ORIGINAL

Niger J Paed 2014; 41 (2): 90 - 95

Paediatric discharges against

medical advice at a tertiary health

centre in Bayelsa State, Nigeria

Duru CO

Peterside O

Ududua AO

DOI:http://dx.doi.org/10.4314/njp.v41i2,2

Accepted: 27th October 2013

Abstract Introduction: Paediatric

discharges against medical advice

(14.0%) were the major diagnosis

in neonates while respiratory tract

infections (18.2%), severe malaria

(15.6%) and septicaemia (14.3%)

were the commonest diagnosis in

older children who were DAMA.

Discharges against medical advice

occurred commonly in the first

week of admission (69.0%) and

among infants (58.0%). Majority

of the patients were from low and

middle social classes (85.8%) with

30% of the children belonging to

families with 4 or more children.

The commonest reasons for

DAMA were financial constraints

(36.7%), lack of clinical improve-

ment (7.5%) and inconvenience of

child’s admission (7.5%). Only

27% of the children’s clinical con-

dition had been noted to have im-

proved before DAMA and fathers

were the signatories to the dis-

charge documents in 68% of cases.

Conclusions: Discharges against

medical advice remain a serious

public health problem with infants

being the most vulnerable. Gov-

ernment provision of free child

health services, improving access

to health facilities through creation

of better road network, better pa-

tient-physician relationship, child

advocacy and female empower-

ment would help to ameliorate this

problem.

Duru CO (

)

(

DAMA) are common hospital

Peterside O, Ududua AO

Department of Paediatrics and Child

Health,

Niger Delta University Teaching

Hospital, Okolobri,

Bayelsa State, Nigeria.

Tel: +2348034302438

Email: duru_chika@yahoo.com

experiences which limit appropri-

ate and comprehensive treatment

as a result of abrupt termination of

physician care. The fact remains

that the children who are the ma-

jor culprits of this practice are not

legally able to participate in this

decision making process which

may negatively affect their health.

Objectives: This present study

was carried out with the aim of

identifying the DAMA preva-

lence, the socio-cultural character-

istics and reason(s) for DAMA

among the paediatric patients ad-

mitted into the Niger Delta Uni-

versity Teaching Hospital,

Bayelsa.

Methods: Case notes of all chil-

dren who had been discharged

against medical advice over a 2

year period(1st of June 2011to

3

1st of May 2013) were retro-

spectively reviewed and analysed.

Results: One hundred and forty-

one children out of a total of 1872

children admitted into the paediat-

ric wards had been discharged

against medical advice, giving a

DAMA prevalence rate of 7.5%.

Out of 120 children whose case

notes were retrieved and analysed,

there were69(57.5%) males and

5

1 (42.5%) females with a male:

female ratio of 1.4:1. Neonatal

septicaemia (32.6%), birth as-

phyxia (27.9%) and prematurity

Keywords: Discharges against

medical advice, child care, advo-

cacy, Nigeria.

Introduction

It is a common experience both in rural and urban hospi-

tals, as patient non-compliance limits appropriate and

comprehensive hospital treatment, thereby putting their

Paediatric discharges against medical advice (DAMA) is

a request to bring a child home when the attending phy-

sician has not given the discharge order . DAMA

1

2

health at risk . DAMA is a likely contributor to unre-

among paediatric patients poses a challenge because the

child is not legally able to participate in this decision

making process which may be detrimental to his or her

ported childhood deaths as children who are DAMA are

exposed to an increased risk of adverse medical condi-

tions including increased morbidity and mortality . It

3

1

health .

has also been noted that subsequent treatment after

9

1

3

18

DAMA may be more difficult and costly .

using the Oyedeji’s social classification system . Those

in social class I and II were grouped as High socioeco-

nomic class, III was Middle socioeconomic class and IV

and V were grouped as Lower socioeconomic class.

Ethical approval was obtained from the Research and

Ethics Committee of the NDUTH. The data was entered

into an Excel spread sheet and analysed by calculation

of means, percentages and ratios. Test of significance

between proportions was assessed using Chi-square and

a p value < 0.05 was considered statistically significant

at a 95% confidence interval.

