India’s Stillbirth Burden May Be Far Higher Than Official Numbers If Counted from Five and Half Months Into Pregnancy : Lancet Study

Is India undercounting its stillbirth burden?

A new Lancet Regional Health – Southeast Asia study says it may be doing so by hundreds of thousands. The study estimates that nearly 5.66 lakh babies were stillborn in the country in 2023 when pregnancy losses from 22 weeks onwards are included instead of the 28-week period India uses.

The study, based on the Global Burden of Disease (GBD) 2023 analysis, estimated 565,900 stillbirths at 22 weeks of gestation (5.5 months) or later, compared with 347,300 when counting only stillbirths at 28 weeks or later (7 months onwards). That puts the estimated burden about 2.19 lakh higher when using the earlier gestational threshold.

The WHO defines a stillbirth as a baby born with no signs of life at or after 22 weeks of pregnancy, but recommends that a 28-week cut-off be used for international comparison. The researchers, however, have chosen the earlier threshold, saying it gives a better picture.

The researchers say the difference is not simply a matter of terminology. The gestational-age threshold used to define and count a stillbirth directly affects how many pregnancy losses appear in health statistics — and therefore how policymakers and health systems understand the burden.

Data were compiled from 122 sources, including surveys, published studies, and vital and sample registration systems, encompassing 2684 location-year observations.

What changes at 22 weeks?

The World Health Organization's ICD-11 definition uses 22 weeks of gestation or more for stillbirth. The study compared this with the 28-week threshold traditionally used in many stillbirth estimates and international comparisons.

Using the 22-week threshold, India's estimated stillbirth rate in 2023 was 25.9 per 1,000 births. At 28 weeks or later, it was 16.1 per 1,000 births.

The researchers analysed data from 122 sources, covering 2,684 location-year observations, and produced estimates for 31 geographic units across India.

Huge differences between states

The study also found wide variation across states.

At 22 weeks or later, stillbirth rates ranged from 9.3 per 1,000 births in Mizoram to 38.2 per 1,000 in Uttar Pradesh — more than a four-fold difference.

Uttar Pradesh and Bihar together accounted for nearly half of India's estimated stillbirths. Five states — Uttar Pradesh, Bihar, Madhya Pradesh, Jharkhand and Chhattisgarh — had stillbirth rates above the national average under both gestational-age definitions.

Existing data may be missing part of the picture

The researchers also compared their estimates with India's Sample Registration System (SRS) for 2023. They found that the national late-gestation stillbirth rate recorded through SRS was 2.3 times lower than the GBD estimate, although neonatal mortality estimates were broadly consistent between the two systems.

The authors say differences in gestational-age definitions, incomplete reporting and difficulties distinguishing stillbirth from early neonatal death can contribute to gaps in surveillance.

They argue that India needs better stillbirth surveillance, including tracking pregnancy losses from 22 weeks onwards, alongside stronger integration of stillbirth prevention into maternal and newborn health programmes.

The significance of the findings goes beyond the headline number. Earlier gestation stillbirths can disappear from national statistics when a later threshold is used. Better measurement, the researchers argue, is necessary to understand where the burden is highest, identify risk factors and ensure that prevention efforts and healthcare resources reach the populations that need them most.