Neonatal Care

Health care for newborns as a unique specialty began in the 1960s. Previously, technology had not existed to allow ventilation and surgical techniques for the premature or very ill newborn infant. Premature infants at that time were nurtured with oxygen and nutrition under the care of concerned pediatricians, and survival depended on their limited ability to mature rapidly outside the maternal environment. Specific physician training and environments for these patients began to develop during that decade and then began to explode in the 1970s. The March of Dimes Foundation formed the Committee on Perinatal Health, and in 1976 its publication Toward Improving the Outcome of Pregnancy defined a regional approach to delivery of neonatal care. The committee recommended defining three levels of care: Level I, newborn nurseries at birth hospitals providing routine care; Level II, larger nurseries at busy birth hospitals providing intermediate support for their moderately ill newborns; and Level III, regional centers that could supply tertiary and surgical care for newborns that would accept transports and support a regional network of lower-level nurseries. This system was the framework for the current situation that exists today, where much of the tertiary care technology and expertise has filtered down to the larger community nurseries.

There are approximately 3200 board-certified neonatologists in the United States. Currently the training requirement for this specialty involves a three-year pediatric residency after medical school, followed by three years of additional fellowship training at an approved program. These specialists staff a wide array of university- and community-based neonatal intensive care units (NICUs). Many are in teaching and administrative roles and have limited patient care exposure. There are approximately 830 NICUs, with a total of 19,000 beds for the delivery of specialized care.

In 2000, there were 4,058,814 births in the United States. Approximately 12% of these were preterm (less than 37 weeks completed gestation), and approximately 12% were born to teen mothers. These two groups account for the majority of the greater than 300,000 newborns per year [Page 385]who require specialized NICU admission. Health care costs of greater than $100,000 per discharge are typical for premature infants weighing less than 1500 grams at birth, accounting for approximately 60,000 births per year. One insurance review of health care claims demonstrated that 68% of all claims exceeding $25,000 per claim involved preterm births or congenital anomalies. This group also is a high-risk group for ongoing medical as well as medical-legal expenses after the initial discharges.

Neonatal care has been responsible for a dramatic reduction in the neonatal mortality rates that have occurred over the past few decades. This has prompted the CDC to credit this as one of the 10 most significant improvements in health care during the last decade. There is still room for improvement in the United States, as well as ample room for advancements to be demonstrated in developing countries, where the death rates for newborns are often 10-fold higher than in developed countries. Economic and cost–benefit analysis may have an inherent conflict with moral and ethical considerations as neonatal care continues to evolve driven by technological advances.

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