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Cross-sectional survey of California childbirth hospitals: implications for defining maternal levels of risk-appropriate care
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OBSTETRICS
Cross-sectional survey of California childbirth hospitals: implications for defining maternal levels of risk-appropriate care Q2
Lisa M. Korst, MD, PhD; Daniele S. Feldman, MD; D. Lisa Bollman, RN, MSN; Moshe Fridman, PhD; Samia El Haj Ibrahim, MPH; Arlene Fink, PhD; Kimberly D. Gregory, MD, MPH OBJECTIVE: Measures of maternal mortality and severe maternal morbidity have risen in the United States, sparking national interest regarding hospitals’ ability to provide maternal risk-appropriate care. We examined the extent to which hospitals could be classified by increasingly sophisticated maternal levels of care. STUDY DESIGN: We performed a cross-sectional survey to identify
hospital-specific resources and classify hospitals by criteria for basic, intermediate, and regional maternal levels of care in all nonmilitary childbirth hospitals in California. We measured hospital compliance with maternal level of care criteria that were produced via consensus based on professional standards at 2 regional summits funded by the March of Dimes through a cooperative agreement with the Community Perinatal Network in 2007 (California Perinatal Summit on Risk-Appropriate Care). RESULTS: The response rate was 96% (239 of 248 hospitals). Only 82
hospitals (34%) were classifiable under these criteria (35 basic, 42 intermediate, and 5 regional) because most (157 [66%]) did not meet
the required set of basic criteria. The unmet criteria preventing assignment into the basic category included the ability to perform a cesarean delivery within 30 minutes 100% of the time (only 64% met), pediatrician availability day and night (only 56% met), and radiology department ultrasound capability within 12 hours (only 83% met). Only 29 of classified hospitals (35%) had a nursery or neonatal intensive care unit level that matched the maternal level of care, and for most remaining hospitals (52 of 53), the neonatal intensive care unit level was higher than the maternal care level. CONCLUSION: Childbirth services varied widely across California
hospitals, and most hospitals did not fit easily into proposed levels. Cognizance of this existing variation is critical to determining the optimal configuration of services for basic, intermediate, and regional maternal levels of care. Key words: childbirth hospital services, hospital staffing, maternal health, maternal levels of care, risk-appropriate care
Cite this article as: Korst LM, Feldman DS, Bollman DL, et al. Cross-sectional survey of California childbirth hospitals: implications for defining maternal levels of risk-appropriate care. Am J Obstet Gynecol 2015;213:xx-xx.
W
orsening measures of maternal mortality and severe morbidity have begun to gain national attention.1 From 1987 to 2009, the pregnancyrelated mortality ratio rose steadily from 7.2 to 17.8 deaths per 100,000 live
births,2 and recent studies have estimated that at least 40% of maternal deaths appear to be preventable.3-6 Recent publications have also recognized steadily increasing rates of severe obstetrical complications6-9 showing
substantial racial disparity, with elevations among African-Americans and women of Hispanic ethnicity.3,9,10 According to Kuklina et al,6 renal failure, pulmonary embolism, adult respiratory distress syndrome, shock, blood
Q1 From Childbirth Research Associates, North Hollywood (Dr Korst); Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Burns Allen
Research Institute (Drs Feldman and Gregory and Ms El Haj Ibrahim); AMF Consulting (Dr Fridman); Division of General Internal Medicine and Health Services Research, Department of Medicine (Dr Fink), and Department of Obstetrics and Gynecology (Dr Gregory), David Geffen School of Medicine at UCLA; and Departments of Health Policy and Management (Dr Fink) and Community Health Sciences (Dr Gregory), Fielding School of Public Health at UCLA, Los Angeles; Community Perinatal Network, Yorba Linda (Ms Bollman); and Langley Research Institute, Pacific Palisades (Dr Fink), CA. Received April 16, 2015; revised May 20, 2015; accepted July 13, 2015. The funding sources had no involvement in the conduct of the research or in the preparation of the manuscript. This study was supported by Agency for Healthcare Research and Quality grant 5 R01 HS020915 (all investigators except D.S.F.). Additional support was provided by the March of Dimes (L.M.K., M.F., and D.L.B.) and by the American Congress of Obstetricians and Gynecologists/Duchesnay USA Research Award in Quality Improvement in Maternity Care (D.S.F.). The authors report no conflict of interest. Corresponding author: Kimberly D. Gregory, MD, MPH. [email protected] 0002-9378/$36.00 ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2015.07.014
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transfusion, and ventilation are all on the rise nationally. Furthermore, rates of severe maternal morbidity appear to vary widely across hospitals.11 This year, in an effort to promote benchmarking and improvement, a call was made for the facility-based identification and reporting of women with severe maternal morbidity.12,13 This call was further supported in February 2015 by the publication of a consensus-based statement from the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine that proposed the development of standards for maternal risk-appropriate care.14 Given that childbirth is the number one reason for hospitalization in the United States at nearly 4 million births per year,15 a national strategy is needed to address this observed increase in childbirth-related maternal morbidity.16 Improved neonatal outcomes have resulted from perinatal regionalization, a term that currently refers to a health care delivery system that optimizes care for preterm newborns,17-19 and this strategy has prompted policy makers to examine the feasibility of creating maternal levels of care1 so that mothers with high-risk conditions could be assured delivery at hospitals with the appropriate resources (eg, the availability of subspecialists, specialty intensive care units, blood banking services, and diagnostic imaging equipment. This initiative requires attention to a stepwise research agenda that includes the following: (1) the development of criteria for defining increasingly sophisticated levels of maternal care; (2) the demonstration that maternal outcomes are improved in women who deliver at facilities that can offer risk-appropriate care; and (3) the elaboration of implementation strategies for such a system. Such an agenda will initially require detailed hospital-level data regarding current configurations of childbirth services, resources and patient care activities, and linkages of these data to childbirth outcomes to identify the factors associated with optimal results. To date, such information has not been available. The purpose of this study was to collect hospital-level data to document
ajog.org the characteristics of childbirth hospitals. This is in preparation for the development of a foundation for defining and implementing maternal levels of care to maximize both maternal and neonatal safety. Although the achievement of a system for maternal riskappropriate health services is a national concern, here we focus on the services offered by California childbirth hospitals, which perform more than 500,000 births each year (12.7% of all US births), more than any other US state.13
M ATERIALS
AND
M ETHODS
This is a cross-sectional assessment of childbirth hospital services designed to determine the extent to which hospitals can be classified by increasingly sophisticated maternal levels of care. Information was obtained from a survey of labor and delivery nurse managers for childbirth hospitals in California that included an array of items regarding hospital services, resources, and patient care activities. The study was approved by the Cedars-Sinai Institutional Review Board (protocol PRO00032669 certified exempt) and complied with all stipulated criteria for participant protection. Professional standards for obstetrical care services are set out in Title 22 of the California State Code of Regulations20 and Guidelines for Perinatal Care, published by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists.21 These publications refer to maternal levels of care but without the specificity needed to define the appropriate setting, provider, or competency required to care for individual patients or to address their pregnancy complications. Several US states have defined such levels, but these definitions vary and are primarily focused on improving neonatal as contrasted to maternal outcomes.22,23 For these reasons, we used recommended maternal level of care criteria that were produced via consensus at 2 regional summits funded by the March of Dimes through a cooperative agreement with the Community Perinatal Network in 2007 (California Perinatal Summit on RiskAppropriate Care),24 which were based on professional standards.20,21
Survey development and administration We devised survey items based on the perinatal summit criteria and categorized them into 5 prespecified domains: hospital structure/context, hospital staffing, hospital clinical resources, and hospital clinical activities. Two interviewers were trained to assure consistent administration of the survey, which they piloted among labor and delivery managers at 5 hospitals to assure face and content validity of the domains and individual items and to assure that these managers would be an adequate and reliable source of information. Upon finalization of all items, interrater reliability was assessed by having each interviewer conduct 5 interviews in the presence of the other, with each interviewer recording results, and agreement determined between the interviewers for each individual item, using Cohen’s kappa for categorical responses and the Shrout-Fleiss intraclass correlation for continuous or mixed responses. In addition, 10 participants were retested at 3 months to assure concordance with their previous responses using the Shrout-Fleiss intraclass correlation. Survey items that did not have good interrater or test-retest reliability (kappa <0.8 or <80% agreement) were eliminated. The survey contained 185 questions that resulted in 293 individual items25 and took approximately 1 hour to complete. Those items that were directly related to the evaluation of meeting the maternal level of care criteria are included in the Appendix (Supplementary Table). The survey was offered to all nonmilitary California childbirth hospitals, and contact information for labor and delivery managers was obtained through the Regional Perinatal Programs of California. The managers were contacted by phone and an appointment made for the interview. Managers were given a $50 gift card as an incentive. A hard copy of the survey was mailed to the managers in advance to assure familiarity with the questions. All surveys were completed between November 2012 and January 2014.
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TABLE 1
Criteria for defining obstetrical levels of care as proposed at the California Perinatal Summit24 and number of hospitals meeting each criteriona Short name
Criterion
Operational definition
Total (n [ 239)
Level 1: basic (all hospitals with childbirth services) Basic 1: cesarean delivery within 30 min 100% of the time
No requirement for 24-h, in-house obstetrician, but MD should be able to respond within 30 min, and be on-call for only one hospital
Ability to perform cesarean delivery within 30 min 100% of the time
152 (63.6%)b
Basic 2: anesthesia available within 30 min
Anesthesia coverage should be able to respond within 30 min
Anesthesia coverage can respond within 30 min
235 (98.3%)
Basic 3: nursery with 24 h, resuscitation/stabilization
Newborn nursery should have 24-h neonatal resuscitation/stabilization capability
Newborn nursery has 24-h neonatal resuscitation/stabilization capability
239 (100%)
Basic 4: pediatric care available day and night
Pediatricians/neonatologists should be able to respond within 30 min and be on-call for only 1 hospital
Pediatrician (or family practitioner)/ neonatologist can attend deliveries both day and night
133 (55.6%)c
Basic 5: radiology ultrasound available within 12 h
Ultrasound capability on call
Obstetrical ultrasound from radiology department available within 12 h
199 (83.3%)d
Basic unused: transport agreement
Formalized transport agreement with a facility capable of providing a higher level of maternal/newborn care
Tracked but not counted as a criterion because it is dependent on the classified level of care
Not applicable
Level 2: Intermediate, all of the above, plus the following Intermediate 1: anesthesia available within 24 h in-house
In-house anesthesia coverage 24 h
In-house anesthesia coverage 24 h
146 (61.1%)
Intermediate 2: dedicated obstetrics anesthesia service
In-house and obstetrics-dedicated anesthesia service
In-house and obstetrics-dedicated anesthesia service
141 (59.0%)e
Intermediate 3: level 1 NICU
CCS intermediate NICU (equivalent to level I NICU in Guidelines for Perinatal Care21)
CCS level 1 NICU or non-CCS equivalent
152 (63.6%)
Intermediate 4: 24-h adult critical care
Adult critical care capability available 24 h, not necessarily on labor and delivery
Adult critical care capability available 24 h, not necessarily on labor and delivery
230 (96.2%)
Intermediate 5: 24-h maternal-fetal medicine service
Maternal-fetal medicine specialist consultation available 24 h
Maternal-fetal medicine specialist consultation available 24 h
198 (82.8%)f
Level 3: regional, all of the above, plus the following Regional 1: 24 hour obstetrician available in-house
Obstetrics coverage (eg, obstetrician hospitalists) available 24 h in-house
Obstetrics coverage (eg, obstetrician hospitalists) available 24 h in-house (not necessarily assigned to all patients)
92 (38.5%)
Regional 2: level 2 or 3 NICU
CCS community or regional NICU (equivalent to levels II-III NICU in Guidelines for Perinatal Care21)
CCS level 2 or 3 NICU or non-CCS equivalent
69 (28.9%)
Regional 3: 24-h neonatologist available
Neonatology coverage (eg, neonatologists, neonatal nurse practitioners) available 24 h, in-house
Neonatologist available for deliveries both day and night (not necessarily in-house)
210 (87.9%)g
Regional 4: 24-h radiology services available
Radiology capability available 24 h, in-house
Radiology capability available 24 h in-house (reading not necessarily in-house)
193 (80.8%)h
Regional 5: 24-h adult critical care plus invasive cardiac monitoring
Adult critical care capability available 24 h, with portion of labor and delivery dedicated to critical care
Adult critical care available 24 h, with capability of invasive monitoring on labor and delivery
99 (41.4%)i
Regional 6: 24-h maternal-fetal medicine on staff
Maternal-fetal medicine specialist consultation available 24 h
Maternal-fetal medicine specialist consultation available 24 h on staff
95 (39.7%)
Korst. Maternal levels of risk-appropriate care. Am J Obstet Gynecol 2015.
