The association between care management and neonatal outcomes: the role of a Medicaid-managed pregnancy medical home in North Carolina.

BACKGROUND: Preterm birth is a significant clinical and public health issue in the United States. Rates of preterm birth have remained unchanged, and racial disparities persist. Although a causal pathway has not yet been defined, it is likely that a multitude of clinical and social risk factors contribute to a pregnant person's risk. State-based public health and provider programmatic partnerships have the potential to improve care during pregnancy and reduce complications, such as preterm birth. In North Carolina, a state-based Medicaid-managed Pregnancy Medical Home Program screens pregnant individuals for psychosocial and medical risk factors and utilizes community-based care management, to offer support to those at highest risk. OBJECTIVE: This study aimed to examine the association between care-management and birth outcomes (low birthweight and preterm birth rates) among high-risk non-Hispanic White and Black pregnant people enrolled in the North Carolina Pregnancy Medical Home. STUDY DESIGN: This was a quasi-experimental study of people in the Medicaid-managed North Carolina Pregnancy Medical Home who had singleton pregnancies and who enrolled in the program between January 2016 and December 2017. Black and White pregnant people were included in the analysis if they had singleton pregnancies, were enrolled in the Pregnancy Medical Home, and for whom there were data regarding care management involvement. Preterm birth and low birthweight were chosen as the outcomes of interest. Two different methodologies were used to test the effect of care management on outcomes: Method 1 evaluated the effect of intensive care management (≥5 face-to-face visits from a care manager) and Method 2 evaluated the effect of the implementation of a specific risk-stratification system. Chi-squared and multivariate logistic regressions were performed as appropriate. RESULTS: From January 1, 2016 to December 31, 2017, a total of 3564 singleton pregnancies occurred among non-Hispanic Black and White pregnant Medicaid beneficiaries, who were a part of the Pregnancy Medical Home in North Carolina. White pregnant people comprised 57% and Black pregnant people comprised 43% of the sample. In the Method 1 analysis, intensive care management was significantly associated with reductions in preterm birth and low birthweight among Black and White pregnant people whereas in the Method 2 analysis, the implementation of a risk-stratification score only resulted in a significant reduction among Black pregnant people. In multivariable logistic modeling, race, number of prenatal visits, and intensive care management were all significantly associated with the outcomes of interest. CONCLUSION: Care management is associated with reductions in preterm birth and low birthweight in the Medicaid-managed Pregnancy Medical Home in North Carolina. This study contributes to a growing body of literature on the role of state-based initiatives in reducing perinatal morbidity. These results are significant as it demonstrates the importance of care coordination and management, in identifying and providing resources for high-risk pregnant people. In the United States, where pregnancy-related outcomes are poor, programs that address the multitude of economic, social, and clinical complexities are becoming increasingly crucial and necessary.

Examining the Ratio of Obstetric Beds to Births, 2000-2019.

The number of U.S. births has been declining. There is also concern about rural obstetric units closing. To better understand the relationship between births and obstetric beds during 2000-2019, we examined changes over time in births, birth hospital distributions (i.e., hospital birth volume, ownership, and urban-rural designation), and the ratio of births to obstetric beds. We analyzed American Hospital Association Annual Survey data from 2000 to 2019. We included U.S. hospitals with at least 25 reported births during the year and at least 1 reported obstetric bed. We categorized birth volume to identify and describe hospitals with maternity services using seven categories. We calculated ratios of number of births to number of obstetric beds overall, by annual birth volume category, by three categories of hospital ownership, and by six urban-rural categories. The ratio of births to obstetric beds, which may represent need for maternity services, has stayed relatively consistent at 65 over the past two decades, despite the decline in births and changes in birth hospital distributions. The ratios were smallest in hospitals with < 250 annual births and largest in hospitals with ≥ 7000 annual births. The largest ratios of births to obstetric beds were in large metro areas and the smallest ratios were in noncore areas. At a societal level, the reduction in obstetric beds corresponds with the drop in the U.S. birth rate. However, consistency in the overall ratio can mask important differences that we could not discern, such as the impact of closures on distances to closest maternity care.

