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Outcomes of hospitalized children in rural Malawi: investigating the association between inpatient mortality and referral [version 3; peer review: 1 approved with reservations, 4 not approved]
Дата публикации: 04-08-2026 09:43:47

Background The under-five mortality rate counted 71 deaths per 1000 live births for children under five in Sub Saharan Africa in 2022, far above the SDG under five-mortality goal of 25 deaths per live 1000 birth. Referral issues are major challenges to child health and there are concerns that care at lower-level facilities may even delay quality emergency care. This study assesses the association between referral status and inpatient mortality among children admitted to Malawian hospitals. Methods We conducted a cohort study of children aged 0-12 years admitted to hospitals in Mchinji district. Data-collection was done from September 2019 to April 2020 at a district-hospital and three community-hospitals. Information was collected from caregivers, patient files and ward admission registers. The primary analysis assesses the association between referral from a health centre and in-hospital outcomes using logistic regression. Inpatient mortality was the primary outcome. Result The 4926 included children demonstrated that 86.6% had gone straight to hospital without referral. The majority were admitted due to malaria (67.9%), sepsis (21.3%) and pneumonia (13.3%). Referred children had a case fatality rate of 5.3%, while the non-referred children had a case fatality rate of 2.5%. Referred children had higher odds of dying (AOR: 2.0, CI 95%: 1.3-3.0), compared to not referred children. Children with anaemia (AOR: 4.1, CI 95%: 2.7-6.3) and malnutrition (AOR: 6.3, CI 95%: 2.7-14.6) had significantly higher odds of dying, than those without these conditions. Conclusion Most children admitted to hospital had not been referred there, and these children had better survival than those who were referred. While being referred could be a proxy for being more severely sick the mortality difference emphasises a need to better understand care-seeking pathways, including referral challenges, to direct interventions to improve timely provision of care for sick children.

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Selstø A, King C, Hildenwall H et al. Outcomes of hospitalized children in rural Malawi: investigating the association between inpatient mortality and referral [version 3; peer review: 1 approved with reservations, 4 not approved]. F1000Research 2026, 12:1053 (https://doi.org/10.12688/f1000research.133981.3)

Research Article

Revised

[version 3; peer review: 1 approved with reservations, 4 not approved]

Previously titled: "Association between no referral versus health centres referrals preceding hospital admission and in-hospital child mortality in rural Malawi"

Annlaug Selstø

https://orcid.org/0009-0002-3704-8502

1,2, Carina King

https://orcid.org/0000-0002-6885-6716

1,3, Helena Hildenwall1,4,5, [...] André Thunberg4, Beatiwel Zadutsa6, Lumbani Banda6, Everlisto Phiri6, Charles Makwenda6

Annlaug Selstø

https://orcid.org/0009-0002-3704-8502

1,2, Carina King

https://orcid.org/0000-0002-6885-6716

1,3, [...] Helena Hildenwall1,4,5, André Thunberg4, Beatiwel Zadutsa6, Lumbani Banda6, Everlisto Phiri6, Charles Makwenda6

Author details Author details

1 Department of Global Public Health, Karolinska Institutet, Stockholm, 171 77 Solna, Sweden
2 Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Postboks 222 Skøyen, 0213, Norway
3 Institute for Global Health, University College London, London, WC1E 6BT, UK
4 Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Huddinge, 141 86, Sweden
5 Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, 141 52 Huddinge, Sweden
6 Parent and Child Health Initiative, Lilongwe, Malawi

Annlaug Selstø
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing

Carina King
Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing

Helena Hildenwall
Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing

André Thunberg
Roles: Data Curation

Beatiwel Zadutsa
Roles: Conceptualization, Data Curation, Writing – Review & Editing

Lumbani Banda
Roles: Data Curation, Writing – Review & Editing

Everlisto Phiri
Roles: Data Curation, Writing – Review & Editing

Charles Makwenda
Roles: Conceptualization, Data Curation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract
Background

The under-five mortality rate counted 71 deaths per 1000 live births for children under five in Sub Saharan Africa in 2022, far above the SDG under five-mortality goal of 25 deaths per live 1000 birth. Referral issues are major challenges to child health and there are concerns that care at lower-level facilities may even delay quality emergency care. This study assesses the association between referral status and inpatient mortality among children admitted to Malawian hospitals.

