Levels of Maternal Care - ncmedsoc.org

ACOG/SMFM Consensus ajog.org

ACOG/SMFMOBSTETRIC CARE CONSENSUS

Levels of maternal care
This document was developed jointly by the American College of Obstetricians and Gynecologists and the Societyfor MaternaleFetal Medicine with the assistance of M. Kathryn Menard, MD, MPH; Sarah Kilpatrick, MD, PhD;George Saade, MD; Lisa M. Hollier, MD, MPH; Gerald F. Joseph Jr, MD; Wanda Barfield, MD; William Callaghan, MD;John Jennings, MD; and Jeanne Conry, MD, PhD
The information reflects emerging clinical and scientific advances as of the date issued, is subject to change, and should not be construed as dictating

an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and

limitations unique to the institution or type of practice.

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

Objectives� To introduce uniform designations

for levels of maternal care that arecomplementary but distinct fromlevels of neonatal care and thataddress maternal health needs,thereby reducing maternal morbidityand mortality in the United States

� To develop standardized definitionsand nomenclature for facilities thatprovide each level of maternal care

� To provide consistent guidelines ac-cording to level of maternal care foruse in quality improvement andhealth promotion

� To foster the development andequitable geographic distribution offull-service maternal care facilitiesand systems that promote proactiveintegration of risk-appropriate an-tepartum, intrapartum, and post-partum services

BackgroundIn the 1970s, studies demonstratedthat timely access to risk-appropriateneonatal and obstetric care couldreduce perinatal mortality. In 1976,the March of Dimes and its partners

The authors report no conflict of interest.

This article is being published in the February2015 issue of Obstetrics & Gynecology (ObstetGynecol 2015;125:502-15).

Copyright February 2015 by the AmericanCollege of Obstetricians andGynecologists, 40912th Street, SW, PO Box 96920, Washington,DC 20090-6920. All rights reserved.

http://dx.doi.org/10.1016/j.ajog.2014.12.030

first articulated the concept of an inte-grated system for regionalized per-inatal care in a report titled TowardImproving the Outcome of Pregnancy.1

This report included criteria that stra-tified maternal and neonatal care into3 levels of complexity, and recom-mended referral of high-risk patientsto higher-level centers with the appro-priate resources and personnel neededto address their increased complexityof care.After the publication of the March

of Dimes report,1 most states devel-oped coordinated regional systemsfor perinatal care. The designatedregional or tertiary care centers pro-vided the highest levels of obstetricand neonatal care, while servingsmaller facilities’ needs through edu-cation and transport services.Numerous studies have validated theconcept that improved neonatal out-comes were achieved through

MONTH 2014

application of risk-appropriatematernal transport systems.2,3 Acomprehensive metaanalysis hasshown increased odds of neonatalmortality for very low birthweight(very LBW, also commonly known asVLBW) infants (<1500 g) bornoutside of a level III hospital (38% vs23%; adjusted odds ratio, 1.62; 95%confidence interval, 1.44e1.83).4

Data indicate higher neonatal mor-tality for very low birthweight infantsborn in hospitals that are staffed byneonatologists in the absence of amore complete multidisciplinaryteam (level II), compared with thoseborn in level III centers.5

Since the March of Dimes report1

was published, the conceptual frame-work of regionalization of care of thewoman and the newborn has changed tofocus almost entirely on the newborn.6,7

The American College of Obstetriciansand Gynecologists (ACOG) and the

American Journal of Obstetrics & Gynecology 1

http://dx.doi.org/10.1016/j.ajog.2014.12.030

ACOG/SMFM Consensus ACOG/SMFM Obstetric Care Consensus ajog.org

American Academy of Pediatrics (AAP)outline the capabilities of health careproviders in hospitals delivering basic,specialty, subspecialty, and regional ob-stetric care in Guidelines for PerinatalCare, seventh edition.6 With 39% ofhospital births in the United Statesoccurring at hospitals that deliver lessthan 500 newborns each year and anadditional 20% occurring at hospitalsthat deliver between 501 newborns and1000 newborns each year,8 it likely is thatthe majority of maternal care in theUnited States is provided at basic-careand specialty-care hospitals. However, arecent commentary noted the need toreaddress “perinatal levels of care” tofocus specifically on maternal healthconditions that warrant designation ashigh risk, and to define specific clinicaland systems criteria to manage suchconditions.9 This document is a call foran integrated, regionalized framework toidentify when transfer of care may benecessary to provide risk-appropriatematernal care.

Although maternal mortality in highresource countries improved substan-tially during the 20th century, maternalmortality rates in the United Stateshave worsened in the past 14 years.10

Currently, the United States is ranked60th in the world for maternal mortal-ity.11 According to a Centers for DiseaseControl and Prevention study,12 theleading causes of maternal mortalityare associated with chronic conditionsthat affect women of reproductive age,and common obstetric complicationssuch as hemorrhage. Moreover, ma-ternal mortality in the United Statesrepresents a small component of thelarger emerging problem of maternalsevere morbidities and near-miss mor-tality that increased by 75% between1998e99 and 2008e09.13 National in-creases in obesity, hypertensive disor-ders, and diabetes among women ofreproductive age increase the risk ofmaternal morbidity and mortality, asdoes the increasing cesarean deliveryrate.14,15 Although specific modifica-tions in the clinical management of theseconditions have been instituted (eg, theuse of thromboembolism prophylaxisand bariatric beds in obstetrics), more

2 American Journal of Obstetrics & Gynecology M

can be done to improve the system ofcare for high-risk women at facility andpopulation levels.Although there is strong evidence

of more favorable neonatal outcomes withregionalized perinatal care, evidence of abeneficial effect on maternal outcome islimited. Maternal mortality is an uncom-mon event, and methods for tracking se-vere morbidity only have been proposedrecently.13 Data indicate that obstetriccomplications are significantly morefrequent in hospitals with low deliveryvolume,16 and that obstetric providerswith the lowest patient volume havesignificantly increased rates of obstetriccomplications compared with high-volume providers.17 Hospital clinical vol-ume likely is a proxy measure for institu-tional and individual experience that maynot be available at hospitals with lowervolumes.18 Also, data indicate that out-comes are better if certain conditions, suchas placenta previa or placenta accreta, aremanaged in a high-volume hospital.19,20 Italso has been noted that maternal mor-tality is inversely related to the populationdensity of maternalefetal medicine sub-specialists at the state level,21 althoughother factors, such as the presence ofobstetricianegynecologists, nurses, andanesthesiologists who have experience inhigh-risk maternity care, also maycontribute to this trend. Although thesefindings provide support for an associa-tion between availability of resources andfavorable maternal outcomes, they do notprove a direct cause and effect relationshipbetween levels of care and outcomes.A number of states have incorpo-

rated maternal care criteria into peri-natal guidelines. Indiana, Arizona, andMaryland emphasize the need for strat-ification of facilities based on levels ofmaternal care that are distinct fromneonatal needs, but use inconsistentdefinitions and nomenclature: the Indi-ana Perinatal Networks guideline ismodeled after the March of Dimesreport and uses levels I, II, and III;22 theArizona system defines levels I, II, IIE,and III of maternal care;23 and theMaryland Perinatal System uses levels I,II, III, and IV.24 Despite their differences,an essential component of each of theseguidelines is the concept of an

ONTH 2014

integrated system in which, just as withneonatal care, level III and level IVmaternal centers serve level I and levelII centers by providing educational re-sources, consultation services, andstreamlined systems for maternal andneonatal transport when necessary.