Discharge against medical advice has commonl_-y₁₂ been

4

reported in many paediatric centres in Nigeria, other

1

4,16

13,15

and Asia with DAMA preva-

African countries

1

0

4

lence rates ranging from 0.96% to 7.4% . Various rea-

sons for DAMA given have included financial con-

straints, dissatisfaction with medical care and treatment,

parent’s impression that child’s clinical condition had

improved, resort to alternative medicine, lack of trust in

orthodox medicine, lack of clinical improvement and

4

- 17

.

inconvenience of child’s hospitalisation

Several studies on_-₁₂DAMA have been carried out in other

4

parts of Nigeria but till date, none has been done in

the Paediatric unit of the Niger Delta University Teach-

ing Hospital (NDUTH), Bayelsa since its inception in

September 2007. This present study was therefore car-

ried out to determine the DAMA prevalence and con-

tributing factors among paediatric patients at the

NDUTH, with the aim of recommending possible solu-

tions to reduce its prevalence.

Results

A total of 1872 children were admitted into the three

paediatric wards of the Niger Delta University Teaching

Hospital, Bayelsa over a two year period (1st June 2011

to 31st May 2013). Of these, 1086 (38.0%) were male

while 786 (42.0%) were female with a male: female

ratio of 1.4:1.

One hundred and forty-one of the admitted children

were discharged against medical advice giving a DAMA

prevalence of 7.5%.Out of these, case notes of 120

(85.1%) children could be retrieved from the medical

records and were analysed. Sixty-nine (57.5%) of the

children were male while 51 (42.5%) were female with a

male: female ratio of 1.4:1.[Table 1] The proportion of

males admitted who were discharged against medical

advice was 6.4% which was similar to the proportion of

females admitted who were discharged against medical

advice (6.5%). Out of the 120children, 43(35.8%) were

neonates, 70 (58.0%) were infants, 52 (43.3%) were

between the ages of 1 to 59 months and 25 (20.8%) were

above the age of five years. Of the 474 neonates who

were admitted, forty-three (9.1%)were DAMA, while

out of1398 of the older children admitted, 77 (5.5%)

were DAMA. This difference was statistically signifi-

Materials and methods

The Niger Delta University Teaching hospital, formerly

a general hospital was converted to a teaching hospital

in September 2007. The Paediatric Department com-

prises of three major wards- the Special Care Baby Unit

(

SCBU) for new-borns from birth to 28 days of life, the

Children’s Emergency Ward (CHEW) for emergency

paediatric medical and surgical cases and the Children’s

Ward (CHW) for relatively stable cases admitted di-

rectly from the outpatient clinics or transferred from the

Children’s emergency ward after life threatening condi-

tions have been treated.

All the wards are equipped with emergency drugs and

materials from the Hospitals Drug Revolving fund to be

used for emergency management of the ill children to

stabilize them before their parents pay a deposit fee for

the rest of the hospital admission. Health care is funded

by parents with a 50% discount on drugs, laboratory and

radiologic investigations as well as bed fees for all pae-

diatric patients. Clinical and laboratory services are pro-

vided on a 24 hour basis for all patients between the

ages of 0 and 18 years.

2

cant χ = 7.49, p value = 0.006.Majority of the children,

95 (79.2%)who were DAMA were under the age of five

years.[Table 1]

Table 1: Age and sex of the 120 children who were dis-

charged against medical advice

Age of patient

Sex

Total (%)

Male (%)

Female (%)

at admission

The hospital numbers of patients who had been dis-

charged against medical advice between 1st June 2011

and 31st May 2013 were retrieved from the ward regis-

ters. Out of a total of 141 patients who had been DAMA

over the study period, the case notes of 120 patients

0

-28 days

1-12 months

3-36 months

28(23.3)

19(15.8)

15(12.5)

8(6.7)

43 (35.8)

27 (22.5)

1

37-59 months

5- 10 years

13(10.8)

2(1.7)

5(4.2)

9(7.5)

1(0.8)

15(12.5)

22 (18.3)

3 (2.5)

20 (16.7)

(

85.1%) we retrieved from the medical records depart-

ment of the hospital and analysed. The information ex-

tracted from the case notes included the age of the child

at admission, sex, working diagnosis, the ward the

>

10 years

Total

2(1.7)

3(2.5)

5 (4.2)

69(57.5)

51(42.5)

120 (100.0)

patient was admitted into, duration of hospital stay be-

fore DAMA and the reason (s) for DAMA. Information

on the parents’ occupation and level of education was

also obtained in order to determine their social class

Table 2shows the duration of hospital stay of the chil-

dren admitted before they were discharged against medi-

cal advice. Eighty four (70.0%) of the children who

were DAMA had been on admission for a week or less;

9

2

with 26 of them (31.0%) occurring within the first 24

hours. Of all the children who were DAMA from the

CHEW,16(50.0%) did so within the first 24 hours of

admission while in the SCBU, 28(65.1%) were DAMA

between one and seven days of admission.

