Challenges in implementing optimal perinatal regionalization: a scoping review

Abstract

Background

Perinatal regionalization is a healthcare model designed to ensure that high-risk mothers and newborns receive care in facilities equipped with appropriate expertise and technology. While evidence supports its effectiveness in improving outcomes, the implementation of regionalized systems remains inconsistent and vulnerable to a range of clinical, structural, and financial barriers. This scoping review aimed to identify, categorize, and synthesize the reported challenges that hinder the effective functioning of perinatal regionalization systems across diverse settings.

Methods

A scoping review methodology was used following the PRISMA-ScR guidelines. Studies were included if they reported on barriers to regionalized perinatal care. PubMed, Science Direct, and Web of Science were searched covering publications up to May 2024; updated in June 2026. Data were extracted and thematically analyzed, leading to the development of a structured framework of challenge domains.

Results

After screening and reviewing the retrieved studies, 41 papers included in final synthesis from which 67 challenges of perinatal regionalization were identified. These challenges were organized into 27 subthemes within seven categories: (1) clinical and medical challenges, including unpredictability of high-risk childbirths and clinical contraindications to maternal transport; (2) socio-economic and geographic barriers, such as distance from tertiary centers and poverty; (3) cultural and patient-centered concerns, including loss of patient rights and connection, and cultural resistance; (4) provider-centered factors, such as loss of prestige, perceived viability, and practice behaviors; (5) organizational and financial disincentives, including competition between hospitals and misaligned reimbursement models; (6) transport and logistical limitations; and (7) structural constraints in low-resource settings, including inadequate infrastructure and weak referral networks.

Conclusion

Perinatal regionalization is undermined by interrelated challenges across multiple levels of the health system. Addressing these barriers requires systemic reform, improved coordination, and context-specific strategies to ensure access to risk-appropriate care for all mothers and newborns. The framework of challenges developed in this review can inform policy, planning, and future research on strengthening regionalized perinatal care.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s40748-026-00294-3.

Introduction

Maternal and neonatal mortality, depends not only on advancements in technology and improvements in socio-economic conditions, but also on how perinatal services are organized [1]. Perinatal regionalization is a program through which maternal and neonatal services are systematically organized to ensure timely identification, referral, and transfer of mothers and newborns to higher-level centers capable of providing risk-appropriate specialized care [2]. It was first introduced in the 1970s as a coordinated system of maternal and neonatal care and was designed to improve outcomes for mothers and newborns by ensuring that high-risk pregnancies and critically ill neonates receive care in facilities equipped with appropriate resources and specialized personnel [3].

Perinatal regionalization integrates levels of care across a network of hospitals, ranging from primary community facilities to tertiary care centers, and coordinates clinical, logistical, and administrative resources. Its goals are to optimize clinical outcomes by preventing complications, reducing transport risks, and delivering care in the most appropriate setting. The objectives of regionalization include risk assessment during childbirth, consultation, referral and transfer, continuing education and clinical support for healthcare professionals of affiliated hospitals, back transfer of newborn to lower-level hospital, telephone consultation services, regional statistics, and long-term follow-up [4]. Back transfer is defined as transferring a stabilized mother or newborn from a higher-level referral center back to a lower-level hospital closer to home for ongoing care, once intensive/specialized services are no longer needed. Perinatal regionalization encompasses both maternal and neonatal care. Although both rely on risk assessment, referral, and transport to ensure risk-appropriate care, maternal and neonatal transport have different clinical indications and may be guided by separate level-of-care criteria [5]. Maternal transfer may be required because of maternal conditions such as severe pre-eclampsia, major obstetric hemorrhage, or other complex medical disorders, or fetal indications such as anticipated very preterm birth or prenatally diagnosed congenital anomalies requiring specialized neonatal services [5]. In contrast, neonatal transfer occurs after birth when a newborn requires a higher level of care, such as for very low birth weight, respiratory failure, or congenital anomalies [6]. Furthermore, some facilities may provide different levels of maternal and neonatal care, making coordination between obstetric and neonatal services an essential component of regionalized systems [5].

Maternal and neonatal services are classified according to the complexity of care they provide, although maternal and neonatal levels may not always coincide within the same facility [5]. For instance, according to this regionalized system, Neonatal Level I hospitals provide care for low-risk, term infants, accounting for approximately 85% of all newborns. Level II hospitals serve about 12% of infants who require a higher level of care compared to term infants. Level III hospitals provide care for approximately 3% of newborns who are severely ill or born with very low birth weight (VLBW). With respect to gestational age, Level I hospitals care for infants born at ≥ 36 weeks, Level II hospitals care for infants born between 32 and 36 weeks, and Level III hospitals care for infants born before 32 weeks of gestation [7].

The importance of perinatal regionalization lies not only in improving survival rates but also in enhancing the quality of care, reducing disparities, and ensuring efficient use of healthcare resources [8]. Over decades of implementation, perinatal regionalization has been associated with positive outcomes such as decreased neonatal morbidity and mortality [8], improved resource allocation, and strengthened referral networks. Regionalization has been associated with reductions in respiratory complications, diminished need for mechanical ventilation, decreased long-term disability [8], and lower rates of complications such as bronchopulmonary dysplasia, necrotizing enterocolitis, and retinopathy of prematurity [3].

However, despite these successes, the evolving healthcare landscape and shifting demographics have revealed persistent and emerging challenges [9]. Competition among hospitals, financial disincentives, logistical barriers, and social determinants have led to trends of deregionalization [9–11]. Although the positive effects of regionalization have been examined in various countries over the past few decades [10, 12, 13], and the existing literature has addressed specific components of its barriers in isolation—for example, the role of transport logistics, insurance-related disincentives, or clinical misjudgment in transfer decisions, to the best of our knowledge, these challenges have not been comprehensively reviewed as an integrated whole. It is therefore essential to map and categorize the challenges faced by perinatal regionalization in order to guide future policy and practice improvements.

