Over the past few decades, advances in neonatal intensive care have led to dramatic improvements in survival among preterm infants, particularly very low birth weight infants (VLBWIs) [1]. However, the management of patent ductus arteriosus (PDA) remains a major challenge in daily clinical practice. Given the heterogeneity in physiological status among infants and the wide variability in the clinical course of PDA, a uniform approach to the timing and modality of treatment is difficult to apply in bedside practice [2]. Consequently, neonatologists play a pivotal role in reducing complications and improving survival by making individualized decisions tailored to each infant’s specific needs and by responding to inherently unpredictable clinical situations [3].

In Korea, the timing of surgical intervention for PDA has recently become a focal point of legal and social controversy. Judicial decisions have tended to focus primarily on clinical outcomes while overlooking the extreme vulnerability of these infants, their underlying comorbidities, and the inherent unpredictability of the neonatal intensive care unit (NICU) environment. This outcome-centered approach, which attributes legal responsibility to physicians for unavoidable adverse events without adequate consideration of the complex clinical context, raises serious concerns regarding the sustainability of neonatal care as an essential medical service. In a healthcare system already facing a shortage of neonatal specialists, disproportionate legal pressures on frontline clinicians may accelerate burnout and workforce attrition, ultimately exacerbating regional disparities in the distribution of critical care resources.

Recognizing this crisis, the Committee on Survey and Statistics of the Korean Society of Neonatology (KSN) conducted a nationwide survey of NICUs. The aim of this study was to provide a clear and realistic assessment of the current surgical infrastructure and specialist workforce for PDA management, with particular attention to regional disparities. By identifying the real-world physical and systemic constraints facing the healthcare system, we sought to generate empirical data that could inform legal and policy measures to protect clinicians and support the development of a more sustainable framework for neonatal intensive care in Korea.

Among the 60 participating hospitals, 22 were located in Seoul, 13 in the Gyeongsang region, 13 in the combined Chungcheong/Jeolla/Gangwon/Jeju region, and 12 in the Gyeonggi/Incheon region. Pediatric cardiologists were available in 52 institutions (86.7%), with regional availability ranging from 61.5% to 95.5%, whereas pediatric thoracic surgeons were available in 34 institutions (56.7%), with particularly limited availability in the Gyeonggi/Incheon region (41.7%). Staffing levels for neonatologists and pediatricians varied substantially across regions. Seoul had the highest number of neonatologists per institution (mean, 4.0), whereas the Gyeongsang region had the lowest (mean, 2.3); similarly, the total number of pediatricians working in the NICU ranged from a mean of 7.6 per institution in Seoul to 4.2 in the Gyeongsang region. These staffing patterns were also closely associated with NICU bed capacity, with units having more than 40 beds employing a mean of 5.9 neonatologists and 10.9 pediatricians per institution, compared with 2.4 and 4.5, respectively, in units with fewer than 20 beds. Marked regional and NICU capacity-related differences were also observed in the availability of in-hospital PDA ligation. The proportion of hospitals capable of performing in-hospital PDA ligation was 86.4% in Seoul and 84.6% in the Gyeongsang region, whereas the corresponding rates were 69.2% in the combined Chungcheong/Jeolla/Gangwon/Jeju region and 58.3% in the Gyeonggi/Incheon region. When stratified by NICU bed capacity, all units with more than 40 beds were capable of performing in-hospital PDA ligation, compared with 77.4% of units with 20 to 40 beds and 68.2% of those with fewer than 20 beds, indicating a lower likelihood of in-hospital surgery in smaller units (Table 1).

Beyond these regional and institutional variations in medical resources, the survey identified several practical constraints and clinical challenges encountered by neonatologists during PDA management. More than half of the responding institutions (50.8%; n=30) reported that shortages of specialists in essential fields such as pediatric cardiology, pediatric surgery, and anesthesiology, along with delays in consultation, represented major limitations. An identical proportion (50.8%) identified the medicolegal burden associated with clinical decision-making as a primary difficulty. Other significant obstacles included challenges in securing receiving hospitals and managing patient transport (30.5%), followed by instability in the supply of essential medications such as intravenous ibuprofen (28.8%). In contrast, 18.6% of institutions (n=11) reported no specific constraints in their clinical environment, further reflecting disparities in the neonatal care landscape across different facilities (Table 2).

