Am J Perinatol 2023; 40(01): 035-041
DOI: 10.1055/s-0041-1727222
Original Article

Association of Rural and Frontier Residence with Very Preterm and Very Low Birth Weight Delivery in Nonlevel III NICUs

Stephanie L. Bourque
1   Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine, Aurora, Colorado
Blair W. Weikel
1   Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine, Aurora, Colorado
Kristin Crispe
2   Department of Family Medicine, University of Colorado, Aurora, Colorado
Sunah S. Hwang
1   Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine, Aurora, Colorado
› Author Affiliations


Objective Delivery of very preterm and very low birth weight neonates (VPT/VLBW) in a nonlevel III neonatal intensive care unit (NICU) increases risk of morbidity and mortality. Study objectives included the following: (1) Determine incidence of VPT/VLBW delivery (<32 weeks gestational age and/or birth weight <1,500 g), in nonlevel III units in Colorado; (2) Evaluate the independent association between residence and nonlevel III unit delivery; (3) Determine the incidence of and factors associated with postnatal transfer.

Study Design This retrospective cohort study used 2007 to 2016 Colorado birth certificate data. Demographic and clinical characteristics by VPT/VLBW delivery in level III NICUs versus nonlevel III units were compared using Chi-square analyses. Multivariable logistic regression was used to estimate the independent association between residence and VPT/VLBW delivery.

Results Among patients, 897 of 10,015 (8.96%) VPT/VLBW births occurred in nonlevel III units. Compared with infants born to pregnant persons in urban counties, infants born to those residing in rural (adjusted odds ratio [AOR] = 1.58, 95% confidence interval [CI]: 1.33, 1.88) or frontier (AOR = 3.19, 95% CI: 2.14, 4.75) counties were more likely to deliver in nonlevel III units and to experience postnatal transfer within 24 hours (rural AOR = 2.24, 95% CI: 1.60, 3.15; frontier AOR = 3.91, 95% CI: 1.76, 8.67). Compared with non-Hispanic Whites, Hispanics were more likely to deliver VPT/VLBW infants in nonlevel III units (AOR = 1.36, 95% CI: 1.15, 1.61).

Conclusion A significant number of VPT/VLBW neonates were born in nonlevel III units with associated disparities by race/ethnicity and nonurban residence.

Key Points

  • Preterm delivery in a nonlevel III NICU increases risk of neonatal morbidity and mortality.

  • A significant number of preterm deliveries in Colorado occur in hospitals with nonlevel III NICUs.

  • Disparities in preterm delivery by race/ethnicity and nonurban residence exist.

