DOI: 10.12688/f1000research.133981.3 ISSN: 2046-1402

Outcomes of hospitalized children in rural Malawi: investigating the association between inpatient mortality and referral

Annlaug Selstø, Carina King, Helena Hildenwall, André Thunberg, Beatiwel Zadutsa, Lumbani Banda, Everlisto Phiri, Charles Makwenda
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Background The under-five mortality rate counted 71 deaths per 1000 live births for children under five in Sub Saharan Africa in 2022, far above the SDG under five-mortality goal of 25 deaths per live 1000 birth. Referral issues are major challenges to child health and there are concerns that care at lower-level facilities may even delay quality emergency care. This study assesses the association between referral status and inpatient mortality among children admitted to Malawian hospitals. Methods We conducted a cohort study of children aged 0-12 years admitted to hospitals in Mchinji district. Data-collection was done from September 2019 to April 2020 at a district-hospital and three community-hospitals. Information was collected from caregivers, 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. Inpatient mortality was the primary outcome. Result The 4926 included children demonstrated that 86.6% had gone straight to hospital without referral. The majority were admitted due to malaria (67.9%), sepsis (21.3%) and pneumonia (13.3%). Referred children had a case fatality rate of 5.3%, while the non-referred children had a case fatality rate of 2.5%. Referred children had higher odds of dying (AOR: 2.0, CI 95%: 1.3-3.0), compared to not 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 not been referred there, and these children had better survival than those who were referred. While being referred could be a proxy for being more severely sick the mortality difference emphasises a need to better understand care-seeking pathways, including referral challenges, to direct interventions to improve timely provision of care for sick children.

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