The economic burden of preterm/very low birth weight care in Nigeria

Costs and cost-effectiveness of treatment setting for children with wasting, oedema and growth failure/faltering: A systematic review

This systematic review aimed to address the existing evidence gaps, and guide policy decisions on the settings within which to treat infants <12 months of age with growth faltering/failure, and infants and children aged <60 months with moderate wasting or severe wasting and/or bilateral pitting oedema. Twelve electronic databases were searched for studies published before 10 December 2021. The searches yielded 16,709 records from which 31 studies were eligible and included in the review. Three studies were judged as low quality, whilst 14 were moderate and the remaining 14 were high quality. We identified very few cost and cost-effectiveness analyses for most of the models of care with the certainty of evidence being judged at very low or low. However, there were 17 cost and 6 cost-effectiveness analyses for the initiation of treatment in outpatient settings for severe wasting and/or bilateral pitting oedema in infants and children <60 months of age. From this evidence, the costs appear lowest for initiating treatment in community settings, followed by initiating treatment in community and transferring to outpatient settings, initiating treatment in outpatients then transferring to community settings, initiating treatment in outpatient settings, and lastly initiating treatment in inpatient settings. In addition, the evidence suggested that initiation of treatment in outpatient settings is highly cost-effective when compared to doing nothing or no programme implementation scenarios, using country-specific WHO GDP per capita thresholds. The incremental cost-effectiveness ratios ranged from $20 to $145 per DALY averted from a provider perspective, and $68 to $161 per DALY averted from a societal perspective. However, the certainty of the evidence was judged as moderate because of comparisons to do nothing/ no programme scenarios which potentially limits the applicability of the evidence in real-world settings. There is therefore a need for evidence that compare the different available alternatives.

A Comparative Cross-sectional Study on Prevalence of Low Birth Weight and its Anticipated Risk Factors

Objective. This study aims to highlight the low birth weight (LBW) in Taiz City (Yemen), as LBW is one of the public health challenges experiencing a profound effect on newborns. Methods. This was a cross-sectional study since the interview and medical records were the sources of data to be analyzed by SPSS. Results. The findings of this study include; a high prevalence of LBW (39.11%), the maternal age was not associated with LBW (P = .68), and education level, economic status, residence place, and health status were not associated with LBW (P < .05). Although the pre-pregnancy BMI, during-pregnancy BMI, MUAC, and gestational age were significantly associated with LBW (P < .05), the only risk factor was gestational age (OR = 9.606, CI = 3.988-23.135, P = .00). Conclusion. LBW is highly prevalent in Taiz (Yemen), so providing good healthcare services is essential to manage LBW incidence.

"I abandoned my job to look after my baby." Understanding the unpriced cost of care of a preterm infant: Caregivers' lived experiences

BACKGROUND

Preterm birth is associated with life-long cost implications on the infant, family, health system, and society at large. The costs related to lost productivity at contributions at work during care of preterm infants are difficult to measure. We aimed to explore and document the unpriced costs parents incur following birth of a preterm infant in the first year of life in a low resource setting.

METHODS

Thirty-nine mothers and five fathers of preterm infants who had ever attended the preterm follow-up clinic after discharge from Mulago National Referral Hospital, were included in a qualitative study between November 2019 and February 2020. Participants were purposively selected, and data were collected using four focused group discussions with mothers and in-depth interviews with the fathers lasting 30-70 minutes each. These were audio-recorded, transcribed and translated. The data were manually analysed using the thematic approach.

FINDINGS

Three themes were generated: i) complex nature of the infant, ii) time to care for the infant, iii) mother as the predominant caregiver. The parents perceived preterm infants as delicate, complicated and their care more costly compared to those born at term. Expressions of need for time to care for their infants, frequent hospital visits and readmission were raised. Availability of the mother as the predominant caregiver some of whose roles cannot be delegated and their experiences following return to work after birth of a preterm were cited by the participants.

CONCLUSION

The results highlight the unpriced costs incurred by the parents through disruption of the work pattern due to the actual and perceived needs of a preterm infant and time to care in a low resource setting. We recommend guidance on financial planning, development of policies and programs on social and financial support for parents and future studies on indirect costs of preterm care.

Households Health Care Financing Methods: Social Status Differences, Economic Implications and Clinical Outcomes Among Patients Admitted in a Pediatric Emergency Unit of a Tertiary Hospital in South West Nigeria

Background. The affordability of health care services by households within a country is determined by the health care financing methods used by her citizens. In accordance with World Health Organization (WHO), health services must be delivered equitably and without imposing financial hardship on the citizens. Aim. This study aimed to determine the pattern of households health care financing method and relate it to the social-background, economic implication and clinical outcome of care in pediatric emergency situations. Method: It is a cross-sectional descriptive study. Result. 210 children from different households were recruited. Majority (75.9%) of the children were aged 0 to 5 years, males (61.2%) and belonged to the low socio-economic status (95.7%). The overall median (IQR) cost of care, income and percentage of income spent on care were ₦10 700 (₦7580-₦19 700), ₦ 65000(₦38000-₦110 000) and 17.6% (7.1%-39.7%) respectively. Though 70 (34.8%) of the respondents were aware of health insurance scheme, only 12.8% were enrolled. There were significant differences in the households' health care financing methods with respect to the socioeconomic status (P = .010), paternal level of education (P < .001), maternal occupation (P = .020), paternal occupation (P = .030) and distribution of income (P < .001). Catastrophic spending was experienced by 67.4% of the household, all of whom paid via out-of-pocket payment (OOPP) (P < .001), catastrophic health spending (CHS) was significantly associated with death and discharge against medical advice (DAMA) (P = .023). All cases of mortality and 93% cases of DAMA occurred with paying out of pocket (OOP) (P = .168). Conclusion. health care services were majorly paid for OOP among households in this study and CHS are high among these households. Clinical and financial outcomes were worse when health care services were paid through OOP.