Association of Maternal Comorbidity With Severe Maternal Morbidity: A Cohort Study of California Mothers Delivering Between 1997 and 2014.

BACKGROUND: Rates of maternal mortality and severe maternal morbidity (SMM) are higher in the United States than in other high-resource countries and are increasing further. OBJECTIVE: To examine the association of maternal comorbid conditions, age, body mass index, and previous cesarean birth with occurrence of SMM. DESIGN: Population-based cohort study using linked delivery hospitalization discharge data and vital records. SETTING: California, 1997 to 2014. PATIENTS: All 9 179 472 mothers delivering in California during 1997 to 2014. MEASUREMENTS: SMM rate, total and without transfusion-only cases; 2019 maternal comorbidity index. RESULTS: Total SMM increased by 160% during this time, and SMM excluding transfusion-only cases increased by 53%. Medical comorbid conditions were associated with an increasing portion of SMM occurrences. Medical comorbid conditions increased over the study period by 111%, and obstetric comorbid conditions increased by 30% to 40%. Identified medical comorbid conditions had high relative risks ranging from 1.3 to 14.3 for total SMM and even higher relative risks for nontransfusion SMM (to 32.4). The obstetric comorbidity index that is most often used may be undervaluing the degree of association with SMM. LIMITATIONS: Hospital discharge diagnosis files and birth certificate records can have misclassifications and may not include all relevant clinical data or social determinants. The period for analysis ended in 2014 to avoid the transition to the International Classification of Diseases, 10th Revision, Clinical Modification, and therefore missed more recent years. CONCLUSION: Obstetric and, particularly, medical comorbid conditions are increasing among women who develop SMM. The maternal comorbidity index is a promising tool for patient risk assessment and case-mix adjustment, but refinement of factor weights may be indicated. PRIMARY FUNDING SOURCE: National Institutes of Health.

Preterm Birth and Receipt of Postpartum Contraception Among Women with Medicaid in North Carolina.

OBJECTIVES: To compare receipt of contraception and method effectiveness in the early postpartum period among women with and without a recent preterm birth (PTB). METHODS: We used data from North Carolina birth certificates linked to Medicaid claims. We assessed contraceptive claims with dates of service within 90 days of delivery among a retrospective cohort of women who had a live birth covered by Medicaid between September 2011 and 2012 (n = 58,201). To estimate the odds of receipt of contraception by PTB status (24-36 weeks compared to 37-42 weeks [referent]), we used logistic regression and tested for interaction by parity. To estimate the relationship between PTB and method effectiveness based on the Center for Disease Control and Prevention Levels of Effectiveness of Family Planning Methods (most, moderate and least effective [referent]), we used multinomial logistic regression. RESULTS: Less than half of all women with a live birth covered by Medicaid in North Carolina had a contraceptive claim within 90 days postpartum. Women with a recent PTB had a lower prevalence of contraceptive receipt compared to women with a term birth (45.7% vs. 49.6%). Women who experienced a PTB had a lower odds of receiving contraception. When we stratified by parity, women with a PTB had a lower odds of contraceptive receipt among women with more than two births (0.79, 95% CI 0.74-0.85), but not among women with two births or fewer. One-fourth of women received a most effective method. Women with a preterm birth had a lower odds of receiving a most effective method (0.83, 95% CI 0.77-0.88) compared to women with a term birth. CONCLUSIONS FOR PRACTICE: Contraceptive receipt was low among women with a live birth covered by Medicaid in North Carolina. To optimize contraceptive use among women at risk for subsequent preterm birth, family planning strategies that are responsive to women's priorities and context, including a history of preterm birth, are needed. SIGNIFICANCE: Access to free or affordable highly effective contraception is associated with reductions in preterm birth. Self-report data indicate that women with a very preterm birth (PTB) are less likely to use highly or moderately effective contraception postpartum compared to women delivering at later gestational ages. Using Medicaid claims data, we found that less than half of all women with a Medicaid covered delivery in North Carolina in 2011-2012 had a contraceptive claim within 90 days postpartum, and one fourth received a most effective method. Women with a PTB and more than two children were least likely to receive any method. Family planning strategies that are responsive to women's priorities and context, including a history of preterm birth, are needed so that women may access their contraceptive method of choice in the postpartum period.

