Objectives

• •
  

  To introduce uniform designations for levels of maternal care that are complementary but distinct from levels of neonatal care and that address maternal health needs, thereby reducing maternal morbidity and mortality in the United States

  
  
• •
  

  To develop standardized definitions and nomenclature for facilities that provide each level of maternal care

  
  
• •
  

  To provide consistent guidelines according to level of maternal care for use in quality improvement and health promotion

  
  
• •
  

  To foster the development and equitable geographic distribution of full-service maternal care facilities and systems that promote proactive integration of risk-appropriate antepartum, intrapartum, and postpartum services

Background

In the 1970s, studies demonstrated that timely access to risk-appropriate neonatal and obstetric care could reduce perinatal mortality. In 1976, the March of Dimes and its partners first articulated the concept of an integrated system for regionalized perinatal care in a report titled Toward Improving the Outcome of Pregnancy . This report included criteria that stratified maternal and neonatal care into 3 levels of complexity, and recommended referral of high-risk patients to higher-level centers with the appropriate resources and personnel needed to address their increased complexity of care.

After the publication of the March of Dimes report, most states developed coordinated regional systems for perinatal care. The designated regional or tertiary care centers provided the highest levels of obstetric and neonatal care, while serving smaller facilities’ needs through education and transport services. Numerous studies have validated the concept that improved neonatal outcomes were achieved through application of risk-appropriate maternal transport systems. A comprehensive metaanalysis has shown increased odds of neonatal mortality for very low birthweight (very LBW, also commonly known as VLBW) infants (<1500 g) born outside of a level III hospital (38% vs 23%; adjusted odds ratio, 1.62; 95% confidence interval, 1.44–1.83). Data indicate higher neonatal mortality for very low birthweight infants born in hospitals that are staffed by neonatologists in the absence of a more complete multidisciplinary team (level II), compared with those born in level III centers.

Since the March of Dimes report was published, the conceptual framework of regionalization of care of the woman and the newborn has changed to focus almost entirely on the newborn. The American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) outline the capabilities of health care providers in hospitals delivering basic, specialty, subspecialty, and regional obstetric care in Guidelines for Perinatal Care , seventh edition. With 39% of hospital births in the United States occurring at hospitals that deliver less than 500 newborns each year and an additional 20% occurring at hospitals that deliver between 501 newborns and 1000 newborns each year, it likely is that the majority of maternal care in the United States is provided at basic-care and specialty-care hospitals. However, a recent commentary noted the need to readdress “perinatal levels of care” to focus specifically on maternal health conditions that warrant designation as high risk, and to define specific clinical and systems criteria to manage such conditions. This document is a call for an integrated, regionalized framework to identify when transfer of care may be necessary to provide risk-appropriate maternal care.

Although maternal mortality in high resource countries improved substantially during the 20th century, maternal mortality rates in the United States have worsened in the past 14 years. Currently, the United States is ranked 60th in the world for maternal mortality. According to a Centers for Disease Control and Prevention study, the leading causes of maternal mortality are associated with chronic conditions that affect women of reproductive age, and common obstetric complications such as hemorrhage. Moreover, maternal mortality in the United States represents a small component of the larger emerging problem of maternal severe morbidities and near-miss mortality that increased by 75% between 1998–99 and 2008–09. National increases in obesity, hypertensive disorders, and diabetes among women of reproductive age increase the risk of maternal morbidity and mortality, as does the increasing cesarean delivery rate. Although specific modifications in the clinical management of these conditions have been instituted (eg, the use of thromboembolism prophylaxis and bariatric beds in obstetrics), more can be done to improve the system of care for high-risk women at facility and population levels.

