<p>The goal of regionalization of neonatal care is to improve infant outcomes by directing patients to hospitals where risk-appropriate care is available. Although evidence shows that regionalized, risk-appropriate neonatal care decreases mortality, especially for high-risk infants, the approach and success of regionalization efforts in the U.S. and around the world is highly variable. Barriers to regionalization exist on the patient, provider, hospital, state, and national levels, which highlight potential opportunities to improve regionalization efforts. Improving neonatal regionalized care delivery requires a collaborative approach inclusive of all stakeholders from patients to national professional organizations, expansion and adaptation of current policies, changes to financial incentives, cross-state collaboration, support of national policies, and partnership between neonatal and obstetric communities to promote comprehensive, regionalized perinatal care.</p>

<p><strong>OBJECTIVE: </strong>To examine quality measures for moderate and late preterm (MLP) infants.</p>

<p><strong>STUDY DESIGN: </strong>By prospectively analyzing Vermont Oxford Network's all NICU admissions database, we adapted Baby-MONITOR, a composite quality measure for extremely/very preterm infants, for MLP infants. We examined correlations between the adapted MLP quality measure (MLP-QM) in MLP infants and Baby-MONITOR in extremely and very preterm infants.</p>

<p><strong>RESULT: </strong>We studied 376,219 MLP (30-36 weeks GA) and 57,595 extremely/very preterm (25-29 weeks GA) infants from 465 U.S. hospitals born from 2016 to 2020. MLP-QM summary scores in MLP infants had weak correlation with Baby-MONITOR scores in extremely and very preterm infants (r = 0.47). There was weak correlation among survival (r = 0.19), no pneumothorax (r = 0.35), and no infection after 3 days (r = 0.45), but strong correlation among human milk at discharge (r = 0.79) and no hypothermia (r = 0.76).</p>

<p><strong>CONCLUSION: </strong>Modest correlation among hospital care measures in two preterm populations suggests the need for MLP-specific care measures.</p>

<p><strong>OBJECTIVE: </strong>To develop and test of a measure of patient-centered care (PCC) culture in hospital-based perinatal care.</p>

<p><strong>DATA SOURCES: </strong>US perinatal hospitals; 1 provided survey development data and 14 contributed data for survey testing.</p>

<p><strong>STUDY DESIGN: </strong>We used qualitative and quantitative methods to develop the Mother-Infant Centered Care (MICC) culture survey. Qualitative methods included observation, focus group, interviews, and expert consultations to adapt items from other settings and create new items capturing dimensions of PCC articulated by The Commonwealth Fund. We quantitatively assessed survey psychometric properties using reliability (Cronbach's α and Pearson correlation coefficients) and validity (exploratory and confirmatory factor analysis [CFA]) statistics, and refined the survey. After confirming aggregation suitability (ICCs), we calculated "MICC culture scores" at the individual-, unit-, and hospital-level and assessed associations between scores and survey-collected, staff-reported outcomes to evaluate concurrent validity.</p>

<p><strong>DATA COLLECTION: </strong>Survey development included 12 site-visit observations, one semi-structured focus group (five participants), two semi-structured interviews, five cognitive interviews, and three expert consultations. Survey testing used online surveys administered to obstetric and neonatal unit staff (N=316).</p>

<p><strong>PRINCIPAL FINDINGS: </strong>Using responses from 10 hospitals with ≥4 responses from both units (n=240), the 20-item MICC culture survey demonstrated reliability (Cronbach's α=0.95) while capturing all PCC dimensions (subscale Cronbach's α=0.72-0.87). CFA showed validity through goodness-of-fit (overall chi-square=214 [p-value=0.012], SRMR=0.056, RMSEA=0.041, CFI=0.97, and TLI=0.96). Aggregation statistics (ICCs&lt;0.05) justify unit- and hospital-level aggregation. Demonstrating preliminary validity, individual-, unit-, and hospital-level MICC culture scores were associated with all outcomes (satisfaction with care provided, within-unit team effectiveness, and relational coordination [RC] between units) (p-values&lt;0.05), except for neonatal unit scores and RC (p-value=0.11).</p>

<p><strong>CONCLUSIONS: </strong>The MICC culture survey is a psychometrically sound measure of PCC culture for hospital-based perinatal care. Survey scores are associated with staff-reported outcomes. Future studies with patient outcomes will aid identification of improvement opportunities in perinatal care.</p>

<p><strong>OBJECTIVE: </strong>To compare postpartum hospitalization length of stay (LOS) and hospital readmission among obstetric patients before (March 2017-February 2020; prepandemic) and during the coronavirus disease 2019 (COVID-19) pandemic (March 2020-February 2021).</p>

<p><strong>METHODS: </strong>We conducted a retrospective cohort study, using Epic Systems' Cosmos research platform, of obstetric patients who delivered between March 1, 2017, and February 28, 2021, at 20-44 weeks of gestation and were discharged within 7 days of delivery. The primary outcome was short postpartum hospitalization LOS (less than two midnights for vaginal births and less than three midnights for cesarean births) and secondary outcome was hospital readmission within 6 weeks of postpartum hospitalization discharge. Analyses compared outcomes before and during the pandemic using standardized differences and Bayesian logistic mixed-effects models, among all births and stratified by mode of delivery.</p>

