State Implementation
Levels of Maternal Care: State Implementation
The ACOG/SMFM Levels of Maternal Care Obstetric Care Consensus defines the required minimal capabilities, physical facilities, and medical and support personnel for Levels of Maternal Care, including level I (basic care), level II (specialty care), level III (subspecialty care), and level IV (regional perinatal health care centers). By focusing on obstetric criteria, we aim to improve the quality and safety of maternal care and improve health outcomes for mothers.
There is much variation in states’ implementation of Levels of Maternal Care. ACOG collected the following information for each state:
- LoMC guidelines: Published state guidelines that define hospital levels of maternal care by specifying minimum capabilities and personnel for every level. Maternal guidelines are further defined as:
1. “Distinct maternal and neonatal criteria” whereby maternal criteria by level is separate from neonatal criteria.
2. “Maternal and neonatal criteria not distinct” whereby maternal criteria by level is blended with neonatal criteria. Maternal criteria may be included in documents titled, “Perinatal Guidelines” or “Neonatal Levels of Care Guidelines.”
Please note: We did not evaluate if states’ guidelines are aligned with the criteria and definitions in the Levels of Maternal Care Obstetric Care Consensus. - Legislation: State has passed a specific legislative bill to establish level of care designation for hospitals that provide maternity care. If maternal-specific designation is not specified, this is noted.
- State regulation: Levels of Maternal Care criteria by hospital level is specified in regulations that govern hospitals in the state. If regulations exist, states specify if designation is a mandatory or voluntary requirement.
- Entity that sets criteria: Organization that sets the criteria for each level designation.
- Method of designation: Method in which the level of care is determined. If a state reported self-designation by hospitals but has no maternal guidelines and no structured process to capture the designation, this is not considered a method of designation.
- Frequency of designation: How often the level of care designation is reviewed.
- LOCATe assessed: State has begun collecting CDC’s Levels of Care Assessment Tool (LOCATe) data. If state requires a LOCATe assessment, this is noted.
Of note, ACOG would like to emphasize these important points in the Levels of Maternal Care Obstetric Care Consensus:
- Criteria for levels of maternal care should be separate and distinct from levels of neonatal care.
- Maternal and neonatal level designations within a facility do not need to match. For example, a freestanding children’s hospital might be neonatal care level IV, with maternal capabilities and personnel consistent with level II designation.
- Specific to capabilities of higher-level facilities, it is critical that all level III and level IV facilities have an ICU that accepts pregnant and postpartum patients. While this analysis didn’t include evaluation of the criteria in states’ guidelines, it was apparent in our review that multiple guidelines did not include this requirement.
LoMC Implementation by State
State | LoMC Guidelines, as of November 2020 | Legislation | State Regulation | Sets Criteria | Method of Designation | Frequency of Designation | LOCATe Assessed |
---|---|---|---|---|---|---|---|
Alabama |
None |
No |
No |
N/A |
N/A |
N/A |
Yes |
Alaska |
None |
No |
No |
N/A |
N/A |
N/A |
No |
Arizona |
Yes: Maternal and neonatal criteria not distinct*
|
No |
No
|
Arizona Perinatal Trust |
Onsite survey |
Every 3 years |
No |
Arkansas |
Yes : Maternal and neonatal criteria not distinct |
No |
No |
Arkansas Board of Health |
Level I & II: self-designation (on hold)
|
Level III+ every 2 years |
Yes |
California |
None |
No |
No |
N/A |
N/A |
N/A |
Yes |
Colorado |
None |
No |
No |
N/A |
N/A |
N/A |
Yes |
Connecticut |
None |
No |
No |
N/A |
N/A |
N/A |
No |
Delaware |
None |
No |
No |
N/A |
N/A |
N/A |
Yes |
District of Columbia |
None |
No |
No |
N/A |
N/A |
N/A |