This scoping review aimed to provide a comprehensive overview of the multifaceted barriers impacting perinatal regionalization by identifying, categorizing, and synthesizing reported challenges, thereby informing strategies to strengthen regionalized care systems and improve maternal and neonatal outcomes in diverse healthcare settings. Countries currently using perinatal regionalization can use the findings of this research to improve their service delivery systems, while countries intending to implement regionalization can consider the results of this study in policy development to achieve optimal outcomes.

Methods

Study design

This study was conducted as a scoping review to map and synthesize the challenges reported in the literature regarding perinatal regionalization. A scoping review methodology was chosen because the aim was to capture the breadth and nature of reported barriers across diverse study designs and contexts, rather than to evaluate the effectiveness of specific interventions or to quantitatively pool outcomes. The review followed the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) guidelines.

Literature search strategy

A primary search was performed in May 2024 in PubMed, Science Direct, and Web of Science with no lower publication-year limit to capture the challenges reported throughout the development of the concept of perinatal regionalization. Following peer-review comments, to improve the sensitivity of the search, a complementary search was conducted in June 2026 in the same databases using new search strategy and expanded terminology. The full database-specific search strategies are provided in Appendix 1. The complementary search was treated as an independent search but with the same eligibility criteria. Eligible studies identified through both searches were included in the final synthesis.

Reference lists of included articles were manually screened to identify additional relevant studies. Citation tracking was performed using Google Scholar. Retrieved articles were managed using EndNote 20 software.

Inclusion and exclusion criteria

Inclusion criteria were: research articles published in English in a peer-reviewed journal reporting at least one barrier or challenge to perinatal regionalization in any section of the article (introduction, methods, results, or discussion), even if it was not the primary outcome or focus of the study. No restrictions were placed on study design because the purpose of this scoping review was to comprehensively map reported challenges across the literature rather than to evaluate intervention effectiveness or causal relationships. Exclusion criteria were: studies focusing solely on clinical outcomes without any mention of system-level or organizational challenges, non-English publications, those papers lacking full text (such as conference abstracts).

Study selection

After removal of duplicates, titles and abstracts were screened independently by two reviewers for relevance to research question. Full texts of potentially eligible articles were then assessed against the inclusion and exclusion criteria. Discrepancies were resolved through discussion and consensus; where necessary, a third reviewer was consulted.

Data extraction

A standardized data extraction form was developed to capture relevant information from each included study, including bibliographic details (first author, year of publication, country) and verbatim descriptions of reported barriers or challenges to perinatal regionalization. No predefined thematic framework was imposed during data extraction.

Data synthesis

A qualitative thematic synthesis was conducted using an inductive approach. The coding and thematic synthesis were conducted manually using Microsoft Word. No specialized qualitative data analysis software was used. Coding and thematic development were conducted jointly by two reviewer and subsequently reviewed by the research team. Disagreements regarding thematic categorization were discussed and resolved by consensus. Formal inter-rater reliability testing was not performed. The extracted text was reviewed repeatedly to achieve familiarity with the data. Then, in the first stage, textual descriptions of challenges from the included studies were listed verbatim and then grouped into preliminary descriptive codes. In the second stage, similar/relevant codes were grouped into subthemes representing recurring concepts across studies. The final seven thematic categories emerged through an iterative process in which related subthemes were consolidated into broader thematic categories following discussion among the reviewers. This thematic synthesis was embedded within the scoping review framework and was intended to provide a structured, conceptually coherent map of challenges rather than to assess the strength of evidence for causal relationships.

The unit of analysis for thematic classification was the reported challenge rather than the study as a whole. Therefore, the thematic categories were not intended to be mutually exclusive at the study level; a single study could contribute to more than one category if it reported multiple distinct challenges.

Critical appraisal

No formal methodological quality or risk-of-bias appraisal of the included studies was undertaken. This decision was consistent with the scoping review aim of mapping the range and nature of reported challenges across a diverse body of literature. Studies were included based on their relevance to the review question regardless of study design or methodological quality. Consequently, this review does not provide an assessment of the overall quality or certainty of the available evidence regarding challenges to perinatal regionalization.

Results

The primary search retrieved 388 records in May 2024, and the complementary expanded search retrieved 695 records in June 2026. Overall, 41 studies met the inclusion criteria, including 10 additional studies identified through the complementary search. The 10 additional studies were generally consistent with the themes identified in the initial synthesis. While their inclusion strengthened the evidence supporting the existing findings, it did not result in the emergence of new major themes or meaningfully change the interpretation of the results. Figure 1 shows the study selection process. The majority of included studies were from USA (34 out of 41), the others comprised one USA-Japan study, one study from each France, Portugal, and Malawi, one multi-country study in Europe, and two global studies. Characteristics of the included studies are provided in Appendix 2.

Fig. 1.

Flow diagram of study selection (PRISMA-ScR)

Analysis of the included studies revealed a wide range of interconnected challenges that hinder the effective implementation and sustainability of perinatal regionalization. A total of 67 challenges were identified and then categorized into 27 items in seven overarching themes: (1) clinical and medical challenges, (2) socio-economic and geographic challenges, (3) cultural and patient-centered challenges, (4) provider-centered challenges, (5) organizational and financial challenges, (6) logistical and transport-related challenges, and (7) context-specific challenges in developing countries. Figure 2 provides a schematic overview of these themes and sub-themes.

Fig. 2.

Summary of challenges of effective perinatal regionalization

The framework presented in Fig. 2 summarizes challenges to perinatal regionalization according to thematic domains rather than stakeholder perspective. This approach was adopted because the included studies generally did not specify whether challenges were reported from the perspective of managers or decision-makers, healthcare providers, or women and families. Therefore, the framework should be interpreted as a holistic synthesis of reported challenges to perinatal regionalization, irrespective of perspective, rather than as a stakeholder-specific classification.

