Delivery at an inadequate level of maternal care is associated with severe maternal morbidity.

BACKGROUND: Implementing levels of maternal care is one strategy proposed to reduce maternal morbidity and mortality. The levels of maternal care framework outline individual medical and obstetrical comorbidities, along with hospital resources required for individuals with these different comorbidities to deliver safely. The overall goal is to match individuals to hospitals so that all birthing people get appropriate resources and personnel during delivery to reduce maternal morbidity. OBJECTIVE: This study examined the association between delivery in a hospital with an inappropriate level of maternal care and the risk of experiencing severe maternal morbidity. STUDY DESIGN: The 40 birthing hospitals in Massachusetts were surveyed using the Centers for Disease Control and Prevention's Levels of Care Assessment Tool. We linked individual delivery hospitalizations from the Massachusetts Pregnancy to Early Life Longitudinal Data System to hospital-level data from the Levels of Care Assessment Tool surveys. Level of maternal care guidelines were used to outline 16 high-risk conditions warranting delivery at hospitals with resources beyond those considered basic (level I) obstetrical care. We then used the Levels of Care Assessment Tool assigned levels to determine if delivery occurred at a hospital that had the resources to meet an individual's needs (ie, if a patient received risk-appropriate care). We conducted our analyses in 2 stages. First, multivariable logistic regression models predicted if an individual delivered in a hospital that did not have the resources for their risk condition. The main explanatory variable of interest was if the hospital self-assessed their level of maternal care to be higher than the Levels of Care Assessment Tool assigned level. We then used logistic regression to examine the association between delivery at an inappropriate level hospital and the presence of severe maternal morbidity at delivery. RESULTS: Among 64,441 deliveries in Massachusetts from January 1 to December 31, 2019, 33.2% (21,415/64,441) had 1 or more of the 16 high-risk conditions that require delivery at a center designated as a level I or higher. Of the 21,415 individuals with a high-risk condition, 13% (2793/21,415), equating to 4% (2793/64,441) of the entire sample, delivered at an inappropriate level of maternal care. Birthing individuals with high-risk conditions who delivered at a hospital with an inappropriate level had elevated odds (adjusted odds ratio, 3.34; 95% confidence interval, 2.24-4.96) of experiencing severe maternal morbidity after adjusting for patient comorbidities, demographics, average hospital severe maternal morbidity rate, hospital level of maternal care, and geographic region. CONCLUSION: Birthing people who delivered in a hospital with risk-inappropriate resources were substantially more likely to experience severe maternal morbidity. Delivery in a hospital with a discrepancy in their self-assessment and the Levels of Care Assessment Tool assigned level substantially predicted delivery in a hospital with an inappropriate level of maternal care, suggesting inadequate knowledge of hospitals' resources and capabilities. Our data demonstrate the potential for the levels of maternal care paradigm to decrease severe maternal morbidity while highlighting the need for robust implementation and education to ensure everyone receives risk-appropriate care.

Escalating Care on Labor and Delivery.

Maternal morbidity and mortality are rising due in part to the rising prevalence of chronic illness, socioeconomic and racial disparities, and advanced maternal age. Prevention of maternal adverse outcomes requires prompt escalation of care to facilities with appropriate capabilities including intensive care services. The development of obstetrical-specific risk assessment tools and protocolized care for the most common causes of maternal intensive care unit (ICU) admission has helped to reduce preventable complications. However, significant work remains to address barriers to the escalation of maternal care and minimize delays in appropriate management.

Maternal mortality in the United States: research gaps, opportunities, and priorities.

Maternal mortality and severe maternal morbidity are urgent issues in the United States. It is important to establish priority areas to address these public health crises. On April 8, 2019, and May 2 to 3, 2019, the Eunice Kennedy Shriver National Institute of Child Health and Human Development organized and invited experts with varied perspectives to 2 meetings, a community engagement forum and a scientific workshop, to discuss underlying themes involved in the rising incidence of maternal mortality in the United States. Experts from diverse disciplines reviewed current data, ongoing activities, and identified research gaps focused on data measurement and reporting, obstetrical and health system factors, social determinants and disparities, and the community perspective and engagement. Key scientific opportunities to reduce maternal mortality and severe maternal morbidity include improved data quality and measurement, understanding the populations affected as well as the numerous etiologies, clinical research to confirm preventive and interventional strategies, and engagement of community participation in research that will lead to the reduction of maternal mortality in the United States. This article provides a summary of the workshop presentations and discussions.

Putting the "M" back in maternal-fetal medicine: A 5-year report card on a collaborative effort to address maternal morbidity and mortality in the United States.

The Centers for Disease Control and Prevention have demonstrated continuous increased risk for maternal mortality and severe morbidity with racial disparities among non-Hispanic black women an important contributing factor. More than 50,000 women experienced severe maternal morbidity in 2014, with a mortality rate of 18.0 per 100,000, higher than in many other developed countries. In 2012, the first "Putting the 'M' back in Maternal-Fetal Medicine" session was held at the Society for Maternal-Fetal Medicine's (SMFM) Annual Meeting. With the realization that rising risk for severe maternal morbidity and mortality required action, the "M in MFM" meeting identified the following urgent needs: (i) to enhance education and training in maternal care for maternal-fetal medicine (MFM) fellows; (ii) to improve the medical care and management of pregnant women across the country; and (iii) to address critical research gaps in maternal medicine. Since that first meeting, a broad collaborative effort has made a number of major steps forward, including the proliferation of maternal mortality review committees, advances in research, increasing educational focus on maternal critical care, and development of comprehensive clinical strategies to reduce maternal risk. Five years later, the 2017 M in MFM meeting served as a "report card" looking back at progress made but also looking forward to what needs to be done over the next 5 years, given that too many mothers still experience preventable harm and adverse outcomes.

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.