Maternal and obstetric characteristics of stillbirths at a rural tertiary care centre in Chhattisgarh, India: a retrospective descriptive study

INTRODUCTION

Stillbirth remains a major public health concern with profound psychological, social, and economic impacts on families and communities. For international comparison, World Health Organization (WHO) defines a stillbirth or fetal death, as a death of fetus with a birthweight ≥1000 grams or a gestational age of ≥28 weeks or a body length of ≥35 cm.¹ India contributes significantly to the global stillbirth burden, with an estimated stillbirth rate of 13 per 1,000 total births as of 2024, many of which occur in rural areas. In Chhattisgarh the stillbirth rate was reported to be equal or more than 10 per 1000 births.² The rural healthcare scenario in India is characterized by disparities in access to quality antenatal care (ANC), intrapartum monitoring, emergency obstetric services, and timely referral systems. Socioeconomic constraints, lack of awareness, and underutilization of maternal healthcare services further exacerbate these issues. Studies suggest that most stillbirths in rural India are preventable.³

Several maternal factors have been strongly associated with stillbirth, including advanced maternal age, teenage pregnancies, anaemia, hypertensive disorders of pregnancy, diabetes, infections, a history of previous stillbirth education, gravidity, concomitant medical conditions and obstetric conditions.⁴ Fetal factors such as congenital anomalies, intrauterine growth restriction (IUGR), multiple pregnancies, and cord accidents are also significantly linked. Furthermore, health system-related issues, such as delays in accessing care, lack of skilled birth attendants, and poorly equipped healthcare facilities, remain pivotal contributors in rural settings.⁵

Recent research emphasizes the "Three Delays Model" in maternal care as a key framework to understand stillbirth causation. These include: delay in recognizing complications and deciding to seek care, delay in reaching a health facility, and delay in receiving appropriate care at the facility. In rural India, these delays are prevalent due to financial and infrastructural barriers. However, the actual implementation and utilization of such programs vary across regions and are often hindered by sociocultural and logistic challenges.⁶ This study aimed to identify the determinants of stillbirth to improve existing management framework in the rural scenario.

METHODS

Study design and setting

A hospital record based retrospective descriptive study was conducted at the Department of Obstetrics and Gynaecology at Bharat Ratna Late Shri Atal Bihari Vajpayee Memorial Government Medical College, Rajnandgaon, Chhattisgarh, India. The study population included all the cases of stillbirths out of total deliveries recorded between the study period from 1st June 2021 to 31st May 2025.

Inclusion criteria

The study included women who were admitted with the diagnosis of Intrauterine fetal death or who had intrauterine fetal death during the course of hospital stay, and delivered stillbirth.

Exclusion criteria

Cases were excluded if the gestational age was less than 28 weeks. Patients who delivered at home or at another health care facility and were referred to our hospital after delivery were also excluded from the study.

Data were collected from individual maternal case records and labour room delivery registers, which included maternal age, booking status, distance of the patient's residence from the study centre, gravida status, gestational age at delivery, mode of delivery, fetal weight, gender, type of stillbirth (fresh or macerated) and high-risk maternal conditions associated with stillbirth. All the data entries were checked and analysed manually using descriptive statistics only. Variables were summarized as frequencies and percentages.

RESULTS

In our institution a total of 12,636 babies were delivered during the study period; among them there were 417 stillbirths with Stillbirth rate of 33.0 per 1000 total births. The demography of the patients with stillbirths are shown in Table 1.

Majority of the patients (52.5%) in the study were aged 21 to 25 years while mean age 25±3.94 years. 64% were educated up to primary school while only 2.4% were found to be undergraduate. Out of the total, 65% were belong to below poverty line and 38.1% women lives 31 to 50 Kms away from our institute. Unfortunately, 81.3% women were found unbooked on admission in the study.

Out of the total patients in the study, nearly half (49.2%) were primigravida while period of gestation was <37 weeks in 57.8% (35.5% between 32 to 37 weeks, and 22.3% are between 28 to 32 weeks). Undiagnosed cases of IUFD on admission were slightly more (52.7%) than diagnosed cases (47.2%). Majority of the patients (86.8%) delivered vaginally while only 13.1% needed caesarean section (Table 2).

In the present study, number of male babies were slightly more (52.3%) than female babies (47.7%). The most common weight range was <2 Kgs (60.9 %) while 39.3% were weight >2 Kgs. Fresh stillbirth was more common (65%) than macerated stillbirth (35%) (Table 3).

