Trends in neonatal mortality and morbidity at a tertiary centre over four decades: a cohort study.

OBJECTIVES: Long-term, hospital-based data on neonatal outcomes from low- and middle-income countries remain scarce, hindering identification of scalable interventions that improve survival in resource-constrained settings. This study aimed to describe secular trends in neonatal mortality and morbidities over four decades in an Indian neonatal unit. DESIGN: Retrospective cohort study. SETTING: Single tertiary-level academic public hospital (New Delhi, India). PARTICIPANTS: All inborn neonates born between 1983 and 2023 (n=80 208). MAIN OUTCOME MEASURES: Neonatal mortality rates (NMR), significant morbidities and sepsis analysed across eight epochs of 4-6 years each. RESULTS: NMR declined considerably in the first three epochs (30.7 to 18.2 per 1000 live births in epoch III) despite an increase in preterm and multiple births but remained stagnant thereafter (17.6 in epoch 8). The survival of very low birthweight neonates increased from 52% (102/197) to 79% (503/639). The incidence of severe perinatal asphyxia (2.4% to 1.3%), severe intraventricular haemorrhage (4.7% to 1.1%) and respiratory distress syndrome (33.1% to 12.5%) decreased, while that of major malformations (2.1% to 3.1%) increased. The incidence of culture-positive sepsis, initially static at around 1.3-2% of live births, declined in the last two epochs (0.7%), with a shift in pathogen profile towards Gram-positive predominance. CONCLUSION: Neonatal survival improved substantially despite progressively higher sickness levels, stemming largely from the improved survival of very low birthweight neonates. We noted significant temporal changes in the morbidity profile and the pathogen profile. Sustained improvements in infection control, antenatal care and intensive support for smaller neonates appear to have contributed to these gains.