Care-Related Determinants of Adverse Outcomes among Low-Birth-Weight Neonates: Evidence from Newborn Unit Practice and Provider Perspectives in Kenya

Context. Survival of low-birth-weight (LBW) neonates depends heavily on modifiable nursing care processes at the bedside, making the newborn unit a decisive site for improvement. Evidence linking measurable care-process conditions to outcomes, and the provider experience that explains them, remains limited in Kenyan county referral settings. Aim. To examine the care-related determinants of severe adverse outcomes among LBW neonates and the provider perspectives that explain them, framed for newborn-unit nursing practice and quality improvement. Methods. A convergent mixed-methods design was applied at Kericho County Referral Hospital. Quantitatively, 169 LBW neonate-mother pairs were analysed; care-process indicators (skilled personnel at admission, warm-chain maintenance, shortage of essential drugs/feeds, and referral/outborn status) were related to a composite severe adverse outcome using Pearson chi-square tests and crude odds ratios (OR) with 95% confidence intervals (CI). Qualitatively, key-informant interviews with newborn-unit providers were analysed thematically and coded to care-process themes; strands were integrated for practice. Findings. A severe adverse outcome occurred in 136/169 neonates (80.5%). Skilled personnel (94.7%) and warm-chain practices (92.9%) were near-universal, whereas 58.6% of neonates faced shortages of essential drugs/feeds and 49.1% were referred (outborn). Shortage of essential drugs/feeds (OR = 2.26, 95% CI [1.04, 4.90], p = .036) and referral/outborn status (OR = 2.25, 95% CI [1.01, 5.00], p = .043) were significantly associated with higher odds of a severe outcome. Warm-chain care was statistically associated but in a counterintuitive direction (OR = 4.81, p = .006), consistent with confounding by indication, while skilled-personnel availability was not associated (p = .834). Provider narratives converged on seven care-process themes: staffing and workload, warm-chain maintenance, infection prevention, drug and equipment availability, referral coordination, monitoring and documentation, and caregiver/transport barriers around the first hour of care. Conclusion. Care-related conditions-commodity supply, referral readiness, thermal care, infection prevention, and monitoring-are clinically modifiable levers that shape whether vulnerable LBW neonates stabilize or deteriorate, even where they do not all retain independent statistical significance after adjustment. Recommendations. Newborn units should protect nurse staffing norms, secure consistent supply of essential neonatal commodities, standardize pre-referral stabilization and thermal-care protocols, and strengthen structured monitoring and documentation, supported by competency-based training and county-level policy. Keywords: low-birth-weight neonates; newborn unit; nursing care processes; warm chain; infection prevention; referral coordination; drug and equipment shortage; quality improvement; provider perspectives; mixed methods