We collected information on 298 neonatal and child deaths of patients who sought care during the illness that led to death, excluding children who were born in a hospital and had a complication there, not leaving the hospital to search for care. Out of these, 252 cases provided full information on the study covariates not related to the mother´s characteristics. Since there were no major variations in cases with or without complete information, results are reported for the sample of children with complete information (n=252), and analyses were replicated for children with additional information about the mother’s characteristics (n=69).
Table 1: Characteristics of sample N=252
|
Neonatesa (n=95)
|
Children (n=157)
|
Total (n=252)
|
Measure
|
N
|
Percent
|
N
|
Percent
|
N
|
Percent
|
Care sought
|
95
|
100%
|
157
|
100%
|
252
|
100%
|
Mother is respondent
|
66
|
69%
|
115
|
73%
|
181
|
72%
|
Male deceased
|
65
|
68%
|
86
|
55%
|
151
|
60%
|
Location of death
|
|
|
|
|
|
|
Hospital deaths
|
88
|
93%
|
127
|
81%
|
215
|
85%
|
En route deaths
|
2
|
2%
|
6
|
4%
|
8
|
3%
|
Home deaths
|
3
|
3%
|
20
|
13%
|
23
|
9%
|
Other health facility deaths
|
1
|
1%
|
2
|
1%
|
3
|
1%
|
Cause of death
|
|
|
|
|
|
|
Perinatal
|
56
|
59%
|
6
|
4%
|
62
|
25%
|
Congenital
|
17
|
18%
|
31
|
20%
|
48
|
19%
|
Otherb
|
22
|
23%
|
120
|
76%
|
142
|
56%
|
Signs and symptomsc
|
|
|
|
|
|
|
Bulging fontanelle
|
0
|
0%
|
11
|
7%
|
11
|
4%
|
Cough
|
0
|
0%
|
47
|
30%
|
47
|
19%
|
Cough severe
|
0
|
0%
|
18
|
11%
|
18
|
7%
|
Lasting cough
|
0
|
0%
|
27
|
17%
|
27
|
11%
|
Diarrhea
|
0
|
0%
|
42
|
27%
|
42
|
17%
|
Die suddenly
|
55
|
58%
|
10
|
6%
|
65
|
26%
|
Fever
|
0
|
0%
|
79
|
50%
|
79
|
31%
|
Fever severe
|
0
|
0%
|
24
|
15%
|
24
|
10%
|
Lasting fever
|
0
|
0%
|
14
|
9%
|
14
|
6%
|
Grunt
|
0
|
0%
|
45
|
29%
|
45
|
18%
|
Lethargic
|
37
|
39%
|
7
|
4%
|
44
|
17%
|
Rash
|
0
|
0%
|
31
|
20%
|
31
|
12%
|
Lasting rash
|
0
|
0%
|
9
|
6%
|
9
|
4%
|
Skin: flaking
|
0
|
0%
|
15
|
10%
|
15
|
6%
|
Skin: red
|
9
|
9%
|
6
|
4%
|
15
|
6%
|
Skin: black
|
0
|
0%
|
13
|
8%
|
13
|
5%
|
a Neonates are classified as under 29 days old and children are classified as 29 days to 5 years.
b For children, the top three “other” causes of death include infectious and parasitic diseases (17%), respiratory diseases (16%), and nervous system diseases (8%).
c Some informants reported several symptoms, so the report of symptoms adds up to more than 100%.
|
General characteristics of the sample are presented in Table 1. A total of 95 patients (37.7%) were neonates, 157 (62.3%) were children under the age of 5, and 138 (59.7%) were male. The mean age at the moment of death was 6.61 days (SD=6.77) for neonates and 11.7 months (SD=13.9) for children. The most common causes of death for neonates were perinatal (59%), and congenital (18%) while the most common causes of death for children were congenital (20%), infectious and parasitic diseases (17%), and respiratory diseases (16%). A total of 215 (85.3%) of the deaths occurred in a hospital, 3 (1.2%) in another health facility or with a doctor, 8 (3.2%) en route to a hospital or other health care center, and 23 (9.1%) in the household or community. The mother was the respondent in 71.8% of cases. The most common symptoms for neonates included sudden death (58%), lethargy (39%), and having red skin (9%). For children, the most common symptoms included fever (50%), cough (30%), grunting (29%), and diarrhea (27%).
