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ORIGINAL ARTICLE
Year : 2017  |  Volume : 20  |  Issue : 2  |  Page : 64-66

Neonatal discharge against medical advice: Experience from a rural tertiary hospital in North Western Nigeria


Department of Paediatrics, Federal Medical Centre, Birnin Kudu, Jigawa State, Nigeria

Date of Web Publication18-Sep-2017

Correspondence Address:
Umma Idris Abdullahi
Department of Paediatrics, Federal Medical Centre, Birnin Kudu, Jigawa State
Nigeria
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DOI: 10.4103/1118-8561.215035

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  Abstract 

Background: Discharge against medical advice (DAMA) is a major public health issue, especially among children owing to its adverse outcome. The aim of this study is to determine the prevalence and reasons for DAMA among neonates admitted in Federal Medical Centre Birnin (FMCB) Kudu, Jigawa State. Materials and Methods: This cross-sectional study was conducted over a period of 5 years in the Special Care Baby Unit of FMCB Kudu, Jigawa State. All the case folders of the neonate whose parents signed DAMA were retrieved, and relevant data were extracted. Results: There were 155 cases of neonatal DAMA during the study. Eighty-three were males (53.5%) with an average duration of hospital stay of 4 ± 3.2 days with most DAMA occurring in the 1st week of admission. Neonatal infections, birth asphyxia, and prematurity were the most common diagnoses. Financial constraint was the major reason for DAMA. Fathers were the signatories in the majority of cases. Conclusion: DAMA is prevalent and is mainly due to socio-cultural and economic factors.

Keywords: Discharge against medical advice, neonatal, rural hospital


How to cite this article:
Abdullahi UI. Neonatal discharge against medical advice: Experience from a rural tertiary hospital in North Western Nigeria. Sahel Med J 2017;20:64-6

How to cite this URL:
Abdullahi UI. Neonatal discharge against medical advice: Experience from a rural tertiary hospital in North Western Nigeria. Sahel Med J [serial online] 2017 [cited 2019 Oct 15];20:64-6. Available from: http://www.smjonline.org/text.asp?2017/20/2/64/215035


  Introduction Top


Discharge against medical advice (DAMA) occurs when an in-patient chooses to leave the hospital before discharge is recommended by the treating clinicians. It increases the risk of adverse outcome ranging from medical complications requiring readmission to death.[1] It is even more complicated with regard to children because it is their parent(s) or caregivers who take the decision and not the patients. This act causes an ethical dilemma to health-care provider, who must balance the respect for patient's wishes to leave with ensuring that they receive the most appropriate care.[1],[2] The prevalence of neonatal DAMA in Nigeria was reported to be 1.7–7.2%.[3],[4],[5],[6] These studies were conducted mostly in cities where the standard of living and general health awareness of the populace are by far better than in rural areas.

The prevalence of DAMA may be higher among the rural dwellers due to the high burden of illiteracy, poverty, and poor health seeking behavior. This study, therefore, is aimed at determining the prevalence, possible reasons, and clinical diagnosis of the neonates whose parents signed DAMA in a rural tertiary hospital.


  Materials and Methods Top


This retrospective study was carried out at the Federal Medical Centre Birnin Kudu (FMCB). It is the major government hospital that provides in-patient neonatal services in Jigawa State and its neighboring state. It was established in the year 2000 for the provision of clinical services, teaching, and research to cater to the needs of the local and wider community. The Special Care Baby Units of the hospital (SCBU) has a capacity of ten beds were all sick neonates are admitted. Parents or guardians bear all the cost of admissions including drugs and investigations. This study was authorized by the Research and Ethical Committee of the hospital.

All consecutive neonates whose caregivers/parents signed DAMA from January 2, 2009, to December 31, 2013, were reviewed. The information obtained from the case files included gestational age, sex, birth weight, place and mode of delivery, admitting diagnosis, and length of hospital stay. Reasons for DAMA were also documented. Patients were grouped into social classes according to Oyedeji system [7] Those in Socioeconomic classes I and II were grouped as high, those in III as middle and those in IV and V as low-income groups.

Microsoft Excel spreadsheet was used for data collection and the data analyzed using Statistical Package for the Social Sciences (SPSS) (SPSS Inc.., Chicago IL) version 15.0.


  Results Top


One thousand three hundred and ninety-seven neonates were admitted during the study, of this 155 (11.1%) were DAMA. Of the 155 DAMA; 83 were male (53.5%) as against 72 (46.5%) females given the M: F of 1:0.9. Most of the babies 145 (93.5%) were delivered vaginally while 10 (6.5%) were delivered by cesarian section. The mean weight at presentation was 2.4 ± 0.8 kg (1.1–4 kg).