Association between indoor residual spraying and pregnancy outcomes: a quasi-experimental study from Uganda

BACKGROUND

Malaria is a risk factor for adverse pregnancy outcomes. Indoor residual spraying with insecticide (IRS) reduces malaria infections, yet the effects of IRS on pregnancy outcomes are not well established. We evaluated the impact of a large-scale IRS campaign on pregnancy outcomes in Eastern Uganda.

METHODS

Birth records (n = 59 992) were obtained from routine surveillance data at 25 health facilities from five districts that were part of the IRS campaign and six neighbouring control districts ∼27 months before and ∼24 months after the start of the campaign (January 2013-May 2017). Campaign effects on low birthweight (LBW) and stillbirth incidence were estimated using the matrix completion method (MC-NNM), a machine-learning approach to estimating potential outcomes, and compared with the difference-in-differences (DiD) estimator. Subgroup analyses were conducted by HIV and gravidity.

RESULTS

MC-NNM estimates indicated that the campaign was associated with a 33% reduction in LBW incidence: incidence rate ratio (IRR) = 0.67 [95% confidence interval (CI): 0.49-0.93)]. DiD estimates were similar to MC-NNM [IRR = 0.69 (0.47-1.01)], despite a parallel trends violation during the pre-IRS period. The campaign was not associated with substantial reductions in stillbirth incidence [IRRMC-NNM = 0.94 (0.50-1.77)]. HIV status modified the effects of the IRS campaign on LBW [βIRSxHIV = 0.42 (0.05-0.78)], whereby HIV-negative women appeared to benefit from the campaign [IRR = 0.70 (0.61-0.81)], but not HIV-positive women [IRR = 1.12 (0.59-2.12)].

CONCLUSIONS

Our results support the effectiveness of the campaign in Eastern Uganda based on its benefit to LBW prevention, though HIV-positive women may require additional interventions. The IRS campaign was not associated with a substantively lower stillbirth incidence, warranting further research.

Evaluating the medical direct costs associated with prematurity during the initial hospitalization in Rwanda: a prevalence based cost of illness study

Background

Prematurity is still the leading cause of global neonatal mortality, Rwanda included, even though advanced medical technology has improved survival. Initial hospitalization of premature babies (PBs) is associated with high costs which have an impact on Rwanda’s health budget. In Rwanda, these costs are not known, while knowing them would allow better planning, hence the purpose and motivation for this research.

Methods

This was a prospective cost of illness study using a prevalence approach conducted in 5 hospitals (University Teaching Hospital of Butare, Gisenyi, Masaka, Muhima, and Ruhengeri). It included PBs admitted from June to July 2021 followed up prospectively to determine the medical direct costs (MDC) by enumerating the cost of all inputs. Descriptive analyses and ordinary least squares regression were used to illustrate factors associated with and predictive of mean cost. The significance level was set at p < 0.05.

Results

A total of 123 PBs were included. Very preterm and moderate PBs were 36.6% and 23.6% respectively and the average birth weight (BW) was 1724 g (SD: 408.1 g). The overall mean MDC was $237.7 per PB (SD: $294.9) representing 28% of Gross Domestic Product (GDP) per capita per year. Costs per PB varied with weight category, prematurity degree, hospital level, and length of stay (LoS) among other variables. MDC was dominated by drugs and supplies (65%) with oxygen being an influential driver of MDC accounting for 38.4% of total MDC. Birth weight, oxygen therapy, and hospital level were significant MDC predictive factors.

Conclusion

This study provides an in-depth understanding of MDC of initial hospitalization of PBs in Rwanda. It also indicates predictive factors, including birth weight, which can be managed through measures to prevent or delay preterm birth.

Implication for prematurity prevention and management

The results suggest a need to revise the benefits and entitlements of insured people to include drugs and interventions not covered that are essential and where there are no alternatives. Having oxygen plants in hospitals may reduce oxygen-related costs. Furthermore, interventions to reduce prematurity should be evaluated using cost-effectiveness analysis since its overall burden is high.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08283-w.

An economic analysis of the cost of survival of micro preemies: A systematic review

OBJECTIVE

This study aimed to systematically review the current literature on the economic costs of micro preemie as well as evidence on the cost-effectiveness of interventions to improve outcomes for micro preemie babies with a birth weight of ≤500 g.

METHOD

We searched MEDLINE, CINAHL, Scopus, ECONLIT, Business Source Premier and Cochrane Library for studies reporting costs of micro preemie from January 2000. Costs were inflated to 2019 United States dollars (US$). All full-text articles were assessed for eligibility and a quality assessment of included articles was conducted using the Drummond and the Larg and Moss checklists.