Publication History

Received: 08 January 2021

Accepted: 25 February 2021

Article published online:
20 April 2021

© 2021. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

  • References

  • 1 March of Dimes. Premature Birth Report Card. March of Dimes. Published 2019. Accessed August 1, 2020 at:
  • 2 Ryan Jr GM. Toward improving the outcome of pregnancy recommendations for the regional development of perinatal health services. Obstet Gynecol 1975; 46 (04) 375-384
  • 3 Profit J, Gould JB, Bennett M. et al. The association of level of care with NICU quality. Pediatrics 2016; 137 (03) e20144210
  • 4 American Academy of Pediatrics Committee on Fetus And Newborn. Levels of neonatal care. Pediatrics 2012; 130 (03) 587-597
  • 5 Kroelinger CD, Okoroh EM, Goodman DA, Lasswell SM, Barfield WD. Comparison of state risk-appropriate neonatal care policies with the 2012 AAP policy statement. J Perinatol 2018; 38 (04) 411-420
  • 6 Robles D, Blumenfeld YJ, Lee HC. et al. Opportunities for maternal transport for delivery of very low birth weight infants. J Perinatol 2017; 37 (01) 32-35
  • 7 Boland RA, Dawson JA, Davis PG, Doyle LW. Why birthplace still matters for infants born before 32 weeks: Infant mortality associated with birth at 22-31 weeks' gestation in non-tertiary hospitals in Victoria over two decades. Aust N Z J Obstet Gynaecol 2015; 55 (02) 163-169
  • 8 Hung P, Henning-Smith CE, Casey MM, Kozhimannil KB. Access to obstetric services in rural counties still declining, with 9 percent losing services, 2004-14. Health Aff (Millwood) 2017; 36 (09) 1663-1671
  • 9 Colorado Rural Health Center. Snapshot of Rural Health in Colorado. Aurora, CO: The State Office of Rural Health; 2018
  • 10 Margerison-Zilko CE, Talge NM, Holzman C. Preterm delivery trends by maternal race/ethnicity in the United States, 2006-2012. Ann Epidemiol 2017; 27 (11) 689-694.e4 , e684
  • 11 Yang X, Hsu-Hage B, Zhang H, Zhang C, Zhang Y, Zhang C. Women with impaired glucose tolerance during pregnancy have significantly poor pregnancy outcomes. Diabetes Care 2002; 25 (09) 1619-1624
  • 12 Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and causes of preterm birth. Lancet 2008; 371 (9606): 75-84
  • 13 Phillips C, Velji Z, Hanly C, Metcalfe A. Risk of recurrent spontaneous preterm birth: a systematic review and meta-analysis. BMJ Open 2017; 7 (06) e015402
  • 14 Office of Disease Prevention and Health Promotion Maternal, Infant, and Child Health Healthy People 2020 Objectives. Published 2020. Accessed October 20, 2020 at:
  • 15 Gould JB, Sarnoff R, Liu H, Bell DR, Chavez G. Very low birth weight births at non-NICU hospitals: the role of sociodemographic, perinatal, and geographic factors. J Perinatol 1999; 19 (03) 197-205
  • 16 Rayburn WF, Richards ME, Elwell EC. Drive times to hospitals with perinatal care in the United States. Obstet Gynecol 2012; 119 (03) 611-616
  • 17 Hung P, Casey MM, Kozhimannil KB, Karaca-Mandic P, Moscovice IS. Rural-urban differences in access to hospital obstetric and neonatal care: how far is the closest one?. J Perinatol 2018; 38 (06) 645-652
  • 18 Kozhimannil KB, Casey MM, Hung P, Prasad S, Moscovice IS. Location of childbirth for rural women: implications for maternal levels of care. Am J Obstet Gynecol 2016; 214 (05) 661.e1-661.e10
  • 19 Kozhimannil KB, Hung P, Henning-Smith C, Casey MM, Prasad S. Association between loss of hospital-based obstetric services and birth outcomes in rural counties in the United States. JAMA 2018; 319 (12) 1239-1247
  • 20 Towers CV, Bonebrake R, Padilla G, Rumney P. The effect of transport on the rate of severe intraventricular hemorrhage in very low birth weight infants. Obstet Gynecol 2000; 95 (02) 291-295
  • 21 Hohlagschwandtner M, Husslein P, Klebermass K, Weninger M, Nardi A, Langer M. Perinatal mortality and morbidity. Comparison between maternal transport, neonatal transport and inpatient antenatal treatment. Arch Gynecol Obstet 2001; 265 (03) 113-118
  • 22 Kaneko M, Yamashita R, Kai K, Yamada N, Sameshima H, Ikenoue T. Perinatal morbidity and mortality for extremely low-birthweight infants: a population-based study of regionalized maternal and neonatal transport. J Obstet Gynaecol Res 2015; 41 (07) 1056-1066
  • 23 Gould JB, Danielsen BH, Bollman L, Hackel A, Murphy B. Estimating the quality of neonatal transport in California. J Perinatol 2013; 33 (12) 964-970
  • 24 Pai VV, Kan P, Gould JB, Hackel A, Lee HC. Clinical deterioration during neonatal transport in California. J Perinatol 2020; 40 (03) 377-384
  • 25 Albritton J, Maddox L, Dalto J, Ridout E, Minton S. The effect of a newborn telehealth program on transfers avoided: a multiple-baseline study. Health Aff (Millwood) 2018; 37 (12) 1990-1996
  • 26 Fang JL, Campbell MS, Weaver AL. et al. The impact of telemedicine on the quality of newborn resuscitation: a retrospective study. Resuscitation 2018; 125: 48-55
  • 27 Center for Disease Control and Prevention Guide to Completing the Facility Worksheets for the Certificate of Live Birth and Report of Fetal Death. Accessed October 30, 2020 at:
  • 28 U.S. Census Bureau. Colorado QuickFacts Population Estimates, 2017. Accessed July 11, 2020 at: