Association between care-seeking at health centres preceding hospital admission and in-hospital child mortality in rural Malawi

Abstract

Background: Mortality among children with acute illness in low-income countries remains high. Referral issues and limitations in emergency care are major challenges to child health and a hypothesis is that care at lower-level facilities delays quality emergency care. This study investigates the extent of care-seeking at health centres prior to hospital admission for sick children, and its association with inpatient mortality in Malawi. Methods: We conducted a retrospective cohort study of children aged 0-12 years admitted to hospitals in Mchinji district, Malawi. Data was collected from September 2019 to April 2020 from one district hospital and three community hospitals. Information was collected from caregivers of admitted children, patient files and ward admission registers. The primary analysis assesses the association between referral from a health centre and in-hospital outcomes using logistic regression. Result: A total of 4926 children were included. The majority (n=4265, 86.6%) had gone straight to hospital without being referred from another health facility. The most common diagnoses were malaria (n= 3345, 67.9%), meningitis or sepsis (n= 1047, 21.3%) and pneumonia (n= 656, 13.3%). Children that were referred from a health centre had a case fatality rate of 5.3%, while those that came straight to the hospital had a case fatality rate of 2.5%. Children who had been referred from a health centre had higher odds of dying (AOR: 2.0, CI 95%: 1.3-3.0), compared to self-referred children. Children with anaemia (AOR: 4.1, CI 95%: 2.7-6.3) and malnutrition (AOR: 6.3, CI 95%: 2.7-14.6) had significantly higher odds of dying, than those without these conditions. Conclusion: Most children admitted to hospital had been taken there without a referral, and these children had better survival than those who had been referred. A better understanding of care-seeking pathways, including referral challenges, may direct interventions to improve timely provision of care for sick children.