| Summary: | <p><strong>Background:</strong> In India, the burden of stillbirth remains high. Facility-based stillbirth reviews have the potential to improve the quality of future care and reduce stillbirth incidence. However, evidence about conducting such reviews effectively at the facility level in India remains limited.</p>
<p><strong>Aim:</strong> To develop an evidence-based, comprehensive model for a facility-based stillbirth review in six states in India to inform the planning, extension and scale-up of the nationwide Sentinel Stillbirth Surveillance System.</p>
<p><strong>Methods:</strong> A mixed-methods approach was employed including: (1) a systematic review of types and methods of facility-based stillbirth review processes; (2) secondary analyses of existing cohort data to calculate stillbirth rates, identify risk factors for stillbirth, and explore survival probabilities of fetuses at high risk of intrapartum stillbirth by gestational age; (3) two qualitative studies to explore current stillbirth review processes in India, and identify facilitators and barriers for implementation and sustainability using the capability, opportunity, motivation and behaviour (COM-B) model.</p>
<p><strong>Results:</strong> The systematic review identified facility-based stillbirth reviews implemented worldwide, and its evidence formed the basis of an initial logic model outlining components of a successful stillbirth review process. The stillbirth rate in 13 hospitals across six states in India was 22.0 per 1,000 total births. Key risk factors identified were hypertensive disorders of pregnancy, anaemia, <10<sup>th</sup> percentile birthweight for gestational age, <4 antenatal check-ups, and <100 days of antenatal iron and folic acid supplementation. Qualitative findings highlighted that despite efforts to improve data quality, pregnancy care, and review quality through stillbirth reviews, gaps remained in standardised stillbirth reporting, documentation of findings, and follow-up of recommendations. Opportunities for quality improvement included implementing key performance indicators to evaluate outcomes and the impact of the review process. Facilitators related to social opportunities included creating a blame-free environment for discussion, ensuring participation from all levels of the health system, and addressing cultural perceptions of stillbirth and post-mortem examinations. Facilitators related to physical opportunities were having clear stillbirth definitions and collecting minimum stillbirth data. Supporting healthcare professionals with targeted training and mentoring had the potential to increase capability. Reflective motivation, specifically, the beliefs in the benefits of stillbirth reviews for both the facility and the community, was a notable factor in the willingness of healthcare professionals to implement and sustain stillbirth reviews despite system-level barriers.</p>
<p><strong>Conclusion:</strong> Findings from the five research activities were triangulated into a logic model that was iteratively refined. The final model contextualised global evidence to address India’s diverse health system challenges, linking inputs, activities, and outcomes while identifying facilitators, barriers and evaluation needs – critical components for implementing and sustaining stillbirth review processes. The logic model also identifies priority areas where stillbirth reviews could have the greatest impact. The model and recommendations from this study have the potential to support India’s goal of reducing stillbirth rates to <10 per 1,000 total births by 2030.</p>
|
|---|