Trends in Resources for Neonatal Intensive Care at Delivery Hospitals for Infants Born Younger Than 30 Weeks’ Gestation, 2009-2020

IMPORTANCE: In an ideal regionalized system, all infants born very preterm would be delivered at a large tertiary hospital capable of providing all necessary care. OBJECTIVE: To examine whether the distribution of extremely preterm births changed between 2009 and 2020 based on neonatal intensive care resources at the delivery hospital. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study was conducted at 822 Vermont Oxford Network (VON) centers in the US between 2009 and 2020. Participants included infants born at 22 to 29 weeks’ gestation, delivered at or transferred to centers participating in the VON. Data were analyzed from February to December 2022. EXPOSURES: Hospital of birth at 22 to 29 weeks’ gestation. MAIN OUTCOMES AND MEASURES: Birthplace neonatal intensive care unit (NICU) level was classified as A, restriction on assisted ventilation or no surgery; B, major surgery; or C, cardiac surgery requiring bypass. Level B centers were further divided into low-volume (<50 inborn infants at 22 to 29 weeks’ gestation per year) and high-volume (≥50 inborn infants at 22 to 29 weeks’ gestation per year) centers. High-volume level B and level C centers were combined, resulting in 3 distinct NICU categories: level A, low-volume B, and high-volume B and C NICUs. The main outcome was the change in the percentage of births at hospitals with level A, low-volume B, and high-volume B or C NICUs overall and by US Census region. RESULTS: A total of 357 181 infants (mean [SD] gestational age, 26.4 [2.1] weeks; 188 761 [52.9%] male) were included in the analysis. Across regions, the Pacific (20 239 births [38.3%]) had the lowest while the South Atlantic (48 348 births [62.7%]) had the highest percentage of births at a hospital with a high-volume B– or C-level NICU. Births at hospitals with A-level NICUs increased by 5.6% (95% CI, 4.3% to 7.0%), and births at low-volume B–level NICUs increased by 3.6% (95% CI, 2.1% to 5.0%), while births at hospitals with high-volume B– or C-level NICUs decreased by 9.2% (95% CI, −10.3% to −8.1%). By 2020, less than half of the births for infants at 22 to 29 weeks’ gestation occurred at hospitals with high-volume B– or C-level NICUs. Most US Census regions followed the nationwide trends; for example, births at hospitals with high-volume B– or C-level NICUs decreased by 10.9% [95% CI, −14.0% to −7.8%) in the East North Central region and by 21.1% (95% CI, −24.0% to −18.2%) in the West South Central region. CONCLUSIONS AND RELEVANCE: This retrospective cohort study identified concerning deregionalization trends in birthplace hospital level of care for infants born at 22 to 29 weeks’ gestation. These findings should serve to encourage policy makers to identify and enforce strategies to ensure that infants at the highest risk of adverse outcomes are born at the hospitals where they have the best chances to attain optimal outcomes.