Nigerian Journal of Paediatrics

Determinants of discharge against medical advice amongst neonates admitted at federal teaching hospital Gombe

Niger J Paediatr 2019; 46 (1):5 – 8

ORIGINAL

Jalo I

CC – BY Determinants of discharge against

Isaac EW

Alkali YS

medical advice amongst neonates

Nduibisi V

admitted at Federal Teaching

Hospital Gombe, Nigeria

DOI:http://dx.doi.org/10.4314/njp.v46i1.2

Accepted: 16th February 2019

Abstract : Objective: Discharge

of the person signing DAMA with

Against Medical Advice (DAMA)

the patient and the reason (s) for

Jalo I (

)

is a major problem in health care

signing DAMA were recorded in a

Isaac EW, Alkali YS, Nduibisi V

delivery in Nigeria. Children,

proforma.

Department of Paediatrics,

especially neonates, who can nei-

Results: Out of the 1,110 neonates

Federal Teaching Hospital/College

ther understand nor contribute to

admitted during the study period,

of Medical Sciences, Gombe State

decision concerning their own

103 were discharged against medi-

University, Gombe, Nigeria

health, are the most commonly

cal advice giving a DAMA rate of

Email: iliyajalo50@gmail.com

affected. The objective of this

9.3%: Male 50(48.5%) and Female

study was to identify the reasons

53(51.5%). Majority 98(95.1%) of

proffered for DAMA in neonates

DAMA cases were signed by the

and persons involved in making

father and the main reason stated

such decisions.

for DAMA was financial con-

Materials and methods:

A de-

straint 62(60.2%).

scriptive study of consecutive

Conclusion : Financial constraint

neonates who were discharged

was the main stated reason for

against medical advice from the

DAMA and the father was the sig-

Special Care Baby Unit at Federal

natory to DAMA in majority of

Teaching Hospital (FTH), Gombe

newborn in FTH, Gombe.

from January 2016 to December

2017. Patients’ Biodata, Diagno-

Key Word: Determinants,

sis, Socio demographic character-

DAMA, Neonates

istics of both parents, relationship

Introduction

model of decision making in our community. In Africa

and other developing countries, the concept of autonomy

Discharge against Medical Advice (DAMA) is a major

is still very controversial and not wholly acceptable

problem in health care delivery in Nigeria.

1-3

The preva-

mainly because of the communal way of life in these

communties . An individual is considered as part of a

lence rates of DAMA range between 0.002% to 5.7%

depending on the population studied and region . Rates

family or clan and important decisions concerning them

ranging from 1% to 2% have been reported in the United

must be taken by elders of the community or head of the

family.

10,11

States of America , while 1.3%, 5.7% and 1.2% were

reported from Port Hacourt , Benin and Lagos respec-

tively. Children, especially neonates, who can neither

Discharge against medical advice can be frustrating for

understand nor contribute to decision concerning their

the physician because it interrupts Patient – Physician

own health are the most commonly affected.

1,5

relationship often jeopardizing favorable outcome for

the patient . The objective of this study is to identify the

According to World Health Organization estimates, out

of 130 million babies born each year about 4 million die

persons involved in making decisions and reasons prof-

during the neonatal period . Studies have shown that

fered for neonates discharged against medical advice in

patients discharged against medical advice have high

Federal Teaching Hospital Gombe. It is hoped that find-

mortality rates therefore, contributing significantly to

ings from this study will help in shaping policies that

neonatal mortality.

5,9

will address this frustrating practice.

The

conflict

between

the

professional

values

(beneficence) of the physician and autonomy (self deter-

mination) of the patient is the most prominent ethical

Subject and Method

dilemma in discharge against medical advise .

The issue of discharge against medical advice is more

The study was conducted at the Special Care Baby Unit

complicated in the case of newborn not only that he

(SCBU) of Federal Teaching Hospital (FTH) Gombe,

lacks capacity for consent but by the extended family

which is a 450-bed capacity tertiary health institution

located in Gombe metropolis. The Hospital serves as a

Table 1: Demographic characteristics of study subjects

referral centre for private hospitals in the state, twelve

Characteristic

Frequency

Percent

(12) secondary health institutions within Gombe State

Gender

and other health care facilities in neighboring states of

Male

51.5

Bauchi, Yobe, Borno and Adamawa. The SCBU is di-

Female

48.5

vided into inborn unit with capacity to admit 10 to 15

Place of Delivery

babies and out born units with 8 to 10 bed capacity.

Inborn

68.0

Staff complement includes one consultant, two senior

Outborn

32.0

registrars, three registrars, interns and 24 hours nursing

Antenatal care

Booked

79.6

coverage.

Unbooked

20.4

Mode of Delivery

Consecutive neonates who were discharged against

SVD

68.9

medical advice while on admission and receiving treated

Emergency C/S

26.2

at both inborn and out born units of the SCBU from

Elective C/S

4.9

January 2016 to December 2017(two years) were re-

Counseled before Admission

cruited for the study. Patients’ Biodata, Anthropometry,

Yes

83.5

Diagnosis, Socio demographic characteristics of both

16.5

parents, relationship of the person signing DAMA with

the patient and the reason (s) for signing DAMA were

Table 2: Diagnoses of Subjects that were DAMA in FTH,

recorded in a proforma.

Gombe

Data was analyzed using SPSS version 23. Results were

Diagnosis

Frequency

Percent

presented in tables of simple percentages, graphs and

Severe perinatal asphyxia

31.1

Chi square was used to compare means of variables.

Respiratory distress syndrome

23.3

Relation was significant if the P – Value is less than

Sepsis

20.4

0.05

Congenital malformation

17.5

Ethical clearance was obtained from the Research and

Meconium aspirationsyndrome

4.9

Ethics Committee of Federal Teaching Hospital Gombe.

