Operationalizing risk-appropriate perinatal care in a rural US State: directions for policy and practice.

BACKGROUND: Risk-appropriate care improves outcomes by ensuring birthing people and infants receive care at a facility prepared to meet their needs. Perinatal regionalization has particular importance in rural areas where pregnant people might not live in a community with a birthing facility or specialty care. Limited research focuses on operationalizing risk-appropriate care in rural and remote settings. Through the implementation of the Centers for Disease Control and Prevention (CDC) Levels of Care Assessment Tool (LOCATe), this study assessed the system of risk-appropriate perinatal care in Montana. METHODS: Primary data was collected from Montana birthing facilities that participated in the CDC LOCATe version 9.2 (collected July 2021 - October 2021). Secondary data included 2021 Montana birth records. All birthing facilities in Montana received an invitation to complete LOCATe. LOCATe collects information on facility staffing, service delivery, drills, and facility-level statistics. We added additional questions on transport. RESULTS: Nearly all (96%) birthing facilities in Montana completed LOCATe (N = 25). The CDC applied its LOCATe algorithm to assign each facility with a level of care that aligns directly with guidelines published by the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG), and Society for Maternal-Fetal Medicine (SMFM). LOCATe-assessed levels for neonatal care ranged from Level I to Level III. Most (68%) facilities LOCATe-assessed at Level I or lower for maternal care. Close to half (40%) self-reported a higher-level of maternal care than their LOCATe-assessed level, indicating that many facilities believe they have greater capacity than outlined in their LOCATe-assessed level. The most common ACOG/SMFM requirements contributing to the maternal care discrepancies were the lack of obstetric ultrasound services and a physician anesthesiologist. CONCLUSIONS: The Montana LOCATe results can drive broader conversations on the staffing and service requirements necessary to provide high-quality obstetric care in low-volume rural hospitals. Montana hospitals often rely on Certified Registered Nurse Anesthetists (CRNA) for anesthesia services and telemedicine to access specialty providers. Integrating a rural health perspective into the national guidelines could enhance the utility of LOCATe to support state strategies to improve the provision of risk-appropriate care.

Geographic access to critical care obstetrics for women of reproductive age by race and ethnicity.

BACKGROUND: The goal of risk-appropriate maternal care is for high-risk pregnant women to receive specialized obstetrical services in facilities equipped with capabilities and staffing to provide care or transfer to facilities with resources available to provide care. In the United States, geographic access to critical care obstetrics varies. It is unknown whether this variation in proximity to critical care obstetrics differs by race, ethnicity, and region. OBJECTIVE: We examined the geographic access, defined as residence within 50 miles of a facility capable of providing risk-appropriate critical care obstetrics services for women of reproductive age, by distribution of race and ethnicity. STUDY DESIGN: Descriptive spatial analysis was used to assess geographic distance to critical care obstetrics for women of reproductive age by race and ethnicity. Data were analyzed geographically: nationally, by the Department of Health and Human Services regions, and by all 50 states and the District of Columbia. Dot density analysis was used to visualize geographic distributions of women by residence and critical care obstetrics facilities across the United States. Proximity analysis defined the proportion of women living within an approximate 50-mile radius of facilities. Source data included the 2015 American Community Survey from the United States Census Bureau and the 2015 American Hospital Association Annual Survey. RESULTS: Geographic access to critical care obstetrics was the greatest for Asian and Pacific Islander women of reproductive age (95.8%), followed by black (93.5%), Hispanic (91.4%), and white women of reproductive age (89.1%). American Indian and Alaska Native women had more limited geographic access (66%) in all regions. Visualization of proximity to critical care obstetrics indicated that facilities were predominantly located in urban areas, which may limit access to women in frontier or rural areas of states including nationally recognized reservations where larger proportions of white women and American Indian and Alaska Native women reside, respectively. CONCLUSION: Disparities in proximity to critical care obstetrics exist in rural and frontier areas of the United States, which affect white women and American Indian and Alaska Native women, primarily. Examining insurance coverage, interstate hospital referral networks, and transportation barriers may provide further insight into critical care obstetrics accessibility. Further exploring the role of other equity-based measures of access on disparities beyond geography is warranted.

Levels of Maternal Care in the United States: An Assessment of Publicly Available State Guidelines.

