Perinatal regionalization: a geospatial view of perinatal critical care, United States, 2010-2013

Abstract

Background: Perinatal services exist today as a dyad of maternal and neonatal care. When perinatal care is fragmented or unavailable, excess morbidity and mortality may occur in pregnant women and newborns.

Objective: The objective of the study was to describe spatial relationships between women of reproductive age, individual perinatal subspecialists (maternal-fetal medicine and neonatology), and obstetric and neonatal critical care facilities in the United States to identify gaps in health care access.

Study design: We used geographic visualization and conducted surface interpolation, nearest neighbor, and proximity analyses. Source data included 2010 US Census, October 2013 National Provider Index, 2012 American Hospital Association, 2012 National Center for Health Statistics Natality File, and the 2011 American Academy of Pediatrics directory.

Results: In October 2013, there were 2.5 neonatologists for every maternal-fetal medicine specialist in the United States. In 2012 there were 1.4 level III or higher neonatal intensive care units for every level III obstetric unit (hereafter, obstetric critical care unit). Nationally, 87% of women of reproductive age live within 50 miles of both an obstetric critical care unit and a neonatal intensive care unit. However, 18% of obstetric critical care units had no neonatal intensive care unit, and 20% of neonatal intensive care units had no obstetric critical care unit within a 10 mile radius. Additionally, 26% of obstetric critical care units had no maternal-fetal medicine specialist practicing within 10 miles of the facility, and 4% of neonatal intensive care units had no neonatologist practicing within 10 miles.

Conclusion: Gaps in access and discordance between the availability of level III or higher obstetric and neonatal care may affect the delivery of risk-appropriate care for high-risk maternal fetal dyads. Further study is needed to understand the importance of these gaps and discordance on maternal and neonatal outcomes.

Keywords: critical care; geospatial; neonatal; obstetric; perinatal.

FIGURE 1. Reproductive-age women within 50 miles of a perinatal critical care unit

Women of reproductive age (ages 15–44 years) living within 50 miles of a perinatal critical care unit, by subspecialty and state, 2012. A, Access to level III obstetric critical care unit. Green areas indicate access in state, dark red areas indicate access in state but closest obstetric critical care unit is out of state, purple areas indicate access but to obstetric critical care unit out of state, white areas indicate no access, but closest obstetric critical care unit is in state, blue areas indicate no access and closest obstetric critical care unit is out of state, and splatter indicates populated area. B, Access to level III or higher neonatal intensive care unit. Green areas indicate access in state, dark red areas indicate access in state, but closest neonatal intensive care unit is out of state, purple areas indicate access, but neonatal intensive care unit is out of state, white areas indicate no access but closest neonatal intensive care unit is in state, blue areas indicate no access, and closest neonatal intensive care unit is out of state, and splatter indicates populated area.

FIGURE 2. Proximity relationship of perinatal units

Proximity relationship of perinatal units: 10 mile zones around hospitals with level III or higher obstetric and/or neonatal critical care units, United States, 2012. Dark green circles indicate obstetric critical care unit and neonatal intensive care unit are adjacent, green circles indicate an obstetric critical care unit, and pink circles indicate neonatal intensive care unit. Note: the zone sizes for Alaska and Hawaii were modified to enable visualization.

FIGURE 3. Relationship of perinatal practitioners and perinatal critical care facilities

Relationship of perinatal practitioners and perinatal critical care facilities: perinatal critical care hospitals overlaid with office location of perinatal specialists, United States, 2013. A, Maternal fetal-medicine practitioners and obstetric critical care units. Black circles indicate maternal-fetal medicine practitioner, and green circles indicate obstetric critical care unit. B, Neonatologists and neonatal intensive care units. Black circles indicate neonatologists, and purple circles indicate neonatal intensive care unit.