Guha’s Neonatology: Principles and Practice Dipak K Guha, Arvind Saili, Swarnarekha Bhat, Arvind Shenoi
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1Principles of Neonatology2
Section 1 Perspectives of Neonatology in India

Milestones in Neonatology in India1

ON Bhakoo
Praveen Kumar
Perinatal period is the most hazardous one in a person's life; yet it was the last one to be recognized as of any importance in improving the health of society. The global burden of neonatal deaths is estimated to be 4 million per year. Ninety six percent of which is contributed by the developing countries.1 As many as two million neonates die every year in South East Asia region and of them 1.2 million are in India alone. Neonatal health is undoubtedly, one of the most significant health challenges facing the developing world. The advanced countries launched neonatal intensive care programs in late sixties and early seventies which have resulted in the survival of fetuses of very low gestation previously considered not viable. However in India, we are still struggling to get minimal care facilities for our neonates. The neonatal mortality rate (NMR) in our country is 5 to 6 times higher as compared to the developed nations.2,3 In India, over one-third of all newborn infants are LBW, of these one-third are preterm and two-third are born term (small for dates). The LBW rate in India is one of the highest in the world and in contrast with that of 6 percent in Canada, 7 percent in USA and UK, 9 percent in China, 10 percent in Egypt and 25 percent in Sri Lanka.3a In India, nearly 70 percent of neonatal mortality occurs among LBW infants.4,5
 
SECULAR TRENDS IN NEONATAL MORTALITY
The infant mortality rate (IMR) in the country has declined steadily from 165 per 1000 live births in 1950s, 129 in 1976, 110 in 1981 to 71 in 1997. On the other hand, the NMR has shown a much slower fall from 80 in 1950 to 47 per 1000 live birth in 1996.6 As a result of this, the NMR has been forming an increasing proportion of IMR over the years and currently accounts for 65 percent of the infant deaths (Fig. 1.1).3,6-9 It is obvious that the programs of child health have not made the desired impact on the national NMR. This is because these programs have focussed largely on diarrhea, infectious diseases and respiratory illnesses which have an effect mainly on post-neonatal mortality while the inputs required to lower neonatal mortality are different.
India is a vast country, a subcontinent, with a population of more than 1000 millions, distributed in 28 states and 7 union territories divided into over 466 districts. Inevitably there is wide disparity in NMR amongst various population groups within the country with rural NMR being almost double that of urban areas.3 In the urban slums, NMR is close to 50 inspite of proximity to health care facilities, whereas the non-slum urban areas have a low NMR of around 20.10,11 A major reason for the high neonatal mortality is lack of care at birth.12 According to the National Family Health Survey,13 only 25.6 percent deliveries occur in institutions.
4
zoom view
Fig. 1.1: National trends in mortality rates2,3
The remaining three quarters take place at home. Of them, nearly 88 percent deliveries are attended by untrained personnel, either the TBAs (47%) or related friends (41%). The reported coverage for antenatal care is 62 percent.14 Regional differences are also notable as regard to the care at birth. For instance, the proportion of institutional deliveries in southern state of Kerala and Tamil Nadu are 96.8 and 64 percent respectively, while in Rajasthan, Bihar and UP are only 7-14.7 percent.6,8,13 Similarly, there are wide variations in NMR between various states. Improvement in some states may not be reflected in the national figures because of the dilution effect of more populated worse-off states. Hence, it is important to look at the statewise break-up of the mortality rates.