This document has 4 objectives:(1) introduce uniform designations forlevels of maternal care that are comple-mentary but distinct from levels ofneonatal care and that address maternalhealth needs, thereby preventing furtherincreases in maternal morbidity andmortality in theUnited States; (2) developstandardized definitions and nomencla-ture for facilities that provide each level ofmaternal care, including birth centers; (3)provide consistent guidelines of serviceaccording to level of maternal care for usein quality improvement and health pro-motion; and (4) foster the developmentand equitable geographic distribution offull-service maternal care facilities andsystems that promote proactive integra-tion of risk-appropriate antepartum,intrapartum, and postpartum services.This document focuses on maternal careand does not include an in-depth dis-cussion about high-risk neonatal carecapability based on gestational age orbirthweight. Nevertheless, optimal peri-natal care requires synergy in institutionalcapabilities for the woman and the fetusor neonate.

Definitions of levels of maternalcareIn this document, maternal care refersto all aspects of antepartum, intrapartum,and postpartum care of the pregnantwoman. In order to standardize a com-plete and integrated system of perinatalregionalization and risk-appropriatematernal care, a classification systemshould be established for levels ofmaternal care that pertain to birth centers(as defined in the Birth Centers section ofthis document), basic care (level I), spe-cialty care (level II), subspecialty care(level III), and regional perinatal healthcare centers (level IV) (Tables 1 and 2).This system is in concert with ACOG andAAP Guidelines for Perinatal Care, sev-enth edition.6 Although data on which tobase these distinctions in resources and

TABLE 1Levels of maternal care: definitions, capabilities, and types of health care providersa

BIRTH CENTER

Definition Peripartum care of low-risk women with uncomplicated singleton term pregnancies with a vertex presentation whoare expected to have an uncomplicated birth.

Capabilities � Capability and equipment to provide low-risk maternal care and a readiness at all times to initiate emergencyprocedures to meet unexpected needs of the woman and newborn within the center, and to facilitate transportto an acute care setting when necessary.

� An established agreement with a receiving hospital with policies and procedures for timely transport.� Data collection, storage, and retrieval.� Ability to initiate quality improvement programs that include efforts to maximize patient safety.� Medical consultation available at all times.

Types of health careproviders

Every birth attended by at least 2 professionals:

� Primary maternal care providers. This includes CNMs, CMs, CPMs, and licensed midwives who are legallyrecognized to practice within the jurisdiction of the birth center; family physicians; and ob-gyns.

� Availability of adequate numbers of qualified professionals with competence in level I care criteria and ability tostabilize and transfer high-risk women and newborns.

Examples of appropriatepatients (not requirements)

� Term, singleton, vertex presentation

LEVEL I (BASIC CARE)

Definition Care of uncomplicated pregnancies with the ability to detect, stabilize, and initiate management of unanticipatedmaternalefetal or neonatal problems that occur during the antepartum, intrapartum, or postpartum period untilpatient can be transferred to a facility at which specialty maternal care is available.

Capabilities Birth center capabilities plus:

� Ability to begin emergency cesarean delivery within a time interval that best incorporates maternal and fetal risksand benefits with the provision of emergency care.

� Available support services, including access to obstetric ultrasonography, laboratory testing, and blood banksupplies at all times.

� Protocols and capabilities for massive transfusion, emergency release of blood products, and management ofmultiple component therapy.

� Ability to establish formal transfer plans in partnership with a higher-level receiving facility.� Ability to initiate education and quality improvement programs to maximize patient safety, and/or collaborate with

higher-level facilities to do so.


Birthing center providers plus:

� Continuous availability of adequate number of RNs with competence in level I care criteria and ability to stabilizeand transfer high-risk women and newborns.

� Nursing leadership has expertise in perinatal nursing care.� Obstetric provider with privileges to perform emergency cesarean available to attend all deliveries.� Anesthesia services available to provide labor analgesia and surgical anesthesia.


Any patient appropriate for a birth center, plus capable of managing higher-risk conditions such as:

� Term twin gestation� Trial of labor after cesarean delivery� Uncomplicated cesarean delivery� Preeclampsia without severe features at term

LEVEL II (SPECIALTY CARE)

Definition Level I facility plus care of appropriate high-risk antepartum, intrapartum, or postpartum conditions, both directlyadmitted and transferred from another facility.

Capabilities Level I facility capabilities plus:

� Computed tomography scan and ideally magnetic resonance imaging with interpretation available.� Basic ultrasonographic imaging services for maternal and fetal assessment.� Special equipment needed to accommodate the care and services needed for obese women.

ACOG. Levels of maternal care. Am J Obstet Gynecol 2015. (continued)

ajog.org ACOG/SMFM Obstetric Care Consensus ACOG/SMFM Consensus

MONTH 2014 American Journal of Obstetrics & Gynecology 3

TABLE 1Levels of maternal care: definitions, capabilities, and types of health care providersa (continued)

LEVEL II (SPECIALTY CARE) (continued)


Level I facility health care providers plus:

� Continuous availability of adequate numbers of RNs with competence in level II care criteria and ability to stabilizeand transfer high-risk women and newborns who exceed level II care criteria.

� Nursing leadership and staff have formal training and experience in the provision of perinatal nursing care andshould coordinate with respective neonatal care services.

� Ob-gyn available at all times.� Director of obstetric service is a board-certified ob-gyn with special interest and experience in obstetric care.� MFM available for consultation onsite, by phone, or by telemedicine, as needed.� Anesthesia services available at all times to provide labor analgesia and surgical anesthesia.� Board-certified anesthesiologist with special training or experience in obstetric anesthesia available for consultation.� Medical and surgical consultants available to stabilize obstetric patients who have been admitted to the facility or

transferred from other facilities.


