Timely Access to Neonatal Intensive Care Units: Non-metropolitan Premature Infants at Risk

Introduction: Infants born at 34 weeks or less gestation are at increased risk of neonatal mortality and morbidity. Neonatal intensive care units (NICUs) are capable of effectively managing the sequelae of prematurity and improving outcomes. Our objective was to evaluate the proportion of Medicaidinsured infants who delivered in NICU hospitals and determine if maternal residence influenced the ability to access such facilities. Methods: We linked American Hospital Association annual survey data to an existing health services database that included birth certificate data, CMS State Medicaid Research Files of Georgia and Area Resource Files. Delivery in a NICU hospital was our primary outcome and maternal residence was our main exposure variable. Covariates were constructed to reflect the plethora of risk factors associated with preterm delivery or NICU access including maternal and fetal demographic characteristics, maternal medical conditions and antenatal care factors. We performed Chi-square and Students t tests when appropriate for bivariate comparisons between women living in metropolitan versus non-metropolitan areas. A p value of < 0.05 was considered statistically significant. We calculated risk ratios for delivering in a NICU hospital and each covariate. A multivariate logistic regression model was fit with significant covariates to determine the influence of maternal residence on delivery in a NICU hospital. Results: All Medicaid-insured women who delivered an infant at 34 weeks or less were included in our study (n=2065). Sixty-seven percent of our population lived in metropolitan areas and nearly 75% delivered in NICU hospitals. Even when adjusting for significant risk factors, non-metropolitan women had 3.16 (95% Confidence interval: 2.72, 3.67) times the risk of not delivering in a hospital without a NICU compared to women living in metropolitan areas. Discussion: Strengthening regionalized perinatal network systems are crucial to improving access to NICU hospitals for preterm infants born to non-metropolitan mothers. Tailoring current policies and outreach efforts to target this disparity should improve neonatal outcomes and help achieve Healthy People 2010 Goals.Master of Public Healt