Infant mortality is unimaginably tragic and too common in some communities. Infant mortality risks vary across states, and there are elevated risks for infants who are Black or Native American, as well as those in more remote and rural areas of the country. Many of these deaths are preventable, but prevention requires access to specialty care for many infants who are born early or with clinical complications.
Addressing Infant Health Risks
Hospital-based specialized care for high-risk newborns, such as those born preterm or with congenital anomalies, is not available at every hospital where infants are born. This type of care is provided in neonatal intermediate or neonatal intensive care units (NICUs), where multidisciplinary teams can deliver advanced monitoring and treatment. Many of the leading causes of infant mortality are conditions for which effective treatments exist, but survival often depends on getting to the right level of care quickly. When these specialty neonatal services are not available where a baby is born, access to treatment depends on processes like stabilization, emergency transfers, and coordination between hospitals, which can vary across regions and health systems.
Access to Perinatal Care is Changing
Timely access to risk-appropriate care for pregnant patients and infants is the goal of perinatal regionalization, which is a system-level strategy that identifies hospitals’ capacities to ensure that moms and babies get risk appropriate care. However, planning and implementation of regionalization strategies has become more complicated as the landscape of perinatal care changes. Between 2010 and 2022, there was a steady rise in the percentage of hospitals that dropped basic childbirth services, with losses concentrated among rural hospitals and varying in magnitude across states. These losses more frequently occur in hospital settings with low birth volumes, high fixed costs for maintaining services, and workforce shortages. As access to childbirth services declines, it is also important to understand access to specialty care for infants who need it.
Measuring Higher-Level Neonatal Care Access
Our maternity care team at the University of Minnesota Rural Health Research Center has developed a methodology to measure whether hospitals have childbirth-related care. We also published county-level data and state-by-state reports, focused on obstetric care access. As we turn toward measuring neonatal care access, we used data from the American Hospital Association Annual Surveys, Centers for Medicare & Medicaid Services Provider of Services Files, and primary sources to identify birth hospitals and those with higher-level (intermediate or intensive) neonatal care. One key measure we developed was assessing the ratio of higher-level neonatal care per 100,000 reproductive-age women. We calculated this by state overall and for rural and urban counties within states. At the AcademyHealth Annual Research Meeting this year, we will present our data on the availability of higher-level neonatal care access in rural and urban areas across all U.S. states and show how it has changed between 2010 and 2023. Conference attendees will learn about the broader implications of these trends for clinicians, policymakers, health systems, and families.
Unique Challenges in Rural Communities
Higher-level neonatal care is less common at rural birth hospitals and concentrated in urban settings, leading to geographic differences in access for high-risk infants. For families in rural areas, this can mean traveling long distances for delivery or relying on transfers after birth if their newborn requires more specialized care. In 2022, the Mississippi Delta region–an area that faces high maternal and infant health risks–lost its only NICU, forcing high-risk newborns to be transferred elsewhere for higher-level care. These patterns reflect broader challenges that rural families face in accessing risk-appropriate care around the time of childbirth.
Some states have made investments and led efforts that reflect their unique needs and geographies. For example, Maine has taken steps to strengthen local readiness for infant resuscitation and stabilization among clinicians practicing in rural birth hospitals. Similarly, Montana has focused on building referral systems for high-risk maternal-infant dyads and enhancing ground and air transport methods for complications related to childbirth. Such strategies may become increasingly important to support timely stabilization and transfer of infants with higher-acuity care needs, and these examples point to the importance of this research for informing policy efforts.
Implications for Policy and Practice
For infants born with complex medical needs, access to higher-level neonatal care can mean the difference between life and death. Our findings show that this access challenge is closely tied to where people live and where they give birth. More than 2.6 million reproductive age women (15-44) live in rural communities that do not have childbirth services, and even when birth services are available, only 17 percent of these rural hospitals had higher-level neonatal care in 2022. At the same time, rural hospitals continue to face a range of pressures, reflected in broader discussions about financing rural health systems. These gaps highlight the need to better understand how system capacity, geography, and regionalization of care shapes access to risk-appropriate services for mothers and infants. Ensuring availability of higher-level neonatal care is important for all U.S. communities; rural areas and highly rural states may require particular attention.