Methods

We conducted a cohort study of children aged 0-12 years admitted to hospitals in Mchinji district. Data-collection was done from September 2019 to April 2020 at a district-hospital and three community-hospitals. Information was collected from caregivers, patient files and ward admission registers. The primary analysis assesses the association between referral from a health centre and in-hospital outcomes using logistic regression. Inpatient mortality was the primary outcome.

Result

The 4926 included children demonstrated that 86.6% had gone straight to hospital without referral. The majority were admitted due to malaria (67.9%), sepsis (21.3%) and pneumonia (13.3%). Referred children had a case fatality rate of 5.3%, while the non-referred children had a case fatality rate of 2.5%. Referred children had higher odds of dying (AOR: 2.0, CI 95%: 1.3-3.0), compared to not referred children. Children with anaemia (AOR: 4.1, CI 95%: 2.7-6.3) and malnutrition (AOR: 6.3, CI 95%: 2.7-14.6) had significantly higher odds of dying, than those without these conditions.

Conclusion

Most children admitted to hospital had not been referred there, and these children had better survival than those who were referred. While being referred could be a proxy for being more severely sick the mortality difference emphasises a need to better understand care-seeking pathways, including referral challenges, to direct interventions to improve timely provision of care for sick children.

Keywords

In-hospital child mortality; Care-seeking, Referral; Paediatric; Malawi; low-income country

Corresponding author: Annlaug Selstø Competing interests: No competing interests were disclosed.

Grant information: This work was supported by The Swedish Research Council [2017-05579]; The Laerdal Foundation [40348]; Einhorn Family Foundation and Pediatric Health Initiative (travel grant awarded to AS)
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Copyright:  © 2026 Selstø A et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Selstø A, King C, Hildenwall H et al. Outcomes of hospitalized children in rural Malawi: investigating the association between inpatient mortality and referral [version 3; peer review: 1 approved with reservations, 4 not approved]. F1000Research 2026, 12:1053 (https://doi.org/10.12688/f1000research.133981.3) First published: 29 Aug 2023, 12:1053 (https://doi.org/10.12688/f1000research.133981.1) Latest published: 04 Aug 2026, 12:1053 (https://doi.org/10.12688/f1000research.133981.3)

Revised Amendments from Version 2

After receiving the review of the second version of our article, we made some changes to address the questions raised. These include an even more focused article title and a more clearly defined aim of the study. To address concerns regarding unknown distances from most referring health facilities to the included district hospital, we invited an additional researcher, André Thunberg, to join the article, as he could provide valuable insight into the study location and distances. This information has been added, and a supplementary table has been included to address the reviewers’ concerns. This also involved adding some text at the end of the Data sources/Methods section, at the end of the Results section, and at the end of the Discussion. Additional limitations concerning confounding factors such as disease severity, differences in diagnoses between facilities, and distances/home address have also been added.

See the authors' detailed response to the review by Kimberly Baltzell
See the authors' detailed response to the review by Sumathi Swaminathan
See the authors' detailed response to the review by Alden Blair
See the authors' detailed response to the review by Faisal Elgasim Ahmed
See the authors' detailed response to the review by Bryan Vonasek

