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INTRODUCTION

KEY QUESTIONS

  • What are the definitions of maternal levels of care?

  • What are the benefits of regionalization of maternal care?

  • What barriers prevent successful regionalization of maternal care?

  • How can OB/GYN hospitalists promote regionalization to reduce maternal morbidity and mortality?

Maternal morbidity and mortality ratios continue to increase in the United States, in contrast to other well-resourced nations. The 26.6% increase in the US maternal mortality ratio from 2000 to 2014 (23.8/100,000 live births) was paralleled by a 75% increase in major maternal morbidity.1,2 The most common causes of maternal mortality are hemorrhage, thromboembolic events, cardiac disease, sepsis, and hypertensive disorders,3 and 40% of maternal deaths are believed to be preventable.4

Efforts to reduce the morbidity and mortality ratio in the United States have included education and standardization. For instance, the incidence of maternal hemorrhage was reduced in California after the introduction of team training, simulation drills, and the use of protocols and checklists.5 However these efforts do not address the problem of variable resource distribution, such as the case of women living in rural areas of British Columbia, Canada, who were shown to have increased rates of eclampsia, thromboembolism, and uterine dehiscence compared to their urban counterparts.6 Efforts to reduce maternal mortality in well-resourced areas should focus on the optimal use of those resources.

In 1976, the March of Dimes published Toward Improving the Outcome of Pregnancy, an opinion statement in response to rising levels of maternal and neonatal mortality. This document called for an “integrated system of regionalized perinatal care” based on a referral network to ensure that high-risk patients received care at centers equipped with the appropriate resources. The report stratified maternal and neonatal care into three tiers and called upon facilities with higher levels of care to collaborate with facilities with lower care levels for transport services, education, data collection and quality initiatives.7

After publication of this report, the concept of regionalized perinatal care was widely adopted by the neonatal community, and numerous studies demonstrated improved neonatal outcomes in risk-appropriate care settings.811 For instance, a meta-analysis by Lasswell et al (2010) demonstrated increased odds of neonatal morbidity for low-birth-weight infants (weighing less than 1500 g) born at facilities other than Level III hospitals (38% vs. 23%, with an adjusted odds ratio of 1.62 and a 95% confidence interval [CI] [1.44–1.83]).10 Menard et al (1998) demonstrated a higher neonatal mortality for low-birth-weight infants at Level II facilities (with a neonatologist present, but lacking a complete multidisciplinary team) vs. Level III.11 Neonatal care regionalization persists, as was recently reaffirmed by the American Academy of Pediatrics.12

Regulation of neonatal care levels is formalized through state agencies that survey and grant the appropriate care level through hospital licensing, certification, and approval of proposals for expansion based on need. Clear definitions identify the required ...

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