Process and costs for readiness to safely implement immediate kangaroo mother care: a mixed methods evaluation from the OMWaNA trial at five hospitals in Uganda

Abstract

Background: Preterm birth complications result in > 1 million child deaths annually, mostly in low- and middle-income countries. A World Health Organisation (WHO)-led trial in hospitals with intensive care reported reduced mortality within 28 days among newborns weighing 1000-1799 g who received immediate kangaroo mother care (iKMC) compared to those who received standard care. Evidence is needed regarding the process and costs of implementing iKMC, particularly in non-intensive care settings.

Methods: We describe actions undertaken to implement iKMC, estimate financial and economic costs of essential resources and infrastructure improvements, and assess readiness for newborn care after these improvements at five Ugandan hospitals participating in the OMWaNA trial. We estimated costs from a health service provider perspective and explored cost drivers and cost variation across hospitals. We assessed readiness to deliver small and sick newborn care (WHO level-2) using a tool developed by Newborn Essential Solutions and Technologies and the United Nations Children's Fund.

Results: Following the addition of space to accommodate beds for iKMC, floor space in the neonatal units ranged from 58 m² to 212 m². Costs of improvements were lowest at the national referral hospital (financial: $31,354; economic: $45,051; 2020 USD) and varied across the four smaller hospitals (financial: $68,330-$95,796; economic: $99,430-$113,881). In a standardised 20-bed neonatal unit offering a level of care comparable to the four smaller hospitals, the total financial cost could be in the range of $70,000 to $80,000 if an existing space could be repurposed or remodelled, or $95,000 if a new unit needed to be constructed. Even after improvements, the facility assessments demonstrated broad variability in laboratory and pharmacy capacity as well as the availability of essential equipment and supplies.

Conclusions: These five Ugandan hospitals required substantial resource inputs to allow safe implementation of iKMC. Before widespread scale-up of iKMC, the affordability and efficiency of this investment must be assessed, considering variation in costs across hospitals and levels of care. These findings should help inform planning and budgeting as well as decisions about if, where, and how to implement iKMC, particularly in settings where space, devices, and specialised staff for newborn care are unavailable.

Trial registration: ClinicalTrials.gov, NCT02811432 . Registered: 23 June 2016.

Keywords: Implementation; Intervention costs; Kangaroo mother care; Low birthweight; Newborn care; Preterm; Service readiness.

Fig. 1

Inpatient care for small and sick newborns: WHO standards by level of care. HIV = human immunodeficiency virus. ^*Including drying, skin-to-skin contact with the mother, delayed cord clamping, and hygienic cord care. ^{^}Including Vitamin K, eye care, vaccinations, weighing, and clinical examinations. ^†Including bacterial infections, jaundice, diarrhoea, feeding problems, birth defects, and other problems. ^‡Hospitals providing special care should introduce these interventions before upgrading to intensive care. Figure adapted from ‘Survive and Thrive: Transforming care for every small and sick newborn’ (2019) [8]

Fig. 2

Key drivers of economic costs of improvements at the five Ugandan hospitals. The upper panel shows drivers of total economic costs, and the lower panel shows drivers of annualised economic costs

Fig. 3

Total financial costs of improvements vs. the number of neonatal beds at the five Ugandan hospitals

Fig. 4

Hospital readiness to deliver neonatal care: baseline assessments after renovation of five Ugandan hospitals. Bar data indicate the number of hospitals (range: 0–5); bar colour indicates the type of facility: national referral hospital (blue); regional referral hospital (maroon); district hospital (lavender). CPAP = continuous positive airway pressure. CSF = cerebrospinal fluid. ^*Any power outage (from grid or backup source) more than 30 min in the last 7 days. ^{^}Any stockout of pharmaceutical product in the last 3 months. ^†Data missing for Hospital-3, a regional referral facility. Images depicted in figure taken from ‘Implementation Toolkit: Small and sick newborn care’ (2022) [32], and ‘NEST360 Health Facility Assessment Summary Feedback Report’ (unpublished observations; Rebecca Penzias, Christine Bohne, Joy Lawn)