Introduction

Many countries, mostly in Sub-Saharan Africa (SSA), continue to suffer from a high child mortality rate.1 In 2022 the under-5 mortality was 71 deaths per 1,000 live births in SSA, and 40 per 1,000 for Malawi.2 This is far from the Sustainable Development Goal (SDG) 3,2 to decrease the under-five mortality to less than 25 deaths per 1,000 live births by 2030.3 The Lancet Global Health Commission on Quality Healthcare argued in 2018 that poor quality of healthcare is a now a bigger barrier than access to care in reducing child mortality and accounts for as much as 60% of avoidable deaths in low and middle-income countries (LMIC).4 The Integrated Management of Childhood Illness (IMCI) and integrated Community Case Management (iCCM) programs, were developed to improve the quality of care for sick children in low-income settings. Children with signs of severe illness in the community or in the health centre should be referred to higher level facilities for further management.5 IMCI does not include any components of emergency case management, and primary healthcare facilities in low-income countries commonly lack the resources to treat severely ill children.6 Furthermore, challenges in the identification of severely ill children have been reported under IMCI, potentially leading to missed referrals.7

Delays in care seeking for young children in LMIC have been reported due to guardians’ inability to recognise illness, household challenges in mobilising resources and/or deciding to seek care, especially in poor and less educated households.8–10 This, along with referral challenges within the health system including waiting times, poor triage, and lack of referral transport, could lead to increased risks for children who are brought to primary care with an acute illness, as adequate care at a higher-level facility may be further delayed.

This study was performed to assess the association between referral to hospital from another healthcare facility, compared to self-directed presentation to hospital, and inpatient survival. The aim of this was to try and further explore whether primary care referrals could be linked with mortality, and therefore provide evidence for how to better target clinical care.

Methods
Study setting

Malawi was one of ten countries in SSA that achieved the Millennium Development Goal 4 to reduce child mortality.11 Despite the improvements in child mortality in Malawi, the mortality rate still falls short of the SDGs. The Malawian healthcare system, who heavily depends on external financing, is organized in public (free of charge), private for profit and private not for profit sector.12 The Ministry of Health supports services in the private not for profit sector in essential care, such as maternal and child health. This sector is dominated by non-governmental organisations and religious institutions, such as The Christian Health Association of Malawi (CHAM).13 Malawi adopted and implemented IMCI in 1999 and iCCM was introduced in Malawi in 2007. The World Health Organisations (WHO) Emergency Triage Assessment and Treatment (ETAT)14 has been implemented in Malawian tertiary and secondary hospitals.

Mchinji is a district in the Central Region of Malawi with a mainly rural population and with an under-five population of approximately 90,000 in 2018. In 2018 574.000 (95.3%) of the population in Mchinji lived in rural areas while only 28.000 (4.7%) lived in urban.15 The country economy heavily relies on agriculture, with 80% of the population working in this field.16 Data was collected at the paediatric department of the main district hospital, Mchinji District Hospital (MDH) and the three CHAM community hospitals within the district. The primary care health centres do not offer any inpatient care, and children in need of admission are referred to hospital for further care. In our study we defined “referred” as those children whose caregiver reported that they were referred by a healthcare worker from a health centre to one of the included hospitals. It may also include children referred from one health facility to another, e.g. referred to the district hospitals from any of the included community hospitals.

The recruitment and data collection were planned for one year from the 9th of September 2019 but was stopped in April 2020 due to the Covid-19 pandemic.

Study design

This was an observational cohort study involving all children admitted to hospitals within Mchinji district during the study period.

Participants

Children aged 0-12 years old who were admitted to a paediatric ward at any of the four hospitals within Mchinji District during the study period were eligible for enrolment to the study. The only exclusion criteria were neonates (age <28 days) who were born within the included hospitals, as they were unable to present with a referral history.

Data sources

Data collection involved interviews with guardians and patient file review which was performed by study data collectors. Two of these were based at MDH and one each in the three community hospitals. The data collectors had a minimum education of completed secondary school and could read and write in English and Chichewa. All data collectors attended one week of training on the study protocol and ethics in research. They were supervised on a weekly basis by field supervisors and a clinical officer. Data collectors approached caretakers of admitted children in the hospitals and asked for their consent to participate in the study. Following consent, data was collected on whether the caretaker had brought the child straight to the hospital, or whether another health facility had been visited before coming to the hospital. Patient demographics, including patient age, sex, admission diagnosis, the time and day of the hospital admission and outcomes were recorded from patient files and ward admission books. Data collectors follow up on patient outcomes. Data was entered into password protected tablets using Open Data Kit (ODK) for electronic data collection. A data collection supervisor and a data manager checked the data for completeness on a weekly basis. In our case the data was then exported to Stata for analysis. Data can also be analysed in other software such as R. As data was collected at the hospital during admission, and records were kept over all patients, the risk of loss to follow up bias was minimal. All admitted children in the relevant age groups were invited to participate, eliminating the risk of selection bias.