[Table 1] depicts that prematurity was the diagnosis in the 40 of the 155 cases accounting for 25.8%, which is closely followed by neonatal sepsis 37 (23.9%).
Table 1: Clinical Diagnosis of Neonates who DAMA

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The average length of stay was 4 ± 3.2 days with most DAMA occurring in the 1st week of admission. Most of the babies were from low socio-economic class. Fathers were signatories in most cases [Table 2].
Table 2: Duration of hospital stay, socioeconomic status, and signatory to the discharge against medical advice

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Most of the parents cited financial constraints and lack of improvement as the reasons for DAMA as depicted in [Table 3].
Table 3: Reasons for discharge against medical advice

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  Discussion Top


The prevalence of DAMA in this study was found to be very high at 11.2%. This is similar to 12.2% reported from a rural hospital in Ethiopia [8] but higher than the 1.7–5.2%[3],[9] from urban centers in Nigeria. The higher prevalence in this study highlights the high level of poverty and the ignorance among the rural dwellers studied since the majority of the parents were from low socio-economic class and financial constraints were given as the most common reason for DAMA.

The majority of the babies whose parents signed DAMA were delivered via SVD. This finding is similar to other Nigerian reports from Sokoto and Port Harcourt by Onankpo [3] and Eke,[4] respectively. This may probably be explained by the fact that their mothers got ambulant early and discharged home compared to the caesarean section were mothers remained hospitalized for a relatively longer time.

Prematurity, birth asphyxia and neonatal infections (sepsis and tetanus) were the most common diagnoses among the neonates whose caregivers signed DAMA in this study which is in conformity to what was documented in the literature.[3],[4],[5] It is important to note that these conditions are the three most common cause of death among neonates in the developing world.[10] This calls for aggressive health education and community awareness to improve their health seeking behavior and the implications of their actions and inactions on the neonatal morbidity and mortality.

Most of the DAMA occurred in the first 7 days of admission. This agrees with the findings from the previous Nigerian studies.[3],[4],[5] It is possible that the desire to take the newborn baby home for naming ceremony may have contributed to this action in the 1st week of admission. It is also likely possible that they are seeking alternative care from traditional healers or the children are abandoned to their fate.

A financial constraint was the main reason for DAMA in this study which is in keeping with other reports from Nigeria.[3],[4],[5],[6] This is so in that all the admission expenses were paid by the parents in this study which is in sharp contrast to reports from Oman [11] and Saudi [12] were nonfinancial reasons were the most common cause of DAMA as most of them had insurance cover. Extending the National Health Insurance Scheme to cover for people in the rural community will go a long way in protecting families from huge medical bills and improve their overall well-being.

Fathers were the signatory to the decision to DAMA as reported by other authors in Nigeria [3],[4],[5] and Oman,[11] thus highlighting fathers as the principal decision makers and the custodians of the family's resources in our environment.


  Conclusions Top


Neonatal discharge against medical advise was mostly attributable to financial constraint among patients in low socioeconomic class.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Yong TY, Fok JS, Hakendorf P, Ben-Tovim D, Thompson CH, Li JY. Characteristics and outcomes of discharges against medical advice among hospitalised patients. Intern Med J 2013;43:798-802.  Back to cited text no. 1
[PUBMED]    
2.
Jeffrey T, Berger MD. Discharge against medical advice: Ethical considerations and professional obligations. J Hosp Med 2008;3:403-8.  Back to cited text no. 2
    
3.
Onankpa BO, Ali T, Abolodje E. A study on prevalence of discharge against medical advice in a tertiary care hospital in Nigeria. Int J Med Res Health Sci 2014;3:297-30.  Back to cited text no. 3
    
4.
Opara P, Eke G. Discharge against medical advice amongst neonates admitted into a Special Care Baby Unit in Port Harcourt, Nigeria. Internet J Pediatr Neonatol 2010;40:12-5.  Back to cited text no. 4
    
5.
Onyiriuka AN. Discharge of hospitalized under-fives against medical advice in Benin City, Nigeria. Niger J Clin Pract 2007;10:200-4.  Back to cited text no. 5
[PUBMED]    
6.
Imoudu IA, Ahmad H, Yusuf MO, Makarfi HU, Umara T. An analysis of neonatal morbidity and mortality in Azare, North-Eastern Nigeria. IOSR-JDMS 2014;13:25-8.  Back to cited text no. 6
    
7.
Oyedeji GA. Socioeconomic and cultural background of hospitalized children in Ilesha. Nig J Paediatr 1985;12:111-7.  Back to cited text no. 7
    
8.
Woldehanna TD, Idejene ET. Neonatal mortality in a teaching hospital, North Western Ethiopia. Cent Afr J Med 2005;51:30-3.  Back to cited text no. 8
[PUBMED]    
9.
Okechukwu AA. Discharge against medical advice in children at University of Abuja Teaching Hospital, Gwagwalada, Nigeria. J Med Med Sci 2011;2:949.  Back to cited text no. 9
    
10.
WHO. World Health Organization/Newborn Death and Illness. Available form: http://www./int/pmnch/media.[Last accessed on 2016 Feb 02].  Back to cited text no. 10
    
11.
Al-Sadoon M, Al-Shamousi K. Discharge against medical advice among children in Oman: A university hospital experience. Sultan Qaboos Univ Med J 2013;13:534-8.  Back to cited text no. 11
[PUBMED]    
12.
Al-Turkistani HK. Discharge against medical advice from neonatal intensive care unit: 10 years experience at a university hospital. J Family Community Med 2013;20:113-5.  Back to cited text no. 12
[PUBMED]    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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   Abstract
  Introduction
   Materials and Me...
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