The Inverse Care Law in Action: How Neonatal ICU Expansion Widened Geographic Disparities in Ecuador (2010–2024)

The Inverse Care Law in Action: How Neonatal ICU Expansion Widened Geographic Disparities in Ecuador (2010–2024) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Inverse Care Law in Action: How Neonatal ICU Expansion Widened Geographic Disparities in Ecuador (2010–2024) Jose Daniel Sanchez Redroban, Sergio Curay, Esteban Tapia, Angel Alarcon This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8628937/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background: Neonatal mortality remains a critical challenge in middle-income countries despite significant healthcare investments. Ecuador experienced unprecedented health infrastructure expansion (2010–2017), including construction of tertiary hospitals and neonatal intensive care units (NICUs), yet neonatal mortality reduction has shown geographic heterogeneity and temporal deceleration. Objectives: To evaluate the impact of NICU capacity expansion on neonatal mortality in Ecuador (2010–2024), examine the Inverse Care Law hypothesis in resource distribution, quantify access inequity using concentration indices, and determine incremental cost-effectiveness ratios compared to preventive interventions. Methods: We conducted a nationwide ecological study integrating interrupted time-series analysis and cross-sectional equity assessment. Data sources included vital statistics registries (2010–2024), hospital discharge databases (2022–2024), and census-based socioeconomic indicators. Poisson regression models estimated neonatal mortality rate (NMR) trends following major hospital inaugurations. Equity was assessed through Gini coefficients for bed distribution and concentration curves adjusted for Unsatisfied Basic Needs (UBN) indices. Cost-effectiveness analysis calculated incremental cost per disability-adjusted life year (DALY) averted. Descriptive analyses included correlation matrices and log-transformed histograms for skewed distributions. Results: The dataset comprised 671 canton–year observations (2022–2024) with no missing values in core variables. National NMR declined from 10.9 per 1,000 live births in 2010 to 5.4 in 2024 (50.5% reduction), but provincial disparities persisted. Pichincha and Guayas concentrated 68% of NICU beds (6.22 and 3.67 beds per 1,000 births, respectively), while Bolívar, Carchi, and Amazonian provinces lacked functional Level III units. The Gini coefficient for bed distribution was 0.67. Live births by occurrence showed extreme right-skewness, with few cantons concentrating high values. Correlation matrices revealed strong associations between live births (occurrence and residence) and perinatal discharges (r > 0.85), with relevant correlations between infrastructure indicators, suggesting population size/service effects and potential collinearity. Interrupted time-series analysis revealed no immediate step-change in NMR following major hospital inaugurations. Cost-effectiveness analysis estimated $8,182 USD per DALY averted. The concentration index for mortality was −0.18, confirming disproportionate burden in poorer provinces. Conclusions: NICU expansion contributed to neonatal survival improvements but faces structural limitations including geographic maldistribution, saturated referral systems, and unresolved social determinants. The ecological nature of canton-level data reveals territorial concentration patterns but precludes individual-level causal inference. Achieving further mortality reduction requires transitioning from hospital-centric models to integrated health networks emphasizing regionalized intermediate care, neonatal transport systems, and upstream preventive interventions targeting prematurity and perinatal complications. Neonatal intensive care Neonatal mortality Health equity Health policy Ecuador Interrupted time-series analysis Cost-effectiveness analysis Ecological study Full Text Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 13 May, 2026 Reviewers agreed at journal 22 Apr, 2026 Reviewers agreed at journal 28 Feb, 2026 Reviewers invited by journal 26 Feb, 2026 Editor assigned by journal 20 Jan, 2026 Submission checks completed at journal 20 Jan, 2026 First submitted to journal 17 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8628937","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":598644862,"identity":"e7f1d84a-4144-4cf8-8cdc-2d48ce22db0b","order_by":0,"name":"Jose Daniel Sanchez Redroban","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBUlEQVRIiWNgGAWjYDCCAyBUAGLxAHEFAwMbkJIgrMUApuUMgwRRWhjgWhjbIKrxauE7fvbggQ8GdfLm7GcPPvw573AdHwPzwds8DDbyuLRInslLODjD4LDhzp68ZAPJbYeBDmNLtuZhSDNswKHF4ECOwWEegwOMG27wmEkYgrXwmEnzMBxOwGWLwfk3Bof/GNTZA7WY/0icA9LC/w2o5T9uLTeAtjAYMCeCbGE42AC2hQ2o5QBOLZI33hgc7DE4nLzhTI6xZMOxdMk2ZjZjyzkGyTj9wnc+x/jDj4o62w3Hzxh+/FFjzS/f3vzwxpsKO5whhgUwgx1MgoZRMApGwSgYBRgAABXKVDTg9pRKAAAAAElFTkSuQmCC","orcid":"","institution":"Universidad Tecnológica Indoamérica","correspondingAuthor":true,"prefix":"","firstName":"Jose","middleName":"Daniel Sanchez","lastName":"Redroban","suffix":""},{"id":598644863,"identity":"c6ec78fa-a5c4-4b18-8772-00b9910ad9a9","order_by":1,"name":"Sergio Curay","email":"","orcid":"","institution":"Universidad Tecnológica Indoamérica","correspondingAuthor":false,"prefix":"","firstName":"Sergio","middleName":"","lastName":"Curay","suffix":""},{"id":598644864,"identity":"be37d292-f095-407c-bddd-89d034afb338","order_by":2,"name":"Esteban Tapia","email":"","orcid":"","institution":"Universidad Tecnológica Indoamérica","correspondingAuthor":false,"prefix":"","firstName":"Esteban","middleName":"","lastName":"Tapia","suffix":""},{"id":598644865,"identity":"a60e5bda-3bf6-4122-920d-cd13bc3c690a","order_by":3,"name":"Angel Alarcon","email":"","orcid":"","institution":"Universidad Tecnológica Indoamérica","correspondingAuthor":false,"prefix":"","firstName":"Angel","middleName":"","lastName":"Alarcon","suffix":""}],"badges":[],"createdAt":"2026-01-18 03:23:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8628937/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8628937/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103914836,"identity":"4d5dbbab-c434-4473-a42e-0bbd61a11d82","added_by":"auto","created_at":"2026-03-04 12:57:42","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":562438,"visible":true,"origin":"","legend":"","description":"","filename":"UCIN.