As distance to hospital is likely to influence the care seeking pathways, and potentially also the final outcome we assessed the case facility rates (CFR) for facilities classified by distance to MDH. Distance was given in straight line kilometres from the referring facility to MDH.

Sample size

The initial plan was to include all admitted children for one year using routine hospital admission data from the Mchinji district. The assumption was that data from Mchinji district would be sufficiently representative of rural Malawi to make generalisations to the population of interest. While data collection was stopped due to the Covid-19 pandemic the inclusion of close to 5000 children was still deemed enough to yield statistically significant results.

Data analysis

The primary outcome variable for the analysis was inpatient mortality, and primary exposure was if the child had been referred prior to hospital admission. Age and sex of the child, day and time of admission and admission diagnosis were considered potential confounders. Sex was determined from medical records and any difference was explored as there are differences in mortality patterns between sexes in children under-five. All variables were converted into categorical variables. Admission days were categorized as weekdays (Monday to Friday) or weekends (Saturday and Sunday), and time as “day” (8 am to 8 pm) or “night” (8 pm to 8 am). This gave an indication if hospital admissions outside of daytime working hours, when there are less staff on the wards, were associated with higher mortality. Children could be assigned multiple admission diagnoses, we created binary variables for diagnosis category, meaning a total of more than 100% is presented in the diagnosis variable.

Proportions were stratified by facility type (district hospital versus community hospitals) and compared using chi2 tests ( Table 1). Logistic regression analysis was done to determine the associations between the main exposure and outcome ( Table 2). All statistical analysis was preformed using Stata/IC 16.1. Stata was chosen as the researchers had license and experience using this software. Alternatively, the free statistical software R could have been used.

Ethical considerations

Guardians were informed about the study and provided verbal consent for their minors to participate in the study prior to any data collection. Due to literacy levels, study information was given verbally in Chichewa, and consent given verbally –the informed consent was subsequently recorded in the electronic data collection form. Refusal to participate had no impact on the care provided to the patients and study procedure including consenting was approved by the Malawi College of Medicine Research and Ethics Committee (P11/18/25389).

Results

A total of 4926 children, 2322 (47.1%) female and 2604 (52.9%) males, were admitted to hospitals in Mchinji district during the study period. Of these, 172/4926 (3.5%) where less than one month old, 852 (17.3%) where 1 month to 12 months old, 2758 (56.0%) were between 1 and 5 years, and 1138 (23.1%) were aged 5 to 12 years. 4265 (86.6%) of the total admitted children had been brought straight to hospital, and 661 (13.4%) children had been referred from another health care provider ( Table 1). The proportion of admitted children that had been referred was higher at the district hospital compared to the community hospitals (29.0%, vs 3.9%, p<0.001). Out of the 4926 children who were admitted, 141 died with an overall in-hospital mortality of 2.9%. The in-hospital mortality was 5.3% for referred children compared to 2.5% for the non-referred cases (p<0.001). The in-hospital mortality was 3.3% at the district hospital compared to 2.1% at community hospitals for non-referrals (p=0.021). For referred cases, the in-hospital mortality was 5.3% at the district hospital and 5.2% at the community hospitals (p=0.998). The overall in-hospital mortality was higher at the district hospital at 3.9%, compared to 2.2% at the community hospitals (p=0.01). Of the 545 children referred to the district hospitals, 33 had been referred from any of the included community hospitals and 5 of these children died (CFR 15.1%).

