Background: Epilepsy is a serious health problem associated with an increased risk of premature mortality. Few studies have investigated risk factors for this. Understanding these risks may enable the implementation of preventative measures to reduce premature mortality. Methods: A management program for convulsive forms of epilepsy has been in place at the primary health care level in rural West China since May 2005. Demographic data and putative causes of death of attendees of the program since inception to the end of December 2009 have been recorded. Case fatality (CF), the proportional mortality ratios (PMRs) for each cause, and standardized mortality ratios (SMRs) for each age and cause were estimated based on the 2007 Chinese rural population. Results: There were 106 reported deaths (70 male) among 3,568 people. CF was 2.97% during a median of 28 months' follow-up. The highest PMRs were for accidental death (59%) including drowning (45.1%); probable sudden unexpected death in epilepsy (SUDEP) (14.7%); status epilepticus (6.9%), and neoplasm (6.9%). The overall SMR was 4.92 (95% confidence interval 4.0-6.1); the risks were high in young people. The risk of drowning was 82-fold higher in the cohort than the general population. Conclusion: In rural West China, the risk of premature death is nearly 5 times higher in people with convulsive epilepsy than in the general Chinese population and especially high among young people. Accidental death, including drowning, and probable SUDEP are the leading putative causes of death in people with convulsive epilepsy in rural West China. Neurology(R) 2011;77:132-137