Cross-sectional survey of California childbirth hospitals: implications for defining maternal levels of risk-appropriate care




Objective


Measures of maternal mortality and severe maternal morbidity have risen in the United States, sparking national interest regarding hospitals’ ability to provide maternal risk-appropriate care. We examined the extent to which hospitals could be classified by increasingly sophisticated maternal levels of care.


Study Design


We performed a cross-sectional survey to identify hospital-specific resources and classify hospitals by criteria for basic, intermediate, and regional maternal levels of care in all nonmilitary childbirth hospitals in California. We measured hospital compliance with maternal level of care criteria that were produced via consensus based on professional standards at 2 regional summits funded by the March of Dimes through a cooperative agreement with the Community Perinatal Network in 2007 (California Perinatal Summit on Risk-Appropriate Care).


Results


The response rate was 96% (239 of 248 hospitals). Only 82 hospitals (34%) were classifiable under these criteria (35 basic, 42 intermediate, and 5 regional) because most (157 [66%]) did not meet the required set of basic criteria. The unmet criteria preventing assignment into the basic category included the ability to perform a cesarean delivery within 30 minutes 100% of the time (only 64% met), pediatrician availability day and night (only 56% met), and radiology department ultrasound capability within 12 hours (only 83% met). Only 29 of classified hospitals (35%) had a nursery or neonatal intensive care unit level that matched the maternal level of care, and for most remaining hospitals (52 of 53), the neonatal intensive care unit level was higher than the maternal care level.


Conclusion


Childbirth services varied widely across California hospitals, and most hospitals did not fit easily into proposed levels. Cognizance of this existing variation is critical to determining the optimal configuration of services for basic, intermediate, and regional maternal levels of care.


Worsening measures of maternal mortality and severe morbidity have begun to gain national attention. From 1987 to 2009, the pregnancy-related mortality ratio rose steadily from 7.2 to 17.8 deaths per 100,000 live births, and recent studies have estimated that at least 40% of maternal deaths appear to be preventable.


Recent publications have also recognized steadily increasing rates of severe obstetrical complications showing substantial racial disparity, with elevations among African-Americans and women of Hispanic ethnicity. According to Kuklina et al, renal failure, pulmonary embolism, adult respiratory distress syndrome, shock, blood transfusion, and ventilation are all on the rise nationally. Furthermore, rates of severe maternal morbidity appear to vary widely across hospitals.


This year, in an effort to promote benchmarking and improvement, a call was made for the facility-based identification and reporting of women with severe maternal morbidity. This call was further supported in February 2015 by the publication of a consensus-based statement from the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine that proposed the development of standards for maternal risk-appropriate care.


Given that childbirth is the number one reason for hospitalization in the United States at nearly 4 million births per year, a national strategy is needed to address this observed increase in childbirth-related maternal morbidity. Improved neonatal outcomes have resulted from perinatal regionalization, a term that currently refers to a health care delivery system that optimizes care for preterm newborns, and this strategy has prompted policy makers to examine the feasibility of creating maternal levels of care so that mothers with high-risk conditions could be assured delivery at hospitals with the appropriate resources (eg, the availability of subspecialists, specialty intensive care units, blood banking services, and diagnostic imaging equipment.


This initiative requires attention to a stepwise research agenda that includes the following: (1) the development of criteria for defining increasingly sophisticated levels of maternal care; (2) the demonstration that maternal outcomes are improved in women who deliver at facilities that can offer risk-appropriate care; and (3) the elaboration of implementation strategies for such a system. Such an agenda will initially require detailed hospital-level data regarding current configurations of childbirth services, resources and patient care activities, and linkages of these data to childbirth outcomes to identify the factors associated with optimal results. To date, such information has not been available.


The purpose of this study was to collect hospital-level data to document the characteristics of childbirth hospitals. This is in preparation for the development of a foundation for defining and implementing maternal levels of care to maximize both maternal and neonatal safety. Although the achievement of a system for maternal risk-appropriate health services is a national concern, here we focus on the services offered by California childbirth hospitals, which perform more than 500,000 births each year (12.7% of all US births), more than any other US state.


Materials and Methods


This is a cross-sectional assessment of childbirth hospital services designed to determine the extent to which hospitals can be classified by increasingly sophisticated maternal levels of care. Information was obtained from a survey of labor and delivery nurse managers for childbirth hospitals in California that included an array of items regarding hospital services, resources, and patient care activities. The study was approved by the Cedars-Sinai Institutional Review Board (protocol PRO00032669 certified exempt) and complied with all stipulated criteria for participant protection.


