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Indian Journal of Community Medicine

Mortality Trends of Hospital Admission in a Rural Medical College Hospital with Special Emphasis on Infant Mortality

Author(s): P. Chaturvedi, J. Ayengar, D. Chaturvedi

Vol. 29, No. 4 (2004-10 - 2004-12)

Abstract

Methods: The hospital records of all indoor cases from 1999 to 2001 admitted to the Pediatric Ward of Kasturba Hospital attached to Mahatma Gandhi Institute of Medical Sciences.

Results: Over a span of twelve years, there were 21,371 admissions and 1332 (6.2%) deaths. There was a steady decline in total mortality (TM), Infant mortality (IM), Neonatal mortality (NM), Post neonatal mortality (PNM), Under 5 mortality (U5M) and >5 yrs mortality (>5M). IM as % of TM showed a rising trend from 43.9% (1990) to 72.1% (2001) (p<0.001). NM as % of TM showed a rising trend from 24.4% (1990) to 46.5% (2001) (p<0.001). NM as % of IM varied from 53.1% to 73.7% with no noticeable trend. Mortality below 1 year was always 2-3 times more than mortality above 1 year of age. U5M as % of TM varied from 70-85% and showed a rising trend. The leading causes of NM in order of frequency were prematurity, septicaemia, birth asphyxia & meningitis. The leading caue of post-neonatal mortality (PNM) were infections. Deaths due to prematurity declined over the years, due to meningitis had a rising trend and due to sepsis remained nearly static.

Key Word: Infant mortality, Neonatal mortality

Introduction

Almost one fourth children born in developing countries die before their fifth birthday, in sharp contrast to only 2% in developed countries1. 71-73% of Under - 5 Mortality (U5M) is in the first year of life2,3. Neonatal mortality (NM) accounts for 45-62% of infant deaths in India4,6. The leading causes of Infant mortality (IM) continue to be infections (septicaemia, meningitis & severe pneumonia) and prematurity7,8. IM trends of hospital admission reflect the IM in the community. Children coming from rural areas and having low socioeconomic standards are at an increased risk of mortality9.

Kasturba hospital is a rural hospital attached to Mahatma Gandhi Institute of Medical Scinces. 80% of admissions come from nearby villages and belong to low socioeconomic strata. Hence we made an attempt to evaluate the child mortality statistics in our hospital with special empahsis on IM. This data was thus with regard to those women only, who had a health-seeking behaviour, appropriate enough to come to the hospital. A very small percentage of these mothers are able to access health-care in a short time and most are intimidated by socio-cultural restraints and ignorance till it is too late. This study would thus reveal only the tip of the iceberg as far as the problem is concerned.

Methods

The hospital records of all cases from 1st January 1990 to 31st December 2001 (12 years) admitted to the Pediatric Ward (excluding inborn neonates) of Kasturba Hospital, attached to Mahatma Gandhi Institute of Medical Sciences were analyzed retrospectively on a pre-structured questionnaire. The statistical analysis was done on Excel and the Chi Square test was applied for significance.

Results

Over a span of twelve years, there were 21,371 admissions and 1332 (6.2%) deaths. Infants and neonates formed 34% and 11.7% of the total hospital admissions, respectively. Neonates accounted for 1/3 of infant admissions but 2/3 of infant deaths. This trend was almost static over the years. There were no significant differences in the sex of the babies admitted or those who succumbed. Table 1 shows the basic data of admissons and mortality over the 12 years (1990-2001). Mortality % age wise was highest in the neontal period followed by infancy. IM and U5M accounted for 61% and 81.8% of total mortality (TM) respectively. Fig. 1 shows yearly trends in NM, IM and U5M as % of TM. NM as % of IM and U5M was 65.4% & 48.9% respectively. Likewise 1M as % of U5M was 74.7%. All parameters are showing a significant rising trend except NM as % of IM and U5M as % of TM which were nearly static. Table II shows trends in % mortality age-wise, in all the years under study. There is a significant declining trend in the mortality in all the age groups. Table III compares mortality % under 1 year and above 1 year of age and also mortality % under 5 years and over 5 years of age; the former being significantly more than the latter in all the years in both the groups. The leading causes of NM in order of frequency were prematurity (38%), septicaemia (33.3%), birth asphyxia (9.4%) and meningitis (7.0%). The leading causes of PNM were meningitis (17.1%), septicaemia (14.2%), severe pneumonia (12.5%) and congenital heart disease (9.3%). 80% of the CSF cultures were sterile. Only 17 positive CSF cultures were obtained, of which 12 grew penumocooci, 3 grew acinetobacter and only 2 grew H. influenzae. Deaths due to prematurity declined over the years, due to meningitis had a rising trend and due to sepsis remained nearly static.