The analysis of PDA management trends between 2024 and 2025 demonstrated an increase in the total number of in-hospital PDA ligations, rising from 120 to 149 cases. During the same period, out-transfers specifically for PDA ligation increased slightly from four to seven cases, whereas transfers for other surgical conditions or retinopathy of prematurity (ROP) increased from 76 to 92 cases. Despite this growing demand for neonatal surgical care, the availability of other surgical services varied considerably across subspecialties. Pediatric general surgery services were available in 66.7% of institutions (n=40), whereas neurosurgery and orthopedic surgery were available in only 50.0% and 43.3% of institutions, respectively. Regarding ROP management, ophthalmologic screening was available in 96.7% of institutions; however, only 73.3% were capable of providing definitive treatment such as laser photocoagulation or anti-vascular endothelial growth factor injection, within their own facilities. Due to these limitations in in-hospital surgical and therapeutic infrastructure, 23.3% of surveyed institutions reported experiences of out-of-region transfers extending beyond their administrative boundaries (Table 3).

Analysis of the minimum body weight thresholds for surgical intervention among the 45 institutions capable of performing in-hospital PDA ligation showed that 42.2% (n=19) reported having no fixed weight threshold (including <500 g). This was followed by 37.8% (n=17) using a threshold between 500 and 749 g. Other institutions reported thresholds of 750–999 g (13.3%), 1,000–1,499 g (4.4%), and ≥1,500 g (2.2%) (Figure 1,).

Analysis of the clinical and environmental constraints encountered during interhospital transfer for surgery revealed that clinical instability of the infant during transport was the most commonly reported challenge, identified by 54.4% of institutions (n=31). This was followed by difficulty securing a receiving hospital capable of accepting the patient (35.1%). Other reported barriers included difficulty determining the optimal timing for transfer (3.5%) and geographical or environmental limitations (1.8%) (Figure 3). Regarding systemic challenges associated with legal disputes and mediation processes, the shortage of legal experts with specialized medical knowledge was the most frequently cited issue, reported by 58.3% of institutions (n=35). This was followed by inadequate institutional support systems within hospitals (46.7%). Additional concerns included the excessive psychological and financial burden imposed on individual clinicians (31.7%) and the difficulty of demonstrating the appropriateness of clinical decision-making (25.0%) (Figure 4). These medicolegal risks were not merely perceived concerns but were reflected in actual experiences, as 15.5% of responding institutions reported direct involvement in civil or criminal lawsuits or medical dispute mediation related to PDA management, ROP treatment, or other major neonatal surgical procedures. Finally, directors of participating NICUs commonly expressed concern that judicial tendencies to hold clinicians legally responsible for unavoidable complications arising during good-faith treatment may undermine professional clinical judgment and decision-making.

This study provides empirical evidence that the crisis in neonatal intensive care has reached a critical threshold by capturing the firsthand perspectives of NICUs participating in a national neonatal network. The analysis demonstrates that the current neonatal intensive care system in Korea is simultaneously confronting physical limitations, characterized by shortages and exhaustion of specialists in essential supporting departments, and a psychological burden driven by increasing medicolegal responsibilities. This multifaceted crisis suggests that the professional dedication that has sustained neonatal intensive care is no longer sustainable in the absence of institutional safeguards and adequate staffing support. In particular, the marked variation in surgical infrastructure across regions and institutional sizes underscores substantial polarization in essential medical resources, implying that the clinical autonomy of many participating NICUs, except for a limited number of large-scale centers, is becoming increasingly vulnerable. Ultimately, this infrastructural imbalance, coupled with the rapid decline in birth rates and the maldistribution of medical personnel, may create a vicious cycle in which recruitment of new specialists is hindered and burnout among existing staff is accelerated. These findings indicate that the neonatal intensive care system in Korea has entered a structural crisis that is difficult to resolve without systemic intervention. Without immediate and fundamental policy measures at the national level, the right to survival for high-risk infants may become increasingly dependent on geographic location and hospital size, potentially leading to serious disparities in outcomes [4].

The practical reality of infrastructural limitations is most evident in the strained collaboration systems between neonatal units and essential supporting departments, including pediatric cardiology, pediatric surgery, and pediatric anesthesiology. Our findings show that 50.8% of responding institutions identified shortages of supporting specialists as a major constraint, resulting in delays in surgical decision-making and timely intervention for PDA. This professional gap effectively forces neonatologists to assume responsibilities beyond their original scope of practice and into areas requiring expertise from other specialties. The observation that neonatologists personally performed 96.7% of emergency PDA echocardiographic evaluations during nights and holidays, rather than pediatric cardiologists, highlights how workforce shortages in one specialty transfer additional burdens to another, ultimately blurring the boundaries of specialized care [5]. Although this compensatory clinical structure may temporarily preserve continuity of treatment, it may also compromise the assurance of subspecialty expertise and increase the potential for clinical uncertainty [6].

