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


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          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.


          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.


          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.


          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.

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          Most cited references21

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          The cost of prematurity: quantification by gestational age and birth weight.

          To determine gestational age- and birth weight-related pregnancy outcomes and resource use associated with prematurity in surviving neonates. A data set linking birth certificates with maternal and newborn hospital discharge records from hospitals in California (from January 1, 1996, to December 31, 1996) was examined for all singleton deliveries by gestational age (weekly, from 25 to 38 weeks) and birth weight (by 250-g increments from 500 to 3000 or more g). Records were examined for respiratory distress syndrome (RDS), use of mechanical ventilation, length of hospital stay in days, and hospital costs. As expected, RDS, ventilation, length of hospital stay, and costs per case decreased exponentially with increasing gestational age and birth weight. Specifically, neonatal hospital costs averaged 202,700 dollars for a delivery at 25 weeks, decreasing to 2600 dollars for a 36-week newborn and 1100 dollars for a 38-week newborn. Neonatal costs were 224,400 dollars for a newborn at 500-700 g, decreasing to 4300 dollars for a newborn at 2250-2500 g and 1000 dollars for a birth weight greater than 3000 g. For each gestational age group from 25 to 36 weeks, total neonatal costs were similar, despite increasing case numbers with advancing gestational age. Neonatal RDS and need for ventilation were significant at 7.4% and 6.3%, respectively, at 34 weeks' gestation. Significant "excess" costs were found for births between 34 and 37 weeks' gestational age when compared with births at 38 weeks. Prematurity, whether examined by gestational age or birth weight, is associated with significant neonatal hospital costs, all of which decrease exponentially with advancing gestational age. Because total costs for each gestational age group from 25 to 36 weeks were roughly the same (38,000,000 dollars), opportunity for intervention to prevent preterm delivery and decrease costs is potentially available at all preterm gestational ages.
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            Costs of newborn care in California: a population-based study.

            We sought to describe the current costs of newborn care by using population-based data, which includes linked vital statistics and hospital records for both mothers and infants. These data allow costs to be reported by episode of care (birth), instead of by hospitalization. Data for this study were obtained from the linked 2000 California birth cohort data. These data (n = 518,704), provided by the California Office of Statewide Health Planning and Development (OSHPD), contain infant vital statistics data (birth and death certificate data) linked to infant and maternal hospital discharge summaries. In addition to the infant and maternal hospital discharge summaries associated with delivery, these data include discharge summaries for all infant hospital-to-hospital transfers and maternal prenatal hospitalizations. The linkage algorithm that is used by OSHPD in creating the linked cohort data file is highly accurate. More than 99% of the maternal and infant discharge abstracts were linked successfully with the birth certificates. These data were also linked successfully with the infant discharge abstracts from the receiving hospital for 99% of the infants who were transferred to another hospital. The hospital discharge records were the source of the hospital charges and length-of-stay information summarized in this study. Hospital costs were estimated by adjusting charges by hospital-specific ratios of costs to charges obtained from the OSHPD Hospital Financial Reporting data. Costs, lengths of stay, and mortality were summarized by birth weight groups, gestational age, cost categories, and types of admissions. Low birth weight (LBW) and very low birth weight (VLBW) infants had significantly longer hospital stays and accounted for a significantly higher proportion of total hospital costs. The average hospital stay for LBW infants ranged from 6.2 to 68.1 days, whereas the average hospital stay for infants who weighed >2500 g at birth was 2.3 days. Overall, VLBW infants accounted for 0.9% of cases but 35.7% of costs, whereas LBW infants accounted for 5.9% of cases but 56.6% of total hospital costs. Although total maternal and infant costs were similar (approximately 1.6 billion dollars), the distribution of maternal costs was much less skewed. For infants, 5% of infants accounted for 76% of total infant hospital costs. Conversely, the most expensive 3% of deliveries accounted for only 17% of total maternal costs. The very smallest infants make up a hugely disproportionate share of costs; more than half of all neonatal costs are incurred by LBW or premature infants. Maternal costs are similar in magnitude to newborn costs, but they are much less skewed than for infants. Preventing premature deliveries could yield very large cost savings, in addition to saving lives.
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              The economic burden of preterm/very low birth weight care in Nigeria.

              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.

                Author and article information

                BMC Health Serv Res
                BMC Health Serv Res
                BMC Health Services Research
                BioMed Central (London )
                27 July 2022
                27 July 2022
                : 22
                [1 ]JSI Research & Training Institute, Inc, Washington, DC USA
                [2 ]GRID grid.10818.30, ISNI 0000 0004 0620 2260, College of Medicine and Health Sciences, , University of Rwanda, ; Kigali, Rwanda
                [3 ]GRID grid.39381.30, ISNI 0000 0004 1936 8884, Schulich School of Medicine & Dentistry, , University of Western Ontario, ; London, ON Canada
                [4 ]PIVOT Works Inc, Ranomafana, Madagascar
                [5 ]United Nations Population Fund (UNFPA), Kigali, Rwanda
                [6 ]GRID grid.4489.1, ISNI 0000000121678994, University of Granada, ; Granada, Spain
                © The Author(s) 2022

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                Research Article
                Custom metadata
                © The Author(s) 2022

                Health & Social care
                prematurity,preterm birth,medical direct cost
                Health & Social care
                prematurity, preterm birth, medical direct cost


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