Nigerian Journal of Paediatrics

A Ten year review of all cause paediatric mortality in University of Port Harcourt Teaching Hospital Nigeria

Niger J Paediatr 2018; 45 (4):185 – 191

ORIGINAL

Yarhere IE

CC – BY

Nte AR

A Ten-year review of all cause

paediatric mortality in University

of Port Harcourt Teaching

Hospital, Nigeria (2006 – 2015)

DOI:http://dx.doi.org/10.4314/njp.v45i4.4

Accepted: 3rd December 2018

Abstract : Introduction: Morbid-

Results: There were 20,215 admis-

ity and mortality reviews provide

sions and 1,592 (7.87%) mortali-

Yarhere IE

(

)

platforms for quality controls and

ties with more neonatal (4.53%)

Nte AR

improvement in systems already

deaths. Deaths due to Perinatal

Department of Paediatrics,

put in place for health care deliv-

conditions, infections, malaria and

University of Port Harcourt

ery.

A 10-year retrospective

surgical conditions were common-

Teaching Hospital

analysis of paediatric morbidities

est causes of death. Neonatal mor-

Email:

and mortalities was carried out in

tality rate per neonatal admission

iroro.yarhere@uniport.edu.ng

the Department of Paediatrics,

was 16.5% and that of the post

University

Port

Harcourt

neonatal age group was 4.608%.

Teaching Hospital to establish

Factors identified as contributory

their patterns and trends.

to mortalities were delays in recog-

Methods: Data on children admit-

nition of conditions, delays in ac-

ted into the Department from 1

tions, and systems errors.

January 2006 – 31

Dec 2015

Conclusion: Mortality due to

were extracted from admission

pneumonia has reduced more than

books and mortality review cards

that due to diarrhoea and malaria,

in CHEW, SCBU, Wards and

but perinatal conditions are still the

DTU. were analysed. Information

most frequent causes of mortality

retrieved included name, age, sex,

in the neonatal period.

dates and times of admission and

deaths, admitting diagnosis, and

Key words: Childhood deaths,

working diagnosis, and causes of

neonatal deaths, malaria, acute

deaths.

respiratory infections, Nigeria

Introduction

the triaging system in the emergency room. There is

clear need for hospital administrations to put in place

Though there was reduction in the mortality indices in

rigorous, systematic and effective processes to enable

Nigeria from 1990 to 2013, Nigeria did not achieve the

access to prompt quality care to prevent mortality or

child related Millennium development goals set out by

serious morbidity. Open collaborative and transparent

the United Nations before the expiration period in 2015.

reviews of morbidity and mortality in a hospital provide

Childhood mortality is higher in Nigeria than in many

avenues for examination of processes and standards,

other African, and European countries and though the

when available, improvement in areas of practice and

ultimately prevent deaths that are avoidable.

5,6

under 5-mortality rate has improved compared to previ-

Many

ous years the overall mortality seems unchanged or in-

childhood killer diseases like diphtheria, tetanus, and

creasing.

Under-5

mortality

rate

reduced

from

pertussis have been largely reduced because of improved

213.2/1000 in 1990 to 117.4/1000 in 2013 but this pales

care and channeling of funds to those areas. To test the

in comparison with countries like Kenya (98.7 to 70.7)

veracity of this claim, we decided to study a 10-year

and Germany (8.5 to 3.9). Many other sub Saharan Af-

review of all cause mortality in the paediatric unit of the

rican and Asian countries did not halve their childhood

University of Port Harcourt Teaching Hospital. We also

mortality rates but some achieved reduction in the mor-

hoped to see a trend or change from the previous years,

tality and morbidity indices.

as there were improved facilities and skills in managing

childhood diseases

In the years preceding this review in our department,

mortality rate was 7·67% for all admissions, and this

was higher than 4.4% in UBTH in 2012. Many reasons

Materials and Methods

for the high mortality rate were given. Strategies were

put in place to try to reduce this as best as possible like

The study was a retrospective data analyses of morbidity

186

and mortality at the Paediatric Department of the Uni-

both soft wares. Simple rates and proportions were cal-

versity of Port Harcourt Teaching Hospital. It is a train-

culated and comparison done using Chi squared tests

ing site for medical students, resident doctors and other

within various groups, and averages were compared

allied health workers. The department operates a 100

using Student’s “t” test. Where necessary, p values <

bed space unit combining in and out patient services at

0.05 were considered significant.

the Children out patient (CHOP) clinic, Consultant pae-

diatric clinic (CPC), Children medical wards (CHMW) I

and II, Diarrhoea training unit (DTU), and Special care

baby unit (SCBU). A two-way referral system also oper-

Results

ates between the department and other dental, surgical

and psychiatry disciplines. Some children referred to

In the 10 years under review, there were 20, 215 admis-

these other disciplines can be managed and discharged

sions comprising 14, 669 post neonatal children and 5,

without further referral to the Paediatrics department.

