The fight against neonatal mortality in Western Kenya has received a significant boost as the Bili Ruler, a low-cost and highly effective diagnostic tool, is changing outcomes for newborns. By enabling early detection of jaundice, the device is proving to be a game-changer in clinical settings where expensive laboratory equipment is often out of reach.

The Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH) is currently one of the primary sites where the PRISMA (Pregnancy Risk, Infant Surveillance and Measurement Alliance) study is implementing this sub-study. Researchers hope the success at JOOTRH and surrounding facilities will pave the way for a national rollout across Kenya.

Neonatal jaundice—the yellow discoloration of a baby’s skin and eyes—remains one of the top ten leading causes of infant mortality and morbidity globally. In sub-Saharan Africa, the stakes are particularly high. Statistics suggest that globally, jaundice-related complications contribute to a staggering 60% to 80% of neonatal deaths when left untreated.

“Jaundice occupies the seventh space across the leading causes of neonatal mortality,” says Kevin Kasadhe, a Clinical Research Nurse and Trainer with the Kenya Medical Research Institute (KEMRI) and the Cambridge Centre for Global Health Research. “Our goal is to bring this variant of jaundice down through early screening and prompt referral.”

Traditionally, diagnosing jaundice requires Total Serum Bilirubin (TSB) testing, an invasive process involving pricking the infant for blood samples—a method that is often costly and unavailable in level two or three health facilities.

The Bili Ruler, or icterometer, offers a non-invasive alternative. By applying slight pressure to the infant’s nose, health workers can observe color codes through transparent windows. To ensure accuracy across diverse populations, the study complements the ruler with the Monk Skin Tone scale.

“In setups of African origin, we tend to have darker skin pigmentation, which can make visual identification of jaundice difficult,” Kasade explains. “The Monk Skin Tone tool allows us to correlate the Bili Ruler findings with the specific skin tone of the child, ensuring no case is missed due to pigmentation.”

Since its rollout on January 13, 2025, the PRISMA study has seen remarkable engagement, including 2,703 total participants enrolled across the wider pregnancy surveillance platform, 930 children specifically enrolled in the Bili Ruler sub-study and Zero deaths related to jaundice among the identified cases in the study, thanks to early referral and intervention.

The study spans six facilities, including JOOTRH, Kisumu County Referral Hospital, Lumumba Sub-County Hospital, and Koyo Health Center in Kisumu, as well as Siaya County Referral Hospital and Tingwangi in Siaya.

At a cost of approximately Ksh 1,200, the Bili Ruler is positioned as a sustainable solution for the Ministry of Health. Unlike laboratory tests, it can be used by nurses in understaffed clinics or potentially by community health volunteers reaching mothers who deliver at home.

The study monitors infants at critical windows: within 24 hours of birth, at three days, and again at one week. For cases where bilirubin levels exceed 15 mg/dL, immediate referrals are made to pediatricians for phototherapy or other life-saving treatments.

“This tool is a deal-breaker,” concludes Kasade. “By onboarding this into the national platform, we can ensure that we do not leave any community disenfranchised and that every newborn has the chance to thrive.”