Reducing Disparities in Access to High-level Neonatal Intensive Care and Neonatal Outcomes - ABSTRACT Neonatal and infant mortality remains a significant public health issue in the United States (US). One key driver of this disparity in infant mortality rates is the increased risk of very-low-birth weight (VLBW) in women of minority racial/ethnic status and racial/ethnic disparities in preterm-related infant mortality rates. The outcomes of VLBW infants are improved if they deliver at a hospital with a “high- level” neonatal intensive care unit (NICU), which is a unit with the clinical expertise to manage the sickest of infants. Unfortunately, there are studies that suggest that high-risk black infants are more likely to deliver at poor quality obstetric hospitals, especially in urban areas, and bypass hospitals with high-level NICUs for delivery because of the proliferation of delivery hospitals without such services who deliver high-risk infants. As a result, 60% of states have enacted legislation to encourage the transfer of mothers and babies to such centers, with wide variation in the specific types of policies. There is no research to identify the association between such policy elements and patient outcomes, nor how state, hospital, and patient characteristics modify these associations. The overall goal of this project is to determine how specific maternal and infant transfer policies affect racial/ethnic disparities in (1) where VLBW infants deliver, and (2) neonatal mortality and morbidity. We will apply a modification of the Anderson/Aday behavioral model of health care use that we have published to an innovative 17-year population-based cohort of VLBW infants whose data are prospectively collected as part of Vermont Oxford Network which is composed of 870 US NICUs that cover nearly 90% of VLBW births in the US. Using marginal structural models and formal mediation analyses, this study will characterize (1) how the presence of any perinatal policies surrounding neonatal and maternal transfer and specific policy elements differentially affect access to high-level neonatal care for VLBW infants of different racial/ethnic status; (2) determine how transfer policies and characteristics, through changes in access to high-level NICU care, differentially affect rates of neonatal mortality and morbidity in VLBW infants of different race/ethnicity; and (3) define how the combination of specific characteristics of maternal and infant policies and policy load moderate these associations. At the end of this study, we will provide information to stakeholders about how transfer policies related to a unique population, the mother-baby dyad, reduce disparities in infant mortality and improve infant health.
