In 1976, and again in 1993, the March of Dimes Committee on Perinatal Health developed recommendations based on research that supported a network of perinatal care providers who supplied care to a geographic region. The report, titled “Toward Improving the Outcome of Pregnancy” (TIOP I and TIOP II), spurred many states to regionalize care.7 The TIOP I, TIOP II, and TIOP III recommendations included criteria that stratified both maternal and neonatal care into levels of complexity and recommended transfer of both high-risk mothers and high-risk neonates. However, these recommendations were implemented more fully for neonates than they were for mothers.14 By the end of the 1980s, 26 states had regionalized perinatal care, and studies documenting a shift in deliveries from level I to level II and level III centers emerged, together with data documenting reductions in neonatal mortality. However, there has been evidence of deterioration in regionalization, which was summarized in the American Academy of Pediatrics policy statement on Levels of Neonatal Care.6 TIOP III has the concept that regionalization has deteriorated, and is supported by evidence of: (1) a proliferation of the number of NICUs and neonatologists without a consistent relationship with the number of high-risk infants; (2) increasing numbers of small NICUs adjacent to larger NICUs, and (3) the failure of the United States to reach the Healthy People 2010 goal that 90% of deliveries of very low birth weight infants occur in level III centers. Because most infant deaths in the United States occur among the most premature infants, improvements in regionalized systems may reduce mortality among these tiny infants. TIOP III maintained its recommendation for regionalization and added an emphasis on quality improvement methodologies. Table 3-1 compares the content of the three TIOP reports. The American Academy of Pediatrics (AAP) reaffirmed the principle of regionalization, and called for national definitions of levels of care and consistent standards for these designated levels.4 Capabilities are outlined in Table 3-2. TABLE 3-1 Summary of the Content of Toward Improving the Outcomes of Pregnancy (TIOP) I, II, and II Adapted with permission, March of Dimes, 2010.22 TABLE 3-2 Definitions, Capabilities, and Provider Types at Neonatal Care Centers
The Organization of Perinatal Services
Historical Perspective
Year Published
TIOP I
TIOP II
TIOP III
1976
1993
2010
Focus
Regional perinatal care system
Care before and during pregnancy
Care during birth and beyond
Documentation
Financing
Enhancing perinatal health through quality, safety, and performance initiatives
Primary recommendations
Levels of care
Education in regional system
Coordination in regional system
Health promotion
Structure and accountability
Ambulatory and inpatient care
Infant care
Improving the availability of prenatal care providers
Assuring uptake of robust perinatal quality and safety initiatives
Decreasing disparities in perinatal care and outcomes
Empowering women and families
Standardizing regionalization of services
Strengthening the national vital statistics system
Service
Level 1
Well Newborn
Level II
Special Care
Level III
NICU
Level IV
Regional NICU
Care Provided
Provide neonatal resuscitation at every delivery
X
X
X
X
Postnatal care to stable term infants
X
X
X
X
Stabilize and provide care to 35-37 weeks’ gestation infants who are physiologically stable
X
X
X
X
Stabilize infant less than 35 weeks for transfer to higher level of care
X
X
X
X
Care for infants born ≥32 weeks’ gestation and ≥1500 g who are moderately ill with problems expected to resolve rapidly
X
X
X
Mechanical ventilation or CPAP <24h in duration
X
X
X
Convalescent infants after intensive care
X
X
X
Stabilize and transfer infants <32 weeks’ gestation and/or <1500 g to NICU level III
X
X
X
Sustained life support
X
X
Comprehensive care for infants <32 weeks and/or <1500 g with critical illness
X
X
Prompt and readily available access to full range of pediatric medical and surgical specialists, pediatric anesthesiologists, and pediatric ophthalmologists
X
X
Provide a full range of respiratory support that may include high frequency ventilation and inhaled nitric oxide
X
X
Perform advanced imaging with urgent interpretation including CT, MRI, and echocardiogram
X
X
Surgical repair of complex congenital and acquired conditions
X
Full range of pediatric medical and surgical subspecialists and anesthesiologists at the site
X
Facilitate transport and provide outreach education
X
Personnel1
Pediatricians, family physicians, nurse practitioners, other advanced practice registered nurses
X
X
X
X
Pediatric hospitalists, neonatologist, neonatal nurse practitioners
X
X
X
Pediatric medical subspecialists,2 general pediatric surgeons, pediatric anesthesiologists2 and pediatric ophthalmologists2
X
X
Pediatric surgical subspecialists
X 
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The Organization of Perinatal Services
