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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 6  |  Issue : 2  |  Page : 83-87

Epidemiology of child mortality in a tertiary hospital, New Delhi


Department of Pediatrics, VMMC and Safdarjung Hospital, New Delhi, India

Date of Web Publication15-Sep-2017

Correspondence Address:
Manas Pratim Roy
Department of Pediatrics, VMMC and Safdarjung Hospital, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjhs.sjhs_49_16

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  Abstract 

Background: India accounts for 21% death among under-five children but the profile of the children admitted in tertiary hospitals is poorly documented. We conducted secondary analysis of all hospital admissions in pediatrics wards for 1½ years to understand outcomes in different age groups. Methods: Data from October 2014 to March 2016 were retrieved and analyzed, with a focus on the age distribution at admission and death, duration of stay and outcome. Results: Almost 10% admitted children died and another 15% left the hospital before completing treatment. The analysis of 2135 deaths suggests that half of the children died within 24 h of admission. Death rate was highest among children on their 1st day of life (39%), and it reduced gradually with increase in age. Infants share 71% of all the deaths. Conclusion: Maximum death within 1st day of admission demands a further review of our referral system and health seeking behavior.

Keywords: Children, epidemiology, mortality, outcome, tertiary hospital


How to cite this article:
Roy MP, Gupta R, Bhatt M, Meena SK, Aggarwal KC. Epidemiology of child mortality in a tertiary hospital, New Delhi. Saudi J Health Sci 2017;6:83-7

How to cite this URL:
Roy MP, Gupta R, Bhatt M, Meena SK, Aggarwal KC. Epidemiology of child mortality in a tertiary hospital, New Delhi. Saudi J Health Sci [serial online] 2017 [cited 2017 Dec 17];6:83-7. Available from: http://www.saudijhealthsci.org/text.asp?2017/6/2/83/214849


  Introduction Top


Globally, the annual burden of under-five deaths has reduced from 12.7 million in 1990 to 5.9 million in 2015. The mortality rate in this category has also reduced from 91 deaths/1000 live births in 1990 to 43/1000 live births in 2015. This unprecedented rate of reduction has raised hope for the world with fewer losses of lives at childhood, as envisaged by Sustainable Development Goals which set a target of achieving 25 or fewer deaths per 1000 live births by 2030.[1]

Still, India witnesses 1.2 million deaths among under-five children every year and constitutes 21% of global death burden. Marching with the millennium development goals, India has reduced such mortality by 64% since 1990. This substantial progress translates into a reduction of 2.2 million deaths in this age category. Despite such accelerated progress, the country missed the target, which had aimed to reduce the death rate by two-third by 2015, by a narrow margin.[1]

Most child deaths in India occur at home, making it impossible to estimate the contribution of different causes such as diarrhea and pneumonia. In the absence of a national registry, discrete data from different parts of the country reflect huge disparities between states.[2] Verbal autopsy-based studies earlier tried to estimate the burden of child death and analyze major causes responsible for that.[3] However, such efforts are handful and their merit is limited by misclassification. Therefore, even today, we need to depend on sample survey and hospital data for quantification of burden and rationalizing causality. Although the previous record showed only 17% child deaths occurring at health facility, dissection of hospital records are always helpful as they reflect the capacity of health-care delivery services in mitigating challenges.

For negotiating insufficiency in progress, Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) strategy and India Newborn Action Plan (INAP) are the latest commitments by Government of India for empowering health-care facilities across the hierarchy and bringing down child mortality. These initiatives are envisaged to boost the success consolidated so far by grass root implementation of Integrated Management of Neonatal and Childhood Illness (IMNCI).

However, there are not much data available from India on the profile of hospital admissions of the children. In this background, we aimed to find out the mortality profile of admitted children for 1½ years – October 2014 to March 2016 from a tertiary health-care center in New Delhi.


