ORIGINAL

Niger J Paed 2013; 40 (3): 259 –263

Mouneke UV

Ibekwe RC

Eke CB

Ibekwe MU

Chinawa JM

Mortality among paediatric

inpatients in Mile 4 Mission hospital

Abakaliki, south-eastern Nigeria: a

retrospective study

DOI:http://dx.doi.org/10.4314/njp.v40i3,11

Accepted: 27th January 2013

Abstract Background: In the sub-

Medical Records Department for

analysis.

Saharan Africa, one in every five

Mouneke UV

(

)

th

children dies before their 5 birth-

Results: Of the 1110 patients ad-

mitted within this period, 72 died

giving an overall mortality of

6.5%. There were 43 males and 29

females, giving a male: female

ratio of 1.5:1. Most of the deaths

58 (80.6%) occurred among chil-

dren aged younger than 2 years.

Malaria was the most common

presumed cause of death, followed

by gastroenteritis and broncho-

pneumonia. Twelve and half

percent (12.5%) of the children

died within 24 hours of admission.

The commonest causes of death

within 24 hours were severe anae-

mia, pneumonia and gastroenteri-

tis. The modal months for child-

hood mortality in this hospital

were May and August.

Conclusion: Mortality was com-

monest among children younger

than 2 years of age. Malaria, gas-

troenteritis and pneumonia were

the commonest causes of death. A

proactive planning taking into ac-

count the seasonal variation of

these diseases could reduce the

childhood mortality in this centre

Ibekwe RC, Eke CB, Chinawa JM

College of Medicine, University of

Nigeria/University of Nigeria

Teaching Hospital, Ituku- Ozalla,

Enugu State, Nigeria.

day, mostly from preventable

causes. Recent data from Nigeria,

show infant and under-5 mortality

rates of 88 and 143 deaths per

1

000 live births respectively. Al-

though significant efforts have

been made in the last two decades

towards the reduction of child-

hood mortality, the rate still re-

mains unacceptably high.

Objective: The aim of the current

study was to evaluate the pattern

and causes of paediatric

Ibekwe MU

College of Medicine, Ebonyi State

University/Ebonyi state university

Teaching hospital, Abakiliki

(

childhood) mortality at Mile 4

Mission Hospital, Abakaliki. This

will help us to know exactly what

happens in a small mission hospi-

tal with few facilities and limited

skilled medical personnel. In ad-

dition, this is the very first time

this study was undertaken in this

hospital

Materials and Methods: The re-

cords of admissions and deaths of

children managed at the Mile 4

Mission Hospital from the 1st

January 2009 to 31st December

2

009 were retrieved from the

1

-4

Introduction

respectively. Paucity of local epidemiological data

hinders the development of appropriate intervention

strategy; most reports in Nigeria are from hospital-based

studies and₅i_-n₁₀spite of their limitations have been a

useful tool.

Approximately,7.6 million children die annually from

the effects of diseases and poor nutrition. In the sub-

Saharan Africa, for_t_hinstance, one in every five children

dies before their 5 birthday; most of these deaths are

1,2

preventable.

Most previous mortality reports in Nigeria were from

government owned tertiary health facilities that were

highly endowed in both personnel and equipments.

These facilities being referral centres may select the

more severe cases and may not reflect the societal pat-

tern. There are few studies that highlight the experience

in primary/secondary health facilities, and none from

mission hospitals.

sectors attend to more than 60% of medical conditions,

In Nigeria, significant effort has been made in the past

two decades towards the reduction of childhood morbid-

ity and mortality through introduction of policies like

improved immunization coverage, provision of good

health facil₁i_-t₄ies and increase in the number of health

5

-10

personnel.

rate is still high. Recent data report infant and under-5

mortality rates of 88 and 14 deaths per 1000 live births

Despite these efforts, childhood mortality

5

-10

This is important because private

2

60

and mission hospitals play important role in₅_-₁h₀ealth care

delivery especially in South-eastern Nigeria.