Table 1.1 describes the relationship of NMR, perinatal mortality rate (PNMR) and IMR to proverty, female literacy, age at marriage, fertility rates and professional attendance at birth in various states of the country. Only the states of Kerala and Punjab have recorded a NMR of less than 30. The comparison of socioeconomic and health statistics shows that NMR is not dependent on a single factor e.g., whereas 22.7 percent of the population is below poverty line in Punjab as against 25.4 percent in Kerala, the NMR in Punjab is 28 as against 11 in Kerala. One finds similar observations regarding relationship of NMR to female literacy and fertility rates in many states (Table 1.1). In Kerala, the low mortality rates have been ascribed to the development of social services rather than economic development alone.15
The National Health Policy (1983) as a part of health for all initiative, envisaged achieving IMR of less than 60, PNMR of less than 35, incidence of LBW neonates less than 10 percent, universal antenatal care and conduct of all deliveries by trained personnel by the end of the year 2000.13
Table 1.1   Socioeconomic factors and mortality in selected states4,5,8
State
IMR
(1997)
NMR
(1995)
PNMR
(1995)
Population below poverty line (%)
(1993-94)
Female literacy (%)
(1991)
Institutional deliveries
(1995)
Domiciliary deliveries attended by trained person
(1995)
Mean age at marriage (years)
(1995)
Total fertility rate
(1995)
Low NMR states (<30)
Kerala
12
11
16
25.4
86.9
96.8
1.8
21.7
1.8
Punjab
51
28
29
11.7
12.4
85.8
20.8
2.9
Intermediate NMR states (30-60)
Assam
76
47
49
40.8
20.7
15.3
20.3
3.5
Gujarat
62
45
38
24.2
48.5
36.1
36.9
20.7
3.2
Haryana
68
42
42
25.1
40.9
24.2
67.3
19.2
3.7
Bihar
71
44
39
54.9
23.1
14.7
18.6
18.5
4.5
Andhra Pradesh
63
53
52
22.2
33.7
41.9
27
18.1
2.7
Tamil Nadu
53
40
45
35
52.3
64.2
20.8
20.9
2.2
Rajasthan
85
56
47
27.4
20.8
7.6
25.8
18.7
4.4
Maharashtra
47
40
41
36.8
47.5
20.1
18.9
2.9
Uttar Pradesh
85
52
46
40.8
26.0
7.0
41.6
19.6
5.0
High NMR states (>60)
Madhya Pradesh
94
65
56
42.5
28.4
13.9
21.1
19.0
4.2
Orissa
96
62
55
18.6
34.4
13.3
22.4
19.8
3.3
5However, going by the progress made till today, it appears that although some states may succeed in achieving most of the goals, the national figures are short considerably and may even take another decade to achieve the stipulated goals.
Data derived from hospital records do not truly represent the NMR in the community at large but has the advantage of being more reliable in terms of causes of death and reflect the quality of services available. The overall picture of hospital care of the newborn in the country has been unsatisfactory. However, a few hospitals, where good level II neonatal care has been introduced, have shown a marked improvement in the weight specific survival rates. The most dramatic change has been in the survival rates of babies below 2000 grams (Table 1.2).
Table 1.2   Neonatal mortality at PGIMER, Chandigarh
Year
1001-1250
gm (%)
1251-1500
gm (%)
1501-2000
gm (%)
2001-2500
gm (%)
>2500
gm (%)
1973
76.0
53.8
27.4
3.4
0.79
1983
63.2
41.3
19.6
2.4
1.06
1993
30.9
25.8
15.9
2.6
0.85
1999
36.0
21.0
8.0
1.3
0.7
Till recently, availability of data on neonatal-perinatal health was restricted to few isolated centers. National Neonatal-Perinatal Database (NNPD)—1995 compiled earlier and NNDP—2000 which has been recently compiled by National Neonatology Forum (NNF). The data has been prospectively collected from 16 centres in a uniform pattern (Tables 1.3 and 1.4).16,16a This is major milestone in providing accurate information on neonatal morbidity and mortality patterns prevailing in Urban Indian Hospital.
 
CAUSES OF NEONATAL DEATHS
In order to plan the strategy to reduce NMR and for prioritization of resources, it is important to know the contribution of various factors to neonatal deaths. Low birth weight, birth asphyxia/birth trauma and infections are responsible for majority of deaths in the community.17,18 In areas with low NMR, over 60 percent of the neonatal mortality occurs amongst low birth weight babies while in high NMR areas, the contribution by normal birth weight babies matches that of the low birth weight.17,18
Table 1.3   National neonatal-perinatal vital statistics*
1995
2000
Live births
  • Total live births
37082
49964
  • Preterms
12.3%
14.1%
  • Low birth weight (LBW)
32.0%
32.8%
  • Neonates <2000 g
10.2%
11.0%
  • Very low birth weight
    (VLBW) <1500 g
3.3%
3.7%
  • Extremely low birth weight
    (ELBW) <1000 g
0.7%
0.8%
  • Term LBW
67.2%
78.5%
  • Preterm LBW
32.8%
31.5%
Deaths
  • Neonatal Mortality Rate
    (NMR)#
37.7
30.3
  • Early NMR#
33.8
25.6
  • Late NMR#
3.9
4.7
  • Stillbirths
1510
1941
  • Stillbirth rate#
39.1
41.7
  • Perinatal mortality rate
71.6
66.5
* National Neonatal-Perinatal Database (NNPD) 1995, and 2000 NNF, New Delhi # Per 1000 live births.
