Global warming is a predominantly human-caused phenomenon that is altering the planetary and atmospheric environment. These rapid changes in climate lead to significant weather events like extreme heat, drought, wildfires, floods, and storms that further trigger a cascade of mass biodiversity loss and extinction1,2. The relationship between climate change and human health is complex. Extreme weather events directly affect human health by causing mortality, displacement, and temporary and permanent migration. Extreme weather events disrupt agriculture through altered precipitation and temperatures, directly reducing crop yields, thus causing food insecurity. This disruption is further compounded by infrastructure destruction, and together, these issues exacerbate malnutrition due to insufficient food intake and poor diet diversity. Heat and wildfires worsen air quality, causing cardiorespiratory disease as well as other morbidities. Further, increased infectious diseases occur via vector-borne illnesses related to biodiversity breakdown, expansion of vectors beyond typical habitats, and water sanitation issues3, 4, 5, 6.

Women, pregnant persons, children, and infants are disproportionately vulnerable to climate change7. This article explores the multifaceted impact of climate change on pregnancy and neonatal health, with a particular focus on the heightened risks associated with prematurity. We discuss specific climate-related health risks, explore strategies for preventing and mitigating exposure, and emphasize the crucial role of climate health education in addressing these challenges. Furthermore, we will discuss climate vulnerability as a social determinant of health and advocate for integrating climate change screening and counseling into routine perinatal care.

Climate change threatens maternal and child health due to extreme weather events and impacts on air quality, nutrition, water quality, and living conditions8. Maternal malnutrition, exposure to extreme heat, increased transmission of vector-borne infectious diseases, and poor air quality are all risk factors for delivering a preterm and/or a low birth weight infant8, 9, 10, 11.

Extreme heat in pregnancy leads to maternal morbidity from dehydration, altered sleep, and mental health issues12, 13, 14. Weather events result in lower crop yields, precipitating hunger/famine2. An additional 5–170 million people are estimated to be at risk for food insecurity by 20802. This will increase maternal morbidity and mortality from malnutrition15. Increased heat is also associated with the transmission of vector-borne diseases by increasing mosquito and tick density and placing stress on water and sanitation infrastructure8,16. Malaria is one of the most deadly global mosquito-borne illnesses and causes numerous maternal deaths each year8,17. It is associated with maternal anemia, low birth weight, and premature delivery8,16. Other vector-borne diseases have significant perinatal health implications, including Dengue fever, West Nile Virus, Lyme Disease, Zika Virus, and zoonotic diseases (rabies, amebic, and invasive fungal diseases), which are also expected to increase due to the expanding range of ticks and mosquitoes6,18,19. There is a growing concern for the rise of water-borne parasitic illnesses like schistosomiasis, which may further worsen maternal-child health through maternal anemia and infants with low birth weight8.

The number of pediatric fatalities from severe weather events continues to increase20. Susceptibility begins in utero, where extreme heat events and food insecurity are linked to neural tube defects and congenital heart disease19. Infants and children are more vulnerable to the impacts of climate change due to their greater intake of air, food, and water per kilogram of body weight, physiologic limitations due to immature and developing body systems, and reliance on caregivers19,21,22. Malnutrition during food insecurity and drought disproportionately affect infants and children6. Rising temperatures and increased air particulates, pollen, carbon dioxide, nitrogen oxides, sulfur oxides, and volatile organic compounds can alter the lung development in fetuses and children, thus predisposing to and exacerbating asthma and other respiratory illnesses19,21. Mold exposure will increase with heavy precipitation events, further worsening respiratory outcomes19. Air pollution and poor air quality are also linked to neurodevelopmental and pulmonary morbidities23. Children are particularly vulnerable to vector-borne and waterborne diseases7. Globally, infectious diarrhea and malaria constitute two of the leading causes of death for children under five years of age24.

Climate change will increase the number of infants being born preterm and at low birth weight9. There is a significant association between extreme heat exposure during pregnancy and increased risk of preterm birth, low birth weight, and small for gestational age status25. Preterm and low birth weight neonates require intensive care support, increasing healthcare utilization. Exposure to extreme heat, particularly in the weeks prior to delivery, is directly associated with an increased risk of NICU admission26,27. In the U.S., the adverse perinatal effects of temperature extremes disproportionately affect Black and Hispanic mothers27. Similarly, perinatal exposure to extreme weather events, such as hurricanes or tropical cyclones, has also been associated with preterm delivery and low birth weight status25. Following extreme weather events, such as Hurricane Katrina, there is commonly a sharp rise in inadequate prenatal care as healthcare systems are disrupted28.