<p><strong>RESULTS: </strong>Of the 994,268 obstetric patients in the study cohort, 742,113 (74.6%) delivered prepandemic and 252,155 (25.4%) delivered during the COVID-19 pandemic. During the COVID-19 pandemic, the percentage of short postpartum hospitalizations increased among all births (28.7-44.5%), vaginal births (25.4-39.5%), and cesarean births (35.3-55.1%), which was consistent with the adjusted analysis (all births: adjusted odds ratio [aOR] 2.35, 99% credible interval 2.32-2.39; vaginal births: aOR 2.14, 99% credible interval 2.11-2.18; cesarean births aOR 2.90, 99% credible interval 2.83-2.98). Although short postpartum hospitalizations were more common during the COVID-19 pandemic, there was no change in readmission in the unadjusted (1.4% vs 1.6%, standardized difference=0.009) or adjusted (aOR 1.02, 99% credible interval 0.97-1.08) analyses for all births or when stratified by mode of delivery.</p>

<p><strong>CONCLUSION: </strong>Short postpartum hospitalization LOS was significantly more common during the COVID-19 pandemic for obstetric patients with no change in hospital readmissions within 6 weeks of postpartum hospitalization discharge. The COVID-19 pandemic created a natural experiment, suggesting shorter postpartum hospitalization may be reasonable for patients who are self-identified or health care professional-identified as appropriate for discharge.</p>

OBJECTIVES: To determine if birth hospitalization length of stay (LOS) and infant rehospitalization changed during the coronavirus disease 2019 (COVID-19) era among healthy, term infants.

METHODS: Retrospective cohort study using Epic's Cosmos data from 35 health systems of term infants discharged ≤5 days of birth. Short birth hospitalization LOS (vaginal birth <2 midnights; cesarean birth <3 midnights) and, secondarily, infant rehospitalization ≤7 days after birth hospitalization discharge were compared between the COVID-19 (March 1 to August 31, 2020) and prepandemic eras (March 1 to August 31, 2017, 2018, 2019). Mixed-effects models were used to estimate adjusted odds ratios (aORs) comparing the eras.

RESULTS: Among 202 385 infants (57 110 from the COVID-19 era), short birth hospitalization LOS increased from 28.5% to 43.0% for all births (vaginal: 25.6% to 39.3%, cesarean: 40.1% to 61.0%) during the pandemic and persisted after multivariable adjustment (all: aOR 2.30, 95% confidence interval [CI] 2.25-2.36; vaginal: aOR 2.12, 95% CI 2.06-2.18; cesarean: aOR 3.01, 95% CI 2.87-3.15). Despite shorter LOS, infant rehospitalizations decreased slightly during the pandemic (1.2% to 1.1%); results were similar in adjusted analysis (all: aOR 0.83, 95% CI 0.76-0.92; vaginal: aOR 0.82, 95% CI 0.74-0.91; cesarean: aOR 0.87, 95% CI 0.69-1.10). There was no change in the proportion of rehospitalization diagnoses between eras.

CONCLUSIONS: Short infant LOS was 51% more common in the COVID-19 era, yet infant rehospitalization within a week did not increase. This natural experiment suggests shorter birth hospitalization LOS among family- and clinician-selected, healthy term infants may be safe with respect to infant rehospitalization, although examination of additional outcomes is needed.

<p><strong>Importance: </strong>Timely access to clinically appropriate obstetric services is critical to the provision of high-quality perinatal care.</p>

<p><strong>Objective: </strong>To examine the geographic distribution, proximity, and urban adjacency of US obstetric hospitals by annual birth volume.</p>

<p><strong>Design, Setting, and Participants: </strong>This retrospective population-based cohort study identified US hospitals with obstetric services using the American Hospital Association (AHA) Annual Survey of Hospitals and Centers for Medicare &amp; Medicaid provider of services data from 2010 to 2018. Obstetric hospitals with 10 or more births per year were included in the study. Data analysis was performed from November 6, 2020, to April 5, 2021.</p>

<p><strong>Exposure: </strong>Hospital birth volume, defined by annual birth volume categories of 10 to 500, 501 to 1000, 1001 to 2000, and more than 2000 births.</p>

<p><strong>Main Outcomes and Measures: </strong>Outcomes assessed by birth volume category were percentage of births (from annual AHA data), number of hospitals, geographic distribution of hospitals among states, proximity between obstetric hospitals, and urban adjacency defined by urban influence codes, which classify counties by population size and adjacency to a metropolitan area.</p>

