Karen Warren

Background: Despite medical advancements, preterm birth rates in the United States remain high and contribute substantially to infant mortality and long-term morbidity, with Black families disproportionately affected. Very preterm (VPT) infants—born between 24 and 30 weeks’ gestation—are frequently delivered at community hospitals that lack advanced neonatal care and therefore require postnatal transport to tertiary neonatal intensive care units (NICUs). While neonatal transport is essential for optimizing infant outcomes, it can create additional challenges for families, including geographic separation from the NICU, disruptions to early parent-infant bonding, and increased parental psychosocial stress. These challenges may be further intensified by social vulnerability and experiences of perceived discrimination in health care settings. Objective: This study examines associations between neonatal transport, infant health outcomes, and the psychosocial well-being of Black parents with VPT infants. It also examines how structural inequities and social vulnerability shape experiences from delivery through NICU hospitalization. Methods: This protocol describes a longitudinal mixed methods multiple case study at a single perinatal center in South Carolina. Up to 10 cases of VPT Black infants transported from community hospitals between May 2023 and January 2024 are included. Each case includes the infant and mother, with partners invited. Quantitative data include infant outcomes from electronic medical records, neighborhood disadvantage using the Area Deprivation Index, and parent surveys of stress, anxiety, depression, bonding, perceived discrimination, and access to care. Qualitative data come from semistructured interviews guided by an adaptation of the National Institute on Minority Health and Health Disparities Research Framework and analyzed using reflexive thematic analysis. Data are integrated within each case to create structured summaries, followed by cross-case comparisons to identify patterns and variation. Results: The study was funded by the National Institute of Nursing Research in July 2023. Participant enrollment occurred between May 2023 and January 2024, with 6 cases enrolled. Data collection and electronic medical record abstraction were completed in May 2024, with analysis completed by July 2024. This manuscript reports the protocol and analytic plan. Detailed results will be reported in 2 companion manuscripts currently under review; publication of one is anticipated in fall 2026. Conclusions: This protocol outlines a novel mixed methods case study of neonatal transport and infant and parent outcomes among Black families. The study is exploratory and intended to generate hypotheses and inform future larger scale research and intervention development to support parental mental health, reduce disparities, and improve care experiences following preterm birth and neonatal transport.

BACKGROUND Despite medical advancements, preterm birth remains alarmingly high in the United States, contributing significantly to infant mortality and long-term health challenges. Black families are disproportionately affected by these high rates. Very preterm (VPT) infants- those born between 24 and 30 weeks' of gestation- are often delivered at community hospitals that lack specialized neonatal care. These infants require transport to tertiary-level NICUs, which can open the door for complications. In addition to medical complications, neonatal transport can create stress for families and affect parent-infant bonding during a crucial time. These problems are intensified by social vulnerability and perceived discrimination. OBJECTIVE This study examines how neonatal transport affects both infant health outcomes and the psychosocial health of Black parents with VPT infants. It explores how structural inequities, and social vulnerability can shape parental experiences- from delivery and transport to NICU hospitalization. METHODS Using a longitudinal, multiple-case study design with mixed methods, this research follows 10 cases of VPT Black infants transported from community hospitals in South Carolina between May 2023 and June 2024. Each case includes the infant and mother (with an invitation for partners to participate). Quantitative data includes infant health outcomes extracted from electronic medical records and neighborhood disadvantage assessed using the Area Deprivation Index. Parents complete validated surveys measuring stress, anxiety, depression, bonding, discrimination and access. Qualitative data comes from semi-structured interview guides based on an adaptation of the NIMHD Research Framework. Reflexive thematic analysis is used for to analyze these interviews. Data are integrated within and across cases to create detailed case summaries and cross-case comparisons. RESULTS The study received National Institute of Nursing funding in July 2023. This protocol describes only the methods and the analytical approach. In accordance with our grant award, research results will be reported and disseminated through peer-reviewed publications and conferences. CONCLUSIONS This study is the first to explore the overlapping intersections of neonatal transport, infant outcomes, and psychosocial health in Black parents using a mixed-methods case study approach. The findings aim to inform future interventions that reduce disparities, improve parents' experiences, and promote better outcomes for both infants and maternal mental health.

