Challenges in implementing optimal perinatal regionalization: a scoping review

Perinatal regionalization is a healthcare model designed to ensure that high-risk mothers and newborns receive care in facilities equipped with appropriate expertise and technology. While evidence supports its effectiveness in improving outcomes, the implementation of regionalized systems remains inconsistent and vulnerable to a range of clinical, structural, and financial barriers. This scoping review aimed to identify, categorize, and synthesize the reported challenges that hinder the effective functioning of perinatal regionalization systems across diverse settings.

A scoping review methodology was used following the PRISMA-ScR guidelines. Studies were included if they reported on barriers to regionalized perinatal care. PubMed, Science Direct, and Web of Science were searched covering publications up to May 2024; updated in June 2026. Data were extracted and thematically analyzed, leading to the development of a structured framework of challenge domains.

After screening and reviewing the retrieved studies, 41 papers included in final synthesis from which 67 challenges of perinatal regionalization were identified. These challenges were organized into 27 subthemes within seven categories: (1) clinical and medical challenges, including unpredictability of high-risk childbirths and clinical contraindications to maternal transport; (2) socio-economic and geographic barriers, such as distance from tertiary centers and poverty; (3) cultural and patient-centered concerns, including loss of patient rights and connection, and cultural resistance; (4) provider-centered factors, such as loss of prestige, perceived viability, and practice behaviors; (5) organizational and financial disincentives, including competition between hospitals and misaligned reimbursement models; (6) transport and logistical limitations; and (7) structural constraints in low-resource settings, including inadequate infrastructure and weak referral networks.

Perinatal regionalization is undermined by interrelated challenges across multiple levels of the health system. Addressing these barriers requires systemic reform, improved coordination, and context-specific strategies to ensure access to risk-appropriate care for all mothers and newborns. The framework of challenges developed in this review can inform policy, planning, and future research on strengthening regionalized perinatal care.