Introduction

An estimated 130 million babies are born each year and about 4 million of them die in the neonatal period.¹ Globally, these deaths as a proportion of child deaths are increasing. 99% of all neonatal deaths occur in developing countries.¹ In Nigeria, of ^{the 5 million babies born annually, 240 000 (4.8%) die within the first 4 weeks of life.2 Many of these neonates do not have access to good medical care. It is therefore important that those who get to a health service should be properly treated and discharged when they are fit to go home.}

Discharge against medical advice (DAMA) has become a major health problem in health care delivery in Nigeria.³ DAMA is of concern because it is assumed that these patients are leaving too soon and that adverse consequences will follow. These discharges are also distressing for physicians and other health professionals.⁴ Studies have shown that patients discharged AMA have higher rates of readmission, longer subsequent hospital stays, and worse health outcomes. ^5-11Unfortunately, many patients or in this case parents of patients who discharge AMA have dual sources of distress: compelling personal concerns that fuel one's wish to leave and the illness that initially caused the patient/parent to seek care.

Children, especially neonates are victims because they do not take decisions, and cannot understand or contribute to these decisions. Studies done in Nigeria on DAMA in Paediatrics show that neonates are amongst the most involved.^{3, 12} DAMA in neonates adversely affects morbidity and mortality and may retard progress in achieving Millennium Development Goal 4.¹³ The aims of the study were to identify characteristics of patients, and factors influencing DAMA amongst neonates in the Special Care Baby Unit of University of Port Harcourt Teaching Hospital, and to identify factors that can reduce the prevalence.

Subjects, Materials And Method

It was a two year retrospective study (January 2007 – December 2009) of neonates admitted into the Special Care Baby Unit (SCBU) of the University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria.

The SCBU caters for sick neonates in the University of Port Harcourt Teaching Hospital (UPTH) and serves as a referral centre for neonates in Port Harcourt and its environs.

Neonates are admitted directly into the ward from the labor wards, labor ward theatres and post natal wards. Babies referred from other hospitals are first seen in the children’s emergency wards before being transferred into the unit. At admission into the SCBU, an admission deposit is paid via the accounts section by the parents/caregivers. There is a provision for emergency treatment of babies but parents/caregivers directly bear the cost of treatment and all outstanding bills have to be paid at discharge. In the event of a request for discharge against medical advice (DAMA), the most senior nurse and/or doctor are called in to discuss with, and counsel the parents/caregivers on the need for continued hospitalization. When they insist on discharge despite counseling, they are made to sign the discharge document, after which they pay outstanding bills before leaving hospital. The National Health Insurance scheme recently introduced into the country is yet to take full effect in many parts of the nation; therefore many families still have to bear the cost of treatment directly.

Babies are considered inborn if their mothers booked and had their babies in the UPTH. Babies not born in the UPTH, referred from other hospitals, or who were born in UPTH, but whose mothers had been discharged, but had to be admitted into the SCBU from home are considered out born. Babies who were discharged against medical advice were identified from the Nurses records in the SCBU. Case files were then retrieved from the Hospitals Medical Records Department and reviewed.

Information obtained included biodata, place of birth, mode of delivery, gestational age, diagnoses, duration of hospital stay, socio-economic status, reasons for DAMA and signatories to the discharge document. Patients were grouped into social classes according to the system of Oyedeji ¹⁴. 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.

The cost implications of treating a sick term neonate admitted into the Unit over a period of one week were also evaluated. The exchange rate used was N150 to 1 dollar. Data were entered into a Microsoft Excel Spread Sheet and analyzed using SPSS version 15.0. Chi-Square test was used to test for significance. Statistical significance was set at p < 0.05.

Results

There were 63 cases of DAMA out of 1481 babies admitted during the period giving a prevalence of 4.3%. Only 58 case files were however retrieved and these were analyzed. There were 37 males and 21 females giving a M: F ratio of 1.7: 1. Thirty four (59%) of the babies were out born while 24 (41%) were in born.

Birth weights ranged from 1.35 – 4.7kg with a mean (±SD) of 3.05 ± 1.06. Table I shows the mode of delivery and gestational ages of the babies. Thirty eight (65.5%) were spontaneous vaginal deliveries and majority (74.1%) were term babies. Babies delivered operatively were more likely to DAMA, although this difference was not statistically significant (p = 0.05)

Table II shows the various diagnoses of babies. Neonatal sepsis/infections, birth asphyxia and prematurity were the highest ranking. Some babies had more than one diagnoses.

Table III shows duration of hospital stay and socioeconomic status of the parents. The mean duration of stay in Hospital was 5.9 ± 4.6 days. Sixty nine percent (69%) of DAMA occurred in the first week of admission. Twenty two (37.9%) were of low Socio – Economic status. Babies in the low and middle income groups were more likely to DAMA (p < 0.05). There was no information to ascertain this in 9 (15.5%) of the patients. Only one patient (1.7%) was re-admitted after discharge AMA.

Table IV shows reasons for DAMA and signatories to the discharge document.

The commonest reason for DAMA was lack of funds (34.5%) and the father was the main signatory to the discharge document (77.6%).

Table V shows the cost implications of treating a sick term new born in the SCBU for an average of one week. These figures are usually higher in the preterm infant and 3 – 4 times higher in the private sector.