546 neonates ratio of 2·6:1, and an average yearly ad-

All admissions and deaths in the various units of the

mission of 2,012·5/year. We had more male admissions

Department of Paediatrics were retrieved from the

than females, in a ratio of 1·3:1 (8,149 males and 6,520

nurses’ admission books and the mortality cards, from

females) in the post-neonatal age group. In the neonatal

1 of January 2006 and 31 of December 2015. Records

age group however, the ratio was 1·1:1, (2, 919 males

of mortalities and morbidities reviewed at the weekly

and 2, 627 females)

morbidity and mortality meeting were reviewed to aid

The total mortality recorded was 1, 592 comprising 676

identification and coding of the specific and remote

(42.4%) post neonatal deaths and 916 (57.5%) neonatal

causes of mortality. The data extracted from the nurses

deaths giving a ratio of 1:1.3, and a yearly average of

book and mortality cards included; age, sex, dates of

159.2/ year. Average mortality per admission was there-

birth, admissions and deaths, diagnosis at admission,

fore 7.87%, with post neonatal age group contributing

and death, symptoms and signs, autopsy findings if done

3.34% and the neonatal age group contributing 4.53%.

and management modalities including investigations,

The lowest mortality rate was recorded in 2007 and

procedures and therapies.

2013, (7.3%) and the highest was in 2014 (9.3%).

Neonatal mortality rate per neonatal admission was

Outcome variables

16.5% (916/5545) and that of the post neonatal age

group was 4.608% (676/14,669). In the post neonatal

The main outcomes of interest were total admissions and

age group, 22 % of deaths occurred within 24 hours of

deaths in neonatal and post neonatal age groups, age of

admission while in the neonatal age group it was 35%.

death, case-specific mortality rates, and rates of death

per year. Other outcome variables were duration of ad-

Table 1: Distribution of admissions and mortalities in the

mission before death and number of admitted cases that

neonatal and post neonatal age groups for the 10 years under

discharged against medical advice.

review according to sex.

Causes of deaths were coded using the International

Parameters

Total

Sex

Statistical classification of diseases and related health

Male

Female

problems 10 (ICD-10) and were classified according to

Admissions(total)

20,215

Mortalities (total)

1,592

system specific deaths, and because some cases were

Neonatal – admissions

2919

2627

few in number, they were merged with other conditions,

Mortalities

469 (51)

447 (49)

321 (35)

e.g., haemolytic uraemic syndrome was merged into

Within 24 hours

176

145

595 (65)

acute renal failure and renal disorders as a whole. From

After 24 hour

293

302

Post neonatal admis-

the ICD classification, a more clinically useful cause of

sions

8149

6520

death was allocated to the mortality recorded in the card.

Mortalities

349 (52)

349 (48)

Conditions with low mortality rates were classified as

Within 24 hours

149 (22)

miscellaneous for better analyses of the data.

After 24 hour

263

264

527 (78)

Contributory factors to mortalities were also reviewed

Fig 1: Frequency distribution of annual admissions and deaths

using the D.E.C.S. framework, where D stood for De-

in the neonatal age group. Admissions were highest in 2015

year and lowest in 2014 for the neonatal age group but there

lays in presentation, delays in recognition of condition,

were proportionate mortality rates per year irrespective of the

diagnostic errors, and delays in decision making and

number of admissions. The low admission in 2014 was due to

actions, E; technical errors like faulty machine, lack of

a prolonged nationwide resident doctors’ industrial action

oxygen, incubator accidents, errors in omission and end

where thea dmissions and services in weren eonatal age group

of life conditions like cancers etc, C; complexities of

disease burden, compliance with procedures and policy

and communications or team work breakdown, S; lack

800 Annual hospital mortalities the reduced.

599

588

607

658

of supervision of junior staff and system failures.