Over time, the reported challenges to perinatal regionalization evolved from foundational problems of service availability, workforce capacity, and transport logistics toward market-driven deregionalization, including competition among hospitals, reimbursement incentives, and proliferation of lower-level NICUs. In more recent studies, these challenges persisted but were increasingly accompanied by concerns about equitable access to risk-appropriate care, rural distance, insurance-related disparities, inconsistent levels-of-care standards, and fragmentation between maternal and neonatal regionalization systems.

In the following sections, each thematic category is summarized and illustrated with examples from the included studies.

Clinical and medical challenges

The complexity of maternal and neonatal conditions, combined with the unpredictability of critical events such as preterm labor or eclampsia, often impeded timely referral to higher-level facilities. Errors in clinical judgment and the difficulty of forecasting the course of high-risk pregnancies compromised early transfers, particularly in the cases of VLBW infants. Inadequate antenatal care further delayed risk stratification and intervention.

• Error in clinical judgment:

  • Higher-level hospitals sometimes misjudged the appropriateness of transferring a newborn back to a lower-level facility, potentially leading to perinatal loss [14].
    Misinterpretation of the patient’s clinical severity could lead to inappropriate management decisions [15].

• Difficulty in predicting clinical needs:

  • Predicting neonatal intrapartum complications such as asphyxia or meconium aspiration remained difficult, often hindering timely in-utero referral [16].
  • A considerable number of VLBW births, particularly between 24 and 27 weeks of gestation, occurred unexpectedly—even among women previously identified as high-risk—making prevention in lower-level centers challenging [11, 17].
  • Severe maternal conditions such as uncontrolled preeclampsia or HELLP syndrome could emerge abruptly and were often hard to anticipate [5].
  • Sudden obstetric emergencies and maternal health crises meant that not all births could be guaranteed to occur in appropriately equipped facilities [3].
  • Predicting the exact level of care needed for a mother, fetus, or newborn before birth remained a challenge [6].

• Inadequate antenatal care:

  • Inadequate antenatal care impeded early identification and referral of high-risk pregnancies, resulting in VLBW infants being born in hospitals without neonatal intensive care units (NICUs) [18, 19].

• Varying clinical capability of hospitals:

  • Whether a VLBW newborn was transferred often depended on the referring hospital’s capacity to stabilize the newborn [16].
  • Some facilities provided different levels of care for maternal and neonatal services, resulting in mismatches in capabilities [5].

• Viability limits and clinical barriers:

  • Some VLBW infants did not survive long enough after birth to allow for neonatal transport [11].
  • Others were deemed previable at birth (according to explicit clinical criteria or viability guidelines), limiting the feasibility or appropriateness of transfer [19].

• Clinical challenges during transport:

  • Neonatal transport carried risks of clinical complications and placed a substantial burden on the transport team [16].

• Clinical contraindications to transport:

  • Maternal-fetal contraindications to transport included placenta previa, abruptio placenta, antepartum hemorrhage, fetal distress, severe fetal heart rate abnormalities, maternal obesity and instability [5, 17, 20–22].
  • Late admission, including advanced cervical dilation (> 4 cm), precipitate labor, or signs of imminent childbirth, often prevented safe and timely transfer to higher-level facilities [17, 19–23].
  • Some infants were too critically ill to be transferred safely to higher level hospital [19].

Socio-economic and geographic challenges

Geographic distance, socioeconomic disadvantage, and insufficient insurance coverage substantially reduced access to regionalized perinatal care. Women in vulnerable groups were less likely to give birth in high-level centers, increasing risks for both mother and infant.

• Geographic access challenges:

  • Greater residential distance from Level III maternity hospitals or NICU-equipped facilities reduced the likelihood that VLBW infants being born in such centers [17, 18, 24, 25].
  • Rural and frontier populations had limited access to high-level NICU care and risk-appropriate childbirth services, and pregnant rural residents with higher-risk conditions were less likely to receive risk-appropriate care, particularly when distance to appropriate facilities was greater [23, 26–28].
  • Closure of maternity units in rural and socioeconomically depressed communities further reduced access to appropriate clinical services within women’s own communities and increased indirect costs related to transportation, lodging, and child care [27].

• Socio-behavioral risks:

  • Rising socio-behavioral risks among women of childbearing age, such as poverty, substance use, and insufficient or absent prenatal care were reported as challenges to effective regionalization [11, 25].
  • Younger maternal age and lower educational attainment were associated with significantly lower rates of risk-appropriate childbirth care among rural residents [25, 28].
  • In USA, women from racial and ethnic minority groups, had a disproportionately lower likelihood of receiving care at risk-appropriate hospitals compared with women from other racial and ethnic groups [23, 28].

• Poor health insurance:

  • Regionalization efforts were less effective for certain population subgroups, particularly women with inadequate health insurance coverage [18]. Public insurance, including Medicaid or TRICARE in USA, and lack of insurance were associated with lower likelihood of giving birth in risk-appropriate hospitals or hospitals with NICUs compared with commercially insured women [23, 26, 28].

Cultural and patient-centered challenges

Patient disconnection from their local environment and familiar caregivers, cultural opposition to centralized systems, and resistance to back-transfer limited regionalization. The emotional and psychological impact of transfer often conflicted with patient-centered care.

• Loss of patient rights, connection, and preferences:

  • Maternal transfer could lead to a perceived loss of a woman’s ability to choose her physician and disrupt established relationships with her care provider [14]. It could also result in separation from family, community, and familiar medical environments [14]. These experiences can make care feel impersonal, with emotional needs becoming secondary to systemic processes [9]. Clear communication was needed to help patients understand that placing their care in another provider’s hands was justified and that the benefits of transfer outweighed the temporary dislocation [9].
  • Resistance to back-transfer—often due to parental preference to remain at the referral hospital—was reported as a barrier to efficient functioning of regionalized care systems [3].

