Low-birthweight infants born in medical facilitates with neonatal intensive care units (NICUs) or immediately transferred to such facilities after birth have lower morbidity and mortality than their counterparts who are born and remain in medical facilities without neonatal intensive care units. Difference in referral rate is partly related to variations in providers’ perception of the viability of a low-birthweight infant and the affect that perception has on the decisions concerning resuscitation and referral to an appropriate facility.

This study examined the affect of maternal race, insurance status, and use of prenatal care in the first trimester on the likelihood that a very low birthweight infant (500 –1499g) will be born in or transferred to a hospital with neonatal intensive care units. Vital records for 2,596 infants with very low birthweights born during the period from 1988 to 1990 in Alabama were examined. Maternal characteristics were compared across four groups: infants born in hospitals with NICUs with no indication of transfer, infants born after maternal transfer, infant born in other hospitals and then transferred to hospitals with NICUs, and infants born in other hospitals without later transfer.

Regardless of specific birthweight, maternal age, maternal education, parity status, previous fetal or infant loss, and distance to closet NICU, non-White women were 35% more likely than White women to have very low birthweight infants born in hospitals with NICUs. Furthermore, non-White women on Medicaid who began prenatal care during the first trimester were 73% more likely to have very low birthweight infants born in hospitals with NICUs than White women without Medicaid who also had first trimester prenatal care. Among women who presented first at hospitals without NICUs, non-White women without Medicaid who received early prenatal care were 9% (not significant) more likely to be transferred to hospitals with NICUs before delivery than White women without Medicaid who also had first trimester prenatal care. However, non-White women with Medicaid and received early prenatal care were 30% less likely to be transferred. In contrast, White women with Medicaid who received early prenatal care were 82% more likely to be transferred to hospitals with NICUs before delivery than White women without Medicaid who also had first trimester prenatal care.

Thus, Medicaid coverage decreased the likelihood of antenatal transfer for non-White women and increased the likelihood of antenatal transfer for White women. Across all groups, late prenatal care reduced the likelihood of either having low birthweight infants born in hospitals with NICUs or antenatal transfer.

The low rate of maternal transfer among non-White women may be because these women are more likely to initially present and deliver their infants in hospitals with NICUs. Thus, these women may have been underrepresented in the selected subsample of women who were available to receive maternal transfer. Interestingly, the authors believe that Medicaid coverage had no affect on the likelihood of maternal transfer for non-White women, although the OR for non-White, early prenatal care, and without Medicaid was 1.092 (95%CI 0.75-1.59) and for non-White, early prenatal care, and with Medicaid was 0.697 (95%CI 0.45-1.08). The authors state that “some hospitals selectively retain privately insured women for high risk deliveries but refer less well insured women on to subspecialty regional centers.” The authors believe that White women without Medicaid coverage may be more well off and have private insurance, and, thus, the hospitals would want to retain these women. Furthermore, they assert that this did not occur for non-White women without Medicaid coverage since these women were most likely not to have been privately insured. It is possible that non-White women with Medicaid were less likely to be transferred since the hospital received some reimbursement. But, non-White women without Medicaid coverage had no other insurance and thus the initial hospital wanted to transfer these high-risk women to reduce their financial burden. This study shows that the major barrier to receiving appropriate care for very low birthweight is financial and less consideration is paid to maternal risk characteristics. Thus, interventions are necessary, as well as regulation of referral patterns of hospitals and physicians, to ensure that all low-birthweight infants receive care in hospitals with appropriate equipment and personnel regardless of race, insurance coverage, and socioeconomic status.