RESULTS

The search identified three studies that met the inclusion criteria; two cost-of-illness studies and one cost-effectiveness study. Across studies, the mean healthcare spending per micro preemie survivor (in 2019 US$) ranged from US$61,310 (birth admission) to US$263,958 (inpatient and outpatient for the first six months of life). One modelling study reported exclusive human milk diet for micro preemies at birth was more cost-effective compared to the standard approach with cow milk diet from the third-party payer and societal perspectives.

CONCLUSION

Despite significant advances in perinatal care and expanded access to life-saving equipment to improve survival outcomes of micro preemie, there remains a paucity of research on economic costs associated with these babies. No study has utilised quality-adjusted life-years as an outcome measure. Given the chronic conditions and long-term neurologic disability associated with micro preemie survivors, an estimate of the lifetime cost to the individual, healthcare providers and society would provide a benchmark of the potential cost-savings that could accrue from cost-effective interventions to improve the survival rate of micro preemies.

Incidence of Catastrophic Health Expenditures Amongst Hospitalized Neonates in Ekiti, Southwest Nigeria

Background

Neonatal illnesses require huge spending due to prolonged hospital stay. The management of these illnesses is usually financed by individual families which in most instances are living below the poverty line. This healthcare financing method can readily push families into catastrophic spending on health.

Aim

To ascertain the average cost of managing common neonatal illnesses and the financial burden, it constitutes to families in Ekiti State, southwest Nigeria.

Methods

We conducted a cross-sectional study on the out-of-pocket spending involved in managing neonates admitted into and discharged from the SCBU of the Ekiti State University Teaching Hospital, Ado-Ekiti, southwest Nigeria. Data collected included the monthly family income, the money spent on drugs, laboratory investigations and the hospital bill using a purposely designed structured questionnaire. Healthcare spending greater than 10% of the overall family income was described as catastrophic health spending (CHS).

Results

The medical bills for most (95%) of the 119 study participants were paid through the out-of-pocket means and 81.5% of the families spent more than 10% of their monthly earnings (CHS) to settle medical bills. Close to 50% of the families belonged to the lower social economic class. The median (IQR) duration of hospital stay was 2.75 days (3.0–8.0). The median (IQR) total expenditure was N24,500.00 (N13,615.00–N41,487.50). The median (IQR) expenditure for the treatment of prematurity was highest at N55,075.00 (USD 133.10) [N27,350.00 (USD 66.10)–N105,737.50 (USD 255.53)] and more than 60.5% of the expenses was on hospital utilities and consumables. The length of hospital stay showed a robust positive correlation with the total hospital bill (r = 0.576, P < 0.001).

Conclusion

Neonatal illnesses put many households at risk of catastrophic health spending. There is need for increased government investment in health and extension of the health insurance scheme to all the citizens of the country.

The financial burden on families of infants requiring neonatal intensive care

While the high costs of neonatal intensive care have been a topic of increasing study, the financial impact on families have been less frequently reported or summarized. We conducted a systematic review of the literature using Pubmed/Medline and EMBASE (1990-2020) for studies reporting estimates of out-of-pocket costs or qualitative estimates of financial burden on families during a neonatal intensive care unit stay or after discharge. 44 studies met inclusion criteria, with 25 studies providing cost estimates. Cost estimates primarily focused on direct non-medical out-of-pocket costs or loss of productivity, and there was a paucity of cost estimates for insurance cost-sharing. Available estimates suggest these costs are significant to families, cause significant stress, and may impact care received by patients. More high-quality studies estimating the entirety of out-of-pocket costs are needed, and particular attention should be paid to how these costs directly impact the care of our high-risk population.

Preterm Neonatal Mortality and Its Determinants at a Tertiary Hospital in Western Uganda: A Prospective Cohort Study

Background

Prematurity contributes greatly to the neonatal mortality burden in sub-Saharan Africa. This study evaluated the proportion of preterm neonatal death, medical conditions at admission, and determinants of mortality of preterm neonates in the neonatal intensive care unit (NICU) of a tertiary hospital in Western Uganda.

Materials and Methods

A prospective cohort study of 351 consecutively enrolled preterm neonates was conducted from March to June 2019. Interviewer-administered questionnaires and physical assessment of neonates were used to obtain socio-demographic and clinical data for mothers and their preterm neonates. Descriptive statistics for participants’ characteristics were generated, while bivariate and multivariate logistic regression models were fitted so as to establish the determinants of mortality outcome. A p-value <0.05 was considered statistically significant.

Results

In-hospital neonatal mortality of 31.6% (95% CI: 26.9–36.7) was noted, with 65.8% of deaths occurring within 72 hours from admission. The most common medical conditions at admission were: hypothermia (67.2%), respiratory distress syndrome (43.0%), small for gestational age (15.7%), and perinatal asphyxia (14.5%). Under multivariate regression modelling, maternal age ≥35 years (AOR: 4.5; 95% CI: 1.35–15.31), no antenatal care (AOR: 4.7; 95% CI: 1.05–21.21), >4 ANC visits (AOR: 5.3; 95% CI: 1.88–15.21), neonatal resuscitation (AOR: 3.4; 95% CI: 1.66–6.82), outborn status (AOR: 2.3; 95% CI: 1.20–4.50), singleton pregnancy (AOR: 3.7; 95% CI: 1.74–7.89), <28 weeks’ gestation (AOR: 12.0; 95% CI: 2.24–64.27), and male sex (AOR: 2.0; 95% CI: 1.04–3.74), respiratory distress syndrome (AOR: 2.6; 95% CI: 1.22–5.70), apnea (AOR: 6.2; 95.5% CI: 1.09–35.38), hypothermia (AOR: 2.3; 95% CI: 1.09–4.92), and small for gestational age (AOR: 4.7; 95% CI: 2.06–10.74) were significantly associated with mortality.

Conclusion and Recommendations

In-hospital mortality of preterm neonates was high. We identified various maternal and neonatal risk factors, indicating a need for stakeholders to enhance efforts towards prevention of preterm-associated complications and optimize facility-based continuum of care.

Trends in Perinatal Practices and Neonatal Outcomes of Very Low Birth Weight Infants during a 16-year Period at NEOCOSUR Centers

OBJECTIVE

To describe trends in mortality, major morbidity, and perinatal care practices of very low birth weight infants born at NEOCOSUR Neonatal Network centers from January 1, 2001, through December 31, 2016.

STUDY DESIGN

A retrospective analysis of prospectively collected data from all inborn infants with a birthweight of 500-1500 g and 23-35 weeks of gestation.

RESULTS

We examined data for 13 987 very low birth weight infants with a mean birth weight of 1081 ± 281 g and a gestational age of 28.8 ± 2.9 weeks. Overall mortality was 26.8% without significant changes throughout the study period. Decreases in early onset sepsis from 6.3% to 2.8% (P <.001), late onset sepsis from 21.1% to 19.5% (P = .002), retinopathy of prematurity from 21.3% to 13.8% (P <.001), and hydrocephalus from 3.8% to 2.4% (P <.001), were observed. The incidence for bronchopulmonary dysplasia decreased from 17.3% to 16% (P = .043), incidence of severe intraventricular hemorrhage was 10.4%, necrotizing enterocolitis 11.1%, and periventricular leukomalacia 3.8%, and did not change over the study period. Administration of antenatal corticosteroids increased from 70.2% to 82.3% and cesarean delivery from 65.9% to 75.4% (P <.001). The use of conventional mechanical ventilation decreased from 67.7% to 63.9% (P <.001) and continuous positive airway pressure use increased from 41.3% to 64.3% (P <.001). Survival without major morbidity increased from 37.4% to 44.5% over the study period (P <.001).

CONCLUSIONS

Progress in perinatal and neonatal care at network centers was associated with an improvement in survival without major morbidity of very low birth weight infants during a 16-year period. However, overall mortality remained unchanged.

Patient and health system costs of managing pregnancy and birth-related complications in sub-Saharan Africa: a systematic review

BACKGROUND

Morbidity and mortality due to pregnancy and childbearing are high in developing countries. This study aims to estimate patient and health system costs of managing pregnancy and birth-related complications in sub-Saharan Africa.

METHODS

A systematic review of the literature was conducted to identify costing studies published and unpublished, from January 2000 to May 2019. The search was done in Pubmed, EMBASE, Cinahl, and Web of Science databases and grey literature. The study was registered in PROSPERO with registration No. CRD42019119316. All costs were converted to 2018 US dollars using relevant Consumer Price Indices.

RESULTS

Out of 1652 studies identified, 48 fulfilled the inclusion criteria. The included studies were of moderate to high quality. Spontaneous vaginal delivery cost patients and health systems between USD 6-52 and USD 8-73, but cesarean section costs between USD 56-377 and USD 80-562, respectively. Patient and health system costs of abortion range between USD 11-66 and USD 40-298, while post-abortion care costs between USD 21-158 and USD 46-151, respectively. The patient and health system costs for managing a case of eclampsia range between USD 52-231 and USD 123-186, while for maternal hemorrhage they range between USD 65-196 and USD 30-127, respectively. Patient cost for caring low-birth weight babies ranges between USD 38-489 while the health system cost was estimated to be USD 514.

CONCLUSION

This is the first systematic review to compile comprehensive up-to-date patient and health system costs of managing pregnancy and birth-related complications in sub-Saharan Africa. It indicates that these costs are relatively high in this region and that patient costs were largely catastrophic relative to a 10 % of average national per capita income.

Magnitude of low birth weight and maternal risk factors among women who delivered in Debre Tabor Hospital, Amhara Region, Ethiopia: a facility based cross-sectional study

Background

Survival of newborns and long term complications are highly correlated with birth weight. The low birth weight rate is an indicator of a public health problem that includes long-term maternal malnutrition, ill health, and poor health care at population level during pregnancy. On an individual basis, low birth weight is an important predictor of newborn health and survival. We aimed to assess the magnitude of low birth weight and its associated factors among women who delivered in Debre Tabor Hospital (DTH), Amhara, Ethiopia.

Methods

Facility based cross sectional study was employed on 282 mothers who delivered in DTH from December 2018 to March 2019. Single population proportion formula was used to calculate sample size. Data entry was completed in a template prepared in EpiData version 3.1 and analyzed by Statistical Package for Social Sciences (SPSS) version 20. Descriptive statistics were performed to describe the characteristics of the study participants. Crude and adjusted odds ratio with 95% confidence interval were used to identify the significance of association. A p value of < 0.05 was used to decide the significance of the association.