Background: The birthrate of Black preterm (BPT) infants is 65% higher than White preterm (WPT) infants with a BPT mortality that is 2.3 times higher. The incidence of culture-positive late-onset sepsis is as high as 41% in very-preterm infants. The main purpose of this study was to examine thermal gradients and the heart rate in relation to the onset of infection. This report presents disparities in very-preterm infection incidence, bacteria, and mortality data amongst BPT and WPT infants. Methods: 367 preterms born at p = 0.2313) and 27.67 (SD 2.00, p = 0.982) weeks GA. Of the 426 episodes of suspected infections evaluated across all the enrolled infants, the incidence of early-onset sepsis (EOS) was 1.9%, with BPT infants having 2.50 times higher odds of EOS than WPT infants (p = 0.4130, OR (odds ratio) = 2.50, p_or = 0.408). The overall incidence of late-onset sepsis (LOS) was 10.8%, with LOS in 11.9% of BPT infants versus 9.3% (p = 0.489, OR = 1.21, p_or = 0.637) of WPT infants. BPT infants made up 69.2% of the 39 infants with Gram-positive infections vs. 25.6% for WPT infants; 16 infants had Gram-negative culture-positive infections, with 81.2% being BPT infants versus 18.8% being WPT infants. Of the 27 urinary tract infections, 78% were in BPTs. The necrotizing enterocolitis incidence was 6.9%; the incidence in BPT infants was 7.5% vs. 6.5% in WPT infants. The overall mortality was 8.3%, with BPTs at 8.4% vs. WPT infants at 9.3%, (p = 0.6715). Conclusions: BPTs had a higher rate of positive cultures, double the Gram-negative infections, a much higher rate of urinary tract infections, and a higher rate of mortality than their WPT counterparts. This study emphasizes the higher risk of morbidity and mortality for BPTs.

Background: The birthrate of Black preterm (BPT) infant is 65% higher than White preterm (WPT) infants with BPT mortality 2.3 times higher. The incidence of culture positive sepsis is as high as 41% in preterms. This study aimed to examine infections and mortality in BPTs and WPTs. Methods: We enrolled 362 preterms born < 32 weeks gestational age (GA) between 2019-2023 in 5 neonatal intensive care unit (NICU)s to study onset of infections, and dispositions; RedCap data were analyzed for descriptive statistics. Results: 226 BPTs (63.5%) and 107 WPTs (30.8%) enrolled, with 29 other than White or Black, 50.5% female, mean GA of 27.67 weeks and 986.74 grams birthweight. Of 426 suspected infections evaluated in enrolled infants, there were 7 infants with early onset sepsis (EOS) and 39 infants with late onset sepsis (LOS). The incidence of EOS was 1.9% overall, 2.2% in BPTs vs 0.9% in WPTs. LOS incidence was 10.8% overall, 11.9% in BPTs and 9.3% in WPTs. Both BPT and WPT infants had ~ 8% gram-positive LOS events and 3% gram-negative LOS events; however, 82% of all gram-negative LOS episodes occurred in BPTs. There were 27 urinary tract infections and 78% were in BPTs. Two cerebral spinal fluid cultures were positive in BPTs. Necrotizing enterocolitis was diagnosed in 5.8% of the sample, with an incidence of 6.1% in BPTs versus 4.7% in WPTs. Death occurred in 6.0% of the enrolled infants with the rate of death being slightly higher in BPTs (7.0%) versus WPTs (5.6%). Conclusions: BPTs had a higher rate of positive cultures, double the gram-negative infections, a much higher rate of urinary tract infec-tions and a higher rate of mortality than their WPT counterparts. This study emphasizes higher risk of morbidity and mortality for BPTs.