Methods<\/p>\n\n\n\n
This retrospective cohort study included all US hospitals that offered childbirth services (birth hospitals) and identified those with higher-level (intermediate or intensive) neonatal care. The study was deemed non\u2013human participant research and exempt from review and informed consent by the University of Minnesota Institutional Review Board and followed the STROBE<\/a> reporting guideline.<\/a><\/p>\n\n\n\n Using American Hospital Association annual surveys and Centers for Medicare & Medicaid Services Provider of Services files from 2010 to 2022, we applied an enhanced algorithm to identify birth hospitals.6<\/a><\/sup> Birth hospitals were classified as having higher-level neonatal care if data indicated delivery of neonatal intensive care, at least 1 neonatal intensive care bed, or at least 1 neonatal intermediate care bed. Provider of Services files were used for confirmation. Primary reviews of hospital websites and news media were conducted to validate neonatal care status for hospitals with discrepancies between data sources, across years, and in cases of mergers and acquisitions.6<\/a><\/sup><\/a><\/p>\n\n\n\n Hospital rurality was classified using Office of Management and Budget definitions. Urban hospitals were located in metropolitan statistical areas and rural hospitals in counties without an urbanized area of 50\u202f000 inhabitants.<\/a><\/p>\n\n\n\n We assessed losses and gains of higher-level neonatal care from 2010 to 2022 by calculating the percentage of hospitals with higher-level neonatal care among birth hospitals open each year. We compared 2010 and 2022 percentages of hospitals with higher-level care using binomial generalized estimating equation models. Analyses were performed between May 20 and November 3, 2025, using SAS, version 9.4 (SAS Institute Inc) and Stata, version 18.0 (StataCorp LLC). P<\/em> < .05 was considered significant.<\/a><\/p>\n\n\n\n Results<\/p>\n\n\n\n There were 3257 US birth hospitals open at any point from 2010 to 2022 (1149 rural, 2108 urban). In 2010, 160 rural and 1281 urban birth hospitals offered higher-level neonatal care (Table<\/a>). Between 2010 and 2022, 48 rural and 208 urban birth hospitals gained higher-level neonatal care, while 70 rural and 177 urban birth hospitals lost higher-level care. Rural areas saw a net loss of 22 birth hospitals offering higher-level neonatal care, and urban areas saw a net gain of 31 birth hospitals adding this care.<\/p>\n\n\n\n In 2010, 160 of 1131 rural birth hospitals (14.1%) had higher-level neonatal care and in 2022, 152 of 897 (16.9%) did, a nonsignificant difference. Among urban birth hospitals, 1281 of 1995 (64.2%) had higher-level neonatal care in 2010, increasing significantly to 1341 of 1802 (74.4%) in 2022 (P<\/em>\u2009= .01) (Figure<\/a>).<\/p>\n\n\n\n Discussion<\/a><\/p>\n\n\n\n This cohort study suggests that access to higher-level neonatal care is limited at rural birth hospitals, as less than 20% offered this care in 2022 vs 74% of urban hospitals. While rural hospitals are losing childbirth care capacity,2<\/a><\/sup> urban birth hospitals are expanding higher-level neonatal care, accentuating geographic discrepancies in access to care for high-risk infants.<\/a><\/p>\n\n\n\n Study limitations include that hospital data were self-reported and reported neonatal beds may not be used. The denominator for the study outcome decreased each year with hospital and obstetric unit closures, which were more prevalent among rural hospitals. While rurality is a continuum, we applied a dichotomous county-based measure. These hospital-level data do not contain patient-level information, precluding analysis of how higher-level neonatal care changes influenced patient outcomes.<\/a><\/p>\n\n\n\n![\"\"\/](\"https:\/\/cdn.jamanetwork.com\/ama\/content_public\/journal\/jamanetworkopen\/939778\/zld250342t1_1770311122.75274.png?Expires=1777588485&Signature=N6JxbSSRQRtdDyGWEYWSUoC0uUxf0V3o4z1M3nqLE1p98ykYkBZxq9NXRAnhotmOG4ZrE8bpsC-hyg49tTZ0JrUydpC9UPPM08Jxivl6Bkqfm2VIbvOPG8NTWCr41WdOs6NY01Lrkp~2~ufewX9IEnXl-PNtIL0xd2-I-g4aoN6KKeNnEGmxcAJHX-gW-DM7WsB71kZhN3LtUQ8PycMzRePGlWuv0Xk1Xy8a1GaD9AOcLMNdvKW5F~pYtK4gylz24ss8aXMyRXOpNT2Qwaxmv9mCzfrlQCTUP8knvTlxDgMK9Wz~xxIhsfCE0MlhUE4Xs4S7WN0kYDuJhBlvB~2ftA__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA\")
<\/figure>\n\n\n\n![\"\"\/](\"https:\/\/cdn.jamanetwork.com\/ama\/content_public\/journal\/jamanetworkopen\/939778\/zld250342f1_1770311122.77274.png?Expires=1777588485&Signature=TsXVIA9ipbbs5xoIvcZVQVDYRgF8IhE4cKxhCJHGN0nnMIEreuagxvbsYfNHM4nF1KBNecQozZutN~pIwMm7aGozR8DOCrXvw1UhzCNbB4R1ALQFkpCRi5f8zYTp--n7FHZQ~hG5a2luej1HRwiZn5va2CkwO1I6EdY5qANXB8nI3zHS8Zuseqh-sOQq3O-D7DfJzPSU3nzWM-7pv999dLfibdAKAxpurM-Pg~v6Ppyj9BToY269RgCRRea7rpSg5bVFlMwDJYiehSLlEk~gQAGhIaLVokWQbOWcGppCnd9KoNytFYPs6ePBHHdaJMrJxhOU2BRQGhT1UyrnW73~gw__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA\")
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