Racial and Ethnic Disparities in NICU Outcomes: The Impact of Hospital Volume and Level of Care on Very Low Birthweight Infants
Recent advances in neonatology have significantly improved survival rates for very low birthweight (VLBW) infants, defined as those weighing less than 1500 grams at birth. Despite these improvements, disparities in outcomes among different racial and ethnic groups persist, raising critical concerns about equity in neonatal healthcare. A groundbreaking study by Yannekis et al., published in the Journal of Perinatology in 2025, sheds new light on the nuanced relationship between delivery hospital characteristics—specifically neonatal intensive care unit (NICU) volume and level of care—and the risk-adjusted mortality and morbidity rates (RAMMR) experienced by VLBW infants from diverse racial and ethnic backgrounds.
The study meticulously stratifies data on VLBW infants by delivery hospital’s NICU volume and level of care, aiming to uncover how these institutional factors influence outcomes across racial and ethnic groups. Hospitals caring for VLBW infants range in their level of care from Level II (special care nurseries) to Level IV (regional NICUs offering the highest acuity services). Volume considerations reflect the number of VLBW births a center manages annually—an established proxy for experience and resource availability. This stratification is crucial because previous research has identified that higher-volume, higher-level NICUs tend to achieve better overall outcomes, although this has not been extensively dissected in a racially and ethnically stratified manner until now.
According to the data presented, stark disparities in RAMMR are evident and vary significantly as a function of NICU volume and level of care. For example, Black and Hispanic infants consistently display elevated mortality and morbidity risk-adjusted rates compared to non-Hispanic White infants, particularly in hospitals with lower NICU volumes or lower-level NICUs. This pattern indicates that systemic factors contributing to hospital quality and resource availability intertwine with racial and ethnic disparities, exacerbating outcome differences for the most vulnerable infants.
Diving deeper, the study exposes that high-volume Level IV NICUs, known for their comprehensive multidisciplinary teams and advanced technological resources, exhibit a mitigation of racial and ethnic disparities but do not eliminate them entirely. Black and Hispanic infants in these settings still fare worse on certain outcome measures compared to their non-Hispanic White counterparts, suggesting that access to high-level care alone is insufficient to produce equity. Socioeconomic determinants, implicit bias, and care coordination complexities may underlie these persistent differences.
In contrast, hospitals characterized by low-volume NICUs or Level II care demonstrate pronounced disparities. For example, morbidity rates—including bronchopulmonary dysplasia, severe intraventricular hemorrhage, and necrotizing enterocolitis—are disproportionately elevated among minority infants. Importantly, the risk adjustment methodology accounts for infant clinical severity indicators, suggesting that these disparities cannot be fully attributed to biological or initial health differences at birth.
The identification of these discrepancies invites urgent questions about how systemic healthcare infrastructures deliver care to racially and ethnically diverse populations. The authors challenge existing paradigms that prioritize regionalization without simultaneously addressing the quality of care and the nuanced needs of minority populations. They argue that the solution extends beyond simply funneling more infants to high-level NICUs; instead, it necessitates a deliberate focus on inclusive policies, quality improvement initiatives tailored to minority populations, and transparency in reporting disaggregated outcome data.
A remarkable aspect of this study is the comprehensive geospatial analysis overlaying NICU distribution with demographic data. It reveals that minority populations frequently reside in regions where access to high-level NICUs is limited or requires significant travel, which may delay timely care or increase stressors on families. This geographic mismatch complicates the equity equation, showing that proximity and volume are not just administrative concerns but have tangible implications for outcome equity.
The study also highlights the role of hospital-level factors such as staffing ratios, cultural competency training, language services, and family support programs. In institutions with robust support systems tailored to diverse populations, racial and ethnic disparities in outcomes tend to be smaller. These findings underscore the critical importance of integrating social determinants of health frameworks and culturally responsive care models into NICU practice.
Further analysis reveals that within racial groups, infants born at low-volume hospitals had worse outcomes than those born in high-volume hospitals regardless of ethnicity. This underscores the fundamental influence of hospital experience and resources on neonatal outcomes but, notably, the interaction with race and ethnicity compounds vulnerabilities. Thus, the impact of hospital characteristics is not uniform across populations and must be addressed with layered, nuanced strategies.
The authors also discuss potential policy implications. Mapping disparities onto healthcare delivery frameworks suggests that investment in expanding the capacity and capability of NICUs serving minority communities could play a transformative role. However, they caution that such investment must be coupled with initiatives to monitor and mitigate systemic biases and ensure equitable distribution of neonatal technologies and expertise.
Importantly, the study’s risk adjustment approach enhances the robustness of the conclusions by controlling for confounders such as gestational age, birth weight, prenatal interventions, and maternal risk factors. This methodological rigor supports the interpretation that observed disparities are more reflective of systemic care quality differences rather than biological variances alone.
In the broader landscape of neonatal care research, these findings contribute to a growing consensus that health equity demands more granular data analysis and targeted interventions. The study by Yannekis et al. calls for a paradigm shift toward integrating equity metrics into quality improvement benchmarks and hospital accreditation processes. Progress in neonatal outcomes will require continuous, disaggregated monitoring to identify and close gaps effectively.
Finally, this research resonates amid ongoing national conversations about racial disparities in healthcare outcomes. It serves as a compelling call to action within the neonatology community and beyond, advocating for policies that account for complex, intersecting factors affecting vulnerable populations. The future of neonatal care demands not only clinical excellence but also an unwavering commitment to equity, accessibility, and culturally competent care.
As the healthcare community continues to grapple with these challenges, studies like this illuminate the path forward—demonstrating that while hospital NICU volume and level of care matter profoundly, addressing racial and ethnic disparities requires a comprehensive, systemic approach that balances excellence in clinical practice with social justice imperatives.
Subject of Research: Disparities in delivery hospital NICU risk-adjusted mortality and morbidity rates among very low birthweight infants, stratified by race, ethnicity, NICU volume, and level of care.
Article Title: Disparities in delivery hospital risk-adjusted outcomes for very low birthweight infants: the role of NICU volume and level of care.
Article References:
Yannekis, G., Kunz, S.N., Passarella, M. et al. Disparities in delivery hospital risk-adjusted outcomes for very low birthweight infants: the role of NICU volume and level of care. J Perinatol (2025). https://doi.org/10.1038/s41372-025-02434-7
Image Credits: AI Generated
DOI: https://doi.org/10.1038/s41372-025-02434-7