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8628937/v1_covered_5942a3a0-1af0-4083-ae6e-82408580c7d7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Inverse Care Law in Action: How Neonatal ICU Expansion Widened Geographic Disparities in Ecuador (2010–2024)","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":" Neonatal intensive care, Neonatal mortality, Health equity, Health policy, Ecuador, Interrupted time-series analysis, Cost-effectiveness analysis, Ecological study","lastPublishedDoi":"10.21203/rs.3.rs-8628937/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8628937/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Neonatal mortality remains a critical challenge in middle-income countries despite significant healthcare investments. Ecuador experienced unprecedented health infrastructure expansion (2010–2017), including construction of tertiary hospitals and neonatal intensive care units (NICUs), yet neonatal mortality reduction has shown geographic heterogeneity and temporal deceleration.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eObjectives: To evaluate the impact of NICU capacity expansion on neonatal mortality in Ecuador (2010–2024), examine the Inverse Care Law hypothesis in resource distribution, quantify access inequity using concentration indices, and determine incremental cost-effectiveness ratios compared to preventive interventions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMethods: We conducted a nationwide ecological study integrating interrupted time-series analysis and cross-sectional equity assessment. Data sources included vital statistics registries (2010–2024), hospital discharge databases (2022–2024), and census-based socioeconomic indicators. Poisson regression models estimated neonatal mortality rate (NMR) trends following major hospital inaugurations. Equity was assessed through Gini coefficients for bed distribution and concentration curves adjusted for Unsatisfied Basic Needs (UBN) indices. Cost-effectiveness analysis calculated incremental cost per disability-adjusted life year (DALY) averted. Descriptive analyses included correlation matrices and log-transformed histograms for skewed distributions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResults: The dataset comprised 671 canton–year observations (2022–2024) with no missing values in core variables. National NMR declined from 10.9 per 1,000 live births in 2010 to 5.4 in 2024 (50.5% reduction), but provincial disparities persisted. Pichincha and Guayas concentrated 68% of NICU beds (6.22 and 3.67 beds per 1,000 births, respectively), while Bolívar, Carchi, and Amazonian provinces lacked functional Level III units. The Gini coefficient for bed distribution was 0.67. Live births by occurrence showed extreme right-skewness, with few cantons concentrating high values. Correlation matrices revealed strong associations between live births (occurrence and residence) and perinatal discharges (r \u0026gt; 0.85), with relevant correlations between infrastructure indicators, suggesting population size/service effects and potential collinearity. Interrupted time-series analysis revealed no immediate step-change in NMR following major hospital inaugurations. Cost-effectiveness analysis estimated $8,182 USD per DALY averted. The concentration index for mortality was −0.18, confirming disproportionate burden in poorer provinces.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConclusions: NICU expansion contributed to neonatal survival improvements but faces structural limitations including geographic maldistribution, saturated referral systems, and unresolved social determinants. The ecological nature of canton-level data reveals territorial concentration patterns but precludes individual-level causal inference. Achieving further mortality reduction requires transitioning from hospital-centric models to integrated health networks emphasizing regionalized intermediate care, neonatal transport systems, and upstream preventive interventions targeting prematurity and perinatal complications.\u003c/p\u003e","manuscriptTitle":"The Inverse Care Law in Action: How Neonatal ICU Expansion Widened Geographic Disparities in Ecuador (2010–2024)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-04 12:57:28","doi":"10.21203/rs.3.rs-8628937/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"184181150909854435033701068817536034907","date":"2026-05-13T14:16:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"30822084348562600041979187538442767539","date":"2026-04-22T13:46:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"329545248868881035859156261651200899776","date":"2026-02-28T21:21:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-26T18:40:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-20T11:51:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-20T11:49:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal for Equity in Health","date":"2026-01-18T03:16:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f51eb136-d0e7-4e3a-a30e-7a657e42f5a8","owner":[],"postedDate":"March 4th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"184181150909854435033701068817536034907","date":"2026-05-13T14:16:18+00:00","index":52,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-04T12:57:29+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-04 12:57:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8628937","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8628937","identity":"rs-8628937","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}