Introducing First Embrace: an Ambitious Impact charity incubated to save newborns in Nigeria

Executive Summary

Newborns born too small or too soon (vulnerable) account for 70% of the world’s 2 million newborn deaths every year, despite representing just 15% of births. Kangaroo Care, a practice of skin to skin care and exclusive breastfeeding, is proven to reduce mortality among vulnerable newborns by a third compared to conventional care. Despite universal recommendation by the WHO, only 5% of vulnerable newborns receive it.
First Embrace was incubated in the Ambitious Impact program in late 2025 to minimise newborn deaths by scaling Kangaroo Care. One in every ten newborn deaths is in Nigeria, where we work. 

In our first year we evaluated two key questions:

1. Can we cost-effectively deliver Kangaroo Care in a high-burden Nigerian public hospital?
2. Can government partnership provide evidence of a path from policy on paper to implementation at scale?
    

Our early results are highly encouraging on both fronts. The proposed withdrawal of US funding for foreign newborn health is expected to eliminate postnatal care for 11 million newborns. To our knowledge, we are the only organisation scaling Kangaroo Care in Kano State, where the burden of newborn mortality is the highest nationally. The marginal value of funding our work will increase because we reach newborns that no one else would. First Embrace exists to deliver immediate impact for newborns by closing the Kangaroo Care coverage gap where mortality is worst, while developing a blueprint for scale across sub-Saharan Africa.
We are raising $600,000 to expand to 6 hospitals next year, with which we estimate could save around 200 newborn lives while advancing our relationship with the government on the path to scale. Over 80% of this will be spent on direct costs (programs).

This report, written by the FE team, discusses our progress in our first year in detail. We welcome feedback on how we can make our work as impactful as possible. 

A live program dashboard can be found here. 

1. The Problem

20 million underweight newborns are born every year, almost all in lower and middle income countries. As a result these countries account for 81% of newborn deaths. Complications of prematurity are the fifth largest cause of death in low income countries and the number one risk factor for death for children under five globally. 
Sub-Saharan Africa accounts for the most newborn deaths and Nigeria has the region’s largest burden. Here, a newborn dies every 2 minutes and this hasn’t changed since 2018. Hospitals in Nigeria are often crowded, with incubators the only option for caring for vulnerable newborns. When none is available a newborn must go without the care they need or be sent on a dangerous journey to another hospital. Either way they may not survive. 

2. The Solution

Kangaroo Care combines sustained skin-to-skin care, exclusive breastmilk feeding and danger sign training. A meta-analysis of 21 randomised-controlled trials (RCTs) found this intervention reduces mortality among vulnerable newborns by a third, while reducing severe infection (roughly half) and dangerously low temperature (72%) even more. Rather than relying on complex equipment families themselves become their newborn’s lifesaving care.
Universal access to Kangaroo Care could save hundreds of thousands of newborn lives every year. The WHO estimates hospital-based Kangaroo Care for newborns under 2 kilograms save around 125,000 lives annually, while immediate initiation could save around 150,000 lives because three quarters of newborn deaths occur in the first week.
Scaling immediate Kangaroo Care for vulnerable newborns across sub-Saharan Africa could represent the largest single step towards ending preventable newborn mortality.

In 2021, GiveWell suggested Kangaroo Care could be as cost-effective as the best interventions but identified scalable implementation in low-resource settings as critically uncertain. Ansh has since begun to successfully address this in India. In Nigeria that question is unanswered. Previous Nigerian programs (ACCESS, MNCH2, PRRINN-MNCH) established Kangaroo Care feasibility and informed policy but did not pursue population-level implementation. Nigeria has committed to a 95% Kangaroo Care target by 2030. Today, estimates suggest in Africa this is just 5%. 

On the World Bank's government effectiveness indicator India, the country with the most newborn deaths, ranks in the 68th percentile. Nigeria languishes in the 20th, and nine of the ten poorest countries in the world are in sub-Saharan Africa. Whether public systems here are able to effectively own Kangaroo Care at scale is uncertain.
Yet, these health systems here face shared constraints and charities have repeatedly helped governments scale evidence-based health interventions across the region. Demonstrating an efficient Kangaroo Care model in Nigeria could unlock outsized impact by catalysing broader adoption. 

3. Our Approach

In Nigeria, three types of implementation gaps separate policy from practice. First Embrace addresses each one to embed Kangaroo Care into routine services at large public hospitals. Our program design is inspired by Ansh, an Ambitious Impact-incubated charity in India supported by GiveWell and tailored to the Nigerian health system. We are deeply appreciative of their support.  

Resources: Many hospitals in our geography lack the human and physical resources to deliver Kangaroo Care sustainably. Providing only the inputs essential for quality implementation is affordable. We equip wards with what they are missing and embed trained nurses in line with WHO standards. 

Measurement: Kangaroo Care is not routinely measured. Our nurses record every skin-to-skin session and assess newborns for danger signs every four hours using a bespoke application on digital tablets we provide. A monitoring and evaluation (M&E) officer verifies data quality. A live dashboard tracks implementation metrics in real time, allowing rapid feedback and data-driven decision making.