Result

Of a total 282 interviewed mothers who delivered in DTH 12.0% (95%, CI: (8.5, 15.2%)) delivered low birth weight baby. Place of residence (AOR = 0.32, 95%, CI: (0.12, 0.85)), gravidity (AOR = 0.17, 95%, CI: (0.03, 0.97)), status of pregnancy (AOR = 0.29, 95%, CI: (0.09, 0.92)), and hemoglobin levels (AOR = 9.82, 95%, CI: (1.83, 52.73)) were found to be the significant predictors of low birth weight in this study.

Conclusion and recommendation

Place of residence, status of pregnancy, gravidity, and level of hemoglobin were found to be statistically significant with low birth weight. Women who lived in urban areas, who had planned pregnancy, and gravida of < 5 had lower risk of giving low birth weight baby. Whereas, women who had hemoglobin level of < 11 mg/dl were more likely to deliver low birth weight baby. Being a multi-factorial problem, integrated and holistic approach shall be followed to reduce the prevalence, morbidity and mortality related to low birth weight.

Burden, pathology, and costs of malaria in pregnancy: new developments for an old problem

Over the past 10 years, knowledge of the burden, economic costs, and consequences of malaria in pregnancy has improved, and the prevalence of malaria caused by Plasmodium falciparum has declined substantially in some geographical areas. In particular, studies outside of Africa have increased the evidence base of Plasmodium vivax in pregnancy. Rapid diagnostic tests have been poor at detecting malaria in pregnant women, while PCR has shown a high prevalence of low density infection, the clinical importance of which is unknown. Erythrocytes infected with P falciparum that express the surface protein VAR2CSA accumulate in the placenta, and VAR2CSA is an important target of protective immunity. Clinical trials for a VAR2CSA vaccine are ongoing, but sequence variation needs to be carefully studied. Health system and household costs still limit access to prevention and treatment services. Within the context of malaria elimination, pregnant women could be used to monitor malaria transmission. This Series paper summarises recent progress and highlights unresolved issues related to the burden of malaria in pregnancy.

Estimation of economic burden of preterm and premature births in Iran

Background: Tremendous difficulties are imposed on families with preterm and premature babies, both at birth and during their lifetime. The present study aimed at evaluating the potential economic impact of preterm and premature birth in Iran. Methods: In this descriptive cross-sectional study (2014-2015), we studied preterm and premature newborns, who have been subjected to hospitalization in Ali-Asghar hospital. We followed social perspective to estimate the economic consequences of preterm and premature birth in 3 categories of direct medical, direct non-medical, and indirect costs. Required data were collected from documents in the NICU, and studying medical records, and interviewing their parents. Data were analyzed by Microsoft Excel. Results: Direct medical, direct non-medical and indirect affairs were 84%, 6%, and 10% of the total cost, respectively. The estimated social costs were 373, 529, 189; 508, 774, 181; and 529, 481, 996 US dollars (according to their corresponding incidence of 5.8%, 7.9%, and 9.9%). We also found that 75% of the direct medical costs of initial hospitalization were due to intensive care beds. Conclusion: The economic burden of preterm and premature birth in Iran is considerable and to decrease the costs, it is necessary to implement preventive programs for preterm and premature newborns and to provide management care and support for families dealing with this problem.

Very low birth weight is associated with brain structure abnormalities and cognitive function impairments: A systematic review

Very low birth weight (VLBW) children are at risk of structural brain abnormalities and neurocognitive deficits. Since survival rate of the very low birth weight infants has increased over the past decade, a better understanding of the long-term neurocognitive outcomes is needed. The present systematic review investigated the association between VLBW and cognitive function as well as brain structure. PubMed/Medline, Google Scholar, Scopus and Web of Science databases were searched up from January 2000 to January 2015. The study was restricted to the articles that were about VLBW and its association with cognitive function and brain structure. The initial search yielded 721 articles. There were 44 studies eligible for inclusion after applying the exclusion criteria: 24 follow-up, 14 cohort, and 6 longitudinal studies. Based on this systematic review, we suggest that VLBW is positively related to several cognitive problems and brain structure abnormalities. These findings provide evidence about the importance of early assessment of cognitive development and brain structure to identify at-risk children and provide their specific requirements as early as possible.

Cost-Effectiveness of Pre-exposure HIV Prophylaxis During Pregnancy and Breastfeeding in Sub-Saharan Africa

INTRODUCTION

Antiretroviral pre-exposure prophylaxis (PrEP) for the prevention of HIV acquisition is cost-effective when delivered to those at substantial risk. Despite a high incidence of HIV infection among pregnant and breastfeeding women in sub-Saharan Africa (SSA), a theoretical increased risk of preterm birth on PrEP could outweigh the HIV prevention benefit.

METHODS

We developed a decision analytic model to evaluate a strategy of daily oral PrEP during pregnancy and breastfeeding in SSA. We approached the analysis from a health care system perspective across a lifetime time horizon. Model inputs were derived from existing literature and local sources. The incremental cost-effectiveness ratio (ICER) of PrEP versus no PrEP was calculated in 2015 U.S. dollars per disability-adjusted life year (DALY) averted. We evaluated the effect of uncertainty in baseline estimates through one-way and probabilistic sensitivity analyses.

RESULTS

PrEP administered to pregnant and breastfeeding women in SSA was cost-effective. In a base case of 10,000 women, the administration of PrEP averted 381 HIV infections but resulted in 779 more preterm births. PrEP was more costly per person ($450 versus $117), but resulted in fewer disability-adjusted life years (DALYs) (3.15 versus 3.49). The incremental cost-effectiveness ratio of $965/DALY averted was below the recommended regional threshold for cost-effectiveness of $6462/DALY. Probabilistic sensitivity analyses demonstrated robustness of the model.