No |
Florida |
None |
No |
No |
N/A |
Onsite survey via FPQC pilot program |
N/A |
No |
Georgia |
Yes: Maternal designation not specified |
Yes |
State health department |
Level I: self-designation
|
Every 3 years |
Yes |
|
Hawaii |
None |
No |
No |
N/A |
N/A |
N/A |
No |
Idaho |
None |
No |
No |
N/A |
N/A |
N/A |
No |
Illinois |
Yes: Maternal and neonatal criteria not distinct*# |
Yes |
State health department |
Onsite survey |
Every 3 years |
Yes |
|
Indiana |
Yes: Distinct maternal and neonatal criteria |
Yes |
State health department |
Onsite survey |
Every 3 years |
No |
|
Iowa |
Yes: Distinct maternal and neonatal criteria |
No |
Yes |
State health department |
Level I: self-designation only
|
Every 3 years |
Yes |
Kansas |
None |
No |
No |
N/A |
N/A |
N/A |
No |
Kentucky |
None |
No |
No |
N/A |
N/A |
N/A |
No |
Louisiana |
Yes: Distinct maternal and neonatal criteria |
No |
Yes |
State health department |
Self-designation |
N/A |
No |
Maine |
None |
No |
No |
N/A |
N/A |
N/A |
Yes |
Maryland |
Yes: Maternal and neonatal criteria not distinct |
No |
Yes |
Maryland Institute for Emergency Medical Services Systems |
Level I/II: self-designation
|
Every 5 years |
No |
Massachusetts |
Yes: Maternal and neonatal criteria not distinct |
No |
Yes |
State health department |
Self-designation |
Once |
Yes |
Michigan |
None |
No |
No |
N/A |
N/A |
N/A |
Yes (within perinatal region) |
Minnesota |
None |
No |
No |
N/A |
N/A |
N/A |
No |
Mississippi |
Yes: Maternal and neonatal criteria not distinct# |
No |
Yes |
State health department |
N/A |
N/A |
Yes |
Missouri |
None: Uses LoMC Obstetric Care Consensus |
Yes |
State health department |
Onsite survey by external organization optional |
Every 3 years |
Yes |
|
Montana |
None |
No |
No |
N/A |
N/A |
N/A |
Yes |
Nebraska |
None |
No |
No |
N/A |
N/A |
N/A |
Yes |
Nevada |
None |
No |
No |
N/A |
N/A |
N/A |
Yes |
New Hampshire |
None |
No |
No |
N/A |
N/A |
N/A |
Yes |
New Jersey |
None |
No |
No |
N/A |
N/A |
N/A |
Yes |
New Mexico |
None |
No |
No |
N/A |
N/A |
N/A |
Yes |
New York |
Yes: Maternal and neonatal criteria not distinct*# |
No |
Yes |
State health department |
Level I/II: Self-designation; onsite survey TBD
|
To be determined |
No |
North Carolina |
None |
No |
No |
N/A |
N/A |
N/A |
Yes (within perinatal region) |
North Dakota |
None |
No |
No |
N/A |
N/A |
N/A |
No |
Ohio |
Yes: Maternal and neonatal criteria not distinct |
No |
Yes |
State health department |
Onsite survey |
Every 3 years |
No |
Oklahoma |
None |
No |
No |
N/A |
N/A |
N/A |
No |
Oregon |
None |
No |
No |
N/A |
N/A |
N/A |
No |
Pennsylvania |
None |
No |
No |
N/A |
N/A |
N/A |
No |
Rhode Island |
None |
No |
No |
N/A |
N/A |
N/A |
No |
South Carolina |
Yes: Maternal and neonatal criteria not distinct# |
No |
Yes |
State health department |
Onsite survey |
Annual |
No |
South Dakota |
None |
No |
No |
N/A |
N/A |
N/A |
No |
Tennessee |
Yes: Maternal and neonatal criteria not distinct |
No |
No |
State health department |
Self-designation |
Annual |
Yes |
Texas |
Yes: Distinct maternal and neonatal criteria |
Yes |
State health department |
Level I: self-designation
|
Every 3 years |
No |
|
Utah |
None |
No |
No |
N/A |
N/A |
N/A |
Yes |
Vermont |
None |
No |
No |
N/A |
N/A |
N/A |
Yes |
Virginia |
None |
No |
No |
N/A |
N/A |
N/A |
Yes |
Washington |
Yes: Maternal and neonatal criteria not distinct |
No |
No |
State health department |
N/A |
N/A |
Yes |
West Virginia |
None |
No |
No |
N/A |
N/A |
N/A |
Yes |
Wisconsin |
None: Uses LoMC Obstetric Care Consensus |
No |
No |
Wisconsin Association for Perinatal Care |
Self-designation |
N/A |
No |
Wyoming |
None |
No |
No |
N/A |
N/A |
N/A |
Yes |
*State is updating guidelines.
#State guidelines do not include language that level III/IV facilities must have an ICU that accepts pregnant and postpartum patients.
Acknowledgements
ACOG would like to thank the following individuals for their contributions to this project: Sarah Kilpatrick, MD, PhD, M. Kathryn Menard, MD, MPH, David Goodman, MS, PhD, Catherine Vladutiu, PhD, MPH, Andrea Catalano, MPH, and Katie Lichter, MD, MPH.