Early neonatal transfers after moderate and late preterm birth: a nationwide cohort study based on the French National Health Data System

OBJECTIVES: To investigate how level of maternity unit and clinical risk factors influence early neonatal transfer among moderate and late preterm (MLP; 32-36 weeks' gestation (WG)) infants. METHODS: We conducted a nationwide cohort study including all liveborn MLP infants in France between 2014 and 2021. Infants with congenital malformations, stillbirths, and out-of-hospital births were excluded. Neonatal transfers within 48 h after birth, with death before 48 h as a competing event, were analyzed by gestational age, maternity level (I/IIa/IIb/III) and major clinical risk groups, including multiple pregnancy, small for gestational age (SGA) and/or fetal growth restriction (FGR) and maternal pregnancy complications. RESULTS: Among 309,062 MLP infants, 6.7% were transferred (6.5%) or died (0.2%). Transfer rates declined by gestational age from 14.7% at 32 weeks to 3.4% at 36 WG. Transfers were most frequent in level I (19.0%) and IIa (9.5%) units, compared with level IIb (3.5%) and III (3.0%) units. Clinical risk, particularly SGA/FGR, was associated with high transfer rates in level I and II units, even at later gestations (88.2% at 34 WG and 33.1% at 36 WG in level I units). CONCLUSION: Variability in transfer rates in subgroups of MLP infants highlights the need for risk-stratified regionalization policies. IMPACT: Early neonatal transfer within 48 h affects a substantial proportion of moderate and late preterm infants (32-36 weeks' gestation), highlighting mismatches between neonatal care needs and the level of maternity care at birth. In a nationwide cohort of over 300,000 infants in France, early transfer rates were higher among clinically vulnerable infants, particularly those with fetal growth restriction or small-for-gestational-age status when born in lower-level maternity units. Incorporating risk stratification beyond gestational age into perinatal regionalization strategies may reduce avoidable transfers and improve equity and early neonatal outcomes.