Relationship between distance of referring facilities and haemoglobin change in children in Malawi

Paediatr Int Child Health. 2021 Nov;41(4):253-261. doi: 10.1080/20469047.2022.2044674. Epub 2022 Mar 1.


Background: Anaemia is a significant cause of mortality in children in sub-Saharan Africa where blood transfusion is often available only at referral hospitals. Understanding the pattern of referrals by health facilities is essential to identify the delays that affect child survival.

Aim: To determine if there was a correlation between change in haemoglobin (Hb) level and distance from referring facilities to Kamuzu Central Hospital (KCH) in Malawi, and whether distance affected mortality rates.

Methods: This was a retrospective cohort study of 2259 children referred to KCH whose Hb was measured at the referring facility or at KCH. Maps were created using ArcGIS® software. The relationship between distance from KCH and change in Hb was assessed by χ2 analysis and multiple linear regression with SAS© software.

Results: The majority of children were referred by health facilities in the Lilongwe District. When categorised as Hb <4, 4-6 or >6 g/dL, 87.0% of children remained in the same category during transfer. There was no significant relationship between Hb drop and distance from KCH. Distance from KCH was not a significant predictor of Hb level at KCH or Hb change. However, mortality rates were significantly higher in facilities that were 10-50 km from KCH than in those which were <10 km away.

Conclusions: Using distance as a proxy for time, this suggests that referring facilities are transferring children sufficiently quickly to avert significant reductions in Hb. Despite this, there is a need to identify the factors that influence the decision to transfer anaemic children.

Keywords: Anaemia; international health; public health; sub-Saharan Africa.

MeSH terms

  • Anemia* / epidemiology
  • Blood Transfusion
  • Child
  • Hemoglobins*
  • Humans
  • Malawi / epidemiology
  • Retrospective Studies


  • Hemoglobins