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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 30  |  Issue : 5  |  Page : 514-518

Childhood dead-before-arrival at a Nigerian tertiary health facility: A call for concern and improvement in health care delivery


1 Department of Paediatrics and Child Health, Ekiti State University Teaching Hospital, Ekiti State University, Ado-Ekiti, Ekiti State, Nigeria
2 Department of Paediatrics and Child Health, Obafemi Awolowo University Teaching Hospitals Complex, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria

Date of Submission27-May-2021
Date of Decision23-Jun-2021
Date of Acceptance11-Aug-2021
Date of Web Publication11-Oct-2021

Correspondence Address:
Dr. Adewuyi Temidayo Adeniyi
Department of Paediatrics and Child Health, Ekiti State University Teaching Hospital, Ekiti State University, Ado-Ekiti, Ekiti State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJM.NJM_100_21

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  Abstract 


Background: Dead-before-arrival (DBA) is a term used to describe patients who had no sign of life at the time of presentation to the hospital. Little information exists about it in children. This study sets out to determine the prevalence and pattern of DBA among children presenting to a tertiary health facility in Nigeria. Materials and Methods: Standardized verbal autopsy was used to ascertain the details about children aged 1 month to 14 years who were cases of DBA at the Children Emergency Ward of the Wesley Guild Hospital, Ilesa, Nigeria, over 12 months. Socio-demographic history, symptoms before demise, treatment received, and suspected cause (s) of death were documented. The prevalence of DBA was compared to the in-hospital mortality during the period. Results: A total of 64 (7.4%) of the 863 emergency admissions were cases of DBA. Median (interquartile range) age was 18.0 (8.0–52.5) months, male: female was 1.7 and over 78.1% were under-fives. Infections such as malaria, sepsis, and gastroenteritis were the most common suspected causes of death, followed by accidental injuries from a road traffic crash, drowning, and aspirations. Cases of DBA were significantly higher than in-hospital mortality during the study period (7.4% vs. 5.6%). Conclusion: In-hospital mortality may be a tip of the iceberg as cases of DBA, and those who did not present to the hospital at all may take the lion share of childhood mortality. Making basic health care available and affordable to the populace may help reduce the burden of DBA.

Keywords: Children emergency, dead-before-arrival, mortality, verbal autopsy


How to cite this article:
Adeniyi AT, Kuti BP, Adegoke SA, Oke OJ, Aladekomo TA, Oyelami OA. Childhood dead-before-arrival at a Nigerian tertiary health facility: A call for concern and improvement in health care delivery. Niger J Med 2021;30:514-8

How to cite this URL:
Adeniyi AT, Kuti BP, Adegoke SA, Oke OJ, Aladekomo TA, Oyelami OA. Childhood dead-before-arrival at a Nigerian tertiary health facility: A call for concern and improvement in health care delivery. Niger J Med [serial online] 2021 [cited 2021 Dec 8];30:514-8. Available from: http://www.njmonline.org/text.asp?2021/30/5/514/327942




  Introduction Top


Dead-before-arrival (DBA) describes patients who already have evidence of clinical death and no sign of life at the time of presentation to a health care facility.[1]

A recent report from Lagos, Nigeria, showed that DBA constituted 11.5% of emergency room (ER) mortality over five years.[2] A similar report from Ghana showed a DBA prevalence of 31.1% over three years.[1] Patel et al. reported 186 cases of DBA across all age range over a prospective 12-month period in India.[3] The prevalence of DBA is thus variable, and it occurs across all levels of health care.[1],[4]

Contributory factors to DBA in Nigeria include poverty, poor health-seeking behavior, and delayed access to quality care.[5],[6],[7] Children are at the receiving end because they depend on the health-seeking behavior of their caregivers and may be medically mismanaged because of poor communication of their symptoms, tendency for danger signs to be overlooked by caregivers, and a dearth of pediatricians. In 2011, the child to pediatrician ratio in Nigeria was 157,878 to one, as against 1400 to one in the United States of America in the same year.[8],[9] Most pediatricians in Nigeria practice in urban areas, resulting in a paucity of specialist care in rural areas.[8] This is worsened by the increase in the brain drain of health care professionals.

Health care is planned on available information and data. It is known that the mortality rate in the emergency unit of a hospital reflects the quality of health care available in that hospital.[4],[10] Other factors that have been described to influence ER mortality include crowding, ER boarding time, the severity of the patient's illness, and ER staffing.[11],[12],[13],[14] The frequency of DBA, however, reflects prehospital factors, which should also be considered in formulating health policies. This study was conducted to determine the prevalence and pattern of DBA in children in a tertiary health care facility in Nigeria. This may create awareness about this important but often neglected and underreported phenomenon and possibly influence health care planning and policy formulation.