In 144 cases (34.5%), no maternal high-risk factors were identified hence categorized as unexplained etiology. Preeclampsia (8.8%) and Meconium-stained liquor (6.7%) were the next most frequent factors. Eclampsia (5.3%) and premature rupture of membrane (PROM) (4.8%) also contributed notably. Conditions like preterm labour (3.8%), vaginal birth after caesarean section (VBAC) (2.9%), and obstructed labour (2.6%) were present but less frequent (Table 4).

DISCUSSION

Stillbirth remains a critical public health challenge in developing countries underscoring the need for equitable access to quality antenatal care. The findings align with and diverge from recent Indian studies, highlighting critical areas for intervention. Below, the results are discussed in comparison with similar studies, focusing on demographic distribution, healthcare access, clinical outcomes, and risk factors.

Sociodemographic profile

The study found that the majority of stillbirths occurred in women aged 21–25 years (52.5%). This contrasts with a study by Avachat et al (Maharashtra), where the highest stillbirth rates were observed in women aged 26–30 years (45%), likely due to higher fertility in that age group in their cohort.⁷ Similarly, a study by Venkatesh et al (Uttar Pradesh), reported a peak in stillbirths among women aged 25–29 years (38%), attributing this to higher parity and limited healthcare access in older age groups.⁸ The younger age peak in our study may reflect early marriages and pregnancies in rural Chhattisgarh, emphasizing the need for targeted antenatal care for younger mothers.

The socio-economic status and female literacy also influence pregnancy outcome. Women’s education is associated with decline in SBR. This study has revealed that most of the women who landed with stillbirth were less educated, 64% were educated up to primary school and from below poverty line (65%), which can be compared to studies conducted by Asalkar et al (Maharashtra), where 57.8% were educated up to high school and Mufti et al (Srinagar, Jammu and Kashmir), where 74.7% belonged to lower middle class.^9,10

Healthcare access and antenatal care

A significant proportion of women lived 31–50 km from health centres (38.1%), with 21.3% residing >50 km away. This echoes findings by da Costa Pereira et al (Jharkhand), where distance (>30 km) was associated with 50% higher stillbirth risk due to delayed care.¹¹ Conversely, a study by Gautam et al in Punjab found that even women living <10 km away faced stillbirths, emphasizing quality over proximity.¹² The rural-urban disparity in our study underscores the need for mobile health units and community-based care.

Unbooked pregnancies dominated (81.3%), consistent with Almeta et al in Assam, where 75% of stillbirths occurred in unbooked cases due to lack of risk stratification.¹³ In contrast, a study by Gwako et al (Tamil Nadu), reported lower unbooked rates (60%), attributing better outcomes to universal antenatal coverage.¹⁴ The high unbooked rate in our study reflects systemic barriers like poverty, illiteracy, cultural practices and poor health-seeking behaviour.

Nearly half (49.2%) of stillbirths occurred in primigravida women, while 23.3% were in women with third gravida or above. This aligns with findings from Wie et al where primigravida accounted for 48% of stillbirths, likely due to inexperience in recognizing pregnancy complications.¹⁵ Conversely, a study by Nath et al in Kerala reported higher stillbirth rates in multigravida (35%), linking it to cumulative risks like anaemia and hypertensive disorders.¹⁶ The high primigravida proportion in our study underscores the importance of first-pregnancy care in rural areas.

Most stillbirths (57.8%) occurred <37 weeks, followed by >37 weeks (42.2%), this mirrors findings from a study by Pandey et al (Andhra Pradesh, reported a higher proportion of preterm stillbirths (28–32 weeks, 40%), mainly attributed to hypertension and infection.¹⁷ In contrast, a study by Altijani et al in Rajasthan, where term stillbirths (>37 weeks) dominated (45%), often due to intrapartum complications like obstructed labour.¹⁸ The high preterm stillbirths in our study suggests gaps in antepartum monitoring and emergency obstetric care in rural scenario. Undiagnosed IUFD cases (52.7%) were slightly higher than diagnosed ones (47.2%). This aligns with Patidar et al in Uttarakhand, where 55% of IUFDs were undiagnosed, citing poor ultrasound access.¹⁹ The high undiagnosed rate in our study calls for enhanced fetal movement awareness and routine Doppler screenings in high-risk pregnancies.