The process of transferring patients to other hospitals, which often becomes inevitable because of the lack of in-hospital treatment infrastructure, is also hindered by serious systemic obstacles. Our findings, identifying clinical instability of the infant during transport (54.4%) and the inability to find a receiving hospital that could accept the patient (35.1%) as the primary barriers to transfer, suggest that the current transfer system does not function as a safe alternative for high-risk neonates. In situations where minimum body weight thresholds for surgery differ across institutions and only a limited number of centers are equipped to accept extremely low birth weight infants, the process of identifying an appropriate facility may itself result in missing the critical window for treatment. Long-distance transport conducted without the support of specialized neonatal transport teams is highly likely to cause hypothermia or hemodynamic instability in preterm infants, which may have a significant negative impact on prognosis [7,8]. Therefore, to improve the survival of preterm infants born in institutions where in-hospital surgery is unavailable, it is necessary to move beyond simply securing hospital beds and prioritize the establishment of dedicated neonatal transport infrastructure to ensure safety during transit, together with coordinated networks between regional surgical hubs [9,10].

The medicolegal risks encountered by clinicians in clinical settings represent a substantial threat that extends beyond psychological anxiety, effectively discouraging the recruitment of specialists into essential medical fields and accelerating the loss of existing personnel. Our findings that 15.5% of responding institutions had experienced actual legal disputes or mediations, and that more than half of clinicians (50.8%) identified medicolegal burden as a major practical constraint, suggest that the neonatal intensive care environment remains constantly exposed to risk without an institutional safety net. In particular, neonatal medical malpractice lawsuits in Korea last more than 4 years on average and often involve high compensation claims, imposing considerable psychological and administrative burdens on neonatologists and encouraging the avoidance of high-risk patients or the practice of defensive medicine [11,12]. A further concern is that, although neonatal care inherently involves a high probability of unavoidable adverse outcomes, the judicial system tends to focus on breaches of duty of care by individual neonatal subspecialists rather than on systemic limitations or errors [13,14]. This environment has become a major factor contributing to the avoidance of residency applications in high-risk specialties, while quantitative evidence from overseas has consistently shown that high litigation risk leads to avoidance of high-risk procedures and withdrawal from clinical practice by specialists [15,16]. Furthermore, the shortage of specialized legal support systems (58.3%) and the lack of institutional safeguards (46.7%) identified in this survey may intensify the sense of isolation experienced by clinicians, potentially leading them to provide more passive care to minimize legal exposure rather than pursue the most appropriate treatment [17,18]. The current structure, in which medicolegal risks outweigh the professional dedication of individual clinicians, may ultimately undermine the sustainability of the neonatal intensive care system. This study has some limitations. First, as a cross-sectional survey, it reflects the clinical and infrastructural conditions at a single point in time, which may not fully account for the dynamic changes or longitudinal trends in the neonatal care system. Second, although the KNN represents the majority of major tertiary centers in Korea, these findings may not entirely capture the unique operational environments or specific systemic constraints faced by smaller, non-participating clinics and regional hospitals that operate outside this network.

In conclusion, the sustainability of the neonatal intensive care system in Korea has reached a critical stage that can no longer be maintained solely through the sacrifice of individual clinicians, making the development of integrated national policies an urgent priority. Future policy initiatives should first involve the establishment of a regional network for PDA management along with the expansion of safe neonatal transport infrastructure to ensure timely transfer of infants requiring emergency surgery or intervention. Second, it is essential to strengthen institutional collaboration among pediatric cardiologists, pediatric thoracic surgeons, and neonatologists, while providing practical compensation and support systems for nighttime and holiday diagnostic coverage to ensure the availability of supporting specialists. Third, in addition to securing a stable supply chain for essential medications, legal safeguards should be reinforced to provide protection from criminal liability for unavoidable adverse events in high-risk essential medical services, thereby allowing neonatal subspecialists to pursue evidence-based treatment without the constant burden of medicolegal risk. Ultimately, the policy implications of this study extend beyond the selection of treatment modalities for a specific condition such as PDA. A comprehensive redesign encompassing standardized guidelines for high-risk neonatal care, equitable regional accessibility, workforce expansion, and stabilization of the transfer system is required. Such measures are essential to prevent further deterioration of the neonatal healthcare system in Korea and to safeguard the survival of future generations.