Delays in the search for care for all children and for those who first sought care in public or private facilities are presented in Tables 2a and 2b. Among the cases with information on the search for care process (n=252), 154 cases (61.1%) visited more than one facility. Of the complete cases, 199 (79%) visited a public facility first, and 53 (21%) visited a private facility first. On average, children visited 1.88 places to seek care, with this number significantly higher for children who initially visited a private facility (mean=2.58, SD=0.13) rather than a public facility (mean=1.7, SD=0.06). Regarding the first delay (time to start seeking care), the mean time to start seeking care was 98.6 hours, or 4.1 days. It is important to note 143 (56.7%) of respondents reported under one hour for the first delay, but the mean is skewed due to some respondents reporting time up until 60 days. Median measures are presented in Table 2b. In relation to the second delay (time to get to the facility where care was provided), the mean travel time to the first facility where care was sought was 1.41 hours, and the total travel time was 2.9 hours. For the third delay, adding the waiting time in all places visited, children had to wait on average 1.32 hours to receive care. There was a marginally significant difference between children who first sought care at a public versus a private facility, with children who first visited a private facility having higher odds of experiencing any delay.
Table 2a: Means of measure of delay experienced by deceased children in the search for care
Measure
|
Total (n=252)
|
Public first (n=199)
|
Private first (n=53)
|
p-value
|
Delay 1: Time to start seeking care (hours)
|
98.6 (23.08)
|
82.46 (24.25)
|
159.19 (61.04)
|
|
Number of places visited to seek care
|
1.88 (0.06)
|
1.7 (0.06)
|
2.58 (0.13)
|
***
|
Travel distance to first facility (kms)
|
68.78 (48.74)
|
84.42 (62.73)
|
14.73 (10.6)
|
|
Travel time to first facility (hours)
|
1.41 (0.36)
|
1.67 (0.46)
|
0.45 (0.06)
|
|
Travel cost to first facility (MX pesos)
|
176.73 (25.69)
|
195.33 (34.26)
|
134.74 (31.46)
|
|
Total distance traveled for all visits (kms)
|
82.78 (49.04)
|
95.95 (62.61)
|
37.27 (32.3)
|
|
Delay 2: Total travel time for all visits (hours)
|
2.9 (0.48)
|
3.17 (0.61)
|
1.88 (0.27)
|
|
Total travel cost to all facilities (MX pesos)
|
345.7 (48.5)
|
301.42 (52.03)
|
445.66 (104.99)
|
|
Cost of care at first facility (MX pesos)
|
3555 (1865.54)
|
1283.33 (302.99)
|
4139.14 (2340.66)
|
|
Total cost for all visits (MX pesos)
|
6749.32 (2915.49)
|
1350 (328.93)
|
8137.71 (3637.41)
|
|
Delay 3: Wait time at first facility (hours)
|
1.32 (0.29)
|
1.58 (0.36)
|
0.29 (0.08)
|
*
|
*** p<.01, ** p<.05, * p<.1
|
|
|
|
|
Table 2b: Medians of measure of delay experienced by deceased children in the search for care
Measure
|
Total (n=252)
|
Public first (n=199)
|
Private first (n=53)
|
p-value
|
Delay 1: Time to start seeking care (hours)
|
1
|
1
|
3
|
|
Number of places visited to seek care
|
2
|
2
|
2
|
***
|
Travel distance to first facility (kms)
|
6
|
6.5
|
3
|
|
Travel time to first facility (hours)
|
0.5
|
0.5
|
0.33
|
|
Travel cost to first facility (MX pesos)
|
70
|
70
|
70
|
|
Total distance traveled for all visits (kms)
