( infants each year. Other high-level hi...)Low Weight Newborns at Greater Risk in Community Hospitals,Health

infants each year. Other high-level, high-volume neonatal ICUs in the Bay Area are at the University of California-San Francisco; California Pacific Medical Center in San Francisco; Alta Bates Summit Medical Center in Berkeley and Oakland, and Good Samaritan Hospital in San Jose.

Only about one in five very-low-birth-weight infants in the study were born at such centers, despite the fact that more than 90 percent of the births occurred within urban areas with at least 100 very-low-weight births. The move away from regional centers is growing as increasing numbers of neonatal ICUs spring up at community hospitals around the state. Many of these new neonatal ICUs offer lower levels of care that, although sufficient for many infants, may not be optimal for very small newborns.

"Most of the babies admitted to the neonatal ICU have very little risk of death," said Phibbs. "Clearly, a 35-week-gestation newborn who doesn't need mechanical ventilation doesn't need to be in a big tertiary center. The extremely premature kids, however, do need that extra level of care."

Phibbs and his co-workers linked birth certificates and hospital discharge records of more than 48,000 very-low-birth-weight infants born in California between 1991 and 2000 with fetal and infant death certificates. They found that infants born at lower-level, lower-volume neonatal ICUs were between 1.2 and 3.1 times more likely to die than those born at higher-level, higher-volume centers.

It's not just that practice makes perfect. Regardless of a staff's skill, smaller neonatal ICUs that treat fewer infants don't have the same economies of scale as larger hospitals. And little things matter. A lack of dedicated, 24-hour anesthesia coverage for a woman needing an emergency caesarean section can make the difference between a live, but struggling, premature infant and a baby who dies before delivery. Attending physicians available around the clock can also
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