E-ISSN:2349-3267
P-ISSN:2349-5499

Research Article

Morbidity

Pediatric Review - International Journal of Pediatric Research

2020 Volume 7 Number 3 March
Publisherwww.medresearch.in

Morbidity and Mortality pattern in Neonatal ICU in a tertiary care teaching hospital of Puducherry, South India

Maheswari K.1, Sharma N.2*
DOI: https://doi.org/10.17511/ijpr.2020.i03.02

1 Maheswari K, Associate Professor, Department of Paediatrics, Sri Venkateshwara Medical College Hospital and Research Centre, Puducherry, India.

2* Neha Sharma, Assistant professor, Department of Paediatrics, Sri Venkateshwara Medical College Hospital and Research Centre, Puducherry, India.

Objectives: This study was undertaken to know about the morbidity and mortality pattern of neonates admitted in neonatal ICU in a tertiary care teaching hospital. Materials and Methods: This is a hospital-based, retrospective, descriptive study, done on newborns admitted to neonatal ICU of Sri Venkateshwara Medical College Hospital and Research Centre, Puducherry from January 2018-December 2019 (24 months). Results: As about 935 neonates were admitted to neonatal ICU. About 781 neonates were analyzed. Maternal details showed that (70.6%) were educated and (29.3%) of them were uneducated. Morbidity pattern studied in 773 (98.9%) neonates showed that, neonatal jaundice (19.2%), neonatal sepsis (12.1%), TTNB (11.7%), HIE (10.9%), RDS (10.3%), was the common reason for admission. Feeding difficulties were observed in (6.5%), IDM for blood glucose monitoring (5.9%), LBW/preterm care (5.1%), meningitis (2.9%), seizures (2.7%), NEC (2.4%), MAS (2.1%), congenital anomalies (1.9%). The outcome noted in the morbidity pattern was that 99.7% were discharged and 0.25% were referred. Analysis of mortality pattern 8(1.02%) showed that, according to birth weight <1 kg (37.5%) was the most common cause of death, followed by 1-1.5 kg (25%), 1.5 -2.49 kg (25%), > 2.5 kg (12.5%). Maternal complications contributing to neonatal mortality was observed in (75%), it was not seen in (25%). The cause of death noted was prematurity with RDS and sepsis in (62.5%), septic shock with MODS in (12.5%), aspiration pneumonitis (12.5%), prematurity with HIE and pulmonary hemorrhage (12.5%). Conclusion: Neonatal jaundice, neonatal sepsis being the most common etiology for neonatal morbidity. Measures should be taken to diagnose jaundice earlier in high-risk cases. Steps should be taken to control neonatal sepsis by following sterile precautions during delivery. Prematurity and ELBW are the leading cause of neonatal mortality.

Keywords: Neonatal ICU, Morbidity, Mortality pattern, Low birth weight, Prematurity

Corresponding Author How to Cite this Article To Browse
Neha Sharma, Assistant professor, Department of Paediatrics, Sri Venkateshwara Medical College Hospital and Research Centre, Puducherry, India.
Email: 		Maheswari K, Sharma N. Morbidity and Mortality pattern in Neonatal ICU in a tertiary care teaching hospital of Puducherry, South India. Pediatric Rev Int J Pediatr Res. 2020;7(3):122-128.
Available From
https://pediatrics.medresearch.in/index.php/ijpr/article/view/585

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2020-03-12 2020-03-23 2020-03-28 2020-03-31
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
No Nil Yes 9%

© 2020 by Maheswari K, Neha Sharma and Published by Siddharth Health Research and Social Welfare Society. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

Pediatric Review - International Journal of Pediatric Research 2020;7(3)122
Maheswari K. et al: Morbidity and Mortality pattern in Neonatal

Introduction

The neonatal period is defined as up to the first 28 days of life and further divided into very early(birth to less than 24 hrs), early(birth to less than 7 days) and late neonatal period (7 days to less than 28 days). Prematurity defined as less than 37 completed weeks of gestation. Term neonate – neonate born between 37 to 42 weeks of gestation. Post-term neonate-born after 42 weeks of gestational age. ELBW defined as a birth weight less than 1Kg. LBW defined as a birth weight less than 2.5Kg [1]. The neonatal period is the most vulnerable period of human life for diseases and most of these are preventable. Moreover, a neonate is 500 times more likely to die on the first day of life than at one month of age [2]. It is estimated that 130 million neonates are born each year and out of these 4 million dies in the first 28 days of life [3].