CONCLUSIONS

Providing PrEP to pregnant and breastfeeding women in SSA is likely cost-effective, although more data are needed about adherence and safety. For populations at high risk of HIV acquisition, PrEP may be considered as part of a broader combination HIV prevention strategy.

The financial burden of sickle cell disease on households in Ekiti, Southwest Nigeria

Background

Studies on economic impact of sickle cell disease (SCD) are scanty despite its being common among children in developing countries who are mostly Africans.

Objective

To determine the financial burden of SCD on households in Ado Ekiti, Southwest Nigeria.

Methods

A longitudinal and descriptive study of household expenditures on care of 111 children with SCD managed at the pediatric hematology unit of the Ekiti State University Teaching Hospital was conducted between January and December 2014.

Results

There were 64 male and 47 female children involved, aged between 15 and 180 months. They were from 111 households, out of which only eight (7.2%) were enrolled under the National Health Insurance Scheme. The number of admissions and outpatients’ consultations ranged from 1 to 5 and 1 to 10 per child, respectively. Malaria, vaso-occlusive crisis, and severe anemia were the leading comorbidities. The monthly household income ranged between ₦12,500 and ₦330,000 (US$76 and US$2,000) with a median of ₦55,000 (US$333), and health expenditure ranged between ₦2,500 and ₦215,000 (US$15 and US$1,303) with a mean of ₦39,554±35,479 (US$240±215). Parents of 63 children lost between 1 and 48 working days due to their children’s ill health. Parents of 23 children took loans ranging between ₦6,500 and ₦150,000 (US$39 and US$909) to offset hospital bills. The percentage of family income spent as health expenditure on each child ranged from 0.38 to 34.4. Catastrophic health expenditure (when the health expenditure >10% of family income) occurred in 23 (20.7%) households. Parents who took loan to offset hospital bills, low social class, and patients who took ill during the study period significantly had higher odds for catastrophic health expenditure (95% confidence interval [CI] 5.399–87.176, P=0.000; 95% CI 2.322–47.310, P=0.002; and 95% CI 1.128–29.694, P=0.035, respectively).

Conclusion

SCD poses enormous financial burden on parents and households.

Targeted health department expenditures benefit birth outcomes at the county level

BACKGROUND

Public health leaders lack evidence for making decisions about the optimal allocation of resources across local health department (LHD) services, even as limited funding has forced cuts to public health services while local needs grow. A lack of data has also limited examination of the outcomes of targeted LHD investments in specific service areas.

PURPOSE

This study used unique, detailed LHD expenditure data gathered from state health departments to examine the influence of maternal and child health (MCH) service investments by LHDs on health outcomes.

METHODS

A multivariate panel time-series design was used in 2013 to estimate ecologic relationships between 2000-2010 LHD expenditures on MCH and county-level rates of low birth weight and infant mortality. The unit of analysis was 102 LHD jurisdictions in Washington and Florida.

RESULTS

Results indicate that LHD expenditures on MCH services have a beneficial relationship with county-level low birth weight rates, particularly in counties with high concentrations of poverty. This relationship is stronger for more targeted expenditure categories, with expenditures in each of the three specific examined MCH service areas demonstrating the strongest effects.

CONCLUSIONS

Findings indicate that specific LHD investments in MCH have an important effect on related health outcomes for populations in poverty and likely help reduce the costly burden of poor birth outcomes for families and communities. These findings underscore the importance of monitoring the impact of these evolving investments and ensuring that targeted, beneficial investments are not lost but expanded upon across care delivery systems.

Out-of-pocket cost of managing sick newborns in Enugu, southeast Nigeria

Background

Neonatal illnesses usually require long hospital stays and specialized care and/or facilities, which usually results in huge medical bills. With more than 70% of people in Nigeria living on less than US$2 per day, these bills are not affordable to many families’ livelihoods.

Aim

This study aims to determine the average cost of managing neonatal illnesses in Enugu in southeast Nigeria and the proportion of family income spent on these illnesses. It further seeks to ascertain the cost of various components in the management of neonatal diseases.

Methods

This is a longitudinal and descriptive study involving 106 newborns admitted to the sick baby unit of the Enugu State University Teaching Hospital and the out-of-pocket medical expenditure in the management of their illnesses.

Results

A hundred and six newborns participated in the study. All (100%) medical bills were out-of-pocket payments, and 103 (97.2%) of these were catastrophic health expenditure (more than 10% of total family monthly income). The average duration of hospital stay and cost of managing a neonatal illness was 12.86±8.81 days and ₦36,382±19,389.72 (US$223±119), respectively. This expenditure amounted to 157%, 71%, and 25% of total monthly family income for the low, middle, and upper socioeconomic class families, respectively, with a mean percentage of 85%. Families with a total monthly income of less than ₦10,000 (US$61), ₦10,000–49,999 (US$61–306), and ₦50,000–100,000 (US$306–612) and more than ₦100,000 (US$612) on average spent 683%, 108%, 54%, and 20% of their monthly income on their newborn’s illness. Hospital and utility bills compared with bills accruing from drug and laboratory investigations account for a significantly larger proportion of total cost incurred in neonatal sepsis (₦23,499±14,987 [US$144±92], P=0.001), low birth weight (₦39,863±24,003 [US$224±147], P=0.001), severe anemia (₦40,504±13,923 [US$248±85], P=0.001), transient tachypnea of the newborn (₦10,083±1,078 [US$62±7], P=0.001), birth asphyxia (₦24,398±14,096 [US$149±86], P=0.001), and meningitis (₦26,731±7,675 [US$164±47], P=0.001), whereas cost for laboratory investigations was significantly higher for neonatal jaundice (₦11,690±3,169 [US$72±19], P=0.001). There was a strong positive correlation between duration of hospital stay and total medical cost incurred (r=0.897, P=0.001).