582

600

533

537

476

400

ADMISSIONS

387

Statistical analysis

200

DEATHS

106

108

The data retrieved were entered into excel spreadsheets,

and copied into SPSS v 20 for IBM and analysed using

2006

2007

2008

2009

2010

2012

2013

2014

2015

187

Fig 2: Frequency distribution of annual admissions and

least 10. The disease burden was also highest among

deaths in the post- neonatal age group. Admissions were

under 5 children who contributed 91·9% of the total and

highest in the 2007 and 2012 years, they were also low-

children greater than 10 years were only 2·7%. Though

est in 2014. Mortalities rates were proportionate yearly

there was a drop in the infection disease burden from the

even in the years (2009 and 2014) with reduced admis-

year 2010 through 2014, and a slight increase in 2015,

the differences in proportion was not significant, χ =

sions; ranges between 3·73% and 5·55%.

Annual admissions and mortality in the post neonatal age group

11·703 and p = 0·231.

2000

Case-specific mortality for infectious diseases is as fol-

1800

lows; diarrhoeal diseases 107/2075 (5·16%), AIDS

1740

1671

1600

1641

1631

38/683 (5·56%), Tuberculosis 28/347 (8·07%) and Shig-

1563

1491

1400

ella 12/152 (7·89%).

1257

1200

1226

Table 2: Frequency of case specific mortality in the 10

1000

ten-year review for neonatal and post neonatal age groups

800

Neonatal

Admissions Deaths Percentage

709

600

Disease conditions

DEATHS

400

Prematurity

665

186

ADMISSIONS

Neonatal sepsis

1405

224

200

Neonatal jaundice

941

Birth asphyxia

849

232

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

Infant of diabetic mothers

222

Acute surgical conditions

399

153

38.3

Age

Post neonatal

Diarrhoea

2075

4.6

The admission rate was highest among children less than

Pneumonia

4880

100

2.05

1 year of age, including the neonatal age groups,

Meningitis

1631

3.86

(10, 357 children i.e. 51·2%)

Malaria

4038

129

3.19

The age range of post neonatal mortality was 1 – 165

Sickle cell disease

1902

0.53

months, with a mean of 25·71 months and median of 15

Oncologic diseases

203

17.24

months and 91% of these children of the post neonatal

Cardiac diseases

267

6.74

death was 60 months or less (under 5). Neonatal age

Neurologic diseases (except men- 10

ingitis)

683

13.4

range was 1 hour – 27 days with a mean of 3 days, me-

HIV/AIDS

312

21.15

dian of 5 days, and 78% of these were under 2 days of

Renal diseases

849

5.77

age. Children between 6 and 14 years were only 68(10

Nutrition/ Endocrine

291

4.81

%) of the population and most of them died of chronic

Acute surgical conditions

systemic illnesses.

Mortality due to Malarial diseases (B)

All cause mortality

There were 101 malarial related deaths during the 10-

Neonates with conditions necessitating surgical inter-

year review with 37 males (36·6%) and 64 females

(63·4%), the difference of which was significant, χ =

ventions had the highest mortality rate with 38·3% (153

out of 399), and prematurity and related complications

7·218 and p = 0·007. The mean age was 28·62 months,

had the second highest case specific mortality rates

with a range of 2 – 97 months and a median of 18

(31%) even though most neonates were admitted with

months. Many of these cases presented in the February,

neonatal sepsis, with mortality rate of 13·3%.

March and April, and there was a gradual decrease in

Conditions affecting the respiratory tract like pneumonia

frequency of deaths as the years progressed with the

had the highest number of admissions (4880), however

highest in 2006 and the lowest between 2010 and 2015.

death was 100 giving a case fatality rate of 2% as

Though these differences existed within months and

against a case fatality rate of 4·58% in diarrhoeal dis-

years, they were not significant, p = 0·675 and 0·305

eases (129 / 4038) and malaria 3·19%.

respectively.

