Unveiling the Hidden Burden: Key Findings from the Latest NFHS Analysis
The latest analysis of National Family Health Survey (NFHS) data has brought to light a critical issue in India's maternal health landscape: the significant undercounting of stillbirths, particularly those occurring before 28 weeks of gestation. Stillbirth, defined by the World Health Organization (WHO) as the death of a baby before or during delivery after 28 completed weeks of pregnancy or weighing at least 1,000 grams, has long been a public health challenge in India. However, this study expands the view by including earlier gestations, revealing a much higher true burden.
Researchers from institutions like the International Institute of Health Management Research (IIHMR) in New Delhi and Mahidol University in Thailand examined data from over 542,000 women across NFHS-3 (2005-06), NFHS-4 (2015-16), and NFHS-5 (2019-21). Their findings, published in The Lancet Regional Health - Southeast Asia on March 31, 2026, show national stillbirth rates (SBR) of 12.8 per 1,000 total births at ≥28 weeks, rising to 16.2 at ≥24 weeks and 22.0 at ≥20 weeks. Shockingly, about 42% of stillbirths in 2019-21 happened between 20 and 28 weeks—cases often missed in standard reporting.
This undercounting stems from varying definitions and incomplete data capture in routine systems like the Sample Registration System (SRS) and Civil Registration System (CRS), which report lower rates (e.g., SRS at around 3-4 per 1,000). NFHS, with its detailed reproductive calendars, offers a more comprehensive picture but still faces recall bias and misclassification challenges.
Understanding Stillbirths and the Role of NFHS in Tracking Them
The National Family Health Survey (NFHS), conducted by the Ministry of Health and Family Welfare (MoHFW) with support from the International Institute for Population Sciences (IIPS), is India's flagship demographic and health survey. It collects data on fertility, mortality, nutrition, and more from representative household samples. NFHS-5 (2019-21) covered all states and union territories, providing district-level insights for the first time.
Stillbirth tracking in NFHS relies on women's recall of pregnancy outcomes in the past five years via a reproductive calendar module, categorizing events as births (B), terminations (T), pregnancies (P), or contraceptives (C). Gestational age is approximated from month of outcome relative to last menstrual period. While innovative, this method can underreport early losses due to stigma, cultural taboos around discussing fetal death, and confusion with miscarriages or induced terminations.
India bears about 17-20% of the global stillbirth burden, with rates higher than the global average of 13.9 per 1,000 in 2019. The Every Newborn Action Plan (ENAP), to which India is committed, targets a single-digit SBR by 2030, but accurate baseline data is essential.
Trends Over Time: Progress and Plateaus
The study reveals a 36.3% decline in SBR (≥28 weeks) from 19.4 per 1,000 in 2005-06 to 12.4 in 2015-16, but only a modest 5.3% drop to 11.7 by 2019-21. Similar patterns hold for earlier thresholds. This slowdown may reflect pandemic disruptions, improved reporting, or stalled interventions.
By 2019-21, 51.4% of states/UTs and 51.9% of districts achieved single-digit SBR at ≥28 weeks, up from 20% in 2005-06. However, 12.2% of districts exceed 20 per 1,000, indicating hotspots in northern, central, and eastern regions. Spatial clustering (Moran's I 0.168) suggests targeted interventions could yield high impact.
Regional Variations: Hotspots and Success Stories
District-level maps highlight disparities: higher SBR in states like Uttar Pradesh, Bihar, Madhya Pradesh, and Rajasthan, often linked to rural poverty. Urban-rural gaps persist, with rural areas showing elevated risks. Southern states like Kerala and Tamil Nadu fare better, thanks to robust health systems.
Proportion of early stillbirths (20-28 weeks) varies: highest in Gujarat (54.9%), Himachal Pradesh (53.1%), Jammu & Kashmir (47.2%). These patterns underscore the need for gestation-specific surveillance.Read the full Lancet study for district maps.
Risk Factors Identified: From Socioeconomic to Biological
Multivariable analysis of 176,019 recent births (NFHS-5) pinpointed key risks for ≥28-week stillbirths:
- Maternal illiteracy (adjusted OR 1.5)
- Short stature (<145 cm, aOR 1.8)
- Anaemia (aOR 1.3)
- Unclean cooking fuel (aOR 1.2)
- Rural residence (aOR 1.2)
- Scheduled Caste (aOR 1.3)
Protective factors include desired delayed pregnancy (aOR 0.7) and joint family living (aOR 0.9). Other studies corroborate: pregnancy-induced hypertension, preterm birth, infections, and poor antenatal care (ANC).
Why the Undercounting? Data Collection Challenges Exposed
India's routine data sources falter: SRS reports 3.7 per 1,000 (2020), 2.6 times lower than NFHS's 9.7. Reasons include incomplete civil registration (only 60-70% births registered), misclassification as neonatal deaths, and gestation cutoff inconsistencies. Home births (40% in rural areas) evade facility reporting.
NFHS improves via household surveys but suffers from 1-7% missing data and stigma—families may report early losses as miscarriages. The study used multiple imputation and sensitivity tests to mitigate biases.
Global Context: India's Share and Benchmarks
India contributes ~17% of global stillbirths, with SBR above the 2025 SDG target of 12 per 1,000. Comparators: SRS (3-4), HMIS (12.4), CRS (6.6), GBD (17.3 in 2019). Aligning with WHO's ≥22-week option could bridge gaps.UNICEF stillbirth dashboard.
Health and Economic Implications: A Preventable Tragedy
Each stillbirth inflicts profound grief, increases maternal depression risk (2-3x), and costs ~$1-2 billion annually in India (lost productivity, care). Early stillbirths strain neonatal care less but signal systemic ANC failures. Northern hotspots correlate with high IMR/NMR, demanding integrated action.
Pathways to Reduction: Evidence-Based Interventions
ENAP strategies: Improve ANC (8 contacts), manage hypertension/diabetes, promote hygiene, skilled birth attendance. Community mobilization via ASHA workers, better data via digital HMIS, and gestation-agnostic registration. States like Kerala halved SBR via universal ANC; scale nationally.
- Strengthen ANC: Screen for anaemia, stature.
- Fuel switch: LPG Pradhan Mantri Ujjwala Yojana.
- Equity focus: SC/ST, rural outreach.
- Surveillance: Civil Registration modernization.
Research Frontiers: Filling the Academic Gaps
Academic institutions like IIHMR, PHFI, and IIPS lead with NFHS reanalysis. Future: Cause-specific audits, verbal autopsies, AI for data cleaning. Multidisciplinary studies on climate impacts (heatwaves raise risk 20-30%).
Prospective cohorts needed beyond retrospective NFHS. Collaborate with global bodies like WHO for standardized protocols.
Policy Roadmap: Towards Single-Digit SBR by 2030
MoHFW must mandate ≥20-week reporting in CRS/HMIS, train registrars on gestation assessment (ultrasound/LMP). Integrate with LaQshya (quality care) and Surakshit Matritva Aashwasan (high-risk ANC). Budget: Allocate 1-2% health spend to stillbirth prevention.NHM maternal health guidelines.
Outlook: Hope Through Data-Driven Action
With NFHS-6 underway, refined estimates will guide. If trends continue, single-digit SBR feasible by 2030, averting 100,000+ stillbirths yearly. Researchers, policymakers, and communities must unite—accurate data is the first step to every baby breathing.
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