Table 1.4   Neonatal survival according to birth weight*
Births weight (g)
Survival (%)
1995
2000
< 1000
22.3
72.4
1000-1249
44.5
58.3
1250-1449
69.2
75.4
1500-1749
81.0
88.7
1750-1999
92.3
94.8
2000-2249
96.0
97.3
2250-2499
98.0
98.7
2500-2999
98.9
99.0
3000-3449
99.1
99.4
≥ 3500
99.2
99.2
* National Neonatal-Perinatal Database (NNPD) 1995, and 2000 NNF, New Delhi.
Neonatal tetanus which was responsible for 25-33 percent of total neonatal deaths in the early 80s seems to have been controlled to a large extent, but it may account for some deaths in areas with high NMR.13
The 1995 and 2000 report of the National Neonatal-Perinatal Database reveals that birth asphyxia/trauma and infections are responsible for nearly half of neonatal deaths nationwide (Table 1.5). While interpreting this data one has to keep in mind that most of 6the centres assigned the cause of death based in clinical criteria alone with little microbiological and autopsy support. A systematic study of all perinatal deaths where cause of death was assigned after ascertaining clinicopathological correlation in each case shows that immaturity and intraventricular hemorrhage by themselves are not the primary causes of deaths in significant numbers (Table 1.6).19
Table 1.5   Primary causes of neonatal deaths*
Cause
1995 (%)
2000 (%)
Perinatal hypoxia/trauma
26.0
19.9
Infections (septicemia/meningitis)
19.3
22.7
Hyaline membrane disease
13.5
14.3
Other respiratory problems (pneumonia/pulmonary hemorrhage)
6.5
2.1
Extreme prematurity
11.4
15.5
Intraventricular bleed
6.1
4.3
Congenital malformations
9.6
7.1
Other known causes
10.2
12.6
Cause not established
1.6
Birth trauma
0.5
* National Neonatal-Perinatal Database (NNPD) 1995 and 2000 NNF, New Delhi.
Table 1.6   Primary causes of perinatal mortality-autopsy study13
Extrinsic perinatal hypoxia
43.3%
Infection
17.9%
Hyaline membrane disease
11.9%
Congenital malformations
10.5%
Extreme prematurity
2.2%
Other known causes
6.6%
Cause not established
7.5%
As the NMR decreases, lower birth weight categories comprise a higher proportion of neonatal death e.g. 85-90 percent of neonatal deaths occur among LBW babies in PGIMER, Chandigarh and AIIMS, New Delhi. We have observed that different diseases dominate as the major causes of neonatal deaths at different gestations, e.g. asphyxia is the leading killer in babies >37 weeks (>2000 grams), sepsis in 33-36 weeks gestation (1500-2000 grams), while respiratory distress is responsible for maximum deaths amongst babies of 28-32 weeks gestation (<15000 grams). In preterm babies perinatal asphyxia, though not the direct cause, is an important contributor in more than 50 percent of neonatal deaths. Similarly bacterial sepsis contributes substantially to death even in babies > 1500 gm.
 
EVOLUTION OF NEONATAL CARE IN INDIA
The evolution of neonatal care practices in our country can be divided into the following five steps which by and large took place in the same sequence.
  1. Awareness about neonatal tetanus as the major killer came about 40 years ago.20 Soon it was realized that use of tetanus immunization of the pregnant mother and meticulous asepsis at the time of delivery and cord care was the key to the prevention of the malady.
  2. Infection was recognized as a major preventable cause of neonatal morbidity and mortality. Apart from the emphasis on general measures of asepsis in the care of the newborn, a concerted campaign to promote breastfeeding and to discourage bottle feeding was undertaken. It was demonstrated that involvement of mothers in the care of sick babies, even in the hospitals, decreased the incidence of cross-infections, led to better weight gain and improved survival rates.21,22,22a
  3. Hypothermia among neonates was noted to be a common problem even in a tropical country like ours. It was shown that costly incubators were not essential for managing a large proportion of low birth weight babies especially those >1300 grams. These babies can be easily kept warm by raising the room temperature, reducing radiant heat losses by covering the baby and nursing them close to the mother.