The State of North Carolina's Perinatal Health.

In working to improve the health of North Carolinians, a critical focus starts with our mothers and infants and their surrounding communities. North Carolina's perinatal outcomes, as evidenced by maternal morbidity and mortality, infant mortality, preterm births, and the larger context of lifelong physical and mental health of our citizens, offer areas for improvement and policy implications. In addition, the unacceptable disparities that remain despite some overall improvement in outcomes warrant full attention. This issue of the NCMJ highlights the state of perinatal health in North Carolina; the importance of a risk-appropriate perinatal system of care; the opportunities for supporting our parents, children, and families; and how we as a state and as a community can come together to improve the safety and experience of giving birth in North Carolina and beyond.

Obstetric Care Consensus #9: Levels of Maternal Care: (Replaces Obstetric Care Consensus Number 2, February 2015).

Maternal mortality and severe maternal morbidity, particularly among women of color, have increased in the United States. The leading medical causes of maternal mortality include cardiovascular disease, infection, and common obstetric complications such as hemorrhage and vary by timing relative to the end of pregnancy. Although specific modifications in the clinical management of some of these conditions have been instituted, more can be done to improve the system of care for high-risk women at facility and population levels. The goal of levels of maternal care is to reduce maternal morbidity and mortality, including existing disparities, by encouraging the growth and maturation of systems for the provision of risk-appropriate care specific to maternal health needs. To standardize a complete and integrated system of perinatal regionalization and risk-appropriate maternal care, this classification system establishes levels of maternal care that pertain to basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV). The determination of the appropriate level of care to be provided by a given facility should be guided by regional and state health care entities, national accreditation and professional organization guidelines, identified regional perinatal health care service needs, and regional resources. State and regional authorities should work together with the multiple institutions within a region, and with the input from their obstetric care providers, to determine the appropriate coordinated system of care and to implement policies that promote and support a regionalized system of care. These relationships enhance the ability of women to give birth safely in their communities while providing support for circumstances when higher level resources are needed. This document is a revision of the original 2015 Levels of Maternal Care Obstetric Care Consensus, which has been revised primarily to clarify terminology and to include more recent data based on published literature and feedback from levels of maternal care implementation.

Emergency Care Utilization Among Pregnant Medicaid Recipients in North Carolina: An Analysis Using Linked Claims and Birth Records.

Objectives To estimate the rate of pregnancy-associated emergency care visits and identify maternal and pregnancy characteristics associated with high utilization of emergency care among pregnant Medicaid recipients in North Carolina. Methods A retrospective cohort study using linked Medicaid hospital claims and birth records of 107,207 pregnant Medicaid recipients who delivered a live-born infant in North Carolina between January 1, 2008 and December 31, 2009. Rates were estimated per 1000 member months of Medicaid coverage. High utilization was defined as ≥ 4 visits. Emergency care visits included encounters in the emergency department or obstetric triage unit during pregnancy that did not result in hospital admission. Results During the study period, 57.5% of pregnant Medicaid recipients sought emergency care at least once during pregnancy. There were 171,909 emergency care visits with an overall rate of 202.3 visits per 1000 member months. Among the subset of pregnant women with Medicaid coverage for the majority of their pregnancy (n = 75,157), 18.1% were high utilizers. High emergency care utilization was associated with young age, black race, lower education, tobacco use, late preterm delivery, multifetal gestation, and having ≥ 1 comorbidity. Threatened labor and abdominal pain were the leading indications for visits. Conclusion Utilization of hospital-based emergency care services was common in this cohort of pregnant Medicaid recipients. Additional research is needed to assess the drivers for accessing care through the emergency department, and to examine differences in pregnancy outcomes and health care costs between high and low utilizers.

