In February 2015, the American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal Fetal Medicine (SMFM) developed the document, “Levels of Maternal Care.” This consensus document was endorsed by the American College of Nurse-Midwives (ACNM), the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), the American Association of Birth Centers, and the Commission for the Accreditation of Birth Centers. In addition, the American Academy of Pediatrics, the American Society of Anesthesiologists, and the Society for Obstetric Anesthesia and Perinatology have reviewed the content and are supportive of the Levels of Maternal Care.

The Levels of Maternal Care Obstetric Care Consensus promotes the development of relationships between institutions with different levels of maternal care that are complementary but distinct from levels of neonatal care. This cooperative and multi-level approach supports pregnant women receiving maternal health care in facilities that best meets their individual needs.

By establishing levels of maternal care, ACOG and SMFM envision the following outcomes: 

  • Standardized definitions and nomenclature for facilities that provide each level of maternal care

  • Consistent guidelines according to each level of maternal care for use in quality improvement and health promotion

  • Equitable geographic distribution of full-service maternal care facilities and systems that promote proactive integration of risk-appropriate antepartum, intrapartum, and postpartum services

  • Uniform designations for levels of maternal care that are complementary but distinct from levels of neonatal care

In order to standardize a complete and integrated system of perinatal regionalization and risk-appropriate maternal care, a classification system was proposed for levels of maternal care that includes birth centers (as defined in the Birth Centers section of the Levels of Maternal Care document), basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV). See Table 1 for definitions.

Table 1

Levels of Maternal Care Definitions


 

Why Is It Important to Define Levels of Maternal Care?  

Although maternal mortality in high-resource countries improved substantially during the 20th century, maternal mortality rates in the United States have worsened.

 


 

Assessing Levels of Care

In 2012, the CDC developed the Levels of Care Assessment Tool (LOCATe) to address a need identified by states and national partners for a simple tool that standardizes the assessment of maternal and neonatal care capabilities of facilities. LOCATe assesses a facility’s capability based on criteria published by the American Academy of Pediatrics, ACOG, and SMFM. The tool provides facilities with an overview of how their maternal and neonatal services are distributed and empowers stakeholders to lead data-informed discussions for improving systems of risk-appropriate care. The CDC has engaged several states in the implementation of LOCATe.

ACOG and SMFM, in partnership with the Centers for Disease Control and Prevention, Arizona Perinatal Trust, and National Perinatal Information Center, developed the Levels of Maternal Care verification program. The verification program expands on the work achieved with LOCATe by using the results as the initial step for information-gathering to support the Levels of Maternal Care verification program. The program involves a site visit by a multi-disciplinary team of maternal health care providers who work with an obstetric facility’s perinatal team and leadership to verify the level of care, using a new tool that aligns with the 2015 ACOG/SMFM Levels of Maternal Care Obstetric Care Consensus.  

Current Program Status

ACOG pilot-tested the verification program in 14 facilities across three states (Georgia, Illinois, and Wyoming). A multidisciplinary team representing organizations with expertise in maternal risk-appropriate care performed an onsite comprehensive review of the maternal services available in each facility using the results from the CDC Levels of Care Assessment Tool as a pre-visit screening. A verification program that could be implemented on a local, state, or regional scale is being developed, leveraging the lessons learned from the pilot.

Read the Levels of Maternal Care Commentary for more information on the process in developing the program and lessons learned from the pilot. Please note: The commentary on the Levels of Maternal Care Verification Pilot, published in Obstetrics & Gynecology in December 2018 (Obstet Gynecol 2018; 132: 1401-1406), describes the availability of a “toolkit” in the fall 2018, which can be used to facilitate a Levels of Maternal Care verification program. During the process of finalizing the toolkit resources, the Levels of Maternal Care Obstetric Care Consensus (OCC) was submitted for periodic review, according to ACOG’s standard process, and is currently undergoing review and possible revision. Any potential revisions to the OCC may result in changes to the resources in the toolkit, as the forms must be aligned with the OCC. Therefore, ACOG will hold on making the toolkit available until the OCC review is completed and any potential changes to the toolkit resources are made. The toolkit will be made available as soon as possible, and we appreciate your patience and understanding.

ACOG has also launched a program in Texas to provide survey services for Levels II, III, and IV hospitals that provide maternity care and require state designation, per a new Texas statute. Recognizing the critical importance of implementing a program that accounts for the geographic and health care diversity of the lone star state, ACOG involved Texas providers and key organizations in the state in its development, opened a Texas-based office, and recruited over 130 Texas-based obstetrician-gynecologists, maternal nurses, and maternal-fetal medicine specialists to serve as surveyors. ACOG conducted the first maternal survey in the state in July 2018. Learn more about ACOG’s Texas program.   

Collaborating Organizations

American College of Obstetricians and Gynecologists (ACOG)

Founded in 1951, the American College of Obstetricians and Gynecologists (The College) is the specialty's premier professional membership organization dedicated to the improvement of women’s health. With more than 58,000 members, the College is a 501(c)(3) organization and its activities include producing the College's practice guidelines and other educational material.

Society for Maternal-Fetal Medicine (SMFM)

The Society of Maternal Fetal Medicine (SMFM), established in 1977, represents more than 2,000 obstetricians with additional formal education and training in maternal-fetal medicine.  Its members specialize in treating high-risk, complicated pregnancies. The Society also serves as an advocate for improving public policy, and expanding research funding and opportunities for maternal-fetal medicine.


Centers for Disease Control and Prevention (CDC)

The Centers for Disease Control and Prevention (CDC) is one of the major operating components of the U.S. Department of Health and Human Services. As the nation’s health protection agency, CDC saves lives and protects people from health threats. To accomplish this mission, CDC conducts critical science and provides health information that protects our nation against expensive and dangerous health threats, and responds when these threats arise.


Arizona Perinatal Trust (APT)

Established in 1980, the Arizona perinatal trust is a private-public partnership of hospitals, health care professionals, and state agencies throughout Arizona that are committed to an effective regionalized perinatal health care system through certification, perinatal education, and perinatal data review.

National Perinatal Information Center/Quality Analytic Services (NPIC/QAS)

NPIC is a nonprofit organization that seeks to improve perinatal health by providing expert analysis of large data sets, development of comparative benchmarking quality and utilization reports, evaluation of direct service programs, and project consultation and management to member neonatal care centers.

  

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