Table 1. Distribution of patient characteristics and mortality between hospitals.TotalMchinji district hospitalCommunity hospitalsDeaths (n/N)Case fatality rate (%)Deaths (n/N)Case fatality rate (%)Deaths (n/N) Case fatality rate (%)Referral Referred35/6615.329/5455.36/1165.2Non-referred 106/42652.544/13323.362/29332.1Age <29 days6/1723.62/414.94/1313.11–12 months33/8523.918/2836.415/5692.6>1–5 years79/27582.937/10423.642/17162.5>5–12 years23/11382.016/5053.27/6331.1Sex Female71/23223.138/8704.433/14522.3Male70/26042.735/10073.535/15872.2Admission diagnosis Pneumonia17/6562.612/3543.45/3021.3Malaria97/33452.944/10254.353/23202.3Diarrhoea8/3432.32/742.76/2692.2Sepsis22/10472.16/2482.416/7992.0Anaemia37/4418.421/18011.716/2616.1Malnutrition8/5813.83/348.85/2420.8Trauma3/1981.52/1211.71/771.3Other10/4392.34/1522.66/2872.1Admission time Weekday113/36033.159/14244.154/21792.5Weekend28/13232.114/4533.114/8701.6Day120/39783.065/16833.955/22952.4Night*21/9482.28/1944.113/7541.7
Referral history and in-hospital mortality risk

The adjusted odds ratio of in-hospital mortality was 1.9 (95% CI:1.3-2.9) for children who were admitted to hospital who had been referred compared to those who were not referred. Table 2 presents the unadjusted (UOR) and adjusted Odds Ratios (AOR) for the variables included in the logistic regression analysis.

Table 2. Association of patient characteristics and presence of referral with in-hospital mortality.VariableUnadjusted odds ratio p-value 95% CIAdjusted odds ratio p-value 95% CIReferral Not referred1.0Referred2.2<0.0011.5-3.21.90.0011.3-2.9Age <29 days1.01–12 months1.10.8100.5-2.70.70.5450.3-2.0>1–5 years0.80.6370.4-1.90.50.1060.2-1.2>5–12 years0.60.2390.2-1.40.30.0280.1-0.9Sex Male1.0Female1.20.4380.8-1.61.10.4880.8-1.6Admission diagnosis *Pneumonia0.90.6550.5-1.51.00.9040.6-1.9Malaria1.00.8180.7-1.51.40.1950.6-2.2Sepsis0.70.0980.4– 1.10.90.5200.5-1.4Diarrhoea0.80.5420.4-1.61.00.9500.5-2.2Anaemia3.9<0.0012.6-5.74.1<0.0012.6-6.3Malnutrition5.7<0.0012.6-12.36.2<0.0012.7-14.4Trauma0.50.2550.2-1.61.00.9710.3-3.4Other0.70.4430.4-1.50.90.7190.4-1.8Admission time Weekday1.00.0590.4-1.00.80.2010.5-1.2Weekend0.7Night1.0Day1.40.1850.9-2.21.20.4830.7-1.9

For the different age-groups, neonates (age <29 days) represented 3.5% of all admissions (172/4926), with a CFR of 3.6%. Infants, aged 1 to 12 months, represented 17.3% (852/4926) of the admitted children and had the highest CFR at 3.9%. The biggest group of admitted children (56.0%) were between 1 and 5 years of age (2758/4926) while 1138 children (23.1%) were between 5 to 12 years of age. The children aged 1-5 year-old had a CFR of 2.9% and the CFR for children aged 5-12 years old was 2.0%. Only a small difference was seen depending on sex, with 52.9% of the admitted children being males and 47.1% females, and with a CFRs of 2.7% and 3.1%, respectively (p-value: 0.437).

Most of the other included factors did not show any statistical significance. The exceptions were children in the age-group from 5 to 12 years, whose AOR for in-hospital mortality was 0.3 compared to neonates (95% CI: 0.1-0.9).