  Materials and Methods Top


The study was a hospital-based, cross-sectional study conducted over 12 months (January to December 2018) at the Children Emergency Ward (CEW) of the Wesley Guild Hospital (WGH), Ilesa, Osun State, southwest Nigeria. The WGH is a tertiary hospital, an arm of the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife, Nigeria. The facility caters to the health care needs of the population within the semi-urban town of Ilesa and also for referrals from surrounding towns both within and outside the state. Ilesa equally has one public secondary health care facility and 46 public primary health care centers. Ethical approval for the study was obtained from the Ethics and Research Committee of the OAUTHC (with a protocol number ERC/2014/08/05) as an adjunct to a study titled “Hypoxemia among emergently ill children at the WGH, Ilesa,” which had been previously conducted at the same study location. Confidentiality was maintained throughout the study.

The study population included all children aged from 1 month to 14 years who were brought into the CEW and who on arrival had no sign of life and were confirmed dead. A standardized verbal autopsy form[15] was used to obtain and record information about the age, gender, and nature, and duration of the symptoms the patient had before demise. Patients were assumed to have had anemia only if the parents or caregivers had noticed pallor (whiteness of the palms and/or soles) at any time in the course of the illness before the presentation. The possibility of sepsis was considered only if the patient has had symptoms for at least a week and/or the patient had symptoms suggestive of pathology in two or more systems. Information was also obtained about the treatment that was given, where the treatment was sourced from, and whether treatment was sought in any health care facility. A full general physical examination was conducted on all patients to identify any physical features that may give further clues to the possible cause of death. To ensure their cooperation, all the required information for the study was obtained from the parents/caregivers and/or other informants before the demise of the patient were disclosed to them. The number of cases of DBA was compared with the in-patient mortality at CEW over the same period.

Data analysis was done with Statistical Package for the Social Sciences (SPSS), version 20.0 (IBM Corporation, Chicago, USA, 2011). Categorical data were summarized using proportions and percentages, while continuous data were summarized using mean and standard deviation for normally distributed variables and median and interquartile range (IQR) for nonnormally distributed variables. Statistical differences between the categorical variables were determined using the Pearson Chi-square test of association, and P < 0.05 at 95% confidence interval was considered as being significant.


  Results Top


A total of 64 children presented as cases of DBA over the 12-month study period. Within the same time, a total of 863 children presented for treatment at the CEW, making the case incidence of DBA to be 1: 13.5.

The age of the cases of DBA ranged from 1 month to 13 years, with a median (IQR) age of 18.0 (8.0–52.5) months. There were 40 males and 24 females (male: female ratio 1.7: 1) and 78.2% (50 of 64) of the children were under-fives. Highlights of the age and sex distribution of the cases of DBA are shown in [Table 1].
Table 1: Age and sex distribution of the cases of dead-before-arrival

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Severe anemia resulting from various causes, most commonly malaria, was the suspected cause of death in 46.9% of the cases of DBA [Table 2]. Children under the age of five years accounted for 78.2% of the cases, while there were only four (6.2%) adolescents. Forty-two (34.4%) of the cases had sought care in a health care facility in the course of the illness before their demise.
Table 2: Suspected causes of death as related to age distribution among the dead-before-arrival

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Death resulting from accidental causes was identified in 16 (25.0%) of the cases of DBA. These included cases of road traffic crash complicated by severe head injuries, aspiration, electrocution, and poisoning [Table 2]. The road traffic crashes involved more of the school-aged children, while the drowning and home accidents involved more of under-five children.

Secondary causes of death were suspected in some of the patients. These included hypoglycemia (two), metabolic acidosis (two), sinusitis (three), aspiration (four), cellulitis (four), and sepsis (ten). Considering both primary and secondary causes of death together, significantly more under-five cases of DBA resulted from possible infectious causes than children older than five years as 62 (88.6%) of the 70 infectious causes of death compared to eight (57.1%) of the 14 noninfectious causes occurred in children less than five years. x2 = 8.297; P = 0.004 [Table 3].
Table 3: Infectious and noninfectious cases of dead-before-arrival as related to age distribution*

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Only 48 out of the 863 patients admitted during the period died while on admission, giving an in-patient mortality rate of 5.6%. Significantly more cases of mortality occurred outside the facility (DBA) than in-hospital mortality as 64 (57.1%) of the 112 total mortalities (DBA and inpatient mortality) recorded at the CEW during the period died before arrival at the hospital (DBA).


  Discussion Top


The study shows an alarming rate of childhood DBA in our health facility, which significantly exceeded the in-patient mortality at the CEW during the same study period. The majority of the cases of DBA were infants and under-five children, similar to the finding by Olatunya et al.[16] in another tertiary health care facility in southwest Nigeria. Also in this study, infectious conditions accounted for a majority of the mortalities. Noninfectious causes were more common in school-age children and adolescents and most of the cases had not sought care from any health care facility before presenting with no sign of life at our facility.

