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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 24  |  Issue : 1  |  Page : 47-52

Under-five mortality at the children’s emergency room of Federal Medical Centre, Umuahia, Southeastern Nigeria


Department of Paediatrics, Federal Medical Centre (FMC), Umuahia, Abia State, Nigeria

Date of Web Publication1-Aug-2019

Correspondence Address:
Dr. Chikaodili A Ibeneme
Department of Paediatrics, Federal Medical Center (FMC), Umuahia, Abia State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmh.IJMH_9_19

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  Abstract 

Background: Under-five children’s death is one of the vital indices of a society’s development and a telling evidence of their priorities and values. An audit of the common causes of mortality among under-fives is essential in ensuring optimum child survival. Aim: To determine the magnitude, causes, and determinants of under-five deaths at the Federal Medical Centre, Umuahia, Southeastern Nigeria. Subjects and Methods: A retrospective review of all postneonatal under-five deaths at the Children’s Emergency Room from January 2012 to December 2016, was carried out and the information was analyzed. Results: Of a total of 6141 under-fives admitted during the 5-year period, 197 died giving a mortality rate of 32 per 1000 LB. Boys accounted for 106 (53.8%) with no gender difference in the mortality rates (P = 0.262). The leading primary causes of death were sepsis, severe malaria, diarrheal disease, meningitis, pneumonia, and severe acute malnutrition, accounting for 95%. Deaths due to malaria occurred more among the preschool age group than that among infants and toddlers (P = 0.013), whereas those due to pneumonia were more prevalent among infants (P = 0.012). Diarrheal disease caused more deaths during the dry weather season (P = 0.009). Approximately 40% of the deaths occurred within 24h of arrival to the Emergency Unit. The most common complications leading to death were dehydration, severe anemia, shock, heart failure, and hypoglycemia. Conclusion: The leading causes of under-fives deaths in our center are preventable infectious diseases. Intensification of goal-targeted, disease-specific preventive measures is recommended.

Keywords: Infections, mortality, Nigeria, under-fives


How to cite this article:
Ibeneme CA, Ezuruike EO, Korie FC, Chukwudi NK. Under-five mortality at the children’s emergency room of Federal Medical Centre, Umuahia, Southeastern Nigeria. Int J Med Health Dev 2019;24:47-52

How to cite this URL:
Ibeneme CA, Ezuruike EO, Korie FC, Chukwudi NK. Under-five mortality at the children’s emergency room of Federal Medical Centre, Umuahia, Southeastern Nigeria. Int J Med Health Dev [serial online] 2019 [cited 2019 Aug 21];24:47-52. Available from: http://www.ijmhdev.com/text.asp?2019/24/1/47/263550




  Introduction Top


The future of all societies rests on the shoulders of the children.[1] Therefore, an audit of the common causes of mortality during childhood is essential in ensuring the optimum health of under-fives.[1],[2] Child mortality remains a challenge to health-care professionals and policy makers, thus the various global interests at developing interventions aimed at reducing it.[3],[4] The renewed commitment at reducing child mortality in the world through the recommended sustainable development goals can only be achieved if the drivers of these deaths are monitored and identified.[3] Global under-five mortality rate (per 1000 live births [LB]) was reported to be 39 in 2017.[5] In Africa, it declined from 163 in 1990 to 100 in 2011.[6] In 2015, under-five mortality rate in Nigeria was reported to be 117 per 1000 LB.[7]

Under-five mortality rate is an important index of child mortality and an indicator of a country’s level of socioeconomic development and quality of life. It is also the broadest and most widely used measure of child survival.[1],[8] The spatial differences in the causes of under-five mortality between developed and developing countries have been largely explained by the level of advancement in medical technology, access to health care, and adequacy of the policies that affect public health in the developed nations.[1],[9] However, some researchers believe that the reasons for such differences remain unknown.[10]

Although, globally, the probability of under-five deaths declined substantially from 2000 to 2015, this decline failed to meet the target set by the concluded Millennium Development Goal 4.[11] Previous studies in Africa indicate that most of the under-five deaths are from vaccine-preventable and communicable causes.[12],[13],[14],[15] A study on child mortality carried out in our center over a decade ago focused on children from birth to the age of 14 years.[16] Since then, there have been improvements in child care services in our facility in the form of provision of facilities and skilled man power development.