  Methods Top


We conducted secondary analysis of official data from a tertiary hospital for 1½ years. At the end of each month, data were gathered from admission registers. They were scrutinized by the investigators for any disparity and data were cross-matched again, before being put into departmental record. Such records from October 2014 to March 2016 were retrieved for the study purpose. We excluded intramural newborns (babies delivered in our hospital) as their characteristics are much different from rest of the admitted children in terms of care provided during birth and subsequent care. We also did not include surgical cases, thus excluding road traffic accidents, operated cases, and few congenital anomalies for which surgery is indicated. Data entry and analysis were done with Microsoft Excel.


  Results Top


We analyzed 20,756 hospital admissions from our hospital, spanning over a period of 1½ years. Female:male ratio among admitted children was 624:1000. Out of all the admissions, 17% were neonates whereas 48% were infants. The number of admitted children under 5 years of age constituted almost 74% of the total admission [Figure 1].
Figure 1: Age-wise break up of admitted children

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A total number of death was 2135 (10%). Of them, 39% were female. Gender specific mortality rate was higher in females (10.4% versus 10.2% in males). Overall, 71% of all deaths took place among infants. About 38% were in neonatal period, and rest were postneonatal [Figure 2].
Figure 2: Age-wise break up of death among admitted children

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Most of the children (73%) were discharged. About 15% of the children left hospital before completion of treatment. Some of them intimated before leaving while rest did not [Figure 3].
Figure 3: Outcome of admitted children

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After age-wise break-up, death rate was seen highest among children admitted on their 1st day of life (39%) and lowest among children above 1 year of age (6%). Among admitted neonates, 23% died. With the increase in age of the admitted children, higher discharge rate was seen. The rate of leaving hospital among different age group was between 14% and 18% [Figure 4].
Figure 4: Proportional outcome in different age groups of admitted children

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Most of the death occurred within first 24 h of admission [Figure 5].
Figure 5: Duration of stay of children dying in the hospital

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  Discussion Top


Meaningful statistics from hospitals are largely underutilized in India, let alone any policy decision out of that. Therefore, to bridge the knowledge gap, we analyzed data on children admitted to our hospital over 1½ years. Mortality rate from our study was similar to a previous study.[4] Higher deaths in tertiary centers could be attributed to referral from peripheral hospitals at the critical hours. In fact, the ultimate outcome of the patients depends on many factors including severity of the diseases, prior treatment, time of referral, and condition at admission. Without detail analysis, relative contribution of these factors could not be ascertained.

Male dominance among admitted, as noted previously, is a major concern.[4],[5],[6] It may be due to skewed sex ratio in Delhi and its surroundings. Different rates of illness among different genders could also be a potential cause. However, the possibility of a preference for taking male children to hospital cannot be ruled out. Biased affection for male children is a documented problem in North India.[7] In fact, higher death rate among females could also be a result of negative attitude toward girl child.

In our set-up, only 17% of the total admissions were neonates. This differs from Sen et al. who reported 30% representation by this age group.[8] Excluding neonates delivered in our hospital could be an explanation for this difference. However, considering the fact that those babies were delivered in a tertiary hospital, the characteristics would be different from rest of the children admitted to our hospital after being referred from some other hospitals.

There is gradual reduction in mortality rate with increasing age of the children. We recorded 23% mortality among neonates, which is much less than Roy (37%).[4] However, our postnatal mortality is comparable with Roy but higher than two other studies.[4],[9],[10] Among children between 1 and 5 years old, our finding (6% mortality rate) was again greater than previous researches.[4],[5] The disparity in death rate between our study and previous researches could be ascribed to the fact that our hospital, being a tertiary hospital at the capital of the country with no rejection policy, serves to all the surrounding states and usually deals with critical and moribund cases referred from tertiary hospitals/medical colleges of different states. Nevertheless, we documented drop in vulnerability among elder children as highlighted earlier.[9],[10]

More than 85% death took place among under-five children. Earlier, Patil and Godale reported similar proportion from Latur.[5] The promotion of IMNCI till the level of primary care is a national commitment made for reducing preventable deaths in this age group. This emphasizes special focus on pneumonia, diarrhea, and malnutrion – the greatest challenges of child health in the present world. The effectiveness of IMCI in reducing child mortality has been documented at different parts of the world earlier.[11],[12],[13]

Almost 68% of the children died within first 48 h. Late referral and delay in transport have already been pointed out previously as a major point of concern.[4] For reducing infant deaths due to delayed transport, the government has introduced Janani Shishu Suraksha Karyakram (JSSK), a program that provides free transport to higher hospital. National ambulance service also looks after the same issue for older children. However, building capacity of the health personnel on facility based newborn care assumes higher significance to put a regulation on unnecessary referral to higher center and mainstreaming the procedure by informing and discussing the cases with receiving hospitals. It would translate into less referral and management of the eligible cases at the secondary level of care.

