Relationship between distance of referring facilities and haemoglobin change in children in Malawi

ABSTRACT

Background

Anaemia is a significant cause of mortality in children in sub-Saharan Africa where blood transfusion is often available only at referral hospitals. Understanding the pattern of referrals by health facilities is essential to identify the delays that affect child survival.

Aim

To determine if there was a correlation between change in haemoglobin (Hb) level and distance from referring facilities to Kamuzu Central Hospital (KCH) in Malawi, and whether distance affected mortality rates.

Methods

This was a retrospective cohort study of 2259 children referred to KCH whose Hb was measured at the referring facility or at KCH. Maps were created using ArcGIS® software. The relationship between distance from KCH and change in Hb was assessed by χ² analysis and multiple linear regression with SAS© software.

Results

The majority of children were referred by health facilities in the Lilongwe District. When categorised as Hb <4, 4–6 or >6 g/dL, 87.0% of children remained in the same category during transfer. There was no significant relationship between Hb drop and distance from KCH. Distance from KCH was not a significant predictor of Hb level at KCH or Hb change. However, mortality rates were significantly higher in facilities that were 10–50 km from KCH than in those which were <10 km away.

Conclusions

Using distance as a proxy for time, this suggests that referring facilities are transferring children sufficiently quickly to avert significant reductions in Hb. Despite this, there is a need to identify the factors that influence the decision to transfer anaemic children.

KEYWORDS:

• Anaemia
• sub-Saharan Africa
• international health
• public health

Acknowledgments

The authors would like to acknowledge the study and their families. In addition, the authors are grateful to the data clerks who collected the data for the registry, and to the KCH paediatric staff for their diligent care of the patients.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The study data are available from Kamuzu Central Hospital ([email protected]) upon reasonable request.

Abbreviations

ArcGIS: geographic information systems software; GADM: database of global administrative areas; Hb: haemoglobin; KCH: Kamuzu Central Hospital; LMIC: low- and middle-income countries; MRDT: malaria rapid diagnostic test; REDCap: research electronic data capture; SAS: statistical analysis system.

Additional information

Funding

The project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number and title (T32HP30038, National Research Service Award (NRSA) for Primary Medical Care). In addition, the database was supported by the National Centre for Advancing Translational Sciences (NCATS), National Institutes of Health (NIH), through grant award number UL1TR001111. The content of the article is of the authors and should not be construed as the official position of HRSA, HHS, the US Government or the NIH.

Notes on contributors

Elizabeth M. Keating

Elizabeth M. Keating is an Assistant Professor in Paediatric Emergency Medicine and Global Health, University of Utah, USA and a Fogarty Global Health Fellow.

Jeff A. Robison

Jeff A. Robison is an Associate Professor of Paediatrics in Paediatric Emergency Medicine, University of Utah, USA.

Msandeni Chiume

Msandeni Chiume is the Head of the Department of Paediatrics, Kamuzu Central Hospital, Malawi.

Marissa Taddie

Marissa Taddie is a Geographic Information Systems Analyst in the Department of Family and Preventive Medicine, Division of Public Health, University of Utah, USA.

James A. VanDerslice

James A. VanDerslice is an Associate Professor in the Department of Family and Preventive Medicine, Division of Public Health, University of Utah, USA.

L. Scott Benson

L. Scott Benson is an Associate Professor in the Department of Family and Preventive Medicine, Division of Public Health, University of Utah, USA.

Elizabeth Fitzgerald

Elizabeth Fitzgerald is an Assistant Professor of Paediatric Emergency Medicine, University of North Carolina Chapel Hill School of Medicine, USA, and Director of UNC Paediatric Global Health.

Heather L. Crouse

Heather L. Crouse is an Associate Professor of Paediatrics in Paediatric Emergency Medicine, Baylor College of Medicine, USA.

Michelle D. Eckerle

Michelle D. Eckerle is an Assistant Professor of Paediatrics in Paediatric Emergency Medicine, Cincinnati Children’s Hospital, USA.

Emily J. Ciccone

Emily J. Ciccone is an Infectious Diseases Fellow, University of North Carolina Chapel Hill School of Medicine, USA.

Christina A. Porucznik

Christina A. Porucznik is an Associate Professor in the Department of Family and Preventive Medicine, Division of Public Health, University of Utah, USA.