Can we prevent stillbirths in India: a mixed methods study assessing intrapartum care and public health facilities

In India, stillbirth remains asignificant, adverse pregnancy outcome and an important marker of gaps in the quality of maternal and newborn care. Even though institutional deliveries have improved, a significant percentage of stillbirths happen during the intrapartum phase, frequently as a result of poor monitoring, a failure to recognize complications promptly, and a lack of facility readiness. This study aimed to assess process indicators of intrapartum care quality and facility readiness across four diverse rural districts in India and identify key systemic and contextual challenges, for informing improvement strategies to strengthen intrapartum care quality and facility readiness. In the formative phase of an implementation research project, we carried out a sequential mixed-methods study. Direct, non-participating observations of 159 women in labour and readiness evaluations of 143 public health facilities comprised the quantitative component. Focus groups and in-depth interviews with healthcare professionals and community stakeholders were used to gather qualitative data. Descriptive statistics and thematic analysis were used to triangulate the data. Adherence to evidence-based intrapartum care practices varied across sites. Partograph use was documented in 12 of 159 deliveries (7.5%), and intermittent foetal heart rate (FHR) monitoring during the second stage of labour was observed in 108 cases (67.9 %). Blood pressure monitoring during labour was inconsistently performed across facilities. Oxytocin administration during the first stage of labour was observed in 10 women (6.2%), while use for active management of the third stage exceeded 23% across sites. Among 143 facilities assessed, shortages of paediatricians and anaesthetists were noted in two districts, and bedside availability of functional FHR monitoring equipment was limited in peripheral facilities. Qualitative findings identified high workload, multitasking, staffing shortages, and documentation burden as key barriers to real-time monitoring and protocol adherence. Facility births alone are insufficient to ensure safe maternal and neonatal outcomes, as significant gaps remain in intrapartum care processes and facility preparedness across rural public health facilities in India. There is an urgent need for targeted interventions to improve real-time labour monitoring, increase workforce capacity, and deliver comprehensive emergency obstetric care. To meet national stillbirth reduction targets, strategies for implementing data-driven audits and embedding quality improvement cycles are essential.