National Partnership for Maternal Safety: Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period.

Complications arising from hypertensive disorders of pregnancy are among the leading causes of preventable severe maternal morbidity and mortality. Timely and appropriate treatment has the potential to significantly reduce hypertension-related complications. To assist health care providers in achieving this goal, this patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. This is one of several patient safety bundles developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. These safety bundles outline critical clinical practices that should be implemented in every maternity care setting. Similar to other bundles that have been developed and promoted by the Partnership, the hypertension safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. This commentary provides information to assist with bundle implementation.

17-Hydroxyprogesterone caproate (17OHP-C) coverage among eligible women delivering at 2 North Carolina hospitals in 2012 and 2013: A retrospective cohort study.

BACKGROUND: Although a weekly injection of 17-hydroxyprogestone caproate is recommended for preventing recurrent preterm birth, clinical experience in North Carolina suggested that many eligible patients were not receiving the intervention. OBJECTIVE: Our study sought to assess how well practices delivering at 2 major hospitals were doing in providing access to 17-hydroxyprogesterone caproate treatment for eligible patients. STUDY DESIGN: This retrospective cohort analysis studied all deliveries occurring between January 1, 2012, and December 31, 2013, at 2 large hospitals in North Carolina. Women were included if they had a singleton pregnancy and history of a prior spontaneous preterm birth. We extracted demographic, payer, and medical information on each pregnancy, including whether women had been offered, accepted, and received 17-hydroxyprogesterone caproate. Our outcome of 17-hydroxyprogesterone caproate coverage was defined as documentation of ≥1 injection of the drug. RESULTS: Over the 2-year study period, 1216 women with history of a prior preterm birth delivered at the 2 study hospitals, of which 627 were eligible for 17-hydroxyprogesterone caproate eligible after medical record review. Only 296 of the 627 eligible women (47%; 95% confidence interval, 43-51%) received ≥1 dose of the drug. In multivariable analysis, hospital of delivery, later presentation for prenatal care, fewer prenatal visits, later gestation of prior preterm birth, and having had a term delivery immediately before the index pregnancy were all associated with failed coverage. Among those women who were "covered," the median number of 17-hydroxyprogesterone caproate injections was 9 (interquartile range, 4-15), with 84 of 296 charts (28%) not having complete information on the number of doses. CONCLUSION: Even under our liberal definition of coverage, less than half of eligible women received 17-hydroxyprogesterone caproate in this sample. Low overall use suggests that there is opportunity for improvement. Quality improvement strategies, including population-based measurement of 17-hydroxyprogesterone caproate coverage, are needed to fully implement this evidence-based intervention to decrease preterm birth.

Postpartum Health Services Requested by Mothers with Newborns Receiving Intensive Care.

Objectives Our pilot study aimed to build knowledge of the postpartum health needs of mothers with infants in a newborn intensive care unit (NICU). Methods Between May 2008 and December 2009, a Certified Nurse Midwife was available during workday hours to provide health care services to mothers visiting their infants in the NICU at a large tertiary care center. Results A total of 424 health service encounters were recorded. Maternal requests for services covered a wide variety of needs, with primary care being the most common. Key health concerns included blood pressure monitoring, colds, coughs, sore throats, insomnia and migraines. Mothers also expressed a need for mental health assessment and support, obstetric care, treatment for sexually transmitted infections, tobacco cessation, breastfeeding assistance, postpartum visits, and provision of contraception. Conclusions Our study suggests that mothers with babies in the NICU have a host of health needs. We also found that women were receptive to receiving health services in a critical care pediatric setting. Intensive care nurseries could feasibly partner with in-patient mother-baby units and/or on-site obstetric clinics to increase access to health care for the mothers of the high-risk newborns in their units. Modifications should be made within health care systems that serve high-risk infants to better address the many needs of the mother/baby dyad in the postpartum period.