Background: Recent increases in maternal mortality and severe maternal morbidity highlight the need to improve systems for safe maternity care. We sought to identify whether publicly available state perinatal guidelines incorporate levels of maternal care (LoMC) criteria. Materials and Methods: We searched websites for 50 U.S. states and Washington, D.C. for LoMC guidelines. The Health Resources and Services Administration's Title V Program directors confirmed/updated search results through January 2018. Data abstracted included: (1) definitions of levels; (2) provider types; (3) facility capabilities and services; and (4) programmatic responsibilities as promoted in the 2015 Society for Maternal/Fetal Medicine and American College of Obstetricians and Gynecologists consensus document on LoMC. Results: LoMC guidelines were identified for 17 states; 12 defined four levels and five defined three levels of care. In Level I, 14/17 states specified obstetric provider availability for every birth and five specified an available surgeon to perform emergency cesareans. Fourteen states specified the availability of blood bank and laboratory services at all times. In the highest level (III or IV), 16/17 state guidelines specified a maternal/fetal medicine specialist; all but two specified anesthesia providers or services. Ten states referenced availability of an onsite intensive care unit in their highest level. All 17 state guidelines specified maternal transport and referral systems. Conclusions: Only one-third of states have publicly available perinatal guidelines incorporating LoMC criteria. Definitions, criteria, and nomenclature varied. Lack of LoMC guidelines with standardized criteria limits monitoring and evaluation of regionalized systems of maternal care.

Risk-Appropriate Care to Improve Practice and Birth Outcomes.

Identification and referral of women with high-risk pregnancies to hospitals better equipped and staffed to provide care for them have been important steps to improve birth outcomes. Based on recent recommendations from the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine to provide regionalized maternal care for pregnant women at high risk and reduce rates of maternal morbidity and mortality, health care organizations and providers have refocused their attention to women's well-being rather than solely on the well-being of the fetus or newborn. Opportunities to improve practice and birth outcomes exist through the implementation of a more standardized and integrated system of risk-appropriate care.

Implementing CDC's Level of Care Assessment Tool (LOCATe): A National Collaboration to Improve Maternal and Child Health.

Perinatal regionalization, or risk-appropriate care, is an approach that classifies facilities based on capabilities to ensure women and infants receive care at a facility that aligns with their risk. The CDC designed the Levels of Care Assessment Tool (LOCATe) to assist jurisdictions working in risk-appropriate care in assessing a facility's level of maternal and neonatal care aligned with the most current American College of Obstetricians and Gynecologists/Society for Maternal-Fetal Medicine (ACOG/SMFM) and American Academy of Pediatrics (AAP) guidelines. LOCATe produces standardized assessments for each hospital that participates and facilitates conversations among stakeholders in risk-appropriate care. This article describes how public health departments implement and use LOCATe in their jurisdictions.

US and territory telemedicine policies: identifying gaps in perinatal care.

BACKGROUND: Perinatal regionalization is a system of maternal and neonatal risk-appropriate health care delivery in which resources are ideally allocated for mothers and newborns during pregnancy, labor and delivery, and postpartum, in order to deliver appropriate care. Typically, perinatal risk-appropriate care is provided in-person, but with the advancement of technologies, the opportunity to provide care remotely has emerged. Telemedicine provides distance-based care to patients by consultation, diagnosis, and treatment in rural or remote US jurisdictions (states and territories). OBJECTIVE: We sought to summarize the telemedicine policies of states and territories and assess if maternal and neonatal risk-appropriate care is specified. STUDY DESIGN: We conducted a 2014 systematic World Wide Web-based review of publicly available rules, statutes, regulations, laws, planning documents, and program descriptions among US jurisdictions (N = 59) on telemedicine care. Policies including language on the topics of consultation, diagnosis, or treatment, and those specific to maternal and neonatal risk-appropriate care were categorized for analysis. RESULTS: Overall, 36 jurisdictions (32 states; 3 territories; and District of Columbia) (61%) had telemedicine policies with language referencing consultation, diagnosis, or treatment; 29 (49%) referenced consultation, 30 (51%) referenced diagnosis, and 35 (59%) referenced treatment. In all, 26 jurisdictions (22 states; 3 territories; and District of Columbia) (44%), referenced all topics. Only 3 jurisdictions (3 states; 0 territories) (5%), had policy language specifically addressing perinatal care. CONCLUSION: The majority of states have published telemedicine policies, but few specify policy language for perinatal risk-appropriate care. By ensuring that language specific to the perinatal population is included in telemedicine policies, access to maternal and neonatal care can be increased in rural, remote, and resource-challenged jurisdictions.