(continued)
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391 392 TABLE 1 393 24 Criteria for defining obstetrical levels of care as proposed at the California Perinatal Summit and number 394 of hospitals meeting each criteriona (continued) 395 Short name Criterion Operational definition Total (n [ 239) 396 Unable to assess Not applicable Regional unused 1: perinatal Outpatient perinatal follow-up services, 397 follow-up education, and case management provided 398 to referring hospitals 399 Not applicable Tracked but not counted as a criterion Regional unused 2: transport Formalized transport agreements and 400 because it is dependent on the classified agreement regional cooperative agreements with all 401 facilities transporting high-risk mothers and level of care 402 infants to them 403 CCS, California Children’s Services; NICU, neonatal intensive care unit. 404 a If a hospital did not respond regarding a criterion, it was categorized as not met. The number of nonresponses for each criterion was zero unless otherwise specified by subsequent footnotes; b c d e f g h i 405 n (nonresponse) ¼ 1; n (nonresponse) ¼ 5; n (nonresponse) ¼ 39; n (nonresponse) ¼ 34; n (nonresponse) ¼ 27; n (nonresponse) ¼ 5; n (nonresponse) ¼ 19; n (nonresponse) ¼ 5. 406 Korst. Maternal levels of risk-appropriate care. Am J Obstet Gynecol 2015. 407 408 409 basic, intermediate, or regional maternal integrated delivery system and 5 comData management 410 munity hospitals) did not respond. The The interviewer entered information level of care criteria. 411 We used 2 methods to categorize hos- majority of respondents were adminisinto SurveyMonkey (Palo Alto, CA), and 412 data were exported into SAS (SAS pitals. In method 1, maternal level of care trative directors and nurses (n ¼ 141; 413 criteria were grouped into 3 sets: basic 59.0%), followed by clinical directors or version 9.3; SAS Institute, Cary, NC). 414 Information regarding neonatal in- (5 criteria), intermediate (5 criteria), and nurse managers (n ¼ 85; 35.6%), and 415 tensive care unit (NICU) level was added regional (6 criteria). To be classified as others (n ¼ 13; 5.4%). The mean (SD) 416 to the data set. Basic/primary care hospi- basic, a hospital had to meet all 5 basic number of years working at the current 417 tals (no NICU) were identified in an criteria. To be classified as intermediate, a hospital was 12.4 (10.1) (median, 11.0; 418 annual report from the California Office hospital had to meet all 5 basic and all 5 range, 0.1e46 years), and the mean (SD) 419 of Statewide Health Planning and Devel- intermediate criteria. To be classified as number of years in the current position 420 opment as having obstetric beds but no regional, a hospital had to meet all 5 basic, was 5.6 (5.8) (median, 4.0; range, 0.1e30 421 NICU beds.26 Hospitals with NICUs were 5 intermediate, and 6 regional criteria. In years). 422 Interrater reliability was calculated for classified as having an intermediate cases in which the survey respondent did 423 NICU, community NICU, or regional not know whether the criterion was met 10 hospitals. For the 270 categorical 424 NICU as designated by California Chil- by their hospital, the criterion was desig- items, the mean (SD) kappa values were 425 dren’s Services (CCS),27-30 a state pro- nated as not met. The number of hospitals 0.94 (0.15); items with kappa values 426 gram for children with special health for which specific items had missing an- <0.8 were discarded (n ¼ 28). For the 23 427 continuous items, the mean (SD) ½T1 428 care needs, with intermediate NICUs swers is noted in Table 1. Because several items did not have agreement rate was 0.98 (0.06); items providing less advanced care than com429 munity or regional NICUs and regional 100% response rates and to better un- with <80% agreement were discarded 430 NICUs providing the most advanced care. derstand the potential of hospitals (n ¼ 2). For the 10 hospitals that were 431 Facilities with licensed intensive care to meet the maternal level of care retested, the mean agreement rate (SD) 432 for newborn nursery beds but no desig- criteria, we did a second set of analyses for all 293 items was 0.96 (0.12); items 433 nation by the CCS were also identified by (method 2) that allowed hospitals to with <80% agreement were discarded 434 this report.26 For analytical purposes, miss 1 criterion at any of the levels and (n ¼ 26). In total, 34 survey items were 435 those NICUs without a CCS designation reassigned maternal levels of care based deemed unreliable and excluded from 436 were assigned a comparable designation on this approach. This credit could be analyses. 437 The maternal level of care criteria are as an intermediate NICU if they had less applied only once, starting from the 438 than 15 beds and a community NICU if basic level. The goal of method 2 was to listed in Table 1 with the operational 439 relax the criteria, as in a sensitivity definitions and the reference names for they had 15 or more beds. 440 analysis, to permit the assignment of a the criteria. Table 1 also describes the 441 category if one had not been assigned number of hospitals meeting each indi442 Data analyses vidual maternal level of care criterion. with method 1. 443 Most hospitals did not map easily to We mapped all appropriate survey items 444 maternal levels of care. Table 2 describes ½T2 445 to the criteria defined by the California R ESULTS Perinatal Summit,24 and hospitals were The survey response rate was 96% (239 of the number of hospitals that met basic, 446 categorized regarding whether they met 248 hospitals). Nine hospitals (ie, four intermediate, and regional criteria by 1.e4 American Journal of Obstetrics & Gynecology MONTH 2015 FLA 5.2.0 DTD YMOB10528_proof 28 July 2015 9:51 pm ce
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TABLE 2
Percentage of hospitals (n [ 239) meeting perinatal summit criteria for maternal levels of care, by 2 methods and associated NICU levelsa Maternal level of careNICU level of care
NICU level of care
Method 1: met all criteria Met basic criteria set
Met intermediate criteria set
Met regional criteria set n (%)
Final level assignment No NICU of maternal level (basic of care services)
No
No
No
116 (48.5%)
No
Yes
No
35 (14.6%)
No
No
Yes
2 (0.8%)
0 (0%)
0 (0%)
0 (0%)
2 (100%)
No
Yes
Yes
4 (1.7%)
0 (0%)
0 (0%)
0 (0%)
4 (100%)
Yes
No
No
31 (13.0%)
Yes
No
Yes
4 (1.7%)
Yes
Yes
No
42 (17.6%)
Yes
Yes
Yes
5 (2.1%)
Intermediate Community NICU NICU
75 (64.5%) 20 (17.2%) None: 157 (65.7%)
Basic: 35 (14.6%)
0 (0%)
12 (32.3%)
Intermediate: 42 (17.6%) 0 (0%) Regional: 5 (2.1%)
0 (0%)
11 (31.4%)
Regional NICU
21 (18.1%)
0 (0%)
24 (68.6%)
0 (0%)
8 (22.9%)
11 (31.4%)
4 (11.4%)
13 (31.0%)
27 (64.3%)
2 (4.8%)
1 (20.0%)
0 (0%)
4 (80.0%)
42 (91.3%)
3 (6.5%)
1 (2.2%)
0 (0%)
2 (12.5%)
2 (12.5%)
12 (75.0%)
0 (0%)
0 (0%)
0 (0%)
0 (0%)
1 (33.3%)
239 total Method 2: met all criteria but one No
No
No
46 (69.7%)
No
Yes
No
16 (24.2%)
No
No
Yes
No
Yes
Yes
4 (6.1%)
Yes
No
No
73 (98.6%)
Yes
No
Yes
1 (1.4%)
Yes
Yes
No
79 (100%)
Intermediate: 79 (33.1%) 2 (2.5%)
Yes
Yes
Yes
20 (100%)
Regional: 20 (8.4%)
None: 66 (27.6%)
0 (0%) Basic: 74 (31.0%)
41 (55.4%) 16 (21.6%)
0 (0%)
0 (0%) 0 (0%)
0 (0%) 3 (66.7%)
16 (21.6%)
1 (1.4%)
26 (32.9%)
49 (62.0%)
2 (2.5%)
5 (25.0%)
5 (25.0%)
10 (50.0%)
239 total NICU, neonatal intensive care unit. a
Method 1: final assignment of maternal level of care category was based on hospital meeting all maternal level of care criteria in each category, with all basic criteria met to be assigned to basic, all basic and intermediate criteria met to be assigned to intermediate, and all basic, intermediate, and regional criteria met to be assigned to regional; method 2: equivalent to method 1 except that credit could be given for a total of 1 missing basic, intermediate, or regional criterion to meet the previously mentioned requirements. This credit could be applied only once, starting from the basic level.
Korst. Maternal levels of risk-appropriate care. Am J Obstet Gynecol 2015.
methods 1 and 2. Using method 1, 82 hospitals (34.3%) were classified: 35 (14.6%) met basic criteria only, 42 (17.6%) met both basic and intermediate criteria, and 5 (2.1%) met basic, intermediate, and regional criteria. The remaining 157 hospitals (65.7%) could not be classified. The principal criteria preventing assignment into the basic category included the ability to perform a cesarean delivery within 30 minutes 100% of the time (only 63.6% met), pediatrician availability day and night (only 55.6%
met), and radiology department ultrasound capability within 12 hours (only 83.3% met). Although not used as a criterion, many hospitals with limited resources lacked transport agreements to more sophisticated hospitals. Of the 82 hospitals that could be assigned a maternal level of care under method 1, only 48 (58.5%) had transport agreements in place that were appropriate for their level. Of the 239 hospitals, 152 (63.6%) had a licensed NICU, and of these, 112 (73.7%) were assigned a level of care
from the CCS. Of the 40 hospitals with a NICU without a CCS designation, 34 (85.0%) were classified as intermediatelevel NICUs (the most basic NICU level), and the remainder were classified as community-level NICUs. Compared with other hospitals, hospitals with nonCCS NICUs were equally likely to be assigned a maternal level of care using method 1 (68 of 199 [34.2%] vs 14 of 40 [35.0%]; P ¼ .93). The NICU levels associated with the assigned maternal levels of care are described in Table 2. Only 29 of the 82
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hospitals classified under method 1 (35.4%) had a nursery or NICU level that matched the maternal level of care. The NICU level for most remaining hospitals (52 of 53) was higher than the maternal level of care. Using maternal levels assigned under method 2, 82 of the 173 classified hospitals (47.4%) had a nursery or NICU level that matched the maternal level of care. Of the remaining 91 hospitals, 84 (92.3%) had a NICU level that was higher than the maternal level of care.
