SMALL AND SICK NEWBORN CARE: LEARNING FOR IMPLEMENTATION ACROSS AFRICA AND BEYOND: Supplement 2

Background: Kangaroo Mother Care (KMC) reduces neonatal mortality and morbidity among preterm and low birthweight (LBW) infants, but implementation and quality vary across sub-Saharan African (SSA) hospitals. This study reports KMC coverage and quality of care for preterm and LBW neonates admitted to hospitals in the NEST360 Alliance (Kenya, Malawi, Tanzania, Nigeria) and examines the association between KMC provision and survival to discharge. Methods: We conducted a cross-sectional study using routinely collected neonatal inpatient data from hospitals participating in the NEST360 Alliance. Newborns weighing under 2500g were eligible for KMC and included in coverage and quality analyses (January 2021-December 2024). Quality-of-care cascades quantified attrition along the KMC care pathway from eligibility to successful delivery, defining quality as the proportion of eligible neonates reaching each successive step. Mixed-effects logistic regression assessed the association between KMC and survival at discharge, including variation by illness severity and, among KMC recipients, by timing of initiation across severity and birthweight strata. Results: Of 375,238 neonatal admissions across 66 hospitals, 125,844 neonates were eligible for KMC and had KMC documentation available. Among these, 64,619 (51.3%) received KMC. All four countries showed improved coverage over the study period, with the largest absolute increases in Nigeria (27.6%) and Tanzania (27.4%). Excluding Kenya, where KMC timing data were unavailable, 92.1% of neonates started on KMC had a documented start date; of these 44,264 neonates, 12,934 (29.2%) were initiated on KMC on the first day of life. The quality cascade showed eligible neonates were lost at each step, from eligibility through to documented, timely, and sustained KMC. Among neonates eligible for both KMC and CPAP, 39.4% of those started on KMC also received documented CPAP at some point during admission. After adjustment for patient-level factors, receiving KMC was associated with improved survival across all severity groups, with the greatest absolute benefit among the most critically ill neonates (adjusted predicted survival 7% vs 80% without and with KMC, respectively). Conclusion: KMC coverage improved substantially across NEST360-implementing hospitals between 2021 and 2024, demonstrating progress in implementation. However, important gaps remain in the quality and timeliness of KMC delivery. More investment in high-quality KMC implementation, supported by robust monitoring systems linked with quality improvement, are essential to improve outcomes for small and sick newborns across sub-Saharan Africa.