• Cultural resistance and local powers against regionalization:

  • Regionalization was viewed in some contexts by both the public and healthcare professionals as a bureaucratic and impersonal system that limited individual freedom and prioritized administrative control over human-centered care. This perception, rooted in cultural values of USA such as personal choice and local autonomy, contributed to resistance [1, 9].
  • Efforts to develop cohesive national perinatal care systems faced significant obstacles in the U.S. due to professional rivalries, institutional self-interest, decentralized governance, and political fragmentation. Unlike smaller, more homogenous countries with centralized health policies, the U.S. lacked a unified federal framework, resulting in widely varying state-level approaches to regionalized care [10].

Provider-centered challenges

Variation in provider practices, influenced by concerns about status, inter-facility competition, and clinical autonomy emerged as a major barrier. Inconsistent adherence to guidelines and misconceptions about fetal viability or overconfidence in local capability frequently contributed to delayed or denied transfers.

• Matter of status and prestige:

  • Receiving obstetricians could feel reduced to a technician role when pediatricians led the admission process following a maternal or neonatal transfer [14].
  • Referring hospitals sometimes perceived a loss of status or prestige when transferring patients to higher-level centers [9].
  • In the context of heightened competition for institutional prestige, opening of a NICU would strengthen the hospital’s reputation and thus drove many hospitals to expand perinatal services. This may help increase the overall patient volume across all services [29–31].
  • Some hospitals feared that failing to demonstrate an ability to manage high-risk infants could lead to loss of obstetric services altogether, further motivating the establishment or expansion of NICU capacity [31, 32].

• Perceived viability:

  • Physicians’ perceptions of the viability of low-birth-weight newborns influenced decisions on resuscitation and referral. In some cases, obstetricians considered fetuses previable and therefore unlikely to benefit from Level III care, choosing not to transfer to a Level III facility [18, 20]. Such perceptions could differ from, or override, explicit viability guidelines, reflecting caregivers’ interpretation of viability and expected benefit from specialized care, rather than objective contraindications to transfer.

• Professional links and cooperation:

  • Differences in the strength of referral networks between subspecialty centers and other institutions contributed to variation in regionalization practices [18].
  • The presence or absence of clear transfer protocols played a critical role in facilitating timely and appropriate patient referrals [17, 22].
  • Lack of formal consultation agreements between institutions hindered effective coordination and referral [22].
  • Inadequate communication among providers regarding the availability and potential impact of specialized interventions could delay or prevent appropriate referrals [22].

• False beliefs of providers:

  • Some obstetricians in Level II hospitals chose to deliver premature or potentially compromised fetuses locally, relying on neonatal transport teams for postnatal transfer, even when antenatal maternal transfer would have been feasible. The study findings indicate that this behavior could stem from the belief that access to neonatal transport made in-utero transfer less necessary [8].

• Practice behaviors:

  • Rising malpractice litigation in USA drove some obstetricians, particularly in community settings, to advocate for the establishing NICUs and high-risk maternity services within their own hospitals accelerating the spread of perinatal technology and expertise beyond tertiary centers, contributing to the proliferation of smaller NICUs [15, 29, 31, 33, 34].
  • The willingness to transfer patients varied, influenced by clinical, institutional, and cultural factors [17]. In some contexts, such as private hospitals in Australia, maternal and fetal transfers were less commonly accepted [9]. At certain gestational ages (e.g., 30–31 weeks), the perceived lower severity of the newborn’s condition led some providers to favor childbirth in less specialized facilities rather than referring to Level III centers [17].
  • Decision about transfer depended not only on clinical guidelines but also on clinicians’ assessments of illness severity and contextual factors [5, 8]. Each clinician responded to situations based on the level of care available at their own facility, the distance to the nearest referral center, and the logistical means at their disposal, while also weighing the potential benefits of transfer against the risks of moving the patient away from her community [5, 17, 21].

Healthcare organization and financial challenges

Regionalization was weakened by systemic fragmentation and financial incentives that favored competition over coordination. The spread of small, under-resourced Level II NICUs—often driven by hospital profit motives—led to service duplication and undermined regional care. Reimbursement policies discouraged timely referrals, especially across state lines, and encouraged hospitals to retain profitable, low-risk patients (“cream skimming”). Disjointed maternal and neonatal care standards and insurance disparities further disrupted integration.

• State border barriers:

  • Many women of reproductive age lived closer to appropriate critical care facilities located in neighboring states but were transferred to more distant hospitals within their own state due to regulatory or administrative barriers, affecting timely access to appropriate perinatal care in USA [14, 35].

• Increased availability of specialist workforce and technology:

  • Advances in neonatal technology and the availability of user-friendly NICU equipment facilitated the spread of neonatal intensive care into non-tertiary hospitals [4, 13, 33, 34, 36].
  • The rapid increase in the number of neonatologists, neonatal nurse practitioners, and NICU-trained staff—driven by expanded training programs—enabled staffing of neonatal units across the country [4, 10, 13, 15, 31, 33, 34, 36]. Newly trained specialists often sought opportunities to practice their expertise, encouraging hospitals, including smaller and private institutions, to open NICUs [30]. Some level II facilities employed full-time neonatologists and offered 24-hour NICU coverage, reducing reliance on regional centers and formal transfer agreements [19]. Workforce growth also created imbalances, with neonatologists outnumbering maternal-fetal medicine specialists, influencing service availability and priorities in perinatal care [10, 37].
  • During the 1990s, the growth of low- and mid-level NICUs in USA was associated with a rising share of preterm births occurring in non-tertiary hospitals [27, 36]. In addition to increasing in number, NICUs also increased in size and sophistication, with some community hospitals offering tertiary-level neonatal services [31].

