Shadow over the North: Uttar Pradesh and Bihar Account for Half of India’s Stillbirths

NEW DELHI — In a sobering revelation for public health in South Asia, a comprehensive new study reveals that nearly half of all stillbirths in India in 2023 occurred in just two states: Uttar Pradesh and Bihar.

The analysis, published in The Lancet Regional Health – Southeast Asia by the India State-Level Disease Burden Initiative Stillbirth Collaborators, provides the most detailed state-by-state assessment of fetal mortality in the country to date. Part of the broader Global Burden of Disease (GBD) project, the report highlights deep geographic disparities, revealing that where a mother lives in India drastically dictates her chances of carrying a pregnancy to a safe delivery.

The Scale of Loss: Key Findings and Geographic Disparities

According to the analysis, which compiled data from 122 national surveys, peer-reviewed studies, and official registration systems, India recorded an estimated 5,65,900 stillbirths at 22 weeks of gestation or later in 2023. This translates to an overall Stillbirth Rate (SBR) of 25.9 per 1,000 total births.

When measured using the narrower 28-week threshold, the total stands at approximately 3,47,300 stillbirths (16.1 per 1,000 total births).

   INDIA STILLBIRTH BURDEN (2023)
   ┌─────────────────────────────────────────────────────────┐
   │ Total Stillbirths (≥22 weeks): ~5,65,900                │
   │ National Rate (SBR): 25.9 per 1,000 total births        │
   ├─────────────────────────────────────────────────────────┤
   │ Concentration: ~50% in Uttar Pradesh & Bihar            │
   │ Regional Variance: 9.3 (Mizoram) ───► 38.2 (U.P.)       │
   └─────────────────────────────────────────────────────────┘

The data exposes a massive four-fold disparity across India’s geographical landscape:

• Highest Rate: Uttar Pradesh recorded the country’s highest stillbirth rate at 38.2 per 1,000 total births (at $\ge$22 weeks).

• Lowest Rate: Mizoram recorded the lowest at 9.3 per 1,000 total births.

• The High-Burden Hub: Uttar Pradesh and Bihar combined contributed nearly 50% of the nationwide total.

The Hidden 40%: The Threshold Problem

A critical takeaway from the study involves how fetal deaths are defined and tracked.

The World Health Organization (WHO) recommends tracking stillbirths from 22 weeks of gestation (or a birthweight of $\ge$500 grams). However, routine tracking in India—including the Sample Registration System (SRS)—has historically logged losses only from 28 weeks onward.

The study demonstrates that the stillbirth rate at $\ge$22 weeks is 1.6 times higher than at $\ge$28 weeks. By ignoring fetal losses that occur between 22 and 27 weeks, current surveillance mechanisms miss roughly 40% of all stillbirths nationwide.

“Counting only late-gestation stillbirths misses two-fifths of losses,” the study authors note, warning that India’s true stillbirth burden has been “markedly underestimated” due to incomplete reporting windows.

What Drives the Numbers? Clinical and Social Drivers

To understand why these tragedies cluster so heavily in northern and central India, researchers look at a combination of clinical complications and underlying social determinants of health.

1. Clinical Complications and Health System Failures

The study points to critical gaps in emergency obstetric care and referral pipelines:

• Deferred and Referred Deliveries: Tragic delays occurring when high-risk mothers are shuffled between overwhelmed facilities without receiving immediate care.

• Hypertensive Disorders: Unmanaged preeclampsia and eclampsia, which restrict blood flow to the placenta.

• Severe Hemorrhage: Uncontrolled bleeding before or during labor.

• High-Risk Profiles: Multiple births (twins/triplets) and prior histories of preterm birth or pregnancy loss.

2. Socioeconomic Determinants

Longitudinal data spanning 2005–2021 from the National Family Health Survey (NFHS) shows that stillbirth risk is deeply interwoven with systemic poverty and equity gaps. Increased risk correlates strongly with:

• Maternal Malnutrition: Severe maternal anemia and short maternal stature ($\le$155 cm), reflecting chronic, intergenerational undernutrition.

• Environmental Exposures: Daily use of unclean solid cooking fuels (e.g., firewood, dung), exposing pregnant women to indoor air pollution.

• Social Vulnerability: Illiteracy, rural isolation, and belonging to historically marginalized Scheduled Caste categories.

Conversely, women residing in joint family systems and those with access to family planning to delay pregnancies showed lower stillbirth risks, pointing to the protective benefits of social support and reproductive autonomy.

Expert Perspectives: Bridging Data and Clinical Practice

Public health experts and clinicians not affiliated with the study stress that fetal deaths between 22 and 28 weeks are not inevitable losses; with modern maternal-fetal medicine, many are preventable.

“A fetus at 24 or 26 weeks requires timely detection of distress, blood pressure management, and accessible neonatal care,” notes independent public health researchers reviewing the GBD findings. “When health systems fail to capture early losses, they also fail to investigate why those pregnancies ended prematurely, leaving systemic gaps unaddressed.”

The study authors call for urgent action:

“Addressing the stillbirth burden in India would require improved surveillance, tracking stillbirths by the 22-week or later threshold, and an integration of stillbirth prevention within broader maternal and newborn health initiatives. These findings demonstrate the urgent need for coordinated multi-sectoral action to strengthen antenatal, intrapartum, and emergency obstetric care.”

Actionable Takeaways for Mothers, Families, and Clinicians

While policy reform moves slowly, evidence-based clinical practices can save lives today.

Study Limitations and Data Challenges

While the study offers a powerful dataset, the authors acknowledge several limitations.

Discrepancies remain among India’s primary tracking mechanisms—the Sample Registration System (SRS), the Health Management Information System (HMIS), and survey data like the NFHS. Inconsistent gestational age cutoffs often lead to the misclassification of stillbirths as early neonatal deaths (and vice versa). Furthermore, home births and unrecorded facility deaths in remote districts remain underrepresented.

Additionally, recent national survey trends rely on fieldwork that overlapped with COVID-19 pandemic disruptions, which may introduce recall bias.

Despite these limitations, independent experts agree that the convergence of spatial data consistently identifies northern and central India as critical priority zones requiring immediate resource allocation.

The Path Forward

As India strives toward achieving United Nations Sustainable Development Goal 3 (SDG 3)—which calls for ending preventable deaths of newborns and children—addressing the stillbirth crisis in states like Uttar Pradesh and Bihar is essential. Moving forward, shifting national surveillance to include all losses from 22 weeks onward will ensure that every loss is counted, every systemic failure is evaluated, and every mother receives the care she deserves.

Medical Disclaimer: This article is for informational purposes only and should not be considered medical advice. Always consult with qualified healthcare professionals before making any health-related decisions or changes to your treatment plan. The information presented here is based on current research and expert opinions, which may evolve as new evidence emerges.

References

1. https://health.economictimes.indiatimes.com/news/industry/stillbirths-from-uttar-pradesh-bihar-accounted-for-half-of-countrys-total-in-2023-analysis/132713289?utm_source=top_story&utm_medium=homepage