The most common birth weight range was 1.6–2 kg (26.1%), with 20.4% weighing 0.5–1 kg. This aligns with Gupta et al in Bihar, where low birth weight (<2.5 kg) accounted for 60% of stillbirths, linked to maternal malnutrition and poor fetal growth.²⁰ Conversely, a study by Singh et al (Odisha) found higher proportions of extremely low birth weight (<1 kg, 25%), emphasizing the role of preterm delivery.²¹ The predominance of moderately low birth weights in our study suggests chronic malnutrition and suboptimal antenatal care.

Characteristics of stillbirth and SBR

The stillbirth rate (SBR) observed in our hospital was 33 per 1,000 births, which is notably higher than the rates reported in several recent Indian studies. For instance, Gupta et al documented an SBR of 20.5 per 1,000 births in Bihar, attributing the comparatively lower rate to enhanced antenatal care coverage and increased institutional deliveries, similarly Pandey et al reported an SBR of 24 per 1,000 births in Andhra Pradesh, where early identification of high-risk pregnancies and improved emergency obstetric care contributed to better outcomes (12,17,20). In Punjab, Gautam et al recorded an even lower SBR of 18 per 1,000 births, which was linked to higher literacy rates and better healthcare accessibility in the region.^12,17,20

The higher stillbirth rate in our study can be explained by several contextual factors. A significant proportion of women (38.1%) resided 31–50 km away from healthcare facilities, leading to delays in seeking and receiving timely care. Additionally, the majority were recorded as unbooked at the study institution. The predominance of fresh stillbirths (65%) further underscores gaps in intrapartum monitoring and emergency obstetric services in our scenario.

Fresh stillbirths (65%), macerated cases (35%), indicating intrapartum events as a major contributor. Similar findings were reported by Ritesh et al in Madhya Pradesh, often due to delays in seeking care.²² In contrast, a study by Shah et al Mumbai reported equal proportions, linking macerated stillbirths to undiagnosed antepartum complications.²³ The high fresh stillbirth rate in our study highlights the need for improved intrapartum care and timely referrals.

High-risk factors contributing to stillbirth

The most common aetiology was unexplained in 34.5% of patients, followed by preeclampsia (8.8%) and Meconium-Stained Liquor (6.7%), similar findings were reported by Usmani et al in Delhi, where 30% of stillbirths had no identifiable cause.²⁴ In contrast, a study by Kumar et al in Haryana identified PIH (25%) and anaemia (20%) as leading causes.²⁵