|
12
|
17
|
4
|
|
Delay 2: Total travel time for all visits (hours)
|
1
|
1
|
1.17
|
|
Total travel cost to all facilities (MX pesos)
|
120
|
100
|
150
|
|
Cost of care at first facility (MX pesos)
|
700
|
1000
|
700
|
|
Total cost for all visits (MX pesos)
|
800
|
1000
|
750
|
|
Delay 3: Wait time at first facility (hours)
|
0
|
0
|
0
|
*
|
*** p<.01, ** p<.05, * p<.1
|
|
|
|
|
We then explored the factors associated with the occurrence of each delay. Table 3 presents the odds ratios of presenting the first delay (start search for care) for each covariate, crude and adjusted for all variables in the final model. After adjustment for covariates, children who sought care first in public hospitals had lower odds of presenting this delay, that is, starting the search for care one hour or more after the problem was identified by the mother (adjusted OR=0.38, 95% CI 0.16, 0.86). Children whose caregiver reported coughing, lethargy, or rash as a symptom in the verbal autopsy were more likely to delay the start of searching for care as compared to children whose caregiver did not report these symptoms (adjusted OR=4.38, 95% CI 1.14, 18.06, adjusted OR=2.68, 95% CI 1.20, 6.16, and adjusted OR=5.54, 95% CI 1.71, 21.54, respectively). Contrastingly, children whose caregivers reported grunting as a symptom were less likely to delay the start of the search for care than those whose caregiver did not report this symptom (adjusted OR=0.23, 95% CI 0.08, 0.57).
Table 3. Factors associated with beginning search for care among deceased children under 5, Yucatan, Mexico, 2015–2016
|
First delay (n=252)
|
|
|
Crude OR (95% CI)
|
Adjusted OR (95% CI)a
|
Enrollment in medical insurance
|
|
|
Social security (IMSS or ISSSTE)
|
1.0 (Ref)
|
1.0 (Ref)
|
No insurance
|
1.28 (0.87, 1.89)
|
2.83 (0.43, 24.48)
|
Seguro Popular
|
0.94 (0.82, 1.09)
|
0.85 (0.43, 1.68)
|
Place of death
|
|
|
Private facility
|
1.0 (Ref)
|
1.0 (Ref)
|
Private hospital
|
1.21 (0.88, 1.65)
|
1.12 (0.23, 6.62)
|
Public facility
|
0.94 (0.77, 1.14)
|
0.55 (0.22, 1.36)
|
Public hospital
|
0.80** (0.68, 0.95)
|
0.38** (0.16, 0.86)
|
Age group
|
|
|
Neonate b
|
1.0 (Ref)
|
1.0 (Ref)
|
Child
|
1.21*** (1.06, 1.37)
|
1.53 (0.59, 4.11)
|
Cause of death
|
|
|
CoD other
|
1.0 (Ref)
|
1.0 (Ref)
|
CoD congenital
|
0.88 (0.75, 1.04)
|
0.75 (0.31, 1.73)
|
CoD perinatal
|
0.84** (0.72, 0.97)
|
0.75 (0.31, 1.80)
|
Symptoms reported in verbal autopsy
|
|
|
Bulging fontanelle
|
1.13 (0.83, 1.52)
|
0.76 (0.15, 3.67)
|
Cough
|
1.29*** (1.10, 1.50)
|
4.38** (1.14, 18.06)
|
Cough severe
|
1.14 (0.90, 1.45)
|
0.51 (0.12, 2.16)
|
Lasting cough
|
1.35*** (1.11, 1.65)
|
1.46 (0.33, 6.71)
|
Diarrhea
|
1.25*** (1.06, 1.47)
|
1.78 (0.73, 4.48)
|
Die suddenly
|
0.90 (0.78, 1.03)
|
1.28 (0.57, 2.87)
|
Fever
|
1.24*** (1.09, 1.42)
|
1.61 (0.66, 3.93)
|
Fever severe
|
1.08 (0.87, 1.33)
|
0.60 (0.18, 1.94)
|
Lasting fever
|
1.16 (0.89, 1.52)
|
1.01 (0.23, 4.68)
|
Grunt
|
0.96 (0.82, 1.13)
|
0.23*** (0.08, 0.57)
|
Lethargic
|
1.06 (0.90, 1.24)
|
2.68** (1.20, 6.16)
|
Rash
|
1.42*** (1.19, 1.71)
|
5.54*** (1.71, 21.54)
|
Lasting rash
|
1.27 (0.92, 1.78)
|
0.54 (0.08, 3.80)
|
Skin (flaking, red, or black)
|
1.10 (0.93, 1.30)
|
1.50 (0.66, 3.44)
|
a Adjusted by variables in the table.