C OMMENT National efforts to examine and stem the rise in severe maternal morbidity have encouraged interest in strategies to classify childbirth hospitals by their resources and patient care activities and thus develop systems for maternal riskappropriate care, or maternal levels of care.14,16 However, our data demonstrated that given the wide variation in childbirth services that exists, only one third of hospitals could be assigned to a maternal level of care category using a scheme that had been derived from a large consensus-based conference. The unmet criteria preventing assignment into the basic category included the ability to perform a cesarean delivery within 30 minutes 100% of the time (only 64% met), pediatrician availability day and night (only 56% met), and radiology department ultrasound capability within 12 hours (only 83% met). The criteria used for each level were derived by consensus of expert opinion. However, our results suggest that such theoretical requirements may not reflect the services actually offered by childbirth hospitals and that efforts to acknowledge and resolve these discrepancies are warranted. Consequently, the maternal level of care criteria empirically adopted here are intended as a starting point for discussion, and room for debate remains regarding which of the stated criteria should be required (eg, obstetrician and pediatrician availability) and whether additional services should be considered as essential for basic maternal care (eg, the availability of a blood bank or labor and delivery emergency response team).
ajog.org Our separate analysis that allowed leeway for missing one maternal level of care criterion demonstrated that 91 more hospitals could be classified and suggests that targeted efforts to assure that all childbirth hospitals meet a set of basic criteria have some potential for success. The maternal level of care criteria utilized here were available at the time of this study, which was conducted prior to the publication of the Obstetric Care Consensus (OCC) on maternal levels of care.14 The California Perinatal Summit criteria are very specific and the majority of them were easily operationalized for use within the survey. This need for specific criteria would preclude a direct comparison of the Summit criteria to the more general guidelines used by the OCC. For example, the OCC has constructed 4 levels of care, in addition to birth centers, and the OCC guidelines have no specifications for the response times of the health care providers or the turnaround time for laboratory and radiology tests. This study included nearly every childbirth hospital in California, which was due in part to previous experience with this effort31 and extensive networking of members of the study team. The principal limitation of this study was that the data were obtained through self-reports. Although in most cases we were able to contact the most knowledgeable person on the labor and delivery unit (ie, the nurse manager), there were areas of inquiry that were unaddressed at some hospitals, particularly with respect to the extent of services and responsibilities of other departments such as radiology and anesthesiology, and criteria related to regional transport agreements and perinatal education. Specific queries regarding the nature of these services may need to be redirected to more knowledgeable personnel in future efforts to increase the response rate to these survey items. In cases in which the participant did not know whether the service was offered, we were unable to document that the hospital met the criterion and may have underestimated the service capability of the
hospital and consequently the maternal level of care. For this reason, we used a second methodology for categorizing hospitals that relaxed the requirements by allowing the hospitals to miss 1 criterion. This second method demonstrated that the rectification of 1 criterion moved many more hospitals toward the goal of meeting basic criteria and fitting into a scheme for classifying hospitals by maternal levels of care. We emphasize that this study does not begin to address the implicit questions regarding how hospitals can overcome the many obstacles to reorganizing and optimizing their service structure. Since the 1980s, there have been growing concerns regarding the weakening, or de-regionalization, of established perinatal networks and the subsequent impact on newborn morbidity and mortality, particularly for those born to younger, less educated, nonwhite women.32-36 The rise in cesarean delivery rates has been attributed in part to the inability of community hospitals to manage high-risk mothers,37 coupled with a reluctance to transfer them.38 In lieu of antenatal transfer, practitioners tend to deliver these mothers, transferring the newborn if they are unable to provide the appropriate care; hence, both mother and newborn may receive suboptimal care.32,36,39 Fee structures and payment policies do not incentivize maternal referral and transport, given that fees for delivery of the infant are generally much higher than those for the provision of prenatal care.40,41 Further barriers include the lack of formalized consultation agreements, referral resources, maternal transport teams, providers’ lack of understanding of interventions available and the potential to improve outcomes, and patient instability or active labor. Community hospitals are often under economic pressure to open specialty NICUs to reduce the number of transfers of newborns, and women with high-risk pregnancies, to other facilities. Our data support these observations in that, when maternal and NICU levels did not match, the NICU level was likely to be higher than the maternal level,
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allowing hospitals to keep many highrisk newborns but raising questions regarding the capacity of the hospital to provide maternal risk-appropriate care. The benefits of NICU regionalization have been demonstrated.17-19 The impact of de-regionalization, the benefits and risks of assigning maternal levels of care, and the theoretical mismatch of maternal and neonatal levels of care need to be further characterized and understood. The results of this study should encourage progress toward reaching a definition and achieving implementation of a system of maternal risk-appropriate care. For the time being, cognizance of the wide variation in existing childbirth services will be critical to the development of guidance regarding both the optimal configuration of services for basic, intermediate, and regional maternal levels of care and the regionalization approach taken. ACKNOWLEDGMENTS We are grateful to the many individuals and organizations that have contributed to this effort, including the staff of all of the participating hospitals. We want to specifically acknowledge the Regional Perinatal Programs of California for their assistance in providing introductions and contact information for participants and Kevin Van Otterloo of the Community Perinatal Network in Yorba Linda, CA, for his assistance with recruitment and scheduling participant interviews.
REFERENCES 1. D’Alton MD, Bonanno CA, Berkowitz RL, et al. Putting the “M” back in maternal-fetal medicine. Am J Obstet Gynecol 2013;208:442-8. 2. Creanga AA, Berg CJ, Ko JY, et al. Maternal mortality and morbidity in the United States: where are we now? J Womens Health 2014;23: 3-9. 3. Berg CJ, Harper MA, Atkinson SM, et al. Preventability of pregnancy-related deaths: results of a state-wide review. Obstet Gynecol 2005;106:1228-34. 4. Geller SE, Rosenberg D, Cox SM, et al. The continuum of maternal morbidity and mortality: factors associated with severity. Am J Obstet Gynecol 2004;191:939-44. 5. Mitchell C, Lawton E, Morton C, McCain C, Holtby S, Main E. California pregnancyassociated mortality review: mixed methods approach for improved case identification, cause of death analyses and translation of findings. Matern Child Health J 2014;18:518-26.
6. Kuklina EV, Meikle SF, Jamieson DJ, et al. Severe obstetric morbidity in the United States: 1998-2005. Obstet Gynecol 2009;113(2 Part 1): 293-9. 7. Berg CJ, MacKay AP, Cheng Q, Callaghan WM. Overview of maternal morbidity during hospitalization for labor and delivery in the United States: 1993e1997 and 2001e2005. Obstet Gynecol 2009;113:1075-81. 8. Wen SW, Huang L, Liston R, et al. for the Maternal Health Study Group, Canadian Perinatal Surveillance System. Severe maternal morbidity in Canada, 1991e2001. CMAJ 2005;173:759-64. 9. Goffman D, Madden RC, Harrison EA, Merkatz IR, Chazotte C. Predictors of maternal mortality and near-miss maternal morbidity. J Perinatol 2007;27:597-601. 10. Creanga AA, Bateman BT, Kuklina EV, Callaghan WM. Racial and ethnic disparities in severe maternal morbidity: a multistate analysis, 2008e2010. Am J Obstet Gynecol 2014;210: 435.e1-8. 11. Korst LM, Fridman M, Lu MC, et al. Monitoring childbirth morbidity using hospital discharge data: further development and application of a composite measure. Am J Obstet Gynecol 2014;211:268.e1-16. 12. Callaghan WM, Grobman WA, Kilpatrick SJ, Main EK, D’Alton M. Facility-based identification of women with severe maternal morbidity: it’s time to start. Obstet Gynecol 2014;123:978-81. 13. Kilpatrick SJ, Berg C, Bernstein P, et al. Standardized severe maternal morbidity review. Obstet Gynecol 2014;124(2 Part 1):361-6. 14. American College of Obstetricians and Gynecologists. Levels of maternal care. ACOG Obstetric Care Consensus no. 2. Obstet Gynecol 2015;125:502-15. 15. Martin JA, Hamilton BE, Osterman MJK, Curtin SC, Mathews TJ. Births: final data for 2012. Natl Vital Stat Rep 2013;62:1-86. 16. Hankins GDV, Clark SL, Pacheco LD, O’Keeffe D, D’Alton M, Saade GR. Maternal mortality, near misses, and severe morbidity. Obstet Gynecol 2012;120:929-34. 17. Phibbs CS, Backer LC, Caughey AB, Danielsen B, Schmitt SK, Phibbs RH. Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants. N Engl J Med 2007;356:2165-75. 18. Lasswell SM, Barfield WD, Rochat RW, Blackmon L. Perinatal regionalization for very low-birth-weight and very preterm infants. JAMA 2010;304:992-1000. 19. Chung JH, Phibbs CS, Boscardin WJ, Kominski GF, Ortega AN, Needleman J. The effect of neonatal intensive care level and hospital volume on mortality of very low birth weight infants. Med Care 2010;48:635-44. 20. California Code of Regulations. Title 22. Social Security. Available at: https://govt.westlaw. com/calregs/Browse/Home/California/California CodeofRegulations?guid¼I6F56A7E1D4B611DE 8879F88E8B0DAAAE&originationContext¼docu menttoc&transitionType¼Default&contextData¼ %28sc.Default%29. Accessed March 23, 2015.
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21. American Academy of Pediatrics (AAP) Committee on Fetus and Newborn, American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice In: Riley LE, Stark AR, Kilpatrick SJ, Papile LA, eds. Guidelines for perinatal care, 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012. 22. Maryland Department of Health and Mental Hygiene. Maryland perinatal system standards, 2012. Available at: http://phpa.dhmh.maryland. gov/mch/SitePages/perinatal_standards.aspx. Accessed March 23, 2015. 23. Tennessee Department of Health, Women’s Health/Genetics Section. Tennessee Perinatal Care System, guidelines for regionalization, hospital care levels, staffing and facilities, 2014. 7th ed. Available at: http://health.tn.gov/Downloads/ Regionalization%20Guidelines%20Approved% 202014.pdf. Accessed March 23, 2015. 24. California Perinatal Summit maternal levels of care criteria. Available at: http://amf-consulting. com/mqi/wp-content/uploads/2014/12/MaternalLevels-of-Care.pdf. Accessed March 23, 2015. 25. Maternal Level of Care Survey Items, Childbirth Survey II. Available at: http://www. amf-consulting.com/mqi/wp-content/uploads/ 2015/01/Childbirth-Survey.-FINAL.pdf. Acces sed March 23, 2015. 26. State of California Office of Statewide Health Planning and Development, Healthcare Information Division. Hospital annual utilization data, 2014. Available at: http://www.oshpd.ca.gov/ hid/Products/Hospitals/Utilization/Hospital_Uti lization.html. Accessed March 23, 2015. 27. California Department of Health Care Services. Approved neonatal intensive care units and high-risk infant follow-up programs. Available at: http://www.dhcs.ca.gov/services/ccs/ Pages/NICUSCC.aspx. Accessed March 23, 2015. 28. California Department of Health Care Services. Neonatal intensive care unit (regional) listing. Available at: http://www.dhcs.ca.gov/services/ ccs/scc/Pages/NICURegional.aspx. Accessed March 23, 2015. 29. California Department of Health Care Services. Neonatal intensive care unit (community) listing. Available at: http://www.dhcs.ca.gov/ services/ccs/scc/Pages/NICUCommunity.aspx. Accessed March 23, 2015. 30. California Department of Health Care Services. Neonatal intensive care unit (intermediate) listing. Available at: http://www.dhcs.ca.gov/ services/ccs/scc/Pages/NICUIntermediate.aspx. Accessed March 23, 2015. 31. Shihady IR, Broussard P, Bolton LB, et al. Vaginal birth after cesarean: do California hospital policies follow national guidelines? J Reprod Med 2007;52:349-58. 32. Gould JB, Sarnoff R, Liu H, Bell DR, Chavez G. Very low birthweight births at nonNICU hospitals: the role of sociodemographic, perinatal, and geographic factors. J Perinatol 1999;19:197-205. 33. Pollack LD. An effective model for reorganization of perinatal services in a metropolitan
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area: a descriptive analysis and historical perspective. J Perinatol 1996;16:3-8. 34. Handler A, Rosenberg D, Driscoll M, et al. Regional perinatal care in crisis: a case study of an urban public hospital. J Public Health Policy 1991;12:184-98. 35. Dobrez D, Gerber S, Budetti P. Trends in perinatal regionalization and the role of managed care. Obstet Gynecol 2006;108: 839-45. 36. Yeast JD, Poskin M, Stockbauer JW, Shaffer S. Changing patterns in regionalization
ajog.org of perinatal care and the impact on neonatal mortality. Am J Obstet Gynecol 1998;178: 131-5. 37. Rybak EA. Hippocratic ideal, Faustian bargain and Damocles’ sword: erosion of patient autonomy in obstetrics. J Perinatol 2009;29: 721-5. 38. Lessaris KJ, Annibale DJ, Southgate WM, Hulsey TC, Ohning BL. Effects of changing health care financial policy on very low birthweight neonatal outcomes. South Med J 2002;95:426-30.