Levels of maternal care.

In the 1970s, studies demonstrated that timely access to risk-appropriate neonatal and obstetric care could reduce perinatal mortality. Since the publication of the Toward Improving the Outcome of Pregnancy report, more than 3 decades ago, the conceptual framework of regionalization of care of the woman and the newborn has been gradually separated with recent focus almost entirely on the newborn. In this current document, maternal care refers to all aspects of antepartum, intrapartum, and postpartum care of the pregnant woman. The proposed classification system for levels of maternal care pertains to birth centers, basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV). The goal of regionalized maternal care is for pregnant women at high risk to receive care in facilities that are prepared to provide the required level of specialized care, thereby reducing maternal morbidity and mortality in the United States.

Predicting Preterm Birth Among Women Screened by North Carolina's Pregnancy Medical Home Program.

OBJECTIVE: To determine which combination of risk factors from Community Care of North Carolina's (CCNC) Pregnancy Medical Home (PMH) risk screening form was most predictive of preterm birth (PTB) by parity and race/ethnicity. METHODS: This retrospective cohort included pregnant Medicaid patients screened by the PMH program before 24 weeks gestation who delivered a live birth in North Carolina between September 2011-September 2012 (N = 15,428). Data came from CCNC's Case Management Information System, Medicaid claims, and birth certificates. Logistic regression with backward stepwise elimination was used to arrive at the final models. To internally validate the predictive model, we used bootstrapping techniques. RESULTS: The prevalence of PTB was 11 %. Multifetal gestation, a previous PTB, cervical insufficiency, diabetes, renal disease, and hypertension were the strongest risk factors with odds ratios ranging from 2.34 to 10.78. Non-Hispanic black race, underweight, smoking during pregnancy, asthma, other chronic conditions, nulliparity, and a history of a low birth weight infant or fetal death/second trimester loss were additional predictors in the final predictive model. About half of the risk factors prioritized by the PMH program remained in our final model (ROC = 0.66). The odds of PTB associated with food insecurity and obesity differed by parity. The influence of unsafe or unstable housing and short interpregnancy interval on PTB differed by race/ethnicity. CONCLUSIONS: Evaluation of the PMH risk screen provides insight to ensure women at highest risk are prioritized for care management. Using multiple data sources, salient risk factors for PTB were identified, allowing for better-targeted approaches for PTB prevention.

Pregnancy Medical Home Care Pathways Improve Quality of Perinatal Care and Birth Outcomes.

The clinical leadership of the Pregnancy Medical Home (PMH) program develops and disseminates clinical pathways to promote evidence-based practice and to improve quality of care and outcomes. PMH pathways represent the first standardized clinical guidance for obstetric providers statewide across all care settings.

Society for maternal-fetal medicine (SMFM) special report: the maternal-fetal medicine subspecialists' role within a health care system.

A maternal-fetal medicine (MFM) subspecialist has advanced knowledge of the medical, surgical, obstetrical, fetal, and genetic complications of pregnancy and their effects on both the mother and fetus. MFM subspecialists are complementary to obstetric care providers in providing consultations, co-management, or transfer of care for complicated patients before, during, and after pregnancy. The MFM subspecialist provides peer and patient education and performs research concerning the most recent approaches and treatments for obstetrical problems, thus promoting risk-appropriate care for these complicated pregnancies. The relationship between the obstetric care provider and the MFM subspecialist depends on the acuity of the maternal and/or fetal condition and the local resources. To achieve the goal of promoting early access and sustained adequate prenatal care for all pregnant women, we encourage collaboration with obstetricians, family physicians, certified midwives, and others, and we also encourage providing preconception, prenatal, and postpartum care counseling and coordination. Effective communication between all obstetric care team members is imperative. This special report was written with the intent that it would be broad in scope and appeal to a diverse readership, including administrators, allowing it to be applied to various systems of care both horizontally and vertically. We understand that these relationships are often complex and there are more models of care than could be addressed in this document. However, we aimed to promote the development of a highly effective team approach to the care of the high-risk pregnancy that will be useful in the most common models for obstetric care in the United States. The MFM subspecialist functions most effectively within a fully integrated and collaborative health care environment. This document defines the various roles that the MFM subspecialist can fulfill within different heath care systems through consultation, co-management, and transfer of care, as well as education, research, and leadership.

