title: Sociodemographic and obstetric characteristics of stillbirths in China: a census of nearly 4 million health facility births between 2012 and 2014.
abstract: BACKGROUND
  Very little is known about the burden and determinants of stillbirths in China. We used data from a national surveillance system for health facility births to compute a stillbirth rate representative of all facility births in China and to explore sociodemographic and obstetric factors associated with variation in the stillbirth rate.
  
  
  METHODS
  We used data from China's National Maternal Near Miss Surveillance System between Jan 1, 2012, and Dec 31, 2014, which covers 441 hospitals in 326 urban districts and rural counties. The surveillance aimed to enumerate all maternal deaths and near misses in health facilities, and collected data prospectively for all pregnant or post-partum women admitted to the obstetric department. We restricted the analysis to births of 28 or more completed weeks of gestation or 1000 g or heavier birthweight. We examined the strength of association between sociodemographic characteristics, gestational age, and obstetric complications and stillbirths using logistic regression, taking account of the sampling strategy and clustering of births within hospitals and in cases of more than one birth per woman.
  
  
  RESULTS
  There were 3 956 836 births and 37 855 stillbirths, giving a stillbirth rate of 8·8 per 1000 births (95% CI 8·8-8·9). The stillbirth rate was particularly high for women younger than 15 years of age (59·9 stillbirths per 1000 births), those who had not sought antenatal care (38·3 per 1000), the unmarried (32·5 per 1000), those with no education (26·9 per 1000), or those who had had four or more births (23·2 per 1000). A high proportion (29 319 [78·2%] of 37 514) of stillbirths occurred at gestational ages of younger than 37 weeks, and about two thirds (24 787 [66·1%] of 37 514) were in women without any maternal complication at the time of birth. Of babies born at normal gestations (37-41 weeks), maternal complications substantially increased the risk of stillbirth (odds ratio comparing antepartum or intrapartum complications with no complication 3·96 [95% CI 3·66-4·29]), but only a small proportion (1638 [4·4%] of 37 514) of stillbirths fell into this group.
  
  
  CONCLUSIONS
  Our analysis of nearly 4 million births in 441 health facilities in China suggests a stillbirth rate of 8·8 per 1000 births between 2012 and 2014. Stillbirths do not feature in the Chinese Government's 5 year plans and most information systems do not include stillbirths. The Government need to start paying attention to stillbirths and invest strategically in antenatal care, particularly for the most disadvantaged women, including the very young, unmarried, and illiterate, and those at high parity.
  
  
  BACKGROUND
  National Health and Family Planning Commission of the People's Republic of China, National Natural Science Foundation of China, China Medical Board, WHO, and UNICEF.
authors.affiliation: National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
authors.forename: Jun
authors.initials: J
authors.lastname: Zhu
authors.affiliation: National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
authors.forename: Juan
authors.initials: J
authors.lastname: Liang
authors.affiliation: National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
authors.forename: Yi
authors.initials: Y
authors.lastname: Mu
authors.affiliation: National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
authors.forename: Xiaohong
authors.initials: X
authors.lastname: Li
authors.affiliation: UNICEF China, Beijing, China.
authors.forename: Sufang
authors.initials: S
authors.lastname: Guo
authors.affiliation: UNICEF China, Beijing, China.
authors.forename: Robert
authors.initials: R
authors.lastname: Scherpbier
authors.affiliation: National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
authors.forename: Yanping
authors.initials: Y
authors.lastname: Wang
authors.affiliation: National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
authors.forename: Li
authors.initials: L
authors.lastname: Dai
authors.affiliation: National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
authors.forename: Zheng
authors.initials: Z
authors.lastname: Liu
authors.affiliation: National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
authors.forename: Mingrong
authors.initials: M
authors.lastname: Li
authors.affiliation: National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
authors.forename: Chunhua
authors.initials: C
authors.lastname: He
authors.affiliation: National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
authors.forename: Changfei
authors.initials: C
authors.lastname: Deng
authors.affiliation: National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
authors.forename: Ling
authors.initials: L
authors.lastname: Yi
authors.affiliation: National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
authors.forename: Kui
authors.initials: K
authors.lastname: Deng
authors.affiliation: National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
authors.forename: Qi
authors.initials: Q
authors.lastname: Li
authors.affiliation: National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
authors.forename: Xia
authors.initials: X
authors.lastname: Ma
authors.affiliation: WHO China Representative Office, Chaoyang District, Beijing, China.
authors.forename: Chunmei
authors.initials: C
authors.lastname: Wen
authors.affiliation: Department of Paediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China. Electronic address: dezhimu@yahoo.com.
authors.forename: Dezhi
authors.initials: D
authors.lastname: Mu
authors.affiliation: West China School of Public Health, Sichuan University, Chengdu, Sichuan, China; Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK. Electronic address: carine.ronsmans@lshtm.ac.uk.
authors.forename: Carine
authors.initials: C
authors.lastname: Ronsmans
mesh_terms: D000293:Adolescent; D000328:Adult; D002681:China / Q000453:epidemiology; D036861:Delivery, Obstetric; D004522:Educational Status; D005260:Female; D005865:Gestational Age; D006761:Hospitals; D006801:Humans; D016015:Logistic Models; D017533:Marital Status; D008423:Maternal Age; D008875:Middle Aged; D016017:Odds Ratio; D010298:Parity; D011247:Pregnancy; D011248:Pregnancy Complications; D011295:Prenatal Care; D050497:Stillbirth / Q000453:epidemiology*; D055815:Young Adult