39. Nowakowski L, Barfield WD, Kroelinger CK, et al. Assessment of state measures of riskappropriate care for very low birth weight infants and recommendations for enhancing regionalized state systems. Matern Child Health J 2012;16:217-27. 40. Fisher ES, Bynum JP, Skinner JS. Slowing the growth of health care costs—lessons from regional variation. N Engl J Med 2009;360:849-52. 41. Staebler S. Regionalized systems of perinatal care: health policy considerations. Adv Neonatal Care 2011;11:37-42.
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A PPENDIX SUPPLEMENTARY TABLE
Survey items related to criteria for determining hospital-specific obstetrical levels of care as proposed at the California Perinatal Summit24 Short name of criterion
Survey item(s)
Basic criteria Basic 1: cesarean delivery within 30 min 100% of the time To meet criterion, must answer (a)
How often would you say your hospital is able to successfully perform an emergency cesarean delivery within 30 min when one is called for? a) 100% b) 75e99% c) 51e74% d) 50% or less e) Almost never f) Unknown
Basic 2: anesthesia available within 30 min To meet criterion, must answer part 1 (a) and part 2 (a), (b), (c), (d), or (e)
Is there 24-h in-house anesthesia coverage for all labor and delivery patients? a) Yes b) No c) Do not know If there is not 24-h in-house anesthesia coverage, describe duration of coverage and policies for arrival at the hospital. a) There is 24-h in-house coverage b) In-house during weekdays, then on call 30 min or less from home c) Always on call from home, must be there 30 min or less d) On call from home less than 30 min but must be in-house if epidural and/or trial of labor after cesarean delivery e) No MD on call, CRNA only with expectation of arrival 30 min or less f) On call from home, expectation longer than 30 min for arrival g) Unknown
Basic 3: nursery with 24-h resuscitation/ stabilization To meet criterion, must answer (a)
Do you have 24-h access to neonatal resuscitation/stabilization capability? a) Yes b) No c) Unknown
Basic 4: pediatric care available day and night To meet criterion, must answer part 1 (a) and part 2 (a)
Please specify what type of health care providers might be likely to attend a delivery during the day? Attending pediatrician a) Yes b) No c) Unknown If coverage for the baby is not the same at night, please specify. a) Coverage is the same at night b) No neonatologist is available at night c) No pediatrician is available at night d) Multiple staff not available at night e) Other: specify f) Unknown
Basic 5: Radiology ultrasound available within 12 h To meet criterion, must answer part 1 (a) or (b) and part 2 (a) or (b)
If a pregnant woman on labor and delivery needs any of the following radiology studies, please indicate the statement that best describes the turnaround time to getting at least a preliminary read for each of these both during the day and at night. Obstetrical ultrasound day a) 1e4 h b) 5e12 h c) Longer than 12 h d) Not applicable e) Unknown Obstetrical ultrasound night a) 1e4 h b) 5e12 h c) Longer than 12 h d) Not applicable e) Unknown
Korst. Maternal levels of risk-appropriate care. Am J Obstet Gynecol 2015.
(continued)
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Research 1007 1008 1009 1010 1011 1012 1013 1014 1015 1016 1017 1018 1019 1020 1021 1022 1023 1024 1025 1026 1027 1028 1029 1030 1031 1032 1033 1034 1035 1036 1037 1038 1039 1040 1041 1042 1043 1044 1045 1046 1047 1048 1049 1050 1051 1052 1053 1054 1055 1056 1057 1058 1059 1060 1061 1062
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ajog.org
SUPPLEMENTARY TABLE
Survey items related to criteria for determining hospital-specific obstetrical levels of care as proposed at the California Perinatal Summit24 (continued) Short name of criterion
Survey item(s)
Basic unused: transport agreement To meet criterion, must answer part 1 (b)
Do you have a formal transport agreement or RCA with other hospitals for maternal transport? a) No b) Yes c) Unknown How many times a month do you transfer maternal patients to a higher level of care? Open-ended answer How many times a month do you accept a transfer of a maternal patient to provide a higher level of care? Open-ended answer How many times a month do you transfer patients to a lower level of care? Open-ended answer
Intermediate criteria listed previously plus following Intermediate 1: anesthesia available within 24 h in-house To meet criterion, must answer (a)
Is there 24-h in-house anesthesia coverage for all labor and delivery patients? a) Yes b) No c) Unknown
Intermediate 2: dedicated obstetrics anesthesia service To meet criterion, must answer part 1 (a) and part 2 (a)
Is the in-house anesthesia provider responsible for patients not in labor and delivery? a) No b) Yes c) We do not have 24-h in-house anesthesia d) Unknown If yes, what are the anesthesiologists’ responsibilities? a) They have no other responsibilities b) Mainly cover labor and delivery but sometimes go to main operating room c) Mainly cover main operating room but sometimes go to labor and delivery d) Cover the whole hospital e) Priority is labor and delivery but go where needed (eg, codes, main operating room, emergency room) f) Dedicated to labor and delivery weekdays, but nights and weekends cover other parts of the hospital g) Unknown
Intermediate 3: level 1 NICU To meet criterion, must answer part 1 (a) and part 2 (a), (b), (c), or (d)
Does your hospital have an NICU? a) Yes b) No c) Unknown If yes, what is the acuity level? a) 1 b) 2 c) 3 d) 4 e) We do not have an NICU f) Unknown If yes, is it CCS certified? a) Yes b) No c) We do not have an NICU d) Unknown
Intermediate 4: 24-h adult critical care To meet criterion, must answer (a)
Do you have 24-h adult critical care capability? a) Yes b) No c) Unknown
Korst. Maternal levels of risk-appropriate care. Am J Obstet Gynecol 2015.
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(continued)
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ajog.org 1119 1120 1121 1122 1123 1124 1125 1126 1127 1128 1129 1130 1131 1132 1133 1134 1135 1136 1137 1138 1139 1140 1141 1142 1143 1144 1145 1146 1147 1148 1149 1150 1151 1152 1153 1154 1155 1156 1157 1158 1159 1160 1161 1162 1163 1164 1165 1166 1167 1168 1169 1170 1171 1172 1173 1174
Research
SUPPLEMENTARY TABLE
Survey items related to criteria for determining hospital-specific obstetrical levels of care as proposed at the California Perinatal Summit24 (continued) Short name of criterion
Survey item(s)
Intermediate 5: 24-h maternal-fetal medicine To meet criterion, must answer part 1 (a) or (b) and part 2 (b)
Does your hospital have an MFM specialist (obstetrician-gynecologist subspecialist in high-risk obstetrics)? a) On staff b) Not on staff but available by phone c) Outpatient only d) Not available e) Occasionally sees patients in-house f) Uses telemedicine g) Unknown If MFM is available, is MFM consultation readily available 24 h a day? a) No b) Yes c) Occasionally d) MFM is not available e) Unknown
Regional criteria all listed previously plus the following Regional 1: 24-h obstetrician available in-house To meet criterion, must answer (a)
Describe your attending physician coverage on labor and delivery. a) In-house coverage 24 h/d, 7 d/wk b) MD coverage 24 h/d, 7 d/wk but not in-house c) Mixed model: some laborist, some coverage from home/office d) In-house coverage part of the time e) All patients covered by residents with in-house attending supervision f) Unknown
Regional 2: level 2 or 3 NICU To meet criterion, must answer part 1 (a) and part 2 (b), (c), or (d)
Same items as for intermediate 3: level 1 NICU
Regional 3: 24-h neonatologist available To meet criterion, must answer part 1 (a) and part 2 (a)
Please specify what type of health care providers might be likely to attend a delivery during the day? Attending neonatologist a) Yes b) No c) Unknown If coverage for the baby is not the same at night, please specify. a) Coverage is the same at night b) No neonatologist is available at night c) No pediatrician is available at night d) Multiple staff not available at night e) Other: specify f) Unknown
Regional 4: 24-h radiology services available To meet criterion, must answer (a)
Does your hospital have 24-h radiology reading? a) Yes b) No c) Unknown
Regional 5: 24-h adult critical care plus invasive cardiac monitoring To meet criterion, must answer part 1 (a) and part 2 (a)
Do you have 24-h adult critical care capability? a) Yes b) No c) Unknown Is invasive maternal monitoring available to the delivery area, including equipment for CVP and arterial pressure monitoring? a) Yes b) No c) Unknown
Korst. Maternal levels of risk-appropriate care. Am J Obstet Gynecol 2015.
(continued)
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ajog.org
SUPPLEMENTARY TABLE
Survey items related to criteria for determining hospital-specific obstetrical levels of care as proposed at the California Perinatal Summit24 (continued) Short name of criterion
Survey item(s)
Regional 6: 24-h MFM on staff To meet criterion, must answer part 1 (a) and part 2 (b)
Same items as for intermediate 5: 24-h MFM
Regional unused 1: perinatal follow-up
Unable to assess
Regional unused 2: transport agreement To meet criterion, must answer part 1 (b)
Same items as for basic unused: transport agreement
CCS, California Children’s Services; CRNA, certified registered nurse anesthetist; CVP, central venous pressure; MFM, maternal fetal medicine; NICU, neonatal intensive care unit; RCA, regional cooperative agreement. Korst. Maternal levels of risk-appropriate care. Am J Obstet Gynecol 2015.
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OBSTETRICS
Cross-sectional survey of California childbirth hospitals: implications for defining maternal levels of risk-appropriate care Q2
Lisa M. Korst, MD, PhD; Daniele S. Feldman, MD; D. Lisa Bollman, RN, MSN; Moshe Fridman, PhD; Samia El Haj Ibrahim, MPH; Arlene Fink, PhD; Kimberly D. Gregory, MD, MPH OBJECTIVE: Measures of maternal mortality and severe maternal morbidity have risen in the United States, sparking national interest regarding hospitals’ ability to provide maternal risk-appropriate care. We examined the extent to which hospitals could be classified by increasingly sophisticated maternal levels of care. STUDY DESIGN: We performed a cross-sectional survey to identify
hospital-specific resources and classify hospitals by criteria for basic, intermediate, and regional maternal levels of care in all nonmilitary childbirth hospitals in California. We measured hospital compliance with maternal level of care criteria that were produced via consensus based on professional standards at 2 regional summits funded by the March of Dimes through a cooperative agreement with the Community Perinatal Network in 2007 (California Perinatal Summit on Risk-Appropriate Care). RESULTS: The response rate was 96% (239 of 248 hospitals). Only 82
hospitals (34%) were classifiable under these criteria (35 basic, 42 intermediate, and 5 regional) because most (157 [66%]) did not meet
the required set of basic criteria. The unmet criteria preventing assignment into the basic category included the ability to perform a cesarean delivery within 30 minutes 100% of the time (only 64% met), pediatrician availability day and night (only 56% met), and radiology department ultrasound capability within 12 hours (only 83% met). Only 29 of classified hospitals (35%) had a nursery or neonatal intensive care unit level that matched the maternal level of care, and for most remaining hospitals (52 of 53), the neonatal intensive care unit level was higher than the maternal care level. CONCLUSION: Childbirth services varied widely across California
hospitals, and most hospitals did not fit easily into proposed levels. Cognizance of this existing variation is critical to determining the optimal configuration of services for basic, intermediate, and regional maternal levels of care. Key words: childbirth hospital services, hospital staffing, maternal health, maternal levels of care, risk-appropriate care
Cite this article as: Korst LM, Feldman DS, Bollman DL, et al. Cross-sectional survey of California childbirth hospitals: implications for defining maternal levels of risk-appropriate care. Am J Obstet Gynecol 2015;213:xx-xx.