Although there is strong evidence of more favorable neonatal outcomes with regionalized perinatal care, evidence of a beneficial effect on maternal outcome is limited. Maternal mortality is an uncommon event, and methods for tracking severe morbidity only have been proposed recently. Data indicate that obstetric complications are significantly more frequent in hospitals with low delivery volume, and that obstetric providers with the lowest patient volume have significantly increased rates of obstetric complications compared with high-volume providers. Hospital clinical volume likely is a proxy measure for institutional and individual experience that may not be available at hospitals with lower volumes. Also, data indicate that outcomes are better if certain conditions, such as placenta previa or placenta accreta, are managed in a high-volume hospital. It also has been noted that maternal mortality is inversely related to the population density of maternal–fetal medicine subspecialists at the state level, although other factors, such as the presence of obstetrician–gynecologists, nurses, and anesthesiologists who have experience in high-risk maternity care, also may contribute to this trend. Although these findings provide support for an association between availability of resources and favorable maternal outcomes, they do not prove a direct cause and effect relationship between levels of care and outcomes.

A number of states have incorporated maternal care criteria into perinatal guidelines. Indiana, Arizona, and Maryland emphasize the need for stratification of facilities based on levels of maternal care that are distinct from neonatal needs, but use inconsistent definitions and nomenclature: the Indiana Perinatal Networks guideline is modeled after the March of Dimes report and uses levels I, II, and III; the Arizona system defines levels I, II, IIE, and III of maternal care; and the Maryland Perinatal System uses levels I, II, III, and IV. Despite their differences, an essential component of each of these guidelines is the concept of an integrated system in which, just as with neonatal care, level III and level IV maternal centers serve level I and level II centers by providing educational resources, consultation services, and streamlined systems for maternal and neonatal transport when necessary.

This document has 4 objectives: (1) introduce uniform designations for levels of maternal care that are complementary but distinct from levels of neonatal care and that address maternal health needs, thereby preventing further increases in maternal morbidity and mortality in the United States; (2) develop standardized definitions and nomenclature for facilities that provide each level of maternal care, including birth centers; (3) provide consistent guidelines of service according to level of maternal care for use in quality improvement and health promotion; and (4) foster the development and equitable geographic distribution of full-service maternal care facilities and systems that promote proactive integration of risk-appropriate antepartum, intrapartum, and postpartum services. This document focuses on maternal care and does not include an in-depth discussion about high-risk neonatal care capability based on gestational age or birthweight. Nevertheless, optimal perinatal care requires synergy in institutional capabilities for the woman and the fetus or neonate.

Background

In the 1970s, studies demonstrated that timely access to risk-appropriate neonatal and obstetric care could reduce perinatal mortality. In 1976, the March of Dimes and its partners first articulated the concept of an integrated system for regionalized perinatal care in a report titled Toward Improving the Outcome of Pregnancy . This report included criteria that stratified maternal and neonatal care into 3 levels of complexity, and recommended referral of high-risk patients to higher-level centers with the appropriate resources and personnel needed to address their increased complexity of care.

After the publication of the March of Dimes report, most states developed coordinated regional systems for perinatal care. The designated regional or tertiary care centers provided the highest levels of obstetric and neonatal care, while serving smaller facilities’ needs through education and transport services. Numerous studies have validated the concept that improved neonatal outcomes were achieved through application of risk-appropriate maternal transport systems. A comprehensive metaanalysis has shown increased odds of neonatal mortality for very low birthweight (very LBW, also commonly known as VLBW) infants (<1500 g) born outside of a level III hospital (38% vs 23%; adjusted odds ratio, 1.62; 95% confidence interval, 1.44–1.83). Data indicate higher neonatal mortality for very low birthweight infants born in hospitals that are staffed by neonatologists in the absence of a more complete multidisciplinary team (level II), compared with those born in level III centers.

Since the March of Dimes report was published, the conceptual framework of regionalization of care of the woman and the newborn has changed to focus almost entirely on the newborn. The American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) outline the capabilities of health care providers in hospitals delivering basic, specialty, subspecialty, and regional obstetric care in Guidelines for Perinatal Care , seventh edition. With 39% of hospital births in the United States occurring at hospitals that deliver less than 500 newborns each year and an additional 20% occurring at hospitals that deliver between 501 newborns and 1000 newborns each year, it likely is that the majority of maternal care in the United States is provided at basic-care and specialty-care hospitals. However, a recent commentary noted the need to readdress “perinatal levels of care” to focus specifically on maternal health conditions that warrant designation as high risk, and to define specific clinical and systems criteria to manage such conditions. This document is a call for an integrated, regionalized framework to identify when transfer of care may be necessary to provide risk-appropriate maternal care.