Systems: Delivering reliable care requires strong systems. We conduct quality improvement meetings and systematise procurement. Our nurses identify newborns both from hospital registers and by weighing newborns when records are incomplete. We follow up newborns until the end of the neonatal period to support their health and Kangaroo Care. We investigate every death as far as possible to identify preventable factors.

4. Results 

Our primary outcome is neonatal mortality. We evaluate our program's impact against a baseline mortality estimate derived from authoritative Nigerian data and apply the Cochrane effect size (33%) against it to be conservative. This is a pre-post comparison.

4.1 Baseline Neonatal Mortality

We aimed to estimate baseline mortality among all vulnerable newborns in Nigeria. Representative estimates of the total prevalence of vulnerability are unavailable because gestational age is not routinely measured in Nigeria, precluding reliable estimation. We therefore follow GiveWell's approach to estimate mortality among low birth weight newborns only. This excludes premature newborns of normal weight (8% of our beneficiaries so far), whose mortality risk may differ.

We use the lowest authoritative estimate of Nigeria's neonatal mortality. Other authoritative estimates (39 (UNICEF) to 41 (NDHS 2023–24)) imply baseline mortality above 20% among vulnerable newborns. In our prospective hospital baseline (n=80) mortality was 26%. Excluding newborns who died on day of birth and day 1 (our average time to initiation of Kangaroo Care currently is 45 hours) mortality was 16.9%. We discuss the limitations of different methods in our analysis of it.
We expect our impact to be highly counterfactual because no other actor supports the government in implementing Kangaroo Care at scale and Nigeria's neonatal mortality has not declined since 2018. 
To conservatively estimate our impact we use 18% as the baseline neonatal mortality.

4.2 Outcome 

Program impact 

In the subgroup of three RCTs where skin-to-skin was under 2 hours a day, the Cochrane analysis found no mortality benefit. We exclude newborns who received less than this (20%) from our reach (and accordingly impact).

We consider this estimate of our program's effectiveness conservative for four reasons:

1. We use the Cochrane reduction which looked at evidence for stable newborns. 26% of our newborns are unstable, receiving intensive care.
2. The newborns we discount from our reach are often referred to other hospitals or receive other treatments in intensive care which our nurses support, so receive some rather than no intervention from our program.
3. Half our newborns received immediate Kangaroo Care. Immediate initiation provides a 25% mortality reduction (WHO iKMC RCT) over delaying. Thus immediate Kangaroo Care likely reduces mortality by more than 33% compared to conventional care. We do not combine effects as independence can not be assumed and there is no randomised evidence on immediate compared to conventional care.
4. Beyond Kangaroo Care, our nurses refer unstable newborns to intensive care, which plausibly has a significant but unquantified mortality effect.

We observed program mortality of 7% (23 deaths among 320 newborns). We can only enroll newborns who survive long enough to be registered. Our cost-effectiveness estimate is unaffected because it applies the lower Cochrane effect size. 
A community Kangaroo Care program run by eHealth Africa and Dimagi independently follow up a subset of our cohort. So far they’ve observed 7% neonatal mortality (3 deaths among 43 referred newborns, small sample), providing external corroboration of our outcome ascertainment.

4.3 Cost-effectiveness

We calculate our cost-effectiveness across a year running the charity at one hospital.
This year our seed grant from Ambitious Impact gave us $163,150 of deployable capital (after fiscal sponsorship fees). This provided 7 months of programming after charity setup, in-country scoping and nurse training.

Observed Costs, annualised

Current cost-effectiveness

We model a mortality reduction of 35% at regional scale. At this scale over 90% of costs are spent directly on programs. As economies of scale take hold (a similar number of senior staff have the capacity to manage far more hospitals) our program becomes hugely more cost effective.

Cost-effectiveness at 2 State Scale (12 hospitals)

5. Implementation Lessons

Below are some key implementation learnings from our first year.

Dose and immediate initiation can be improved.
The duration of skin-to-skin contact and the timing of initiation are robustly linked causal drivers of Kangaroo Care effectiveness. Increasing both is our highest program priority and their trajectory is positive (average skin to skin hours improved by 40% from the start to the end of the pilot and the immediate initiation rate doubled over the same period).

Elements of caregiver behaviour are changeable. 
Mothers initially resisted overnight admission, a key barrier reported in the implementation literature. This changed quickly during the pilot, with the average length of stay increasing to five days by the second month. 

Data incompleteness limits estimation of reach among targetable population.
Incomplete hospital records make it difficult to estimate what proportion of targetable newborns we reach. Newborns are not always weighed at birth and referred newborns are not consistently recorded due to workload pressures. Supporting improvement of hospital processes is a priority. Our CEA models enrolled newborn reach only.

Institutional partnerships can be developed quickly.
We secured government and ethical approvals and launched our programme within four months of incubation. This suggests these partnerships can rapidly support high-quality implementation.