Table I : Basic Data - 1990-2001 (12 year analysis)

Age 0 to <1Mo >1mo to 1 yr 0 to 1 yr >1 yr to 5 yrs 0 to 5 yrs >5 yrs Total
TA 2,506 4,912 7,418 7,044 14,462 6,909 21,397
TD 532 281 813 276 1,089 243 1,332
% (Mortality, age-wise) 21.2 21.1 11.0 3.9 7.5 3.5 6.2
% Total Mortality 39.9 21.1 61.0 20.7 81.8 18.3 100.00
TA = Total Admissions, TD = Total Deaths

Discussion

In our study the U5M was 81.8% of TM, IM was responsible for 74.7% of Under-5 deaths. NM accounted for 39.9% of total deaths, 65.4% of infant deaths and 48.9% of U5M. There are regional variations as well as rural-urban differences in the infant mortality pattern throughout the country. Infant Mortality Rate (IMR) differes from 124 in rural Orissa to as low as 16 in Kerala10. The rural IMR in India (182/1000) is almost double that in urban areas (45/1000)11. Maharashtra has presently achieved the target IMR < 60, presently being 48 (combined) - rural (56) and urban (31)12.

The infant mortality in our study showed a declining trend in the last 12 years but an increasing contribution to total deaths. NM accounted for

55-70% of infant deaths with an almost static trend over the years. The IM was 11.0% & NM was 21.2% which were high, reflecting the "high risk", referred babies presenting with multiple complications. Hence this data can be compared to other rural hospital databases only and not to community-based data.

The IM has shown an increasing trend from 43.1% (1990) to 72.1 % (2001) (p<0.001) and NM has similarly increased 24.4% (1990) to 46.5%

(2001) (p<0.001) as percentage of total dealths. The child mortality has subsequantly shown a rise from 73.2% (1990) to 84.9% (2001) while over 5 mortality (>5M) has declined from 26.8% (1990) to 15.1 % (2001). These trends reflect that the various child health strategies implemented in the last decade have to be critically analyzed and the focus has to include more vigorously on improving on neonatal survival and non-health issues in a big way with emphasis on females.

Female Empowerment, literacy and socioeconomic independance continue to be distant dreams and need to be promoted on a war footing13. The doctrine adopted in Kerala need to be extrapolated to rest of India14. Empowerment of women for socioeconomic independance through home based agro, and handicraft production should be encouraged; but care has to be taken to prevent dual exploitation of women at the same time. The National Plan of Action for the Girl Child is based on the theme "Survival, protection and development" has been evolved and will be implemented in the IX Plan Period (1997-2002)15. As years and targets fly by, our focus shifts to newer goals for IMR; 50 by 2002 and 30 by 201016. Good antenatal care, care of the new born and female literacy have always been identified as important modifiable factors17-19. As 80% of deliveries are still non-institutional, to improve neonatal survival, it is important to evolve some community based projects which should include along with health care20, supply of safe drinking water and environmental sanitation 21.

