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 Table of Contents  
Year : 2017  |  Volume : 20  |  Issue : 1  |  Page : 16-19

Signing against medical advice in a special care baby unit in a tertiary center in Northwestern Nigeria

1 Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
2 Department of Paediatrics, Federal Medical Centre, Birnin Kebbi, Nigeria

Date of Web Publication11-Jan-2017

Correspondence Address:
Dr. Ibrahim Aliyu
Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University, Kano
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DOI: 10.4103/1119-0388.198099

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Introduction: Children are at the mercy of their caregivers in most developing countries where inadequate health policies and funding make accessing health-care difficult and expensive. Therefore, it may not be surprising for caregivers declining medical care for their children. This study therefore seeks to determine the prevalence of signing against medical advice (SAMA) and common reasons for SAMA in our health center. Materials and Methods: This was a retrospective review of all cases of SAMA seen over a 3-year period from January 2010 to December 2012. Results: There were 59 cases of SAMA comprising 32 (54.2%) males and 27 (45.8%) females, male to female ratio of 1.2:1. Low birth weight (26%), birth asphyxia (12%), and neonatal sepsis (11%) were the most common diagnoses associated with cases of SAMA. The cost of medical care was the most common reason of asking for SAMA (66.0%), followed by preference for alternative care (17%). The year 2011 recorded the highest case of SAMA with 33 cases reported while 2010 and 2012 had 13 cases each. January 2012 had the highest cases of SAMA. Conclusion: SAMA is of great concern; this was observed more among newborns with diagnoses of low birth weight and birth asphyxia. Furthermore, the cost of care was a major reason for asking for SAMA, hence a drawback in delivering effective healthcare.

Keywords: Nigeria, signing against medical advice, special care baby unit

How to cite this article:
Aliyu I, Lawal TO. Signing against medical advice in a special care baby unit in a tertiary center in Northwestern Nigeria. Trop J Med Res 2017;20:16-9

How to cite this URL:
Aliyu I, Lawal TO. Signing against medical advice in a special care baby unit in a tertiary center in Northwestern Nigeria. Trop J Med Res [serial online] 2017 [cited 2018 Jul 18];20:16-9. Available from: http://www.tjmrjournal.org/text.asp?2017/20/1/16/198099

  Introduction Top

The newborn period is a delicate period for child survival. They are at transition toward adaptation to our environment, which if not properly handled could result in neonatal morbidity or death. Neonatal morbidity and mortality contribute significantly to infant morbidity and mortality.[1] Neonatal death accounts for about 40% global under-five mortality,[2] about 39% of global neonatal mortality is contributed by Sub-Saharan countries,[3] and Nigeria accounts for 6% of this figure according to the 2005 statistics.[4] Therefore, contributory factors such as signing against medical advice (SAMA) should be adequately addressed. SAMA[5] is defined as patient/caregiver declining acceptance from a physician or health institution of any further medical care/assistance before full recovery despite been duly informed and understanding the medical implication of their action.[6],[7] Other acronyms for this are DAMA (discharge against medical advice)[8],[9] and LAMA (leaving against medical advice).[10] The physician's goal in patient care is to ensure successful treatment, recovery, and discharge; the reward is priceless and internally fulfilling. Furthermore, children are dependent; therefore, most decisions concerning their health-related matters are made by their caregivers, some of which may be detrimental. These children may end up in the wrong facility such as traditional healers, resulting in significant complications or death. This study therefore seeks to determine the prevalence of SAMA and the reasons why caregivers seek for SAMA in our institution.

  Materials and Methods Top

This was a retrospective review of all cases of SAMA seen over a 3-year period from January 2010 to December 2012 in the special care baby unit of Federal Medical Centre, Birnin Kebbi. All records of SAMA were reviewed, and relevant information such as the age, sex, duration of hospital stay, diagnosis, and socioeconomic status and reasons for asking for SAMA were retrieved from the files. The socioeconomic status of the parents/caregivers was classified into lower, middle, and upper class using that proffered by Oyedeji.[11]

Data analysis

The data obtained were entered and analyzed using Statistical Package for Social Sciences version 16 (SPSS Inc., Chicago, Illinois, USA). The results were presented as frequency tables; mean and standard deviation were calculated for quantitative variables. Fisher's exact test of significance was adopted, and P < 0.05 was adjudged to be statistically significant.

