Stillbirths at 22- and 28-weeks' gestation or longer for the states in India: findings from the Global Burden of Disease Study 2023.

Background: The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD), for the first time, estimated stillbirth rate (SBR) by the WHO ICD-11 definition (≥22 weeks' gestation) for 204 countries, highlighting the extent of underestimation in stillbirth burden as compared with using only the late gestation (≥28 weeks' gestation) SBR estimation to understand the stillbirth burden. Given the size of its population, India accounted for the highest global burden of stillbirths for both gestation period cut-offs. Given the extent of state-level heterogeneity in disease burden in India, state-disaggregated SBR is necessary to enable policymakers and researchers to tailor strategies that are more responsive to local needs and institutional capacities, thereby enhancing the effectiveness of interventions and related resource allocation. Methods: Data were compiled from 122 sources, including surveys, published studies, and vital and sample registration systems, encompassing 2684 location-year observations. SBRs were estimated for 31 geographic units using spatiotemporal Gaussian process regression to model the ratio of SBR to neonatal mortality rate (NMR), integrating GBD 2023 fertility and all-cause neonatal mortality assessments. Estimates were produced for SBR and number of stillbirths for ≥22 and ≥28 weeks' gestation with 95% uncertainty intervals (UIs) for year 2023. Secondary analyses evaluated the relationship between SBR at the state-level with the Sustainable Development Goal 3 (SDG3; good health and wellbeing) state index score developed by the NITI Aayog and compared GBD results with India's Sample Registration System (SRS) for late gestation SBR and neonatal mortality rate (NMR) for 2023. Findings: An estimated 565,900 (462,600-702,900) and 347,300 (284,600-430,000) stillbirths occurred in India in 2023, corresponding to SBRs of 25.9 (95% UI 21.3-32.0) and 16.1 (13.2-19.8) at ≥22 weeks' and ≥28 weeks of gestation, respectively. SBR for both definitions varied four-fold between states, from 9.3 (6.8-12.6) in Mizoram to 38.2 (29.0-50.8) in Uttar Pradesh, with the latter and Bihar together accounting for nearly half of India's total stillbirths. A modest inverse correlation was observed between SBR and SDG3 index score (≥22 weeks p = 0.053, r = -0.350 and ≥28 weeks p = 0.034, r = -0.383). Comparison with SRS 2023 revealed substantial under-reporting in SBR, with national late-gestation SBR 2.3 times lower than GBD estimates, though NMR values were consistent across systems. Interpretation: India's true stillbirth burden is markedly underestimated using the ≥28-week definition. Improved surveillance, tracking stillbirths by the ≥22-week threshold, and integration of stillbirth prevention within broader maternal and newborn health initiatives are essential to address the stillbirth burden in India. Investments are also needed to improve both the availability and quality of data on the magnitude, causes, risk factors, and geographic disparities in stillbirth occurrences for appropriate action to address early gestation stillbirths in India. Funding: Gates Foundation.