To compare cost effectiveness of ‘Kangaroo Ward Care’ with ‘Intermediate intensive care’ in stable very low birth weight infants (birth weight < 1100 grams): a randomized control trial

Each year about 20 million infants of low birth weight (LBW) are born around the globe, which imposes a heavy burden on health care and social system in developing countries. Medical care of LBW and very low birth weight (VLBW) infants is complex, demands an expensive infrastructure and highly skilled staff. The care of LBW and VLBW is usually a very disruptive experience for families. The financial burden for managing these LBW and VLBW is huge for developing countries like India and finding a cheap and cost effective intervention is an always ongoing research in these countries [1]. KMC has shown to be the most feasible, readily available, and preferred intervention for decreasing neonatal morbidity and mortality in developing countries especially for LBW infants [2]. It is a powerful, easy-to-use method to promote the health and well-being of infants born preterm as well as full-term and in decreasing the burden on health care facilities of the developing countries [3]. Hence, we planned this secondary analysis to compare the cost effectiveness of Kangaroo ward care (KWC) versus Intermediate intensive care (IIC) in care of VLBW neonates.

This is a secondary analysis of the randomized controlled trial which was conducted in a tertiary care nursery of the Department of Neonatology, Fernandez hospital, Hyderabad from November 2013 to August 2015. The study protocol was approved by the Institutional research board (IRB) of Fernandez hospital, Hyderabad and the study is registered at clinical trial registry, India with registration number CTRI/2014/05/004625.

Written informed consent was obtained from the parents or guardian before randomization of the infant in either of groups. They were provided with written and verbal information including on the potential risk and benefits involved on the research. One copy of research fact sheet was kept with the parents. Parents were explained about the voluntary nature of participation in the research, about non-penalization in event of non-participation and about the option of withdrawing their infant from the study at any point they wished without offering any reason. Confidentiality of the subjects was maintained.

Infants with birth weight less than 1100 g, gestation age ≤ 32 weeks, singleton, tolerating spoon or tube feeds of 150 ml/kg/day, not on intravenous fluids, breathing room air and hemodynamically stable (without any vasopressor support, normal blood pressure and maintaining temperature in incubator care with <25 % heater output) were included in the study. Infants with major malformations were excluded.

All eligible preterm infants were randomized to receive either ‘Kangaroo ward care’ (KWC) or ‘Intermediate Intensive Care’ (IIC) group once the infant reached a weight of 1150 g. Random numbers were generated by a web based computer programme (research randomizer.org). Individual group assignments were placed in a serially numbered, opaque sealed envelope that was opened only after obtaining consent from the parents.

In this secondary analysis we report the cost effectiveness of “Kangaroo ward care” in stable VLBW infants in comparison to “Intermediate intensive care”. Early shifting of infants to KMC ward where baby care was by the mother led to significant reduction of cost to the parents using “bottom-up” method and hospital cost using “top- down” method. This cost difference can be explained by significant reduction in both post randomization NICU stay (KWC 1.7 ± 3.4 days vs 7.2 ± 3.0 days IIC) and post randomization hospital stay in KWC group (KWC 14.8 ± 5.2 days vs 17.0 ± 5.8 days). In this study the cost was calculated from randomization to ‘discharge from hospital’, post randomization stay and total number of days during which neonate received IIC and KWC were same. The results this study show that KWC is a cheap and easily doable intervention and can save nearly 512 USD per infant in a developing country setting where financial burden to family from hospital costs is a big problem.

Cattaneo et al. evaluated the cost efficiency of KMC when compared to conventional methods of care (CMC). The cost variables included two types of running costs: salaries and other items (food for mothers and babies, laundry and linen, drugs and other medical supplies, X-ray and laboratory, fuel and electricity and maintenance of equipment). The cost of salaries was calculated by estimating the proportion of staff time spent on KMC and CMC and multiplying it by the number of months worked during the study by different categories of health workers; the other costs by keeping accurate monthly records. The authors showed that KMC was cheaper than conventional methods of care (CMC) in terms of salaries (US$ 11,788 vs US$ 29,888) and other running costs (US$ 7501 vs US$ 9876) [9]. The savings from KMC in comparison to CMC are approximately 40 % of the total cost as in the trial from Cattaneo et al and nearly 50 % as in our trial.

Jannati et al. conduced a retrospective cost effective analysis of KMC and CMC. In the study infants randomized to CMC group were nursed either under servo controlled radiant warmers or in a cradle under hot lamps in the NICU. The total cost was calculated and the cost of each procedure was determined by standard “bottom-up” cost-accounting method. The resource utilization was recorded for each procedure, and the cost of each item was estimated on the basis of the hospital acquisition cost for the item. All other hospital costs were determined by “top-down” accounting methods based on hospital’s annual accounting report. They showed the mean cost of hospitalization per individual infant for KMC was 3539.47$, whereas for CMC group it was 2907.27$ [10]. The cost savings of nearly 630$ per patient in the study by Janani et al is close to the savings reported by us in this study.

In a previous study from our institute comparing KMC with Conventional care in stable very low birth weight infants, post randomization , infants in the KMC group had an average of 11.5 days lesser stay in the NICU. This shorter stay in the NICU resulted in a mean cost saving of nearly US $ 500 (25,000 INR) for each patient enrolled in the KMC group compared with that enrolled in the CMC group [11]. This results are comparable to present study as in both study cost bared by the parents has been taken in to account. Both the study groups (KWC and IIC) in this trial are similar to the KMC arm of our previous trail. However, the mean weight at randomization for the infants in the KWC group in this trail is lower than the mean weight at randomization for the infants in the KMC arm of our previous trial. Thus early initiation of KWC as in this study may further add to the cost reduction for stable preterm infants. Thus combing the results of this study and our previous study very ealry initiation of KWC in stable preterm infants, may on an average save nearly 1000$ to each patient in comparison to conventional care.

Kangaroo mother care is a cheap and cost effective intervention in both developed and developing countries. The mere implementation of KMC in the care of low birth weight infants in developing countries will lead to significant monetary for the parents and also decongestion of NICU, reduced role of nursing care and involvement of mother in baby care.

CPAP, continuous positive airway pressure; EBM, expressed breast milk; ELBW, extremely low birth weight; FCC, Family centred care; INR, Indian Rupees; IVH, intraventricular haemorrhage; IIC, intermediate intensive care; KMC, Kangaroo mother care; KWC, Kangaroo ward care; LBW, low birth weight; NEC, Necrotizing enterocolitis; PDA, patent ductus arteriosus; PVL, periventricular leukomalacia; ROP, retinopathy of prematurity; SSC, Skin to skin contact; SD, standard deviation; VLBW, very low birth weight