Mortality due to common childhood illnesses (A)

Mortality due to respiratory diseases including pneumo-

nia, bronchiolitis (J)

In post neonatal period, infections (A) like diarrhoeal

diseases; Shigella and HIV were the most frequent

Seventy-seven children died from respiratory related

causes of deaths constituting 185 (27·4%) of deaths.

diseases, with a case-specific mortality of 77/4880

Breaking this down further revealed diarrhoea contribut-

(1·58%). Males constituted 65(84·4%) and females were

ing 107 (15·8%), AIDS, 38 (5·6%), Tuberculosis 28

12 (15·6%) and the difference in proportion was signifi-

cant χ = 36·481 and p < 0·001. There was a drop in

(4·2%) and Shigella 12 (1.8%). There were 109 males

(58·9%) and 76 females (41·1%) and the difference in

mortalities with the progression in years with 2007 hav-

proportion was significant, χ = 5·886 and p = 0·015.

ing the highest (14) and 2009 having the lowest (3).

March and December were the months with the highest

Monthly distribution of cases showed low mortalities in

number of disease burden 21 each, and October had the

the dry months of the year (October through to Febru-

ary) and the rainy seasons of the years had higher

188

mortality rates. Again, children less than 60 months con-

Contributory factors to mortality following weekly mor-

tributed a high proportion of mortalities (92·2%).

bidity and mortality reviews

Mortalities due to Nervous system diseases including

During the weekly morbidity and mortality review meet-

meningitis, demyelination diseases of the CNS (G)

ings in the 10-year under review, there were 1,368 cases

discussed and contributory factors determined based on

There were 58 deaths from CNS related diseases consti-

the reports by the managing team. Using the D.E.C.S.

tuting 8.6% of total post neonatal mortalities, with more

framework, the following were noted as contributory

males 49 (84·5%), and 9 females (15·5%), χ = 27·59

factors to the mortalities reviewed as shown in table 2.

and p < 0·001. The age range of these children was 7 –

165 months and most of these were children less than 60

Table 3: Contributory factors to mortality

months 84%. The rainy season months had the highest

Contributory factors

Frequency

Percentage

number of patients, 38 (65·5%) and the difference in

of total

proportion was significant χ = 5·586 and p = 0·018 and

D Delays in recognition of condi-

113

7·09

2014 saw the lowest number of CNS related mortalities.

tion

Case-specific mortality was high in CNS related dis-

Delays in response

2·51

eases 58/1631 (4%).

Diagnosis error

5·60

Delays in decision making

1·26

E Errors – technical

5·40

Mortality due to neoplasia C

Errors of omission

3·58

End of life conditions

387

24·31

There were 57 (8·4%) of post neonatal mortalities with

C Complexity of disease burden

450

28·27

male preponderance 40 (70%) of neoplastic mortality

(delays in presentation)

and the difference was significant χ = 9·28 and p =

Compliance with policy and

1·76

0·002. There were more blood related cancers than solid

procedure

tumors, and the duration of illness between diagnosis

Communication or team work

2·20

and death ranged from 2 weeks – 3 years. Age range of

S Supervision of junior staff

2·32

System failure or error

4·10

children was 12 – 96 months and the mode was 12

months. There were 2 yearly peaks of mortality 2007

and 2012 and October was the month with the highest

Kindly note that multiple combinations exist in this table, with

number of mortality. The case-specific mortality for

delay in presentation to the hospital contributing the highest.

neoplasia was the highest 57/203 (28%) in this report.

Mortality due to Sepsis

Discussion

Sepsis was diagnosed in as many as 345 children over

This study represents a review of mortalities in the pae-

the period under review with a steady decline in the di-

ditarics department showing the admission and mortality

agnosis from 2009 to 2015. The mortality rate for sepsis

rate over a decade. The admission rate for the hospital

in post neonatal children was 7.5% with 51 cases. Of

was lower than that reported by Abhulimhen et al in

these cases, only 4 (7·8%) were over 5 years and the rest

Benin and Kano, Nigeria but higher than our previous

were under 5 years. The age range was 5 – 138 months

report in Port Harcourt, and that in Gusau, Northern

with a mean of 28 months, median of 20 months. There

Nigeria. These rates are low compared to what is ob-

were more females, 31 (60.8%) than males and the dif-

tainable in developed countries with admission rates as

ference was not significant χ = 2·373 and p = 0·123.

high as 20,000 / year.

3,10,11,12

Though true, the paradox

Many children, 308/345 (89·3%) diagnosed with sepsis

cannot be missed, where in countries with poor health

had initial diarrhoeal diseases that terminated into septic

care facilities and higher population like Nigeria, the

process. There was seasonal variation in the proportion

recorded admission rates are lower than countries with

of mortalities due to sepsis as many more children were

better health care and lower population.

lost during the dry seasons of the year χ = 4·412 and p =

0·036.

