Childhood undernutrition is still a major global health problem, contributing to morbidity, mortality and increased risk of disability [1, 2]. Globally about 25 to 35 million under-five children have Severe Acute Malnutrition (SAM) [3] and 19 million preschool-age children are suffering from severe wasting (4). The African and South-East Asia Region account the highest proportion [3, 4]. A vast majority of children suffering from acute malnutrition (13 million) are found in Sub Saharan Africa; which means 9.4% of all under-five children in the region have acute malnutrition [3]. As evidenced by previous studies, severe acute malnutrition is still a serious problem also in Ethiopia [5-8].

Malnutrition contributes to 50 - 60% of deaths in children globally [4, 5, 9, 10] and severe wasting alone attributed 4.4% of the 7.6 million deaths occurring annually among under 5 children [4, 9]. The risk of death is also nine times higher among Severely Acute Malnourished (SAM) than well-nourished children; severe wasting alone is estimated to account for around 400,000 child deaths each year [2-4]. In Ethiopia, malnutrition contributes to an estimated 270,000 deaths of under-five children each year (6), accounts for 11% of the deaths of under-five children [11] and it constitutes 20% of primary diagnosis in pediatric hospital admissions [12].

Mortality of children during treatment in hospital and health center based stabilization centers is also a major problem in Ethiopia [5-8]. Even though there is an improvement from previous records, the case-fatality rates at some stabilization center are still unacceptably high [5, 7, 8]. In many health facilities, the mortality rate from SAM at present is over the standards cut off point [7]. In different studies, the mortality on therapeutic management ranges from 3.6% in a study conducted in SNNPR to 28.67% in Sekota hospital [7, 13]. Death commonly occurs within the first 48 hours after admission, related to faulty treatment and late admission [8, 13, 14].

Despite the existence of inpatient and outpatient nutrition programs with a common protocol, such higher mortality rate in inpatient units at different health institutions has been attributed to either co-morbidities, poor adherence to the WHO therapeutic guidelines, severity of disease during admission or development of severe complication after admission and delayed diagnosis and treatment initiation [7, 8, 13, 14]. Currently, many children are diagnosed at a later stage of their illness after they developed complication which needs hospital admission and the outcome is commonly poor [7, 14].

To reduce the load of a patient admitted to hospitals and increase access to SAM care, WHO designed a program to manage SAM cases at health center levels since 2000. The program was adopted in different developing countries including Ethiopia. After successful pilot trials in 2000-2002 by Non-governmental organizations, Ethiopia implemented the program since 2003. With this program, service is expanded from hospital-based cares to the Community-Based Therapeutic Care (CTC) approach aimed to ensure access and coverage; which includes Community outreach, Outpatient Treatment Program (OTP), Targeted Supplementary Feeding program (TSF) and Inpatient Treatment [5].

However, since its implementation in Ethiopia, the treatment outcome of health center-based care was not assessed in relation to the existing hospital-based management. Therefore, this study comparatively assessed the treatment outcome in terms of survival time, cure rate, mortality rate, and default rate, length of stay, weight gain and identified possible predictors of mortality. The finding will have a higher contribution to health care providers, planners and policymakers at large.

The study showed that the cumulative probability of survival at a different time is significantly different at HSC and HCSC with shorter survival at HSC. During the follow-up period, 28(13.86%) children from HSC and 5(2.5%) children from HCSC died. While 155(76.73%) children from HSC and 145(73.23%) children from HCSC got cured, eighteen (4.5%) children being defaulted. Death is significantly higher at the hospital, while default rate and cure rate are not significantly different. Altered pulse rate (Brady/tachycardia), NG tube insertion, anemia and hypoglycemia were found to be independent predictors of death.

Children admitted at HSC and HCSC are significantly different in that, HSC are younger than MUAC <11.5 and non-edematous than HCSC. Children are also more likely to be with complication and altered vital status in HSC than HCSC during admission. This finding was reported in previous studies [7, 14]. The fact that hospital stabilization centers are referral ties for health center SC, more complicated cases are expected to be higher at HSC.

However, unlike other studies, the prevalence of malaria is not significantly different (p.value=0.163) at HCSC and HSC which could be due to the similarity of health facilities in terms of geography and malaria prevalence. As more complicated cases are admitted in HSC, children needed parenteral fluid and medication than HCSC. While the routine medications; Folic acid, Vitamin A and Amoxicillin were significantly highly provided at HCSC.

