Abstract
In Zambia, a significant number of infants die in the community. It is hypothesized that delays in care contribute to many of these so-called "brought in dead" infants. We analyzed free-text narratives from verbal autopsies, in which families narrate the final series of events leading to each infant's death. Using the 3-delays model framework and working iteratively to achieve consensus, we coded each narrative using NVivo software to identify, characterize, and quantify the contribution of delays and other factors to the fatal outcome. Verbal autopsies were collected from 230 families of brought in dead infants younger than 6 months of age. As many as 82.8% of infants had 1 or more delays in care. The most-common delay was in the family's decision to seek care (54.8%), even as severe symptoms were frequently described. Similarly, 27.8% of infants died en route to a health care facility. Delays in receiving adequate care, including infants dying while waiting in line at a clinic or during referral from a clinic to a hospital, occurred in 24.7% of infants. A third of infants had been previously evaluated by a clinician in the days before their death. Delays in care were the rule rather than the exception in this population of Zambian infants. Accessing care requires families to navigate significant logistic barriers, and balance complex forces in deciding to seek care. Strategies to avoid such delays could save many infants lives.
Highlights
To estimate severity of medical status, we developed a modified list of danger signs based on the Integrated Management of Childhood Illness guidelines, as detailed in Fig 1.9,10 The process of identifying common themes related to infant deaths was iterative
More infants were boys (54%), and most lived in households with other siblings (82%). All lived with their biological mother; a quarter of fathers did not live in the home
Delay 1: decision to seek care Delay 2: reaching care Delay 3: receiving adequate care No delay, includes sudden unexplained infant death (SUID) and cases in which no delay was identified Location of death At home En route At the clinic, in line At the clinic, under care Referred to University Teaching Hospital (UTH) and died en route or before receiving care Location unspecified Danger signs mentioned in narratives Fever Convulsions, fits, seizures Excessive crying, irritability Respiratory distress Diarrhea Vomiting Difficulty feeding or refusing feeding Infant seen by a provider shortly before death Family expresses uncertainty regarding cause of death
Summary
In Zambia, a significant number of infants die in the community. It is hypothesized that delays in care contribute to many of these so-called “brought in dead” infants.
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