<p><strong>Results: </strong>The study included 26 900 hospital-years of data from 3207 distinct US hospitals with obstetric services, reflecting 34 054 951 associated births. Most infants (19 327 487 [56.8%]) were born in hospitals with more than 2000 births/y, and 2 528 259 (7.4%) were born in low-volume (10-500 births/y) hospitals. More than one-third of obstetric hospitals (37.4%; 10 064 hospital-years) were low volume. A total of 46 states had obstetric hospitals in all volume categories. Among low-volume hospitals, 18.9% (1904 hospital-years) were not within 30 miles of any other obstetric hospital and 23.9% (2400 hospital-years) were within 30 miles of a hospital with more than 2000 deliveries/y. Isolated hospitals (those without another obstetric hospital within 30 miles) were more frequently low volume, with 58.4% (1112 hospital-years) located in noncore rural areas.</p>

<p><strong>Conclusions and Relevance: </strong>In this cohort study, marked variations were found in birth volume, geographic distribution, proximity, and urban adjacency among US obstetric hospitals from 2010 to 2018. The findings related to geographic isolation and rural-urban distribution of low-volume obstetric hospitals suggest the need to balance proximity with volume to optimize effective referral and access to high-quality perinatal care.</p>

<p><strong>OBJECTIVE: </strong>To examine whether the coronavirus disease 2019 (COVID-19) pandemic altered risk of adverse pregnancy-related outcomes and whether there were differences by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection status among pregnant women.</p>

<p><strong>METHODS: </strong>In this retrospective cohort study using Epic's Cosmos research platform, women who delivered during the pandemic (March-December 2020) were compared with those who delivered prepandemic (matched months 2017-2019). Within the pandemic epoch, those who tested positive for SARS-CoV-2 infection were compared with those with negative test results or no SARS-CoV-2 diagnosis. Comparisons were performed using standardized differences, with a value greater than 0.1 indicating meaningful differences between groups.</p>

<p><strong>RESULTS: </strong>Among 838,489 women (225,225 who delivered during the pandemic), baseline characteristics were similar between epochs. There were no significant differences in adverse pregnancy outcomes between epochs (standardized difference&lt;0.10). In the pandemic epoch, 108,067 (48.0%) women had SARS-CoV-2 testing available; of those, 7,432 (6.9%) had positive test results. Compared with women classified as negative for SARS-CoV-2 infection, those who tested positive for SARS-CoV-2 infection were less likely to be non-Hispanic White or Asian or to reside in the Midwest and more likely to be Hispanic, have public insurance, be obese, and reside in the South or in high social vulnerability ZIP codes. There were no significant differences in the frequency of preterm birth (8.5% vs 7.6%, standardized difference=0.032), stillbirth (0.4% vs 0.4%, standardized difference=-0.002), small for gestational age (6.4% vs 6.5%, standardized difference=-0.002), large for gestational age (7.7% vs 7.7%, standardized difference=-0.001), hypertensive disorders of pregnancy (16.3% vs 15.8%, standardized difference=0.014), placental abruption (0.5% vs 0.4%, standardized difference=0.007), cesarean birth (31.2% vs 29.4%, standardized difference=0.039), or postpartum hemorrhage (3.4% vs 3.1%, standardized difference=0.019) between those who tested positive for SARS-CoV-2 infection and those classified as testing negative.</p>

<p><strong>CONCLUSION: </strong>In a geographically diverse U.S. cohort, the frequency of adverse pregnancy-related outcomes did not differ between those delivering before compared with during the pandemic, nor between those classified as positive compared with negative for SARS-CoV-2 infection during pregnancy.</p>

<p><strong>AIM: </strong>Cardiopulmonary resuscitation (CPR) in hospitalized infants is a relatively uncommon but high-risk event associated with mortality. The study objective was to identify factors associated with mortality and survival among infants who receive CPR in the neonatal intensive care unit (NICU) or pediatric intensive care unit (PICU).</p>

<p><strong>METHODS: </strong>Retrospective observational study of infants with an index CPR event in the NICU or PICU between 1/1/06 and 12/31/18 in the American Heart Association's Get With The Guidelines-Resuscitation registry. Associations between patient, event, unit, and hospital factors and the primary outcome, mortality prior to discharge, were examined using multivariable logistic regression.</p>

<p><strong>RESULTS: </strong>Among 3,521 infants who received CPR, 2,080 (59%) died before discharge, with 25% mortality during CPR and 40% within 24 hours. Mortality prior to discharge occurred in 65% and 47% of cases in the NICU and PICU, respectively. Factors most strongly independently associated with pre-discharge mortality were vasoactive agent before CPR (adjusted odds ratio (aOR): 2.77, 95% confidence interval (CI) 2.15-3.58), initial pulseless condition (aOR: 2.38, 95% CI 1.46-3.86) or development of pulselessness (aOR: 2.36, 95% CI 1.78-3.12), and NICU location compared with PICU (aOR: 3.85, 95% CI 2.86-5.19). Endotracheal intubation during CPR was associated with decreased odds of pre-discharge mortality (aOR: 0.40, 95% CI 0.33-0.49).</p>

<p><strong>CONCLUSION: </strong>Infants who receive CPR in the intensive care unit experience high mortality rates; identifiable patient, event, and unit factors increase the odds of mortality. Further investigation should explore the association between unit type, resuscitation processes, and mortality.</p>