Inequitable Access to Risk-Appropriate Neonatal Care: Evidence from a Regionalized Perinatal System in Arkansas

Objective Evaluate access to risk-appropriate neonatal care in Arkansas and examine associations of geography, hospital availability, and county-level maternity care access with birth triage, neonatal transfers, neonatal intensive care unit (NICU) utilization. Study Design Population-based retrospective cohort study of all live births in Arkansas from 1/1/2014, through 12/31/2023. Linked birth certificate, hospital neonatal level, county maternity care access data were analyzed. Exposures included distance to nearest risk-appropriate facility and local hospital availability. Outcomes included birth and transfer triage, NICU utilization. Results Among 358,183 live births, 76.5% were over-triaged, 3.3% under-triaged, and 20.1% risk-appropriate. Under-triage was most common when nearest appropriate facility was distant (mean 51.2 miles). Transfers were predominantly over-triaged (82.4%). NICU utilization was highest in counties with greater maternity care access despite similar high-acuity birth rates. Conclusion Triage patterns were driven more by geography than clinical need, indicating opportunities to improve alignment between neonatal risk and site of care.