A baby is an inestimable blessing and bother. The perinatal and neonatal period in spite of its shortness is considered the most critical phase of life [4]. It reflects the health and various demographic parameters of the mother and baby [5,6]. According to the national family health survey-3(NFHS-3) report, the current neonatal mortality rate (NMR) in India is 39 per 1000 live births, accounts for nearly 77% of all the infant deaths (57/1000) and nearly half of all the under-five child deaths (74/1000). The rate of neonatal mortality varies widely among the different states of India, ranging from 11per 1000live births in Kerala to 48 per 1000 live births in Uttar Pradesh [7]. Understanding the pattern of mortality is essential in improving newborn survival.

Overall, there is a decline in under-5 mortality at the global level, however neonatal mortality still remains high and is a major contributor to under-5 mortality [8]. Currently, several Asian countries, including India are in this phase, despite the development of maternal and child health services [9]. India contributes to nearly 25% of mortality around the world [10]. The challenge ahead of us is to meet every newborn target of ten or fewer neonatal deaths per 1000 live births in every country by 2035 [11]. Information on the admission and mortality pattern of hospitalized neonates should reflect the major causes of illnesses and standard of care provided to neonates in a particular locality. Such information will identify gaps and provide a basis on which interventions to improve neonatal outcomes will be designed [12].

Materials and Methods

Study design: This is a Hospital-based, retrospective, descriptive study.

Setting: Hospital based study in a tertiary care center in Puducherry, South India

Participants: Neonates(first 28 days of life) admitted and treated in neonatal ICU in the pediatric department from January 2018- December 2019 in Sri Venkateshwara medical college hospital and research center, Puducherry.

Inclusion criteria

Neonates born in our hospital and admitted to the neonatal ICU of the Paediatric department. Complete patient information along with the investigation reports in the medical records.

Exclusion criteria

Medical records with incomplete information.

Neonates referred from outside.

Data source: The patients needed for this study were identified by reviewing our neonatal ICU nominal register. The hospital records of these newborns admitted to Neonatal ICU were retrieved from the medical records department following due permission.

Study size: 935 neonates

Quantitative variable: morbidity and mortality pattern

Statistical analysis: simple proportion test.

The following data was collected from the medical records department (MRD) about the neonates included in this study.

*Gender, mode of delivery, booking and immunization details of the mother, maternal education, maternal complications (if any), gestational age and birth weight of the newborn, APGAR score, Ballard score, the provisional and final diagnosis of the neonate, date of admission/discharge/death of the baby.

*History, examination details, investigations were noted (CBC, CRP, serum bilirubin, blood group, coombs test, chest X-ray, USG abdomen, USG cranium, ABG, CSF analysis, urine routine, microscopy, stool for occult blood, LFT, RFT), the course in the hospital and treatment given were recorded.

Pediatric Review - International Journal of Pediatric Research 2020;7(3)123
Maheswari K. et al: Morbidity and Mortality pattern in Neonatal

Results

Out of the 935 neonates admitted to neonatal ICU, 154 were excluded. Morbidity and mortality pattern of the remaining,781 neonates were analyzed.

Table-1: Distribution of neonates according to maternal, sociodemographic data. (n=781).

Data Number Percentage (%)
Baseline details of mother maternal education
Educated 552 70.6
Uneducated 229 29.3
Maternal complications
Present 472 60.4
Absent 309 39.5
Mode of delivery
LSCS 403 51.6
SVD 312 39.9
Instrumental Delivery 66 8.4
Baseline details of the neonate
Gender
Male 366 46.8
Female 415 53.1
Birth weight
< 1 Kg 3 0.38
1-1.5 Kg 96 12.2
1.5 -2.49 Kg 283 36.2
>2.5 Kg 399 51.0
Gestational age
Preterm 175 22.4
Term 549 70.2
Post-term 57 7.2