Position statement on fetal myelomeningocele repair.

Following the promising multicenter randomized trial results of in utero fetal myelomeningocele repair; we anticipate that an increasing number of tertiary care centers may want to offer this therapy. It is essential to establish minimum criteria for centers providing open fetal myelomeningocele repair to ensure optimal maternal and fetal/pediatric outcomes, as well as patient safety both short- and long-term; and to advance our knowledge of the role and benefit of fetal surgery in the management of fetal myelomeningocele. The fetal myelomeningocele Maternal-Fetal Management Task Force was initially convened by the Eunice Kennedy Shriver National Institute of Child Health and Human Development to discuss the implementation of maternal fetal surgery for myelomeningocele. The decision was made to develop the optimal practice criteria presented in this document for the purpose of medical and surgical leadership. These criteria are not intended to be used for legal or regulatory purposes.

Hospital Discharge Codes and Overestimating Severe Maternal Morbidity During Delivery Hospitalization.

Our objective was to identify birth hospitalization severe maternal morbidity (SMM) diagnoses that were also coded during prior encounters and, thus, potentially falsely carried forward as de novo SMM events. This retrospective cohort study included pregnant patients with births between 2016 and 2020. We applied the SMM algorithm to the birth hospitalization and encounters occurring prepregnancy, antepartum, and postpartum. The primary outcome was the rate of SMM diagnoses recorded during the birth hospitalization that were also coded on previous encounters. There were 1,380 (1.8%) birthing patients with SMM. Of patients with SMM codes at the birth hospitalization, 19.0% had the same SMM code during a prior encounter. Certain SMM events may be prone to carry-forward errors and may not signify a de novo birth hospitalization event.

Putting the "M" back in maternal-fetal medicine.

Although maternal death remains rare in the United States, the rate has not decreased for 3 decades. The rate of severe maternal morbidity, a more prevalent problem, is also rising. Rise in maternal age, in rates of obesity, and in cesarean deliveries as well as more pregnant women with chronic medical conditions all contribute to maternal mortality and morbidity in the United States. We believe it is the responsibility of maternal-fetal medicine (MFM) subspecialists to lead a national effort to decrease maternal mortality and morbidity. In doing so, we hope to reestablish the vital role of MFM subspecialists to take the lead in the performance and coordination of care in complicated obstetrical cases. This article will summarize our initial recommendations to enhance MFM education and training, to establish national standards to improve maternal care and management, and to address critical research gaps in maternal medicine.