b Neonates are classified as under 29 days old and children are classified as 29 days to 5 years.
|
*** p<.01, ** p<.05, * p<.1
|
Table 4 presents the analysis of factors associated with the second delay (transport time). After adjustment for covariates, children who were entitled to Seguro Popular had twice the odds of having a one-hour or longer travel time as compared to children with other forms of medical insurance (adjusted OR=2.31, 95% CI 1.10, 5.00). When analyzing the symptoms reported in the verbal autopsy, children whose caregiver reported cough or a skin condition as a symptom were more likely to have long travel times (adjusted OR=6.02, 95% CI 1.25, 35.77, adjusted OR=2.14, 95% CI 0.89, 5.32 respectively), while children whose caregiver reported lasting cough as a symptom had lower odds of presenting this delay as compared to those who did not report it (adjusted OR=0.15, 95% CI 0.02, 0.78). Children who had to visit two or more facilities to seek care had much higher odds of experiencing this delay compared to children who visited only one facility (adjusted OR=16.13, 95% CI 7.16, 39.48). We also adjusted for cost of transportation; however, due to missing data, this brought the number of complete cases down by over half to n=114. Cases that had higher than the median transportation costs had significantly higher odds of experiencing a travel time of one hour or longer (adjusted OR=4.30, 95% CI 1.19, 17.71).
Table 4. Factors associated with delays in transportation among deceased children under 5, Yucatan, Mexico, 2015–2016
Second delay (n=252)
|
|
Crude OR (95% CI)
|
Adjusted OR (95% CI)a
|
Enrollment in medical insurance
|
|
|
Social security (IMSS or ISSSTE)
|
1.0 (Ref)
|
1.0 (Ref)
|
No insurance
|
1.06 (0.72, 1.57)
|
1.14 (0.14, 8.88)
|
Seguro Popular
|
1.16** (1.00, 1.34)
|
2.31** (1.10, 5.00)
|
Place of death
|
|
|
Private facility
|
1.0 (Ref)
|
1.0 (Ref)
|
Private hospital
|
0.80 (0.58, 1.11)
|
0.65 (0.12, 3.38)
|
Public facility
|
0.87 (0.72, 1.07)
|
0.92 (0.34, 2.44)
|
Public hospital
|
0.82** (0.69, 0.97)
|
1.85 (0.69, 5.09)
|
Age group
|
|
|
Neonateb
|
1.0 (Ref)
|
1.0 (Ref)
|
Child
|
1.01 (0.89, 1.15)
|
0.43 (0.14, 1.26)
|
Cause of death
|
|
|
CoD other
|
1.0 (Ref)
|
1.0 (Ref)
|
CoD congenital
|
