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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

No

Alaska

None

No

No

 N/A

N/A

N/A

No

Arizona

Yes: Maternal and neonatal criteria not distinct*

Not publicly available

No

No

Voluntary implementation

Arizona Perinatal Trust

Onsite survey

Every 3 years

 No

Arkansas

YesMaternal and neonatal criteria not distinct

No

No

Voluntary implementation

Arkansas Board of Health

 

Level I & II: self-designation (on hold)

Level III+: onsite survey

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

N/A

N/A

No

Georgia

Yes: Distinct maternal and neonatal criteria

Yes: Maternal designation not specified

Yes

Voluntary implementation

State health department

Level I: self-designation

Level II/III: onsite survey

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 

Yes

Mandatory implementation

State health department

Onsite survey

Every 3 years

Yes

Indiana

Yes: Distinct maternal and neonatal criteria

Yes

Yes

Mandatory implementation

State health department

Onsite survey

Every 3 years

No

Iowa

YesDistinct maternal and neonatal criteria

 No

Yes

Voluntary implementation

State health department

Level I: self-designation only

Level II & III: onsite survey by state perinatal care team or external organization

Level IV: onsite survey by external organization only

Every 3 years

Yes

State requires LOCATe assessment

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

Mandatory implementation

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

Mandatory implementation Level III/IV only

Maryland Institute for Emergency Medical Services Systems

Level I/II: self-designation

Level III/IV: onsite survey

Every 5 years

No

Massachusetts

Yes: Maternal and neonatal criteria not distinct

No

Yes

Mandatory implementation

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

Voluntary implementation

State health department

N/A

N/A

Yes

Missouri

None: Uses LoMC Obstetric Care Consensus

Yes 

Yes

Mandatory implementation

State health department

Onsite survey by external organization optional

Every 3 years

Yes

State requires LOCATe assessment

Montana

None

No

No

N/A

N/A

N/A

No

Nebraska

None

No

No

N/A

N/A

N/A

Yes

Nevada

None

No

No

N/A

N/A

N/A

No

New Hampshire

None

No

No

N/A

N/A

N/A

Yes

New Jersey

None

No

No

N/A

N/A

N/A

No

New Mexico

None

No

No

N/A

N/A

N/A

Yes

New York

YesMaternal and neonatal criteria not distinct*#

No

Yes

Mandatory implementation

State health department

Level I/II: Self-designation; onsite survey TBD

Level III/Regional Perinatal Centers: onsite survey

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

Mandatory implementation

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

Mandatory implementation

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

Yes

Voluntary implementation

State health department

Self-designation

Annual

Yes

Texas

Yes: Distinct maternal and neonatal criteria

Yes

Yes

Mandatory implementation

State health department

Level I: self-designation

Level II/III/IV: onsite survey by external organization only

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

No

Washington

Yes: Maternal and neonatal criteria not distinct

No

No

Voluntary implementation

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

Voluntary implementation

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.