Abstract

The care of very low birth weight (VLBW) neonates may impose an enormous burden on professional resources and finances of caregivers. This study seeks to evaluate the immediate cost of care of VLBW babies in a developing economy. Twenty-four hospital case records VLBW babies who survived till discharge over a 1 year period at the University College Hospital, Ibadan, Nigeria were reviewed. Estimates of the out of pocket costs of managing these babies were calculated. The overall cost of hospital care ranged from US$211.1 to US$1573.9. The direct (median) and indirect (median) cost of care ranged from US$80 to US$1055 (US$247.3) and US$101.0 to US$1128.1 (US$257.2), respectively. These constituted 22.8% and 3966.3% (median 133.4%) of the combined family income. In conclusion, the cost of care of the VLBW deliveries in Nigeria is very high for the level of the economy and constitutes a major financial burden on the family.

Introduction

The prevalence of low birth weight (LBW) ranges from 5.8% to 28.3% in Asia and 17.2% to 21.3% of all births in Africa [1, 2]. In Nigeria, LBW accounts for about 14% of the 5.3 million annual deliveries [3] and is a principal contributor to neonatal morbidity and mortality in developing countries [2–5].

Prevention, early recognition and treatment of preconceptional malnutrition and conceptional maternal events, such as malaria, anaemia, malnutrition, hypertension and diabetes mellitus, which increase the risks of LBW can reduce the prevalence and burden of preterm/LBW deliveries and therefore generate significant cost savings and health improvements.

Malaria in pregnancy for instance, may be causally related to 35% of preventable LBW deliveries but incidence of malaria and therefore LBW can be reduced at affordable cost [6].

The cost of immediate hospital care of preterm/LBW deliveries and long-term community care may impose significant financial and emotional burden on the parents, society and the health system [7–11] as well as being professionally labour intensive. In the United States it has been estimated that the expected costs of delivery and initial care of a baby weighing 1000 g at birth can exceed $100 000 [12], however, there are no documented estimates of costs of care for LBW/VLBW (very low birth weight) in sub-Saharan Africa.

In Nigeria, the per capita government expenditure on health is US$7 representing 30.4% of total expenditure on health while the remaining 69.6% being from private resources which comprise of 6.7% from prepaid packages and 90.4% directly out of pocket of families [13].

There is no available data on the economic implications of care of VLBW infants within the first few weeks of life in Nigeria, and this study therefore seeks to evaluate the direct and indirect costs of hospital care of VLBW babies in the immediate newborn period in Ibadan, Nigeria.

Materials and Methods

The study was conducted at the special care baby unit (SCBU) of the University College Hospital, Ibadan, Nigeria; the leading tertiary healthcare facility in Nigeria, servicing a population of approximately 5 million people. A total of 1853 babies were delivered in the labour ward during the year of study with 289 (15.6%) being LBW of which 41 (2.2%) were VLBW and were admitted. In addition, 26 outborn infants weighing <1500 g were also admitted into the SCBU. Thirty-one (43.6%) of 67 babies survived till discharge but complete hospital records were available for evaluation in only 24 cases. In this Centre, discharge weight for VLBW is at least 1800 g.

Social class stratification was based on the Oyedeji classification [14], where classes 1 and 2 are regarded as upper class and 3–5 as lower class. In this review, the cost of care was evaluated till discharge of baby. For this review, direct cost of care refers to all expenditures borne by parents in the course of hospitalization of the baby, which included drugs, intravenous fluids, investigations, blood transfusions, dressings, consumables and bed fees. Indirect costs of care refer to cost of mother's extended hospital stay for baby's sake, cost of transportation of mother or other care giver to hospital during hospitalization of baby. The term cost burden is used in this article to refer to direct and indirect costs expressed as a percentage of household income and also compared with per capita government spending on health.

During antenatal care services, in order to prevent anaemia and malaria, drugs such as folic acid, ferrous sulphate and sulphadoxine-pyrimethamine are routinely prescribed which cost $5 throughout pregnancy. The cost of managing hypertension, anaemia and diabetes mellitus in pregnancy in order to prevent LBW or preterm birth was also estimated to be about US$95, US$95.2 and US$ 204.8, respectively. This includes cost of additional investigations, such as urinalysis, blood glucose monitoring, liver and renal function tests and more frequent abdominal ultrasound scans as well as drug therapy.

Results

Sixty-seven VLBW babies were admitted during the study period, constituting 18.6% of the total of 360 admissions into the SCBU. Thirty-one (46.3%) survived till discharge while 36 (53.7%) patients died. Complete data were available in 24 of the survivors.

The birth weight of the babies ranged from 800 g to 1460 g with a mean ± SD of 1240 ± 170 g and the gestational ages ranged from 25 to 38 weeks with a mean ± SD of 31.3 ± 3.2 weeks. Of the 24 cases with complete records, 21 were preterm with weight appropriate for gestational age while 2 were term but small for gestational age (SGA) and 1 was preterm SGA.

The spectrum of problems the babies had included sepsis (100%), jaundice (58%), respiratory distress of varying aetiologies (25%), anaemia (22%), perinatal asphyxia (12.5%), patent ductus arteriosus (8.2%) and infant of diabetic mother (4.2%).

All babies were admitted within 13 h of life with median age at admission being 2 h. The duration of hospital stay ranged from 19 to 79 days with a median of 28 days.