The aim of this study was to report the disease pattern,

and causes of deaths among children admitted at the

paediatric ward of Mile 4 Mission hospital, Abakaliki.

facility for this service. The data collected were entered

into the data editor of SPSS software package version

19.0. Analysis was involved calculating simple percent-

ages and, proportions and constructing, charts and ta-

bles. The influence of sex, age, disease entities, and du-

ration of hospital stay on outcome (death) was assessed.

Proportions were compared. The differences in propor-

tions were tested for statistical significance using the

students T –tests .Significance was based on P<0.05.

Materials and Methods

Mile 4 Mission Hospital is located approximately 6 kilo-

metres from Abakaliki, the capital city of Ebonyi State,

South-Eastern Nigeria. It was established in 1946 by the

Roman Catholic Church to provide care for patients with

Tuberculosis and Leprosy. Its scope of care was later

expanded to address the health needs of people living

around the area who are mostly peasant farmers.

More than 2000 Paediatric cases are attended to in the

Outpatient clinic that is run by the Medical Officers/

NYSC doctor. Of this number approximately 1500 of

them are children above the Neonatal age. In the current

study, 74% of this figure was admitted into the Paediat-

ric ward. The Paediatric department of the hospital in-

cludes a separate in-patient ward that caters for children

above the Neonatal age and a fairly well equipped Spe-

cial Care newborn Unit that is housed in the same build-

ing with the Maternity ward and Obstetrics and Gynae-

cology Theater. For the purpose of this study, only data

records of the patients admitted into the in-patient ward

were used, as such, excluding the data from the New-

born Unit.

Results

A total of 1110 (74%) patients were admitted into the

Paediatric ward out of the 1500 children (Excluding

Neonates) that were seen during the study period. Of

this, 72 (6.5%) died, 43 of them were males and 29 were

females. The male: female ratio was 1.5:1.0.

In Table 1 the pattern of admissions and deaths are

shown. The ages of the children ranged from 5weeks to

16years with a mean age of 17.1± 13.1 months. Most of

the admissions 875 (78.8%) and deaths 58 (80.6%) were

among children ≤ 24months of age.

Table 1: The distribution of admissions and mortality

according to the age group of the study population.

Age group (MTHS)

Admissions Mortality per

age group

Mortality per

age group

(%)

>

4wks-12mths

550

325

119

43

36

22

10

1

6.6

6.8

8.4

2.3

4.0

4.2

1

2

3

4

3-24

5-36

7-48

9-60

The Paediatric in-patient ward is made up of two very

large rooms each measuring roughly about 25feet by

25

1

5feet. They collectively house about 50 medium sized

>

60

48

2

cots and five adult beds for older children as well as an

isolation room at the very end of it. There is no dedi-

cated children emergency ward, thus all children who

are admitted are kept in the in-patient Paediatric ward.

The ward makes use of the Hospital Laboratory and

blood bank, while all radiological requests are either

carried out at the Teaching Hospital that is located about

seven kilometres away or at the Federal Medical Centre

that is about five kilometres away.

The Paediatric department of the hospital was started in

the 2005 but was effectively put to use in 2009. The

department is manned by two Post-NYSC Medical Offi-

cers and twoYouth Corp Doctors who do the daily ward

rounds as well as take the night calls. They are super-

vised by a visiting part-time Consultant Paediatrician

who consults there twice a week, and is also available on

call basis in cases of emergencies, and diagnostic and or

management challenges. The Nursing Staff includes 8

General Nursing Officers and 1 Matron.

Total

1110

72

6.5

Table 2 highlights the various causes of death among

these children. Malaria (37.5%), Gastro-enteritis

(

23.6%), bronchopneumonia (15.3%) and anaemic heart

failure (15.3%) were the major causes of deaths. Most of

the deaths due to gastroenteritis (76.4%) occurred in

infancy, while deaths due to severe malaria occurred in

older age-groups. The mean duration of hospital stay

was 3.9 ± 4.1 days, with 25% of the patients dying

within 24 hours of admission. Majority of deaths

(

58.3%) occurred in the first 72 hours of admission.

