Emily Sheffield, MPH, highlights rural gaps in access to higher-level neonatal care

Higher-level neonatal care plays a critical role in reducing infant mortality, particularly for newborns with complex medical needs. Emily C. Sheffield, MPH, graduate research assistant at the University of Minnesota, explains that extensive research has demonstrated improved survival outcomes for high-risk infants—such as those born preterm or with very low birth weights—when they receive care in hospitals equipped with intermediate or intensive neonatal services, including neonatal intensive care units.

Compared with hospitals that offer childbirth services but lack advanced neonatal capabilities, facilities with higher-level care provide specialized expertise, greater clinical experience, and access to essential interventions. Hospitals with larger patient volumes also tend to achieve better outcomes, as clinicians maintain proficiency in managing complex neonatal cases and have the infrastructure necessary to support critically ill newborns.

Sheffield’s study examined changes in access to higher-level neonatal care between 2010 and 2022, focusing on rural and urban birth hospitals. In 2010, just over 14% of rural birth hospitals offered intermediate or intensive neonatal care. By 2022, this figure had risen slightly to nearly 17%, although the increase was not statistically significant.

In contrast, urban hospitals saw a significant rise—from 64% in 2010 to almost 75% in 2022. Importantly, the total number of birth hospitals declined in both rural and urban areas because of hospital closures and loss of obstetric services. As a result, despite a modest percentage increase in rural hospitals offering higher-level care, the absolute number declined.

Between 2010 and 2022, 48 rural hospitals gained higher-level neonatal services while 70 lost them, resulting in a net loss of 22 facilities. Urban areas experienced a net gain of 31 hospitals, with 208 adding services and 177 discontinuing them.

These trends have important implications for health disparities. Rural communities already face reduced access to childbirth and neonatal services, and infant mortality rates increase with greater rurality. High-risk infants in the most rural areas may therefore face compounded risks because of both medical vulnerability and geographic barriers to specialized care. The widening gap in service availability between rural and urban hospitals may contribute to persistent survival disparities.

Addressing these challenges requires multifaceted strategies. While maintaining high-level neonatal services in low-volume rural hospitals can be difficult because of fixed costs, workforce shortages, and skill maintenance requirements, improvements can be made through strengthened referral and transfer systems—particularly prenatal maternal transfers when high-risk conditions are identified.

Expanding simulation training can help rural clinicians stabilize newborns before transfer, and telemedicine consultations can connect rural providers with neonatal specialists. Together, these approaches can help bridge geographic gaps and improve outcomes for high-risk rural infants.

No relevant disclosures.

Reference

Kozhimannil KB, Sheffield EC, Busse CE, Interrante JD, McDaniel CE, Handley SC. Availability of higher-level neonatal care in rural and urban US hospitals, 2010-2022. JAMA Netw Open. 2026;9(2):e2559680. doi:10.1001/jamanetworkopen.2025.59680