CONCLUSION

In this study, stillbirths were frequently observed among unbooked pregnancies, primigravidae and pregnancies with a gestational age <37 weeks. A considerable proportion of stillbirth were fresh stillbirths, with the underlying cause remaining unexplained in several cases. Additionally, many women resided at considerable distances from the healthcare facility potentially contributing to delay in accessing appropriate obstetric care. These findings highlight the need to strengthen antenatal care, identify high risk pregnancies, timely recognition of fetal compromise, ensure timely referral, improve healthcare accessibility, and provide quality intrapartum care to reduce stillbirths in the study setting.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. World Health Organization. International statistical classification of diseases and related health problems, 10th revision (ICD-10). Vol. 2: instruction manual. Geneva: World Health Organization; 2010. Available from: https://icd.who.int/browse10/Content/statichtml/ICD10Volume2en2010.pdf Accessed on 15 September 2026.
2. 2. International Institute of Population Science (IIPS) National Family Health Survey (NFHS 4) Fact Sheet Government of India, New Delhi 2019-20. Available at: http://www.rchiips.org/nfhs/factsheet_NFHS-4.shtml. Accessed on 3 June 2026.
3. 3. Vinolia R, Bant DD. A study on the major risk factors of stillbirth in the rural areas of Dharwad district: a prospective study. Int J Community Med Public Health2018;5:2232-6.
4. 4. Ravikumar S, Shetty S, Malempati LM. A Retrospective Analysis of Intrauterine Fetal Demise Cases in a Tertiary Care Hospital: Insights into Maternal Factors and Obstetric Outcome. J Health Allied Sci NU. 2026;16:112-8.
5. 5. Blencowe H, Suarez-Idueta L, Jayaratne K, Kidanto H, Aggarwal N. Stillbirth in Low-Resource Settings. Clin Perinatol. 2026;53(1):165-77.
6. 6. Gadapani Pathak B, Maurya S, Bisht S, Vats P, Mukerjee R, Anand VK, et al. Exploring pathways leading to stillbirths and gaps in postnatal care among affected women in a rural north Indian district: A qualitative study using the social autopsy lens. PLoS One. 2026;21(5):e0347994.
7. 7. Avachat SS, Phalke DB, Phalke VD. Risk factors associated with stillbirths in the rural area of Western Maharashtra, India. Arch Med Health Sci. 2015;3(1):56-9.
8. 8. Venkatesh U, Bera OP, Grover A, Shastri S, Chakraborty S. Epidemiology and determinants of stillbirth disparities in India: a geospatial hotspot clustering study using integrated population-level data. Lancet Reg Health Southeast Asia. 2025;40:100647.
9. 9. Asalkar MR, Surve M, Dhakne SR, Shivamurthy HM. Review of causes of stillbirths in a rural referral hospital: a cross-sectional study. Int J Reprod Contracept Obstet Gynecol. 2018;7(9):3695-701.
10. 10. International Journal of Reproduction, Contraception, Obstetrics and Gynecology
11. 11. Mufti AH, Mufti S, Wani NJ. Intrauterine fetal death associated socio-demographic factors and obstetric causes: a retrospective study. Int J Reprod Contracept Obstet Gynecol. 2020;9:4027-31.
12. 12. da Costa Pereira J, Soares MF, Ximenes DA, Guterres AB. The effect of distance to health facilities on skilled birth attendance. Health Smart. 2026;2(2):107-20.
13. 13. Gautam D, Pandey AK, Banerjee R, Saroha E, Gupta U, Thalakiya R, et al. Optimising delivery models for evidence-based interventions to reduce stillbirth in Punjab, India: a study protocol for implementation research. BMJ Open. 2025;15(11):e098597.
14. 14. Mary A, Rahman M, Nath P. Epidemiological profile and risk factors of stillbirth in a tertiary care hospital in South Assam. Int J Curr Pharm Rev Res. 2026;18(2).
15. 15. Gwako GN, Were F, Obimbo MM, Kinuthia J, Gachuno OW, Gichangi PB. Association between utilization and quality of antenatal care with stillbirths in four tertiary hospitals in a low-income urban setting. Acta Obstet Gynecol Scand. 2021;100(4):676-83.
16. 16. Wie JH, Pak SE, Kim RY, Chung YH, Park IY, Park YG, et al. Gestational age-specific risk of stillbirth during term pregnancy according to maternal age. Arch Gynecol Obstet. 2019;299(3):681-8.
17. 17. Nath SR, Sunitha S, Pradeesh PG, Ravindran R. Identification of factors leading to stillbirth with ReCoDe system (Relevant Condition at Death system) in a tertiary care centre in Kerala. Eur J Cardiovasc Med. 2024;14(5):765-73.
18. 18. Pandey A, Widyastari D, Samutachak B, Punpuing S, Bandyopadhyay Neogi S. National, state and district-level estimates of stillbirth in India at 20 weeks' gestation or longer using national family health survey data (2005-21). Lancet Reg Health Southeast Asia. 2026;48:100757.
19. 19. Altijani N, Carson C, Choudhury SS, Rani A, Sarma UC, Knight M, et al. Stillbirth among women in nine states in India: rate and risk factors in study of 886,505 women from the annual health survey. BMJ Open. 2018;8(11):e022583.
20. 20. Patidar S, Mahadik K. Profile of intrauterine fetal demise in Central India: is it preventable? Int J Reprod Contracept Obstet Gynecol. 2025;14(2):550-4.
21. 21. Gupta M, Samant M, Malhotra J, Singh PP. Stillbirth rate and maternal risk factors for antenatal stillbirth in Bihar: a hospital-based cross-sectional study. J Family Med Prim Care. 2025;14(6):2187-92.
22. 22. Singh S, Nayak MK, Routray PK, Naik SS, Mohakud NK. Quality assessment of stillbirth review: a pilot study in ten high-priority districts in Odisha. Indian J Community Med. 2021;46(3):430-3.
23. 23. Rawat R, Toppo M, Pal DK. Still births in a tertiary care hospital of Bhopal: a cross-sectional study. J Evol Med Dent Sci. 2015;4(5):767-72.
24. 24. Shah J, Kansaria HJ, More V. Analysis of stillbirth as per ReCoDe classification system. J South Asian Feder Obst Gynae. 2023;15(3):283-6
25. 25. Usmani O, Chaudhary K, Fatima M, Wasim S, Khan S, Ahmad S. Unexplained stillbirths: understanding the complexities. J Neonatal Surg. 2025;14(24S):433-42.
26. 26. Kumar M, Singh A, Garg R, Goel M, Ravi V. Hypertension during pregnancy and risk of stillbirth: challenges in a developing country. J Matern Fetal Neonatal Med. 2021;34(23):3915-21.