In a recent article [1], the authors describe the process of
issuing ‘well baby certificates’ to 1668 babies whose
mothers opted for puerperal sterilization within a week of
delivery. It is mentioned that 210 of these babies weighed
less than 2.5 kg, out of which 17 weighed less than 2 kg (16
small for gestational age and one preterm). We have some
concerns regarding the observations of the authors.
Babies weighing less than 2.5 kg, small
for gestational age and premature babies are known to be
high risk infants [2]. Low birth weight is associated with
high neonatal and infant mortality [2]. It is therefore,
surprising to note that these high risk infants, known to be
at increased risk for neonatal and post-neonatal deaths have
been classified as ‘well babies’ and issued pediatrician’s
certificate for ‘neonatal well being’. The birth weight and
gestational age criteria chosen by the authors to define a
well baby need to be clarified.
Secondly, it is imperative that a follow
up be done to see how many of these 1668 babies were alive
and thriving well at least till one year of age. This is
especially important in a developing country like India
where infant mortality rate is very high (57 deaths per
1,000 live births according to NFHS-3) [3]. In addition,
data regarding morbidities such as congenital malformations,
metabolic disorders, growth and developmental abnormalities
that may not have manifested in the neonatal period also
need to be assessed.
Thirdly, the National family planning
programme does not contain a provision for a formal
pediatrician’s signed ‘certificate’ in order to mandate
puerperal sterilization [4]. It is unclear whether the ‘well
baby certificates’ issued by the authors are a part of the
authors’ hospital policy or departmental protocol. The legal
standing for such a certificate is also unclear. Taking into
account the relative uncertainty regarding the health of the
newborn, pediatricians may potentially face litigations for
issuing such ‘certificates’, especially in the absence of
screening for disorders such as inborn errors of metabolism,
hypothyroidism, cardiac or other structural abnormalities.
Couples should be therefore counseled regarding these issues
and written informed consent should be taken explaining
these facts in case they opt for puerperal sterilization. In
fact, some authorities have suggested doing away with
puerperal sterilization [5], encouraging couples to delay
sterilization till the child is 12 months or older (when the
baby would have survived the precarious time after delivery
to guarantee its survival, proper growth and development)
along with increasing the availability of effective
reversible contraceptives, as options that India may
consider to avert post-sterilization regret. This seems to
be a prudent and rational approach, given the high
prevailing infant and neonatal mortality rates in India.
1. Karthikeyan G, Ratnakumari TL. Well
baby certificate for puerperal sterilization-A critical
appraisal. Indian Pediatr. 2013;50:151-2.
2. Carlo WA. The high risk infant. In:
Kliegman RM, Stanton BF, St.Geme JW, Schor NF, Behrman RE.
ed. Nelson Textbook of Pediatrics.19th ed.
Philadephia: Elsevier; 2011. p. 625-31.
3. International Institute for Population
Sciences (IIPS) and Macro International. National Family
Health Survey (NFHS-3), 2005-06: India. Mumbai: IIPS; 2008.
4. Reference Manual for Minilap Tubectomy.
Family Planning Division. Ministry of Health and Family
Welfare. New Delhi: Government of India; 2009.
5. Singh A, Ogollah R, Ram F, Pallikadavath S.
Sterilization regret among married women in India:
implications for the Indian national family planning
program. Int Perspect Sex Reprod Health. 2012;38:187-95.