Conclusion

Health expenditure on neonatal illness is high and leads to catastrophic expenditure for the majority of households in the state. There is a need for effective health insurance schemes to help subsidize and cushion this disastrous and impoverishing health expenditure on families for improved neonatal survival in Nigeria.

Prevalence and predictors of hypoxaemia in respiratory and non-respiratory primary diagnoses among emergently ill children at a tertiary hospital in south western Nigeria

BACKGROUND

Hypoxaemia is a potentially harmful complication of both acute lower respiratory tract infections (ALRI) and non-ALRI in children but its contribution to burden and outcomes of hospital admissions in Africa is unclear. We investigated prevalence and predictors of hypoxaemia in ALRI and non-ALRI according to age and primary diagnoses in emergently ill children in south western Nigeria.

METHODS

In 1726 emergently ill children admitted to a tertiary hospital in Ibadan, south western Nigeria, oxygen saturation was measured shortly after admission. Hypoxaemia was defined as oxygen saturation <90%. Clinical features and the primary admission diagnoses were recorded. Prevalence of hypoxaemia according to age and diagnoses was calculated. Symptoms and signs associated with hypoxaemia were compared between children with ALRI and those with non-ALRI.

RESULTS

Hypoxaemia was detected in 28.6% (494/1726) of admissions. Prevalence of hypoxaemia varied in different conditions: it was 49.2% (154/313) in ALRI, 41.1% (188/454) in neonates, 27.2% (6/22) in post-neonatal tetanus, 23.3% (14/60) in sickle cell anaemia, 22.6% (38/168) in septicaemia and 14.4% (76/527) of malaria cases. Nasal flaring (OR 3.86; 95% CI 1.70 to 8.74) and chest retraction (OR 4.77; 95% CI 1.91 to 11.92) predicted hypoxaemia in ALRI but not in non-ALRI.

CONCLUSIONS

Hypoxaemia is common among Nigerian children admitted to an emergency unit and is associated with a poor outcome irrespective of primary admission diagnosis. Provision of equipment to measure oxygen saturation and facilities for effective oxygen delivery might substantially reduce mortality.

Paediatricians' perspectives on global health priorities for newborn care in a developing country: a national survey from Nigeria

BACKGROUND

An understanding of the perception of paediatricians as key stakeholders in child healthcare delivery and the degree of congruence with current investment priorities is crucial in accelerating progress towards the attainment of global targets for child survival and overall health in developing countries. This study therefore elicited the views of paediatricians on current global priorities for newborn health in Nigeria as possible guide for policy makers.

METHODS

Paediatric consultants and residents in the country were surveyed nationally between February and March 2011 using a questionnaire requiring the ranking of nine prominent and other neonatal conditions based separately on hospital admissions, mortality, morbidity and disability as well as based on all health indices in order of importance or disease burden. Responses were analysed with Friedman test and differences between subgroups of respondents with Mann-Whitney U test.

RESULTS

Valid responses were received from 152 (65.8%) of 231 eligible physicians. Preterm birth/low birthweight ranked highest by all measures except for birth asphyxia which ranked highest for disability. Neonatal jaundice ranked next to sepsis by all measures except for disability and above tetanus except mortality. Preterm birth/low birthweight, birth asphyxia, sepsis, jaundice and meningitis ranked highest by composite measures while jaundice had comparable rating with sepsis. Birth trauma was most frequently cited under other unspecified conditions. There were no significant differences in ranking between consultants and residents except for birth asphyxia in relation to hospital admissions and morbidity as well as sepsis and tetanus in relation to mortality.

CONCLUSIONS

Current global priorities for neonatal survival in Nigeria largely accord with paediatricians' views except for neonatal jaundice which is commonly subsumed under "other" or "miscellaneous" neonatal conditions. While the importance of these priority conditions extends beyond mortality thus suggesting the need for a broader conceptualisation of newborn health to reflect the current realities, paediatricians should be actively engaged in advancing the attainment of global priorities for child survival and health in this population.

Costs associated with low birth weight in a rural area of Southern Mozambique

BACKGROUND

Low Birth Weight (LBW) is prevalent in low-income countries. Even though the economic evaluation of interventions to reduce this burden is essential to guide health policies, data on costs associated with LBW are scarce. This study aims to estimate the costs to the health system and to the household and the Disability Adjusted Life Years (DALYs) arising from infant deaths associated with LBW in Southern Mozambique.