Any patient appropriate for level I care, plus higher-risk conditions such as:

� Severe preeclampsia� Placenta previa with no prior uterine surgery

LEVEL III (SUBSPECIALTY CARE)

Definition Level II facility plus care of more complex maternal medical conditions, obstetric complications, and fetal conditions

Capabilities Level II facility capabilities plus:

� Advanced imaging services available at all times.� Ability to assist level I and level II centers with quality improvement and safety programs.� Provide perinatal system leadership if acting as a regional center in areas where level IV facilities are not available

(refer to level IV).� Medical and surgical ICUs accept pregnant women and have critical care providers onsite to actively collaborate

with MFMs at all times.� Appropriate equipment and personnel available onsite to ventilate and monitor women in labor and delivery until

they can be safely transferred to the ICU.


Level II health care providers plus:

� Continuous availability of adequate numbers of nursing leaders and RNs with competence in level III care criteria andability to transfer and stabilize high-risk women and newborns who exceed level III care criteria, and with specialtraining and experience in the management of women with complex maternal illnesses and obstetric complications.

� Ob-gyn available onsite at all times.� MFM with inpatient privileges available at all times, either onsite, by phone, or by telemedicine.� Director of MFM service is a board-certified MFM.� Director of obstetric service is a board-certified ob-gyn with special interest and experience in obstetric care.� Anesthesia services available at all times onsite.� Board-certified anesthesiologist with special training or experience in obstetric anesthesia in charge of obstetric

anesthesia services.� Full complement of subspecialists available for inpatient consultations.


Any patient appropriate for level II care, plus higher-risk conditions such as:

� Suspected placenta accreta or placenta previa with prior uterine surgery� Suspected placenta percreta� Adult respiratory syndrome� Expectant management of early severe preeclampsia at less than 34 weeks of gestation

LEVEL IV (REGIONAL PERINATAL HEALTH CARE CENTERS)

Definition Level III facility plus onsite medical and surgical care of the most complex maternal conditions and critically illpregnant women and fetuses throughout antepartum, intrapartum, and postpartum care

Capabilities Level III facility capabilities plus:

� Onsite ICU care for obstetric patients.� Onsite medical and surgical care of complex maternal conditions with the availability of critical care unit or ICU beds.� Perinatal system leadership, including facilitation of maternal referral and transport, outreach education for fa-

cilities and health care providers in the region, and analysis and evaluation of regional data, including perinatalcomplications and outcomes and quality improvement.



4 American Journal of Obstetrics & Gynecology MONTH 2014

TABLE 1Levels of maternal care: definitions, capabilities, and types of health care providersa (continued)

LEVEL IV (REGIONAL PERINATAL HEALTH CARE CENTERS) (continued)


Level III health care providers plus:

� MFM care team with expertise to assume responsibility for pregnant women and women in the postpartum periodwho are in critical condition or have complex medical conditions. This includes comanagement of ICU-admittedobstetric patients. MFM team member with full privileges is available at all times for onsite consultation andmanagement. The team is led by a board-certified MFM with expertise in critical care obstetrics.

� Physician and nursing leaders with expertise in maternal critical care.� Continuous availability of adequate numbers of RNs who have experience in the care of women with complex

medical illnesses and obstetric complications; this includes competence in level IV care criteria.� Director of obstetric service is a board-certified MFM, or board-certified ob-gyn with expertise in critical care obstetrics.� Anesthesia services are available at all times onsite.� Board-certified anesthesiologist with special training or experience in obstetric anesthesia in charge of obstetric

anesthesia services.� Adult medical and surgical specialty and subspecialty consultants available onsite at all times to collaborate with

an MFM care team.


Any patient appropriate for level III care, plus higher-risk conditions such as:

� Severe maternal cardiac conditions� Severe pulmonary hypertension or liver failure� Pregnant women requiring neurosurgery or cardiac surgery� Pregnant women in unstable condition and in need of an organ transplant

CMs, certified midwives; CNMs, certified nurseemidwives; CPMs, certified professional midwives; ICU, intensive care unit; MFM, maternalefetal medicine subspecialists; ob-gyns, obstetricianegynecologists; RNs, registered nurses.a These guidelines are limited to maternal needs. Consideration of perinatal needs and the appropriate level of care should occur following existing guidelines. In fact, levels of maternal care andlevels of neonatal care may not match within facilities. Additionally, these are guidelines, and local issues will affect systems of implementation for regionalized maternal care, perinatal care, orboth.

Data adapted from American Academy of Pediatrics Committee on Fetus and Newborn.7

ACOG. Levels of maternal care. Am J Obstet Gynecol 2015.


capacity for maternal care are limited, thedefinitions were created from the char-acteristics of successful regionalizedperinatal systems in a number of states(Background section). In this context,regionalized perinatal systems represent acombination of maternal and neo-natal services. Establishing clear, uniformcriteria for designation ofmaternal centers that are integratedwith emergency response systems willhelp ensure that the appropriatepersonnel, physical space, equipment,and technology are available to achieveoptimal outcomes, as well as to facilitatesubsequent data collection regardingrisk-appropriate care. Trauma is not in-tegrated into the levels of maternal carebecause trauma levels are already es-tablished. Pregnant women shouldreceive the same level of trauma care asnonpregnant patients. This documentaddresses the care provided at birth cen-ters and hospitals, but home birth is notincluded.

Once levels of maternal care areestablished, analysis of data collectedfrom all facilities and regional systemswill inform future updates to the levelsof maternal care. Consistent with thelevels of neonatal care published by theAAP,7 each level reflects required mini-mal capabilities, physical facilities, andmedical and support personnel. Notethat each higher level of care includesand builds on the capabilities of thelower levels. As with the AAP-definedlevels of neonatal care, the system willbe modified as analysis is completed.The goal of regionalized maternal care

is for pregnant women at high riskto receive care in facilities that are pre-pared to provide the required level ofspecialized care. Each facility shouldhave a clear understanding of its capa-bility to handle increasingly complexlevels of maternal care, and should havea well-defined threshold for transferringwomen to health care facilities thatoffer a higher level of care. These

MONTH 2014

proposed categories of maternal care aremeant to facilitate this process. Theseguidelines also are intended to foster thedevelopment of equitably distributedresources throughout the country.These are guidelines, not mandates, andgeographic and local issues will affectsystems of implementation for region-alized perinatal care. In fact, levels ofmaternal and neonatal care may notmatch within facilities. However, apregnant woman should be cared for atthe facility that best meets her needsas well as her neonate’s needs. Becauseall facilities cannot maintain the breadthof resources available at subspecialtycenters, interfacility transport of preg-nant women or women in the post-partum period is an essential componentof a regionalized perinatal health caresystem. To ensure optimal care of allpregnant women, all birth centers, hos-pitals, and higher-level facilities shouldcollaborate to develop and maintainmaternal and neonatal transport plans


TABLE 2Levels of maternal care by services

Required service

Level of maternal care

Birth centers Level I Level II Level III Level IV

Nursing Adequate numbers ofqualified professionalswith competence inlevel I care criteria