Statewide assessment of telehealth use for obstetrical care during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic started a period of rapid transition to telehealth in obstetrical care delivery to maintain social distancing and curb the spread of the virus. The use of telehealth, such as telephone and video visits, remote imaging interpretation, and provider-to-provider consultations, increased in the early months of the pandemic to maintain access to prenatal and postpartum care. Although there is considerable literature on the use of telehealth in obstetrical care, there are limited data on widespread telehealth use among different practice types and patient populations during the pandemic and whether these are preferred technologies. OBJECTIVE: This study aimed to describe variations in telehealth use for obstetrical care among practices in North Carolina during the COVID-19 pandemic and to outline future preferences and needs for continued telehealth use. This study also aimed to delineate telehealth use among rural and micropolitan and metropolitan practices to better understand if telehealth use varied by practice location. STUDY DESIGN: A web-based survey was distributed to practice managers of obstetrical practices in North Carolina from June 14, 2020 to September 14, 2020. Practice managers were contacted through assistance of the Community Care of North Carolina Pregnancy Medical Home program. Practice location was defined as rural, micropolitan, or metropolitan based on the county population. The survey assessed telehealth use before and during the COVID-19 pandemic, types of modalities used, and preferences for future use. Descriptive statistics were performed to describe survey responses and compare them by practice location. RESULTS: A total of 295 practice managers were sent a web-based survey and 98 practice managers responded. Responding practices represented 66 of 100 counties in North Carolina with 50 practices from rural and micropolitan counties and 48 practices from metropolitan counties. The most common type of provider reported by practice managers were general obstetrician and gynecologists (85%), and the most common practice type was county health departments (38%). Overall, 9% of practices reported telehealth use before the pandemic and 60% reported telehealth use during the pandemic. The most common type of telehealth modality was telephone visits. There were no significant differences in the uptake of telehealth or in the modalities used by practice location. A total of 40% of practices endorsed a preference for continued telehealth use beyond the COVID-19 pandemic. The most commonly reported need for continuation of telehealth use was assistance with patient access to telehealth technologies (54%). There were no significant differences in the preferences for telehealth continuation or future needs by practice location. CONCLUSION: Telehealth use increased among a variety of practice types during the pandemic with no variation observed by practice location in terms of modalities used, future preferences, or needs. This study assessed statewide uptake of and differences in obstetrical telehealth use during the early COVID-19 pandemic. With telehealth becoming an integral part of obstetrical care delivery, this survey has implications for anticipating the needs of practices and designing innovative solutions for providers and pregnant people beyond the COVID-19 pandemic.

Scheduled deliveries: avoiding iatrogenic prematurity.

The balance of maternal, fetal, and neonatal risks of continued pregnancy versus iatrogenic delivery must be based on best evidence. Although avoiding elective deliveries prior to 39 weeks is well established to improve neonatal outcomes, several "soft" conditions are commonly considered to require delivery prior to 39 weeks. Review of existing literature suggests that with some of these conditions, delivery can be safely delayed until later in pregnancy or even allowed to proceed without intervention. Late preterm and early term deliveries contribute substantially to neonatal morbidity and health care costs and should be considered only if the risks of continuing the pregnancy exceed the neonatal risks related to early birth. In this article, we review some the common clinical scenarios that may result in scheduled early term or late preterm births, with a focus on practice strategies for improving maternal and neonatal outcomes.

CDC LOCATe: discrepancies between self-reported level of maternal care and LOCATe-assessed level of maternal care among 463 birth facilities.

OBJECTIVE: Describe sources of discrepancy between self-assessed LoMC (level of maternal care) and CDC LOCATe®-assessed (Levels of Care Assessment Tool) LoMC. STUDY DESIGN: CDC LOCATe® was implemented at 480 facilities in 13 jurisdictions, including states, territories, perinatal regions, and hospital systems, in the U.S. Cross-sectional analyses were conducted to compare facilities' self-reported LoMC and LOCATe®-assessed LoMC. RESULT: Among 418 facilities that self-reported an LoMC, 41.4% self-reported a higher LoMC than their LOCATe®-assessed LoMC. Among facilities with discrepancies, the most common elements lacking to meet self-reported LoMC included availability of maternal-fetal medicine (27.7%), obstetric-specializing anesthesiologist (16.2%), and obstetric ultrasound services (12.1%). CONCLUSION: Two in five facilities self-report a LoMC higher than their LOCATe®-assessed LoMC, indicating discrepancies between perceived maternal care capabilities and those recommended in current LoMC guidelines. Results highlight an opportunity for states to engage with facilities, health systems, and other stakeholders about LoMC and collaborate to strengthen systems for improving maternal care delivery.