The Indian rural statistics analyzing the causes of death, implicate, prematurity, respiratory infection and diarrhea of newborn to be the leading causes of infant mortality, accounting for 53.5%, 17.0% and 7.4% of deaths respectively22. Infections have been studied to be responsible for nearly 70% of infant mortality in other studies23. Severe pneumonia, meningitis and septicemia are the major contributors7,8. In our study too, septicemia, prematurity, meningitis and severe pneumonia were the leading causes accounting for 26.3%, 24.9%, 10.5% and 7.4% of death respectively. In our analysis, the diagnosis of meningitis was based on CSF findings and these cases were excluded from the group of septicemia. Since only 2 cultures were positive for Hemophilus influenzae B, could we have missed Hemophilus influenzae B infection due to the fastidious growth of the organism? Could deaths due to severe penumonia have been contributed by HiB infection? Properly planned studies are required for more information regarding this, with emphasis on proper techniques for culturing HiB. Meningitis surveillance studies depend on this isolation of the bacterium with a well equipped laboratory and resources24. In India, a number of hospital-based studies have shown that, as in other parts of the world, HiB is generally the most common endemic cause of bacterial meningitis in children25-27. The case of the use of HiB vaccine in the national immunization schedule needs a second review. The WHO recommends " In geographical regions where the burden of HiB disease is unclear, efforts should be made to evaluate the problem28". Improved RCH have reflected in the declined trends of neonatal mortality due to prematurity. This trend has also been observed in another study29.

Good maternal and child health care services are essential for decreases in all child mortality statistics30-32. The non-health issues can be ignored no longer and have to be dealt with more seriousness and determination. There is an urgent need for a more dedicated use of powerful tools for health education, through the media and newspapers in the local languages to convey these alarming statistics and solutions for the same. A concerted effort to strenghthen the community based neonatal and infant care programmes has to be made, if any drastic decreases are to be achieved in our child mortality statistics.

Table II: Yearly Mortality Trends Age-Wise

Age/
year
<1 mo >1m to 1 yr 0 to 1 yr (IM) >1 to 5 yrs 0 to 5 yrs >5 yrs TM
1990  
TA 110 250 360 479 839 560 1,399
TD 30 24 54 36 90 33 123
(% TA) 27.3 9.6 15.0 7.5 10.7 5.9 8.8
1991  
TA 150 421 571 540 1,111 634 1,745
TD 60 32 92 56 148 44 192
(% TA) 40.0 7.6 16.1 10.3 13.3 6.9 11.0
1992  
TA 139 272 411 438 849 498 1,347
TD 44 26 70 32 102 25 127
(% TA) 31.7 9.6 17.0 7.6 12.0 5.0 9.4
1993  
TA 254 333 587 494 1,081 454 1,535
TD 56 21 77 29 106 17 123
(% TA) 22.0 6.3 13.1 5.9 9.8 3.7 8.0
1994  
TA 162 266 428 423 851 422 1,273
TD 39 14 53 12 65 20 85
(% TA) 24 5.3 12.4 2.8 7.6 4.7 6.7
1995  
TA 196 394 590 526 1,116 418 1,534
TD 41 22 63 21 84 11 95
(% TA) 20.9 5.6 10.7 4.0 7.5 2.6 6.2
1996  
TA 178 436 614 562 1,176 550 1,726
TD 43 30 73 22 95 22 117
(% TA) 24.2 6.9 11.9 3.9 8.1 4.0 6.8
1997  
TA 139 374 513 502 1.015 516 1,531
TD 17 15 32 8 40 9 49
(% TA) 12.2 4.0 6.2 1.6 3.9 1.8 3.2
1998  
TA 248 473 721 653 1.374 639 2,013
TD 40 25 65 11 76 15 91
(% TA) 16.1 5.3 9.0 1.7 5.5 2.4 4.5
1999  
TA 334 594 928 833 1,761 738 2,499
TD 56 24 80 28 108 18 126
(% TA) 16.8 4.0 8.6 2.9 6.1 2.4 5.0
2000  
TA 295 596 891 939 1,830 739 2,569
TD 66 26 92 10 102 16 118
(% TA) 22.4 4.4 10.3 1.1 5.6 2.2 4.6
2001  
TA 301 503 804 655 1,459 741 2,200
TD 40 22 62 11 73 13 86
(% TA) 13.3 4.4 7.7 5.0 5.0 1.8 3.9
 
TA 2,506 4,912 7,418 7,044 14,462 6,909 21,371
TD 532 281 813 276 1,089 243 1,332
(% ) mortality 21.2 21.1 11.0 3.9 7.5 3.5 6.2
TA = Total Admissions,  TD = Total Deaths

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Department of Pediatrics,
Mahatma Gandhi Institute of Medical Sciences,
Sevagram, Wardha, Maharashtra
E-mail: [email protected]

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