# Facilitators and barriers to implementing and sustaining facility-based stillbirth reviews in India: a qualitative study

## TL;DR

This study explores what helps or hinders healthcare workers in India from carrying out stillbirth reviews, which can improve maternity care and reduce preventable stillbirths.

## Contribution

The study identifies practical facilitators and barriers to implementing stillbirth reviews in India using a behavioral framework.

## Key findings

- Creating a blame-free environment and training are key to successful stillbirth reviews.
- Clear definitions and data collection standards improve consistency in reviews.
- Regular training and IT support can address workload and capability challenges.

## Abstract

Stillbirth reviews provide opportunities to improve the quality of maternity care and reduce preventable stillbirths. In India, facility-based stillbirth reviews have been part of the National Health Mission since 2016, yet their implementation has been inconsistent. This study aimed to identify the facilitators and barriers to implementing and sustaining facility-based stillbirth reviews as reported by Indian healthcare professionals.

A qualitative study was conducted between August to October 2023 using focus group discussions with purposively sampled healthcare professionals from eight hospitals in India, which included those that conduct stillbirth reviews and those that do not. Discussions were analysed using the Framework Method. We applied the capability, opportunity, motivation, and behaviour (COM-B) model to identify facilitators and barriers and used the Behaviour Change Wheel to link these to intervention functions.

Important factors related to capability included record-keeping skills, understanding the importance of documentation, and training on how to conduct effective stillbirth reviews. Under social opportunity, key facilitators were 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 opportunity included the presence of clear stillbirth definitions and the collection of minimum stillbirth data. 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.

Strengthening the implementation and sustainability of facility-based stillbirth reviews in India requires targeted, practical interventions. Creating a blame-free environment can be supported through workshops emphasising the learning purpose of reviews, having neutral facilitators to guide discussions, and asking participants to sign a code of conduct ‘charter’ pledging their commitment to providing a safe environment for all panel members and the community, incorporating this into local stillbirth review guidelines. Clear national guidelines on stillbirth definitions, combined with training on accurate data collection and reporting, will improve consistency. Regular training and mentoring should focus on building healthcare professionals’ capability in record-keeping and effective review practices. Strengthening information technology infrastructure and providing protected time for reviews will address workload challenges. Additionally, fostering motivation through peer-led discussions and sharing positive outcomes can encourage continued commitment to stillbirth reviews.

The online version contains supplementary material available at 10.1186/s12884-025-07912-6.