About 15% of the children left hospital before completion of treatment. Some of them intimated before leaving while rest did not. These cases pose double burden to the health-care delivery system – first, such acts cause loss of limited resources available at the public hospital and second, deprives someone else from getting same care from the hospital.[14] Earlier, it was documented that about 10% children were discharged against medical advice (DAMA).[15] This large chunk of patients is a potential area where we could reduce mortality. Follow-up should be designed to understand the outcomes of this group of patients, which ultimately helps in recognizing their fates at community after they leave the hospital.

Our study found infants to constitute 71% of the deaths. This is in accord with what documented in the Eastern part of the country.[4] If we focus on infant deaths, about 54% of them die in neonatal period. Approximately, 27% mortality among children admitted in neonatal period is similar to Das.[9]

Global estimation put 44% under-five deaths in neonatal period.[16] Million death study from India also estimated the proportion in the same range (43%).[3] Our study also revealed 44% of under-five mortality (38% of total) in this age group. Keeping greater proportion of death among neonates in view, the government has adopted strategies such as antenatal corticosteroid by auxiliary nurse midwife (ANM), promotion of kangaroo mother care, improved breastfeeding practices, and training of ANM/staff nurses in newborn care. The introduction of INAP is another sincere effort put forward by the government. Apart from care during delivery and postnatal period, the intervention under this plan has been extended to cover ante-natal care for yielding a better obstetric outcome.[17] Nutrition Rehabilitation Centers (NRC), being set up at district hospitals across the country, would help in early recognition and treatment of co-existing malnourishment, thus reducing further complications to a great extent.

About half of all the deaths took place within first 48 h of the admission. Before getting referred to a tertiary center, parents of a sick baby usually consult some nearby hospital. If we consider a delay in arranging transport to the higher center, in many of the cases, by the time the child gets admitted, the golden hours for saving the life of the babies are already over. Delay in referral is another factor that plays decisive role in many circumstances, rather than the disease. It has been documented previously that delay in referral could hamper the treatment of the child.[18] Creating local model and boosting existing hospital set ups are important to cut short the delay in providing treatment to moribund children.

At a time, when there are synchronized efforts of creating sick newborn care unit at each priority district and focus on relating NRC with treating facility, we could expect a steady reduction in neonatal mortality over the next few years.[19] The introduction of JSSK to ensure zero expense transport to referred hospital for infants is another boost in recent times. These initiatives would definitely have a dent in the chunk of child mortality across the country.

The limitations of the study include the use of secondary data in which uniformity in data collection procedure and quality of data might be vital issues. Exclusion of surgical cases might be another area which could be improvised. A prospective study with standard case definitions and further analysis of the distribution of causes of death will be a real eye-opener in future. Being a hospital-based study comprising 20,000 admissions, this study could be the first step in setting priorities for limited medical resources and designing future road map for ending preventable child deaths.


  Conclusion Top


From epidemiological point of view, 10% death and 15% DAMA/abscond among admitted children in our tertiary hospital are the most important findings of our study. More than 50% death within first 24 h should also be counted with priority. Follow-up of the DAMA/absconded children will give us insight about not only their outcomes but qualitative issues to be addressed at our settings. Standard referral protocol, therefore, should be formed and circulated across the country to stop the unnecessary shifting of patients to tertiary care centers, thus distributing patient load evenly among hospitals. Synchronization of efforts put together at different levels would pave ways for curbing child death in our country.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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UNICEF. The UN Inter-Agency Group for Child Mortality Estimation. Levels and Trends in Child Mortality: Report 2015. New York: UNICEF; 2015.  Back to cited text no. 1
    