Preterm infants commonly have respiratory, gastrointestinal, and neurodevelopmental co-morbidities resulting in medical complexity that may require frequent follow-up with healthcare services, chronic medication, or technology for breathing, feeding, or mobility29,30. These medically fragile infants are even more vulnerable to previously described air pollution, infectious illness, energy insecurity, food shortages, or displacement. Infants who require NICU care are already predisposed to increased healthcare utilization, but when also exposed to severe climate events, medical needs are amplified22,30,31.

The American Academy of Pediatrics (AAP) urges pediatricians to assess climate vulnerability, educate and counsel families, and provide resources and assistance for mitigation and adaptation strategies32. The NICU team is uniquely positioned to counsel high-risk families. Assessing family needs is an essential preventative measure. Previous studies have demonstrated that food insecurity, transportation issues, and medical complexity are associated with increased hospitalization31. Although there are no specific screening tools that assess climate vulnerability in the neonate, consideration of the following: gestational age, technology dependence, medical complexity, and additional social determinants of health may highlight those neonates uniquely susceptible.

Social determinants of health screens that assess food security, water access, housing, energy security, chronic conditions, and transportation access can generally screen for climate vulnerability33. There are some climate-specific and social determinants of health screening tools. For example, the Heat-Related Illness Screening Tool (HIST) is a screening tool to identify individuals at risk for heat-related morbidity and mortality based on their physical, environmental, and social vulnerabilities34. Some screening parameters evaluate occupational risks, access to cooling, pre-existing health, mental or behavioral conditions, physical limitations, medication needs, resources, and social determinants of health35. The Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE) Questionnaire is an example of a comprehensive social determinant of health screening tool that assesses resource needs (food, utilities, clothing, transportation, and housing status), social support, education level, employment, household income level, insurance status, and language preference36. Previous studies have shown that utilization of the PRAPARE tool identified the needs of families in the NICU that were previously unrecognized, allowing teams to place necessary referrals and provide increased assistance36. These resources could include social work, case management, psychological support, and legal support36,37. Additionally, the AAP recommends that families have specific disaster plans and emergency supplies38. Families that have children with special needs should also have written information that summarizes their child’s health condition, as well as additional medications, and immunization records in case of an extreme weather event38.

Awareness of the specific health risks posed by the effects of climate change may be limited among healthcare workers39. Most North American physicians acknowledge the impact of climate change and have firsthand experience of the related health effects in their own patients, yet many also report a lack of comfort addressing the topic40. Patients more commonly view climate change as a generalized health threat, rather than as having an impact on their personal health41. Providers who care for pregnant people and newborns should understand and incorporate the perinatal impact of climate change and extreme weather events into routine healthcare. The American College of Obstetricians and Gynecologists (ACOG) has recognized climate change as a serious women’s health concern42,43. ACOG recommends that obstetric care providers consider taking an environmental health history to identify and reduce certain toxic and modifiable exposures during pregnancy43. The 2024 AAP policy statement on climate change and children acknowledges the threat of climate change to children’s physical and mental health, recognizing this threat disproportionately affects children from socially disadvantaged backgrounds32. Similar to ACOG, the AAP recommends pediatric healthcare providers incorporate assessment, education, and counseling on the health risks imposed by climate change and extreme weather events into clinical practice32. Studies illustrate that patients can be accepting of climate-related information from trusted healthcare providers, and climate-related counseling can be further legitimized when tied to health-specific outcomes44,45. Work examining patient-level climate-informed counseling is limited. However, the small number of studies completed suggests that patients show greater awareness of health risks after receiving climate-specific health guidance from their medical provider41,45,46. Clinicians should consider targeted counseling at key stages in a child’s NICU course to empower parents to face these challenges (Table 1).

Providers should be aware of the resources available to educate families on the effects of climate change on perinatal and newborn health. For example, the AAP maintains several online resources for professionals (Climate Change: https://www.aap.org/en/patient-care/climate-change/)50. Healthychildren.org, a parenting website sponsored by the AAP, also provides parent-centered information on the health effects of extreme heat and air pollution on babies and pregnant people, as well as information on individual actions that can combat climate change48, 51.

