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New, small NICUs – convenient, or risky?

Imposing hospital facade

The big hospital downtown, Swedish Medical Center at First Hill in Seattle. This wing, one of several in the big complex, was where our son was treated in the NICU.

Five months in the NICU made the daily drive to Swedish Medical Center in Seattle quite tiresome. And then we met some Alaskans in the waiting room, who told us stories about being hustled on to air ambulances when pre-term labor was discovered, about husbands who had never seen their child because they had to stay with the other children, and about getting tired of living at the Ronald McDonald House.

I said, “There really ought to be a NICU in Juneau like the one here so you can be closer to home!”

A year after our family got home from the hospital, I went to a talk given by a neonatologist about how preemie care developed, and discovered that the issue of building smaller NICUs at community hospitals is complicated and controversial.

It takes a Level III NICU to deal with a micropreemie such as our son, born at 22 weeks and 6 days of gestation. Having seen the wonders a Level III NICU can do, I would think more of them ought to be better. A smaller facility ought to have advantages, too, because a baby would get more personal attention from doctors. Parents would not feel lost in a huge institution.

It turns out the opposite is true. Bigger, busier NICUs have higher survival rates. A study published in The New England Journal of Medicine in 2007 looked at survival rates in NICUs in California from 1991 to 2000, and found that very-low-birthweight infants (under 1,500 grams) were more likely to survive if they were treated in NICUs that deal with 100 or more VLBW infants per year. They concluded that 21 percent of preemie deaths were preventable if the babies’ care could be shifted to the larger hospitals.

In the 1960s and 1970s, new medical technologies such as ventilators and CPAP became available for preemies, but not every hospital had them, or had doctors trained in their use. Hospitals formed referral networks to get women in pre-term labor transferred to a regional perinatal center before giving birth.

Hospital administrators went along with this idea because it did not look like preemie care was going to make much money, so giving up low-revenue patients was not a problem, according to pediatricians John Lantos and William Meadow in their 2006 book, Neonatal Bioethics: The Moral Challenges of Medical Innovation.

As neonatal medicine advanced, hospitals discovered that preemie care was profitable. Hospitals could put 8 or 10 intensive-care patients in to a room that could hold only two adults. This was a substantial productivity increase – a rare thing for hospitals as their productivity is limited by the number of beds they can fit in a space. NICUs made money, and many hospitals wanted to open them.

Hospitals also have a motive to retain babies for their NICUs because Labor and Delivery is typically a money-losing department for hospitals, but the fees the hospital receives for a NICU stay can help recover some of that loss. To illustrate this relationship, Lantos and Williams included financial information from the University of Chicago Hospital in their book:

The NICU, which accounted for 4 percent of the patients in the hospital, generated 10 percent of the hospital’s revenue. By contrast, adult medical/surgical patients comprised 54 percent of admissions and 53 percent of revenue, adult cardiology patients comprised 10 percent of admissions and 11 percent of revenue, obstetrics had 15 percent of admissions and only 6 percent of revenue.

Hospitals advertise heavily to women expecting babies because women make most of the medical decisions for families. A positive experience with a birth is believed to bring family members back in later years. NICUs are part of this advertising, not because people want to go there, but because a NICU makes the hospital look modern and advanced.

The trend of smaller hospitals opening small NICUs is known as de-regionalization, and whenever it shows up in medical-journal articles, it is generally described negatively because small NICUs have a hard time keeping neonatologists and other specialists on call 24 hours a day, often sharing neonatologists between facilities and stretching resources thin.

Lantos and Williams predict in their book that the trend of de-regionalization is going to continue because of the financial incentives for hospitals, but they offer some hope that the disparity in survival outcomes for very-low-birthweight infants will get better in small facilities. As medical technology becomes more user friendly, and the use of surfactant becomes better understood by more doctors in the small hospitals, the outcomes should improve, they say.

Parents generally don’t think about this difference in care between types of hospital. Before Gabriel was born, I did not even know what the acronym “NICU” stood for. While we were in the NICU at the big hospital, we saw a large number of specialists come through on the rotation to take care of Gabriel, which at first annoyed us, and later made us glad there were so many pairs of eyes watching our son. Several suburban hospitals have opened new NICUs around Seattle to compete for babies like Gabriel since he was born. If child No. 2 comes along, it might be tempting to go to one of the nearer hospitals with a shiny new NICU, but if the future child is a preemie, would the care there be as good?

Eric Ruthford About Eric Ruthford

Thomas Eric Ruthford (WA) is the father of one child, Gabriel, who was born at 22 weeks and 6 days of gestation, setting a record for most immature survivor to come out of his NICU, the busiest one in the state. Thomas and his wife, Miri, live in Washington state. Thomas was a newspaper reporter in the late 90s, and is now a non-profit manager. He has also served in the U.S. Peace Corps in Ukraine, teaching English as a foreign language. He is working on a book about Gabriel, and how neonatal care developed. You can find him on Twitter @MicroPreemieDad, or his personal blog.


  1. In the UK, the system of moving away from smaller units to a “centre of excellence” for NNICU care has happened over the past 20 years or so. The last place to change was Scotland. For years pretty much every unit cared for all levels of NNICU. It worked well for families as being quite a rural nation, it was difficult for parents to be moved so far away from home, however, it led to major shortages in Level 3 cots as often babies were being kept at the unit away from home for far too long. Eventually the system changed and now Level 3 babies are taken to the nearest large unit, leaving Level 1 & 2 cots more available at local units. Our local unit previously cared for fewer than 10 level 3 babies per year. They did their best but their skills were not sharp. The closest large level 3 unit cares for hundreds.

    It took me a long time to sell this change to parents, but when given the information about outcomes and staffing and availability, they all agreed it was a much better solution. Unfortunately we are a bit behind on making sure there are appropriate, and affordable, accommodations available for parents, but hopefully this will change. In an ideal world we’d all stay at home but in the end it has to be what is good for the babies.

    ps – Really don’t like the thought that provision of NNICU care could be based on whether it was profitable. Our NHS may be cash strapped, and finances have to be spent wisely but the thought of it being all about profit…..whew, I’m not sure I can get my head round that!

    • Thank you for your thoughtful reply! I am glad to hear that the UK does have a good regionalization system. I hear you on the thoughts about profit — the fee-for-service model in the United States is quite odd. Maybe people over here read George Orwell’s 1984 too literally and thought that’s what national health would do. But Orwell was English, so perhaps we can blame you. 🙂


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