• Staff and facility problems in referring and referral hospitals:

  • Bed availability and capacity constraints in NICUs at tertiary care centers affected the ability to accommodate referred high-risk newborns [15, 17, 38].
  • Even in well-established regional perinatal centers, staffing shortages and inadequate facilities could lead to overdependence on junior physicians and trainee nurses [9].
  • Advances in neonatal intensive care increased the number of infants requiring NICU admission and improved survival at lower gestational ages further increased demand, sometimes exceeding capacity at large regional centers [34].
  • Lack of dedicated referral resources and maternal transport teams hindered timely transfers [22].
  • Limitations in specialized services—such as pediatric ophthalmology or rehabilitative therapies—at community hospitals posed barriers to back-transfer and disrupted optimal regionalization practices [3].
  • Imbalances in the distribution of neonatal care beds also posed organizational challenges, with barely adequate tertiary-care beds, a surplus of primary-care beds, and relatively few secondary-care facilities reported in some settings [32, 38].In some settings, newborn transport depended on local ambulance services with untrained personnel or army helicopter services with minimally trained personnel, limiting the safety and effectiveness of neonatal transfer [38].

• Financial incentives and reimbursement:

  • Payment policies and insurance regulations in the USA were major obstacles to effective regionalization. Because childbirth services were reimbursed at higher rates than prenatal care, providers had limited financial incentive to refer mothers to higher-level centers antenatally [10, 11, 22]. Limited reimbursement for back-transfer of recovering infants further discouraged their return to local hospitals [3, 4, 39]. These structural disincentives disproportionately affected rural and Medicaid patients, who often had the greatest need for to risk-appropriate care [3, 23, 26]. Developing reimbursement systems that encourage early prenatal engagement and support timely maternal and neonatal transfers was described as challenging [6].
  • Reimbursement structures —particularly fee-for-service models and bundled payments for prenatal and childbirth care— contributed to the expansion of NICUs in private community hospitals and discouraged maternal transfers [15, 33, 37]. Because physician and hospital payments are often tied to the childbirth itself, providers could be reluctant to refer patients to higher-level centers, preferring to retain them for financial reasons [10, 26, 27, 39]. Hospitals—especially in rural areas—often faced strong financial incentives to keep patients locally rather than refer them to higher-level centers [22]. Transferring mothers or newborns could lead to loss of revenue for the referring hospital, either through forfeited childbirth payments or shifting reimbursement to the receiving facility [9, 13]. To avoid these losses and reduce costly neonatal transports, some community hospitals invested in opening their own NICUs, even when they lacked full capacity for high-risk care [16, 40]. The presence of a NICU further incentivized hospitals and obstetricians to keep patients locally, even when more specialized care was warranted [10].
  • The federal shift toward market-based healthcare in the early 1980s in USA, and the growth of managed care, introduced financial pressures that weakened regionalized perinatal systems [11, 13, 33, 36]. Hospitals and payers sometimes limited referrals, particularly for high-risk cases, while lack of insurance disrupted coordinated care [11]. These financing challenges contributed to fragmented services and potentially compromised outcomes for vulnerable neonates [40].
  • Financial competition among hospitals—particularly smaller and community-based facilities—drove the expansion of obstetric services and the proliferation of Level II NICUs as institutions sought to attract well-insured patients and secure market share [3, 10, 11, 15, 19, 29, 34, 41]. In this environment, some hospitals retained high-risk or VLBW infants despite lacking appropriate resources [11, 18]. These competitive dynamics undermined regionalized care by weakening referral systems, encouraging duplication of service, and contributing to the financial instability of tertiary centers, ultimately disrupting coordinated perinatal care delivery and leading to cut backs to outreach programs provided by a Level III centers [4].
  • The proliferation of ambiguously defined Level II NICUs led to the creation of small, often inefficient units that duplicated expensive services and blurred distinctions between levels of care [4, 13, 30, 32, 33]. These centers sometimes retained well-insured moderately high-risk patients—despite limited capacity to maintain patient volume and financial viability [18]. The sickest mothers were typically transferred antenatally, reflecting selective referral practices [8]. At the same time, some regional (Level III) centers selectively admitted low-risk or privately insured patients to help cover the costs of high-acuity care, while avoiding referrals involving poor insurance coverage [18, 42]. These patterns of “cream skimming” on both ends contributed to fragmentation, reduced back-transfers, and weakened regional collaboration [4, 13].

• Centralization of care rather than regionalization:

  • Establishment of new NICUs rarely originated from community needs but rather they appeared in university hospitals where staff and finance are available [32]. There was a risk of centralization rather than balanced regionalization. Level III centers could function as de facto monopolies attracting and retaining both high-risk and low-risk patients. This pattern could deprive local providers of patient volume, leading not only to financial strain but also to the gradual erosion of clinical expertise among staff who no longer manage complex cases firsthand [9, 13].

• Varying definitions of levels of care:

  • Despite national U.S. guidelines established by professional bodies such as the AAP and ACOG/SMFM, definitions of levels of care varied by state, resulting in inconsistency in perinatal care delivery. Current guidelines often treated maternal and neonatal care separately, with limited integration, failing to fully reflect the interconnected nature of the mother-infant dyad and limiting the development of coordinated, risk-appropriate systems of care [10].
  • With the growth of managed care in USA, some hospital administrators no longer relied on established levels-of-care frameworks when evaluating perinatal service capabilities and instead adapted level-of-care stratification to local circumstances and institutional needs [27].

Transport and logistical challenges

Transport systems were frequently under-resourced and, at times, unsafe. Equipment failures, logistical constraints, and long travel distances disrupted timely access to appropriate maternal and neonatal care.

• Problems with transfer equipment and logistics:

  • Equipment failures, including vehicle malfunctions, posed serious risks during long-distance neonatal or maternal transport [16].
  • Transferring patients and family members between hospitals created logistical challenges that could delay or complicate care [9].
  • For mothers living far from regional centers, the availability and quality of ambulance services and other transport options significantly influenced where VLBW infants were born [24].
  • During air transport, safety and access issues—such as improperly secured incubators or poorly positioned seating for the transport team—could hinder effective care for the newborn during transit [43].