1.16* (0.98, 1.36)
|
2.09 (0.82, 5.47)
|
CoD perinatal
|
1.07 (0.92, 1.24)
|
1.69 (0.66, 4.37)
|
Delay
|
|
|
First delay
|
1.08 (0.95, 1.22)
|
0.96 (0.47, 1.97)
|
Number of places visited
|
|
|
One facility
|
1.0 (Ref)
|
1.0 (Ref)
|
Two or more facilities
|
1.60*** (1.43, 1.79)
|
16.13*** (7.16, 39.48)
|
Symptoms reported in verbal autopsy
|
|
|
Bulging fontanelle
|
1.07 (0.79, 1.45)
|
0.74 (0.14, 4.08)
|
Cough
|
1.15* (0.98, 1.35)
|
6.02** (1.25, 35.77)
|
Cough severe
|
1.08 (0.85, 1.38)
|
0.60 (0.11, 3.19)
|
Lasting cough
|
0.96 (0.79, 1.17)
|
0.15** (0.02, 0.78)
|
Diarrhea
|
1.08 (0.92, 1.28)
|
1.69 (0.63, 4.58)
|
Die suddenly
|
0.88* (0.76, 1.01)
|
0.80 (0.34, 1.90)
|
Fever
|
1.08 (0.94, 1.23)
|
1.46 (0.55, 3.92)
|
Fever severe
|
1.07 (0.87, 1.32)
|
0.71 (0.20, 2.46)
|
Lasting fever
|
1.19 (0.91, 1.56)
|
1.81 (0.38, 9.79)
|
Grunt
|
1.22** (1.04, 1.43)
|
1.77 (0.67, 4.82)
|
Lethargic
|
1.00 (0.85, 1.17)
|
0.95 (0.39, 2.33)
|
Rash
|
1.08 (0.89, 1.31)
|
1.36 (0.43, 4.57)
|
Lasting rash
|
0.86 (0.61, 1.20)
|
0.24 (0.03, 1.57)
|
Skin (flaking, red, or black)
|
1.17* (0.99, 1.38)
|
2.14* (0.89, 5.32)
|
a Adjusted by variables in the table.
b Neonates are classified as under 29 days old and children are classified as 29 days to 5 years.
|
*** p<.01, ** p<.05, * p<.1
|
|
|
Factors related to the third delay (waiting times in health facilities) are presented in Table 5. In the final multivariable model, children who first sought care in a public facility or hospital had higher odds of having a wait time as compared to those waiting up to one hour (adjusted OR=4.97, 95% CI 1.83, 14.57, adjusted OR=4.56, 95% CI 1.70, 13.25, respectively). Children reported to have had a bulging fontanelle as a symptom had higher odds of having long waiting times at the health unit (adjusted OR=17.77, 95% CI 2.67, 360.25). Children whose caregiver reported a rash or sudden infant death syndrome as a symptom had lower odds of having this delay (adjusted OR=0.24, 95% CI 0.07, 0.75, and adjusted OR=0.46, 95% CI 0.19, 1.07, respectively). Children who presented the first delay (time to decide to seek care) and visited two or more facilities also had positive odds of presenting the third one (adjusted OR=2.26, 95% CI 1.18, 4.41, adjusted OR=2.79, 95% CI 1.29, 6.15).
