Women’s Health Experts Recommend Obstetric Care Designations to Improve Maternal Care

New Document, Second in ACOG/SMFM Obstetric Care Consensus Series, Addresses Growing U.S. Maternal Mortality Rates

Washington, DC—Organizations representing women’s healthcare providers today released the first-ever consensus document establishing levels of care for perinatal and postnatal women. “Levels of Maternal Care,” the second in the joint American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine (SMFM) Obstetric Care Consensus Series, proposes a classification system that would promote regionalized care, allowing pregnant women at high risk to receive care in facilities that are prepared to meet their specific needs.

A similar model of an integrated system for regionalized, stratified perinatal care has led to improved neonatal outcomes in recent decades, but the focus of these efforts has primarily been centered on the newborn, rather than the mother. In the meantime, maternal mortality rates in the United States have actually worsened in the past 14 years.

“It is essential to remember that when we are addressing obstetrical outcomes, we have two very important patients: mother and child,” said Sarah J. Kilpatrick, MD/PhD, Chair of the Department of Obstetrics and Gynecology at Cedars-Sinai Medical Center in Los Angeles, California, and a lead author of the document. “Our goal for these consensus recommendations is to create a system for maternal care that complements and supplements the current neonatal framework in order to reduce maternal morbidity and mortality across the country.”

“Quality maternal care depends upon close collaboration among obstetricians, nurses, anesthesiologists, and other healthcare providers, and that collaboration is reflected by the organizations that have endorsed and supported this consensus document,” said M. Kathryn Menard, MD/MPH, Vice Chair for Obstetrics and Director, Maternal-Fetal Medicine at the University of North Carolina School of Medicine, also a lead author. “Implementing these important recommendations – and thereby moving forward to improve maternal safety – will require additional collaboration among other members of the healthcare community.”

The joint Obstetric Care Consensus identifies four objectives for a levels of care classification system:

• To introduce uniform designations for levels of maternal care that are complementary but distinct from neonatal levels of 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; and 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.

To that end, the consensus document recommends a five-part classification system based on a facility’s ability to handle various levels of maternal care. Each healthcare facility should have a clear understanding of its own classification, as well as a well-defined threshold and system for transferring women to facilities that offer higher levels of care, if needed.

In addition, because levels of maternal care and neonatal care may not match within individual facilities, a pregnant woman should be cared for at the facility that best meets both her needs and her baby’s needs.

The proposed classifications are as follows:

• Birth centers provide peripartum care to low-risk women with uncomplicated, single baby, term pregnancies with no anticipated complications. Cesarean deliveries and operative vaginal deliveries are not offered at birth centers.
• Level-I facilities (basic care) provide care to women who are low risk and are expected to have an uncomplicated birth. They have the capability to perform routine intrapartum and postpartum care that is anticipated to be uncomplicated.
• Level-II facilities (specialty care) provide care to appropriate high-risk pregnant women, both admitted and transferred to the facility. In addition to the capabilities of a level-I facility, level-II facilities should have an attending obstetrician-gynecologist at all times, as well as access to a maternal-fetal medicine subspecialist available for consultation onsite, by phone, or by telemedicine as needed.
• Level-III facilities (subspecialty care) provide all level-I and level-II services, and also have maternal-fetal medicine services available at all times and led by a maternal-fetal subspecialist. An obstetrician-gynecologist is available onsite at all times. A full complement of subspecialists should also be available for inpatient consultations and an on-site intensive care unit should be equipped to accept pregnant women. Designation of level III should be based on the demonstrated experience and capability of the facility to provide comprehensive management of severe maternal and fetal complications. Level-III facilities should service as regional care centers in regions with no Level-IV designated facilities.
• Level-IV facilities (regional perinatal health care centers) include the capabilities of all other levels of care, with additional capabilities and considerable experience in the care of the most complex and critically ill pregnant women throughout antepartum, intrapartum, and postpartum care. This includes maternal-fetal medicine care teams with the expertise to assume care of pregnant and postpartum women in critical condition or with complex medical conditions. This includes comanagement of ICU-admitted obstetric patients.

“Despite recent medical advances, maternal mortality is on the rise in the United States, with the U.S. Centers for Disease Control and Prevention reporting a 75 percent increase in maternal deaths in just 12 years,” said SMFM President Vincenzo Berghella, MD. “We hope that our Levels of Maternal Care recommendations will help to turn the tide and improve maternal safety across the country.”

“As obstetrician-gynecologists, we firmly believe that the best outcome of delivery is a healthy baby and a healthy mother,” said ACOG President John C. Jennings, MD. “A maternal care infrastructure that allows more American women to get the quality care that they need will also help those women go home to their families. That’s an outcome that we all want.”

The Obstetric Care Consensus acknowledges that there are barriers to implementation of the classification framework, and that questions remain as to whether accrediting bodies are needed to establish and monitor the levels of maternal care as well as how to provide the resources necessary.

The ACOG/SMFM consensus document was endorsed by the American Association of Birth Centers; the American College of Nurse-Midwives; the Association of Women’s Health, Obstetric and Neonatal Nurses; and the Commission for the Accreditation of Birth Centers. Separately, the leadership of the American Academy of Pediatrics, the American Society of Anesthesiologists, and the Society for Obstetric Anesthesia and Perinatology have reviewed and expressed support for the recommendations. Obstetric Care Consensus #2 “Levels of Maternal Care” is published in the February issue of Obstetrics & Gynecology.

The following recommendations are also published in the February issue of Obstetrics & Gynecology:

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The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of approximately 58,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org

The Society for Maternal-Fetal Medicine (est. 1977) is the premiere membership organization for obstetricians/gynecologists who have additional formal education and training in maternal-fetal medicine. The society is devoted to reducing high-risk pregnancy complications by sharing expertise through continuing education to its 2,000 members on the latest pregnancy assessment and treatment methods. It also serves as an advocate for improving public policy, and expanding research funding and opportunities for maternal-fetal medicine. The group hosts an annual meeting in which groundbreaking new ideas and research in the area of maternal-fetal medicine are shared and discussed. Visit www.smfm.org.