Continuously available RNswith competence in level Icare criteriaNursing leadership hasexpertise in perinatalnursing care

Continuously available RNswith competence in level IIcare criteriaNursing leadership has formaltraining and experience inperinatal nursing care andcoordinates with respectiveneonatal care services

Continuously available nursingleaders and RNs with competencein level III care criteria and havespecial training and experiencein the management of womenwith complex maternal illnessesand obstetric complications

Continuously available RNs withcompetence in level IV care criteriaNursing leadership has expertise inmaternal intensive and critical care

Minimum primarydelivery providerto be available

CNMs, CMs, CPMs, andlicensed midwives

Obstetric provider withprivileges to performemergency cesareandelivery

Ob-gyns or MFMs Ob-gyns or MFMs Ob-gyns or MFMs

Obstetrics surgeon Available for emergencycesarean delivery

Ob-gyn available at all times Ob-gyn onsite at all times Ob-gyn onsite at all times

MFMs Available for consultation onsite,by phone, or by telemedicine,as needed

Available at all times onsite,by phone, or by telemedicinewith inpatient privileges

Available at all times for onsiteconsultation and management

Director of obstetricservices

Board-certified ob-gyn withexperience and interestin obstetrics

Board-certified ob-gyn withexperience and interestin obstetrics

Board-certified MFM orboard-certified ob-gyn withexpertise in critical care obstetrics

Anesthesia Anesthesia servicesavailable

Anesthesia services availableat all timesBoard-certified anesthesiologistwith special training or experiencein obstetrics, available forconsultation

Anesthesia services availableat all timesBoard-certified anesthesiologistwith special training or experiencein obstetrics is in charge ofobstetric anesthesia services

Anesthesia services available at all timesBoard-certified anesthesiologist withspecial training or experience inobstetrics is in charge of obstetricanesthesia services

Consultants Established agreementwith a receiving hospitalfor timely transport,including determinationof conditions necessitatingconsultation and referral

Established agreementwith a higher-levelreceiving hospitalfor timely transport,including determinationof conditions necessitatingconsultation and referral

Medical and surgical consultantsavailable to stabilize

Full complement of subspecialistsavailable for inpatient consultation,including critical care, generalsurgery, infectious disease,hematology, cardiology, nephrology,neurology, and neonatology

Adult medical and surgical specialtyand subspecialty consultants availableonsite at all times, including thoseindicated in level III and advancedneurosurgery, transplant, orcardiac surgery


ACOG/SM

FM

Consen

sus

ACOG/SMFM

Obstetric

Care

Consensus

ajog.o

rg

6American

JournalofObstetrics

&Gynecology

MONTH

2014

TABLE

2Levelsof

maternalcareby

services

(continued)

Requiredservice

Levelofmaternalcare

Birth

centers

LevelI

LevelII

LevelIII

LevelIV

ICU

Appropriateequipm

entandpersonnel

availableonsitetoventilateand

monitorwom

eninlaboranddelivery

untilsafelytransferredtoICU

Acceptspregnantwom

en

Collaboratesactivelywith

theMFM

care

team

inthemanagem

entofallpregnant

wom

enandwom

eninthepostpartum

period

who

areincriticalconditionor

have

complex

medicalconditions

Com

anages

ICU-adm

itted

obstetric

patientswith

MFM

team

CMs,certified

midwives;CNMs,certified

nursee

midwives;CPM

s,certified

professionalmidwives;ICU,intensivecareunit;MFM

s,maternalefetalm

edicinespecialists;ob-gyns,obstetriciane

gynecologists;RNs,registered

nurses.

ACOG.L

evelsofmaternalcare.A

mJObstetGynecol2015.


and cooperative agreements capableof managing the health care needsof womenwho develop complications;receiving hospitals should openlyaccept transfers. The appropriate carelevel for patients should be driven bytheir medical need for that care andnot limited by financial constraint.Because of the importance of accuratedata for the assessment of outcomes,all facilities should have requirementsfor data collection, storage, andretrieval.

An important goal of regionalizedmaternal care is for higher-level facil-ities to provide training for qualityimprovement initiatives, educationalsupport, and severe morbidity andmortality case review for lower-levelhospitals. In those regions that donot have a facility that qualifies as alevel IV center, any level III facilities inthe region should provide the educa-tional and consultation function (Ta-ble 3 and Appendix).

Birth centersIn 1995, the American Association ofBirth Centers (www.birthcenters.org)defined birth centers as “a homelikefacility existing within a healthcaresystem with a program of caredesigned in the wellness model ofpregnancy and birth. Birth centersprovide family-centered care forhealthy women before, during andafter normal pregnancy, labor andbirth.” This common definition isused in this document and includesbirth centers regardless of their loca-tion. Birth centers provide peripartumcare to low-risk women with uncom-plicated singleton term pregnancieswith a vertex presentation who areexpected to have an uncomplicatedbirth. Cesarean delivery or operativevaginal delivery are not offered at birthcenters.

In a freestanding birth center, everybirth should be attended by at least 2professionals. The primary maternitycare provider that attends each birthis educated and licensed to providebirthing services. Primary maternitycare providers include certifiednurseemidwives (CNMs), certified

MONTH 2014

midwives, certified professional mid-wives, and licensed midwives who are le-gally recognized to practice within thejurisdiction of the birth center;family physicians; and obstetricianegynecologists. In addition, there shouldbe adequate numbers of qualified pro-fessionals available who have completedorientation and demonstrated compe-tence in the care of obstetric patients(women and fetuses) consistent withlevel I care criteria and are able to stabilizeand transfer high-risk women and new-borns. Medical consultation should beavailable at all times. These facilitiesshould be ready to initiate emergencyprocedures (including cardiopulmonaryand newborn resuscitation and stabiliza-tion) at all times,7 to meet unexpectedneeds of the woman and newbornwithin the center, and to facilitate trans-port to an acute care setting when neces-sary.Toensureoptimal careof allwomen,a birth center should have a clear under-standing of its capability to providematernal and neonatal care and thethreshold at which it should transferwomen to a facility with a higher level ofcare. A birth center should have anestablished agreement with a receivinghospital and have policies and pro-cedures in place for timely transport.These transfer plans should include riskidentification; determination of condi-tions necessitating consultation; referraland transfer; anda reliable, accurate, andcomprehensive communication systembetween participating facilities andtransport teams. All facilities shouldhave quality improvement programsthat include efforts to maximize patientsafety.