6. Plans

Improvement

Skin-to-skin hours are around 50% lower in the intensive care unit, where around half of enrolled newborns spend at least part of their admission. According to the inverse care law these are the newborns likely to benefit most from Kangaroo Care. We will conduct qualitative interviews with clinicians and analyse barriers using the COM-B behaviour change framework. We have also begun supporting fathers and the wider family to provide skin-to-skin care as surrogate skin to skin provision drove high hours in the WHO iKMC RCT. To increase immediate initiation, our nurses now provide prenatal counselling in labour wards, antenatal clinics and vaccination appointments. We also facilitate peer counselling between experienced and newly enrolled mothers, an approach supported by a large randomised evidence base. These approaches could significantly improve our program’s cost-effectiveness.

Our trained nurses delivering group counselling on Kangaroo Care.

Expansion

Our pilot has generated demand from two additional hospitals, and routine data indicate at least six high-burden hospitals in Kano could benefit from implementation with a similar number in neighbouring Katsina. Considering organisational development and program quality, we judge 15 hospitals as the limit on expansion next year. We plan to expand our work to save many more newborn lives next year.

We believe government delivery offers the most credible long-term route to equitable, population-level coverage. A crucial factor in our decision to work in Nigeria was not just the existence of policy aiming at universal reach, but the precedent that impact-focussed organisations have scaled evidence-based health interventions with government. Our strategy is therefore to demonstrate high-quality implementation while supporting government ownership from the outset. The Kano Ministry of Health has already asked us to organise a legislative workshop to support domestic financing of Kangaroo Care. Our next objective is to help domesticate Nigeria's Every Newborn Action Plan (2017) in Kano and establish a dedicated state budget line. If successful, this could provide a practical model for wider adoption. Other AIM organisations have had success with this approach in Northern Nigeria.

Founding team with the Honourable Commissioner of Health, Kano State and the Maternal and Neonatal Health Coordinator.

By Year 5, we aim to operate across all of Nigeria's highest-burden states while maintaining a cost per life saved below $4,000. Achieving this reach will depend on being able to overcome the critical bottlenecks for government in scaling Kangaroo Care. As government financing increases, our role would gradually shift from direct delivery toward technical assistance. This would allow expansion into other geographies where Kangaroo Care remains neglected, prioritised by need.

Evaluation

We will conduct a rigorous evaluation in Year 2 or 3, using a stepped-wedge cluster-randomised design in which the sequence of hospital entry is randomised. This lets each hospital serve as its own control before crossover, and as a comparison for hospitals not yet started where we continue collecting baseline data. We will estimate the mortality effect using a mixed-effects model with fixed effects for time and intervention status and a random effect for hospitals, giving a more causal estimate of effectiveness. We will seek input on the methodology, preregister the final protocol and make results publicly available for external evaluation.

Partnerships

We are in ongoing engagement with the WHO team including Professor Ebunoluwa Adejuyigbe, who are conducting  WHO iKMC-IR study. We plan to continue collaborating with Dimagi and eHealth Africa who provide community-based Kangaroo Care to referred newborns after discharge.

7. Team

Founding
Ikra Gulzar is a pharmacist with clinical experience in critical care and paediatrics. She has led regional health policy approvals, developed clinical protocols, and trained allied healthcare professionals. 
Wesley Quadros is a doctor with clinical exposure to neonatology, and research-to-policy translation in sub-Saharan Africa. He has experience supporting medical education and clinical research including working on a randomised controlled trial. 

Program
Gabriel Obiero brings a decade of experience in public health program management and grant administration in large-scale health interventions (Global Fund, USAID) in resource-constrained environments across Nigeria.
Hamdi Labaran brings 4 years of experience in data management and monitoring across health programs. She elicits actionable insights and improves our evaluation systems.

Advisors
We are grateful to be supported by an experienced group of advisors including Supriya Bansal (Ansh), Patrick Stadler (formerly New Incentives), Sarah Eustis-Guthrie (GiveWell), Jerry Montgomery (formerly Save the Children), and Dr Aishatu Adamu (University of Oxford Centre for Global Health).

8. Funding

Our current runway ends in December 2026. This year we have established both a program and government work with encouraging early results.
We are raising $600,000 to expand to six high-burden hospitals in Year 2, saving around 200 newborn lives while advancing our government advocacy.  For $975,000 we can expand our program to 12 hospitals across 2 states, assessing our program's geographical replicability and potentially saving 450 lives.
If you are interested in supporting our work through funding or collaboration, please contact [email protected]. We are happy to share further analyses and materials for larger funding decisions.

Thank you

We thank the Kano State Ministry of Health, Ambitious Impact and its seed funders, our partner hospital, Professor Ebunoluwa Adejuyigbe, Professor Zubaida Farouk, Dr Musa Sufi, eHealth Africa, Dimagi and Ansh for their support and collaboration. 

Thank you for reading.

Appendix A: Implementation model in detail

Appendix B: Scientific basis of Kangaroo Care

Figure by HealthLearn on how skin-to-skin contact and early breastfeeding reduce neonatal mortality.