Professional standards for obstetrical care services are set out in Title 22 of the California State Code of Regulations and Guidelines for Perinatal Care, published by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. These publications refer to maternal levels of care but without the specificity needed to define the appropriate setting, provider, or competency required to care for individual patients or to address their pregnancy complications. Several US states have defined such levels, but these definitions vary and are primarily focused on improving neonatal as contrasted to maternal outcomes. For these reasons, we used recommended maternal level of care criteria that were produced via consensus at 2 regional summits funded by the March of Dimes through a cooperative agreement with the Community Perinatal Network in 2007 (California Perinatal Summit on Risk-Appropriate Care), which were based on professional standards.


Survey development and administration


We devised survey items based on the perinatal summit criteria and categorized them into 5 prespecified domains: hospital structure/context, hospital staffing, hospital clinical resources, and hospital clinical activities. Two interviewers were trained to assure consistent administration of the survey, which they piloted among labor and delivery managers at 5 hospitals to assure face and content validity of the domains and individual items and to assure that these managers would be an adequate and reliable source of information.


Upon finalization of all items, interrater reliability was assessed by having each interviewer conduct 5 interviews in the presence of the other, with each interviewer recording results, and agreement determined between the interviewers for each individual item, using Cohen’s kappa for categorical responses and the Shrout-Fleiss intraclass correlation for continuous or mixed responses.


In addition, 10 participants were retested at 3 months to assure concordance with their previous responses using the Shrout-Fleiss intraclass correlation. Survey items that did not have good interrater or test-retest reliability (kappa <0.8 or <80% agreement) were eliminated. The survey contained 185 questions that resulted in 293 individual items and took approximately 1 hour to complete. Those items that were directly related to the evaluation of meeting the maternal level of care criteria are included in the Appendix ( Supplementary Table ).


The survey was offered to all nonmilitary California childbirth hospitals, and contact information for labor and delivery managers was obtained through the Regional Perinatal Programs of California. The managers were contacted by phone and an appointment made for the interview. Managers were given a $50 gift card as an incentive. A hard copy of the survey was mailed to the managers in advance to assure familiarity with the questions. All surveys were completed between November 2012 and January 2014.


Data management


The interviewer entered information into SurveyMonkey (Palo Alto, CA), and data were exported into SAS (SAS version 9.3; SAS Institute, Cary, NC).


Information regarding neonatal intensive care unit (NICU) level was added to the data set. Basic/primary care hospitals (no NICU) were identified in an annual report from the California Office of Statewide Health Planning and Development as having obstetric beds but no NICU beds. Hospitals with NICUs were classified as having an intermediate NICU, community NICU, or regional NICU as designated by California Children’s Services (CCS), a state program for children with special health care needs, with intermediate NICUs providing less advanced care than community or regional NICUs and regional NICUs providing the most advanced care.


Facilities with licensed intensive care for newborn nursery beds but no designation by the CCS were also identified by this report. For analytical purposes, those NICUs without a CCS designation were assigned a comparable designation as an intermediate NICU if they had less than 15 beds and a community NICU if they had 15 or more beds.


Data analyses


We mapped all appropriate survey items to the criteria defined by the California Perinatal Summit, and hospitals were categorized regarding whether they met basic, intermediate, or regional maternal level of care criteria.


We used 2 methods to categorize hospitals. In method 1, maternal level of care criteria were grouped into 3 sets: basic (5 criteria), intermediate (5 criteria), and regional (6 criteria). To be classified as basic, a hospital had to meet all 5 basic criteria. To be classified as intermediate, a hospital had to meet all 5 basic and all 5 intermediate criteria. To be classified as regional, a hospital had to meet all 5 basic, 5 intermediate, and 6 regional criteria. In cases in which the survey respondent did not know whether the criterion was met by their hospital, the criterion was designated as not met. The number of hospitals for which specific items had missing answers is noted in Table 1 .



