Risk-appropriate care during the perinatal period, or perinatal regionalization, is a coordinated, tiered system of service provision that provides high-risk obstetric patients with access to well-equipped and staffed resources including Neonatal Intensive Care Units.^1–4 Perinatal regionalization directs patients to the best resourced and skilled locations based on risk³ and is an important component of care for very premature and very low birth weight neonates.⁵ Recent research indicates that infants who receive care at higher level facilities have higher rates of survival than those receiving care at lower level facilities.⁵ Regionalized perinatal networks are designed to centralize advanced care technology and skills for high-risk neonates and mothers, using well-defined care capability levels for both women and infants.^3,6,7 In the ideal clinical network, with well-defined policies, delivery of care occurs within a designated perinatal region through identification of high-risk maternity patients who are appropriately transferred (from one facility to another) during the antenatal period.^8,9 An ideal system would also transport (the physical movement of the patient via ground, air or water vehicles) convalescing neonates and mothers back to community facilities to eventually transition home or into community care.

Changes from a cooperative model of perinatal health care delivery towards a competitive model in some regions of the United States,^10–12 and the varying perception of the viability of very low birth weight/preterm infants,¹³ has contributed to a rapid increase in the number of hospitals that offer specialized care for high-risk neonates. Thompson et al.¹⁴ found that the United States had a birth density of neonatologists (neonatologists per 10 000 live births) 1.7 and 1.8 times higher than Australia and Canada, respectively, and 2.3 times higher than the United Kingdom; such high density in resources and work-force resulted in the ‘de-regionalization’ of care for at-risk neonates.^10,12

To better understand how de-regionalization of care has affected maternal and neonatal transfers, studies have examined factors influencing timely referral of obstetric patients (maternal transfer) or neonates (neonatal transfer) to institutions with appropriate resources for both high-risk maternal and infant care. Studies have focused on transport indices/scores such as the Transport Risk Index of Physiologic Stability (TRIPS), California TRIPS and Mortality Index for Neonatal Transportation;^15–19 as well as referral patterns,²⁰ methods of communication,^21,22 insurance type/status,^23–25 and ground transport times. Researchers concluded that these factors impact transfers and ultimately, patient health.²⁶

Despite single^{10,22,27–31} and multi-state^32–34 studies on perinatal regionalized systems, generalizability of findings is limited. No study has examined the scope of transfer policies and regulations within and among all United States and territories. As effective regionalization involves not only facilities with defined care capabilities but also timely and coordinated referral of obstetric and neonatal patients, an assessment of maternal and neonatal transfer policies provides insight into the organization and potential effectiveness of perinatal regionalization in the United States. Therefore, the objective of this study is to summarize two essential components of maternal and neonatal transfer policies – transport and reimbursement – among US states and territories.

Monitoring and facilitating transfer of at-risk maternal and neonatal patients operationalizes risk-appropriate care. Presented here is the first summary of the maternal and neonatal transport polices within the 50 US states and eight territories. Only two-thirds of states have developed state-level policies to address neonatal transport for risk-appropriate care and well-defined policies for inter-hospital transfers. In addition, fewer than two-thirds of states have developed a policy for maternal transport, a key strategy in improving the survival of high-risk infants.⁶ Among states with existing transport policies, fewer than one-half have specified back-transport policies. However, states with neonatal transport policies typically have well-developed reimbursement components, particularly for neonatal transport within Medicaid. Reimbursement for maternal transport is addressed in policy by only one-fifth of states. Finally, the majority of US territories do not have well-defined maternal or neonatal transport policies, which could critically impact the transfer of patients from remote areas to facilities with risk-appropriate capabilities.

A major achievement of perinatal regionalization is the development of antenatal and neonatal transport policies within and between state hospital systems.³⁶ A benefit of a well-designed inter-state/region hospital transport service is the timely provision of care, an important component of regionalized systems.⁴ Fully developed transport policies address issues to reduce lack of insurance status (for example, private vs Medicaid vs none),^23–25,37 distance from appropriate hospital³⁸ and competition for patients,³⁹ to ensure efficiency in transfer and receipt of care. In an ideal setting, a good system functions independently of insurance status, prepares for the challenges of distance and allocates resources to address competitive market forces.