The diagnosis with the highest CFR was malnutrition at 13.8%, followed by anaemia at 8.5% with an AOR of 6.2 (95% CI 2.7-14.4) and AOR 4.1 (95% CI: 2.6-6.3) respectively. A bigger proportion of children died from malnutrition at the community hospitals than at the district hospital, however the result was not significant (20.8%, vs 8.8%, p<0.191). The proportion of children that died of anaemia was higher in the district hospital (11.7%) than at the community hospitals (6.2%, p=0.039).

Mortality and distances

In the analysis of referral distances to MDH, the corresponding CFR showed a clear pattern that shorter distances had a higher mortality. Children referred from facilities <20 km from MDH had a CFR of 9.2% - the highest, while those from >40 km had the lowest CFR of 2.4% (see Annex Table 1).

Discussion

We observed a higher in-hospital mortality among children who had been referred from a lower-level facilities compared to children who were brought straight to hospital in a rural Malawian setting. Most children who are admitted to hospital had been brought there without seeking any previous care at lower-level facilities. In terms of diagnosis, we found children with malnutrition and anaemia carry an increased mortality risk.

The in-hospital mortality was twice as high for children who had been referred to hospital from a lower-level facility compared to children who were brought straight to the hospital. The CFR was highest for children who had been referred from any of the community hospitals to the district hospital. While our data did not collect information on the severity of the condition at the health centre, nor the cause of death, its plausible that the referred group represents more severe illness with an increased mortality risk, as the system is set up to refer severe cases to higher level facilities (district hospital in this case).12 However, children with non-severe illnesses are not meant to be cared for as inpatients in this context, and the paediatric ward often functions above capacity during peak malaria and pneumonia seasons that were captured in our data. Therefore, admitted children in this setting should represent those with signs of severity or minor operative needs.

Additional explanations to the mortality difference could be that adequate care was delayed during the time it took to seek and receive care elsewhere, followed by the time it took to complete referrals. Lower-level facilities have limited abilities to offer stabilisation of severely ill children with transport issues for referrals reported as a main constraint.16,17 Delays may also occur within facilities, including the decision to refer a child.18 While IMCI was rolled out in 1999 and includes guidelines on when to refer a sick child, challenges in implementation have been reported including limitations in equipment, training, and adherence to guidelines.17,19 To ensure that all in need are referred early, current IMCI guidelines may need more objective definitions for timely stabilisation.20,21

The majority of children admitted to the included hospitals had come straight to the hospital. This may suggest a good awareness among guardians on when a child’s illness requires hospital care. Alternatively, a general preference for hospital care, linked to lack of trust in lower level facilities,22 may also explain this. A study conducted in Southern Malawi reported that patient satisfaction with the primary healthcare system demonstrated considerable variation23 and better facility quality is associated with a higher utilisation of sick child healthcare services.24 Another explanation could also be, given the logistical challenges of completing referrals deaths can occur in transit. Previous data from Mchinji district have shown that 13% of suspected pneumonia deaths in children occur in transit,18 and amongst children who died following a referral from a health centre, 45% occurred in 24-hours, and half of those never made it to hospital.20 This may explain the finding that the CFR was lowest for the furthest facilities, if the most severely sick children die in transit. But also, knowing this, healthcare workers might be hesitant to initiate referrals for the most severely ill if they know the travel time is long, or expensive. Previous experiences among caregivers in similar situations may also lead them to bypass lower-level facilities and go directly to a higher-level hospital, such as MDH.

The highest mortality was seen among children diagnosed with malnutrition and anaemia. This confirms findings from previous studies25–27 and children with these diagnoses also suffer an increased risk of post-discharge mortality.28,29 It is possible that the ETAT guidelines need to pay more attention to malnourished children with multiple diagnoses for priority and stabilisation at admission, and IMCI and iCCM should focus on earlier referral for children with malnutrition and anaemia. For age differences, young children had the highest mortality. While neonates generally suffer the highest mortality rates, in this study the mortality was highest among infants.

