30-Year Boom in NICU Capacity Hasn’t Lowered Mortality

The number of neonatologists in the United States has grown 227% in the last three decades and the number of neonatal intensive care unit (NICU) beds has grown 48%, but those increases appear to have had no effect on lowering newborn mortality rates, said authors of a new study.

Authors, led by Gwenyth M. Gasper, MS, with the Dartmouth Institute for Health Policy and Clinical Practice, in Hanover, New Hampshire, wrote that “although NICU care is highly effective in the treatment of serious newborn illness, recent growth in the number of total neonatologists and NICU beds has occurred independent of need and is not associated with newborn mortality at either the individual or the regional level.”

Findings were published on March 24 in JAMA Pediatrics.

Researchers Say Further Growth Warrants Scrutiny

The researchers concluded that, “The benefits and costs of current NICU capacity and further growth warrant clinical and policy scrutiny.”

However, an expert not involved with the study said the numbers don’t tell the whole story of NICU care.

The study points out that from 1991 to 2020, the number of neonatologists increased from 0.44 to 1.44 per 1000 live births (227%) and NICU beds per 1000 live births increased from 5.43 to 8.02 (48%). Over the same period, mortality decreased from 3.87 to 2.21 (−43%) and 180-day mortality decreased from 6.27 to 3.19 (−49%) per 1000 live births. However, there was no meaningful correlation between change in regional capacity (neonatologists: r, −0.12; 95% CI, −0.25 to 0.00; NICU beds: r, −0.07; 95% CI, −0.19 to 0.06) and change in regional neonatal mortality.

The lack of an association held up even with stratification by gestational age, maternal education, and maternal race or ethnicity and restriction of the infant population to very low birthweight newborns, which the authors pointed out is “a uniquely high-risk population.”

Growth Followed NICUs’ Success 

NICU care has been highly effective in the treatment of serious newborn illness and has led to dramatic reductions in neonatal morbidity. Success stimulated growth, but the growth was uneven by region, the authors noted.

“Regions with higher perinatal risk are not more likely to experience higher capacity growth. Furthermore, despite its association with NICU utilization, higher NICU bed capacity is not reliably associated with lower risk of inpatient mortality or short-term post discharge outcomes, suggesting possible oversupply in some regions,” the authors wrote.

Numbers Don’t Tell the Whole Story

Robert Kiley, MD, medical director of Neonatology at Children’s Hospital Colorado, Colorado Springs, who was not involved with the study, told Medscape Medical News he wouldn’t expect the growth in number of NICUs and neonatologists to correlate with decreased mortality.

“I’m not sure how having more bed space decreases mortality necessarily,” he said. “Also, the study doesn’t separate out level 2 from level 3 or 4 NICUs,” which offer very different services, he pointed out.

He said the numbers don’t take into account a changing landscape over the study period in which “more than 500 labor and delivery departments,” mostly in rural areas, have been shuttered and women with pregnancy complications who might have gone to those specialists are delivering in emergency departments at their nearest hospital that may not be equipped to resuscitate small or sick babies.

“Then those babies have to get flown in or driven in to regionalized NICUs. That’s going to make mortality probably worse,” he explained.

Not All Are at the Bedside

As to the increase in neonatologists, he said that spike may be misleading because in academic centers, a neonatologist “may do a month or 2 of clinical work per year” and the rest may be scholarly activities and research. “They’re definitely not full-time clinical neonatologists,” he noted. “The way the researchers count neonatologists is “if you clinically touch a patient. It doesn’t matter if it’s 2 months out of the year or someone like me who’s touching patients 11 and a half months a year. They also give credit to neonatal fellows who are in training and that’s also taking an attending neonatologist out of their bedside role to do more teaching.”

More emphasis on work-life balance has also meant more part-time neonatologists, he added.

He said there may very well be enough NICUs and neonatologists currently as the authors suggest, but they are not distributed across regions with the most need.

Additionally, having so many NICUs concentrated in certain areas, “dilutes the experience of neonatologists, nurse practitioners, and neonatal nurses,” he said. “Quality improvement comes from multiple, repetitive exposures to very similar patients.” 

More Effective Strategies

Gasper and colleagues wrote that instead of growing the number of units and neonatologists, alternative strategies such as developing new technologies and more fully implementing care models known to be highly effective may better drive mortality down.

Kiley agreed that better adherence to proven care plans likely will help reduce mortality. Consistently using proven care plans will also help hospitals taking women who need an NICU but can’t drive the long distance to get to one.

He added that advances in the field have helped address morbidity, if not mortality. “As we’re resuscitating smaller and smaller babies, we’re giving them a shot at life, but that will also increase our mortality rate. But I’d like to think that at least we’re improving our morbidity rates — that our care plans, for example, that we execute on these small babies decrease their risk of cerebral palsy, decrease their risk of infections. As a physician on the ground, that’s where I like to think I move the needle most.”

A co-author, David Goodman, reported receiving grants from the US National Institute of Child Health and Human Development during the conduct of the study. Kiley reported no relevant financial relationships.

Marcia Frellick is an independent Chicago-based healthcare journalist. She regularly covers primary care and specialties including pediatrics, infectious disease, cardiology, dermatology, and oncology/hematology.