According to Table 1- It was seen that out of 781 neonates admitted to ICU, the baseline details of the mother showed that 552(70.6%) of mothers were educated. 229 (29.3%) of mothers were uneducated. Maternal complications were seen in 472(60.4%) of mothers. 309 (39.5%) of mothers did not have any complications during pregnancy. The mode of delivery was LSCS in 403 (51.6%), SVD in 312 (39.9%), instrumental delivery in 66 (8.4%). Baseline details of the neonates admitted to neonatal ICU showed that males were 366 (46.8%). Female neonates were 415 (53.1%). Distribution according to birth weight of neonates showed that < 1 kg were 8 (1%), 1-1.5 kg were 96 (12.2%), 1.5-2.49kgwere 283 (36.2%), >2.5 kg 394(50.4%). The pattern according to gestational age showed that preterm neonates were 175 (22.4%), term neonates were 549 (70.2%), post-term neonates were 57 (7.2%).

Table-2: Distribution of neonates according to morbidity pattern (n=773).

Data No. Percentage
Diagnosis
Neonatal jaundice 149 19.2
Sepsis 94 12.1
TTNB 91 11.7
HIE 85 10.9
RDS 80 10.3
Feeding difficulties 51 6.5
IDM (blood glucose monitoring) 46 5.9
Preterm/LBW care 40 5.1
Meningitis 23 2.9
Seizures 21 2.7
NEC 19 2.4
MAS 17 2.1
Congenital anomalies 15 1.9
Cephalhematoma 13 1.6
Hypothermia 12 1.5
Hypoglycemia 10 1.2
Polycythemia 2 0.25
Subgaleal bleed 2 0.25
Thigh abscess 1 0.12
Brain abscess 1 0.12
CAH 1 0.12
Outcome
Discharged 771 99.7
Referred 2 0.25

According to Table-2, Morbidity pattern was studied in 773 neonates and it was observed that, neonatal jaundice was the most common diagnosis 149 (19.2%) for admission in neonatal ICU.This was; followed by neonatal sepsis 94 (12.1%), TTNB 91 (11.7%), HIE 85 (10.9%), RDS 80 (10.3%), Feeding difficulties were observed in 51 (6.5%), IDM neonates admitted for blood glucose monitoring were 46 (5.9%), neonates for LBW/preterm care were 40 (5.1%), meningitis 23(2.9%), seizures 21 (2.7%), NEC 19 (2.4%), MAS 17 (2.1%), Congenital anomalies 15 (1.9%), Cephalhematoma 13 (1.6%), hypothermia 12 (1.5%), hypoglycemia 10 (1.2%), polycythemia 2 (0.25%), Subgaleal bleed 2 (0.25%), Thigh abscess 1 (0.12%), brain abscess 1 (0.12%), CAH 1 (0.12%). The outcome noted was, out of 773 neonates admitted to neonatal ICU, 771(99.7%) were discharged. 2(0.25%) neonates were referred at parents request (CAH, Sepsis).

Table-3: Distribution of neonates according to mortality pattern (n=8).

Pediatric Review - International Journal of Pediatric Research 2020;7(3)124
Maheswari K. et al: Morbidity and Mortality pattern in Neonatal
Data No/percentage (%)
Factors contributing to mortality
Birth weight
<1 kg 3 (37.5)
1-1.5 kg 2 (25)
1.5-2.49 kg 2 (25)
>2.5 kg 1(12.5)
Gestational age
Preterm 6 (75)
Term 2 (25)
Post-term Nil
Maternal complications (PIH, APH, GDM, Hypothyroidism, BOH)
Present 6 (75)
Absent 2 (25)
Cause of death
Prematurity with RDS and sepsis 5 (62.5)
Septic shock and MODS 1 (12.5)
Aspiration pneumonitis 1 (12.5)
Prematurity with birth asphyxia and pulmonary hemorrhage 1 (12.5)

According to Table -3, it was seen that among the factors that contributed to mortality, the pattern of distribution among birth weight observed was <1 kg, 3 (37.5%), 1-1.5 kg, 2 (25%),1.5-2.49 kg, 2 (25%), >2.5 kg, 1 (12.5%). According to the gestational age, mortality was maximum in preterms 6 (75%), term neonates 2 (25%), no mortality was observed in post-term neonates. Maternal complications contributing to neonatal mortality was observed in 6 (75%), it was absent in 2 (25%). The cause of death noted was prematurity with RDS and sepsis in 5 (62.5%), Septic shock with MODS 1 (12.5%), Aspiration pneumonitis in 1 (12.5%), prematurity with birth asphyxia and pulmonary hemorrhage 1 (12.5%).