This may partly be explained by the study’s exclusion of facility-born neonates. Evidence from a study on place of death and care-seeking prior to death suggests that poor illness recognition is a major driver of neonatal mortality, whereas deaths among older children despite care-seeking indicate deficiencies in quality of care and referral systems.30 The strengths of this study include a district wide approach with a large sample of children included. However, there are some major limitations that preclude any conclusion on the overall mortality-risks in the study population. Firstly, it is possible that referred children as a group were suffering from more severe conditions than the ones who were not referred. The study also did not collect any information on the symptoms at the time the decision to seek care was made, or whether any illness progression occurred during the time spent on care seeking prior to reaching the hospital. Indeed, the high CFR among children referred from community hospitals to the district hospital may suggest increased illness severity and a higher need for more advanced care among these children, rather than facility or referral delays.

Secondly, we did not collect any data on reasons for referrals and whether the selection of children to be referred adhered to guidelines. Thirdly, there is also the possibility that caretakers who were recommended referral to hospital could not make their way there, causing an under-estimation of post-referral mortality. Similarly, we did not assess post-discharge mortality which is reportedly high in many SSA settings.28 It might also be, that the diagnosis at the health center differ from hospital admission diagnoses, which we did not explore. Finally, it would have been useful to collect information on the child’s home location or the starting point of the care-seeking journey to determine whether families lived close to the hospital. Although these data were not collected, the majority of the Mchinji population reside in rural areas15 and it is therefore reasonable to assume that most families have a health centre geographically closer to them than one of the hospitals, in particular the district hospital.

To conclude, the higher in-hospital mortality demonstrated between children who were referred from a health centre compared to not-referred cases may be caused by more severe illness and greater need for more advanced care. However, given the overall high CFRs among referred cases it is also plausible that it is linked to poor quality care at primary healthcare facilities, inadequate guidelines for when to refer a sick child and/or or difficulties to completing referrals. Future studies to better understand the demonstrated mortality pattern should include data on illness severity and caretaker’s reasons for care-seeking choices. The vulnerability of children with malnutrition and/or anaemia should be especially considered when assessing sick children at all levels of the health care system.

Acknowledgements

We would like to thank all the children and their parents/caretakers who participated in this study, and the healthcare workers who supported our data collector teams in their work. We are also grateful to the data collectors for their hard work, and the Mchinji District Health Management Team for their input and support.

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Version 3

VERSION 3 PUBLISHED 29 Aug 2023

Comment

Grant information

This work was supported by The Swedish Research Council [2017-05579]; The Laerdal Foundation [40348]; Einhorn Family Foundation and Pediatric Health Initiative (travel grant awarded to AS)
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Article Versions (3)

Published: 04 Aug 2026, 12:1053

Published: 07 Jan 2025, 12:1053

Published: 29 Aug 2023, 12:1053

Copyright

© 2026 Selstø A et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Open Peer Review

Current Reviewer Status: ?

Key to Reviewer Statuses VIEW HIDE

ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions

Version 3

VERSION 3

PUBLISHED 04 Aug 2026

Revised

Reviewer Report 06 Aug 2026

Faisal Elgasim Ahmed, Urology Research Center, Al-Thora General Hospital, Department of Urology, School of Medicine, Ibb University of Medical Sciences, Ibb, Yemen 

Approved with Reservations

VIEWS 0

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: medicine and surgery

Close

Version 2

VERSION 2

PUBLISHED 07 Jan 2025

Revised

Reviewer Report 31 Dec 2025

Kimberly Baltzell, University of California San Francisco, San Francisco, USA 

Not Approved

VIEWS 0

  • Is the work clearly and accurately presented and does it cite the current literature?

    Partly

  • Is the study design appropriate and is the work technically sound?

    Partly

  • Are sufficient details of methods and analysis provided to allow replication by others?

    Yes

  • If applicable, is the statistical analysis and its interpretation appropriate?

    No

  • Are all the source data underlying the results available to ensure full reproducibility?

    Partly

  • Are the conclusions drawn adequately supported by the results?

    No

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: I am a nurse scientist with a history of work in Malawi and also maternal and neonatal health.