  Results Top

There were 59 cases of SAMA out of 1120 admissions into the special care baby unit, resulting in a prevalence of 5.3%. There were 32 (54.2%) males and 27 (45.8%) females, with male to female ratio of 1.2:1

[Table 1] shows that most of the caregivers are resident outside Birnin Kebbi (51%) and that low birth weight (26%), birth asphyxia (12%), and neonatal sepsis (11%) are the most common diagnoses associated with cases of SAMA. Vaginal delivery (62.7%) was the most common mode of delivery, and majority were delivered in our tertiary center (64.4%). Most of them presented after the 1st day (52.5%) of life, with a range of 1-14 days and mean of 2.2 ± 3.1. Duration of hospital stay ranged between 1 and 75 days, with a mean stay of 11.75 ± 11.6; however, majority (49.2%) spent between 8 and 14 days before requesting for SAMA.
Table 1: Clinical profile of cases with signing against medical advice

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The cost of medical care was the most common reason for asking for SAMA (66.0%), followed by preference for alternative care (17%); majority of the caregivers were of a lower socioeconomic class (78%) [Table 2].
Table 2: Common reasons for signing against medical advice and the socioeconomic class of their caregivers

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[Table 3] shows that majority of those in the lower socioeconomic class attributed cost of accessing health care as the main reason for requesting for SAMA (Fisher's exact test = 53.028; P = 0.000).
Table 3: Comparing the social class of the subjects with the reason for requesting for signing against medical advice

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The year 2011 recorded the highest case of SAMA with 33 cases reported while the years 2010 and 2012 had 13 cases each. January 2012 had the highest cases of SAMA [Figure 1].
Figure 1: Pie chart showing frequency of cases of SAMA according to months and years. 8 = August 2010; 9 = September 2010; 10 = October 2010; 13 = January 2011; 14 = February 2011; 15 = March 2011; 16 = April 2011; 17 = May 2011; 19 = July 2011; 20 = August 2011; 21 = September 2011; 22 = October 2011; 23 = November 2011; 25 = January 2012; 26 = February 2012; 27 = March 2012

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  Discussion Top

SAMA has both medical and ethical implications,[12] especially in children, and it has been associated with high rate of readmissions and complications.[13],[14],[15] In advanced societies with established child welfare programs, some reasons put forward by parents seeking for SAMA defines the concept of child abuse/neglect.[16] However, limited resources hinder the effective protection of the right of the child, which involve reporting to the child protection agency, and such children will be withdrawn from their caregivers and placed under protective custody;[16] unfortunately, our social welfare services attached to hospitals are being reduced to seeking financial assistance for in-patients

This study recorded a SAMA prevalence of 5.3%, which is similar to a DAMA prevalence of 4.3% reported by Opara and Eke[17] in Port Harcourt and 5.3% reported by Roodpeyma and Hoseyni from Tehran[18] but higher than the prevalence of 0.96% reported by Oyedeji in Ibadan;[19] Ibekwe et al. in Abakaliki[20] also recorded an overall prevalence of 1.5%, infants made up 52.2% with neonates constituting 37.8% in their study. Our prevalence was also higher than that of Onankpa et al., who reported a rate of 1.7% among neonates in Sokoto,[21] but lower than those of Onyiriuka, who documented 7.5% in neonates,[22] while Woldehanna and Idejene in Northwestern Ethiopia[23] and Gloyd et al. in Core d'Ivoirea[24] reported prevalence of 12.2% and 12.0%, respectively. The reasons for these wide variations are not very clear, but the socioeconomic differences of the caregivers may be a significant factor; Fetuga et al.[25] reported that 92.1% of cases of DAMA occur in those of the lower socioeconomic class though higher than the 78% observed in our study; similarly, Ndu et al.[26] highlighted this observation among African-American; furthermore, the presence of effective and well-equipped facility[27] may influence the performance and outcome of care which may result in shorter hospital stay and caregivers overall satisfaction.

More male neonates were involved in cases of SAMA; this similar observation was reported by Onyiriuka[22] but differed from that of Onankpa et al.,[21] who observed it more among female neonates. As Onyiriuka[22] noted that most African cultures give preference to the male child, parents can go extra miles to ensure their survival; however, when the cost of care exceeds their affordability, the inevitable such as SAMA occurs.

Birth asphyxia, neonatal sepsis, and low birth weight were the most common morbidities associated with SAMA patients. These babies are likely to have longer hospital stay, hence incurring more cost. This is similar to the observation in previous reports.[21],[22] These are life-threatening illness which if not properly treated may result in severe complications or the demise of the newborn.

Majority of the cases were delivered via spontaneous vertex delivery in our tertiary center, and majority spent about 2 weeks on admission. However, the cost of care was the main reason for SAMA; therefore, an effective health insurance scheme which should be extended to the community will help in mitigating this problem.

Kebbi is predominantly an agrarian society; although September 2011, October 2011, and January 2012 recorded higher numbers of SAMA, this did not show any clear periodicity.