The cumulative probability of Survival at the end of 1^st, 2^nd and 3^rd week was 97%, 92% and 86%, respectively with the overall mean survival time of 77.5 (95% CI=81-94) day. The mean survival time was also significantly different for HSC and HCSC (Log Rank =7.54, p.value=0.006). The survival of children at HSC is significantly lower than HCSC, which could be due to baseline difference. Similar studies had reported shorter survival at hospital SC [6-8, 14].

This study revealed that 13.86% of children admitted at HSC died during the period of follow up which is higher than the minimum SPHERE standard of 10% mortality [15] and the finding of Jarso et al [14] and Girum et al. [8]. On the other hand, death at HCSC is significantly lower than HSC (p.value <0.001) and other similar studies [7, 14]. Such discrepancy may be due to health status difference during admission, in which hospital admissions have severe complications. However, the finding is not consistent with some other studies [7, 16]; in which, 28.67% and 40.5% of children died. The earlier findings are particularly due to the enrolment of only severe and complicated cases, while the latter is due to high prevalence of HIV. In addition, such discrepancy may result from differences in management and severity.

There is no significant difference in terms of recovery/cure rate and default rate. However, HCSC did not attained the international (SPHERE) standard of cure rate >75%. This could be due to a significant proportion of medical referral, which reduced the proportion of cure. This finding is similar to most national studies in which recovery rate of >75% and default rate of <10% was reported [14, 17]. These similarities could be due to the implementation of identical admission criteria, management protocol, management setting and health care providers.

On the other hand, the average length of stay in the stabilization centers was significantly higher at HSC, however, in both cases, the average length of stay in admission is much lower than the international (SPHERE) standard set for management of severe acute malnutrition which is less than 30 days [15]. In the same way, the average length of stay was lower than the finding of other national studies [7, 14]. But a hospital stay is similar to other hospital-based studies [17]. Generally, the length of stay in HSC is higher due to the underlying medical conditions of children; chronic comorbid conditions like TB that spend a long time in the hospital.

The average weight gain of 8.8 g/kg/day was also in agreement with the minimum international standard set for management of SAM which is an average weight gain of 8 g/kg/day [15] and no difference was observed between health facilities. However, it is lower than a study conducted in similar settings [14] and a study conducted at a community-based treatment setup [16-18] which could be due to the difference in prevalence of grade 3 edema and length of stay.

Adjusting for the effect of other variables, the hazard of death among children who have altered pulse rate was 2.44 times higher than those who have normal pulse rate (AHR=2.44, 95% CI=1.47-4.0, p.value <0.001). This is in line with another study, in which the presence of altered pulse led to the increased risk of death in children [8, 19]. Since, altered pulse rate is a primary indicator of the presence of shock, serious infections, severe dehydration and fluid and electrolyte imbalance higher hazard of death is expected among exposed children.

Those children who feed with NG tube were 1.8 times more likely to die than children who feed per mouth. This could be explained by the fact that NG tube required when the child have altered consciousness, shock or serious infection and failed appetite test and complications like aspiration in part contributes to high mortality. Similarly, the hazard rate of death among children with anemia was 1.53 times higher than their counterparts. Research conducted in Sekota hospital of north Ethiopia, Dilla university referral hospital, JURH of south-west Ethiopia, South Africa and Niger reported the same finding [7, 8, 14, 20, 21]. This is because, during anemia, the prevalence of infection and the probability of heart failure increase and overall compliance will decrease.

Accordingly, the risk of death in children who have hypoglycemia was 1.78 times higher than their Normo-glycemic counterparts. The increased hazard of death in Hypoglycemia among severely malnourished children was also reported by other authors [8, 22], but in contrasts, to this study, a research conducted in Ugandan found no adequate association between hypoglycemia and increased hazard of death [23]. The other variables like type of SAM, DHN, altered pulse rate and administration of parenteral antibiotic failed to show association independently and significantly when other variables were controlled.

The study compared the survival status and treatment outcome of SAM management at HSC and HCSC and identified possible predictors, which is first of its kind, since Health center based stabilization centers were established and used strong model (cox-proportional hazard model) to identify predictors. Admission data was collected before the outcome is known, which reduces bias and is easy to establish temporal relationship since the outcome is death. However, the findings of this study might suffer from the fact that it is retrospective study, records may not be reliable and variables may be missing.