2.
Jha P. Avoidable mortality in India: Past progress and future prospects. Natl Med J India 2002;15 Suppl 1:32-6.  Back to cited text no. 2
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Million Death Study Collaborators, Bassani DG, Kumar R, Awasthi S, Morris SK, Paul VK, et al. Causes of neonatal and child mortality in India: A nationally representative mortality survey. Lancet 2010;376:1853-60.  Back to cited text no. 3
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Roy RN, Nandy S, Shrivastava P, Chakraborty A, Dasgupta M, Kundu TK. Mortality pattern of hospitalized children in a tertiary care hospital of Kolkata. Indian J Community Med 2008;33:187-9.  Back to cited text no. 4
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5.
Patil SW, Godale LB. Mortality pattern of hospitalized children in a tertiary care hospital in Latur: A record based retrospective analysis. Natl J Community Med 2013;4:96-9.  Back to cited text no. 5
    
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Singhi S, Gupta G, Jain V. Comparison of pediatric emergency patients in a tertiary care hospital vs. a community hospital. Indian Pediatr 2004;41:67-72.  Back to cited text no. 6
    
7.
Gupta R, Makhija S, Sood S, Devgan V. Discrimination in seeking medical care for female child from birth to adolescence – A retrospective study. Indian J Pediatr 2016;83:410-3.  Back to cited text no. 7
    
8.
Sen A, Mahalanabis D, Singh AK, Som TK, Bandyopadhyay S. Impact of a district level sick newborn care unit on neonatal mortality rate: 2-year follow-up. J Perinatol 2009;29:150-5.  Back to cited text no. 8
    
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Das PK, Sarkar GN, Mallick A, Sahoo S, Sarkar U. Mortality profile in children in a city based pediatric referral hospital in Eastern India. Indian J Prev Soc Med 2008;39:143-8.  Back to cited text no. 9
    
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Shukla S, Das DK, Behera JN. Post neonatal under five mortality – A hospital based study. IOSR J Dent Med Sci2015;14:42-5.  Back to cited text no. 10
    
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Rakha MA, Abdelmoneim AN, Farhoud S, Pièche S, Cousens S, Daelmans B, et al. Does implementation of the IMCI strategy have an impact on child mortality? A retrospective analysis of routine data from Egypt. BMJ Open 2013;3. pii: E001852.  Back to cited text no. 11
    
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Arifeen SE, Hoque DM, Akter T, Rahman M, Hoque ME, Begum K, et al. Effect of the Integrated Management of Childhood Illness strategy on childhood mortality and nutrition in a rural area in Bangladesh: A cluster randomised trial. Lancet 2009;374:393-403.  Back to cited text no. 12
    
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Armstrong Schellenberg JR, Adam T, Mshinda H, Masanja H, Kabadi G, Mukasa O, et al. Effectiveness and cost of facility-based Integrated Management of Childhood Illness (IMCI) in Tanzania. Lancet 2004;364:1583-94.  Back to cited text no. 13
    
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Awasthi S, Pandey N. Rural background and low parental literacy associated with discharge against medical advice from a tertiary care government hospital in India. Clin Epidemiol Glob Health 2015;3:24-8.  Back to cited text no. 14
    
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Roy MP, Gupta R. Leaving against medical advice: Underestimated challenge in children. Indian Pediatr 2016;53:264.  Back to cited text no. 15
    
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Liu L, Oza S, Hogan D, Perin J, Rudan I, Lawn JE, et al. Global, regional, and national causes of child mortality in 2000-13, with projections to inform post-2015 priorities: An updated systematic analysis. Lancet 2015;385:430-40.  Back to cited text no. 16
    
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Government of India. India newborn action plan. New Delhi: Ministry of Health and Family Welfare; 2014.  Back to cited text no. 17
    
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Bapat U, Alcock G, More NS, Das S, Joshi W, Osrin D. Stillbirths and newborn deaths in slum settlements in Mumbai, India: A prospective verbal autopsy study. BMC Pregnancy Childbirth 2012;12:39.  Back to cited text no. 18
    
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    Figures

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



 

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