  Conclusion Top

SAMA is of great concern; this was observed more among newborns with diagnosis of low birth weight and birth asphyxia. The cost of care is still a major drawback in delivering effective healthcare to Nigerian children. Therefore, improving our standard of living and provision of health insurance cover will help in reducing the prevalence of this menace.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Owa JA, Osinaike AI. Neonatal morbidity and mortality in Nigeria. Indian J Pediatr 1998;65:441-9.  Back to cited text no. 1
Lawn JE, Kinney MV, Black RE, Pitt C, Cousens S, Kerber K, et al. Newborn survival: A multi-country analysis of a decade of change. Health Policy Plan 2012;27:iii6-28.   Back to cited text no. 2
Lawn JE, Cousens S,Zupan J. Neonatal Survival Steering Team. 4 million neonatal deaths: When? where? why? Lancet 2005;365:891-900.  Back to cited text no. 3
Jimoh BM, Anthonia OC, Chinwe I, Oluwafemi A, Ganiyu A, Haroun A, et al. Prospective evaluation of cases of discharge against medical advice in Abuja, Nigeria. ScientificWorldJournal 2015;2015:314817.  Back to cited text no. 4
Stern TW, Silverman BC, Smith FA, Stern TA. Prior discharges against medical advice and withdrawal of consent: What they can teach us about patient management. Prim Care Companion CNS Disord 2011;13. pii: PCC.10f01047.  Back to cited text no. 5
Alfandre DJ. I′m going home: Discharges against medical advice. Mayo Clin Proc 2009;84:255-60.  Back to cited text no. 6
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Baptist AP, Warrier I, Arora R, Ager J, Massanari RM. Hospitalized patients with asthma who leave against medical advice: Characteristics, reasons, and outcomes. J Allergy Clin Immunol 2007;119:924-9.  Back to cited text no. 9
Nwokediuko SC, Arodiwe EB. Discharge against medical advice in Enugu, South Eastern Nigeria - Some ethical and legal aspects. Int J Med Health Dev 2008;13:34-8.  Back to cited text no. 10
Oyedeji GA. The socio-economic and cultural background of hospitalized children in Illesha. Niger J Paediatr 1985;12:111-7.  Back to cited text no. 11
Berger JT. Discharge against medical advice: Ethical considerations and professional obligations. J Hosp Med 2008;3:403-8.  Back to cited text no. 12
Fiscella K, Meldrum S, Franks P. Post partum discharge against medical advice: Who leaves and does it matter? Matern Child Health J 2007;11:431-6.  Back to cited text no. 13
Anis AH, Sun H, Guh DP, Palepu A, Schechter MT, O′Shaughnessy MV. Leaving hospital against medical advice among HIV-positive patients. CMAJ 2002;167:633-7.  Back to cited text no. 14
Uzodike E. Child abuse and neglect in Nigeria - Socio-legal aspects. Int J Law Policy Fam 1990;4:83-96.  Back to cited text no. 15
Issa FY, Awoyemi AO. Child fostering and adoption in Nigeria: A case study of Kwara State and literature review. Trop J Health Sci 2006;13:1-5.  Back to cited text no. 16
Opara P, Eke G. Discharge against medical advice amongst neonates admitted into a special care baby Unit in Port Harcourt, Nigeria. Internet J Pediatr Neonatol 2010;40:12-5.  Back to cited text no. 17
Roodpeyma S, Hoseyni SA. Discharge of children from hospital against medical advice. World J Pediatr 2010;6:353-6.  Back to cited text no. 18
Oyedeji GA. Hospital discharges of children against medical advice. Niger J Paediatr 1986;13:1-5.  Back to cited text no. 19
Ibekwe R, Muoneke V, Nnebe-Agumadu U. Factors influencing discharge against medical advice among paediatric patients in Abakaliki, Southeastern Nigeria. J Trop Paediatr 2009;55:39-41.  Back to cited text no. 20
Onankpa BO, Ali T, Abolodje E. A study on prevalence of discharge against medical advice in a tertiary care hospital in Nigeria. Int J Med Res Health Sci 2014;3:297-301.  Back to cited text no. 21
Onyiriuka AN. Discharge of hospitalized under-fives against medical advice in Benin City, Nigeria. Niger J Clin Pract 2007;10:200-4.  Back to cited text no. 22
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Woldehanna TD, Idejene ET. Neonatal mortality in a teaching hospital, North Western Ethiopia. Cent Afr J Med 2005;51:30-3.  Back to cited text no. 23
Gloyd S, Koné A, Victor AE. Pediatric discharge against medical advice in Bouaké Cote d′Ivoire, 1980-1992. Health Policy Plan 1995;10:89-93.  Back to cited text no. 24
Fetuga MB, Adekanmbi AF, Ogunlesi TA. Paediatric discharges against medical advice in Sagamu. Niger J Paediatr 2006;33:99-103.  Back to cited text no. 25
Ndu IK, Asinobi IN, Ekwochi U, Amadi OF, Osuorah CD, Ayuk AC, et al. Discharge against medical advice (DAMA) among the paediatric age group in Enugu State university teaching hospital Parklane, Enugu. J Exp Res 2016;4:55-62.  Back to cited text no. 26
Ibrahim SA, Kwoh CK, Krishnan E. Factors associated with patients who leave acute-care hospitals against medical advice. Am J Public Health 2007;97:2204-8.  Back to cited text no. 27


  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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