Where you live in the United States and the color of your skin can increase your risk of maternal mortality and morbidity. Standardizing maternal care and implementing maternal level-of-care designations are key to improving health outcomes for women and newborns. OB hospitalists play an important role in achieving both goals.

In 2015, the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) took an important step in reducing maternal mortality in the U.S. by outlining a plan to standardize pregnancy and delivery care and improving transparency. Many states have since adopted recommendations from the joint consensus statement on maternal level-of-care designations (MLOCD), but reducing negative outcomes and disparities in maternal care remains elusive. Maternal mortality in the U.S. remains an alarming issue in most states. Rates in several states are many times that of western industrial rates for both maternal mortality and severe maternal morbidity.

The goal of standardizing maternal levels of care is to reduce maternal mortality and existing outcome disparities. Level-of-care designations can improve patient outcomes when healthcare providers use uniform definitions, standardized descriptions of maternity facility capabilities and personnel, and a framework for integrated systems that address maternal health needs. Resource allocation is expected of administrations to provide sufficient personnel to support data collection and analysis. A real time Quality Assessment Performance Improvement (QAPI) Program that identifies clinical issues at the system level recognizes the need for correction, designs and applies the correction and shows evidence of continued correction is key to continuous improvement. The primary goal of an QAPI is system improvement and is different from traditional risk mitigation and peer review that focuses primarily on individual improvement.

The ACOG/SMFM birthing facility levels of care are as follows:

  1. Level I, Basic Care: For low to moderate-risk pregnancies, demonstrating the ability to detect, stabilize and initiate management of unanticipated maternal-fetal or neonatal problems until the patient can be transferred to a facility with specialty maternal care.
  2. Level II, Specialty Care: Level I, plus moderate to high-risk conditions.
  3. Level III, Subspecialty Care: Levels I and II, plus care for more complex maternal medical conditions, obstetric complications and fetal conditions.
  4. Level IV, Regional Perinatal Health Care Centers: Levels I, II, III, plus on-site medical and surgical care of the most complex maternal conditions and critically ill pregnant women and fetuses throughout antepartum, intrapartum and postpartum care.

Each level is expected to provide educational resources to the lower-level hospitals that refer patients to that hospital. Networks of transport are established and can be enhanced by this type of intelligence and simulation sharing.

A number of states, including Indiana, Arizona, Maryland, Iowa, Georgia and Texas have implemented these designations, ranging from basic to comprehensive care. There are significant differences in designation by state, but they all rely on a tiered framework of care.

“Either for prenatal care or at the time of delivery or post-partum recovery, you have a scalable system that moves the most high-risk patients up to the highest level of care as needed,” says Dr. Charles Jaynes, Ob Hospitalist Group Market Medical Director and Level of Maternal Care Surveyor in Texas.

Many other states have implemented the CDC LOCATe system to assess maternal and neonatal care levels, focusing on facility capacity and service delivery. The CDC LOCATe, or the Levels of Care Assessment Tool, is also designed to help states assess their maternal and newborn care capacity. While both systems aim to improve maternal and neonatal outcomes, the CDC's approach is more about assessment and data collection, while the ACOG/SMFM designation provides specific levels of care criteria. In Texas the state legislature has set forth an extensive set of rules that apply to each level of care. This system is administered by the state Department of Health and Human Services (DHHS) who controls the financial allocation of obstetrical Medicaid funding based on a hospitals level of care designation.

The state of California has led the way in reducing maternal mortality and morbidity. In 2006, California developed the Maternal Quality of Care Collaborative (CMQCC), in response to rising maternal mortality and morbidity rates. The CMQCC conducted a thorough analysis of maternal deaths, including demographic data, contributing factors and opportunities for improvement. Linking causes with potential interventions helped them design toolkits that are now used to address the most common causes of maternal mortality. Through the efforts of the CMQCC, California has decreased its maternal mortality rates by more than half.

How hospitals can improve care with maternal care designations

Dr. Jaynes recommends four ways hospital leaders can improve care with maternal care designations

  1. Prepare for your designation survey well ahead by closely following the rules designated in your state. A resource should be your state’s Department of Health and Human Services.
  2. Ascertain the percent of payer volume attributable to Medicaid births and plan accordingly. Know the population you serve, where do they come from, what is their composition, what are their risk. Have tools for risk stratification for clinical issues like maternal hypertension and hemorrhage. Have standardized evidence protocols to address those identified risk. Track the success or failure of treatment.
  3. Optimize patient care by beginning a dialogue with community providers. Everyone involved should have accountability to optimize the provision of a “culture of safety”. This includes not only care providers and nursing staff but also the hospital administrators and boards of directors.
  4. Share evidence-based outcome data among policymakers, health regulators and hospital administrators to determine the impact of maternal leveling and make necessary adjustments to improve patient care.

Levels of care designations can help reverse the trend of closing delivery systems in rural areas. In Texas, for example, hospitals that provide maternal care are surveyed for maternal-level care designation. This creates a local delivery unit that knows its obstetrical population and is prepared to identify and refer high-risk patients to an appropriate higher level of care. Higher level hospitals are required to clinically support lower level of care hospitals with education, simulation and when needed, transport.

Ways OB hospitalists can help hospitals improve maternal levels of care

Partnering with OB hospitalists can lead to safer deliveries and better maternal care across all designations.

Lower maternal morbidity and mortality:

Hospitals with 24/7 coverage of OB hospitalists have lower levels of severe maternal morbidity than those that use non-hospitalist OB/GYN providers, according to this study. Ob Hospitalist Group (OBHG) clinicians Dr. Amy VanBlaricom and Dr. Dyanne Tappin participated in the research, published in the Journal of Patient Safety.

Standardized protocols and emergency training

OB hospitalists help hospitals standardize maternal care and adhere to evidence-based labor, delivery and postpartum care protocols. Local hospitals that support fewer deliveries rarely see emergency situations like a postpartum hemorrhage that can cause maternal mortality. OB hospitalists are trained to deal with emergencies and even participate in simulation training.

Addressing racial disparities

A recent analysis from OBHG shows there are no differences in racial disparities observed in clinical outcomes associated with care that involved an OB hospitalist. In an analysis of patient-reported racial identification from 31,000 deliveries and 319,000 patient encounters, results exceeded national goals for all races. They showed improved clinical outcomes, including C-sections and readmission rates within 48 hours for patients under 34 weeks gestational age.

Care for all patients

OB hospitalist companies (like OBHG) care for all patients regardless of payer status.

Learn more about how our partnerships work and reach out to speak with us today regarding what a hospital partnership could provide your team.

OBHG is the nation’s largest and only dedicated provider of customized women’s health solutions, focused on improving access to care and ensuring all women receive timely, unconditional obstetric care. Our team partners with all levels of hospitals across the nation to improve maternal safety and outcomes and reduce physician burnout. 

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