The outcome of this reduced admission rate like in our

review is reflective in the mortality rates experienced in

Mortality due to renal diseases N

our hospital and other resource constrained settings. For

instance, in countries with high admission rates, the

Renal diseases constituted 5·9% (40/676) of total mor-

mortality rates are low, whereas countries with low ad-

tality in the period under review. The year 2010 saw the

mission rates have higher mortality rates.

2,3,10

Increasing

highest number of deaths from renal conditions 7/40

and strengthening the primary and secondary health care

(17·5%) with a steady decline afterwards. Age range of

systems in Nigeria and other developing countries will

children who died from renal conditions was 2 – 130

not only increase admission rates but will also drive

months with a mean of 25·91 months and median of

down mortality rates.

17·50 months.

As at 2013, WHO estimated a global mortality rate of

13·2 / 1, 000 live births, but while many developed na-

tions have rates as low as 0·6 / 1,000 live births like

189

Luxemburg, Nigeria has a rate of 128/ 1, 000 live births

mortality.

4,7,10,13

Straightforward pneumonia without

like in our study.

1,2,10

Though there is a reduction in

complications is amenable to antibiotic treatment so

these mortality figures over the years in each country

when these children present early, treatment and even-

surveyed, the rate of drop is not proportional in the re-

tual cure is possible thus reducing the mortality in this

source-constrained countries compared to the developed

study. However, with late presentations and change in

countries. In our survey, there was no significant drop in

the disease process, use of antibiotics and oxygen ther-

mortality rates per admission over the 10-year period.

apy may not stop the progression and complications of

This means there was little or no improvement in ser-

respiratory diseases but they can reduce mortality rates

by 35 – 50%. Ventilators and assisted mechanical venti-

vices rendered in these years and more needs to be done.

Majority of deaths were due to certain conditions origi-

lation in the emergency rooms of Nigerian hospitals will

nating in the perinatal periods, as seen in other parts of

improve the outcome of children with severe respiratory

Nigeria

8,13

and the developed countries.

10,11,12,14

This has

compromise as this tides the child over until the patho-

been the norm for a long time and is similar to our previ-

logic process causing the damage is mitigated or re-

ous report, with preterm birth complications being the

moved.

leading cause in this period. While efforts are being

made to reduce preterm deliveries, more effort should be

The malaria case specific mortality rate in this series is

put into newer technologies to manage the preterm ba-

2.5%, and in a world trying to eradicate malaria, this is

bies immediately they have been delivered. Every year

high considering the efforts put in to roll back malaria,

during the Paediatric Association of Nigeria conference,

but lower than the rate estimated in the World Health

statistics between 2000 and 2013. This rate is much

Helping Babies Breath courses are organized for nurses

and medical doctors to improve neonatal resuscitation

lower than that reported by Abhulimen et al because it

skills. The effect of this is yet to be felt as the equipment

was an Emergency room report while ours was all ma-

needed are rarely maintained as revealed in the audit

larial admissions in the wards and emergency room. The

done by Oloyede et al in Akwa Ibom State. Improving

complications leading to malarial deaths included anae-

on this type of audit and encouraging it in all states will

mic heart failure, cerebral malarial and hypoglycaemia

show the true nature of our neonatal care and buttress

but most patients had multiple combinations. The trend

the reason for the slow or non-achievement of Millen-

of reduced malarial mortality also stems from the fact

nium development targets in Nigeria.

that many parents start early malarial treatment as soon

as the child gets a fever as recommended by many

Diarrhoeal diseases are still major causes of death from

health bodies trying to reduce the malaria burden in

this report and many others in Nigeria and the world.

Nigeria.

The case fatality rate is still high at 5.16% out of 2,075

children treated in the years under review, which is

From our analyses, the age at which children die remain

higher than the previous results from the same center in

the same over the years with under-five mortality being

the highest and fewer teenage deaths.