W
orsening measures of maternal mortality and severe morbidity have begun to gain national attention.1 From 1987 to 2009, the pregnancyrelated mortality ratio rose steadily from 7.2 to 17.8 deaths per 100,000 live
births,2 and recent studies have estimated that at least 40% of maternal deaths appear to be preventable.3-6 Recent publications have also recognized steadily increasing rates of severe obstetrical complications6-9 showing
substantial racial disparity, with elevations among African-Americans and women of Hispanic ethnicity.3,9,10 According to Kuklina et al,6 renal failure, pulmonary embolism, adult respiratory distress syndrome, shock, blood
Q1 From Childbirth Research Associates, North Hollywood (Dr Korst); Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Burns Allen
Research Institute (Drs Feldman and Gregory and Ms El Haj Ibrahim); AMF Consulting (Dr Fridman); Division of General Internal Medicine and Health Services Research, Department of Medicine (Dr Fink), and Department of Obstetrics and Gynecology (Dr Gregory), David Geffen School of Medicine at UCLA; and Departments of Health Policy and Management (Dr Fink) and Community Health Sciences (Dr Gregory), Fielding School of Public Health at UCLA, Los Angeles; Community Perinatal Network, Yorba Linda (Ms Bollman); and Langley Research Institute, Pacific Palisades (Dr Fink), CA. Received April 16, 2015; revised May 20, 2015; accepted July 13, 2015. The funding sources had no involvement in the conduct of the research or in the preparation of the manuscript. This study was supported by Agency for Healthcare Research and Quality grant 5 R01 HS020915 (all investigators except D.S.F.). Additional support was provided by the March of Dimes (L.M.K., M.F., and D.L.B.) and by the American Congress of Obstetricians and Gynecologists/Duchesnay USA Research Award in Quality Improvement in Maternity Care (D.S.F.). The authors report no conflict of interest. Corresponding author: Kimberly D. Gregory, MD, MPH. [email protected] 0002-9378/$36.00 ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2015.07.014
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transfusion, and ventilation are all on the rise nationally. Furthermore, rates of severe maternal morbidity appear to vary widely across hospitals.11 This year, in an effort to promote benchmarking and improvement, a call was made for the facility-based identification and reporting of women with severe maternal morbidity.12,13 This call was further supported in February 2015 by the publication of a consensus-based statement from the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine that proposed the development of standards for maternal risk-appropriate care.14 Given that childbirth is the number one reason for hospitalization in the United States at nearly 4 million births per year,15 a national strategy is needed to address this observed increase in childbirth-related maternal morbidity.16 Improved neonatal outcomes have resulted from perinatal regionalization, a term that currently refers to a health care delivery system that optimizes care for preterm newborns,17-19 and this strategy has prompted policy makers to examine the feasibility of creating maternal levels of care1 so that mothers with high-risk conditions could be assured delivery at hospitals with the appropriate resources (eg, the availability of subspecialists, specialty intensive care units, blood banking services, and diagnostic imaging equipment. This initiative requires attention to a stepwise research agenda that includes the following: (1) the development of criteria for defining increasingly sophisticated levels of maternal care; (2) the demonstration that maternal outcomes are improved in women who deliver at facilities that can offer risk-appropriate care; and (3) the elaboration of implementation strategies for such a system. Such an agenda will initially require detailed hospital-level data regarding current configurations of childbirth services, resources and patient care activities, and linkages of these data to childbirth outcomes to identify the factors associated with optimal results. To date, such information has not been available. The purpose of this study was to collect hospital-level data to document
ajog.org the characteristics of childbirth hospitals. This is in preparation for the development of a foundation for defining and implementing maternal levels of care to maximize both maternal and neonatal safety. Although the achievement of a system for maternal riskappropriate health services is a national concern, here we focus on the services offered by California childbirth hospitals, which perform more than 500,000 births each year (12.7% of all US births), more than any other US state.13
M ATERIALS
AND
M ETHODS
This is a cross-sectional assessment of childbirth hospital services designed to determine the extent to which hospitals can be classified by increasingly sophisticated maternal levels of care. Information was obtained from a survey of labor and delivery nurse managers for childbirth hospitals in California that included an array of items regarding hospital services, resources, and patient care activities. The study was approved by the Cedars-Sinai Institutional Review Board (protocol PRO00032669 certified exempt) and complied with all stipulated criteria for participant protection. Professional standards for obstetrical care services are set out in Title 22 of the California State Code of Regulations20 and Guidelines for Perinatal Care, published by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists.21 These publications refer to maternal levels of care but without the specificity needed to define the appropriate setting, provider, or competency required to care for individual patients or to address their pregnancy complications. Several US states have defined such levels, but these definitions vary and are primarily focused on improving neonatal as contrasted to maternal outcomes.22,23 For these reasons, we used recommended maternal level of care criteria that were produced via consensus at 2 regional summits funded by the March of Dimes through a cooperative agreement with the Community Perinatal Network in 2007 (California Perinatal Summit on RiskAppropriate Care),24 which were based on professional standards.20,21
Survey development and administration We devised survey items based on the perinatal summit criteria and categorized them into 5 prespecified domains: hospital structure/context, hospital staffing, hospital clinical resources, and hospital clinical activities. Two interviewers were trained to assure consistent administration of the survey, which they piloted among labor and delivery managers at 5 hospitals to assure face and content validity of the domains and individual items and to assure that these managers would be an adequate and reliable source of information. Upon finalization of all items, interrater reliability was assessed by having each interviewer conduct 5 interviews in the presence of the other, with each interviewer recording results, and agreement determined between the interviewers for each individual item, using Cohen’s kappa for categorical responses and the Shrout-Fleiss intraclass correlation for continuous or mixed responses. In addition, 10 participants were retested at 3 months to assure concordance with their previous responses using the Shrout-Fleiss intraclass correlation. Survey items that did not have good interrater or test-retest reliability (kappa <0.8 or <80% agreement) were eliminated. The survey contained 185 questions that resulted in 293 individual items25 and took approximately 1 hour to complete. Those items that were directly related to the evaluation of meeting the maternal level of care criteria are included in the Appendix (Supplementary Table). The survey was offered to all nonmilitary California childbirth hospitals, and contact information for labor and delivery managers was obtained through the Regional Perinatal Programs of California. The managers were contacted by phone and an appointment made for the interview. Managers were given a $50 gift card as an incentive. A hard copy of the survey was mailed to the managers in advance to assure familiarity with the questions. All surveys were completed between November 2012 and January 2014.
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TABLE 1
Criteria for defining obstetrical levels of care as proposed at the California Perinatal Summit24 and number of hospitals meeting each criteriona Short name
Criterion
Operational definition
Total (n [ 239)
Level 1: basic (all hospitals with childbirth services) Basic 1: cesarean delivery within 30 min 100% of the time
No requirement for 24-h, in-house obstetrician, but MD should be able to respond within 30 min, and be on-call for only one hospital
Ability to perform cesarean delivery within 30 min 100% of the time
152 (63.6%)b
Basic 2: anesthesia available within 30 min
Anesthesia coverage should be able to respond within 30 min
Anesthesia coverage can respond within 30 min
235 (98.3%)
Basic 3: nursery with 24 h, resuscitation/stabilization
Newborn nursery should have 24-h neonatal resuscitation/stabilization capability
Newborn nursery has 24-h neonatal resuscitation/stabilization capability
239 (100%)
Basic 4: pediatric care available day and night
Pediatricians/neonatologists should be able to respond within 30 min and be on-call for only 1 hospital
Pediatrician (or family practitioner)/ neonatologist can attend deliveries both day and night
133 (55.6%)c
Basic 5: radiology ultrasound available within 12 h
Ultrasound capability on call
Obstetrical ultrasound from radiology department available within 12 h
199 (83.3%)d
Basic unused: transport agreement
Formalized transport agreement with a facility capable of providing a higher level of maternal/newborn care
Tracked but not counted as a criterion because it is dependent on the classified level of care
Not applicable
Level 2: Intermediate, all of the above, plus the following Intermediate 1: anesthesia available within 24 h in-house
In-house anesthesia coverage 24 h
In-house anesthesia coverage 24 h
146 (61.1%)
Intermediate 2: dedicated obstetrics anesthesia service
In-house and obstetrics-dedicated anesthesia service
In-house and obstetrics-dedicated anesthesia service
141 (59.0%)e
Intermediate 3: level 1 NICU
CCS intermediate NICU (equivalent to level I NICU in Guidelines for Perinatal Care21)
CCS level 1 NICU or non-CCS equivalent
152 (63.6%)
Intermediate 4: 24-h adult critical care
Adult critical care capability available 24 h, not necessarily on labor and delivery
Adult critical care capability available 24 h, not necessarily on labor and delivery
230 (96.2%)
Intermediate 5: 24-h maternal-fetal medicine service
Maternal-fetal medicine specialist consultation available 24 h
Maternal-fetal medicine specialist consultation available 24 h
198 (82.8%)f
Level 3: regional, all of the above, plus the following Regional 1: 24 hour obstetrician available in-house
Obstetrics coverage (eg, obstetrician hospitalists) available 24 h in-house
Obstetrics coverage (eg, obstetrician hospitalists) available 24 h in-house (not necessarily assigned to all patients)
92 (38.5%)
Regional 2: level 2 or 3 NICU
CCS community or regional NICU (equivalent to levels II-III NICU in Guidelines for Perinatal Care21)
CCS level 2 or 3 NICU or non-CCS equivalent
69 (28.9%)
Regional 3: 24-h neonatologist available
Neonatology coverage (eg, neonatologists, neonatal nurse practitioners) available 24 h, in-house
Neonatologist available for deliveries both day and night (not necessarily in-house)
210 (87.9%)g
Regional 4: 24-h radiology services available
Radiology capability available 24 h, in-house
Radiology capability available 24 h in-house (reading not necessarily in-house)
193 (80.8%)h
Regional 5: 24-h adult critical care plus invasive cardiac monitoring
Adult critical care capability available 24 h, with portion of labor and delivery dedicated to critical care
Adult critical care available 24 h, with capability of invasive monitoring on labor and delivery
99 (41.4%)i
Regional 6: 24-h maternal-fetal medicine on staff
Maternal-fetal medicine specialist consultation available 24 h
Maternal-fetal medicine specialist consultation available 24 h on staff
95 (39.7%)
Korst. Maternal levels of risk-appropriate care. Am J Obstet Gynecol 2015.
