Levels of Risk-Appropriate Care: Ensuring Women Deliver at the Right Place at the Right Time

Risk-appropriate care, or care in a facility with the capabilities and staffing to adequately meet the needs of patients, is not a new concept in medicine. ^{1 –3} For decades, clinical organizations, including the American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine (ACOG/SMFM), have partnered to publish risk-appropriate care guidelines, particularly for neonates. ⁴ In 2012, AAP published a revised neonatal levels of care designation policy statement to provide uniform definitions and standards of service for provision of neonatal care, ⁵ with reaffirmation in 2015. ⁶

Neonatal risk-appropriate care decreases mortality risk for very low birth weight infants born in facilities with equipment available and staff trained to care for these high-risk patients. ^{7 –9} However, clinical guidelines have not readily translated to systems change with state-level neonatal risk-appropriate care policies on levels of care in less than half of the United States. ^10,11 Among states with policies, variability in how levels are defined, including equipment, capabilities, subspecialty staffing, telemedicine, and transport, affects standardized provision of care. ^10,12,13

Renewed attention on maternal care and the role of subspecialists, including maternal–fetal medicine, on care of pregnant and postpartum women with severe morbidities or obstetrical complications require a focus on levels of maternal care, ensuring women deliver at facilities that best match their health care needs. ¹⁴ A recent analysis of recommendations made by 13 maternal mortality review committees identified establishing maternal levels of care for all hospitals and developing policies to ensure transport to hospitals with appropriate level of maternal care as common themes for preventing pregnancy-related deaths. ¹⁵ In 2015, ACOG/SMFM published guidelines that established levels of maternal care equivalent to, but distinct from, the existing guidance of the Guidelines for Perinatal Care 7th edition, ¹⁶ with a revision issued in 2019 to clarify terminology. ¹⁷ In 2016, ACOG/SMFM developed a maternal care verification program piloted in three states to provide on-site comprehensive review of services to inform individual facility compliance with the guidelines. ¹⁸ However, to date, we are not aware of any standardized assessment of how states integrated the clinical guidance into state guidelines or policy.

In levels of maternal care in the United States: an assessment of publicly available state guidelines, Vladutiu and colleagues provide an assessment of state-level guidelines on levels of maternal care. ¹⁹ The authors provide an in-depth review of publicly available policies that describes how states define levels of maternal care; determine criteria for providers, facility capabilities, and services; and require necessary services including transport and outreach. Vladutiu and colleagues conclude the assessment by highlighting the variability in state-level policies, the need for evaluating the impact of levels of maternal care on maternal outcomes in states, and a call for the use of standardized language in state-level policies. The review of state levels of maternal care policies provides a snapshot of how state agencies, including state departments of health, integrate clinical guidelines into standards of care, ensuring equitable and appropriate accessibility to all women. In addition, by review of policies that are publicly accessible, authors highlight the importance of transparency to support a common understanding among providers and facilities, and accountability for provision of care.

Vladutiu and colleagues provide a foundational assessment of state guidelines, building the case to support the adoption of standardized language in defining levels of maternal care. This publication is timely, as ACOG/SMFM recently updated the levels of maternal care guidelines in response to feedback from providers throughout the United States. ¹⁷ Further opportunities to facilitate the adoption of the updated guidelines include implementation of the Centers for Disease Control and Prevention's Levels of Care Assessment Tool (LOCATe), designed to provide standardized assessment of facility equipment, capabilities, and staffing using the ACOG/SMFM 2015 and AAP 2012 guidelines. ²⁰ LOCATe may also be used as a tool to inform partnership between public health and clinical care. As providers, facilities, and state health departments begin to examine guidelines for levels of maternal care, ensuring the standard of care available to all women is paramount. ²¹

As evidence of the benefits for instituting state level guidelines regarding levels of maternal care continues to develop, consideration of how standardized reporting within and across jurisdictions, maternal mortality review committee recommendations, and quality improvement initiatives could better inform the delivery of risk-appropriate care to decrease pregnancy-related mortality and near miss events is warranted. Such changes could influence broad-ranging prevention efforts, change practice, and impact resource allocation. Both neonatal and maternal risk-appropriate care focus on provision of services to meet the needs of the patients, and state policies that define levels of care can ensure equitable access to services and consideration of the mother–infant dyad in clinical decision-making. Nationwide reviews of state health services policies, such as the work by Vladutiu and colleagues, provide information that can further support partnership between state health departments, delivery facilities, and other stakeholders, to ensure services for women and infants are based on the most current clinical evidence on care capabilities, equipment, and staffing.