12 (15.6%) and septicaemia; 11 (14.3%).From the pae-

diatricians assessment in the case notes, majority of the

children’s clinical condition; 88 (73.3%) had not im-

proved before they were DAMA by their parents while

32 (26.7%) were improving before their DAMA.

Table 2: Duration of paediatric hospital admission before

DAMA in the three paediatric wards

Table 3: Reasons given by parents for paediatric DAMA

according to the parental social class

Duration

of admis-

sion

SCBU

CHW

CHEW

TOTAL

Reason for DAMA

Parental social class

No (%) of

DAMA

cases

Lower

SEC

Middle

SEC

Upper

SEC

<

7

1 day

days

4(9.3%)

6(13.3%)

16(50.0%)

14(43.8%)

26(21.7%)

58(48.3%)

28(65.1%)

16(35.6%)

Financial constraints 28

11

4

5

-

44(36.7%)

9 (7.5%)

Lack of clinical

improvement

Inconvenience of

child’s hospitaliza-

tion

5

8

-14 days

14 days

10(23.3%)

1(2.3%)

16(35.6%)

7(15.5%)

2(6.2%)

28(23.3%)

8(6.7%)

>

0(0.0%)

3

9 (7.5%)

4

3(100.0%)

45(100.0%)

32(100.0%)

120(100.0%)

Dissatisfaction with

medical care

Refusal of blood

transfusion

Resort to spiritual/

herbal solution

Perceived improve-

ment in child’s

health

5

1

2

4

2

-

7 (5.8%)

5(4.2%)

3(2.5%)

Note: SCBU- Special Care Baby Unit, CHW- Children’s Ward,

CHEW- Children’s Emergency ward

-

Thirty-one (26.0%) of the children who were DAMA

were the first and only child of the family while 36

-

(

30.0%) were from larger families with four or more

1

children. (Fig 1)

No reasons given

Total (%)

15

60

17

43

8

17

40(33.3%)

120

(50.0%)

(35.8%)

(14.2%)

(100.0%)

Inconvenience of child hospitalization includes far distance of hospi-

tal from home, no one to care for other siblings at home, maternal

ill-health and need for child to go back to school

Table 4: Major diagnosis in the patients who were discharged

against medical advice

Diagnosis in admitted neonates

No(%) of neonates % of the total

that were DAMA

DAMA cases

(n=120)

(n=43)

Fathers were responsible for the signing the DAMA

form of 82(68.0%) children followed by mothers in 34

Neonatal septicaemia

Birth asphyxia

Prematurity

Congenital anomalies

Macrosomic babies & hypogly-

caemia

Breast abscess

Neonatal jaundice

Neonatal tetanus

14 (32.6%)

12 (27.9%)

6 (13.9%)

4(9.3%)

11.7%

10.0%

5.0%

3.3%

2.5%

(

28.0%) and a third party in 4(4.0%) children.

Concerning the parents of the children who were

DAMA, 60 (50.0%) were from the Lower Socioeco-

nomic class while 43 (36.0%) and 17 (14.0%) were from

Middle and Upper socioeconomic classes respectively.

The commonest reasons given for DAMA were financial

constraints; 44 (36.7%), lack of clinical improvement; 9

3(7.0%)

2(4.7%)

1(2.3%)

1.7%

0.8%

Diagnosis in older children

No (%) of older

children that were

DAMA (n=77)

% of the total

DAMA cases

(n=120)

(

7.5%), inconvenience of child’s hospitalization;9(7.5%)

and dissatisfaction with medical services; 7(5.8%). Fac-

tors underlying the inconvenience of the child’s hospi-

talization included presence of other siblings at home,

far distance of hospital from home, maternal ill health

and the need for the child to go back to school. How-

ever, in 40 (33.3%) of the children, no reasons were

given by the parents for their choice to discharge their

children against medical advice. (Table 3)

Respiratory tract

infections

Severe malaria

Septicaemia

Retroviral disease

Acute diarrhoeal disease

14(18.2%)

11.7%

12(15.6%)

11(14.3%)

6(7.8%)

10.0%

9.2%

5.0%

6(7.8%)

Febrile seizures

Protein energy malnutrition

5 (6.5%)

