Clinical and Nonclinical Factors and Advanced Neonatal Resuscitation Interventions.

Importance: Approximately 1% of newborns receive advanced neonatal resuscitation interventions (ANRIs; consisting of endotracheal intubation, chest compressions, and epinephrine administration), the likelihood of which increases with known clinical factors. Associations of socioeconomic status (SES) and health system factors with ANRI are unknown. Objective: To examine the associations among maternal SES, remoteness of maternal residence, birth-site level of service, clinical factors, and ANRIs. Design, Setting, and Participants: This cross-sectional study used an administrative dataset of all live births at 34 weeks' gestation or later between January 1, 2000, and December 31, 2020, in Alberta, Canada, a jurisdiction with universal health care and provincially coordinated Neonatal Resuscitation Program training. Hospital births and home births attended by registered midwives were included. Statistical analyses were conducted from August 1 to September 30, 2025. Exposures: Maternal SES (classified according to Pampalon Material Deprivation Index quintiles), remoteness of residence (categorized using the Statistics Canada Remoteness Index), birth-site level of service, and clinical factors (including maternal, intrapartum, and fetal or neonatal characteristics). Main Outcomes and Measures: The primary outcome was any ANRI. Secondary outcomes were individual interventions (endotracheal intubation, chest compression, epinephrine administration). Multivariable logistic regression with stepwise variable selection was used to examine associations between SES and health system factors and the primary outcome. Results: A total of 966 475 live births at 34 weeks' gestation or later were analyzed, of whom 1.0% received ANRI. Neonates had a mean (SD) gestational age of 38.9 (1.48) weeks and included 494 835 males (51.2%); mothers had a mean (SD) age of 29.4 (5.46) years. Compared with level 2 birth sites, level 3 birth sites had lower odds of ANRI (odds ratio [OR], 0.57; 95% CI, 0.53-0.61) and all interventions. Births at level 1A sites (OR, 2.53; 95% CI, 1.99-3.15) and home births (OR, 1.44; 95% CI, 1.18-1.74) had higher odds of ANRI and chest compressions (OR, 7.32 [95% CI, 5.61-9.40] and 4.12 [95% CI, 3.29-5.11], respectively). All level 1 births (level 1C: OR, 0.54; 95% CI, 0.49-0.60; level 1B: OR, 0.52; 95% CI, 0.45-0.59; and level 1A: OR, 0.4 95% CI, 0.20-0.71) and home births (OR, 0.27; 95% CI, 0.16-0.43) were associated with lower odds of endotracheal intubations. There were no associations for maternal SES and maternal residence remoteness. The most significant clinical factors associated with ANRI were maternal general anesthesia (OR, 4.89; 95% CI, 4.47-5.34), lower gestational age (highest OR at 34 weeks: 3.60; 95% CI, 3.11-4.15), cesarean delivery (OR, 1.80; 95% CI, 1.60-2.02), meconium-stained amniotic fluid (OR, 2.05; 95% CI, 1.94-2.17), and macrosomia (OR, 1.83; 95% CI, 1.55-2.16). Conclusions and Relevance: In this cross-sectional study, maternal SES and maternal residence remoteness were not associated with increased odds of ANRI, and birth sites with a lower level of service were associated with higher odds of chest compressions but lower odds of endotracheal intubations. Clinicians should be prepared to resuscitate neonates exposed to general anesthesia.