Unravelling the panorama of vital statistics on Chinese neonates

China accounts for about a fifth of the world's population. With an annual birth rate of 11–12%, or 16 million, as well as wide regional heterogeneity in demographic characteristics, socioeconomic development, and medical resource allocation, it is very difficult, if not impossible, to retrieve vital statistics on all Chinese neonates. Nonetheless, the past decade has witnessed a boom of data production focused on infant mortality and mortality of children younger than 5 years, by virtue of national surveillance systems that sample hospital birth data from cities and counties.1Feng XL Guo S Hipgrave D et al.China's facility-based birth strategy and neonatal mortality: a population-based epidemiological study.Lancet. 2011; 378: 1493-1500Summary Full Text Full Text PDF PubMed Scopus (84) Google Scholar, 2Rudan I Chan KY Zhang JS et al.WHO/UNICEF's Child Health Epidemiology Reference Group (CHERG). Causes of deaths in children younger than 5 years in China in 2008.Lancet. 2010; 375: 1083-1089Summary Full Text Full Text PDF PubMed Scopus (185) Google Scholar, 3Wang Y Zhu J He C et al.Geographical disparities of infant mortality in rural China.Arch Dis Child Fetal Neonatal Ed. 2012; 97: F285-F290Crossref PubMed Scopus (29) Google Scholar, 4Liang J Mao M Dai L et al.Neonatal mortality due to preterm birth at 28–36 weeks' gestation in China, 2003–2008.Paediatr Perinat Epidemiol. 2011; 25: 593-600Crossref PubMed Scopus (23) Google Scholar However, the stillbirth rate—an indicator of the quality of neonatal and perinatal health care—has been underappreciated and remains largely unexplored. In this issue of The Lancet Global Health, Jun Zhu and colleagues5Zhu J Liang J Mu Y et al.Sociodemographic and obstetric characteristics of stillbirths in China: a census of nearly 4 million health facility births between 2012 and 2014.Lancet Glob Health. 2016; (published online Jan 18.)http://dx.doi.org/10.1016/S2214-109X(15)00271-5Google Scholar report data retrieved from China's National Maternal Near Miss Surveillance System (NMNMSS), yielding a stillbirth rate of 8·8 per 1000 births for the period 2012–14. By comprehensively incorporating datasets based on level II (county or city district) and level III (provincial and subprovincial regional) hospital deliveries, this study is to our knowledge the largest to date and fills a gap in China's vital statistics. One significant limitation, however, is the exclusion of level I (township) hospitals and home deliveries. According to a survey of a subprovincial complete birth population for one region in 2010, births occurring in level I hospitals accounted for 52% of the population compared with 33% and 15% in level II and III hospitals, respectively.6Sun L Yue H Sun B et al.for the Huai'an Perinatal-Neonatal Study GroupEstimation of high risk pregnancy contributing to perinatal morbidity and mortality from a birth population-based regional survey in 2010 in China.BMC Pregnancy Childbirth. 2014; 14: 338Crossref PubMed Scopus (18) Google Scholar Of note, the stillbirth rate in level II and III hospitals was 7–8 times that in level I hospitals, demonstrating highly centralised management of high-risk pregnancies and deliveries.6Sun L Yue H Sun B et al.for the Huai'an Perinatal-Neonatal Study GroupEstimation of high risk pregnancy contributing to perinatal morbidity and mortality from a birth population-based regional survey in 2010 in China.BMC Pregnancy Childbirth. 2014; 14: 338Crossref PubMed Scopus (18) Google Scholar The proportion of home deliveries ranged from 2·5% in cities to 36·1% in the least developed rural area during 1996–2008.1Feng XL Guo S Hipgrave D et al.China's facility-based birth strategy and neonatal mortality: a population-based epidemiological study.Lancet. 2011; 378: 1493-1500Summary Full Text Full Text PDF PubMed Scopus (84) Google Scholar However, the New Rural Cooperative Medical Scheme, a nationwide health-care insurance policy launched since 2010 to cover all rural residents' hospital costs including subsidies to encourage hospital delivery for rural pregnant women,7Government of ChinaMedical and health services in China.http://www.china-embassy.org/eng/zt/bps/t1001641.htmGoogle Scholar along with the suspension of level I hospitals unqualified for facility-based deliveries, might have reduced the rate of home births and caused a shift in birth distribution from low-level to high-level hospitals. Given the absence of data from level I hospitals and a lack of clarity on the distribution of births among different levels of hospitals excluded from the sampling, the capacity of Zhu and colleagues' study to represent the national