One-third (33.3%) of the parents of the VLBW babies belong to social class 3 and 23.8% belong to social class 2 with a mean combined monthly parental income of US$301.6 ± 134.4 and US$711.1 ± 339.0, respectively. Only 14.3% of the parents belong to the upper social class 1 with combined monthly parental income of US$992–US$1984, while 19% and 9.5% belonged to social classes 4 and 5 with combined monthly parental income of US$95.2 ± 73.0 and US$60 ± 34.5, respectively.

The overall cost of care ranged from US$211.1 to US$1573.9 with a median of US$417.3. The direct cost of care ranged from US$80 to US$1055 with a median of US$247.3 while indirect cost ranged from US$101.0 to US$1128.1 with median of US$257.2. The families spent between 22.8% and 3966.3% (median 133.4%) of their combined monthly income on the care of these babies. Table 1 shows the analysis of the cost of care with oxygen and drugs accounting for most of the expenditure on care.

Table 1

Direct cost of care of VLBW babies

 N (total n = 24) Mean ± SD (US$) Median (US$) Min–max (US$) 
Incubator care 23 6.17 ± 3.45 4.29 1.67–14.76 
Oxygen 12 105.82 ± 142.47 50.79 12.70–507.94 
Phototherapy 19 0.83 ± 0.41 0.79 0.24–1.51 
Intravenous fluids 24 40.57 ± 29.74 29.4 8.57–115.0 
Drugs 24 89.12 ± 61.92 78.25 5.87–216.27 
Investigations 24 28.53 ± 14.73 27.38 2.38–61.31 
Transfusion 10 63.49 ± 29.93 29.93 25.4–126.98 
Consumables 24 64.43 ± 33.75 47.3 23.33–143.49 
Hospital fee 24 64.43 ± 33.75 47.30 23.33–143.49 
Total cost 24 315.76 ± 228.73 247.30 80.0–1055.12 
 N (total n = 24) Mean ± SD (US$) Median (US$) Min–max (US$) 
Incubator care 23 6.17 ± 3.45 4.29 1.67–14.76 
Oxygen 12 105.82 ± 142.47 50.79 12.70–507.94 
Phototherapy 19 0.83 ± 0.41 0.79 0.24–1.51 
Intravenous fluids 24 40.57 ± 29.74 29.4 8.57–115.0 
Drugs 24 89.12 ± 61.92 78.25 5.87–216.27 
Investigations 24 28.53 ± 14.73 27.38 2.38–61.31 
Transfusion 10 63.49 ± 29.93 29.93 25.4–126.98 
Consumables 24 64.43 ± 33.75 47.3 23.33–143.49 
Hospital fee 24 64.43 ± 33.75 47.30 23.33–143.49 
Total cost 24 315.76 ± 228.73 247.30 80.0–1055.12 

Discussion

VLBW can have significant immediate, short- and long-term physical, emotional and financial consequences for baby, family and health care delivery system due to increased costs of care within limited resources available. The cost of care has been estimated to be inversely related to birth weight, such that on average, babies born weighing 1000–1499 g cost more than four times higher than those born weighing at least 1500 g. Estimates of the cost of care of VLBW deliveries can be a source of information for budgetary planning for clinical care as well as provide a basis for assessing competing strategies for prevention services.

In developing countries such as Nigeria, where the incidence of LBW has been estimated as 14%, the cost implication of neonatal care is largely unreported and not often considered for healthcare planning. In Nigeria as other developing economies, the cost of care is largely borne by families of babies with minimal support from government.

This study estimated the cost of hospital care for VLBW babies in the neonatal intensive care unit of a tertiary care health facility in Nigeria. This limited review demonstrated that the high financial expenditure on care of VLBW in Nigeria was borne by families at an astronomical range of 22.8–3966.3% of their combined monthly income. In the absence of significant healthcare insurance and government spending on health, the financial burden of immediate care of VLBW babies may negate the Millennium Development Goal 4 and also compromise later care of these babies and other members of the families.

The high cost of immediate management may hinder optimal care in childhood as parents will still have to find money to repay the costs of care incurred, which may impact significantly on the overall care of other members of the family. Though this study did not evaluate the cost of care beyond the immediate discharge from hospital, other studies have documented the significant economic costs of preterm birth or LBW following the infant's initial discharge from the neonatal unit. McCormick et al. [15] report that preterm or LBW infants are significantly more likely to consume hospital and community health services during the early years of life than infants born at full term or at normal birth weight.

The high cost of immediate care of VLBW babies may underscore the need for less expensive and cost-effective preventive strategies during pregnancy, such as IPTp, folic acid and iron administration and improved maternal nutrition which have been shown to increase birth weight. In the United States, it has been estimated that each VLBW delivery that results instead in a normal birth will save $59 700 in the neonatal period [10]. Estimates of cost of care of VLBW babies in the United States vary between $30 500 and $129 000 and length of hospital stay between 31 and 94 days. Comparatively the present study shows a duration of hospital admission between 19 and 79 days while the cost of care of VLBW babies in Nigeria ranged from US$211.1 to US$1573.9. Though this cost is smaller compared with the cost of care in the United States because the services in Nigeria are less technologically intensive, these costs were direct out of pocket expense by the families and it constituted between 22.8% and 3966.3% of their monthly income.

Coping strategies are vitally important for poor households faced with illness cost shocks, since the costs associated with serious illness can absorb a large proportion of the household budget as seen in this review even among the high income earners. The results of this study showed that the cost of caring for VLBW is relatively very high for the families and may have long-term economic implications for the families and healthcare delivery systems. There is therefore the need for improved social support, strengthening the recently established health insurance scheme and similarly exploring competing low cost preventive strategies, such as increased access to quality antenatal care.

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