Levels of Maternal Care: Updated Guidance and Implementation

Learn about the revised Levels of Maternal Care Obstetric Care Consensus (updated in 2019).


Revised Levels of Maternal Care Obstetric Care Consensus

In July, 2019, ACOG and the Society for Maternal-Fetal Medicine (SMFM) revised the 2015 Levels of Maternal Care Obstetric Care Consensus (OCC) to:

  • Reaffirm the need for levels of maternal care, which includes uniform definitions, a standardized description of maternity facility capabilities and personnel, and a framework for integrated systems that addresses maternal health needs
  • Clarify definitions and revise criteria by applying experience from jurisdictions that are actively implementing levels of maternal care
  • Reduce maternal morbidity and mortality by encouraging the growth and maturation of systems for the provision of risk-appropriate care specific to maternal health needs. This includes development of collaborative relationships between hospitals of differing levels of maternal care in proximate regions, which ensures that:
    • Every maternity hospital has the personnel and resources to care for unexpected obstetric emergencies
    • Risk assessment is judiciously applied
    • Consultation and referral are readily available when high-risk care is needed 

Levels of Maternal Care Definitions

Like the previous guidance, each level of maternal care reflects required minimal capabilities, physical facilities, and medical and support personnel. Each higher level of care includes and builds on the capabilities of the lower levels.

Level Definition
Accredited Birth Center Care for low-risk women with uncomplicated singleton term vertex pregnancies who are expected to have an uncomplicated birth
Level I (Basic Care) Care of low- to moderate-risk pregnancies with ability to detect, stabilize, and initiate management of unanticipated maternal-fetal or neonatal problems that occur during the antepartum, intrapartum, or postpartum period until the patient can be transferred to a facility at which the specialty maternal care is available
Level II (Specialty Care) Level I facility plus care of appropriate moderate- to high-risk antepartum, intrapartum, or postpartum conditions
Level III (Subspecialty Care) Level II facility plus care of more complex maternal medical conditions, obstetric complications, and fetal conditions
Level IV (Regional Perinatal Health Care Centers) Level III facility plus on-site medical and surgical care of the most complex maternal conditions and critically ill pregnant women and fetuses throughout antepartum, intrapartum, and postpartum care


Regionalization and Access to Maternal Care

The Levels of Maternal Care Obstetric Care Consensus is intended to maintain and increase access to care by developing, strengthening, and better defining relationships among facilities within a region. Although geographic and local issues will affect systems of implementation for regionalized maternal care, this, in turn, should facilitate consultation and transfer of care when appropriate, allowing low- to moderate-risk women to stay in their communities and pregnant women with high-risk conditions to receive care in facilities that are prepared to provide the required level of specialized care.

Levels of Maternal Care Verification Program

The Levels of Maternal Care verification program was developed by a multidisplinary core team in an effort to further support consistent interpretation of the guidelines. In addition to ACOG and SMFM, the core team includes representatives from:

The verification program involves a comprehensive onsite review to verify the maternal level of care of a hospital in alignment with ACOG and SMFM guidelines. In developing the verification program, the core team also aimed to expand on the work achieved with the CDC Levels of Care Assessment Tool by using a hospital’s results as the initial step in the verification process.

ACOG pilot-tested the verification program in 14 facilities across three states (Georgia, Illinois, and Wyoming). A multidisciplinary team 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.

This commentary, published by ACOG in January 2019, provides more information on the process in developing the verification program and lessons learned from the pilot.