63 percent), Turkey (63 percent), Georgia (62 percent), North Macedonia (62 percent), Belarus (60 percent), Mongolia (57 percent), Netherlands (55 percent), Azerbaijan (53 percent), Estonia (53 percent), India (53 percent), Kazakhstan (52 percent), Romania (52 percent), El Salvador (50 percent), Peru (48 percent) and Latvia (46 percent).
 
• India's stillbirth rate (i.e. stillbirths per 1,000 total births) was 29.6 in 2000, was 20.2 in 2010 and was 13.9 in 2019. The percentage decline in India's stillbirth rate during 2000–2019 was -53.0 percent. The annual rate of reduction (ARR) in stillbirth rate during 2000-2019 was -4.0 percent.

• The total number of stillbirths in India was 852,386 in 2000, 535,683 in 2010 and 340,622 in 2019. The percentage decline in stillbirths during 2000–2019 was -60.0 percent. The annual rate of reduction (ARR) in total number of stillbirths during 2000–2019 was -4.8 percent. India witnessed 24,116,000 livebirths and 24,457,000 total births in 2019.  

• Women in sub-Saharan Africa and Southern Asia bear the greatest burden of stillbirths in the world. More than three quarters of estimated stillbirths in 2019 occurred in these two regions, with 42 percent of the global total in sub-Saharan Africa and 34 percent in Southern Asia.

• In 2019, stillbirth rate per 1,000 total births in Afghanistan was 28.4 (total stillbirth in 2019: 35,384), Bangladesh was 24.3 (total stillbirth in 2019: 72,508), Bhutan was 9.7 (total stillbirth in 2019: 127), China was 5.5 (total stillbirth in 2019: 92,170), India was 13.9 (total stillbirth in 2019: 340,622), Maldives was 5.8 (total stillbirth in 2019: 41), Myanmar was 14.1 (total stillbirth in 2019: 13,493), Nepal was 17.5 (total stillbirth in 2019: 9,997), Pakistan was 30.6 (total stillbirth in 2019: 190,483) and Sri Lanka was 5.8 (total stillbirth in 2019: 1,943).

• Data are essential to understanding the burden of stillbirths and identifying where, when and why they occur.

• Immediate actions are needed to strengthen data systems and their ability to collect, analyse and use timely, quality and disaggregated stillbirth data. To improve stillbirth data availability and quality, it is recommended that countries and relevant stakeholders:

a. Align the stillbirth definition and measures with international standards
b. Integrate stillbirth-specific components within relevant plans for data system strengthening and improvement
c. Record stillbirth outcomes in all relevant maternal and newborn health programmes, including routine HMIS (registers and monthly reporting forms)
d. Provide training and support to include stillbirths within civil and vital registration systems as the coverage of these systems increases
e. Include information on timing of stillbirth (antepartum or intrapartum) in all settings and record causes and contributing factors to stillbirth where possible
f. Report and review stillbirth data locally – at facility or district level – alongside data on neonatal deaths (by day of death) to reduce incentives for misreporting of outcomes, and to monitor potential misclassification.
g. Collate reported stillbirth rate data up the data system to a national level to enable tracking of progress towards the ENAP target of 12 stillbirths or fewer per 1,000 total births in every country by 2030 and to enable monitoring of geographical inequities.

• Ending preventable stillbirths is among the core goals of the UN’s Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030) and the Every Newborn Action Plan (ENAP). These global initiatives aim to reduce the stillbirth rate to 12 or fewer third trimester (late) stillbirths per 1,000 total births in every country by 2030.

References

A Neglected Tragedy: The global burden of stillbirths -- Report of the UN Inter-agency Group for Child Mortality Estimation, 2020 (released in October 2020), please click here to read more

Press release: One stillbirth occurs every 16 seconds, according to first ever joint UN estimates, World Health Organisation, 8 October, 2020, please click here to access

Sample Registration System Statistical Report 2018 (released in June 2020), published by the Office of the Registrar General & Census Commissioner, please click here to read more

Sample Registration System Statistical Report 2011, published by the Office of the Registrar General & Census Commissioner, please click here to read more

Govt should next focus on well-being of the child from womb to first five years -Abhishek Anand, Vikas Dimble and Arvind Subramanian, The Indian Express, 6 January, 2021, please click here to read more

Topping the wrong chart: India has highest number of stillbirths -Kiran Pandey, Down to Earth, 9 October, 2020, please click here to read more

Finding the data on missing girls -Sabu M George, The Hindu, 2 August, 2019, please click here to access

 

Image Courtesy: UNDP India