A cross-sectional study of nearly 1 million late-preterm and term births found that birth sites with lower levels of service—including those without pediatrics, neonatal intensive care, or obstetrics—were associated with higher odds of chest compressions.1
Advanced neonatal resuscitation interventions (ANRIs), defined as endotracheal intubation, chest compressions, and epinephrine administration, are rarely performed in late-preterm and term births. However, newborns can be born in critical condition and require these advanced interventions.
“We theorized that clinical factors, such as maternal health conditions, pregnancy complications, fetal/neonatal risk factors, and nonclinical factors, such as how remotely a pregnant woman lived and what hospital/birth setting she delivered in, can all influence whether a baby born late preterm or term receives advanced resuscitation interventions,” said the study’s senior author Brenda Hiu Yan Law, MD, MSc.
The study analyzed 966,475 live births at 34 weeks’ gestation or later, with 1% of these births receiving ANRI. Maternal socioeconomic status (SES), estimated by Pampalon Material Deprivation Index determined by postal code, and maternal residence remoteness were not associated with higher odds of ANRI; but birth sites with lower levels of service were. Compared with Level 2 birth sites, Level 3 birth sites (tertiary hospitals with high-level neonatal ICUs) had lower odds of ANRI (OR, 0.57; 95% CI, 0.53-0.61) and all interventions. Additionally, earlier gestational age was significantly associated with ANRI risk, with the risk falling each week after 34 weeks until 38 weeks.
The fact that maternal lower SES and residence remoteness were not independently associated with higher odds of advanced resuscitation was surprising to the study authors.
“I think the clinical implication is that when maternal and fetal risk factors are present, a baby may be better taken care of if born at a higher level of service. Therefore, as much as feasible, these births should occur in those higher levels of service, which could mean that the mother is directed there prior to going into labor or if they’re already in labor and if it’s feasible that the mother could be transferred,” said Henry C. Lee, MD, Professor at the University of California San Diego and National Senior Director for Resuscitation Science at the American Heart Association.
The study also examined clinical factors associated with the need for ANRI and found that maternal general anesthesia was highly associated with ANRIs, regardless of whether an emergency cesarean section was performed (OR, 4.89; 95% CI, 4.47-5.34). Whether this is a direct result of the types of system medications used, or another reason, is unknown. Receipt of regional maternal anesthesia, such as epidural and spinal anesthesia, was also associated with ANRI risk but to a lesser extent (OR 1.82 and 1.39, respectively).
Much of neonatal resuscitation research has been done in either very or extremely preterm infants less than 32 weeks’ gestational age in tertiary care or large hospitals. This research described the real-world experience of neonatal resuscitation in a variety of clinical settings, ranging from home births to community hospitals to large, tertiary care hospitals. The study also assessed a relatively low-risk population (term and late-preterm infants), which, in general, is understudied.
This study did not explore why differences exist among various hospitals and birth sites. Level 1A facilities (those without operating room capability) and home births were associated with significantly higher ANRI risk when compared with Level 2 facilities; however, Level 1B and 1C facilities (those with operating room capability) were associated with ANRI risk similar to that of Level 3 facilities (OR 0.69 and 0.61, respectively), suggesting that specific elements of delivery locations may substantially affect ANRI risk. Based on the data, it’s unclear whether these variations stem from lack of professional training, equipment shortages, procedural inconsistency, or other factors.
“The question of ‘why’ would be key to explore in the future, for our health system in Alberta and in other similar health systems with rural and urban populations, to determine what quality improvement can be done to ensure that care is delivered equitably no matter where a child is born and that even birth sites with fewer resources can perform optimal neonatal resuscitation,” Dr. Law said.
References
1. Pickett B, Pan B, Crawford S, et al. Clinical and nonclinical factors and advanced neonatal resuscitation interventions. JAMA Netw Open. 2026;9(4):e269923. doi:10.1001/jamanetworkopen.2026.9923