(continued)
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391 392 TABLE 1 393 24 Criteria for defining obstetrical levels of care as proposed at the California Perinatal Summit and number 394 of hospitals meeting each criteriona (continued) 395 Short name Criterion Operational definition Total (n [ 239) 396 Unable to assess Not applicable Regional unused 1: perinatal Outpatient perinatal follow-up services, 397 follow-up education, and case management provided 398 to referring hospitals 399 Not applicable Tracked but not counted as a criterion Regional unused 2: transport Formalized transport agreements and 400 because it is dependent on the classified agreement regional cooperative agreements with all 401 facilities transporting high-risk mothers and level of care 402 infants to them 403 CCS, California Children’s Services; NICU, neonatal intensive care unit. 404 a If a hospital did not respond regarding a criterion, it was categorized as not met. The number of nonresponses for each criterion was zero unless otherwise specified by subsequent footnotes; b c d e f g h i 405 n (nonresponse) ¼ 1; n (nonresponse) ¼ 5; n (nonresponse) ¼ 39; n (nonresponse) ¼ 34; n (nonresponse) ¼ 27; n (nonresponse) ¼ 5; n (nonresponse) ¼ 19; n (nonresponse) ¼ 5. 406 Korst. Maternal levels of risk-appropriate care. Am J Obstet Gynecol 2015. 407 408 409 basic, intermediate, or regional maternal integrated delivery system and 5 comData management 410 munity hospitals) did not respond. The The interviewer entered information level of care criteria. 411 We used 2 methods to categorize hos- majority of respondents were adminisinto SurveyMonkey (Palo Alto, CA), and 412 data were exported into SAS (SAS pitals. In method 1, maternal level of care trative directors and nurses (n ¼ 141; 413 criteria were grouped into 3 sets: basic 59.0%), followed by clinical directors or version 9.3; SAS Institute, Cary, NC). 414 Information regarding neonatal in- (5 criteria), intermediate (5 criteria), and nurse managers (n ¼ 85; 35.6%), and 415 tensive care unit (NICU) level was added regional (6 criteria). To be classified as others (n ¼ 13; 5.4%). The mean (SD) 416 to the data set. Basic/primary care hospi- basic, a hospital had to meet all 5 basic number of years working at the current 417 tals (no NICU) were identified in an criteria. To be classified as intermediate, a hospital was 12.4 (10.1) (median, 11.0; 418 annual report from the California Office hospital had to meet all 5 basic and all 5 range, 0.1e46 years), and the mean (SD) 419 of Statewide Health Planning and Devel- intermediate criteria. To be classified as number of years in the current position 420 opment as having obstetric beds but no regional, a hospital had to meet all 5 basic, was 5.6 (5.8) (median, 4.0; range, 0.1e30 421 NICU beds.26 Hospitals with NICUs were 5 intermediate, and 6 regional criteria. In years). 422 Interrater reliability was calculated for classified as having an intermediate cases in which the survey respondent did 423 NICU, community NICU, or regional not know whether the criterion was met 10 hospitals. For the 270 categorical 424 NICU as designated by California Chil- by their hospital, the criterion was desig- items, the mean (SD) kappa values were 425 dren’s Services (CCS),27-30 a state pro- nated as not met. The number of hospitals 0.94 (0.15); items with kappa values 426 gram for children with special health for which specific items had missing an- <0.8 were discarded (n ¼ 28). For the 23 427 continuous items, the mean (SD) ½T1 428 care needs, with intermediate NICUs swers is noted in Table 1. Because several items did not have agreement rate was 0.98 (0.06); items providing less advanced care than com429 munity or regional NICUs and regional 100% response rates and to better un- with <80% agreement were discarded 430 NICUs providing the most advanced care. derstand the potential of hospitals (n ¼ 2). For the 10 hospitals that were 431 Facilities with licensed intensive care to meet the maternal level of care retested, the mean agreement rate (SD) 432 for newborn nursery beds but no desig- criteria, we did a second set of analyses for all 293 items was 0.96 (0.12); items 433 nation by the CCS were also identified by (method 2) that allowed hospitals to with <80% agreement were discarded 434 this report.26 For analytical purposes, miss 1 criterion at any of the levels and (n ¼ 26). In total, 34 survey items were 435 those NICUs without a CCS designation reassigned maternal levels of care based deemed unreliable and excluded from 436 were assigned a comparable designation on this approach. This credit could be analyses. 437 The maternal level of care criteria are as an intermediate NICU if they had less applied only once, starting from the 438 than 15 beds and a community NICU if basic level. The goal of method 2 was to listed in Table 1 with the operational 439 relax the criteria, as in a sensitivity definitions and the reference names for they had 15 or more beds. 440 analysis, to permit the assignment of a the criteria. Table 1 also describes the 441 category if one had not been assigned number of hospitals meeting each indi442 Data analyses vidual maternal level of care criterion. with method 1. 443 Most hospitals did not map easily to We mapped all appropriate survey items 444 maternal levels of care. Table 2 describes ½T2 445 to the criteria defined by the California R ESULTS Perinatal Summit,24 and hospitals were The survey response rate was 96% (239 of the number of hospitals that met basic, 446 categorized regarding whether they met 248 hospitals). Nine hospitals (ie, four intermediate, and regional criteria by 1.e4 American Journal of Obstetrics & Gynecology MONTH 2015 FLA 5.2.0 DTD YMOB10528_proof 28 July 2015 9:51 pm ce
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TABLE 2
Percentage of hospitals (n [ 239) meeting perinatal summit criteria for maternal levels of care, by 2 methods and associated NICU levelsa Maternal level of careNICU level of care
NICU level of care
Method 1: met all criteria Met basic criteria set
Met intermediate criteria set
Met regional criteria set n (%)
Final level assignment No NICU of maternal level (basic of care services)
No
No
No
116 (48.5%)
No
Yes
No
35 (14.6%)
No
No
Yes
2 (0.8%)
0 (0%)
0 (0%)
0 (0%)
2 (100%)
No
Yes
Yes
4 (1.7%)
0 (0%)
0 (0%)
0 (0%)
4 (100%)
Yes
No
No
31 (13.0%)
Yes
No
Yes
4 (1.7%)
Yes
Yes
No
42 (17.6%)
Yes
Yes
Yes
5 (2.1%)
Intermediate Community NICU NICU
75 (64.5%) 20 (17.2%) None: 157 (65.7%)
Basic: 35 (14.6%)
0 (0%)
12 (32.3%)
Intermediate: 42 (17.6%) 0 (0%) Regional: 5 (2.1%)
0 (0%)
11 (31.4%)
Regional NICU
21 (18.1%)
0 (0%)
24 (68.6%)
0 (0%)
8 (22.9%)
11 (31.4%)
4 (11.4%)
13 (31.0%)
27 (64.3%)
2 (4.8%)
1 (20.0%)
0 (0%)
4 (80.0%)
42 (91.3%)
3 (6.5%)
1 (2.2%)
0 (0%)
2 (12.5%)
2 (12.5%)
12 (75.0%)
0 (0%)
0 (0%)
0 (0%)
0 (0%)
1 (33.3%)
239 total Method 2: met all criteria but one No
No
No
46 (69.7%)
No
Yes
No
16 (24.2%)
No
No
Yes
No
Yes
Yes
4 (6.1%)
Yes
No
No
73 (98.6%)
Yes
No
Yes
1 (1.4%)
Yes
Yes
No
79 (100%)
Intermediate: 79 (33.1%) 2 (2.5%)
Yes
Yes
Yes
20 (100%)
Regional: 20 (8.4%)
None: 66 (27.6%)
0 (0%) Basic: 74 (31.0%)
41 (55.4%) 16 (21.6%)
0 (0%)
0 (0%) 0 (0%)
0 (0%) 3 (66.7%)
16 (21.6%)
1 (1.4%)
26 (32.9%)
49 (62.0%)
2 (2.5%)
5 (25.0%)
5 (25.0%)
10 (50.0%)
239 total NICU, neonatal intensive care unit. a
Method 1: final assignment of maternal level of care category was based on hospital meeting all maternal level of care criteria in each category, with all basic criteria met to be assigned to basic, all basic and intermediate criteria met to be assigned to intermediate, and all basic, intermediate, and regional criteria met to be assigned to regional; method 2: equivalent to method 1 except that credit could be given for a total of 1 missing basic, intermediate, or regional criterion to meet the previously mentioned requirements. This credit could be applied only once, starting from the basic level.
Korst. Maternal levels of risk-appropriate care. Am J Obstet Gynecol 2015.
methods 1 and 2. Using method 1, 82 hospitals (34.3%) were classified: 35 (14.6%) met basic criteria only, 42 (17.6%) met both basic and intermediate criteria, and 5 (2.1%) met basic, intermediate, and regional criteria. The remaining 157 hospitals (65.7%) could not be classified. The principal criteria preventing assignment into the basic category included the ability to perform a cesarean delivery within 30 minutes 100% of the time (only 63.6% met), pediatrician availability day and night (only 55.6%
met), and radiology department ultrasound capability within 12 hours (only 83.3% met). Although not used as a criterion, many hospitals with limited resources lacked transport agreements to more sophisticated hospitals. Of the 82 hospitals that could be assigned a maternal level of care under method 1, only 48 (58.5%) had transport agreements in place that were appropriate for their level. Of the 239 hospitals, 152 (63.6%) had a licensed NICU, and of these, 112 (73.7%) were assigned a level of care
from the CCS. Of the 40 hospitals with a NICU without a CCS designation, 34 (85.0%) were classified as intermediatelevel NICUs (the most basic NICU level), and the remainder were classified as community-level NICUs. Compared with other hospitals, hospitals with nonCCS NICUs were equally likely to be assigned a maternal level of care using method 1 (68 of 199 [34.2%] vs 14 of 40 [35.0%]; P ¼ .93). The NICU levels associated with the assigned maternal levels of care are described in Table 2. Only 29 of the 82
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hospitals classified under method 1 (35.4%) had a nursery or NICU level that matched the maternal level of care. The NICU level for most remaining hospitals (52 of 53) was higher than the maternal level of care. Using maternal levels assigned under method 2, 82 of the 173 classified hospitals (47.4%) had a nursery or NICU level that matched the maternal level of care. Of the remaining 91 hospitals, 84 (92.3%) had a NICU level that was higher than the maternal level of care.
C OMMENT National efforts to examine and stem the rise in severe maternal morbidity have encouraged interest in strategies to classify childbirth hospitals by their resources and patient care activities and thus develop systems for maternal riskappropriate care, or maternal levels of care.14,16 However, our data demonstrated that given the wide variation in childbirth services that exists, only one third of hospitals could be assigned to a maternal level of care category using a scheme that had been derived from a large consensus-based conference. The unmet criteria preventing assignment into the basic category included the ability to perform a cesarean delivery within 30 minutes 100% of the time (only 64% met), pediatrician availability day and night (only 56% met), and radiology department ultrasound capability within 12 hours (only 83% met). The criteria used for each level were derived by consensus of expert opinion. However, our results suggest that such theoretical requirements may not reflect the services actually offered by childbirth hospitals and that efforts to acknowledge and resolve these discrepancies are warranted. Consequently, the maternal level of care criteria empirically adopted here are intended as a starting point for discussion, and room for debate remains regarding which of the stated criteria should be required (eg, obstetrician and pediatrician availability) and whether additional services should be considered as essential for basic maternal care (eg, the availability of a blood bank or labor and delivery emergency response team).
