Understanding the role of parental decision-making and quality of clinical care in under-5 mortality in Western Kenya: an application of the Three Delays model

BACKGROUND: Our objective was to assess the role of delayed healthcare seeking and clinical care among deceased children aged < 5 years enrolled in Child Health and Mortality Prevention Surveillance (CHAMPS) in Western Kenya. METHODS: We conducted a retrospective descriptive analysis of verbal autopsies, health records, and postmortem-determined causes of death determined by an expert panel for decedent children aged < 5 years enrolled in CHAMPS-Kenya (2017-2022). We used the Three Delays framework to describe delays in (1) deciding to seek care, (2) reaching healthcare facilities, and (3) receiving adequate clinical care. Proportions were compared with Chi-square testing. RESULTS: There were 814 enrolled cases in CHAMPS-Kenya and 611 had complete data and were included in our analysis. Nearly all cases (97.9%, n = 598/611) experienced at least one delay. Delayed caregivers' decisions to seek clinical care increased by child's age from 52.0% of < 1-day old deaths (n = 53/102) to 70.9% of child deaths among those aged 12-59 months (n = 83/117, p < 0.001), and were more common in malaria (52/63,82.5%) and malnutrition (51/64,79.7%) deaths than in deaths from other causes. Delays in receiving adequate clinical care were more common (84.9%, n = 519/560) than parental delays in deciding to seek care (58.9%, n = 366). All HIV deaths (31/31, 100.0%) and most malaria deaths (n = 57/63, 90.5%) experienced suboptimal or delayed clinical care. CONCLUSIONS: Nearly all young children who died experienced delays in seeking and receiving adequate clinical care prior to their death. Reducing childhood mortality requires a multi-pronged approach including caregiver education on the detection and response to danger signs, availing a functional referral system, and providing adequate clinical care.