Birth center facility licenses currently areavailable in more than 80% of states in theUnited States and state requirements foraccreditation for birth centers vary. Threenational agencies (Accreditation Associa-tion for Ambulatory Health Care [www.aaahc.org], The JointCommission [www.jointcommission.org], and The Com-mission for the Accreditation of BirthCenters [www.birthcenteraccreditation.org/]) provide accreditation of birth cen-ters. The Commission for the Accredita-tion of BirthCenters is the only accreditingagency that chooses to use the national


http://www.birthcenters.org

http://www.aaahc.org

http://www.aaahc.org

http://www.jointcommission.org

http://www.jointcommission.org

http://www.birthcenteraccreditation.org/

http://www.birthcenteraccreditation.org/


American Association of Birth CentersStandards for Birth Centers in its accred-itation process.

Level I facilities (basic care)Level I facilities (basic care) providecare to women who are low risk andare expected to have an uncomplicatedbirth (Table 1). Level I facilities havethe capability to perform routine intra-partum and postpartum care that isanticipated to be uncomplicated.6 Asin birth centers, maternity care pro-viders, midwives, family physicians, orobstetricianegynecologists should beavailable to attend all births. Adequatenumbers of registered nurses (RNs) areavailable who have completed orienta-tion, demonstrated competence in thecare of obstetric patients (women andfetuses) consistent with level I carecriteria, and are able to stabilize andtransfer high-risk women and new-borns. Nursing leadership should haveexpertise in perinatal nursing care.An obstetric provider with privileges toperform an emergency cesarean deliveryshould be available to attend deliveries.Anesthesia services should be availableto provide labor analgesia and surgicalanesthesia. Level I facilities have thecapability to begin an emergency cesar-ean delivery within a time interval thatbest incorporates maternal and fetalrisks and benefits with the provisionof emergency care.6,25 Support servicesinclude access to obstetric ultrasonog-raphy, laboratory testing, and bloodbank supplies at all times. All hospitalswith obstetric services should have pro-tocols and capabilities in place formassive transfusion, emergency releaseof blood products (before full compati-bility testing is complete), and formanagement of multiple componenttherapy. These facilities and healthcare providers can appropriatelydetect, stabilize, and initiate manage-ment of unanticipated maternal, fetal,or neonatal problems that occur duringthe antepartum, intrapartum, or post-partum period until the patient canbe transferred to a facility at which spe-cialty maternal care is available. Toensure optimal care of all pregnantwomen, formal transfer plans should

8 American Journal of Obstetrics & Gynecology M

be established in partnership with ahigher-level receiving facility. Theseplans should include risk identification;determination of conditions necessi-tating consultation; referral and transfer;and a reliable, accurate, and compre-hensive communication system betweenparticipating hospitals and transportteams.6 All facilities should have educa-tion and quality improvement programsto maximize patient safety, provide suchprograms through collaboration withfacilities with higher levels of care thatreceive transfers, or both. Examples ofwomen who need at least level I careinclude women with term twin gesta-tion; women attempting trial of laborafter cesarean delivery; women expectingan uncomplicated cesarean delivery; andwomen with preeclampsia without se-vere features at term.

Level II facilities (specialty care)Level II facilities (specialty care) providecare to appropriate high-risk pregnantwomen, both admitted and transferredto the facility. In addition to the capa-bilities of a level I (basic care) facility,level II facilities should have the infra-structure for continuous availability ofadequate numbers of RNs who havedemonstrated competence in the care ofobstetric patients (women and fetuses).Orientation and demonstrated compe-tence should be consistent with level IIcare criteria and include stabilizationand transfer of high-risk women andnewborns who exceed level II carecriteria. The nursing leaders and staff ata level II facility should have formaltraining and experience in the provisionof perinatal nursing care and shouldcoordinate with respective neonatalcare services. Although midwives andfamily physicians may practice in level IIfacilities, an attending obstetricianegynecologist should be available at alltimes. A board-certified obstetricianegynecologist with special interest andexperience in obstetric care should bethe director of obstetric services. Accessto a maternalefetal medicine subspe-cialist for consultation should be avail-able onsite, by phone, or by telemedicineas needed. Anesthesia services shouldbe available at all times to provide

ONTH 2014

labor analgesia and surgical anesthesia.A board-certified anesthesiologist withspecial training or experience in obstet-ric anesthesia should be available forconsultation. Support services includelevel I capabilities plus computed to-mography scan and, ideally, magneticresonance imaging with interpretationavailable; basic ultrasonographic imag-ing services for maternal and fetalassessment; and special equipmentneeded to accommodate the care andservices needed for obese women.6

Medical and surgical consultantsshould be available to stabilize obstetricpatients who have been admitted to thefacility or transferred from other facil-ities. Examples of women who need atleast level II care include women withsevere preeclampsia and women withplacenta previa with no prior uterinesurgery.

Level III facilities (subspecialty care)Level III facilities (subspecialty care)provide all level I (basic care) and level II(specialty care) services, and have sub-specialists available onsite, by phone, orby telemedicine to assist in providingcare for more complex maternal andfetal conditions. Level III facilities willfunction as the regional perinatal healthcare centers for some areas of the UnitedStates if there are no level IV facilitiesavailable. In these areas, the level III fa-cilities will be responsible for the lead-ership, facilitation of transport andreferral, educational outreach, and datacollection and analysis outlined in theRegionalization section discussed later inthis document.

Designation of level III should bebased on the demonstrated experienceand capability of the facility to providecomprehensive management of severematernal and fetal complications. Anobstetricianegynecologist is availableonsite at all times and a maternalefetalmedicine subspecialist is available atall times, either onsite, by phone, orby telemedicine, and should have inpa-tient privileges. The director of thematernalefetal medicine service shouldbe a board-certified maternalefetalmedicine subspecialist. A board-certifiedobstetricianegynecologist with special

TABLE 3Summary and recommendations for levels of maternal care

Summary and recommendationsGrade ofrecommendations

In order to standardize a complete and integrated system of perinatal regionalization and risk-appropriate maternalcare, a classification system should be established for levels of maternal care that pertain to birth centers (as definedin the Birth Centers section of this document), basic care (level I), specialty care (level II), subspecialty care (level III),and regional perinatal health care centers (level IV).

1CStrong recommendation,low quality evidence

Introduce uniform designations for levels of maternal care that are complementary but distinct from levels ofneonatal care.


Establishing clear, uniform criteria for designation of maternal centers that are integrated with emergency responsesystems will help ensure that the appropriate personnel, physical space, equipment, and technology are available toachieve optimal outcomes, as well as to facilitate subsequent data collection regarding risk-appropriate care.


Each facility should have a clear understanding of its capability to handle increasingly complex levels of maternalcare, and should have a well-defined threshold for transferring women to health care facilities that offer a higherlevel of care. To ensure optimal care of all pregnant women, all birth centers, hospitals, and higher-level facilitiesshould collaborate to develop and maintain maternal and neonatal transport plans and cooperative agreementscapable of managing the health care needs of women who develop complications; receiving hospitals shouldopenly accept transfers.