Discussion

Good and regular antenatal care, good care at the time of birth including appropriate and timely intervention and proper care of sick neonates are important in reducing perinatal deaths [13]. Prevention of preterm births, better care during the intrapartum period, more intensive care of very low birth weight and preterm babies would help in reducing the present high perinatal mortality [14]. Neonatal mortality is becoming increasingly important not only because of its share of under-five deaths has been increasing, but also the health interventions needed to address the major causes of neonatal deaths generally differ from under-five deaths and are closely linked to those needed to

protect maternal health [15]. Failure to improve birth outcomes by 2035 will result in an estimated 116 million deaths, 99 million survivors with a disability or lost developmental potential, and millions of adults at increased of non-communicable diseases after low birth weight [16]. In the present study it was seen, out of 781 neonates admitted to neonatal ICU, the baseline maternal sociodemographic features showed, about 552 (70.6%) of mothers were educated. Only 229 (29.3%)of mothers belonged to uneducated category. It was noticed that maternal complications were present in 472(60.4%), absent in 309 (39.5%) of mothers. Mode of delivery was LSCS in 403(51.6%), SVD in 312(39.9%), instrumental delivery in 66 (8.4%). Similar findings were noted in a study conducted in Brazil [17].

Baseline details of neonates admitted to neonatal ICU showed that females (53.1%) outnumbered male neonates (46.8%). But other authors have reported male preponderance [4,18,19]. Distribution according to birth weight of neonates showed that,< 1kg were least common, 3 (0.38%), 1-1.5 kg were 96(12.2%), 1.5-2.49 kg were 283(36.2%), > 2.5kg 399(51.0%), maximum in number. A study done in Gauhati showed that the least number of births were < 1kg and maximum being in 1.5Kg -2.49 Kg [19]. The pattern according to gestational age showed that preterms were 175(22.4%)second most common, term neonates 549(70.2%) being maximum, post term neonates were 57(7.2%), the least. A similar pattern was observed by the study conducted in Gujarat [20]. It was observed that out of 773 (98.9%) morbidity patterns in neonates studied, the most common morbidity in neonates admitted to ICU was neonatal jaundice 149 (19.2%). This was followed by neonatal sepsis 94 (12.1%), TTNB 91 (11.7%), HIE 85 (10.9%), RDS 80 (10.3%) Feeding difficulties 51 (6.5%), IDM babies admitted for blood glucose monitoring 46 (5.9%), LBW/ Preterm care 40 (5.1%), meningitis 23 (2.9%), seizures 21 (2.7%), NEC 19 (2.4%) MAS 17 (2.1%), Congenital anomalies 15 (1.9%), Cephalhematoma 13 (1.6%), Hypothermia 12 (1.5%), Hypoglycemia 10 (1.2%), Polycythemia 2(0.25%), Subgaleal bleed 2 (0.25%). Other rare disorders were Thigh abscess 1 (0.12%), Brain abscess 1 (0.12%), CAH 1 (0.12%). Similar findings were seen in a study conducted in Chandigarh, which showed that neonatal hyperbilirubinemia, followed by neonatal sepsis and respiratory distress as the most common cause of neonatal morbidity [21].

Pediatric Review - International Journal of Pediatric Research 2020;7(3)125
Maheswari K. et al: Morbidity and Mortality pattern in Neonatal

Studies done in Nigeria and Gauhati revealed HIE, sepsis, and prematurity as a major cause of morbidity [12,19]. The outcome noted in the morbidity pattern was that, out of 773 neonates admitted to ICU, 771 (99.7%) were discharged and 2 (0.25%)of them were referred at parents' request. Similar outcomes were noted by studies done in Gujarat and South India [4,8].