  4. The realization that perinatal asphyxia is responsible for more than 50 percent of morbidity in the newborn and is essentially preventable, resulted in special emphasis being given to antenatal and intranatal care. It has also led to a training revolution resulting in training of a large number of doctors, nurses and health workers in proper techniques of neonatal resuscitation.
  5. Use of technology for providing supportive care to sick and small babies in special care baby units (premature nurseries/neonatal intensive care units) was the final step that led to significant improvement in the survival of babies between 1250 and 2000 grams.7
 
HISTORY OF NEONATOLOGY IN INDIA
For achieving the above mentioned ends, pediatricians of our country have gone through two decades of preparation leading to crystallization of thought process, which has resulted in preparation of guidelines based on indigenous experience. The World Health Organisation (WHO) and Ministry of Health conducted a series of workshops on basic neonatal care for pediatricians and nurses during 1960s and 1970s. This resulted in the creation of a band of pediatricians committed to development of neonatal care in the country. Some of them went through extended advanced training in Western countries and set up modern neonatal care units in their respective hospitals in various parts of the country. In a survey about the interests of the members of the Indian Academy of Pediatrics (IAP) conducted in mid-seventies, almost 50 percent responders identified neonatology as their area of interest. This resulted in the formation of a group of workers committed to neonatology under the banner of National Neonatology Forum (NNF) in 1980.23
NNF has been instrumental in preparing a series of documents on various aspects of neonatal care including organization, accreditation of units, teaching and training, neonatal nursing, biomedical equipments, monitoring, nomenclature, data collection, primary care of the newborn communication strategies and neonatal ventilation. NNF faculty has created sets of teaching slides on key topics of newborn care. This resource material is targeted for pediatricians, family physicians, medical officers and undergraduate students.
NNF initiated training in neonatal resuscitation in the form of Neonatal Advanced Life Support (NALS) program in India in 1990. In the first three years of this program, during 233 workshops, it has trained over 10,000 pediatricians, anesthetistis, medical officers and nurses. This program has led to increased awareness about newborn care. The last decade has also seen collaboration of NNF members with American and Australian neonatologists of Indian origin, resulting in mutual exchange of ideas and facilitating short-term training of Indian pediatricians in American and Australian hospitals especially in neonatal assisted ventilation and parenteral nutrition. Following the publication of the document on suggested facilities for level II care neonatal units in the country, increasing number of units have successfully come up to the level of recommended norms and have been declared suitable for providing level II training facilities.24 Facilities for ventilator care have been initiated in selected centers over the last 5-10 years and more than 25 centers currently are able to take care of babies on mechanical ventilation. Recently, NNF has finalized the guidelines for level III units in the country and process of accreditation has started.
With the launching of DM (neonatology) program in 1989, this speciality has really come of age in the country.25 This training course has already been started in 4 centers in the country and is likely to be introduced in many more centers in the next decade. The National Board of Examinations has also formalized the starting of Diplomate of National Board (DNB) in neonatology. These developments are bound to expand the leadership base of the profession.
 
CURRENT STATUS OF NEONATAL CARE IN INDIA
It is paradoxical that in spite of so much interest in neonatal care among pediatricians, the national NMR continues to stay very high. This is largely because of the fact that majority of the deliveries in the rural and a significant proportion in the urban areas are being conducted at home, mostly by Traditional Birth Attendants (TBA). Though pregnancy registration is 40-60 percent, less than half of these get adequate antenatal care, and the standard of neonatal care in this group of population has been poor.
The perinatal care in the rural areas is supposed to be provided by Female Multipurpose Worker (FMPW) through the Primary Health Centers (PHC) and subcenters. FMPWs are being encouraged to train the TBAs of the area and are themselves supervised by the Medical Officers. However, the functioning of this system needs lot of improvement as is reflected in the results of Indian Council of Medical Research (ICMR) collaborative national survey of over 100 PHCs and subcenters. The survey showed that the facilities for basic antenatal and intranatal care such as weighing scale, BP machine, urine analysis, hemoglobin estimation and delivery arrangements were lacking.9 Even pregnancy registration was less than 40 percent. The knowledge about the basic care of a newborn such as environmental temperature control at birth, hand 8washing, tieing of cord, oropharyngeal suction, feeding and recognition of high risk baby, was woefully inadequate amongst health functionaries meant to deliver primary newborn care. In urban slums, the situation is worse-off with no primary health delivery system being available at all.
