Abstract
BACKGROUND: Stillbirth is a significant public health issue worldwide, with India bearing a substantial burden. While male fetuses are biologically more vulnerable, the geographic distribution of sex-specific stillbirth rates remains underexplored. This study investigates district-level stillbirth patterns across India and evaluates their spatial association with maternal, socio-demographic, and delivery care factors. METHODS: This ecological study employed data integration using the Civil Registration System (CRS-2020) and the National Family Health Survey (NFHS-5) to compile district-level estimates of stillbirth rates (SBRs) along with maternal, delivery care, and socio-demographic indicators. SBR was calculated as the number of stillbirths per 1000 total births for each sex. Spatial autocorrelation was assessed using Global and Local Moran's I. Additionally, univariate and bivariate Local Indicators of Spatial Association (LISA) were conducted separately for male and female stillbirth rates to examine spatial clustering and associations with selected correlates, identifying hotspot and cold-spot regions across districts. FINDINGS: The nationwide stillbirth rate (SBR) in 2020 was 6.548 per 1000 total births (female: 6.54; male: 6.63). Stillbirth rates were higher among urban mothers compared to rural mothers. Northern India, particularly Chandigarh, Jammu & Kashmir, and Rajasthan, recorded the highest SBR. Spatial analysis identified stillbirth hotspots primarily in Northern and Central India. Univariate Moran's I indicated strong spatial clustering for maternal factors, including below-normal BMI (Moran's I = 0.62) and iron-folic acid supplementation (Moran's I = 0.551). Bivariate Moran's I showed similar spatial trends for both sexes, with stillbirth rates positively correlated with anemia (female: 0.087; male: 0.078) and institutional births in public facilities (female: 0.084; male: 0.086), and negatively correlated with literacy (female: -0.069; male: -0.063) and cesarean deliveries in private facilities (female: -0.055; male: -0.090). INTERPRETATION: This study found no significant geospatial disparity in sex-specific stillbirth rates across Indian districts, with similar clustering patterns for both sexes. Key determinants included literacy, wealth status, anemia, and cesarean deliveries. District-specific strategies, guided by geospatial insights, are essential for focused public health measures. Strengthening stillbirth registration and utilizing advanced spatial methods are crucial for improved monitoring and intervention planning. FUNDING: No funding was issued for this research.