Challenges specific to developing countries

In many low-resource settings, regionalized perinatal care was hindered by weak infrastructure, workforce shortages, and economic barriers, such as unaffordable transport and user fees. These challenges were compounded by fragile referral systems and the impact of public health crises.

• Insufficient healthcare infrastructure:

  • Health facilities at the primary, secondary, and tertiary levels remained severely inadequate in many settings [25, 44].
  • There were significant shortages of qualified health workers—including midwives, nurses, doctors, and specialists—and available staff were often reluctant to work in rural areas [44].
  • Infrastructure and service quality were poor, even within the limited facilities that do exist [44].
  • Existing healthcare facilities often operated in isolation, lacking integration into a coordinated referral network [44].
  • In several African countries, the HIV epidemic had further weakened health systems [44].

• Economic barriers to access:

  • Individuals from low-income backgrounds, who faced the greatest burden of neonatal and perinatal health issues, often lacked any financial protection for healthcare [44].
  • High costs in the private sector placed essential maternal and neonatal services out of reach for many families [25, 44].
  • Public healthcare facilities were frequently difficult to access and navigate, with delays and administrative barriers that discouraged timely care [44].
  • In some contexts, the loss of adult lives to HIV weakened traditional social support structures, leaving vulnerable populations with limited community assistance [44].
  • In some settings, women’s choice of childbirth location was strongly shaped by distance and the presence or absence of fees; access to transport was difficult, and many women lacked support from their partners [25]. Increased travel distance under regionalization was predicted to increase disutility among pregnant women, especially among poor and less educated women [25].

• Deficient referral and transport systems:

  • Poor road infrastructure and weak communication networks hindered access to healthcare services [44].
  • Functional referral transport systems were largely absent, making timely maternal and neonatal transfers difficult or impossible [44].
  • For low-income families, the cost of private transportation was often unaffordable, further limiting access to higher-level care [44].

Discussion

This scoping review synthesized findings from 41 studies and systematically categorized the diverse challenges that impede effective implementation and maintenance of perinatal regionalization systems. Despite decades of evidence supporting the benefits of regionalized care—including reduced neonatal morbidity and mortality, more efficient use of specialized resources, and improved quality of care— multiple interrelated barriers continued to limit the full realization of its potential across different settings. These barriers collectively undermine the ability to provide risk-appropriate, timely, and equitable care to mothers and neonates, with significant implications for health outcomes and system efficiency. However, because much of the included evidence originated from the United States, the generalizability of these findings to other countries should be interpreted with caution and in light of differences in health-system context.

The temporal pattern observed in this review suggests that challenges to optimal perinatal regionalization have evolved over time. The observed shift indicates that perinatal regionalization is not only a matter of establishing specialized services, but also of maintaining coordinated, equitable, and incentive-aligned systems that ensure high-risk mothers and newborns receive care in the most appropriate setting. Yet, these findings should be interpreted cautiously because the number and context of studies varied across time periods.

Clinical and medical challenges

Clinical and medical barriers hindered perinatal regionalization mainly due to the inherent complexity and unpredictability of maternal and neonatal complications. Inadequate antenatal care was repeatedly associated with VLBW births occurring outside Level III hospitals [18]. Although studies have suggested that approximately 70 to 80% of VLBW births are predictable and theoretically preventable from occurring in level I and II hospitals [11], the unpredictable nature of obstetric emergencies means that strict adherence to level-of-care designation is not always achievable [3].

Accordingly, targets for regionalization adherence in high-income countries are set below 100%. For example, Canada aims for more than 90% of births before 32 weeks to occur in Level III hospitals [7], France, sets a target of 80% [21], and in the United States, the initial goal in 2000 was 90% [13], but the Healthy People 2020 guidelines later adjusted the target to 83.7% [3]. Clinical contraindications to maternal transfer meant that some VLBW or extremely preterm will inevitably be born in Level I and II hospitals [45]. In addition, some conditions such as congenital malformations and inborn errors of metabolism, may not be detected antenatally [46, 47], underscoring the persistent need for neonatal transport even in well-functioning regionalized systems.

Socio-economic and geographic challenges

A finding of this study was that geographic isolation undermined access to regionalized perinatal care. A study conducted in several European countries showed that the likelihood of birth of babies under 32 weeks of gestation in a Level 3 hospital was half as much for mothers living in the fourth quartile of distance compared to those in the first quartile [17]. Greater distance between patients and healthcare facilities reduces service utilization and weakens the connection between healthcare providers and consumers [17]. Moreover, in maternity care, long distances increase the likelihood of childbirth during transport [17].

Socio-economic constraints—including poverty and inadequate insurance—limited the ability of women to travel to or be referred to higher-level facilities [48] These barriers are particularly important because regionalization depends not only on the availability of high-level facilities, but also on whether women can practically and financially access them when needed.

Cultural and patient-centered challenges

Regionalization can be perceived as impersonal and disempowering, when it disrupts patient autonomy, local connection, and continuity of care. Emotional resistance to transfers and back-transfers slows bed turnover and reduces efficiency. Cultural norms that emphasize local care, family decision-making, or distrust of distant institutions compound these challenges. Back-transfer of clinically stabilized neonates to a lower-level hospital reduces family stress and enables more efficient allocation of hospital resources [3]. Moreover, people of a particular city may prefer hospitalization in city A rather than city B. These cultural preferences should be taken into account when developing perinatal regional networks [49]. Therefore, cultural and patient-centered barriers should not be viewed as secondary concerns; rather, they directly influence acceptance, continuity, and the practical functioning of regionalized systems.

Provider-centered challenges

One barrier in this category was the perceived loss of prestige by providers and hospitals, especially the referring ones. In a study conducted in Indonesia, traditional birth attendants were asked to refer high-risk pregnancies to hospitals and thay stated that referring a pregnant woman would reduce their credibility in the eyes of the community [50]. Although this example comes from broader maternal health literature, it illustrates how referral may be perceived as a loss of authority or status in some contexts.