 
Government Programs
The National Health Policy (1983) defined three goals, viz. reduction in IMR, reduction in PNMR and redution in LBW as major objectives related directly or indirectly to the newborn.26 Realizing that NMR and PNMR have been nearly static over the last four decades, the government has recently identified perinatal care as an inportant thrust area for reducing IMR. This resulted in the publication of Government of India recommendations on minimum perinatal care in 1982 followed by the launching of CSSM program in 1992.27 In this program, the newborn was given a separate special status with emphasis on clean and safe delivery, prevention and management of asphyxia, provision of warmth, adequate feeding to the low birth weight babies, identification and management of jaundice and recognition of ‘at risk’ newborns who need to be referred to a hospital. This package of ‘essential newborn care’ was based on the assumption that all newborns need such care as their primary and basic need for intact survival. Provision was also made for skill oriented training of health professionals in ‘essential newborn care’ and providing atleast basic neonatal care equipment at PHC, FRU/CHC and district hospitals. As a part of implementation of this program, the NNF with the active cooperation of Ministry of Health, in a pilot project established such newborn care units in 24 districts and monitored the newborn care and utilization of the training and equipment. Based on this successful experimentation, this project is being extended to all districts of the country.
In 1996, the Government of India launched the Reproductive and Child Health (RCH) program. The neonatal and infant survival are directly related to the health of the women much before and during pregnancy. So, this approach focuses not only on pregnancy and childbirth but also on the overall reproductive health of the woman. The program intends to ensure quality and accessibility of services. RCH program advocated a target free approach. However, this was being interpreted as if there was nothing specific to achieve. Hence, a modification was made emphasizing the role of ‘local participatory planning’. This meant that in each area, people decide their own goals and try to achieve them. Training modules for physicians and health workers have been developed. The training of national trainers is just over and state level training is taking off. It is hoped that RCH will strengthen the gains of newborn care initiated in the CSSM program.
The WHO has recently approached the government to modify the child servival package of RCH program to incorporate the integrated management of childhood illness (IMCI) module. However, the IMCI protocol does not cover the crucial neonatal period. It will be desirable that IMCI guidelines may be enlarged to include the newborn period.
 
Special Neonatal Care
The Government of India report of 1990 accepted that only 20 of the 125 medical colleges in the country had special care neonatal units. A series of surveys of neonatal units conducted in the country revealed that the facilities for special neonatal care were less than satisfactory.28-30 These surveys covered a few nonteaching hospitals also. Out of the 28 neonatal units who responded in the NNF survey conducted during 1988, 50 percent had satisfactory resuscitation facilities while 33 percent had inadequate space.29,30 The number of neonatal beds in relation to the number of high-risk deliveries were inadequate in 25 percent of the hospitals. Only 12 percent of the units had optimum number of nurses for the available beds. Adequate monitoring facilities for the sick newborn existed in only 19 percent of the centers. The situation seems to have started improving during 1990's since to date (i.e. year 1996) 30-35 units in the country have been accredited by NNF as suitable for training in level II neonatal care and 10 units are in position to provide level III care. These units were found to have 90 percent of the recommended facilities for level II care.24 Considering our large population, about 2000 special care neonatal units (i.e. 4 units per district) are required for our country. Hence, in spite of all the efforts, neonatal special care facilities continue to be inadequate.
 
How Can We Reduce NMR?
9Growing enthusiasm about neonatal care in the country is resulting in creation of new special care baby units which are often well equipped for the care of small and sick neonates. Special interest of our academicians for advanced neonatal care needs to be matched by their concern for the primary care of the newborn. Although it is well accepted that level II care is more cost effective than level III care, it is not realized that level 1 care is even more so. Hence, the primary care of the newborn amongst the deprived communities in rural areas and urban slums needs to be reinforced. It is important to realize that unless we improve the perinatal and neonatal care of this larger section of our population, the NMR at the national level will not come down.