Higher-level facilities should provide training for quality improvement initiatives, educational support, and severemorbidity and mortality case review for lower-level hospitals. In those regions that do not have a facility that qualifiesas a level IV center, any level III facilities in the region should provide the educational and consultation function.


Facilities and regional systems should develop methods to track severe maternal morbidity andmortality to assess theefficacy of utilizing maternal levels of care.


Analysis of data collected from all facilities and regional systems will inform future updates to the levels ofmaternal care.


Follow-up interdisciplinary work groups are needed to further explore the implementation needs to adopt theproposed classification system for levels of maternal care in all facilities that provide maternal care.




interest and experience in obstetric careshould direct obstetric services. Anes-thesia services should be available atall times onsite. A board-certified anes-thesiologist with special training orexperience in obstetric anesthesiashould be in charge of obstetric anes-thesia services. A full complement ofsubspecialists, including subspecialistsin critical care, general surgery, infec-tious disease, hematology, cardiology,nephrology, neurology, and neonatologyshould be available for inpatient consul-tations. An onsite intensive care unit(ICU) should accept pregnant womenand have critical care providers onsite toactively collaborate with maternalefetalspecialists at all times. Equipment andpersonnelwith expertisemust be availableonsite to ventilate and monitor women in

the labor and delivery unit until they canbe safely transferred to the ICU.Level III facilities have nursing

leaders and adequate numbers of RNswho have completed orientation anddemonstrated competence in the care ofobstetric patients (women and fetuses)consistent with level III care criteria,including transfer of high-risk womenand newborns who exceed level III carecriteria, and who have special trainingand experience in the management ofwomen with complex maternal illnessesand obstetric complications. Thesenursing personnel continuously areavailable. Level III facilities should beable to provide imaging servicesincluding basic interventional radiology,maternal echocardiography, computedtomography, magnetic resonance

MONTH 2014

imaging, and nuclear medicine imagingwith interpretation should be available atall times. Level III facilities should havethe ability to perform detailed obstetricultrasonography and fetal assessment,including Doppler studies. These facil-ities also should provide evaluation ofnew technologies and therapies. Exam-ples of women who need at least level IIIcare include those women with extremerisk of massive hemorrhage at delivery,such as those with suspected placentaaccreta or placenta previa with prioruterine surgery; women with suspectedplacenta percreta; women with adultrespiratory distress syndrome; andwomen with rapidly evolving disease,such as planned expectant managementof severe preeclampsia at less than 34weeks of gestation.



Level IV facilities (regional perinatalhealth care centers)Level IV facilities (regional perinatalhealth care centers) include the capabil-ities of level I, level II, and level III fa-cilities with additional capabilitiesand considerable experience in the careof the most complex and critically illpregnant women throughout ante-partum, intrapartum, and postpartumcare. Although level III and level IV mayseem to overlap, a level IV facility isdistinct from a level III facility in theapproach to the care of pregnant womenand women in the postpartum periodwith complex and critical illnesses. Inaddition to having ICU care onsite forobstetric patients, a level IV facilitymust have evidence of a maternalefetalmedicine care team that has the expertiseto assume responsibility for pregnantwomen and women in the postpartumperiod who are in critical condition orhave complex medical conditions. Thematernalefetal medicine team collabo-rates actively in the comanagement of allobstetric patients who require criticalcare and ICU services. This includescomanagement of ICU-admitted ob-stetric patients. A maternalefetal medi-cine team member with full privileges isavailable at all times for onsite consul-tation and management. The teamshould be led by a board-certifiedmaternalefetal medicine subspecialistwith expertise in critical care obstetrics.The maternalefetal medicine teammusthave expertise in critical care at thephysician level, nursing level, and ancil-lary services level. A key principle ofcaring for critically ill pregnant andperipartum women is the facility’srecognition of the need for seamlesscommunication betweenmaternalefetalmedicine subspecialists and other sub-specialists in the planning and facilita-tion of care for women with the mosthigh-risk complications of pregnancy.There should be institutional support forthe routine involvement of a maternalefetal medicine care team with the criticalcare units and specialists. There alsoshould be a commitment to havingphysician and nursing leaders withexpertise in maternal intensiveand critical care, as well as adequate

10 American Journal of Obstetrics & Gynecology

numbers of available RNs in level IVfacilities who have experience in thecare of women with complex medicalillnesses and obstetric complications;this includes completed orientation,demonstrated competence in the care ofobstetric patients (women and fetuses)consistent with level IV care criteria.The director of obstetric services isa board-certified maternalefetal medi-cine subspecialist or a board-certifiedobstetricianegynecologist with exper-tise in critical care obstetrics. As in levelIII facilities, anesthesia services areavailable onsite at all times. A board-certified anesthesiologist with specialtraining or experience in obstetric anes-thesia should be in charge of obstetricanesthesia services. Level IV facilitiesshould include the capability for onsitemedical and surgical care of complexmaternal conditions (eg, congenitalmaternal cardiac lesions, vascular in-juries, neurosurgical emergencies, andtransplants) with the availability of crit-ical (or intensive) care unit beds. Thereshould be adult medical and surgicalspecialty and subspecialty consultants (aminimum of those listed in level III)available onsite at all times to collaboratewith the maternalefetal medicine careteam. The designation of level IV alsomay pertain only to a particular specialtyin that advanced neurosurgery, trans-plant, and cardiovascular capabilitiesmay not all be available in the sameregional facility. Examples of womenwho would need level IV care (at least atthe time of delivery) include pregnantwomen with severe maternal cardiacconditions, severe pulmonary hyper-tension, or liver failure; pregnantwomen in need of neurosurgery or car-diac surgery; or pregnant women inunstable condition and in need of anorgan transplant.

RegionalizationRegional centers, which include any levelIII facility that functions in this capacityand all level IV facilities, should co-ordinate regional perinatal healthcare services; provide outreach educa-tion to facilities and health care pro-viders in their region; and provideanalysis and evaluation of regional data,

MONTH 2014

including perinatal complications andoutcomes, as part of collaboration withlower-level care facilities in the region.Community outreach and data analysisand evaluation will require additionalresources in personnel and equipmentwithin these facilities.

Although specific supporting dataare not currently available in maternalhealth, it is believed that concentratingthe care of women with the mostcomplex pregnancies at designatedregional perinatal health care centerswill allow these centers to maintain theexpertise needed to achieve optimaloutcomes. Regionalization of maternalhealth care services requires that therebe available and coordinated special-ized services, professional continuingeducation to maintain competency,facilitation of opportunities for trans-port and back-transport, and collectionof data on long-term outcomes toevaluate the effectiveness of delivery ofperinatal health care services and thesafety and efficacy of new therapies.Because the health statuses of womenand fetuses may differ, referral shouldbe organized to meet the needs ofboth. In some cases with specific careneeds, optimal coordination of carewill not be delineated by geographicarea, but rather by availability of spe-cific expertise (eg, transplant servicesor fetal surgery).