Variation in childbirth services in California: a cross-sectional survey of childbirth hospitals.

OBJECTIVE: The objective of the study was to describe the resources and activities associated with childbirth services. STUDY DESIGN: We adapted models for assessing the quality of healthcare to generate a conceptual framework hypothesizing that childbirth hospital resources and activities contributed to maternal and neonatal outcomes. We used this framework to guide development of a survey, which we administered by telephone to hospital labor and delivery nurse managers in California. We describe the findings by hospital type (ie, integrated delivery system [IDS], teaching, and other [community] hospitals). RESULTS: Of 248 nonmilitary childbirth hospitals in California, 239 (96%)responded; 187 community, 27 teaching, and 25 IDS hospitals reported. The context of services varied across hospital types, with community hospitals more likely to have for-profit ownership, be in a rural or isolated location, and have fewer annual deliveries per hospital. Results included the findings of the following: (1) 24 hour anesthesia availability in 50% of community vs 100% of IDS and teaching hospitals (P < .001); (2) 24 hour in-house labor and delivery physician coverage in 5% of community vs 100% of IDS and 48% of teaching hospitals (P < .001); (3) 24 hour blood bank availability in 88% of community vs 96% of IDS and 100% of teaching hospitals (P = .092); (4) adult subspecialty intensive care unit availability in 33% of community vs 36% of IDS and 82% of teaching hospitals (P < .001); (5) ability to perform emergency cesarean delivery in 30 minutes 100% of the time in 56% of community vs 100% of IDS and 85% of teaching hospitals (P < .001); (6) pediatric care available both day and night in 54% of community vs 63% of IDS vs 76% of teaching hospitals (P = .087); and (7) no neonatal intensive care unit in 44% of community vs 12% of IDS and 4% of teaching hospitals (P < .001). CONCLUSION: Childbirth services varied widely across California hospitals. Cognizance of this variation and linkage of these data to childbirth outcomes should assist in the identification of key resources and activities that optimize the hospital environment for pregnant women and set the groundwork for identifying criteria for the provision of maternal risk-appropriate care.

Cross-sectional survey of California childbirth hospitals: implications for defining maternal levels of risk-appropriate care.

OBJECTIVE: Measures of maternal mortality and severe maternal morbidity have risen in the United States, sparking national interest regarding hospitals' ability to provide maternal risk-appropriate care. We examined the extent to which hospitals could be classified by increasingly sophisticated maternal levels of care. STUDY DESIGN: We performed a cross-sectional survey to identify hospital-specific resources and classify hospitals by criteria for basic, intermediate, and regional maternal levels of care in all nonmilitary childbirth hospitals in California. We measured hospital compliance with maternal level of care criteria that were produced via consensus based on professional standards at 2 regional summits funded by the March of Dimes through a cooperative agreement with the Community Perinatal Network in 2007 (California Perinatal Summit on Risk-Appropriate Care). RESULTS: The response rate was 96% (239 of 248 hospitals). Only 82 hospitals (34%) were classifiable under these criteria (35 basic, 42 intermediate, and 5 regional) because most (157 [66%]) did not meet the required set of basic criteria. The unmet criteria preventing assignment into the basic category included the ability to perform a cesarean delivery within 30 minutes 100% of the time (only 64% met), pediatrician availability day and night (only 56% met), and radiology department ultrasound capability within 12 hours (only 83% met). Only 29 of classified hospitals (35%) had a nursery or neonatal intensive care unit level that matched the maternal level of care, and for most remaining hospitals (52 of 53), the neonatal intensive care unit level was higher than the maternal care level. CONCLUSION: Childbirth services varied widely across California hospitals, and most hospitals did not fit easily into proposed levels. Cognizance of this existing variation is critical to determining the optimal configuration of services for basic, intermediate, and regional maternal levels of care.