Making Progress on Regionalized Maternal Risk-Appropriate Care

In 2015, the American College of Obstetricians and Gynecologists presented levels of maternal care, the first U.S. uniform definitions of maternity facility resources and personnel. ¹ These definitions provide a framework to clearly communicate which hospitals are appropriate for people with complex maternity needs. Definitions for levels of maternal care are one component of regionalized systems for maternal care, also known as perinatal regionalization, which coordinate with community and state maternal health systems.

The goal of a regionalized system is to ensure each person receives care at a facility with resources commensurate to their condition. According to the Three Delays Model presented by Thaddeus and Maine, receiving care at a facility with appropriate resources prevents treatment delays that result in maternal morbidity and mortality. ² When a pregnant person receives care at a facility with the appropriate resources, it is referred to as maternal risk-appropriate care.

This month, DeSisto and colleagues present the results of the first direct evaluation of maternal outcomes by the levels of maternal care in the United States. ³ Achieving these results within 10 years of publishing uniform definitions of levels of maternal care is a tremendous accomplishment for the maternal health community and reflects the coordinated efforts of researchers, policymakers, health care workers, public health professionals, community advocates, and hospital administrators.

The first direct evaluation of outcomes by levels of maternal care provides evidence that regionalized maternal risk-appropriate care may be an effective strategy for reducing the rates of severe maternal morbidity and maternal mortality in the United States. In these data, maternal risk-appropriate care was associated with reduced odds of many adverse outcomes. ³ These findings support the continued effort by U.S. states to regionalize maternal care as a strategy to address preventable maternal morbidity. These findings also support ongoing work to identify the conditions that are best treated with the resources in the highest acuity maternity hospitals, those with dedicated obstetric critical care. As this work continues, the maternal health community will need to address several challenges.

Challenge one: Identify the best implementation strategy to get hospital buy-in for regionalized maternal risk-appropriate care. The Joint Commission offers a maternal level of care verification program within its hospital accreditation options. ⁴ States have adopted a variety of implementation strategies to incentivize hospital verification. For example, Florida offers funds for hospitals to complete the verification process. ⁵ Michigan adopted a system of quality reimbursement payments for verified hospitals. ⁶ Texas adopted a rule that facilities must receive official designations for maternal and neonatal care to receive reimbursement through Medicaid. ⁷ Georgia encourages verification but only requires it to be reported as part of the certificate of need process. ⁸ Missouri requires facilities to report the results of their verification to the Department of Health and Human Services. ⁹ We must conduct an evaluation of these implementation strategies to identify which ones successfully increase the rate of maternal risk-appropriate care and reduce maternal morbidity and mortality.

Challenge two: Identify the best strategies for supporting isolated maternity hospitals. Though most U.S. births occur in high-volume hospitals (56.8%), these hospitals are concentrated in large urban areas. ¹⁰ The result is that 18.9% of low-volume hospitals are more than 30 miles from the next closest hospital, and another 26.5% have another low-volume hospital as their nearest neighbor. Hospitals in isolated communities violate an underlying assumption of regionalized systems—that transfer to a higher acuity hospital is timely and safe. ¹¹ We need a better understanding of the minimum resources necessary to support safe birth in isolated communities and a health care financing system that supports the maintenance of these resources.

Challenge three: Develop strategies for reducing maternal morbidity for women without an identified risk factor. Regionalized maternal risk-appropriate care reduces delays by identifying the best facility for people identified as high-risk. Ideally, risk identification would occur during antepartum care and the birth would be planned for an appropriate facility. However, over 30% of people who experience severe maternal morbidity have no comorbidity currently recognized as increasing risk. ^12,13 When risk is identified during intrapartum care, the imminent delivery and unstable maternal condition complicate transport to a higher acuity hospital. ¹¹ The decision to transport is further hindered in states without policies ensuring reimbursement for maternal transport. ¹⁴ To fully realize the benefits of regionalized maternal risk-appropriate care, we must understand how to build supportive structures for risk identification and maternal transfer.

Regionalized maternal risk-appropriate care requires multi-sector, multi-organization coordination. Receipt of maternal risk-appropriate care is a system-level outcome that indicates all actors were able to coordinate successfully. In contrast, a single gap in coordination can result in a birth at a facility without the appropriate resources to ensure safe care. Over the next 10 years, our work to better understand and improve the intraorganizational coordination to achieve maternal risk-appropriate care will help ensure equitable access to lifesaving maternal care and improve maternal health outcomes.