Measurement and evaluation ofregionalized maternal careImplicit in the effort to establish levelsof maternal care is the goal to providethe best possible maternal outcomes, aswell as ongoing quality improvement.If levels of maternal care improve care,then ensuring that appropriate transferof women occurs should be associatedwith a decrease in preventable maternalsevere morbidities and mortality. Therealso should be a shift toward less severemorbidity in lower-level care facilities.Therefore, facilities and regional systemsshould develop methods to track severematernal morbidity and mortality toassess the efficacy of utilizing maternallevels of care.

Operational definitions are neededto compare data and outcomes


between levels of maternal care. How-ever, waiting for the precise measurebefore establishing tiered levels of careinvites unnecessary delay. Therefore,two constructs to implement with theutilization of levels of maternal care areproposed: (1) identify women at extremerisk of morbidity and (2) identify severemorbidity outcomes that may improvewith appropriate use of maternal levelsof care. Some women at extreme riskof severe morbidities, such as stroke,cardiopulmonary failure, or massivehemorrhage, can be identified during theantepartum period and should givebirth in the appropriate level hospital.Examples of such women include thosewith suspected placenta accreta orplacenta percreta; prior cesarean birthand current anterior previa; severe heartdisease such as complex cardiac malfor-mations and pulmonary hypertension,coronary artery disease, or cardiomyop-athy; severe preeclampsia with uncon-trollable hypertension; and pretermHELLP syndrome (hemolysis, elevatedliver enzymes, low platelet count).

Outcome morbidities that may im-prove with appropriate use of levels ofmaternal care include stroke, returns tothe operating room, massive trans-fusions, severe maternal morbidity, andpotential ICU admissions. The incidenceof these outcomes could decrease or beshifted from lower-level to higher-levelhospitals. For example, known placentaaccreta has the potential for massiveblood loss and need for advanced sur-gical services, which are best available atfacilities with a high designated levelof care. Expectant management ofsevere early preeclampsia, septic shock,and pulmonary hypertension are otherexamples of conditions that requireconsiderable resources likely best avail-able at facilities with a high designatedlevel of care. Although the developmentof comprehensive lists of what condi-tions comprise extreme morbidityrisks and what outcomes ought tobe measured currently is an evolvingprocess, prospective measurement withcontinuous monitoring and evaluationof any regionalized maternal care systemis critical to improvement in care pro-cesses and outcomes.

Determination and implementation oflevels of maternal careMany barriers to the implementationof levels of maternal care may need tobe overcome. The development of theclassification system is the first step;the next step, is the implementation ofthis concept in all facilities that providematernal care. The questions of whetherto have state-level or national-levelaccrediting bodies establish and setthese proposed levels of maternal care, aswell as how to provide the financingneeded to run them, are unanswered.Follow-up interdisciplinary work groupsare needed to further explore the im-plementation needs to adopt the pro-posed classification system for levelsof maternal care in all facilities thatprovide maternal care.The determination of the appropriate

level of care to be provided by a givenfacility should be guided by local andstate health care regulations, nationalaccreditation and professional organiza-tion guidelines, and identified regionalperinatal health care service needs.6 Stateand regional authorities should worktogether with the multiple institutionswithin a region to determine the appro-priate coordinated system of care. -

ACKNOWLEDGMENTS

This document has been endorsed by thefollowing organizations:American Association of Birth CentersAmerican College of Nurse-MidwivesAssociation of Women’s Health, Obstetric andNeonatal NursesCommission for the Accreditation of BirthCentersTheAmericanAcademyof Pediatrics leadership,the American Society of Anesthesiologistsleadership, and the Society for Obstetric Anes-thesia and Perinatology leadership havereviewed the opinion and are supportive of theLevels of Maternal Care.

REFERENCES

1. March of Dimes. Toward improving theoutcome of pregnancy III: enhancing perinatalhealth through quality, safety and performanceinitiatives. White Plains, NY: March of Dimes;2010.2. Paneth N, Kiely JL, Wallenstein S, Marcus M,Pakter J, Susser M. Newborn intensive care andneonatal mortality in low-birth-weight infants: a

MONTH 2014 A

population study. N Engl J Med 1982;307:149-55.3. Gortmaker S, Sobol A, Clark C, Walker DK,Geronimus A. The survival of very low-birthweight infants by level of hospital of birth: apopulation study of perinatal systems in fourstates. Am J Obstet Gynecol 1985;152:517-24.4. Lasswell SM, Barfield WD, Rochat RW,Blackmon L. Perinatal regionalization for verylow-birth-weight and very preterm infants: ameta-analysis. JAMA 2010;304:992-1000.5. Menard MK, Liu Q, Holgren EA,Sappenfield WM. Neo-natal mortality for verylow birth weight deliveries in South Carolina bylevel of hospital perinatal service. Am J ObstetGynecol 1998;179:374-81.6. Guidelines for perinatal care, 7th ed. ElkGrove Village, IL: AAP; Washington, DC: Amer-ican College of Obstetricians andGynecologists; 2012.7. Levels of neonatal care. American Academyof Pediatrics Committee on Fetus and Newborn.Pediatrics 2012;130:587-97.8. American Hospital Association. AHA guide tothe health care field, 2015 ed. Chicago, IL: AHA;2014.9. Hankins GD, Clark SL, Pacheco LD,O’Keeffe D, D’Alton M, Saade GR. Maternalmortality, near misses, and severe morbidity:lowering rates through designated levels ofmaternity care. Obstet Gynecol 2012;120:929-34.10. Main EK. Maternal mortality: new strategiesfor measurement and prevention. Curr OpinObstet Gynecol 2010;22:511-6.11. Kassebaum NJ, Bertozzi-Villa A,Coggeshall MS, Shackelford KA, Steiner C,Heuton KR, et al. Global, regional, and nationallevels and causes of maternal mortality during1990e2013: a systematic analysis for theGlobalBurden of Disease Study 2013 [publishederratum appears in Lancet 2014;384:956].Lancet 2014;384:980-1004.12. Berg CJ, Callaghan WM, Syverson C,Henderson Z. Pregnancy-related mortality in theUnited States, 1998 to 2005. Obstet Gynecol2010;116:1302-9.13. Callaghan WM, Creanga AA, Kuklina EV.Severe maternal morbidity among delivery andpostpartumhospitalizations in theUnitedStates.Obstet Gynecol 2012;120:1029-36.14. Burlingame J, Horiuchi B, Ohana P,Onaka A, Sauvage LM. The contribution of heartdisease to pregnancy-related mortality accord-ing to the pregnancy mortality surveillance sys-tem. J Perinatol 2012;32:163-9.15. May AL, Freedman D, Sherry B,Blanck HM. ObesityeUnited States,1999e2010. Centers for Disease Control andPrevention (CDC). MMWR Surveill Summ2013;62(suppl 3):120-8.16. Kyser KL, Lu X, Santillan DA, et al. The as-sociation between hospital obstetrical volumeand maternal postpartum complications. Am JObstet Gynecol 2012;207:42.e1-7.17. Janakiraman V, Lazar J, Joynt KE, Jha AK.Hospital volume, provider volume, and

