Triage misalignment and early neonatal death in regionalized perinatal care

Regionalized perinatal systems aim to align maternal-infant risk with facility capability, yet most evidence focuses on extremely preterm and very low birth weight infants and evaluates delivery hospital or NICU outcomes in isolation. How triage alignment across the full perinatal care continuum relates to early neonatal mortality, including in lower-risk infants and in settings with declining obstetric capacity, is not well understood.

We conducted a population-based retrospective cohort study of 428,717 live births (2013-2024) in Arkansas, including 1,511 early neonatal deaths (0-6 days). Triage alignment at birth, NICU admission, and interfacility transfer was classified as risk-appropriate, under-triaged, or over-triaged based on concordance between required and actual facility level within a regionalized system. Matched case-control analyses with conditional logistic regression used a sequential modeling strategy distinguishing pre-delivery confounders (gestational age, birth weight) from post-delivery clinical indicators (Apgar score, ventilation, seizures, congenital anomalies), with a nested sensitivity analysis to assess mediation.

Under-triage at birth was associated with five-fold higher early neonatal mortality than risk-appropriate care (56.89 vs. 10.70 per 1,000; P < 0.001). After adjustment for gestational age and birth weight, under-triage remained the strongest independent predictor of early neonatal death (OR 5.85; 95% CI, 4.43-7.72), including among term and normal-birth-weight infants. Distance greater than 30 miles to the delivery facility was independently associated with mortality (OR 2.90; 95% CI, 2.21-3.81), and limited prenatal care remained independently associated with mortality (0 visits: OR 1.51; 95% CI, 1.01-2.24; 1-3 visits: OR 1.78; 95% CI, 1.22-2.59). Localized increases in early neonatal mortality were observed following obstetric unit closures despite relatively stable statewide trends. Black/African American infants had nearly double the early neonatal mortality rate of White infants (5.49 vs. 2.90 per 1,000), with lower prenatal care utilization.

Within a regionalized perinatal system, under-triage at birth and inadequate prenatal care are major determinants of early neonatal death across the risk spectrum. Prenatal risk identification, sufficient engagement with prenatal care, triage alignment at birth, geographic access, and coordinated referral should be treated as core system-level targets for reducing preventable early neonatal mortality.