Seventeen children (23.6%) died after spending between

the four and five days, while the rest 13 (18.1%) were on

admission for longer than five days.

Table 2: Causes of deaths among the study population and age

distribution

Causes

Total

Percentage of total

The study was carried out retrospectively using data

retrieved from ward register and the hospital’s Medical

Records Department, between 1st January 2009 and the

Malaria

27

17

11

4

1

72

37.5

Gastroenteritis

Bronchopneumonia

Anaemic Heart Failure

Meningitis

Septicaemia

Haemorrhage

Total

23.61

15.28

5.55

1.39

3

1st December 2009. Data extracted from the records

included age, sex, date of admission, death, date of

death, and probable cause of death. Postmortem exami-

nation was not done for the patients because of lack of

100.0

2

61

Table 3 shows the relationship between the causes of

death and duration of admission. Majority of children

with severe anaemia (54.5%) died within 24 hours of

admission. The relationship between duration of hospital

stay and cause of death was however, not statistically

significant.

Fig 1: Monthly distribution of admitted cases – Average ad-

mission / Month

Table 3: Association between duration of stay and cause of

death

Duration

of stay

Causes

Ma-

laria

G/e Bpn S.anae Men-

inigitis

Septi-

caemia

Haemo-

Rrhage

mia

<

2

3

4

5

>

1

3

4

6

5

4

27

4

2

1

4

17

4

1

2

-

1

3

11

6

1

-

1

2

11

1

2

-

1

-

1

-

1

-

1

-

Discussion

5

-

1

The mortality rate of 6.5% is lower than the 12.2%,

reported in Ebonyi State University Teaching Hospital, a

tertiary health facility located in the same Abakaliki. It

thus appears that in spite of the limitations in personnel

and facilities, the institution is able to offer commend-

able service to their clients. This difference could also

be due to referral bias, as the more severe cases may

have been referred to Teaching Hospital, thereby result-

ing in their reported higher mortality.

Total

4

2

χ Fischer’s Exact = 40.28; df = 42; P-value = 0.73)

(

In Table 4 the monthly distribution of deaths and its

causes is shown. The peak period of recorded mortality

was between May and August 40 (55.6%). The modal

month was August 17(23.6%). These deaths were

mainly due to severe malaria 19 (47.5%), pneumonia 8

Like in most previous reports from Nigeria and sub-

Saharan Africa, males and children younger ₅th_-₁a₂n 24

(

20.0%) and severe anaemia 6(15.0%). A smaller peak

in February was mainly due to gastroenteritis 5(71.4%).

The monthly differences in the causes of death was sta-

tistically significant (Fischer’s exact= 97.3, p= 0.02).

months constitute the bulk of the mortalities.

The

children in this age group are more prone to diarrhoea

and pneumonia because of their increased risk as a result

of poor hygiene and feeding practices.

1

3-15

The male

preponderance may reflect the male preference in the

typical African society. The reason for the preponder-

ance of male death could be be due to the protective

effect of the double X chromosome in the females as

opposed to the males is unclear, but similar trend has

Table 4: Causes of death with relationship to monthly

distribution

Months

Causes

Men-

inigitis

Ma-

laria

G/

E

BPN S.ana

emia

Septi- Haemo-

caemia Rrhage

5-9

been reported previously in most reports from Nigeria.

Jan

-

3

2

12

-

1

5

4

-

3

2

-

1

-

1

3

2

-

3

-

1

-

1

-

1

-

2

-

1

-

1

-

1

-

1

Feb

Mar

Apr

May

Jun

In India it was postulated that because of cultural bias

for males they are brought to the hospital earlier and

more frequently and may account for the h₁i₆g_,₁h₇er propor-

There is

-

2

1

2

-

tion of male admissions and mortality.

