Why do families of sick newborns accept hospital care? a community-based cohort study in Karachi, Pakistan

Objective: Sick young infants are at high risk of mortality in developing countries, but families often decline hospital referral. Our objective was to identify the predictors of acceptance of referral for hospital care among families of severely ill newborns and infants <59 days old in three low-income communities of Karachi, Pakistan. Study Design: A cohort of 541 newborns and infants referred from home by community health workers conducting household surveillance, and diagnosed with a serious illness at local community clinics between 1 January and 31 December 2007, was followed-up within 1 month of referral to the public hospital. Result: Only 24% of families accepted hospital referral. Major reasons for refusal were financial difficulties (67%) and father/elder denying permission (65%). Religious/cultural beliefs were cited by 20% of families. Referral acceptance was higher with recognition of severity of the illness by mother (odds ratio = 12.7; 95% confidence interval = 4.6 to 35.2), family's ability to speak the dominant language at hospital (odds ratio = 2.0; 95% confidence interval = 1.3-3.1), presence of grunting in the infant (odds ratio = 3.3; 95% confidence interval = 1.2-9.0) and infant temperature <35.5 degrees C (odds ratio = 4.1; 95% confidence interval = 2.3 to 7.4). No gender differential was observed. Conclusion: Refusal of hospital referral for sick young infants is very common. Interventions that encourage appropriate care seeking, as well as community-based management of young infant illnesses when referral is not feasible are needed to improve neonatal survival in low-income countries. Journal of Perinatology (2011) 31, 586-592; doi:10.1038/jp.2010.191; published online 27 January 2011