METHODS AND FINDINGS

Costs incurred by the households were collected through exit surveys. Health system costs were gathered from data obtained onsite and from published information. DALYs due to death of LBW babies were based on local estimates of prevalence of LBW (12%), very low birth weight (VLBW) (1%) and of case fatality rates compared to non-LBW weight babies [for LBW (12%) and VLBW (80%)]. Costs associated with LBW excess morbidity were calculated on the incremental number of hospital admissions in LBW babies compared to non-LBW weight babies. Direct and indirect household costs for routine health care were 24.12 US$ (CI 95% 21.51; 26.26). An increase in birth weight of 100 grams would lead to a 53% decrease in these costs. Direct and indirect household costs for hospital admissions were 8.50 US$ (CI 95% 6.33; 10.72). Of the 3,322 live births that occurred in one year in the study area, health system costs associated to LBW (routine health care and excess morbidity) and DALYs were 169,957.61 US$ (CI 95% 144,900.00; 195,500.00) and 2,746.06, respectively.

CONCLUSIONS

This first cost evaluation of LBW in a low-income country shows that reducing the prevalence of LBW would translate into important cost savings to the health system and the household. These results are of relevance for similar settings and should serve to promote interventions aimed at improving maternal care.

Utilisation of malaria preventive measures during pregnancy and birth outcomes in Ibadan, Nigeria

Background

Malaria remains a major public health problem in sub Saharan Africa and the extent of utilisation of malaria preventive measures may impact on the burden of malaria in pregnancy. This study sought to determine the association between malaria preventive measures utilized during pregnancy and the birth outcomes of birth weight and preterm delivery.

Methods

This cross sectional survey involved 800 mothers who delivered at the University College Hospital, and Adeoyo Maternity Hospital, Ibadan. Data obtained included obstetric information, gestational age, birth weight and self reported use of malaria prevention strategies in index pregnancy.

Results

Most (95.6%) mothers used one or more malaria control measures. The most commonly used vector control measures were window net (84.0%), insecticide spray (71.5%) and insecticide treated bed nets (20.1%), while chemoprophylactic agents were pyrimethamine (23.5%), Intermittent Preventive Treatments with Sulphadoxine-Pyrimethamine (IPTsp) (18.5%) and intermittent chloroquine (9.5%) and 21.7% used herbal medications. The mean ± SD birthweight and gestational age of the babies were 3.02 kg ± 0.56 and 37.9 weeks ± 2.5 respectively. Preterm delivery rate was 19.4% and 9% had low birth weight.

Comparing babies whose mothers had IPTsp with those who did not, mean birth weight was 3.13 kg ± 0.52 versus 3.0 kg ± 0.56 (p = 0.016) and mean gestational age was 38.5 weeks ± 2.1 versus 37.8 weeks ± 2.5 (p = 0.002).

The non-use of IPTsp was associated with increased risk of having low birth weight babies (AOR: 2.27, 95% CI: 0.98; 5.28) and preterm birth (AOR: 1.93, 95% CI: 1.08, 3.44). The non use of herbal preparations (AOR: 0.55, 95% CI: 0.36, 0.85) was associated with reduced risk of preterm birth. The mean ± SD birth weight and gestational ages of babies born to mothers who slept under ITNs were not significantly different from those who did not (p = 0.07 and 0.09 respectively).

Conclusions

There is a need for improved utilisation of IPTsp as well as discouraging the use of herbal medications in pregnancy in order to reduce pregnancy outcome measures of low birth weight and preterm deliveries in this environment.

Factors associated with psychological morbidity in mothers of pre-term infants: a study from Wesley Guild Hospital, Nigeria

This was a cross-sectional prospective study of 57 mothers of pre-term infants consecutively recruited from the Neonatal Intensive Care Unit (NICU) of Wesley Guild Hospital, Ilesa, Nigeria, between April and August 2009. The mothers were screened for psychological morbidity using the General Health Questionnaire (GHQ-30), and the Hospital Anxiety and Depression Inventory (HADS). More than one-third of these mothers (36.8%), showed high levels of psychological distress on the GHQ30, and 19.3% were cases of depression, whereas 12.3% were cases of anxiety on the HADS. Psychological morbidity and depression were related to both neonatal birth weight and gestational age. There was no association between either maternal age at birth, or parity with maternal depression and psychological morbidity. These results indicate that the detection and effective management of postnatal psychological morbidity in mothers of pre-term infants, should be given priority in the design of maternal and child health services in Nigeria.

The state of health economic evaluation research in Nigeria: a systematic review

This study assessed the state of health economic evaluation (including pharmacoeconomic) research in Nigeria. A literature search was conducted to identify health economic articles pertaining to Nigeria. Two reviewers independently scored each article in the final sample using a data collection form designed for the study. A total of 44 studies investigating a wide variety of diseases were included in the review. These articles were published in 34 different journals, mostly based outside of Nigeria, between 1988 and 2009. On average, each article was written by four authors. Most first authors had medical/clinical affiliations and resided in Nigeria at the time of publication of the study. Based on a 1 to 10 scale, with 10 indicating the highest quality, the mean quality score for all studies was 7.29 (SD 1.21) and 59% of the articles were of fair quality (score 5-7); 5% were of even lower quality. The quality of articles was statistically significantly (p < or = 0.05) related to the country of residence of the primary author (non-Nigeria = higher), country of the journal (non-Nigeria = higher), primary objective of the study (economic analysis = higher) and type of economic analysis conducted (economic evaluations higher than cost studies). The conduct of health economic (including pharmacoeconomic) research in Nigeria was limited and about two-thirds of published articles were of sub-optimal quality. More and better quality health economic research in Nigeria is warranted.