Ten steps to reduce NMR in the decreasing order of their cost-effectiveness and in the increasing order of their intensity of care are described in Table 1.7A. It is quite apartment that the causes contributing to high NMR are more amenable to simple interventions used extensively, while improvement in the already low NMR demands selective use of sophisticated technology. Keeping this in mind, Table 1.7B describes prioritization of interventions according to the neonatal mortality rates.
For achieving adequate primary care through health centers (level 1), a massive program for training of medical and paramedical personnel needs to be undertaken.
Table 1.7A   Ten steps to reduce neonatal mortality
  1. Tetanus toxoid to mother, disposable sterile delivery kit
  2. Training of TBA, FMPW and primary care physicians in antenatal care, home delivery, neonatal resuscitation and care of the normal newborn.
  3. Supervized home care of babies more than 1800 grams
  4. Promotion of breastfeeding in hospitals and at home
  5. Identification of high-risk pregnancy and high-risk babies, and their referral.
  6. Improved hospital care of high-risk labor and delivery, optimal management of perinatal asphyxia
  7. Care of low birth weight babies in CHCs and small hospitals with special reference to warmth, asepsis and breast milk
  8. Establishment of special care neonatal units in bigger hospitals
  9. Follow-up of low birth weight babies, developmental assessment and rehabilitation
  10. Establishment of intensive care units equipped with facilities for assisted ventilation
Table 1.7B   Prioritization according to neonatal mortality rate
NMR
(per 1000 live births)
Most effective steps
(refer Table 1.7A)
I.
Very high (>60)
1-4 (Level I)
II.
High (31-60)
5-7 (Level IIA)
III.
Average (16-30)
8-9 (Level IIB)
IV.
Low(≤ 15)
10 (Level III)
TBA, FMPW and primary care physicians need to be trained in proper techniques of antenatal care, safe delivery, neonatal resuscitation, provision of asepsis, warmth and adequate feeding.31 The mothers need to be educated for providing simple essential newborn care at home. The role of NGOs in a vast country like ours cannot be ignored in achieving all this. It has been shown in many localized pockets which have been taken over by NGOs that neonatal mortality can be dramatically decreased with low cost interventions in the community.32 UNICEF in collaboration with various state governments has also taken up the training of district pediatricians as trainers in newborn care in a big way. This scheme has already been implemented in West Bengal, Orissa and Madhya Pradesh. It is hoped that this will set a cascade of training where in the pediatrician further trains all kind of personnel involved in newborn care in his district.
Level II care should be provided in all the medium and large sized hospitals. Level III care at the current stage needs to be developed in the regional centers and gradually extended to all the teaching hospitals. Such level III care will save relatively small number of extra babies who cannot be saved with level II care alone; yet its importance lies more in its spill-over effect of improving the skills which will result in improvement of even level II neonatal care.
The neonatologists have to continue to advocate the cause of the newborn even more aggressively to the society, politicians and administrators so that the neonate is ultimately recognized as an individual in its own right. The obstetricians too need to have an active forum who considers the fetus as an individual and lobby for its right to respectful survival. There is a need to conduct more operational studies in the field involving simple intervention in perinatal care. There is ample scope for young innovative minds to evolve low cost models of neonatal care—both in the hospital and at home. With the current level of enthusiasm and interest in neonatal care on the part of pediatricians, 10politicians and the society, the status of newborn in the country is bound to improve substantially in the next decade.
REFERENCES
  1. World Health Organisation. Essential newborn care-Geneva (WHO/FRH/MSH/96.13)  1996.
  1. Bucciarelli RL. Neonatology in the United States: scope and organization. In: Avery GB, Fletcher MA MacDonald MG, (Eds). Neonatology: Pathophysiology and Management of the Newborn. 4th edn. JB Lippincott Co.,  Philadelphia 1994.
  1. Health Information of India, 1994, Ministry of Health and Family Welfare. 
  1. UNICEF. State of worlds children, New York 1999.
  1. Paul VK, Singh M. Epidemiology in medicine, Bangalore. Interline Publishing,  1992; 127–46.
  1. Villar J, Louner U, Cossio TG. The effect of maternal nutrition on infant health in developing countries. In: Mitra K, Berendnes HW, Saxena BN (Eds) Perinatal Determinants of Child Survival, New Delhi. Indian Council of Medical Research, 1999; 65–85.
