Discharge against medical advice amongst neonates admitted into a Special Care Baby Unit in Port Harcourt, Nigeria

摘要

Background: The greatest risk of childhood death occurs during the neonatal period. The World Health Organization estimates that approximately 4 million newborns die each year with most deaths occurring in developing countries. Any discharge against medical advice (DAMA) amongst this vulnerable group can adversely affect morbidity and mortality.Aim: To identify the causes of DAMA and try to find ways to reduce its incidence in neonates in Port Harcourt, Nigeria. Method: This was a retrospective study done amongst neonates admitted into the Special Care Baby Unit of the University of Port Harcourt Teaching Hospital. Case files of all affected neonates over a 2 year period were reviewed and relevant information obtained and analysed.Results: There were 63 cases of DAMA out of 1481 admissions during the period, giving a prevalence rate of 4.3%. 58 case files were retrieved and analysed. There were 37 males and 21 females with a male: female ratio of 1.7: 1. Preterm babies constituted 25.9% of the cases. The commonest diagnoses were neonatal sepsis and birth asphyxia. Most discharges occurred within the first week of admission (mean =5.9± 4.5days). Common reasons for DAMA were lack of funds and falsely perceived improvement. The discharge document was signed by the father in 77.6% of cases.Conclusion: Poverty, mis-conceived ideas, and other social issues contributed to DAMA in this study. Some babies had life threatening conditions and discharges occurred more within the first few days of life. DAMA in neonates will retard progress in achieving millennium development goal 4. 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.