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Table 1 Characteristics of Levels of Maternal Care and Associated Thresholds for Empiric Levels of Maternal Care

From: Identifying individual hospital levels of maternal care using administrative data

Maternal level Capabilitiesa Health care providersa Examples of appropriate patientsb Threshold of ‘high risk patients’/yearc
Level I (Basic Care) -Capability/equipment to provide low-risk and appropriate moderate-risk maternal care and readiness at all times to initiate emergency procedures
-Stabilization and the ability to facilitate transport to a higher-level hospital when necessary
-Collaboration with higher-level facility partners, to initiate/sustain education and QI programs to maximize patient safety
-Every birth attended by a midwife, family physician or ob-gyn and an appropriately trained/qualified RN
-Physician with privileges to perform emergency cesarean delivery readily available at all times
-Primary maternal care providers, including midwives, family physicians, or ob-gyns readily available at all times
-Appropriately trained/qualified RNs with level-appropriate competencies readily available at all times
-RN leadership has level-appropriate training and experience in maternal care
-Anesthesia providers for labor and surgical anesthesia readily available at all times
-Term twin gestation
-Trial of labor after cesarean delivery
-Uncomplicated cesarean delivery
-Preeclampsia without severe features at term
 
Level II (Specialty Care) Level I facility capabilities plus
-CT scan, MRI, non-obstetric US imaging, and maternal echocardiography with interpretation readily available daily
-Standard obstetric US imaging with interpretation readily available at all times
Level I facility health care providers plus
-Ob-gyn readily available at all times
-Physician OB leadership board-certified in ob-gyn with experience in obstetric care
-MFM readily available at all times for consultation onsite, by phone, or by telemedicine
-Anesthesiologist readily available at all times
-Internal or family medicine physicians and general surgeons readily available at all times for obstetric patients
-Severe preeclampsia
-Placenta previa with no prior uterine surgery
≥5/year Preterm (< 37 week) multiples
≥3/year Primary Cesarean section for placenta previa
≥4/year Severe hypertension after 34 weeks’ gestation
Level III (Subspecialty Care) Level II facility capabilities plus
-All blood components available in-house
-CT scan, MRI, maternal echocardiography, and non-obstetric US imaging services and interpretation readily available at all times
-Specialized obstetric US and fetal assessment with interpretation readily available at all times
-Interventional radiology (capable of uterine artery embolization) readily available at all times
-Equipment/personnel physically present at all times to ventilate/monitor women until ICU transfer
-Onsite medical/surgical ICUs that accept pregnant and postpartum women. ICUs have adult critical care providers physically present at all times
-MFM readily available at all times to communicate/consult for all obstetric ICU patients
-Mechanism to facilitate/accept maternal transfers/transports
-Provide outreach education and patient transfer feedback to level I and II centers
-Provide Perinatal system leadership if acting as a regional center (see Level IV)
Level II facility health care providers plus
-Nursing leaders and adequate number of RNs who have training and experience in the management of women with complex and critical maternal illnesses and obstetric complications.
-Board certified ob-gyn physically present at all times.
-An MFM with inpatient privileges readily available at all times, either onsite, by phone, or by telemedicine. MFM must be able to be onsite and provide direct care within 24 h.
-Director of MFM service is a board-certified MFM.
-Director of obstetric anesthesia services is a board-certified anesthesiologist with OB anesthesia fellowship training or experience in OB anesthesia.
-Full complement of subspecialists, such as critical care, general surgery, infectious diseases, hematology, cardiology, nephrology, neurology, gastroenterology, internal medicine, behavioral health, and neonatology readily available for inpatient consultation at all times
-Suspected placenta accreta or previa with prior uterine surgery
-Suspected placenta percreta
-Adult respiratory syndrome
-Expectant management of early severe preeclampsia at less than 34 weeks of gestation
≥3/year Previous Cesarean section and a placenta previa
≥5/year Preeclampsia before 34 weeks’ gestation
≥3/year Severe hypertension or Eclampsia before 34 weeks’ gestation
≥3/year Acute Respiratory Distress Syndrome
Level IV (Regional Perinatal Health Care Centers) Level III facility capabilities plus
-On-site medical/surgical care for complex maternal conditions with available ICU beds
-On-site ICU care for obstetric patients with primary or co-management by MFM If the woman must be transported by ambulance to the ICU, this is not considered onsite.
-Perinatal system leadership, including facilitation of collaboration with facilities in the region, analysis and review of system perinatal outcome and quality data, provision of outreach education and assistance with QI
Level III health care providers plus
-MFM team with expertise in highly complex, critically ill, or unstable maternal patients
-Board-certified MFM with full inpatient privileges readily available at all times, including co-management of ICU-admitted obstetric patients
-Nursing Service Line leadership with advanced degree and national certification
- RNs with experience in complex medical illnesses/obstetric complications and collaboration between critical care and obstetric RNs
-Board-certified anesthesiologist with OB anesthesia fellowship training or experience in OB anesthesia physically present at all times
-At least one of the following subspecialties readily available at all times onsite: neurosurgery, cardiac surgery, or transplant. If all three subspecialties are not available, there should be a process to transfer women to a facility with the service
-Severe maternal cardiac conditions
-Severe pulmonary hypertension or liver failure
-Pregnant women requiring neurosurgery or cardiac surgery
-Pregnant women in unstable condition and in need of an organ transplant
≥3/year Severe chronic medical conditionsd
≥5/year Severe cardiac conditionse
  1. Abbreviations: OB obstetric, RN nurse, CT computerized tomography, MRI magnetic resonance imaging, US ultrasound, MFM maternal fetal medicine, ICU intensive care unit
  2. aText adapted from 2019 Levels of Maternal Care Statement: Obstetric Care Consensus No. 9: Levels of Maternal Care Obs Gynecol. 2019;134 (2):e41-e55)
  3. bText adapted from 2015 Levels of Maternal Care Statement: Obstetric Care Consensus No. 2: Levels of maternal care. Obs Gynecol. 2015;125 (2):502–515)
  4. cThe study determined annual threshold was created by the authors considering both the volume of patients to clinically indicate a hospital’s intent to deliver the different types of appropriate patients and calculated the sensitivity, specificity, and Youden’s index, summary measure of the Receiver Operative Characteristic curve, for each type of high-risk case to inform threshold cut points
  5. dSevere chronic medical conditions: pulmonary hypertension, liver failure, dialysis, and organ transplant
  6. eSevere cardiac conditions: chronic heart disease, hypertrophic cardiomyopathy, acute/subacute endocarditis, constrictive pericarditis, tamponade, complete atrioventricular block, cardiac device in situ, atrial fibrillation, atrial flutter, congestive heart failure, mitral stenosis, atrial stenosis, dual valve disease, value replacement