Rural hospitals report reduced access to higher-level neonatal care

Rural birth hospitals have limited access to higher-level neonatal care, according to a recent study published in JAMA Network Open.¹

An increase in infant mortality has been observed among rural communities in the United States. These regions also have reduced access to childbirth care, and a greater level of this care is often needed to prevent mortality in infants with high-acuity clinical needs. High-level neonatal care is more often found in urban regions.

Study design and hospital classification

The retrospective cohort study was conducted to evaluate changes in the availability of higher-level neonatal care across rural and urban hospitals between January 1, 2010, and December 31, 2022. All US hospitals offering childbirth services were included in the analysis.

An enhanced algorithm was used to identify birth hospitals from American Hospital Association annual surveys and Centers for Medicare & Medicaid Services Provider of Services files between 2010 and 2022. Birth hospitals with delivery of neonatal intensive care, at least 1 neonatal intensive care bed, or at least 1 neonatal intermediate care bed were considered to have a greater level of neonatal care.

Neonatal care status was verified through primary reviews of hospital websites and news media, while Office of Management and Budget definitions were used to classify hospital rurality. Hospitals were defined as rural if they were not located in an urbanized area of 50,000 inhabitants.

Changes in higher-level neonatal care availability

The percentage of hospitals with higher-level neonatal care among birth hospitals was calculated each year between 2010 and 2022 to evaluate losses and gains of higher-level neonatal care. Percentages were compared using binomial generalized estimating equation models.

Between 2010 and 2022, 3257 birth hospitals were open for any duration of time in the United States. Of these, 1149 were rural and 2108 urban. Higher-level neonatal care was provided by 160 and 1281, respectively, in 2010, with 48 and 208, respectively, gaining higher-level care from 2010 to 2022.

Loss of higher-level neonatal care was reported for 70 rural hospitals and 177 urban hospitals. Overall, rural areas reported a net loss of 22 birth hospitals providing higher-level care between 2010 and 2022, while urban areas reported a net gain of 31.

Care rates and implications

Rates of higher-level neonatal care in 2010 and 2022 for rural birth hospitals were 14.1% and 16.9%, respectively. For urban hospitals, rates were 64.2% and 74.4%, respectively. This indicated a nonsignificant increase in rural regions vs a significant increase in urban regions.

The trial was limited by hospital data being self-reported and neonatal beds potentially being unused. However, the data highlighted a significant reduction in access to childbirth and higher-level neonatal care among rural hospitals vs urban hospitals.

“US infant mortality rates increase with the degree of rurality; therefore, rural-urban differences in higher-level neonatal care availability may contribute to the survival gap for rural infants,” wrote investigators.

Broader trends in neonatal mortality

Prior data have highlighted concerns in mortality among US infants, indicating a decline in overall neonatal deaths but a rise in deaths from fetal malnutrition.² The study, published in JAMA Pediatrics, reported 283,696 neonatal deaths between January 1, 1999, and December 31, 2022.

Of these deaths, 79.8% were linked to the top 10 causes of neonatal mortality, including short gestation and low birth weight. Declines in deaths caused by interstitial emphysema and related conditions and mortality from perinatal respiratory distress were reported, with annual average percent changes (AAPCs) of –5.40% and –3.63%, respectively.

In comparison, the AAPC for slow fetal growth and fetal malnutrition-related mortality was 1.91%, highlighting an increase. This indicated impaired neonatal nutrition, highlighting an additional avenue where care must be improved.

References

1. 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
2. Ebert M. Neonatal deaths in the US decline overall, but malnutrition-related mortality rises. Contemporary Pediatrics. July 11, 2025. Accessed February 17, 2026. https://www.contemporarypediatrics.com/view/neonatal-deaths-in-the-us-decline-overall-but-malnutrition-related-mortality-rises