This study was carried out to determine the burden and determinants of under-five deaths as well as appraise the efforts put over the years at improving child health services at the Federal Medical Centre, Umuahia, Southeastern Nigeria, so as to help health policy makers in critical decisions that will ensure under-five survival.


  Subjects and Methods Top


Study site

Federal Medical Centre is one of the two multispecialty tertiary health facilities in Umuahia, the capital city of Abia State in Nigeria. Umuahia is in the rain forest region of Nigeria with wet and dry seasons. The wet season includes the months of April through October, whereas the dry season spans from November to March.[17] The hospital serves Abia State with a population of approximately 2,845,380 (2006 census),[18] and also provides health services to the adjoining communities of boundary states such as Imo and Akwa Ibom. The pediatric department runs clinical services in its outpatient and inpatient facilities. These include the children’s outpatient clinic for general and specialist consultations, the newborn special care unit, the pediatric general ward for postneonatal admissions, and the children’s emergency room (CHER) where critical cases are stabilized before transfer to the pediatric general ward. The CHER has an average patient attendance of 2250 per annum and is manned by consultant pediatricians, resident doctors, house officers, and trained nursing staff. It is open 24h daily all the year round and receives children aged 1 month–17 years with emergency conditions. Patients spend an average of 48h before they are transferred to the ward or discharged with the exception of those who remain critically ill and needing close monitoring.

Study design

This was a retrospective review of all postneonatal under-five deaths in the CHER of Federal Medical Centre, Umuahia, over a 5-year period (from January 2012 to December 2016). Before commencing the study, ethical approval (FMC/QEH/G.596/Vol.10/375) was sought and obtained from the Health Research Ethics Committee of the hospital. The admission registers were used to identify all the under-five children who died within the period under review. After that, the case records of the identified children were retrieved from the medical records department. Relevant information such as age, sex, month of admission, diagnoses, and cause of death was obtained from the case notes and admission register. The diagnoses were based on clinical assessment and supportive investigations. Laboratory investigations available for patients in the CHER included packed cell volume, full blood count, dipstick urinalysis, urine microscopy, random blood sugar, rapid diagnostic test for malaria, blood film microscopy for malaria parasite, human immunodeficiency virus (HIV) screening, serum electrolytes, urea and creatinine, blood grouping, and crossmatching. Results of these investigations were generated within 20min of request. Occasionally, blood culture reports were available for patients who stay beyond 48h before they are transferred to the general ward.

Data analysis

Data obtained were analyzed using the Statistical Package for the Social Sciences (SPSS) software, version 20.0, for Windows (IBM SPSS, Chicago, Illinois). Descriptive and inferential statistics were used to describe the frequencies and the association of the outcome variables such as causes of under-five deaths. Chi-square and Fisher’s exact tests were used to test for the differences between proportions as appropriate. Significant level was set at P value of <0.05.


  Results Top


A total of 6141 under-five children (comprising 3558 boys and 2583 girls; 2478 aged less than 12 months, and 3663 aged 12–59 months) presented to CHER within the period under review. Of these, 197 died giving an under-five mortality rate of 32 per 1000 LB. Their ages ranged from 1 to 59 months with a median age of 10 months. Mean age was 12.52 ± 10.86 months. Boys accounted for 106 of these deaths giving a mortality rate of 30 per 1000 LB (106/3558) among them, whereas girls accounted for 91 with a mortality rate of 35 per 1000 LB (91/2583) among them. No statistical gender difference was observed in the mortality rates (χ2 = 1.256, P = 0.262). Mortality rate was significantly higher among children aged less than 12 months than in those aged 12–59 months (38 [96/2478] vs. 28 [101/3663] per 1000 LB, χ2 = 4.27, P = 0.039).

