Regional Disparities, Economic Development, and Neonatal Mortality and Hospital Delivery in China.

Importance: A negative association between neonatal mortality and hospital delivery has been found in some low- and lower-middle-income countries but not in rural settings characterized by poor quality of maternal and child health care. Objective: To examine the association between neonatal mortality and hospital delivery in China across urban and rural regions, regional disparities, and varying levels of economic development. Design, Setting, and Participants: This retrospective cohort study used county-level data from 2008 to 2020 from the National Maternal & Child Health Statistics across mainland China. Statistical analysis was conducted from March to December 2023. Exposures: Since 2008, China has strategically leveraged hospital deliveries with national subsidies to diminish neonatal mortality, particularly in rural areas. Main Outcomes and Measures: Neonatal mortality and hospital delivery rates were calculated, and their association was estimated using multivariable fixed-effects linear models of county-level cohort data to adjust for time-invariant differences across counties and controls for gross domestic product (GDP) per capita, women's years of education, hospital beds, and health workers. Results: The analysis included data from 2930 counties, with 198.7 million live births across 36 255 county-year records between 2008 and 2020. The mean (SD) neonatal mortality rate per 1000 live births decreased in rural areas from 12.3 (7.5) in 2008 to 3.9 (2.7) in 2020 and decreased in urban areas from 5.0 (3.1) in 2008 to 2.0 (1.3) in 2020. Hospital delivery rates increased in rural areas from a mean (SD) of 93.4% (11.8%) in 2008 to 99.9% (0.6%) in 2020 and increased in urban areas from 97.7% (6.1%) in 2008 to 100.0% (0.1%) in 2020. In rural areas, an increase of 10 percentage points in hospital deliveries was associated with a neonatal mortality rate of -1.4 (95% CI, -1.9 to -1.0; P < .001) per 1000 live births, whereas this negative association was not observed in urban areas. When the analysis was stratified by regions and incomes, the negative association became considerably stronger in the western and central regions of China, as well as in counties with lower GDP per capita. Conclusions and Relevance: This cohort study of more than 2900 counties in China suggests that an increase in hospital deliveries was associated with reduced neonatal mortality in rural and economically underdeveloped areas in China. To further reduce neonatal mortality and improve newborn health, it is imperative to increase the accessibility of hospital delivery services.