Table 1

Criteria for defining obstetrical levels of care as proposed at the California Perinatal Summit and number of hospitals meeting each criterion a















































































































Short name Criterion Operational definition Total (n = 239)
Level 1: basic (all hospitals with childbirth services)
Basic 1: cesarean delivery within 30 min 100% of the time No requirement for 24-h, in-house obstetrician, but MD should be able to respond within 30 min, and be on-call for only one hospital Ability to perform cesarean delivery within 30 min 100% of the time 152 (63.6%) b
Basic 2: anesthesia available within 30 min Anesthesia coverage should be able to respond within 30 min Anesthesia coverage can respond within 30 min 235 (98.3%)
Basic 3: nursery with 24 h, resuscitation/stabilization Newborn nursery should have 24-h neonatal resuscitation/stabilization capability Newborn nursery has 24-h neonatal resuscitation/stabilization capability 239 (100%)
Basic 4: pediatric care available day and night Pediatricians/neonatologists should be able to respond within 30 min and be on-call for only 1 hospital Pediatrician (or family practitioner)/neonatologist can attend deliveries both day and night 133 (55.6%) c
Basic 5: radiology ultrasound available within 12 h Ultrasound capability on call Obstetrical ultrasound from radiology department available within 12 h 199 (83.3%) d
Basic unused: transport agreement Formalized transport agreement with a facility capable of providing a higher level of maternal/newborn care Tracked but not counted as a criterion because it is dependent on the classified level of care Not applicable
Level 2: Intermediate, all of the above, plus the following
Intermediate 1: anesthesia available within 24 h in-house In-house anesthesia coverage 24 h In-house anesthesia coverage 24 h 146 (61.1%)
Intermediate 2: dedicated obstetrics anesthesia service In-house and obstetrics-dedicated anesthesia service In-house and obstetrics-dedicated anesthesia service 141 (59.0%) e
Intermediate 3: level 1 NICU CCS intermediate NICU (equivalent to level I NICU in Guidelines for Perinatal Care ) CCS level 1 NICU or non-CCS equivalent 152 (63.6%)
Intermediate 4: 24-h adult critical care Adult critical care capability available 24 h, not necessarily on labor and delivery Adult critical care capability available 24 h, not necessarily on labor and delivery 230 (96.2%)
Intermediate 5: 24-h maternal-fetal medicine service Maternal-fetal medicine specialist consultation available 24 h Maternal-fetal medicine specialist consultation available 24 h 198 (82.8%) f
Level 3: regional, all of the above, plus the following
Regional 1: 24-h obstetrician available in-house Obstetrics coverage (eg, obstetrician hospitalists) available 24 h in-house Obstetrics coverage (eg, obstetrician hospitalists) available 24 h in-house (not necessarily assigned to all patients) 92 (38.5%)
Regional 2: level 2 or 3 NICU CCS community or regional NICU (equivalent to levels II-III NICU in Guidelines for Perinatal Care ) CCS level 2 or 3 NICU or non-CCS equivalent 69 (28.9%)
Regional 3: 24-h neonatologist available Neonatology coverage (eg, neonatologists, neonatal nurse practitioners) available 24 h, in-house Neonatologist available for deliveries both day and night (not necessarily in-house) 210 (87.9%) g
Regional 4: 24-h radiology services available Radiology capability available 24 h, in-house Radiology capability available 24 h in-house (reading not necessarily in-house) 193 (80.8%) h
Regional 5: 24-h adult critical care plus invasive cardiac monitoring Adult critical care capability available 24 h, with portion of labor and delivery dedicated to critical care Adult critical care available 24 h, with capability of invasive monitoring on labor and delivery 99 (41.4%) i
Regional 6: 24-h maternal-fetal medicine on staff Maternal-fetal medicine specialist consultation available 24 h Maternal-fetal medicine specialist consultation available 24 h on staff 95 (39.7%)
Regional unused 1: perinatal follow-up Outpatient perinatal follow-up services, education, and case management provided to referring hospitals Unable to assess Not applicable
Regional unused 2: transport agreement Formalized transport agreements and regional cooperative agreements with all facilities transporting high-risk mothers and infants to them Tracked but not counted as a criterion because it is dependent on the classified level of care Not applicable

CCS , California Children’s Services; NICU , neonatal intensive care unit.

Korst. Maternal levels of risk-appropriate care. Am J Obstet Gynecol 2015 .

a If a hospital did not respond regarding a criterion, it was categorized as not met. The number of nonresponses for each criterion was zero unless otherwise specified by subsequent footnotes


b n (nonresponse) = 1


c n (nonresponse) = 5


d n (nonresponse) = 39


e n (nonresponse) = 34


f n (nonresponse) = 27


g n (nonresponse) = 5


h n (nonresponse) = 19


i n (nonresponse) = 5.



Because several items did not have 100% response rates and to better understand the potential of hospitals to meet the maternal level of care criteria, we did a second set of analyses (method 2) that allowed hospitals to miss 1 criterion at any of the levels and reassigned maternal levels of care based on this approach. This credit could be applied only once, starting from the basic level. The goal of method 2 was to relax the criteria, as in a sensitivity analysis, to permit the assignment of a category if one had not been assigned with method 1.