Jul

need to conduct local research to determine if the same

reason applies in Nigeria.

Aug

Sept

Oct

Nov

Dec

Total

-

1

4

27

According to studies from Nigeria and other African

countries, malaria is st₅il_-₁l₀a leading cause of mortality in

2

17

1

11

-

11

-

4

children under 5years.

In our index study, malaria

Fischer’s exact = 97.30 df = 77 P-value = 0.023

(37.5%) was the commonest cause of death. The persis-

tence of severe malaria as the predominant cause of

childhood mortality in 2009 in Nigeria may suggest that

the Roll Back Malaria program and Millennium devel-

opment goal have not achieved their desired results.

However the extent these programs have been imple-

mented in this centre and city may not be known. The

reasons for this include the high cost and unavailability

of the artemesinin based combination drugs, poor mobi-

lization and sensitization about the use of insecticide

treated nets, fake and adulterated drugs and late presen-

tations to hospitals for treatment. Gastroenteritis, bron-

chopneumonia and

Figure 1 shows the distribution of the number of admis-

sions and number of deaths recorded among the study

population. More of the patients were admitted between

the months of January and March while the months of

May and August recorded the highest number of deaths.

2

62

severe anaemia were the other common causes of death.

This trend has been severally reported from other centre

programs targeted at controlling or eradicating these

diseases in this country, and has remained the same in

the past 40 years, in spite of sev₁e₃r_-₁a₅l programs targeted at

controlling or eradicating them.

Conclusion

This study has shown that mortality in Mile 4 Mission

Hospital was commonest among children younger than

2 years of age and was due to infectious diseases such as

severe malaria, gastroenteritis and pneumonia. There

was also a seasonal variation of the diseases. To reduce

these deaths in line with the MDGs, preventive strate-

gies such breastfeeding, immunization, improved hy-

giene and sanitation, malaria prevention using insecti-

cide treated bed nets etc should be implemented in the

community. Similarly, community based management

of diarrhoea, malaria and pneumonia, if implemented on

a wide scale basis will contribute to a further reduction

of cases. The medical officers in the facility should be

equipped with the relevant skills to ensure early diagno-

sis and prompt management of children presenting with

emergencies; equipment and supplies to improve the

management of the cases should also be put in place.

The seasonal distribution of the causes of deaths could

be explained by the fact that the major causes of these

deaths; malaria and bronchopneumonia occur more fre-

quently during the wet season. Wet season encourages

breeding of mosquitoes that transmit malaria and pro-

vides chilling environme₅n_-₉t for micro-organisms which

may result in pneumonia. On the other hand, gastroen-

teritis occurred more during the earl₅y_-₉_,p₁₃a_-r₁t₅ of the year

which coincides with the dry season.

During this

period there is scarcity of potable drinking water which

encourages the transmission of faeco-oral infections.

This pat₅t_-e₉_,r₁n₃_-₁₅had been reported by previous Nigerian

studies.

.

In spite of lack of a dedicated Children Emergency Unit,

the proportion of mortalities in the first 24hours (25%)

is lower than previous reports of bet₆w_,₇e_,₉en 49% and 53%

Conflicting Interest: None

Funding: None

from tertiary institutions in Nigeria.

This lower fig-

ure may partly be due to the early transfer of severe

cases to the two tertiary hospitals located_s_tin the town.

Most of the deaths recorded within the 1 24hours in

this study were due to Gastroenteritis with dehydration/

shock, severe anaemia with cardiac failure and broncho-

pneumonia with severe hypoxaemia which obviously

connote late presentation. It is to be noted that deaths

from these conditions should be preventable and efforts

to do so in this centre should be intensified

Acknowledgements

We acknowledge the Almighty God whose assistance

and ideas through the course of this work were priceless.

We are also grateful to all the doctors and nurses that

work at Mile 4 Hospital. Our gratitude is equally

extended to all the staff of the Health Information

Technology in the hospital.

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