Association between no referral versus health centres referrals preceding hospital admission and in-hospital child mortality in rural Malawi

<ns5:p>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 a hypothesis is that care at lower-level facilities delays quality emergency care. This study investigates the extent of no-referral versus health centres-referrals prior to hospital admission for sick children, and with inpatient mortality associations in Malawi. 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 one 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 (67.9%) were admitted due to malaria, sepsis (21.3%) and pneumonia (13.3%). Referred children had a case fatality rate of 5.3%, while the non-referred 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 were taken without a referral, 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.</ns5:p>