Results


The survey response rate was 96% (239 of 248 hospitals). Nine hospitals (ie, four integrated delivery system and 5 community hospitals) did not respond. The majority of respondents were administrative directors and nurses (n = 141; 59.0%), followed by clinical directors or nurse managers (n = 85; 35.6%), and others (n = 13; 5.4%). The mean (SD) number of years working at the current hospital was 12.4 (10.1) (median, 11.0; range, 0.1–46 years), and the mean (SD) number of years in the current position was 5.6 (5.8) (median, 4.0; range, 0.1–30 years).


Interrater reliability was calculated for 10 hospitals. For the 270 categorical items, the mean (SD) kappa values were 0.94 (0.15); items with kappa values <0.8 were discarded (n = 28). For the 23 continuous items, the mean (SD) agreement rate was 0.98 (0.06); items with <80% agreement were discarded (n = 2). For the 10 hospitals that were retested, the mean agreement rate (SD) for all 293 items was 0.96 (0.12); items with <80% agreement were discarded (n = 26). In total, 34 survey items were deemed unreliable and excluded from analyses.


The maternal level of care criteria are listed in Table 1 with the operational definitions and the reference names for the criteria. Table 1 also describes the number of hospitals meeting each individual maternal level of care criterion.


Most hospitals did not map easily to maternal levels of care. Table 2 describes the number of hospitals that met basic, intermediate, and regional criteria by methods 1 and 2. Using method 1, 82 hospitals (34.3%) were classified: 35 (14.6%) met basic criteria only, 42 (17.6%) met both basic and intermediate criteria, and 5 (2.1%) met basic, intermediate, and regional criteria. The remaining 157 hospitals (65.7%) could not be classified.



Table 2

Percentage of hospitals (n = 239) meeting perinatal summit criteria for maternal levels of care, by 2 methods and associated NICU levels a













































































































Maternal level of care NICU level of care
Method 1: met all criteria
Met basic criteria set Met intermediate criteria set Met regional criteria set n (%) Final level assignment of maternal level of care No NICU (basic services) Intermediate NICU Community NICU Regional NICU
No No No 116 (48.5%) 75 (64.5%) 20 (17.2%) 21 (18.1%) 0 (0%)
No Yes No 35 (14.6%) None: 157 (65.7%) 0 (0%) 11 (31.4%) 24 (68.6%) 0 (0%)
No No Yes 2 (0.8%) 0 (0%) 0 (0%) 0 (0%) 2 (100%)
No Yes Yes 4 (1.7%) 0 (0%) 0 (0%) 0 (0%) 4 (100%)
Yes No No 31 (13.0%) Basic: 35 (14.6%) 12 (32.3%) 8 (22.9%) 11 (31.4%) 4 (11.4%)
Yes No Yes 4 (1.7%)
Yes Yes No 42 (17.6%) Intermediate: 42 (17.6%) 0 (0%) 13 (31.0%) 27 (64.3%) 2 (4.8%)
Yes Yes Yes 5 (2.1%) Regional: 5 (2.1%) 0 (0%) 1 (20.0%) 0 (0%) 4 (80.0%)
239 total
































































































Method 2: met all criteria but one
No No No 46 (69.7%) 42 (91.3%) 3 (6.5%) 1 (2.2%) 0 (0%)
No Yes No 16 (24.2%) None: 66 (27.6%) 2 (12.5%) 2 (12.5%) 12 (75.0%) 0 (0%)
No No Yes 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
No Yes Yes 4 (6.1%) 0 (0%) 1 (33.3%) 0 (0%) 3 (66.7%)
Yes No No 73 (98.6%) Basic: 74 (31.0%) 41 (55.4%) 16 (21.6%) 16 (21.6%) 1 (1.4%)
Yes No Yes 1 (1.4%)
Yes Yes No 79 (100%) Intermediate: 79 (33.1%) 2 (2.5%) 26 (32.9%) 49 (62.0%) 2 (2.5%)
Yes Yes Yes 20 (100%) Regional: 20 (8.4%) 0 (0%) 5 (25.0%) 5 (25.0%) 10 (50.0%)
239 total

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May 5, 2017 | Posted by in GYNECOLOGY | Comments Off on Cross-sectional survey of California childbirth hospitals: implications for defining maternal levels of risk-appropriate care

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