Clinician behaviors, especially in lower-level hospitals, often hinder regionalization due to misjudgment of fetal viability, preference for in-house care, and reliance on neonatal transport. A study conducted in South Carolina, USA, showed that one-third of VLBW infants born in Level I and II hospitals could have been transferred in-utero to a Level III hospital (i.e., there was opportunity to transfer the mother before childbirth) [19]. However, another study conducted in France showed that 90% of childbirths before 32 weeks that occurred in hospitals other than Level III were unavoidable, and in-utero transfer to a Level III hospital had not been possible [21]. These contrasting findings indicate that provider-centered challenges operate within clinical uncertainty and context-specific constraints.

In general, perinatal regionalization cannot be effective without the commitment of care providers [51]. Physicians should not be content with saying, “I did everything I could for this patient.” They should ask themselves how reorganizing services in the region could have prevented the illness or reduced its severity [9]. Providers are influential in determining birth place. Since mothers do not have sufficient information about the capabilities and resources of hospitals, they rely on their care providers when choosing a place of childbirth [10].

Obstetrician malpractice concerns and defensive medicine were other issues in this category affecting in-utero transfer. Obstetricians may be reluctant to accept the risk of complications and birth during transport. Standardized assessment tools and clear criteria for maternal transport would be helpful in this regard as well as legal protection for the obstetricians and documentation standards [52]. Inadequate professional communication also contributes to poor collaboration and delayed transfers. These findings suggest that provider-centered barriers are not merely individual-level problems, but are shaped by professional norms, legal concerns, inter-institutional relationships, and the organization of care.

Healthcare organization and financial challenges

A factor frequently reported to fuel the deregionalization of perinatal care was the increased availability of specialized workforce. Medical education and healthcare provision was integrated in Iran into Ministry of Health and Medical Education to accurately estimate and efficiently train the required health workforce [53]. This strategy potentially can prevent over-production of health workforce and proliferation of Level II NICUs, which their capability and effectiveness are being questioned [13, 19, 20]. It cannot be expected that a neonatologist in a Level II NICU deliver the same services as those provided in a large, specialized Level III NICU. Level III regional hospitals offer access to obstetric, maternal–fetal medicine and pediatric subspecialists, which are essential for optimal neonatal outcomes but generally not available in Level II facilities [20].

Regionalization is severely hindered by fragmented systems and financial incentives that reward hospital competition over coordination. “Cream-skimming” practices by both lower-level and higher-level hospitals limits risk-appropriate care and the risk of centralization of perinatal care at Level III hospitals exist [33]. Given that births before 32 weeks represent only about 1–1.5% of all live births [54], concerns about catastrophic revenue loss from transferring these cases are likely overstated.

In addition, the included literature did not consistently distinguish between public and private healthcare provision, limiting our ability to assess how ownership, financing, and public–private sector integration may influence the challenges of perinatal regionalization. The organization of maternal and newborn health services is another contextual factor that may influence the implementation of perinatal regionalization. Models of care vary across settings, including midwifery-led, obstetrician-led, and shared-care systems. These models may affect how maternal and neonatal risk is identified, how referral decisions are made, how communication occurs between levels of care, and how timely transfer to higher-level centers is achieved. Although this issue was not consistently examined across the included studies, future research should more explicitly assess how different models of maternal and newborn care organization influence the functioning and effectiveness of regionalized perinatal systems.

Transport and logistical challenges

Transport and logistics are integral components of regionalized perinatal care. This review found challenges that undermined timely and safe transfers. The fact that the rate of VLBW births occurring in level III hospitals can never reach 100% highlights the importance of inter-hospital neonatal transfers [55]. A reason for neonatal harm during inter-hospital transfers is the limited skill and experience of the staff involved, as such transfers occur infrequently [12]. For this reason, it is preferable for the neonatal transport team to be based at the receiving hospital, so they can go to the referring hospital, stabilize the infant, and safely carry out the transfer. Infants who undergo postnatal inter-hospital transfer have higher rates of bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), and mortality compared to those who are transferred in utero mainly due to the risk of injury during transport. These injuries may result from equipment failure, lack of neonatal monitoring devices, iatrogenic trauma due to inappropriate treatment, and instability of body temperature during transfer [10, 12]. The literature shows that improvements in the skills and training of neonatal transport team lead to a reduction in mortality among infants born in Level I and II hospitals [4].

Challenges specific to developing countries

In low- and middle-income countries, foundational health-system weaknesses present formidable barriers to regionalized perinatal care. Inadequate infrastructure, workforce shortages, fragmented services, and economic constraints make it challenging to establish functional referral networks. These barriers are often more fundamental than those reported in high-income settings, where the main challenges may relate to coordination, financing, market competition, or adherence to levels-of-care standards. Nevertheless, because the available evidence from developing countries is based on a limited number of studies, extrapolating these findings to all those countries should be done cautiously.

Policy implications

The findings of this scoping review suggest several policy implications. First, clinical and medical barriers highlight the need for stronger system of early risk identification and standardizing care practices [18]. Evidence-based screening tools, clear clinical guidelines, and risk stratification protocols to identify high-risk pregnancies can support early identification [52]. Continuous provider education on referral criteria and neonatal stabilization and strengthening antenatal outreach, particularly in underserved areas, can enhance early detection and care quality [56–58]. Policy measures could include integrating real-time clinical decision support systems, mandating routine antenatal risk assessments, and promoting early maternal transfer- especially before 32 weeks gestation- alongside inter-facility stabilization protocols.

Second, socio-economic and geographic barriers indicate that effective regionalization requires interventions that combine clinical infrastructure with equity-oriented policies [59]. Strategies include expanding insurance coverage (e.g., Medicaid) to support maternal transport, investing rural outreach via mobile clinics and community health workers, and using telehealth-supported triage systems [59, 60]. Policy actions should mandate coverage for maternal and neonatal transport, and facilitate cross-state licensing and payment mechanisms to overcome geographic and administrative barriers [61].