Although maternal mortality in high resource countries improved substantially during the 20th century, maternal mortality rates in the United States have worsened in the past 14 years. Currently, the United States is ranked 60th in the world for maternal mortality. According to a Centers for Disease Control and Prevention study, the leading causes of maternal mortality are associated with chronic conditions that affect women of reproductive age, and common obstetric complications such as hemorrhage. Moreover, maternal mortality in the United States represents a small component of the larger emerging problem of maternal severe morbidities and near-miss mortality that increased by 75% between 1998–99 and 2008–09. National increases in obesity, hypertensive disorders, and diabetes among women of reproductive age increase the risk of maternal morbidity and mortality, as does the increasing cesarean delivery rate. Although specific modifications in the clinical management of these conditions have been instituted (eg, the use of thromboembolism prophylaxis and bariatric beds in obstetrics), more can be done to improve the system of care for high-risk women at facility and population levels.

Although there is strong evidence of more favorable neonatal outcomes with regionalized perinatal care, evidence of a beneficial effect on maternal outcome is limited. Maternal mortality is an uncommon event, and methods for tracking severe morbidity only have been proposed recently. Data indicate that obstetric complications are significantly more frequent in hospitals with low delivery volume, and that obstetric providers with the lowest patient volume have significantly increased rates of obstetric complications compared with high-volume providers. Hospital clinical volume likely is a proxy measure for institutional and individual experience that may not be available at hospitals with lower volumes. Also, data indicate that outcomes are better if certain conditions, such as placenta previa or placenta accreta, are managed in a high-volume hospital. It also has been noted that maternal mortality is inversely related to the population density of maternal–fetal medicine subspecialists at the state level, although other factors, such as the presence of obstetrician–gynecologists, nurses, and anesthesiologists who have experience in high-risk maternity care, also may contribute to this trend. Although these findings provide support for an association between availability of resources and favorable maternal outcomes, they do not prove a direct cause and effect relationship between levels of care and outcomes.

A number of states have incorporated maternal care criteria into perinatal guidelines. Indiana, Arizona, and Maryland emphasize the need for stratification of facilities based on levels of maternal care that are distinct from neonatal needs, but use inconsistent definitions and nomenclature: the Indiana Perinatal Networks guideline is modeled after the March of Dimes report and uses levels I, II, and III; the Arizona system defines levels I, II, IIE, and III of maternal care; and the Maryland Perinatal System uses levels I, II, III, and IV. Despite their differences, an essential component of each of these guidelines is the concept of an integrated system in which, just as with neonatal care, level III and level IV maternal centers serve level I and level II centers by providing educational resources, consultation services, and streamlined systems for maternal and neonatal transport when necessary.

This document has 4 objectives: (1) introduce uniform designations for levels of maternal care that are complementary but distinct from levels of neonatal care and that address maternal health needs, thereby preventing further increases in maternal morbidity and mortality in the United States; (2) develop standardized definitions and nomenclature for facilities that provide each level of maternal care, including birth centers; (3) provide consistent guidelines of service according to level of maternal care for use in quality improvement and health promotion; and (4) foster the development and equitable geographic distribution of full-service maternal care facilities and systems that promote proactive integration of risk-appropriate antepartum, intrapartum, and postpartum services. This document focuses on maternal care and does not include an in-depth discussion about high-risk neonatal care capability based on gestational age or birthweight. Nevertheless, optimal perinatal care requires synergy in institutional capabilities for the woman and the fetus or neonate.