population is limited, and the stillbirth rate could be biased. Furthermore, the births sampled in this study (n=3 956 836) account for about 12% of the total national population (there were 33 million births nationwide during 2012–148National Bureau of Statistics of ChinaAnnual data.http://www.stats.gov.cn/english/Statisticaldata/AnnualDataGoogle Scholar). How many and which provinces have been included in the sampling is the key methodological issue and thus has a significant impact on data representation. Zhu and colleagues state that “urban populations were over-represented in the NMNMSS, particularly in central and western regions”, indicating a biased sample, large as it is. There are other important issues that also need to be addressed. First, births before 28 complete weeks are conventionally excluded from vital statistics registration and analysis by China's family planning system. However, as advances in neonatal intensive care have pushed the boundary of fetal viability to around 22–24 weeks in industrialised countries and 25–27 weeks in emerging regions in China,9Sun L Yue H Sun B et al.for Huai'an Perinatal-Neonatal Study GroupEstimation of birth population-based perinatal-neonatal mortality and preterm rate in China from a regional survey in 2010.J Matern Fetal Neonatal Med. 2013; 26: 1641-1648Crossref PubMed Scopus (38) Google Scholar, 10Fellman V Hellström-Westas L et al.EXPRESS GroupOne-year survival of extremely preterm infants after active perinatal care in Sweden.JAMA. 2009; 301: 2225-2233Crossref PubMed Scopus (508) Google Scholar the stillbirth and perinatal period should be redefined with a threshold earlier than 28 complete gestational weeks. Additionally, there is confusion especially among medical staff in low-level hospitals over the measurement of perinatal and neonatal mortality. Neonates who were born with detectable life signs but died shortly thereafter may be misclassified as stillbirths rather than livebirths, resulting in a biased stillbirth rate and early neonatal mortality. Resuscitation during the early post-partum period followed by parents' withdrawal of their babies' medical treatment owing to financial and prognostic concerns may further contribute to the risk of misclassification. Second, the proportional contribution of abortion to the stillbirth rate is yet to be elucidated. In practice, abortions are registered as miscarriages rather than stillbirths and will probably contribute to an increase in stillbirth rate should they be calculated as such in future. Notably, with universal implementation of the two-child policy starting very recently, we might expect a declining stillbirth rate in years to come. Third, migrant workers (approximately 8% of the total population of 1·34 billion by 2010) shuttling between rural areas and economically advantageous coastal regions have been largely unaccounted for in birth registries.11Sun B Ma L Liu X et al.Development of neonatal respiratory and intensive care: Chinese perspectives.Neonatology. 2012; 101: 77-82Crossref PubMed Scopus (13) Google Scholar Due to the instability of socioeconomic status, the stillbirth rate among migrant populations may be high and should be addressed in future studies. Because of the above limitations of sampling-based surveillance systems such as the NMNMSS, some regions have started to conduct complete birth-population-based regional surveys, which will contribute substantially to our understanding of neonatal vital statistics in China.6Sun L Yue H Sun B et al.for the Huai'an Perinatal-Neonatal Study GroupEstimation of high risk pregnancy contributing to perinatal morbidity and mortality from a birth population-based regional survey in 2010 in China.BMC Pregnancy Childbirth. 2014; 14: 338Crossref PubMed Scopus (18) Google Scholar, 9Sun L Yue H Sun B et al.for Huai'an Perinatal-Neonatal Study GroupEstimation of birth population-based perinatal-neonatal mortality and preterm rate in China from a regional survey in 2010.J Matern Fetal Neonatal Med. 2013; 26: 1641-1648Crossref PubMed Scopus (38) Google Scholar Such surveys include all births in the registry regardless of the hospital level and subjects' socioeconomic status. Efforts should be directed firstly to the birth populations of subprovincial regions in each province, thereafter extending to the whole province level. Step by step, we might expect to obtain birth vital statistics from a comprehensive national perspective. We declare no competing interests. Sociodemographic and obstetric characteristics of stillbirths in China: a census of nearly 4 million health facility births between 2012 and 2014Our 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. Full-Text PDF Open Access