4,11,12,16

2005, but lower than that from Benin, and also lower

There were

than the global estimate for diarrhoeal deaths by Lui et

also fewer teenage admissions in the years under review

al . WHO also noted a non-significant drop in diar-

as teenage issues like teenage pregnancies and their

rhoeal deaths in Nigeria between 2000 (11%) and 2013

complications, road traffic accidents, substance abuse

rarely present to the paediatric department. Hill et al

17,18

(10%) and the reasons for this very marginal gain is not

far-fetched as only 38% of children under 5 years with

in their predictive model showed a relatively high mor-

diarrhoea receive Oral rehydration therapy. As for the

tality within the 5 – 14 year old children compared to

long-term control of diarrhoeal diseases, while many

previous years and under-fives, and based their theory

mothers and caregivers use the universal prevention

on the achievements of programmes aimed at protecting

methods of hand washing before preparing meals and

younger children. In our institution, teenagers with

feeding babies, potable and clean water is still lacking in

chronic diseases like diabetes mellitus, chronic kidney

many parts of Nigeria and the developing world. This

disease, sickle cell anaemia and asthma transition to the

lack of water nullified the effect of hand washing and

adult clinics and continue their care.

universal prevention in diarrhoea control and prevention.

Nigeria met the target of halting and began to reverse

Like in our previous study, 22 % of the observed mortal-

the spread of HIV/AIDS as reported by the W.H.O. in

ity in the post neonatal age group happened during the

2015 (2) but despite this, the percentage of deaths due to

first 24 hours of presentation and more than half of these

HIV/AIDS from 2000 to 2013 increased by one unit

were within the first the first 6 hours. The rate was even

(2% to 3%). Comparing our previous report to this pre-

higher in the neonatal age group and majority of these

sent one, we had a yearly death rate from HIV/AIDS of

mortalities presented either over the weekend or after

3.8 as against 7 (4), which is an improvement and relates

normal working hours. The rates are higher than those

to the global efforts in eradicating this scourge.

seen in Tanzania where mortality within the first 24

hours for newborns was 20% of the total newborn

deaths. The rates may be lower in developed countries

Admissions from respiratory diseases and pneumonia in

the post neonatal age group were the highest in this se-

but Black questioned the reasons for this mortality rate

ries and many others in Nigeria and the world. Mortality

at weekends and came up with several possibilities with

no specific conclusions but several recommendations.

from pneumonia and respiratory diseases however was

lower in this series than others with 1.58% case specific

Improving emergency services and standard of care

190

available during the close of normal work hours will

cussed especially when they have to pay out-of-pocket

therefore reduce the mortality rates in most hospitals.

for services and medications.

Providing emergency care centers in various cities sepa-

rate from the tertiary and improving the secondary

health care centers in Nigeria removes some burden

Conclusion

from the tertiary health care centers and also makes it

possible for patients to access health care in close prox-

In conclusion, though there is a reduction in the case

imity. This will also make the patients present at the

fatality rates with diarrhoea and pneumonia, they still

early part of the children’s disease process. In recent

remain the highest causes of mortality in post neonatal

times, provision of basic items and tools for managing

age groups. There were no emerging diseases in this

simple disease processes have been lacking in many

study causing death though within this period of review,

hospitals.

Ebola and Lassa fever epidemics happened in Nigeria.

Improving and limiting the contributory factors associ-

Understanding that the purpose of any morbidity or mor-

ated with mortality in children will reduce mortality

tality review is to teach, ensure quality control, prevent

rates and the onus is on health institutions to reduce

recurrence of avoidable human and system errors, and

waiting time, improve facilities and equipment and

make sure policies and procedures are followed, a proc-

maintain them.

ess needs to be put in place to make sure these meetings

hold regularly. During our discussions, we noted many

Conflict of interest: None

avoidable mortalities especially those due to delays in

Funding: None

recognition of patient’s condition, errors in knowledge

and diagnosis, non-compliance with management proto-

cols, technical and system failures contributing to the

mortalities recorded. These factors are not different from

Acknowledgement

those obtained in a systematic review by Merali and

other authors, where an audit showed that substandard

We acknowledge the efforts of our residents and con-

practice by health workers contributed most to maternal

sultants who participated in the morbidity and mortality

mortality.

5,6,13,21,22

They concluded that the presence of

review meetings. We also acknowledge specifically Drs.

health care professionals was not enough to prevent

Chidinma Chukwumerije, Chika Aiyedun, Gertrude

mortality, but adequate training and refresher courses

Agbedeyi, Uche Obikwu for coordinating and retrieving

will help ensure minimum standards are maintained.

mortality cards used to generate the statistics for this

Patient delays in accessing health care has been dis-

manuscript.

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