Implementing Levels of Maternal Care Improves Access to Risk-Appropriate Care
May 28, 2024 | Lexa Giragosian
Risk-appropriate care (RAC) is a strategy to ensure that pregnant women and infants with high risk of complications receive care at facilities with personnel who offer services at the required level of specialized care. States can use the process of perinatal regionalization to create coordinated care systems based on levels of maternal care to support RAC access. Implementing and strengthening maternal RAC systems can improve health outcomes for pregnant and birthing populations and reduce the incidence of severe maternal morbidity and mortality.
“Risk-appropriate care is a tiered system of care for moms and newborns that provides the right care, at the right time, the right place, and with the right team.”
Defining Levels of Maternal Care
Levels of maternal care are a classification system that assesses the capacity of facilities to address maternal risk factors and complications. If implemented at the state level, LoMC can improve access to RAC and support standardized, complete, and integrated systems of perinatal regionalization.
| Level of Care | Definition |
|---|---|
| Accredited birth center | Care for low-risk pregnancies with uncomplicated singleton-term pregnancies who are expected to have an uncomplicated birth. The American Association of Birth Centers sets the national standards for birth centers. |
| Level I (basic care) | Care of low- to moderate-risk pregnancies with the ability to detect, stabilize, and initiate management of unanticipated maternal-fetal or neonatal problems that occur during the antepartum, intrapartum, or postpartum period until the patient can be transferred to a facility where specialty maternal care is available. |
| Level II (specialty care) | Level I facility plus care of appropriate moderate- to high-risk antepartum, intrapartum, or postpartum conditions. |
| Level III (subspecialty care) | Level II facility plus care of more complex maternal medical conditions, obstetric complications, and fetal conditions. |
| Level IV (regional perinatal health care centers) | Level III facility 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. |
CDC Levels of Care Assessment Tool℠
CDC’s Levels of Care Assessment Tool (CDC LOCATe) helps partners better understand the landscape of maternal and neonatal care delivery services in their state or jurisdiction. Implementing LOCATe creates a statewide picture of the hospitals’ LoMC to support decision-makers in improving RAC access while informing future analyses of RAC and maternal health. LOCATe is not a tool for formal LoMC designations; it promotes stakeholder engagement and discussion among clinical experts, delivery facilities, and public health.
Implementing LoMC
LoMC implementation varies across states and can involve having published state guidelines on levels of care classifications that highlight the required minimal capabilities, physical facilities, and medical and support personnel. These guidelines can be distinct from neonatal levels of care or can be combined and are often called “perinatal levels of care.”
- States can identify an organization or entity to identify and oversee LoMC. This authority can require facilities to have a LoMC designation or allow for voluntary participation in LoMC designation. This may also vary by the facility’s level.
- Facility LoMC designation can also vary regarding the frequency and method of designation with self-designation, on-site survey, or another method. Designations can be verified through monitoring by the facility, designating authority, and/or the Joint Commission and ACOG’s verification program.
Implementation Facilitators
Finances. Costs associated with implementing LoMC (e.g., LoMC verification/monitoring) are often categorized as additional expenses for maternity care facilities. Resource allocation flexibility can promote staffing capacity and resource availability for participation in verification/monitoring programs within facilities.
State health agency capacity. Depending on how a state structures its program, implementing LoMC requires varying levels of state health agency (SHA) support. SHAs can champion LoMC implementation within their state and are often the entities identified to oversee LoMC and be the designating authority when required.
State policy. Policies supporting RAC systems and establishing LoMC designations as an operating requirement for maternity care facilities can improve maternal health outcomes. States can utilize several policy levers to implement LoMC. For example, Illinois and Indiana laws require the Department of Health (designating authority) to establish a LoMC designation program for hospitals providing maternal/perinatal care.
State Strategies
Collaborate with Relevant Stakeholders
- Convene multi-disciplinary stakeholder meetings and build relationships with payors, clinicians, community organizations, et al. to improve LoMC consumer awareness and support effective LoMC implementation at the state level.
- Promote data sharing and collaboration across jurisdictions to move data to action following LoMC implementation. Create programs/policies based on data to maximize RAC access.
Increase Hospital Participation
- Assess opportunities with Medicaid to align LoMC with jurisdiction's Medicaid quality strategy.
- Advocate for hospitals and health systems to prioritize resource allocation for participation in LoMC implementation.
- Support policies establishing LoMC designation programs for maternal/perinatal hospitals and coordination of RAC access.
Use the LOCATe Tool
- Champion widespread implementation of LOCATe to foster stakeholder discussions on identified LoMC discrepancies.