ajog.org Our separate analysis that allowed leeway for missing one maternal level of care criterion demonstrated that 91 more hospitals could be classified and suggests that targeted efforts to assure that all childbirth hospitals meet a set of basic criteria have some potential for success. The maternal level of care criteria utilized here were available at the time of this study, which was conducted prior to the publication of the Obstetric Care Consensus (OCC) on maternal levels of care.14 The California Perinatal Summit criteria are very specific and the majority of them were easily operationalized for use within the survey. This need for specific criteria would preclude a direct comparison of the Summit criteria to the more general guidelines used by the OCC. For example, the OCC has constructed 4 levels of care, in addition to birth centers, and the OCC guidelines have no specifications for the response times of the health care providers or the turnaround time for laboratory and radiology tests. This study included nearly every childbirth hospital in California, which was due in part to previous experience with this effort31 and extensive networking of members of the study team. The principal limitation of this study was that the data were obtained through self-reports. Although in most cases we were able to contact the most knowledgeable person on the labor and delivery unit (ie, the nurse manager), there were areas of inquiry that were unaddressed at some hospitals, particularly with respect to the extent of services and responsibilities of other departments such as radiology and anesthesiology, and criteria related to regional transport agreements and perinatal education. Specific queries regarding the nature of these services may need to be redirected to more knowledgeable personnel in future efforts to increase the response rate to these survey items. In cases in which the participant did not know whether the service was offered, we were unable to document that the hospital met the criterion and may have underestimated the service capability of the
hospital and consequently the maternal level of care. For this reason, we used a second methodology for categorizing hospitals that relaxed the requirements by allowing the hospitals to miss 1 criterion. This second method demonstrated that the rectification of 1 criterion moved many more hospitals toward the goal of meeting basic criteria and fitting into a scheme for classifying hospitals by maternal levels of care. We emphasize that this study does not begin to address the implicit questions regarding how hospitals can overcome the many obstacles to reorganizing and optimizing their service structure. Since the 1980s, there have been growing concerns regarding the weakening, or de-regionalization, of established perinatal networks and the subsequent impact on newborn morbidity and mortality, particularly for those born to younger, less educated, nonwhite women.32-36 The rise in cesarean delivery rates has been attributed in part to the inability of community hospitals to manage high-risk mothers,37 coupled with a reluctance to transfer them.38 In lieu of antenatal transfer, practitioners tend to deliver these mothers, transferring the newborn if they are unable to provide the appropriate care; hence, both mother and newborn may receive suboptimal care.32,36,39 Fee structures and payment policies do not incentivize maternal referral and transport, given that fees for delivery of the infant are generally much higher than those for the provision of prenatal care.40,41 Further barriers include the lack of formalized consultation agreements, referral resources, maternal transport teams, providers’ lack of understanding of interventions available and the potential to improve outcomes, and patient instability or active labor. Community hospitals are often under economic pressure to open specialty NICUs to reduce the number of transfers of newborns, and women with high-risk pregnancies, to other facilities. Our data support these observations in that, when maternal and NICU levels did not match, the NICU level was likely to be higher than the maternal level,
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allowing hospitals to keep many highrisk newborns but raising questions regarding the capacity of the hospital to provide maternal risk-appropriate care. The benefits of NICU regionalization have been demonstrated.17-19 The impact of de-regionalization, the benefits and risks of assigning maternal levels of care, and the theoretical mismatch of maternal and neonatal levels of care need to be further characterized and understood. The results of this study should encourage progress toward reaching a definition and achieving implementation of a system of maternal risk-appropriate care. For the time being, cognizance of the wide variation in existing childbirth services will be critical to the development of guidance regarding both the optimal configuration of services for basic, intermediate, and regional maternal levels of care and the regionalization approach taken. ACKNOWLEDGMENTS We are grateful to the many individuals and organizations that have contributed to this effort, including the staff of all of the participating hospitals. We want to specifically acknowledge the Regional Perinatal Programs of California for their assistance in providing introductions and contact information for participants and Kevin Van Otterloo of the Community Perinatal Network in Yorba Linda, CA, for his assistance with recruitment and scheduling participant interviews.
REFERENCES 1. D’Alton MD, Bonanno CA, Berkowitz RL, et al. Putting the “M” back in maternal-fetal medicine. Am J Obstet Gynecol 2013;208:442-8. 2. Creanga AA, Berg CJ, Ko JY, et al. Maternal mortality and morbidity in the United States: where are we now? J Womens Health 2014;23: 3-9. 3. Berg CJ, Harper MA, Atkinson SM, et al. Preventability of pregnancy-related deaths: results of a state-wide review. Obstet Gynecol 2005;106:1228-34. 4. Geller SE, Rosenberg D, Cox SM, et al. The continuum of maternal morbidity and mortality: factors associated with severity. Am J Obstet Gynecol 2004;191:939-44. 5. Mitchell C, Lawton E, Morton C, McCain C, Holtby S, Main E. California pregnancyassociated mortality review: mixed methods approach for improved case identification, cause of death analyses and translation of findings. Matern Child Health J 2014;18:518-26.
6. Kuklina EV, Meikle SF, Jamieson DJ, et al. Severe obstetric morbidity in the United States: 1998-2005. Obstet Gynecol 2009;113(2 Part 1): 293-9. 7. Berg CJ, MacKay AP, Cheng Q, Callaghan WM. Overview of maternal morbidity during hospitalization for labor and delivery in the United States: 1993e1997 and 2001e2005. Obstet Gynecol 2009;113:1075-81. 8. Wen SW, Huang L, Liston R, et al. for the Maternal Health Study Group, Canadian Perinatal Surveillance System. Severe maternal morbidity in Canada, 1991e2001. CMAJ 2005;173:759-64. 9. Goffman D, Madden RC, Harrison EA, Merkatz IR, Chazotte C. Predictors of maternal mortality and near-miss maternal morbidity. J Perinatol 2007;27:597-601. 10. Creanga AA, Bateman BT, Kuklina EV, Callaghan WM. Racial and ethnic disparities in severe maternal morbidity: a multistate analysis, 2008e2010. Am J Obstet Gynecol 2014;210: 435.e1-8. 11. Korst LM, Fridman M, Lu MC, et al. Monitoring childbirth morbidity using hospital discharge data: further development and application of a composite measure. Am J Obstet Gynecol 2014;211:268.e1-16. 12. Callaghan WM, Grobman WA, Kilpatrick SJ, Main EK, D’Alton M. Facility-based identification of women with severe maternal morbidity: it’s time to start. Obstet Gynecol 2014;123:978-81. 13. Kilpatrick SJ, Berg C, Bernstein P, et al. Standardized severe maternal morbidity review. Obstet Gynecol 2014;124(2 Part 1):361-6. 14. American College of Obstetricians and Gynecologists. Levels of maternal care. ACOG Obstetric Care Consensus no. 2. Obstet Gynecol 2015;125:502-15. 15. Martin JA, Hamilton BE, Osterman MJK, Curtin SC, Mathews TJ. Births: final data for 2012. Natl Vital Stat Rep 2013;62:1-86. 16. Hankins GDV, Clark SL, Pacheco LD, O’Keeffe D, D’Alton M, Saade GR. Maternal mortality, near misses, and severe morbidity. Obstet Gynecol 2012;120:929-34. 17. Phibbs CS, Backer LC, Caughey AB, Danielsen B, Schmitt SK, Phibbs RH. Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants. N Engl J Med 2007;356:2165-75. 18. Lasswell SM, Barfield WD, Rochat RW, Blackmon L. Perinatal regionalization for very low-birth-weight and very preterm infants. JAMA 2010;304:992-1000. 19. Chung JH, Phibbs CS, Boscardin WJ, Kominski GF, Ortega AN, Needleman J. The effect of neonatal intensive care level and hospital volume on mortality of very low birth weight infants. Med Care 2010;48:635-44. 20. California Code of Regulations. Title 22. Social Security. Available at: https://govt.westlaw. com/calregs/Browse/Home/California/California CodeofRegulations?guid¼I6F56A7E1D4B611DE 8879F88E8B0DAAAE&originationContext¼docu menttoc&transitionType¼Default&contextData¼ %28sc.Default%29. Accessed March 23, 2015.
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21. American Academy of Pediatrics (AAP) Committee on Fetus and Newborn, American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice In: Riley LE, Stark AR, Kilpatrick SJ, Papile LA, eds. Guidelines for perinatal care, 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012. 22. Maryland Department of Health and Mental Hygiene. Maryland perinatal system standards, 2012. Available at: http://phpa.dhmh.maryland. gov/mch/SitePages/perinatal_standards.aspx. Accessed March 23, 2015. 23. Tennessee Department of Health, Women’s Health/Genetics Section. Tennessee Perinatal Care System, guidelines for regionalization, hospital care levels, staffing and facilities, 2014. 7th ed. Available at: http://health.tn.gov/Downloads/ Regionalization%20Guidelines%20Approved% 202014.pdf. Accessed March 23, 2015. 24. California Perinatal Summit maternal levels of care criteria. Available at: http://amf-consulting. com/mqi/wp-content/uploads/2014/12/MaternalLevels-of-Care.pdf. Accessed March 23, 2015. 25. Maternal Level of Care Survey Items, Childbirth Survey II. Available at: http://www. amf-consulting.com/mqi/wp-content/uploads/ 2015/01/Childbirth-Survey.-FINAL.pdf. Acces sed March 23, 2015. 26. State of California Office of Statewide Health Planning and Development, Healthcare Information Division. Hospital annual utilization data, 2014. Available at: http://www.oshpd.ca.gov/ hid/Products/Hospitals/Utilization/Hospital_Uti lization.html. Accessed March 23, 2015. 27. California Department of Health Care Services. Approved neonatal intensive care units and high-risk infant follow-up programs. Available at: http://www.dhcs.ca.gov/services/ccs/ Pages/NICUSCC.aspx. Accessed March 23, 2015. 28. California Department of Health Care Services. Neonatal intensive care unit (regional) listing. Available at: http://www.dhcs.ca.gov/services/ ccs/scc/Pages/NICURegional.aspx. Accessed March 23, 2015. 29. California Department of Health Care Services. Neonatal intensive care unit (community) listing. Available at: http://www.dhcs.ca.gov/ services/ccs/scc/Pages/NICUCommunity.aspx. Accessed March 23, 2015. 30. California Department of Health Care Services. Neonatal intensive care unit (intermediate) listing. Available at: http://www.dhcs.ca.gov/ services/ccs/scc/Pages/NICUIntermediate.aspx. Accessed March 23, 2015. 31. Shihady IR, Broussard P, Bolton LB, et al. Vaginal birth after cesarean: do California hospital policies follow national guidelines? J Reprod Med 2007;52:349-58. 32. Gould JB, Sarnoff R, Liu H, Bell DR, Chavez G. Very low birthweight births at nonNICU hospitals: the role of sociodemographic, perinatal, and geographic factors. J Perinatol 1999;19:197-205. 33. Pollack LD. An effective model for reorganization of perinatal services in a metropolitan
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area: a descriptive analysis and historical perspective. J Perinatol 1996;16:3-8. 34. Handler A, Rosenberg D, Driscoll M, et al. Regional perinatal care in crisis: a case study of an urban public hospital. J Public Health Policy 1991;12:184-98. 35. Dobrez D, Gerber S, Budetti P. Trends in perinatal regionalization and the role of managed care. Obstet Gynecol 2006;108: 839-45. 36. Yeast JD, Poskin M, Stockbauer JW, Shaffer S. Changing patterns in regionalization
ajog.org of perinatal care and the impact on neonatal mortality. Am J Obstet Gynecol 1998;178: 131-5. 37. Rybak EA. Hippocratic ideal, Faustian bargain and Damocles’ sword: erosion of patient autonomy in obstetrics. J Perinatol 2009;29: 721-5. 38. Lessaris KJ, Annibale DJ, Southgate WM, Hulsey TC, Ohning BL. Effects of changing health care financial policy on very low birthweight neonatal outcomes. South Med J 2002;95:426-30.
39. Nowakowski L, Barfield WD, Kroelinger CK, et al. Assessment of state measures of riskappropriate care for very low birth weight infants and recommendations for enhancing regionalized state systems. Matern Child Health J 2012;16:217-27. 40. Fisher ES, Bynum JP, Skinner JS. Slowing the growth of health care costs—lessons from regional variation. N Engl J Med 2009;360:849-52. 41. Staebler S. Regionalized systems of perinatal care: health policy considerations. Adv Neonatal Care 2011;11:37-42.
