Can we prevent stillbirths in India: A mixed-methods multisite study assessing Intrapartum care and public health facilities

Background: In India, stillbirth is still a significant, avoidable pregnancy outcome that reflects ongoing deficiencies in the standard of care for expectant mothers and newborns. 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 the quality of intrapartum care and facility readiness across four diverse rural districts in India, identify key systemic and contextual challenges, and inform improvement strategies for reducing stillbirths. Methods: In the formative phase of an implementation research project, we carried out a sequential mixed-methods study. Direct, non-participating observations of 159 labouring women and readiness evaluations of 134 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. Results: Adherence to evidence-based intrapartum care practices varied significantly between sites. Assessments of fetal heart sound and blood pressure were among the indicators that were not consistently monitored. Real-time documentation was frequently lacking, and partograph use was generally low. Procedures for administering oxytocin and handling emergencies varied. Assessments of facility preparedness showed that while basic newborn supplies and necessary medications were typically available, there was a lack of access to specialists, blood transfusion services, and sophisticated monitoring equipment (such as CTG). According to qualitative findings, multitasking, excessive workloads, and staff shortages are the main obstacles in providing quality care. Conclusion: Despite high rates of institutional births, rural India's lack of adequate intrapartum care and facility preparedness impedes efforts to lower the number of stillbirths. There is an urgent need for targeted interventions to improve real-time labor 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. Keywords: Emergency obstetric care, Facility readiness, Health system, Intrapartum care, Maternal health, Mixed-methods, Rural India, Stillbirth prevention.