Cultural and patient-centered challenges suggest that regionalized care systems should incorporate early counseling, shared decision-making, and culturally sensitive communication to reduce emotional disruption and build trust [62, 63]. Suggested strategies include involving family support teams, using shared electronic medical records, and maintaining care continuity. Policies that allow local adaptation of regionalized models and emphasize communication, emotional support, and stakeholder engagement may improve patient acceptance and experience.

The provider-centered barriers indicate the importance of legal protection for obstetricians when appropriate transfer decisions are made, and robust documentation standards. professional bodies should lead in setting uniform referral standards and incentivizing adherence [9]. Incorporating regionalization principles into OB/GYN residency and continuous medical education curricula also can be helpful [64]. Hospitals must join structured referral networks with clear protocols, roles, and communication.

Financial concerns are powerful drivers of institutional behavior. Outcome-based payments, bundled reimbursement models that reward appropriate referral and back-transfer, and explicit support for Level III centers’ outreach functions may help reduce competition-driven deregionalization. Regulatory tools such as Certificates of Need (CON) for NICU establishment have been used in some jurisdictions to prevent overexpansion of neonatal intensive care services [10]. Policy reforms are needed to align financial incentives with risk-appropriate care—such as outcome-based payments, bundled reimbursement that rewards appropriate referral and back-transfer, and explicit support for Level III centers’ outreach functions [65, 66].

Transport and logistical barriers suggest the need for accreditation standards for transport capacity, ongoing training requirements for neonatal and maternal transport teams, and subsidies for family travel and lodging can help mitigate logistic and financial burdens on families. Telemedicine can also assist in stabilization and decision-making at referring hospitals while transport is being arranged.

In low- and middle-income countries, the strategies must be integrated with broader health-system strengthening efforts through investments in referral networks, mobile health technologies, and training for midwives and other providers [2]. Community-based health worker programs and financial support mechanisms for vulnerable populations can help reduce economic barriers. International aid, public-private partnerships, and sustainable financing schemes may assist in building and maintaining capacity in underserved regions.

Strengths and limitations

This scoping review is, to our knowledge, the first to comprehensively map and thematically synthesize the challenges to perinatal regionalization across multiple levels of the health system. By organizing 67 reported challenges into seven major domains, it provides a strategic framework that can support policymakers, clinicians, and planners in identifying priority areas for intervention.

However, several limitations should be noted. First, the literature was dominated by studies from the United States, which may limit the transferability of some findings to other healthcare models and financing systems. Second, only English-language studies were included, which may have led to the omission of relevant evidence from non-English sources. Third, in keeping with the scoping review design, no formal methodological quality appraisal was conducted. As a result, the challenges identified should be interpreted as themes that recur in the published literature, rather than as findings supported by uniformly high-quality empirical evidence. Some reported challenges may stem from studies with important methodological limitations, and the relative prominence of certain themes may partly reflect publication patterns rather than their true frequency or impact in practice.

Future research could build on this conceptual map by conducting focused systematic reviews, with formal risk-of-bias assessment, on specific domains (e.g., the effects of different reimbursement models on regionalization, or the impact of dedicated transport teams on neonatal outcomes). In addition, empirical studies that evaluate interventions designed to overcome identified barriers, and that incorporate patient and family perspectives, are needed to inform more responsive and equitable regionalization strategies across diverse contexts.

Conclusions

Perinatal regionalization is a critical strategy for improving maternal and neonatal outcomes, but its full potential is often constrained by a wide range of challenges. This scoping review identified clinical uncertainty, socio-economic and geographic barriers, cultural and patient-centered concerns, provider-level behaviors, fragmented referral systems, misaligned financial incentives, and transport and infrastructural limitations as key factors that undermine effective regionalization. In low- and middle-income countries, these barriers are magnified by broader health-system deficits.

Addressing these challenges requires a comprehensive, multi-level approach that strengthens clinical decision-making, improves coordination between providers and institutions, and integrates maternal and neonatal services across all levels of care. Investments are needed in transport infrastructure, referral networks, and workforce training to ensure that providers are equipped to make timely decisions and deliver risk-appropriate care. Realigning financial structures to incentivize early referrals, appropriate use of Level III centers, and effective back-transfer is crucial for achieving more equitable and efficient regionalized care. For low-resource settings, regionalization efforts must be accompanied by foundational improvements in infrastructure, workforce capacity, and financial protection.

By mapping the range of reported challenges and organizing them into a coherent framework, this review provides a basis for targeted policy reforms, system redesign, and future research aimed at strengthening perinatal regionalization and ensuring that high-risk mothers and newborns can reliably access the level of care they need.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

AAP

American Academy of Pediatrics

ACOG

American College of Obstetricians and Gynecologists

BPD

Bronchopulmonary Dysplasia

HIV

Human Immunodeficiency Virus

IVH

Intra-Ventricular Hemorrhage

NICU

Neonatal Intensive Care Unit

PRISMA-ScR

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews

SMFM

Society for Maternal-Fetal Medicine

USA

United States of America

VLBW

Very low birth weight

Author contributions

Study conception and design: MH, LA, MN, EP, AD; Study supervision: MH; data collection: LA, AD; analysis and interpretation of results: MH, LA, MN, EP, AD; draft manuscript preparation: AD; critical revision of manuscript: MH, LA, MN, EP; All authors reviewed the results and approved the final version of the article.

Funding

The authors declared no grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Data availability

All relevant data are included in this paper and the Appendixes.

Declarations

Ethics approval and consent to participate

This review synthesized data from publicly available published studies. No human participants or animals were involved as study subject, and no individual-level data were accessed. Therefore, ethical approval and informed consent were not required. All data sources were appropriately cited.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.