Close

Reviewer Report 30 Dec 2025

Alden Blair, University of California San Francisco, San Francisco, California, USA 

Not Approved

VIEWS 0

  • Is the work clearly and accurately presented and does it cite the current literature?

    Yes

  • Is the study design appropriate and is the work technically sound?

    Partly

  • Are sufficient details of methods and analysis provided to allow replication by others?

    Yes

  • If applicable, is the statistical analysis and its interpretation appropriate?

    No

  • Are all the source data underlying the results available to ensure full reproducibility?

    Partly

  • Are the conclusions drawn adequately supported by the results?

    No

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: I am a mixed-methods epidemiologist whose work focuses on maternal and neonatal health in low- and middle-income countries, with a specific focus on rural and remote areas.

Close

Version 1

VERSION 1

PUBLISHED 29 Aug 2023

Reviewer Report 21 Oct 2024

Sumathi Swaminathan, St John’s National Academy of Health Sciences, St John's Research Institute, Bengaluru, Karnataka, India 

Not Approved

VIEWS 0

  • Is the work clearly and accurately presented and does it cite the current literature?

    Partly

  • Is the study design appropriate and is the work technically sound?

    No

  • Are sufficient details of methods and analysis provided to allow replication by others?

    No

  • If applicable, is the statistical analysis and its interpretation appropriate?

    Partly

  • Are all the source data underlying the results available to ensure full reproducibility?

    Partly

  • Are the conclusions drawn adequately supported by the results?

    No

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Nutrition, Public health, Epidemiology

Close

Reviewer Report 18 Sep 2024

Bryan Vonasek, Michigan State University College of Osteopathic Medicine, East Lansing, Michigan, USA 

Not Approved

VIEWS 0

  • Is the work clearly and accurately presented and does it cite the current literature?

    Partly

  • Is the study design appropriate and is the work technically sound?

    Partly

  • Are sufficient details of methods and analysis provided to allow replication by others?

    No

  • If applicable, is the statistical analysis and its interpretation appropriate?

    Partly

  • Are all the source data underlying the results available to ensure full reproducibility?

    Yes

  • Are the conclusions drawn adequately supported by the results?

    Partly

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Under 5 mortality in Malawi

Close

Reviewer Report 21 Mar 2024

Faisal Elgasim Ahmed, Urology Research Center, Al-Thora General Hospital, Department of Urology, School of Medicine, Ibb University of Medical Sciences, Ibb, Yemen 

Approved with Reservations

VIEWS 0

  • Is the work clearly and accurately presented and does it cite the current literature?

    Partly

  • Is the study design appropriate and is the work technically sound?

    Partly

  • Are sufficient details of methods and analysis provided to allow replication by others?

    Partly

  • If applicable, is the statistical analysis and its interpretation appropriate?

    Partly

  • Are all the source data underlying the results available to ensure full reproducibility?

    Partly

  • Are the conclusions drawn adequately supported by the results?

    Partly

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: I am a urologist. I have worked for 5 years in the field with governmental hospitals in Yemen mainly in the field of surgery and trauma.

Close

Comments on this article Comments (0)

Version 3

VERSION 3 PUBLISHED 29 Aug 2023

Comment

Open Peer Review
Reviewer Status

Alongside their report, reviewers assign a status to the article:

Approved
The paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations
A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved
Fundamental flaws in the paper seriously undermine the findings and conclusions

Reviewer Reports
Invited Reviewers
1 2 3 4 5
Version 3
(revision)
 04 Aug 26 		read
Version 2
(revision)
 07 Jan 25 		read read
Version 1
29 Aug 23 		read read read

  1. Faisal Elgasim Ahmed, Ibb University of Medical Sciences, Ibb, Yemen

  2. Bryan Vonasek, Michigan State University College of Osteopathic Medicine, East Lansing, USA

  3. Sumathi Swaminathan, St John's Research Institute, Bengaluru, India

  4. Alden Blair, University of California San Francisco, San Francisco, USA

  5. Kimberly Baltzell, University of California San Francisco, San Francisco, USA

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