4(5.2%)

4.2%

3.3%

Burns

Trauma

Others (poisoning, neuropsy-

chiatric disorder, chronic ulcer,

CHD, PUD, SCD, surgery ,

helminthiasis)

4(5.2%)

11(14.3%)

3.3%

9.2%

As seen in Table 4, of the 43 neonates who were

DAMA, the three major medical conditions they pre-

sented with were neonatal septicaemia;14 (32.6%), birth

asphyxia; 12 (27.9%) and prematurity; 6(13.9%). Of the

7

est medical conditions they presented with were respira-

tory tract infections; 14 (18.2%), severe malaria;

7 older children who were DAMA, the three common-

Note: CHD- congenital heart disease, PUD- peptic ulcer

disease, SCD- sickle cell disease

9

3

1

9

Discussion

risk group

and these conditions are also the major

2

1

reasons for neonatal admissions in our environment. In

the older children beyond the neonatal age group, infec-

tions such as bronchopneumonia, severe malaria and

septicaemia were the commonest reasons for admission

in these children who were DAMA. This is not surpris-

ing as malaria, diarrhoeal diseases and respiratory tract

infections have recently been reported to be the com-

monest causes of paediatric emergency admissions in

the same institution where this present study was carried

This study shows a DAMA prevalence rate of 7.5%,

which is similar to reports by Okechukw₅u in Abuja

4

(

7.4%) and Onyiriuka in Benin (6.3%). It is much

higher than that reported by Ikefuna and Emodi in

8

Enugu of 1.8%however the authors excluded neonates

1

0

in their study.Oyedeji in his study of DAMA among

79 hospitalised children in Ilesha over a seven year

1

period reported a low prevalence rate of 0.96%. The

marked difference in the DAMA prevalence rate in

Oyedeji’s study compared to this present one could be

2

out. These findings₁₂are similar₁₃to reports from Be-₈

5

11

nin, Lagos, Sagamu and Qatar. Ikefuna and Emodi

in Enugu similarly reported that infectious diseases ac-

counted for more than 50% of cases of DAMA in their

study.

due to₀the lower cost of health care in the 1970s and

1

980s which encouraged longer hospital stays of their

patients. This is especially possible as 29% of the chil-

dren in their study who were DAMA did so after 14

days on admission as compared to 6.7% in this present

Financial constraints were the major reason given for

paediatric DAMA in our study. This was not unexpected

as majority of the patients were from Lower and Middle

social classes with more than 30% of the children being

from families with four or more children. Also about

50% of the DAMA from the CHEW occurred within the

first 24 hours of the child’s admission despite the fact

that these children had life threatening conditions possi-

bly due to financial and emotional unpreparedness for

the admission; a reason₈that was also emphasized by

Ikefuna and Emodi. Financial constraints and Low

socio-economic class also featured prominent_-₉ly as rea-

6

study. Eke and Opara in Port-Harcourt in a recent study

reported a DAMA prevalence of 3.8%. Possible reasons

for this disparity may be the relatively lower percentage

of patients in the lower socioeconomic class (35%) in

their study as compared to the present study (50%). It

has been demonstrated by the present study that DAMA

prevalence is higher among the lower socio-economic

class. Most of the parents in the Port Harcourt

6

study may be better able to afford hospital fees and

therefore be less likely to discharge their children

against medical advice.

4

sons for DAMA in other studies inNigeria. Gloydet

1

4

More than half of all the patients who were DAMA were

infants with over 60% of them being neonates. These

al in their study on DAMA in the paediatric ward of a

central hospital in Bouake, Cote D’Ivoire noted a 5 fold

increase in DAMA rates occurring simultaneously with

5

, 9,

f₁i₀n_,₁d₃ings are similar₁t₅o that of other Nigerian studies.

13

Abdullateef et al in a study of DAMA in the paedi-

atric emergency centre in Al Sadd, Qatar reported that

over 90% of the children who were DAMA were aged

an increase in hospital fees. Roodpegma et al in Iran

gave financial reasons as the fourth reason for DAMA

in their study however most of the patients had health

insurance unlike the present study where he₁a₂lth care is

funded by the parents/guardians. Fetuga et al in

5

less th₂an two years. Both Onyiruika in Benin and Fetuga

1

et al in Sagamu in their studies attributed the increased

DAMA in neonates to be due to socio-cultural reasons

as parents desired to take their children for the tradi-

ti_to_hnal naming ceremony which usually took place on the

Sagamu stated that if hospital fees are subsidized and

families are economically empowered, DAMA rate

would most likely fall. Im₂p₃lementation of a National

and providing free child

8

day of life. Though this was not stated as a reason for

Health Insurance Scheme

DAMA in our study, majority of the neonates who were

DAMA did so within the first week of admission.

health care may help to improve parental health seeking

behaviour and reduce the trend of DAMA.