Additionally, professional organizations continue to call on women and children’s health providers to not only educate but also advocate for policies aimed at mitigating the effects of climate change. The AAP recognizes pediatricians as the ideal advocates to shed light on the ill effects of climate change and extreme weather events on perinatal and pediatric health32,48. They encourage providers to collaborate with coalitions already working to address climate change, prioritizing engagement with the most vulnerable communities, thus including those affected by historical underinvestment and discriminatory policies32.

NICUs, hospitals, and healthcare systems are also threatened by climate change. Organizations that care for women and newborns must adapt mitigation strategies to combat the rising effects of climate change to build resilient health systems. In 2012, the NICU at New York University Langone Medical Center had to evacuate 21 patients during Hurricane Sandy due to a power outage secondary to a coastal surge52,53. Considerations include ensuring a knowledgeable workforce equipped with tools to properly combat the ill health effects of climate change, health information systems adapted to the strain of extreme events, service delivery ready to respond to extreme weather, and adequate financing for these efforts3. Regions most vulnerable to climate change have an added imperative to bolster existing infrastructure to withstand severe events that may result in energy failures, supply chain shortages, waste accumulation, communication failures, and personnel shortages54. Healthcare systems and NICUs must individually evaluate unit-specific mitigation and adaptation strategies. Their strategies may include the evaluation of single-use plastics, energy infrastructure, energy sources, waste disposal, and conservation practices55,56. Hospitals can garner valuable insights from the shared first-hand experiences of disaster-affected facilities, such as the NICU at the Ochsner Foundation Hospital in New Orleans, which remained open throughout Hurricane Katrina. In a post-Katrina commentary, this team highlighted the importance of flexible transport procedures, formation of facility command centers, robust and redundant communication methods, and ground and water evacuation plans57.

ACOG maintains a committee opinion on hospital disaster preparedness that outlines recommendations for hospitals with maternity and neonatal care58. In the face of rising temperatures, facilities should also develop plans specific to the impact of heat waves on their pregnant and newborn patients. Cooling and hydration stations on labor and delivery and staff training on the diagnosis and treatment of heat-related illnesses are ways in which facilities can prepare for the adverse effects of extreme heat on the pregnant population59. There are widely available tools to identify threats and vulnerabilities in health care systems from the U.S. Department of Health and Human Services Sustainable and Climate Resilient Health Care Facilities Initiative6.

Providers in the NICU must be equipped with the knowledge and skills to recognize and address the health impacts of climate change on their patients. Currently, the Accreditation Council for Graduate Medical Education (ACGME) requires that all training programs instruct their learners on recognizing structural and social determinants of health as part of the systems-based practice core competency, but it does not specify what components encompass these determinants60. The AAP has urged educators to integrate climate change impact across all health-professions’ education to prepare those caring for children to provide adequate care for their health needs32. As climate change is a vital social determinant of health, current educational models should incorporate environmental education for NICU clinicians.

Select pediatric residency curricula on climate change have been described in the literature61,62. These include a review of climate change on children’s health, the role of healthcare providers as climate advocates, the importance of recognizing climate change as a key social determinant of health, and how interdisciplinary teams can work together to address the multidisciplinary aspects of climate change. Future neonatology-specific curricula should focus on how climate change affects the maternal-infant dyad, methods towards establishing climate-resilient NICU care systems, and principles of ethical decision-making regarding resource allocation during times of environmental stress (Table 2).

In developing curricular interventions around climate change, educators should consider multiple strategies for delivering such content. Working with environmental health experts and scientists, as well as incorporating published data from diverse sources, will help to develop evidence-based curricula. Case-based scenarios and simulations may help learners integrate such knowledge into practical approaches in a way that has been effective in other health professions73,74. Simulation training that leverages interdisciplinary collaboration could help prepare entire units to respond to climate-related disasters. Content related to climate change could also be incorporated into traditional neonatal topics. For example, a lecture on bronchopulmonary dysplasia could include the additional impact of climate change on respiratory outcomes. The implementation of such curricular interventions will also provide ongoing education to faculty and leaders in neonatology, many of whom are in positions to make changes to current practice and policy but lack awareness and training in issues of climate change as they relate to neonatal health.