Definitions of levels of maternal care

In this document, maternal care refers to all aspects of antepartum, intrapartum, and postpartum care of the pregnant woman. In order to standardize a complete and integrated system of perinatal regionalization and risk-appropriate maternal care, a classification system should be established for levels of maternal care that pertain to birth centers (as defined in the Birth Centers section of this document), basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV) ( Tables 1 and 2 ). This system is in concert with ACOG and AAP Guidelines for Perinatal Care , seventh edition. Although data on which to base these distinctions in resources and capacity for maternal care are limited, the definitions were created from the characteristics of successful regionalized perinatal systems in a number of states (Background section). In this context, regionalized perinatal systems represent a combination of maternal and neonatal services. Establishing clear, uniform criteria for designation of maternal centers that are integrated with emergency response systems will help ensure that the appropriate personnel, physical space, equipment, and technology are available to achieve optimal outcomes, as well as to facilitate subsequent data collection regarding risk-appropriate care. Trauma is not integrated into the levels of maternal care because trauma levels are already established. Pregnant women should receive the same level of trauma care as nonpregnant patients. This document addresses the care provided at birth centers and hospitals, but home birth is not included.

Table 1

Levels of maternal care: definitions, capabilities, and types of health care providers ^a

BIRTH CENTER
Definition	Peripartum care of low-risk women with uncomplicated singleton term pregnancies with a vertex presentation who are expected to have an uncomplicated birth.
Capabilities	• Capability and equipment to provide low-risk maternal care and a readiness at all times to initiate emergency procedures to meet unexpected needs of the woman and newborn within the center, and to facilitate transport to an acute care setting when necessary. • An established agreement with a receiving hospital with policies and procedures for timely transport. • Data collection, storage, and retrieval. • Ability to initiate quality improvement programs that include efforts to maximize patient safety. • Medical consultation available at all times.
Types of health care providers	Every birth attended by at least 2 professionals: • Primary maternal care providers. This includes CNMs, CMs, CPMs, and licensed midwives who are legally recognized to practice within the jurisdiction of the birth center; family physicians; and ob-gyns. • Availability of adequate numbers of qualified professionals with competence in level I care criteria and ability to stabilize and transfer high-risk women and newborns.
Examples of appropriate patients (not requirements)	• Term, singleton, vertex presentation
LEVEL I (BASIC CARE)
Definition	Care of uncomplicated pregnancies with the ability to detect, stabilize, and initiate management of unanticipated maternal–fetal or neonatal problems that occur during the antepartum, intrapartum, or postpartum period until patient can be transferred to a facility at which specialty maternal care is available.
Capabilities	Birth center capabilities plus: • Ability to begin emergency cesarean delivery within a time interval that best incorporates maternal and fetal risks and benefits with the provision of emergency care. • Available support services, including access to obstetric ultrasonography, laboratory testing, and blood bank supplies at all times. • Protocols and capabilities for massive transfusion, emergency release of blood products, and management of multiple component therapy. • Ability to establish formal transfer plans in partnership with a higher-level receiving facility. • Ability to initiate education and quality improvement programs to maximize patient safety, and/or collaborate with higher-level facilities to do so.
Types of health care providers	Birthing center providers plus: • Continuous availability of adequate number of RNs with competence in level I care criteria and ability to stabilize and transfer high-risk women and newborns. • Nursing leadership has expertise in perinatal nursing care. • Obstetric provider with privileges to perform emergency cesarean available to attend all deliveries. • Anesthesia services available to provide labor analgesia and surgical anesthesia.
Examples of appropriate patients (not requirements)	Any patient appropriate for a birth center, plus capable of managing higher-risk conditions such as: • Term twin gestation • Trial of labor after cesarean delivery • Uncomplicated cesarean delivery • Preeclampsia without severe features at term
LEVEL II (SPECIALTY CARE)
Definition	Level I facility plus care of appropriate high-risk antepartum, intrapartum, or postpartum conditions, both directly admitted and transferred from another facility.
Capabilities	Level I facility capabilities plus: • Computed tomography scan and ideally magnetic resonance imaging with interpretation available. • Basic ultrasonographic imaging services for maternal and fetal assessment. • Special equipment needed to accommodate the care and services needed for obese women.