More deaths (57.4%, 113/197) occurred during the dry seasons than the wet seasons (42.6%, 84/197) but no statistical seasonal difference was observed (χ2 = 0.028, P = 0.867). The month with the highest number of deaths was January accounting for 16.2% (32/197) of all deaths, whereas September had the least number of deaths (3.6%, 7/197). Annual mortality rates over the 5 years ranged from 20 to 42 per 1000 LB. [Table 1] shows the yearly numbers of under-five admissions and deaths in CHER. [Figure 1] shows the yearly trend in under-five death rate.
Table 1: Yearly number of under-five admissions and deaths

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,
Figure 1: Yearly trends in the under-five mortality

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The most common causes of under-five deaths were sepsis (37.1%), severe malaria (19.8%), diarrheal disease (16.1%), meningitis (8.1%), pneumonia (7.6%), and severe acute malnutrition (6.1%) as shown in [Table 2].
Table 2: Primary diagnosis/conditions causing death among the under-fives

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[Table 3] shows the most common complications resulting in death and their primary causes. Dehydration and shock were the most common complications noted in the study and often from diarrheal disease and sepsis, respectively. Heart failure as a complication resulted more from severe anemia than other causes. Of 23 patients with heart failure, 15 (65.2%) resulted from severe anemia, whereas 34.8% resulted from non-anemia causes (χ2 = 59.59, P < 0.001). Of the 34 patients with shock, 26 (76.5%) were caused by sepsis, whereas only 4 (11.8%) resulted from non-sepsis causes (χ2 = 25.365, P < 0.001).
Table 3: Complications leading to death and their primary causes

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[Table 4] shows the seasonal differences of the common causes of death. Diarrheal disease caused more deaths during dry seasons than wet seasons (χ2 = 6.735, P = 0.009). Deaths from diarrheal disease peaked from the month of January to March. No significant seasonal difference was observed in the occurrence of the other conditions causing under-five deaths.
Table 4: Seasonal differences of the common causes of death

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[Table 5] shows the age differences of the common causes of under-five deaths. Severe malaria caused more deaths among children aged 12–59 months than in those aged less than 12 months (χ2 = 4.615, P = 0.032). When compared across infancy (<12 months), toddler (12–35 months), and preschool (36–59 months) age groups, malaria caused 11.4%, 29.4%, and 40% of deaths among these age groups, respectively (P = 0.013). Pneumonia, on the contrary, caused more deaths in children aged less than 12 months than in children aged 12–59 months (χ2 = 6.354, P = 0.012). No significant age difference was observed among those that died from sepsis, diarrheal disease, and meningitis.
Table 5: Age differences among the common causes of under-five deaths

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Death within 24h of presentation occurred in 79 (40%) children, whereas 118 (60%) died after 24h.


  Discussion Top


Nigeria has been recording a decline in the under-five mortality rate since 1990 till date with figures ranging from 199 (per 1000 LB) during 1993–1998 to 157 during 2003–2008.[19] Moreover, the following figures (per 1000 LB) have also been published: 104.3,[3] 128 (NDHS 2013),[20] and 117 (UNICEF State of the World’s Children, 2015).[7] However, disparities still exist across health facilities, states, and even regions of the country. Our finding of an under-five mortality rate of 32 per 1000 LB (3.2%) is lower than the aforementioned national under-five mortality rates. However, our figure is comparable with the global under-five mortality rate of 39 per 1000 LB reported in 2017.[5] When compared with the other facility-based studies, it is similar with the findings in Ghana (3.6%)[21] but lower than the findings in Nnewi (11%).[13] The differences observed across facilities within the same region may be associated with the inequalities in man power and equipment as well as variations in social, political, and economical developments of the communities they subserve.[1],[22] Adequate funding of health facilities, health education as well as good health-seeking behavior may assist in reducing the burden of under-five deaths.