Table 5. Factors associated with facility waiting times among deceased children under 5, Yucatan, Mexico, 2015–2016
Third delay (n=252)
|
|
Crude OR (95% CI)
|
Adjusted OR (95% CI)a
|
Enrollment in medical insurance
|
|
|
Social security (IMSS or ISSSTE)
|
1.0 (Ref)
|
1.0 (Ref)
|
No insurance
|
0.82 (0.56, 1.21)
|
0.31 (0.03, 2.44)
|
Seguro Popular
|
0.92 (0.80, 1.06)
|
0.59 (0.29, 1.20)
|
Place of death
|
|
|
Private facility
|
1.0 (Ref)
|
1.0 (Ref)
|
Private hospital
|
1.31 (0.95, 1.79)
|
3.04 (0.61, 15.90)
|
Public facility
|
1.20* (0.99, 1.46)
|
4.97*** (1.83, 14.57)
|
Public hospital
|
1.08 (0.91, 1.29)
|
4.56*** (1.70, 13.25)
|
Age group
|
|
|
Neonateb
|
1.0 (Ref)
|
1.0 (Ref)
|
Child
|
1.22*** (1.07, 1.38)
|
0.71 (0.24, 2.09)
|
Cause of death
|
|
|
CoD other
|
1.0 (Ref)
|
1.0 (Ref)
|
CoD congenital
|
0.88 (0.75, 1.04)
|
0.53 (0.21, 1.25)
|
CoD perinatal
|
0.86** (0.74, 0.99)
|
1.08 (0.42, 2.87)
|
Delays
|
|
|
First delay
|
1.19*** (1.05, 1.34)
|
2.26** (1.18, 4.41)
|
Second delay
|
1.08 (0.95, 1.22)
|
0.90 (0.45, 1.79)
|
Number of places visited
|
|
|
One facility
|
1.0 (Ref)
|
1.0 (Ref)
|
Two or more facilities
|
1.22*** (1.08, 1.38)
|
2.79*** (1.29, 6.15)
|
Symptoms reported in verbal autopsy
|
|
|
Bulging fontanelle
|
1.67*** (1.25, 2.24)
|
17.77** (2.67, 360.25)
|
Cough
|
1.21** (1.04, 1.42)
|
1.77 (0.46, 6.92)
|
Cough severe
|
1.09 (0.86, 1.39)
|
0.44 (0.10, 1.87)
|
Lasting cough
|
1.27** (1.04, 1.54)
|
0.65 (0.15, 2.87)
|
Diarrhea
|
1.24** (1.05, 1.46)
|
1.63 (0.65, 4.15)
|
Die suddenly
|
0.78*** (0.68, 0.89)
|
0.46* (0.19, 1.07)
|
Fever
|
1.32*** (1.16, 1.50)
|
2.05 (0.86, 4.95)
|
Fever severe
|
1.32*** (1.07, 1.62)
|
2.32 (0.75, 7.77)
|
Lasting fever
|
1.37** (1.05, 1.79)
|
2.07 (0.46, 10.26)
|
Grunt
|
1.22** (1.04, 1.43)
|
1.91 (0.76, 4.88)
|
Lethargic
|
0.89 (0.76, 1.04)
|
0.86 (0.34, 2.09)
|
Rash
|
1.08 (0.90, 1.30)
|
0.24** (0.07, 0.75)
|
Lasting rash
|
1.03 (0.74, 1.43)
|
1.10 (0.15, 7.60)
|
Skin (flaking, red, or black)
|
1.00 (0.84, 1.18)
|
0.56 (0.22, 1.35)
|
a Adjusted by variables in the table.
b Neonates are classified as under 29 days old and children are classified as 29 days to 5 years.
|
*** p<.01, ** p<.05, * p<.1
|
|
|
After fitting models adjusting by the wealth index, mother’s education, and mother’s age, results were overall consistent when analyzing the subsample of cases with information about the woman´s characteristics (N=69), with the exception that cases with Seguro Popular were less likely to present the first delay as compared to cases using other forms of insurance (adjusted OR=0.66, 95% CI 0.46, 0.94). When adjusting for socioeconomic characteristics, all variables in the second delay model kept odd ratios estimates in the same direction but became non-significant (maybe due to a reduced sample size), and in the third delay model, cases that experienced a second delay of longer than one-hour travel time had higher odds of experiencing a wait time at the health facility (adjusted OR=1.44, 95% CI 1.06, 1.95). Children who showed symptoms of diarrhea and severe fever had higher odds of experiencing a wait time at the health facility when controlling for socioeconomic characteristics (adjusted OR=1.63, 95% CI 1.05, 2.54, adjusted OR=2.11, 95% CI 1.23, 3.62, respectively).