  1. Registrar General of India. Vital rates in India based on Sample Registration System 1995, New Delhi 1998.
  1. Bhargava SK. Perspective in child health in India. Indian Pediatr 1991; 28: 1403–10.
  1. Registrar General of India, Sample Registration System, Fertility and mortality indicators, 1995, New Delhi 1998.
  1. Bhargava SK, Singh KK, Saxsena BN. A National collaborative study of identification of high-risk families, mother and outcome of their offsprings with particular reference to the problem of maternal nutrition, low birth weight, perinatal and infant morbidity and mortality in rural and urban slum communities. New Delhi, Indian Council of Medical Research, 1990.
  1. Ghosh S, Bhargava SK, Moriyama IM. Longitudinal study of the survival and outcome of a birth cohort. Report of the Research Project. National Centre of Health Statistics,  USA, 1975.
  1. Bhargava SK. Recent trends in perinatal health in South Asia: India. Presented at the Workshop on ‘Improving health of the newborn infant in developing countries’. Kathmandu, Nepal, April 1997; 7–10.
  1. Paul V K, Newborn care in India: a promising beginning, but a long way to go. Semin Neonatol 4: 141–49.
  1. MCH Division, Dept of Family Walfare.  Ministry of Health and Family Walfare. National child survival and safe motherhood program. New Delhi 1994.
  1. International Institute for Population Studies (IIPS). National Family Health Survey (MCH and Family planning). Bombay, India IIPS, 1992–93.
  1. Philip E. Why infant mortality is low in Kerala? Indian J Pediatr 1985; 52: 439–43.
  1. National Neonatal-Perinatal Database-Report for the year 1995. National Neonatology Forum. 
  1. National Neonatal-Perinatal Database-Report for the year 2000. National Neonatology Forum. 
  1. Shah U. Perinatal mortality in India. Can it be reduced through primary health care. Indian J Pediatr 1986; 53: 327–34.
  1. Shah PM, Udani PM. Analysis of vital statistics from the rural community, Palghar-II: perinatal, neonatal and infant mortalities. Indian Pediatr 1969; 6: 651–68.
  1. Joshi VV, Bhakoo ON, Gopalan S, Gupta AN. Primary causes of perinatal mortality-autopsy study of 134 cases. Indian J Med Res 1979; 69: 963–71.
  1. Gordon JE, Singh S, Wyon JB. Tetanus in villages of the Punjab. An epidemiologic study. J Indian Med Ass 1961; 37: 157.
  1. Mohan VM, Karan S. Maternal involvement in the care of high-risk infants in a sick newborn nursery. Indian Pediatr 1986; 23: 121–25.
  1. Mohpal UC. Evaluation of mother's role in the care of low birth weight babies. Thesis submitted for MD (Pediatrics), Postgraduate Institute of Medical Education and Research, Chandigarh, 1990.
  1. Guha DK, Bhatia S. Mother-based neonatal care unit. In: Neonatology—Principles and Practices. 3rd edn. 2004, Jaypee Brothers, New Delhi.
  1. Singh M. The Forum flashbacks: an introspection. Bull Nat Neonatal Forum 1990; 4: 2.
  1. Norms for accreditation of level II special care neonatal units. National Neonatology Forum, 1991.
  1. Bhakoo ON. Training in neonatology in India. India J Pediatr 1990; 57: 145–46.
  1. National Health Policy. Ministry of Health and Family Welfare, Government of India, 1983.
  1. Report of Task Force on Minimum perinatal care, Ministry of Health and Family Welface, Government of India, 1982.
  1. Guha DK, Mahajan J. Status of newborn care in India. Indian Pediatr 1989; 26: 144–49.
  1. Singh M, Deorari AK, Paul VK. Neonatal services in leading hospitals-a sepressing scenario. Bull Nat Neonatal Forum 1988; 2: 3.
  1. Singh M, Paul VK, Deorari AK. Neonatal equipement in leading hospitals-a stark reality. Bull Nat Neonatal Forum 1989; 3: 1.
  1. Bhakoo ON. Can we improve the survival of the newborn in India? Indian J Pediatr 1986; 53: 674–76.
  1. Bang AT, Bang RA, Baitule SB, Reddy MH, Deshmukh MD. Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India. Lacet 1999; 354: 1955–61.