Factors that contributed to mortality 8(1.02%) were analyzed. The present study revealed that maternal complications were seen in 6(75%), not seen in 2(25%) of neonatal deaths. Similar findings were noted by Saini et al in a study done in Chandigarh [21]. Maximum number of deaths were seen in neonates< 1kg 3(37.5%), followed by 1-1.5 kg 2 (25%), 1.5-2.49 kg 2 (25%),minimum death was noted in >2.5 kg 1 (12.5%). These findings were similar to the studies done in Kenya and Trinidad [22,23]. According to the gestational age, maximum mortality was noted in preterms 6 (75%), followed by terms 2 (25%) and there were no deaths in post-term babies. A similar analysis was seen in the studies done in Gauhati and Trinidad [19,23]. The cause of death was prematurity with RDS and sepsis in 5 (62.5%), septic shock and MODS in 1(12.5%), aspiration pneumonitis in 1 (12.5%), prematurity with birth asphyxia and pulmonary hemorrhage 1(12.5%). The present study noted that the most common cause of mortality in neonates was ELBW and prematurity with its complications. This is in accordance with a study done in Trinidad [23].

The major limitation of the present study was, it is a hospital-based study which lacks a full-fledged community data. Since it is a retrospective study, it lacks follow up in neonates admitted to ICU and also referred to neonates. In addition, outborn neonates were excluded. The morbidity and mortality profile reported in this study may, therefore, be an underestimation.

Conclusion

The present study has revealed that maternal complications play an important role in neonatal morbidity and mortality profile, which can be prevented if good antenatal care is given. Neonatal jaundice, neonatal sepsis being the most common etiology for admission in neonatal ICU, measures should be taken to diagnose jaundice earlier in high-risk cases. Steps should be taken to control neonatal sepsis by following sterile precautions during delivery.

TTNB is in the increasing trend, probably due to an increase in LSCS, as the mode of delivery, which should be avoided unless there is a definite indication. A rare diagnosis like thigh abscess, brain abscess are being diagnosed. Emphasis is therefore placed on a high index of suspicion for these types of conditions.

What does the study add to the existing knowledge?

Prematurity and ELBW are the leading cause of mortality. Optimal health care services for pregnant women should be given to improve birth weight as well as prevent premature deliveries. But since this is a retrospective study with a small sample size, the authors would like to recommend further detailed prospective studies in the future, with emphasis on the awareness of the most common and emerging rare etiology of neonatal morbidity profile.

Author’s contribution

The first author contributed to study design and data collection from MRD. The corresponding author contributed to data analysis and interpretation of results.

Acknowledgment

The authors would thank all the MRD staff, for helping us in the collection of patient information from medical records.

Abbreviation

HIE –Hypoxic Ischemic Encephalopathy

TTNB- Transient Tachypnea of Newborn

RDS – Respiratory Distress Syndrome

IDM- Infant of Diabetic Mother

LBW- Low Birth Weight

ELBW- Extremely Low Birth Weight

NEC – Necrotizing Entero Colitis

MAS – Meconium Aspiration Syndrome

CAH- Congenital Adrenal Hyperplasia

PIH – Pregnancy Induced Hypertension

APH – Antepartum Hemorrhage

Pediatric Review - International Journal of Pediatric Research 2020;7(3)126
Maheswari K. et al: Morbidity and Mortality pattern in Neonatal