Figure 1

Table I: Mode of delivery, gestational age of babies and ages At admission

Figure 2

Table II: Diagnoses of babies discharged AMA

Figure 3

Table III: Duration of hospital stay and social classes of parents

Figure 4

Table IV: Reasons for DAMA and signatories to the discharge document

Figure 5

Table V: Cost implications of treating a sick newborn in the SCBU for one week

Discussion

The study showed a prevalence of 4.3% for DAMA in neonates. This prevalence was higher than in other studies in Nigeria for DAMA in Paediatrics. ^{3, 12} These other studies were on DAMA in Paediatrics generally. It is however noteworthy that in these studies, neonates accounted for over 30% of patients affected. This shows that neonates are indeed a high risk group for DAMA in Nigeria . This prevalence was smaller than the 12.2% among neonates recorded in a teaching hospital in North Western Ethiopia.¹⁵ They had smaller numbers of patients (37 of 304 neonates over a 5 year period) and included not just those discharged against medical advice but also those who disappeared for other reasons.

Fifty nine percent (59%) of the babies in this study were out born. Babies referred from peripheral hospitals are usually very ill and are referred because they need specialist attention. DAMA in this group will most certainly have adverse effects on morbidity and mortality.

Babies born by SVD were highest in number for DAMA, this is probably due to the fact that their mothers got ambulant and discharged earlier than those who had had Caesarian sections. In the same vein, as noted in this study, the bigger babies were more likely to be DAMA. Parents would probably feel more comfortable going home with normal sized babies than with small pre-term babies.

Neonatal sepsis/infections followed by birth asphyxia and prematurity were the most prevalent conditions among babies discharged AMA. These are serious, and sometimes life threatening conditions. Other studies have also shown that admission diagnoses of children who are discharged AMA suggest that most ^{had serious, life-threatening illnesses and that they left the hospital prior to having received adequate treatment. 16, 17 These conditions noted in this study have also been observed in other Nigerian studies 3, 12 and in the same order have also been identified by WHO as the greatest killers of newborns in developing countries.18, 19 What happens to these newborns when they leave hospital is a subject that has not been explored in our environment. It has been shown however that patients who discharge AMA have higher rates of re-admission, longer subsequent hospital stays, and worse health outcomes.5, 8, 20}

Many of the babies (69%) were discharged in the first week of life with a good number (20.7%) within the first 24 hours of admission. Many of these babies were less than one week old. This trend is worrisome as up to 50% of neonatal deaths occur within the first 24 hours and as much as 75% occur within the first week of life.²¹ The week immediately following birth is the most crucial period for newborn survival. This is when the mother and child should receive follow-up care to prevent and treat illness.²¹ What happens to a sick neonate within these ages leaving hospital against medical advice can only be imagined.

In contrast to studies in more developed societies ^{4, 23} the readmission rate in our study was low (1.7%). It was also lower than the re-admission rates of 16.2% in Benin City , ²² Nigeria . These other studies were in older children and adults. Some newborns who required re-admission may have gone beyond the neonatal period, so may have been admitted into other wards. The only baby who was re-admitted in this study was re-admitted into the Paediatric ward. What happened to the other babies i.e. whether they died or went to seek alternative sources of care could not be gotten from our records. The low incidence of re-admission may also be due to prevailing socioeconomic circumstances, or patients shying away from re-admission, having signed a written document, or they seek treatment elsewhere. Another possibility may be poor attitude of staff towards patients who discharge AMA. Clinicians caring for patients who seek discharge AMA are often faced with emotionally charged and time-pressured treatment situations. ⁴ This sometimes results in break down of cordial relationships between the clinician and the patient, in this case the parent/caregiver and thus discourages return of the patient to Hospital.

37.9% of DAMA was amongst patients in the low income group. This has been observed in other studies where poverty has been identified as a key factor in DAMA. ^{3, 17, 22} In more developed countries lack of health insurance was a contributory factor to DAMA ^{4, 7} Not surprisingly, lack of funds was one of the main reasons for DAMA in this study. Other reasons for DAMA, included not convenient: some of these had other children at home without a caregiver; some babies were also falsely perceived as having made significant improvement e.g. those who had proven sepsis and were waiting to complete antibiotics. These reasons which have also been noted by other authors^{16, 24} are real and cannot be ignored. It is also noteworthy that the main signatory to the discharge document in this study was the father (77.6%), with the mother contributing in only 12%. A similar finding has also been documented in another Nigerian study. ²² In our environment the father is the custodian of the family’s resources and so has to decide whether or not the family can afford treatment, whether it is convenient or even whether treatment should be accepted. Many mothers do not work outside the home and so are not empowered to take such decisions.

The average cost of treatment for a sick newborn in our unit of N17, 500-N40, 000 (116.7-250 dollars) per week is enormous. In a country where the minimum wage of the average worker is N5,500 (40 dollars) a month ²⁵, the cost implications for the care of a newborn is definitely not within the reach of most citizens. This cost is even higher in the private sector.

Conclusion

DAMA in neonates is a serious public health issue. Many of the babies are discharged at critical periods hence increasing morbidity and mortality. Poverty, mis-conceived ideas, and other social issues are contributory.

Reccommendations

A more universal heath insurance scheme that will get to the grassroots is advocated as this will reduce the rate of DAMA due to poverty. There is also a need for greater focus on female education and empowerment so that women can contribute to family upkeep and take part in decisions concerning the health of their children.

ACKNOWLEDGEMENT