Despite having more boys in our series of under-five deaths, it was nevertheless not significant. This finding concurs with reports by Ntuli et al.[14] South Africa.[1]

Our findings of death being significantly higher among infants have been corroborated by several earlier studies.[12],[13],[15] This has been thought to be due to their relative immaturity and incompetence of their immune system. However, it is known that infant mortality are often reflective of the economic status of the household, environmental factors, health-seeking behaviors, and nutritional practices.[3],[23]

Infections and vaccine-preventable diseases such as sepsis, severe malaria, diarrhea, meningitis, and pneumonia accounted for the major contributors of under-five mortality in our series. This is similar to the findings of the studies carried out in Onitsha,[24] Akure,[25] and Ghana.[15] The nonrecognition of sepsis globally as an under-five killer may be because the World Health Organization global burden for disease report does not include sepsis as a cause of death.[26],[27] Nevertheless, sepsis remains a leading cause of mortality worldwide.[26] The reason for its high fatality rate in our study may not be unconnected to the challenge of late presentation and antibiotic resistance. The persistence of malaria as a major contributor of under-five mortality calls for the need to reappraise the already existing interventions aimed at curbing malaria. In our series, pneumonia ranked fifth, and this may not be unconnected with the introduction of the pneumococcal conjugate vaccine and improved case management. This probably underscores the need for a more concerted effort toward the development of the malaria vaccine.

The seasonality of mortality of disease has been known for decades; however, variations still exist across regions.[28] In our series, mortality because of diarrhea was significantly higher during the dry season of the year (January to March) as was also observed by Ndu et al.[12] This has been linked to the prevalence of rotavirus infection during the dry season. The link, however, was not supported by the study in Gambia,[28] which noted that mortality due to rotaviral diarrhea disease in the dry season was lower. The variation across countries and regions may not be due to only influences of the weather but also on other determinants as socioeconomic status and environmental condition.[29]

Pneumonia as a cause of death was significantly higher in the infants as against those between ages 12 and 59 months. This concurs to the findings in South Africa.[14],[30] This strengthens the renewed call for the improvement of case management.

Severe malaria accounted for more deaths among the preschool age group than among infants and toddlers. Chinawa et al.[24] also observed rising age-specific malaria prevalence among children in Onitsha. This finding may be explained by the personal protective clothing habit of mothers for their infants, thus preventing mosquito bites, also the high levels of lactoferrin and secretory Immunoglobulin A and low levels of p-aminobenzoic acid in breast milk. However, the continued dominance of severe malaria as a cause of mortality, despite the multiple control measures calls for sustained effort toward the development of the malaria vaccine and revamping of our health service delivery system.

Forty percent of the children in our study died within 24h of presenting to the CHER. This is lower than that observed in most earlier studies.[12],[13],[31],[32] The reasons however for this death within hours may not be unconnected with late presentation of patients as observed by Adeboye et al.[32] and the capacity in man power and facilities of our emergency rooms to initiate life-supporting measures.

Limitations of the study

As a retrospective study, which is prone to certain limitations such as incomplete documentation of data, the outcome of our study may not reflect the actual burden of under-five deaths as well as other determinants of under-five mortality. However, our data still represent the enormity of the causes of under-five deaths in the environment.


  Conclusion and Recommendations Top


The prevalent causes of under-five deaths in our center are preventable infectious diseases. This calls for concerted efforts at the intensification of goal-targeted, disease-specific prevention measures. They also highlight the need to strengthen measures aimed at infectious disease control in our environment.

Acknowledgement

We are grateful to the staff in the medical record section and the nurses in the CHER of Federal Medical Centre, Umuahia, for making available the case files and admission registers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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