Though there was an overall male preponderance among

all the age groups of the patients who were DAMA, the

proportion of DAMA in male children was similar to

that in female children which is similar to the findings of

Inconvenience of the child’s hospitalization was another

important reason for DAMA in our study. Various rea-

sons such as far distance of the hospital from the home,

unattended siblings at home, maternal ill health and the

need for₁₀the child to go back to school were stated.

Oyedeji in Ilesha similarly reported the need for the

mothers to go home and attend to other siblings at ho₂me

1

3

Roodpegmaet al in Iran. This is however, in contrast to

5

the reports by Onyiruika in Benin who reported a 2.8

fold increase risk of DAMA in male neonates as com-

pared to female neonates. The reason for this disparity is

not clear however some authors have emphasized the

socio-cultural preference of the male child as potential

custodians of both identity and₂₀lineage especially in the

South Eastern parts of Nigeria.

1

as a major cause of DAMA in his study. Fetuga et al in

Sagamu noted that paediatric admissions may temporar-

ily disrupt the routine care of the family, thereby reduc-

ing the productivity of the caregivers and causing a re-

duction in the family finances. Our hospital is located in

Okolobri, a semi-urban community located about 30km

from Yenagoa the state capital. Apart from the far dis-

tance of the hospital from the main town, accessibility

from most of the neighbouring communities is also a

challenge as the only source of transport from most of

these communities is by sea due to lack of roads.

Neonatal septicaemia, birth asphyxia and prematurity

were the commonest diagnosis among the admitted neo-

nates who were DAMA in our study. These findings are

similar to findings from other₅N_,₆_,i₁g₀e_,₁r₉ian studies though in

different orders of frequency.

Neonates are a high

9

4

Government participation in improving accessibility by

building more roads may help to mitigate this trend.

Lack of clinical improvement and dissatisfaction with

medical services and treatment were also important rea-

sons given for paediatric D₁₁_,A₁₃M_,₁₅A_,₁,₆ which had also been₂

18% of the fathers. Despite this disparity, the authors

noted that the mothers often stayed in the hospital with

the ill child but it was unlikely that the decision to

DAMA was made without the₅knowledge or consent of

1

the fathers. Abdullateef et al in Qatar also reported

reported in other studies.

Moyse and Osmun

mothers as signatories in 87% of the cases of DAMA,

however domestic obligations was a leading cause of

DAMA in their study.

1

7

and Nasir and Babalola both noted that professional

liability is a concern for phy₁s₁i_,c₁i₃a_,₁n₅s caring for patients

who DAMA. Other authors

suggested that more

effective communication₃ is required between physicians

and patients. Al Ayed stated that skilful communica-

tion, flexible routines, policies and procedures, negotia-

ble management options, good clinical care and docu-

mentation could help to deal with this problem.

A major limitation of our study was the fact that we

were unable to retrieve all the case notes from the medi-

cal records department primarily due to poor record

keeping in the admissions and discharges registers.

A third of the cases in our study had no reasons for

DAMA which may be due to ignorance and misinforma-

tion of the caregivers. Advocacy should be made for the

constitution of a panel comprising the paediatrician, the

clinical psychologist, the social worker, the welfare

worker and a legal offic₃er in every hospital as is prac-

tised in other countries. Every care giver intending to

DAMA must meet this panel for appropriate counsel-

ling. This may further reduce the p₅r_,₆e_,v₁₀alence of DAMA.

Conclusions

Paediatric Discharges against medical advice remain a

serious public health problem in low resource countries

with infants being the most vulnerable. Government

provision of free child health services, improving access

to health facilities through the creation of better road

network, better patient-physician relationship, child ad-

vocacy and female empowerment may help to mitigate

this problem.

As reported in many other studies

fathers signed the

discharge documents in majority of the cases of DAMA.

This emphasizes the role of fathers as the principal and

1

2

often sole decision makers in the family. Fetuga et al

Conflict of interest: None

Funding: None

in Sagamu however reported mothers as signatories to

the discharge documents in 80% of cases as compared to

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