Anatomization of Mortality Trends in Under-Twelves in a Tertiary Hospital in Eastern Nigerian: A Cross Sectional Evaluation

Abbreviations: NAUTH: Nnamdi Azikiwe University Teaching Hospital; WHO: World Health Organization; UNICEF: United Nations Children’s Fund; SCBU: Special Care Baby Unit; CHER: Children Emergency Room; PMW: Pediatric Medical Ward; PSW: Pediatric Surgical Ward; A/E: Accident and Emergency; ICU: Intensive Care Unit; PEW: Pediatric Extension Ward; IMR: Infant Mortality Rate, LMICs: Lowand-Middle-Income Countries; MDG: Millennium Development Goals; SDG: Sustainable Development Goals ARTICLE INFO abstract


Background of the Study
The WHO Convention on the rights of the child defines a child as "a person below the age of 18 years unless the laws of a particular country set the legal age for adulthood younger" [1]. Under-12 mortality is the probability of a newborn baby dying between birth and exactly 12 years of age. Child mortality, also known as child death, refers to the death of children under the age of 14 and encompasses neonatal mortality, under-5 mortality, and mortality of children aged 5-14. There is paucity of information about the direct causes of child mortality in developing countries. Child survival remains an urgent concern and as such should not be treated with triviality. Child mortality is a sensitive indicator of a country's development and a representation of its priorities and values [2][3][4][5]. It is unacceptable that about 16,000 children still die every single day -equivalent to 11 deaths occurring every minute. This increasing death toll has a significant effect on the economy of a nation as potential human resources are lost at such tender ages. Socioeconomic determinants, environmental determinants, nutritional status, personal illness control and growth faltering are some of the risk factors known to have a strong relation to child mortality.
Children who die within the first 28 days of life often do so as a result of diseases and conditions that are readily preventable or treatable with proven, cost-effective interventions. Globally, 3 in 4 neonatal deaths are caused by preterm birth complications, complications during labor and delivery (intrapartum-related complications), and sepsis [6,7]. It becomes critically important to accelerate progress in saving the lives of newborns with simple, cost-effective interventions as well as quality care before, during and immediately after birth. This necessitates an evaluation of mortality trend in this population to identify and analyze the risk factors of death as timely and accurate information on the causes of deaths in children less than 5 years old helps in guiding the efforts made to improve child health as a proactive and preventive tool for intervention [8,9]. Data on morbidity and mortality are essential for assessing population health status and disease burden. Valid information on causes of death is an essential tool for the development of national and international health policies for prevention, better management, and control of diseases and complication [10,11]. Most mortality information of countries, communities and facilities are readily available in demographic and health surveys, censuses, hospital medical records among others [12]. Retrospective reviews of these data sources have been the trend of most studies [3,13,14]. This study provided information on the mortality trends in under-12 and explored the associated factors.

Study Area
The study area was Anambra State, an inland state located in the south-central area of southeastern Nigeria. Its capital is Awka.

Study Design
The study was a cross-sectional retrospective study which

Study Setting
The study was conducted in a tertiary health care facility in

Data Collection
Data on mortality of under-12 children was collected using the patient's medical records and death register at the records section of the pediatric department. A detailed data collection was done and categorized according to the various age distribution, gender distribution, clinics and the health condition implicated in each death case from the period of January 2014 to December 2017 and entered into the data collection forms in a presentable manner. This provided an insight into the leading risk factor of mortality and its frequency between the periods.

Data Management
All data in the ordinary recorded from were collated using

Results
Test of association using Chi-square showed no statistically significant association (P>0.05: p =0.999, χ2 = 5.908) between age distribution of death record among the four years. Table 1 shows the distribution of children mortality with respect to gender. There  Tables 2 & 3. Descriptive statistics revealed that Special Care Baby Unit (SCBU) and CHER (Children Emergency Room) were the two major clinics with highest death records. Where the n= total number of deaths in a year.    percent of all deaths in this age group [15].
Despite the substantial progress in reducing child deaths, children from poorer areas or households remain disproportionately vulnerable. It is critical to address these inequities to further accelerate the pace of progress to fulfill the promise to children. This goes to implicate poverty as an important risk factor to child mortality. The risk implicated in under-12 mortality from the study included: to appropriate health-care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant [16,17]. Maternal factors such as maternal education, a birth interval greater than 24 months, adequate breastfeeding are significant protective factors for child survival. Maternal education plays a vital role in the utilization of antenatal care [18][19][20][21][22][23]. In line with the general perception and a well-documented fact, the effects of breastfeeding and birth interval of more than 2 years are significant protective factors [24][25][26][27].
Infants not exclusively breastfed are 15 times more likely to die from pneumonia and 11 times more likely to die from diarrhea than those who are exclusively breastfed [28]. The UNICEF report projects that if all birth to pregnancy intervals were 3 years, approximately 1.6 million under-five deaths could be prevented annually [29]. Efforts should continue to delay the next pregnancy.
In addition, maternal age, i.e., the age of the mother at their first birth is a key correlate of child health outcomes. Teen mothers have children with the worst health outcomes and children of mothers who have their first birth in their early 20s are also at risk of poor health outcomes compared to first-time mothers in their late 20s.
Raj et al showed that children born to mothers in India who were married below the age of 18 were at a higher risk of stunting and underweight as compared to children of women who had married at 18 or older. The effect of the young age of the mother at first birth on poor child health outcomes reflects the interplay of biological and social factors [30][31][32][33][34][35]. Other factors which come to play include proper sanitation and hygiene, nutrition, etc. Poor sanitation and hygiene contribute to fecal pathogens in the environment which, when ingested through contaminated food and water lead to disease.
Under-nutrition has a direct effect on child mortality as it compromises the immune function and increases susceptibility to infectious disease. It is an underlying cause of more than 3 million child deaths per year and is also a consequence of poor health, as infectious diseases increase energy requirements and often reduce appetite and nutrient absorption [36][37][38]. Optimal maternal nutrition is an important contributory factor to the survival of both the mother and child and promotes women's overall health, productivity, and well-being. Two critical pathways through which women's nutrition affects survival outcomes include anemia and calcium deficiency. Pregnancy increases the risk of maternal anemia as the maternal iron requirements increase to support maternal and fetal needs. Epidemiological studies have linked low calcium intake to gestational hypertension which could lead to preeclampsia and eclampsia, now the second most important cause of maternal mortality worldwide [39]. The impact of institutional or nosocomial and community-acquired infections cannot be undermined [40][41][42].

Conclusion
In line with similar studies, there exists a trend of mortality in children with respect to age and gender. These mortality cases are attributable to various factors which have been identified as well as some unknown or unidentified causes (which could be a lag in proper documentation). Mortality can thus be said to arise from the interplay of various factors, hence, hospital-based records to a considerable extent provide relevant information on the trends as well as factors implicated in the mortality trends. This emphasizes the importance of maternal as well as child health in an economy.