Others

2.9

Total

103

100

Fig 1: Reason for DAMA

Result

Out of the 1,110 neonates admitted during the study

period, 103 were discharged against medical advice

(DAMA) giving a DAMA rate of 9.3%. Those dis-

charged against medical advice consisted of 53(51.5%)

male and 50 (48.5%) female with M: F ratio of 1.1:1.

Most 82(79.6%) of the mothers had antenatal and 70

(68.0%) delivered in the hospital. Pre admission coun-

seling was given to 83.5% of mothers. Table 1.

Patients with severe birth asphyxia constituted the high-

est 32(31.1%) number of cases that were discharged

against medical advice. Other cases include Respiratory

distress syndrome 24(23.3%) and sepsis 21(20.4%) Ta-

ble 2. The father was the signatory in 89% of DAMA.

Out of the parents that signed and were discharged

Financial

No reason

Advised by

Adivised by

Others

against medical advice, 37(35.9%) were civil servants

heealth worker other mothers improvement

and 42(40.7%) of them had tertiary education Table 3.

Table 3: Education and occupation of father

The main stated reason for DAMA in this study was

Educational Status

Frequency

financial constraint Fig 1.

Fig. II Reasons for DAMAP ercent

The mean age at admission was 2.36 ± 3.96 days and the

No formal Education

29.1

Primary School

7.8

average duration of hospitalization was 5.54 ±3.42 days.

Secondary School

22.3

At the time of signing discharge against medical advice

Tertiary (below university)

25.2

by parents 36% of patients were assessed be improving

University

15.5

clinically, 32% deteriorating while the remaining 32%

Total

103

100

had no change in their clinical condition.

Occupation

Civil Servants

35.9

Businessmen

32.0

Farmer

20.4

Artisans

4.9

Unemployed

1.9

Others

4.9

Total

103

100

Discussion

The common morbidities for which babies were DAMA

were sepsis, severe birth asphyxia, respiratory distress

The DAMA rate of 9.3% in this study is higher than

syndrome and congenital malformation, this is similar to

earlier reports. and reflect the common neonatal mor-

3,7

previous reports which range from 1.3% to 5.7% from

bidities in the subregion

8,11,14

Abakaliki , Port Harcourt and Binin . The high preva-

. The clinical status of the

lence in this study may be due to poverty which is en-

patient at the time of DAMA might not be a critical fac-

demic in the North east sub region and made worse by

tor in taking the decision as the number of those improv-

the current insurgency. This may be supported by the

ing, deteriorating and those whose condition has not

finding that 58.3% of the parents cited financial con-

changed at the time of DAMA are not significantly dif-

straint as the main reason for DAMA. There were more

ferent. The child’s father was the signatory in 89%,

similar to the report by Abdullahi from Birnin Kebbi,

males than females which is in agreement with previous

reports from Nigeria.

1,3,7

Most parents that signed for

this could be explained by the practice in the north

their neonates to be discharged against medical advice

where women are not allowed to take major decision

did so within the first 7 days of admission with mean

due to cultural/religious factors. Majority of the parents

hospital stay of 5.5 ±3.2 days ,this is similar to report by

who signed DAMA have either secondary or tertiary

Opara from Port Harcourt and Onankpa from Sokoto,

level education. This finding is similar to report by-

Woldehanna and is not consistent with the popular link

the period coincides with the time of naming ceremony

which raises concerns about the role of cultural factors

of such action and decisions with illiteracy. Many

and the need to take the baby home for naming cere-

(35.9%) of the parents who signed DAMA are civil ser-

mony as the main driving force.

vants and businessmen (32.0%). This may be explained

by the dwindling purchasing power of the civil servant

Majority of the patients who were discharged against

occasioned by the prevailing economic situation in

medical advice were inborn, this might be a reflection of

Nigeria.

the high numbers of inborn patients in the study. Most

of the parents who signed DAMA were those whose

The main reason advanced for signing DAMA was fi-

babies were delivered by mothers who had antenatal

nancial constraint which is in agreement with most re-

ports.

8,14,

care. This calls to question the focus of our antenatal

. The finding that some parents were advised by

care and the quality of information that these mothers

staff of the SCBU to sign DAMA raises a lot of concern

receive. Those babies delivered by spontaneous vertex

about the level of confidence health workers have on the

delivery (Normal delivery) were more likely to sign

system. Other parents were advised by mothers who had

DAMA compared to those born through caesarean sec-

earlier signed against medical advice. This new trend of

tion. Possibly because mothers who had normal deliv-

health workers and mothers who have been DAMA en-

ery are discharged early by the obstetrician compared

couraging other mothers to sign DAMA has not been

with those who had Caesarean Section. Since these

reported by other workers. Further critical review of this

mothers are usually forced to surrender their hospital

finding is required because it has potential of affecting

beds they do not have alternative place to stay in the

care of the newborn.

hospital. This results in the parents exerting pressure on

the Paediatrician, leading to decision to sign to be dis-

Authors contributions

charged against medical advice. Although 83.5% of the

Jalo I: Conception and designed of study, analyses and

mothers of babies who were DAMA were counselled

manuscript writing.

before admission, this high rate might be because the

Isaac EW: Statistical analyses, manuscript development

decision was taken by the father who is often not present

Alkali YS: Study design and manuscript development

during counselling at admission. Also this is reflected

Nduibisi V: Data collection, statistical analysis and

by the finding that the father who is usually the head of

manuscript development

the family was the signatory in 89% of cases of dis-

Conflict of interest: None

charge against medical advice in this study.

Funding: None

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