Types of health care providers	Level I facility health care providers plus: • Continuous availability of adequate numbers of RNs with competence in level II care criteria and ability to stabilize and transfer high-risk women and newborns who exceed level II care criteria. • Nursing leadership and staff have formal training and experience in the provision of perinatal nursing care and should coordinate with respective neonatal care services. • Ob-gyn available at all times. • Director of obstetric service is a board-certified ob-gyn with special interest and experience in obstetric care. • MFM available for consultation onsite, by phone, or by telemedicine, as needed. • Anesthesia services available at all times to provide labor analgesia and surgical anesthesia. • Board-certified anesthesiologist with special training or experience in obstetric anesthesia available for consultation. • Medical and surgical consultants available to stabilize obstetric patients who have been admitted to the facility or transferred from other facilities.
Examples of appropriate patients (not requirements)	Any patient appropriate for level I care, plus higher-risk conditions such as: • Severe preeclampsia • Placenta previa with no prior uterine surgery
LEVEL III (SUBSPECIALTY CARE)
Definition	Level II facility plus care of more complex maternal medical conditions, obstetric complications, and fetal conditions
Capabilities	Level II facility capabilities plus: • Advanced imaging services available at all times. • Ability to assist level I and level II centers with quality improvement and safety programs. • Provide perinatal system leadership if acting as a regional center in areas where level IV facilities are not available (refer to level IV). • Medical and surgical ICUs accept pregnant women and have critical care providers onsite to actively collaborate with MFMs at all times. • Appropriate equipment and personnel available onsite to ventilate and monitor women in labor and delivery until they can be safely transferred to the ICU.
Types of health care providers	Level II health care providers plus: • Continuous availability of adequate numbers of nursing leaders and RNs with competence in level III care criteria and ability to transfer and stabilize high-risk women and newborns who exceed level III care criteria, and with special training and experience in the management of women with complex maternal illnesses and obstetric complications. • Ob-gyn available onsite at all times. • MFM with inpatient privileges available at all times, either onsite, by phone, or by telemedicine. • Director of MFM service is a board-certified MFM. • Director of obstetric service is a board-certified ob-gyn with special interest and experience in obstetric care. • Anesthesia services available at all times onsite. • Board-certified anesthesiologist with special training or experience in obstetric anesthesia in charge of obstetric anesthesia services. • Full complement of subspecialists available for inpatient consultations.
Examples of appropriate patients (not requirements)	Any patient appropriate for level II care, plus higher-risk conditions such as: • Suspected placenta accreta or placenta previa with prior uterine surgery • Suspected placenta percreta • Adult respiratory syndrome • Expectant management of early severe preeclampsia at less than 34 weeks of gestation
LEVEL IV (REGIONAL PERINATAL HEALTH CARE CENTERS)
Definition	Level III facility plus onsite medical and surgical care of the most complex maternal conditions and critically ill pregnant women and fetuses throughout antepartum, intrapartum, and postpartum care
Capabilities	Level III facility capabilities plus: • Onsite ICU care for obstetric patients. • Onsite medical and surgical care of complex maternal conditions with the availability of critical care unit or ICU beds. • Perinatal system leadership, including facilitation of maternal referral and transport, outreach education for facilities and health care providers in the region, and analysis and evaluation of regional data, including perinatal complications and outcomes and quality improvement.
Types of health care providers	Level III health care providers plus: • MFM care team with expertise to assume responsibility for pregnant women and women in the postpartum period who are in critical condition or have complex medical conditions. This includes comanagement of ICU-admitted obstetric patients. MFM team member with full privileges is available at all times for onsite consultation and management. The team is led by a board-certified MFM with expertise in critical care obstetrics. • Physician and nursing leaders with expertise in maternal critical care. • Continuous availability of adequate numbers of RNs who have experience in the care of women with complex medical illnesses and obstetric complications; this includes competence in level IV care criteria. • Director of obstetric service is a board-certified MFM, or board-certified ob-gyn with expertise in critical care obstetrics. • Anesthesia services are available at all times onsite. • Board-certified anesthesiologist with special training or experience in obstetric anesthesia in charge of obstetric anesthesia services. • Adult medical and surgical specialty and subspecialty consultants available onsite at all times to collaborate with an MFM care team.
Examples of appropriate patients (not requirements)	Any patient appropriate for level III care, plus higher-risk conditions such as: • Severe maternal cardiac conditions • Severe pulmonary hypertension or liver failure • Pregnant women requiring neurosurgery or cardiac surgery • Pregnant women in unstable condition and in need of an organ transplant

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