Inequitable access to risk-appropriate neonatal care: evidence from a regionalized perinatal system in Arkansas

To evaluate access to risk-appropriate neonatal care in Arkansas and examine relationship among geography, hospital availability, county-level maternity care access, birth triage patterns, neonatal transfers, and neonatal intensive care unit (NICU) utilization.

Population-based retrospective cohort study of all live births in Arkansas from 2014 to 2023 using linked birth certificate, hospital designation, and county-level maternity care access data. Primary exposures included geographic distance to the nearest risk-appropriate facility, local hospital availability, and insurance status. Outcomes included birth triage status (over-, under-, or risk-appropriate), transfer triage patterns, NICU utilization, and the impact of obstetric unit closures.

Among 358,155 live births, 76.5% occurred at facilities providing a higher level of care than required, 20.1% occurred at risk-appropriate facilities, and 3.3% occurred at facilities providing a lower level of care than required. Under-triage was most common when the nearest risk-appropriate facility was geographically distant (mean distance 51.2 miles). Medicaid-covered births experienced under-triage nearly twice as often as privately insured births (4.31% vs. 2.55%; p < 0.001). NICU admission rates varied substantially across county access categories (6.5%-9.3%) despite similar rates of high-acuity births (3.5%-3.9%), consistent with supply-sensitive utilization. Among 6,935 neonatal transfers, 84.3% were directed to facilities providing a higher level of care than required. Of 4,703 transfers to Level IV NICUs, only 3.6% of infants met criteria for Level IV care, and a closer Level III facility was available in 96.1% of cases. Following obstetric unit closures, risk-appropriate births decreased, over-triage increased, and travel distances lengthened.

Access to risk-appropriate neonatal care was shaped more strongly by geography, resource distribution, and referral structure than by measured clinical risk. These findings suggest that regionalized perinatal systems may simultaneously experience inequitable access and supply-sensitive utilization. Strategies including independent transfer triage coordination, preservation of lower-level maternity and nursery capacity, and standardized NICU admission practices may improve alignment between neonatal need and site of care.