GDM – Gestational Diabetes Mellitus

BOH- Bad Obstetric History

MODS- sMulti-Organ Dysfunction Syndrome

LSCS-Lower Segment Caesarean Section

SVD- Spontaneous Vaginal Delivery

CBC- Complete Blood Count

CRP- C- Reactive Protein

CSF- Cerebro Spinal Fluid

USG- Ultrasonography

ABG- Arterial Blood Gas

LFT- Liver Function Test

RFT- Renal Function Test

Reference

  1. Paul VK, Bagga A. GHAI essential pediatrics. CBS Publishers and Distributors. 2018.
  2. UNICEF. The state of Worlds children. UNICEF. 2008;4-114.
  3. Lawan JE, Cousens S, Zupen J. 4 million neonatal deaths- When? Where? Why?. Lancet. 2005;365(9462)891-900.
  4. Modi R, Modi B, Patel JK, Punitha KM. Study of the Morbidity and the Mortality Pattern in the Neonatal Intensive Care Unit at a Tertiary Care Teaching Hospital in Gandhinagar District, Gujarat, India. J Res Med Den Sci. 2015;3(3)208-212.
  5. Kapoor RK, Srivastava AK, Misra PK, Sharma B, Thakur S, Srivastava KL, et al. Perinatal Mortality in Urban Slums in Lucknow. Indian Pediatr. 1996;33(1)19-23.
  6. Rasul CH, Hussain MA, Siddiquey AHM, Rahman MS. Perinatal mortality in a teaching hospital. Indian Pediatr. 1999;36(4)389-390.
  1. Ranjan A, Singh A. Pattern of morbidity and mortality of neonates admitted in tertiary level neonatal intensive care unit in Nalanda Medical College and Hospital, Patna, Bihar, India. Int J Contemp Pediatr. 2016;3(3)854-857.
  2. Kannan R, Rao S, Mithra P, Rajesh SM, Unnikrishnan B, Rekha T. Neonatal mortality and morbidity in a tertiary care hospital of coastal south India. J Nepal Paediatr Soc. 2017;37(3)232-237.
  3. Tran HT, Doyle LW, Lee KJ, Graham SM. A systematic review of the burden of neonatal mortality and morbidity in the ASEAN Region. WHO South East Asia J Public Health. 2012;1(3)239-248.
  4. Sangamam R. Perinatal mortality and morbidity among low birth weight babies. Int J Community Med Public Health. 2015;2(1)51-58.
  5. Bhutta ZA, Das JK, Bahl R, Lawn JE, Salam RA, Paul VK, et al. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost?. Lancet. 2014;384(9940)347-370.
  6. Tomo BO, Ige OO, Abok II, Onwuanaku C, Abah RO, Donli A. Pattern of neonatal admissions and outcome in a tertiary institution in north central Nigeria. J Med Trop. 2019;15(2)121-125.
  7. Shrestha M, Manandhar DS, Dhakal S, Nepal N. Two-year audit of perinatal mortality at Kathmandu Medical College Teaching Hospital. Kathmandu Univ Med J. 2006;4(2)176-181.
  8. Manandhar SR, Manandhar DS, Baral MR, Pandey S, Pandhey S. One-year audit of perinatal mortality at Kathmandu Medical College Hospital. Kathmandu Univ Med J. 2004;2(3)198-202.

Pediatric Review - International Journal of Pediatric Research 2020;7(3)127
Maheswari K. et al: Morbidity and Mortality pattern in Neonatal
  1. Elmi Farah A, Abbas AH, Tahir Ahmed A. Trends of admission and predictors of neonatal mortality- A hospital based retrospective cohort study in Somali region of Ethiopia. PLoS ONE. 2018;13(9)e0203314.
  2. Lawn JE, Blencowe H, Oza S, You D, Lee AC, Waiswa P, et al. Every Newborn- progress, priorities, and potential beyond survival. Lancet. 2014;384(9938)189-205.
  3. Veloso FCS, Kassar LML, Oliveira MJC, Lima THB, Bueno NB, Gurgel RQ et al. Analysis of neonatal mortality risk factors in Brazil- a systematic review and meta-analysis of observational studies. J Pediatr (Rio J). 2019;95(5)519-530.
  4. Sridhar PV, Thammanna PS, Sandeep M. Morbidity Pattern and Hospital Outcome of Neonates Admitted in a Tertiary Care Teaching Hospital, Mandya. Int J Sci Stud. 2015;3(6)126-129.
  5. Saharia NP, Deka A, Vivekananda MS. Mortality and Morbidity Pattern of Neonatal ICU of Gauhati Medical College and Hospital. IOSR J Dent Med Sci. 2016;15(6)73-75.
  1. Modi R, Modi B, Patel J. Comparison of Neonatal Morbidity and Mortality among Late Preterm and Term Neonates at Neonatal Intensive Care in Gujarat. Nat J Community Med. 2015;6(4)483-486.
  2. Saini N, Chhabra S, Chhabra S, Garg L, Garg N. Pattern of neonatal morbidity and mortality- A prospective study in a district Hospital in Urban India. J Clin Neonatol. 2016;5(3)183-188.
  3. Aluvaala J, Okello D, Murithi G, Wafula L, Wanjala L, Isika N et al. Delivery outcomes and patterns of morbidity and mortality for neonatal admissions in five Kenyan hospitals. J Trop Pediatr. 2015;61(4)255-259.
  4. Cupen K, Barran A, Singh V, Dialsingh I. Risk Factors Associated with Preterm Neonatal Mortality- A Case Study Using Data from Mt Hope Women’s Hospital in Trinidad and Tobago. Children (Basel). 2017;4(12)108.

Pediatric Review - International Journal of Pediatric Research 2020;7(3)128