Easily treatable and preventable infectious diseases such as malaria, sepsis, and gastroenteritis were the most frequent suspected causes of death among the infants. Olatunya et al.[16] identified similar conditions as the major causes of BID among under-fives in Ado-Ekiti, southwest Nigeria. This might be a reflection of the relatively low immune status of these children, which could predispose them to infectious diseases. A report from the World Health Organization (WHO) showed that more than half of the causes of death in under-five children are preventable or treatable with simple and affordable interventions.[17] Complications of malaria (severe anemia and cerebral malaria) were the most common suspected causes of death in the 12–59 months' age group in this report. The partial immunity against malaria that is acquired with age in people living in malaria-endemic regions would not have been well acquired by under-five children, and this makes under-five children vulnerable to acute malaria and mortality from its myriads of complications.[18] Complicated malaria is still a significant cause of mortality among under-five children in Nigeria. In the year 2016, complicated malaria was estimated to have contributed about 13% of the under-five mortality in Nigeria.[19] The WHO recommends the use of insecticide-treated nets (ITNs), chemoprophylaxis, and early diagnosis and prompt treatment as interventions for the prevention and treatment of malaria to prevent malaria-related morbidity and mortality in children.[18] Despite the WHO recommendations, the utilization of ITN is still relatively low in households in Nigeria despite high ITN possession rates in most areas.[20],[21],[22],[23] Orji et al.[20] reported an ITN utilization rate of 52.4% in a hospital-based study in southeast Nigeria. Community-based studies by Aderibigbe et al.[21] in southwest Nigeria and Uzoamaka et al.[22] in southeast Nigeria revealed similarly low utilization rates of 58.5% and 20.0%, respectively. All of these ITN utilization rates were much lower than the Roll Back Malaria target of 80% utilization rate by the year 2010.[20] Furthermore, there are still considerable delays in seeking quality health care as many caregivers patronize over-the-counter purchases and inappropriate dosing of antimalarial rather than visit approved health care facilities for appropriate diagnosis and treatment.[24] Furthermore, immunization coverage is considerably low in many Nigerian communities, as 77% of Nigerian children below 23 months were not adequately immunized.[25] Vaccine-preventable illnesses (such as pneumonia, gastroenteritis, some causes of sepsis, and meningitis) still contribute significantly to childhood deaths in Nigeria and were equally prevalent as suspected causes of death in our study population. Improvements in immunization coverage may play a significant role in reducing cases of childhood mortality, including DBA.

In contrast to the under-fives, road traffic injuries and falls constituted half of the cases of BID among those who were older than five years. Similar occurrences were reported as leading causes of death among older children and adolescents by Cunningham et al.[26] in the United States of America and the WHO in her 2019 report on “Mortality among children aged 5–14 years.”[27] Our finding also showed that all the cases of BID in this age group were males. This could be a further reflection of the already well-described, higher risk-taking behavior of males compared to females.[26],[28],[29] However, the finding could have been just an incidental occurrence in this study, considering the small number (only four) of patients involved.

Despite the availability of many private and public health care facilities in the study location, the larger proportion of the cases of DBA in this report had not sought any medical help from a health facility before its demise. They were being treated with self-prescribed, over-the-counter drugs, and herbal medications. This is highly suggestive of a primary delay in medical care, which for various reasons, including financial constraints, cultural and religious beliefs among others, is the most common form of delay in seeking medical treatment in studies done among Nigerians.[30],[31]

A larger number of patients presented as DBA than died during in-hospital care within the study period. This raises the suspicion that the in-hospital mortality rate, particularly at tertiary health care facilities, may constitute only a small proportion of childhood mortality in our environment. Primary and secondary health care facilities are generally closer to the population than tertiary health care facilities like the location of this study. Considering also that this study was done in a semi-urban area that has many other public health care facilities, it would not be out of place to suspect that more cases of DBA are probably being seen at these lower-level health care facilities and other private health facilities and their deaths go unrecorded and undocumented. The cases of DBA in other health facilities, coupled with those who may not present at all to any health facility before and after demise, make it very likely that the unrecorded cases of childhood mortality constitute a very huge burden indeed. There would therefore be a need for more reports from other health facilities to further define the burden of DBA in Nigeria and other developing countries. This might form a solid ground on which to advocate for better quality health care services to be made more available and affordable to the population.

The authors recognized the limitation that postmortem examinations, which would have added more objectivity to the possible cause(s) of death, were not done in any of the patients. This was because caregivers refused to give consent for the procedure considering the circumstances surrounding their deaths. However, the use of a standardized verbal autopsy form that was systematically filled to ascertain the cause(s) of death in these children adequately sufficed for this.


  Conclusion Top


The study has demonstrated a significant burden of DBA in a tertiary health care center in Nigeria, occasioned by primary delay in seeking health care. The study also showed that more patients were brought dead into the study location than died in the course of in-hospital care. A larger proportion of the causes of death identified were preventable. The authors hypothesize that there might be a similar trend in other health care facilities. We thus recommend that similar studies be carried out in multiple health care centers to help define the burden, scope, and risk factors for BID in Nigeria. This would help to facilitate efforts that could be taken to mitigate the trend. We also call for an improved sensitization of the populace to create community awareness about DBA and improve the health-seeking behavior of the population. The health care delivery at primary and secondary levels and the coverage of the National Health Insurance Scheme should be improved. All these would help reduce the primary delays in seeking health care which is a major finding in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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