Despite technology driven progress on neonatal survival,²⁹ the uterus remains the optimal mode of transport for a developing fetus.⁴⁰ Antenatal transfers lead to better neonatal survival when compared with postnatal transfers,^41,42 decreases in short and long-term disabilities and costs,^43–46 and increased bonding between a mother and her critically ill newborn.⁴³ However, the evidence for the specific advances gained with perinatal regionalization is not as well-defined for obstetric care. Over time, perinatal services have been defined separately for maternal and neonatal care, contributing to a break in the continuity of care during labor, delivery and recovery. Sinkin et al.⁴ found that managed care availability was not equally distributed in all regions and remained a significant obstacle for maternal transfer; in some regions a high-risk pregnancy is followed by the maternal–fetal specialist, whereas in others, the specialist acts as a consultant, playing a limited role in labor and delivery.⁴ In addition, differences in perinatal regionalization legislation or financial incentives to hospitals may impact which hospitals establish a lower or higher-level NICU.³³

Equally important in the concept of transport is the return of convalescing neonates, or back-transport, to lower-level hospitals for recovery care and community support. Back-transport is a method of achieving risk-appropriate care, in a resource-efficient manner when tertiary care is no longer indicated.⁴⁷ Returning infants to their community hospitals supports familial bonding and eases financial and emotional stress on parents,⁴⁸ strengthens the patient-provider relationship,⁴⁹ decreases the impact of adverse effects on outcomes for the infant, improves efficiency of NICU bed utilization^37,50–52 and generates net cost savings.^37,53 Although it is important to recognize that cost savings can be impacted by longer periods of hospitalization for back-transported infants. Bose et al.⁵³ concluded that the 34% reduction in cost for back-transporting neonates was offset by a 21% increase in cost required to keep the convalescent infant in the community hospital.⁵³

Despite these benefits, the current results indicate that most states did not specify a back-transport policy. Lack of back-transport policy development in states may directly reflect the disparity between costs and reimbursement. For instance, a hospital that is receiving reimbursement for care of an infant is not incentivized to back-transport the infant, since convalescing care reimbursement would be received by another institution.⁵⁴

Likewise, maintenance of funding is essential for sustaining perinatal regionalized systems; fewer than two-thirds of states and one territory specifically addressed reimbursement for transport. All states with a reimbursement policy included payment for neonatal transport, while fewer than one-third of those with a policy also included a reimbursement for maternal transport. However, the majority of states that had a reimbursement policy also included reimbursement from Medicaid; which finances an estimated 40 to 50% of all births in the United States.^55,56 In addition, the Medicaid population is the largest at-risk group and consumer of risk-appropriate care.^57,58 During the 2009 Association of Maternal and Child Health Programs Perinatal Regionalization meeting, multiple state presentations referenced budget cuts as a barrier to improvements in risk-appropriate care.⁵⁹ It is possible that states without reimbursement policies lack the resources necessary to consider developing policies on reimbursement when considering overall cost reduction efforts.⁵⁴ Without proper funding, long-term sustainability of a comprehensive perinatal regionalization system would be difficult for any state.²⁹ Incorporating other systems of risk-appropriate care, such as disaster preparedness, could provide efficient use of resources in perinatal care.⁶⁰ During economically challenging times, it is critical that budgeting for maternal and neonatal transport be well defined, because appropriate reimbursement incentivizes compliance with regionalization policies.

There are several limitations to this study. The researchers did not contact states directly to obtain additional information regarding state policies. Also, as the internet is a fluid environment, it is possible that states may have updated information that was not available during study data collection. Lastly, since perinatal regionalization is often defined by state and/or regions within a state, the researchers are not able to include an analysis of policies developed at the local, network or hospital level. Regardless of these potential limitations, the presence of state-level transport policies suggest that states are making efforts to support risk-appropriate care.

This systematic review provides a summary of transfer policies for all 50 US states and eight territories. Although more than half of states and a few territories have well-developed transport policies, back-transport policies – critical for convalescing mothers and infants – have been minimally implemented. States and territories with transport policies have reimbursement policies, though reimbursement is focused on neonatal transport. Monitoring maternal and neonatal transport and reimbursement as it relates to perinatal regionalization in the United States is essential as resource constraints require targeted decision-making by states, health officials, hospital systems, hospital administrators and insurance providers. Readily available information related to perinatal regionalization, as presented here, informs allocation and redistribution of resources targeting improvement in the efficiency, effectiveness and quality of risk-appropriate care for mothers and infants.