1.e8 American Journal of Obstetrics & Gynecology MONTH 2015 FLA 5.2.0 DTD YMOB10528_proof 28 July 2015 9:51 pm ce
839 840 841 842 843 844 845 846 847 848 849 850 851 852 853 854 855 856 857 858 859 860 861 862 863 864 865 866 867 868 869 870 871 872 873 874 875 876 877 878 879 880 881 882 883 884 885 886 887 888 889 890 891 892 893 894
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ajog.org 895 896 897 898 899 900 901 902 903 904 905 906 907 908 909 910 911 912 913 914 915 916 917 918 919 920 921 922 923 924 925 926 927 928 929 930 931 932 933 934 935 936 937 938 939 940 941 942 943 944 945 946 947 948 949 950
Research
A PPENDIX SUPPLEMENTARY TABLE
Survey items related to criteria for determining hospital-specific obstetrical levels of care as proposed at the California Perinatal Summit24 Short name of criterion
Survey item(s)
Basic criteria Basic 1: cesarean delivery within 30 min 100% of the time To meet criterion, must answer (a)
How often would you say your hospital is able to successfully perform an emergency cesarean delivery within 30 min when one is called for? a) 100% b) 75e99% c) 51e74% d) 50% or less e) Almost never f) Unknown
Basic 2: anesthesia available within 30 min To meet criterion, must answer part 1 (a) and part 2 (a), (b), (c), (d), or (e)
Is there 24-h in-house anesthesia coverage for all labor and delivery patients? a) Yes b) No c) Do not know If there is not 24-h in-house anesthesia coverage, describe duration of coverage and policies for arrival at the hospital. a) There is 24-h in-house coverage b) In-house during weekdays, then on call 30 min or less from home c) Always on call from home, must be there 30 min or less d) On call from home less than 30 min but must be in-house if epidural and/or trial of labor after cesarean delivery e) No MD on call, CRNA only with expectation of arrival 30 min or less f) On call from home, expectation longer than 30 min for arrival g) Unknown
Basic 3: nursery with 24-h resuscitation/ stabilization To meet criterion, must answer (a)
Do you have 24-h access to neonatal resuscitation/stabilization capability? a) Yes b) No c) Unknown
Basic 4: pediatric care available day and night To meet criterion, must answer part 1 (a) and part 2 (a)
Please specify what type of health care providers might be likely to attend a delivery during the day? Attending pediatrician a) Yes b) No c) Unknown If coverage for the baby is not the same at night, please specify. a) Coverage is the same at night b) No neonatologist is available at night c) No pediatrician is available at night d) Multiple staff not available at night e) Other: specify f) Unknown
Basic 5: Radiology ultrasound available within 12 h To meet criterion, must answer part 1 (a) or (b) and part 2 (a) or (b)
If a pregnant woman on labor and delivery needs any of the following radiology studies, please indicate the statement that best describes the turnaround time to getting at least a preliminary read for each of these both during the day and at night. Obstetrical ultrasound day a) 1e4 h b) 5e12 h c) Longer than 12 h d) Not applicable e) Unknown Obstetrical ultrasound night a) 1e4 h b) 5e12 h c) Longer than 12 h d) Not applicable e) Unknown
Korst. Maternal levels of risk-appropriate care. Am J Obstet Gynecol 2015.
(continued)
MONTH 2015 American Journal of Obstetrics & Gynecology FLA 5.2.0 DTD YMOB10528_proof 28 July 2015 9:51 pm ce
1.e9
951 952 953 954 955 956 957 958 959 960 961 962 963 964 965 966 967 968 969 970 971 972 973 974 975 976 977 978 979 980 981 982 983 984 985 986 987 988 989 990 991 992 993 994 995 996 997 998 999 1000 1001 1002 1003 1004 1005 1006
Research 1007 1008 1009 1010 1011 1012 1013 1014 1015 1016 1017 1018 1019 1020 1021 1022 1023 1024 1025 1026 1027 1028 1029 1030 1031 1032 1033 1034 1035 1036 1037 1038 1039 1040 1041 1042 1043 1044 1045 1046 1047 1048 1049 1050 1051 1052 1053 1054 1055 1056 1057 1058 1059 1060 1061 1062
Obstetrics
ajog.org
SUPPLEMENTARY TABLE
Survey items related to criteria for determining hospital-specific obstetrical levels of care as proposed at the California Perinatal Summit24 (continued) Short name of criterion
Survey item(s)
Basic unused: transport agreement To meet criterion, must answer part 1 (b)
Do you have a formal transport agreement or RCA with other hospitals for maternal transport? a) No b) Yes c) Unknown How many times a month do you transfer maternal patients to a higher level of care? Open-ended answer How many times a month do you accept a transfer of a maternal patient to provide a higher level of care? Open-ended answer How many times a month do you transfer patients to a lower level of care? Open-ended answer
Intermediate criteria listed previously plus following Intermediate 1: anesthesia available within 24 h in-house To meet criterion, must answer (a)
Is there 24-h in-house anesthesia coverage for all labor and delivery patients? a) Yes b) No c) Unknown
Intermediate 2: dedicated obstetrics anesthesia service To meet criterion, must answer part 1 (a) and part 2 (a)
Is the in-house anesthesia provider responsible for patients not in labor and delivery? a) No b) Yes c) We do not have 24-h in-house anesthesia d) Unknown If yes, what are the anesthesiologists’ responsibilities? a) They have no other responsibilities b) Mainly cover labor and delivery but sometimes go to main operating room c) Mainly cover main operating room but sometimes go to labor and delivery d) Cover the whole hospital e) Priority is labor and delivery but go where needed (eg, codes, main operating room, emergency room) f) Dedicated to labor and delivery weekdays, but nights and weekends cover other parts of the hospital g) Unknown
Intermediate 3: level 1 NICU To meet criterion, must answer part 1 (a) and part 2 (a), (b), (c), or (d)
Does your hospital have an NICU? a) Yes b) No c) Unknown If yes, what is the acuity level? a) 1 b) 2 c) 3 d) 4 e) We do not have an NICU f) Unknown If yes, is it CCS certified? a) Yes b) No c) We do not have an NICU d) Unknown
Intermediate 4: 24-h adult critical care To meet criterion, must answer (a)
Do you have 24-h adult critical care capability? a) Yes b) No c) Unknown
Korst. Maternal levels of risk-appropriate care. Am J Obstet Gynecol 2015.
1.e10 American Journal of Obstetrics & Gynecology MONTH 2015 FLA 5.2.0 DTD YMOB10528_proof 28 July 2015 9:51 pm ce
(continued)
1063 1064 1065 1066 1067 1068 1069 1070 1071 1072 1073 1074 1075 1076 1077 1078 1079 1080 1081 1082 1083 1084 1085 1086 1087 1088 1089 1090 1091 1092 1093 1094 1095 1096 1097 1098 1099 1100 1101 1102 1103 1104 1105 1106 1107 1108 1109 1110 1111 1112 1113 1114 1115 1116 1117 1118
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ajog.org 1119 1120 1121 1122 1123 1124 1125 1126 1127 1128 1129 1130 1131 1132 1133 1134 1135 1136 1137 1138 1139 1140 1141 1142 1143 1144 1145 1146 1147 1148 1149 1150 1151 1152 1153 1154 1155 1156 1157 1158 1159 1160 1161 1162 1163 1164 1165 1166 1167 1168 1169 1170 1171 1172 1173 1174
Research
SUPPLEMENTARY TABLE
Survey items related to criteria for determining hospital-specific obstetrical levels of care as proposed at the California Perinatal Summit24 (continued) Short name of criterion
Survey item(s)
Intermediate 5: 24-h maternal-fetal medicine To meet criterion, must answer part 1 (a) or (b) and part 2 (b)
Does your hospital have an MFM specialist (obstetrician-gynecologist subspecialist in high-risk obstetrics)? a) On staff b) Not on staff but available by phone c) Outpatient only d) Not available e) Occasionally sees patients in-house f) Uses telemedicine g) Unknown If MFM is available, is MFM consultation readily available 24 h a day? a) No b) Yes c) Occasionally d) MFM is not available e) Unknown
Regional criteria all listed previously plus the following Regional 1: 24-h obstetrician available in-house To meet criterion, must answer (a)
Describe your attending physician coverage on labor and delivery. a) In-house coverage 24 h/d, 7 d/wk b) MD coverage 24 h/d, 7 d/wk but not in-house c) Mixed model: some laborist, some coverage from home/office d) In-house coverage part of the time e) All patients covered by residents with in-house attending supervision f) Unknown
Regional 2: level 2 or 3 NICU To meet criterion, must answer part 1 (a) and part 2 (b), (c), or (d)
Same items as for intermediate 3: level 1 NICU
Regional 3: 24-h neonatologist available To meet criterion, must answer part 1 (a) and part 2 (a)
Please specify what type of health care providers might be likely to attend a delivery during the day? Attending neonatologist a) Yes b) No c) Unknown If coverage for the baby is not the same at night, please specify. a) Coverage is the same at night b) No neonatologist is available at night c) No pediatrician is available at night d) Multiple staff not available at night e) Other: specify f) Unknown
Regional 4: 24-h radiology services available To meet criterion, must answer (a)
Does your hospital have 24-h radiology reading? a) Yes b) No c) Unknown
Regional 5: 24-h adult critical care plus invasive cardiac monitoring To meet criterion, must answer part 1 (a) and part 2 (a)
Do you have 24-h adult critical care capability? a) Yes b) No c) Unknown Is invasive maternal monitoring available to the delivery area, including equipment for CVP and arterial pressure monitoring? a) Yes b) No c) Unknown
Korst. Maternal levels of risk-appropriate care. Am J Obstet Gynecol 2015.
(continued)
MONTH 2015 American Journal of Obstetrics & Gynecology FLA 5.2.0 DTD YMOB10528_proof 28 July 2015 9:51 pm ce
1.e11
1175 1176 1177 1178 1179 1180 1181 1182 1183 1184 1185 1186 1187 1188 1189 1190 1191 1192 1193 1194 1195 1196 1197 1198 1199 1200 1201 1202 1203 1204 1205 1206 1207 1208 1209 1210 1211 1212 1213 1214 1215 1216 1217 1218 1219 1220 1221 1222 1223 1224 1225 1226 1227 1228 1229 1230
Research 1231 1232 1233 1234 1235 1236 1237 1238 1239 1240 1241 1242 1243 1244 1245 1246 1247 1248 1249 1250 1251 1252 1253 1254 1255 1256 1257 1258 1259 1260 1261 1262 1263 1264 1265 1266 1267 1268 1269 1270 1271 1272 1273 1274 1275 1276 1277 1278 1279 1280 1281 1282 1283 1284 1285 1286
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ajog.org
SUPPLEMENTARY TABLE
Survey items related to criteria for determining hospital-specific obstetrical levels of care as proposed at the California Perinatal Summit24 (continued) Short name of criterion
Survey item(s)
Regional 6: 24-h MFM on staff To meet criterion, must answer part 1 (a) and part 2 (b)
Same items as for intermediate 5: 24-h MFM
Regional unused 1: perinatal follow-up
Unable to assess
Regional unused 2: transport agreement To meet criterion, must answer part 1 (b)
Same items as for basic unused: transport agreement
CCS, California Children’s Services; CRNA, certified registered nurse anesthetist; CVP, central venous pressure; MFM, maternal fetal medicine; NICU, neonatal intensive care unit; RCA, regional cooperative agreement. Korst. Maternal levels of risk-appropriate care. Am J Obstet Gynecol 2015.
1.e12 American Journal of Obstetrics & Gynecology MONTH 2015 FLA 5.2.0 DTD YMOB10528_proof 28 July 2015 9:51 pm ce
1287 1288 1289 1290 1291 1292 1293 1294 1295 1296 1297 1298 1299 1300 1301 1302 1303 1304 1305 1306 1307 1308 1309 1310 1311 1312 1313 1314 1315 1316 1317 1318 1319 1320 1321 1322 1323 1324 1325 1326 1327 1328 1329 1330 1331 1332 1333 1334 1335 1336 1337 1338 1339 1340 1341 1342