Limb fractures are a major source of morbidity in traumatology in Africa. In resource-constrained countries, patients and their families often face difficult choices between modern hospital care and local traditional practices, which are less expensive and geographically more accessible, sometimes leading to trips against medical advice. OAMA compromises the implementation of prescribed treatments and exposes patients to the risk of anatomical and functional complications.

At CHUD-Borgou, Parakou, OAMA, in traumatized patients with limb fractures, it is common. The objective of this study is to identify the determinants of OAMA for member fractures and the associated decision-making profile in order to guide preventive and organizational actions adapted to the local context.

We conducted an observational, descriptive study with prospective and retrospective data collection in the emergency and surgery departments of CHUD-Borgou, located at Parakou in the north of Benin, during the period from January 1^st to September 30^th. It exhaustively covers patients admitted for limb fracture requiring care (surgical = osteosynthesis or external fixator or orthopedic = functional or reduction with plaster).

We consecutively included all the patients described above who were subsequently discharged against medical advice, after having consciously (after informed explanations about the risks involved) signed the refusal of care form in force at our establishment. Parents or guardians have signed these forms for patients who are minors or physically incompetent.

Victims of broken limbs who had finished care with us, those who refused to participate in the study, those lost to follow-up, and the deceased were excluded.

The collection was done in two stages through a standardized survey form including the variables studied (socio-demographic variables, fracture characteristics, proposed and received treatment, SCAM decision-maker, reason for exit...). Part of the collection was carried out during the victim’s hospitalization, and the second part took place away from the medical release against advice (a minimum of 3 months), either at home, on the phone, or at the traditional healer’s for some. The latest control radiographs were funded by the hospital to assess consolidation. The protocol was approved by the local ethics committee, and informed patient consent was obtained.

The data were entered using Epi Data 3.1, and the analysis was done with Stata 17.0. Categorical variables are reported in numbers and percentages; the continuous variables are reported as mean ± standard deviation or median and extreme values. They were considered significant for p = 0.05.

During the study period, 2921 patients were admitted to the emergency room and surgery; Among them, 230 were for limb fractures, a proportion of 7.87%. Of the 230 patients with limb fractures, 60 were discharged against medical advice, 59 of whom met the inclusion criteria and were selected for analysis, resulting in a prevalence of SCAM for limb fractures of 25.65%.

The mean age of patients was 30.55 years ± 17.39 years (3 and 85 years), with the majority concentrated in the 30 - 45 age group. The majority of patients were male, with a sex ratio of 3.91.

Only 6% of our sample had health insurance. More than half of the patients were not enrolled in school. Regarding patient employment, farmers predominated at 27%, followed by artisans, while 45.77% of patients reported a monthly income between 30,000 and 60,000 FCFA, or (46 and 91€), and 15.25% earned less than 30,000 FCFA per month (€46/month). These elements are detailed in Tables 1-3.

Table 1.Age and sex distribution (N = 59).

Table 2. Occupation/job, educational attainment, and place of residence (N = 59).

Table 3.Monthly income.

We noted 39 (66.10%) closed fractures compared to 20 (38.90%) open ones. They were caused by road accidents in 86.44% of cases. The pelvic limb and pelvic girdle were affected in 73% of cases.

Surgical treatment was the most frequently proposed, in 73% of cases compared to 27% for orthopedic treatment (Table 4).

Table 4.Scheduled treatment (N = 59).

In 74.58% of cases, the OAMA decision was made by a parent; among these decision-making parents, 88.64% were male.

The reasons for OAMA are dominated by the preference for traditional treatments, followed by a lack of financial resources and the geographical inaccessibility of patients. Table 5 outlines the different reasons, which may be multiple for the same patient.

Table 5. Decision-maker and reasons for CMMS (N = 59).

*Note: several patients cited several reasons (main and secondary reasons).

The high prevalence of 26.65% is in agreement with the study of Hodonou et al. (25.85%) [1] and that of Hodabalo et al. (28.3%) [2], which shows the persistence of this very worrying phenomenon not only in northern Benin but also in neighboring countries.

The rate of patients with health insurance was low, at 6.78%. Hodabalo et al. reported a higher rate (23.4%), and this was because there were more employees in their sample [1][2]. The patient or his/her parents are then called to bear the entire burden of care in most cases.

The predominance of closed fractures has been observed not only in our study but also by other authors, such as Sawadogo et al. [3], who reported 64% in 2022, and Hodonou et al., who reported 81% in 2017 at the same center. These closed fractures would encourage more OAMA since they have a minimal risk of infection. Patients with diaphyseal fractures were also common, which is consistent with the study by Kouassi et al. [4]. Indeed, it would seem that diaphyseal fractures appear to be more anatomically accessible and easier to immobilize by bond makers due to the means of restraint they use.

The preference for traditional treatments and the lack of financial resources were the main reasons for the OAMA in our series, whereas the study by Yao etal. [5] showed that the lack of financial resources was the main reason. A 2019 study in Niger by Wahab Allassane et al. found that 24% of patients cited trust in traditional treatment as a reason for OAMA [6].

These different results show that the reasons are diverse, but the most common in a developing country like ours remains the lack of financial means and the preference for traditional medicine, supported by its low cost and cultural beliefs.

Strength of the study: With a comprehensive census and community monitoring of patients, this study addresses a key public health issue in some underdeveloped countries, in a context where motorcycle accidents are claiming more and more victims.Study limitations: The sample size is modest, and the study is observational, descriptive, and single-center, based on reported patterns with no control group.

This study highlighted the high frequency of discharges against medical advice.

In northern Benin, these OAMA mostly concern male patients with a low level of education, low and inconsistent income, and without health insurance, who are victims of a closed fracture.

The main reasons identified are a lack of financial resources, the weight of trust in traditional medicine, and the absence of effective public health financing policies.

Working to change the mentality, implement health insurance projects, and improve the dynamization of private health insurance in our underdeveloped countries could help contain the problem.