merican Journal of Obstetrics & Gynecology 11

http://refhub.elsevier.com/S0002-9378(14)02489-2/sref1








































































complications after childbirth in U.S. hospitals.Obstet Gynecol 2011;118:521-7.18. Eller AG, Bennett MA, Sharshiner M,Masheter C, Soisson AP, Dodson M, et al.Maternal morbidity in cases of placenta accretamanaged by a multidisciplinary care teamcompared with standard obstetric care. ObstetGynecol 2011;117:331-7.19. Wright JD, Herzog TJ, Shah M, Bonanno C,Lewin SN, Cleary K, et al. Regionalization of carefor obstetric hemorrhage and its effect onmaternal mortality. Obstet Gynecol 2010;115:1194-200.20. Olive EC, Roberts CL, Algert CS, Morris JM.Placenta praevia: maternal morbidity and place

12 American Journal of Obstetrics & Gynecology

of birth. Aust N Z J Obstet Gynaecol 2005;45:499-504.21. Sullivan SA, Hill EG, Newman RB,Menard MK. Maternal-fetal medicine specialistdensity is inversely associated with maternalmortality ratios. Am JObstet Gynecol 2005;193:1083-8.22. Indiana Perinatal Network. Indiana perinatalhospital standards. Indianapolis, IN: IPN 2012.Available at: http://c.ymcdn.com/sites/www.indianaperinatal.org/resource/resmgr/policy_makers/final_indiana_perinatal_hosp.pdf. Acc-essed Oct. 24, 2014.23. Arizona Perinatal Regional System Inc.Recommendations and guidelines for

MONTH 2014

perinatal and freestanding neonatal care cen-ters in Arizona, 3rd ed. Casa Grande, AZ:APRS; 2012.24. Maryland Department of Health and MentalHygiene. The Maryland perinatal system stan-dards: recommendations of the Perinatal ClinicalAdvisory Committee. Baltimore, MD: DHMH;2014. Available at: http://phpa.dhmh.maryland.gov/mch/Documents/Maryland_Perinatal_System_Standards_2013.pdf. Accessed Oct. 24, 2014.25. Vaginal birth after previous cesareandelivery. ACOG Practice Bulletin No. 115.American College of Obstetricians and Gy-necologists. Obstet Gynecol 2010;116:45-63.























http://c.ymcdn.com/sites/www.indianaperinatal.org/resource/resmgr/policy_makers/final_indiana_perinatal_hosp.pdf








http://phpa.dhmh.maryland.gov/mch/Documents/Maryland_Perinatal_System_Standards_2013.pdf









Appendix

Society for MaternaleFetal Medicine grading system: grading of recommendations assessment, development,and evaluation (GRADE) recommendations

Obstetric Care Consensus documents will use Society for MaternaleFetal Medicine grading approach: http://www.ajog.org/article/S0002-9378%2813%2900744-8/fulltext.

Recommendations are classified as either strong (grade 1) or weak (grade 2), and quality of evidence is classified as high (grade A), moderate(grade B), and low (grade C).a Thus, recommendations can be 1 of following 6 possibilities: 1A, 1B, 1C, 2A, 2B, 2C

Grade ofrecommendation

Clarity of riskand benefit

Quality of supportingevidence Implications

1A. Strongrecommendation,high-qualityevidence

Benefits clearly outweighrisk and burdens,or vice versa.

Consistent evidence fromwell-performed randomizedcontrolled trials or overwhelmingevidence of some other form.Further research is unlikely tochange confidence in estimateof benefit and risk.

Strong recommendations, can applyto most patients in most circumstanceswithout reservation. Clinicians shouldfollow a strong recommendation unlessa clear and compelling rationale for analternative approach is present.

1B. Strongrecommendation,moderate-qualityevidence

Benefits clearly outweighrisk and burdens,or vice versa.

Evidence from randomized controlledtrials with important limitations(inconsistent results, methodologicalflaws, indirect or imprecise), or verystrong evidence of some other researchdesign. Further research (if performed)is likely to have impact on confidencein estimate of benefit and risk and maychange estimate.

Strong recommendation, and applies tomost patients. Clinicians should followstrong recommendation unless clearand compelling rationale for alternativeapproach is present.

1C. Strongrecommendation,low-qualityevidence

Benefits appear to outweighrisk and burdens,or vice versa.

Evidence from observational studies,unsystematic clinical experience, orfrom randomized controlled trials withserious flaws. Any estimate of effectis uncertain.

Strong recommendation, and applies tomost patients. Some of evidence basesupporting recommendation is, however,of low quality.

2A. Weakrecommendation,high-qualityevidence

Benefits closely balancedwith risks and burdens.

Consistent evidence from well-performedrandomized controlled trials or overwhelmingevidence of some other form. Furtherresearch is unlikely to change confidencein estimate of benefit and risk.

Weak recommendation, best actionmay differ depending on circumstancesor patients or societal values.

2B. Weakrecommendation,moderate-qualityevidence

Benefits closely balancedwith risks and burdens;some uncertainty inestimates of benefits,risks, and burdens.

Evidence from randomized controlled trialswith important limitations (inconsistent results,methodological flaws, indirect or imprecise),or very strong evidence of some other researchdesign. Further research (if performed) is likelyto have effect on confidence in estimate ofbenefit and risk and may change estimate.

Weak recommendation, alternativeapproaches likely to be better forsome patients under somecircumstances.

2C. Weakrecommendation,low-qualityevidence

Uncertainty in estimatesof benefits, risks, andburdens; benefits maybe closely balanced withrisks and burdens.

Evidence from observational studies,unsystematic clinical experience, or fromrandomized controlled trials with seriousflaws. Any estimate of effect is uncertain.

Very weak recommendation, otheralternatives may be equally reasonable.

Best practice Recommendation in which either: (i) there is enormous amount of indirect evidence that clearly justifies strong recommendation(direct evidence would be challenging, and inefficient use of time and resources, to bring together and carefully summarize), or(ii) recommendation to contrary would be unethical.

Modified from grading guide. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013. Available at: http://www.uptodate.com/home/grading-guide. Retrieved October 9, 2013.

a Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. GRADE WorkingGroup. BMJ 2008;336:924-6.


MONTH 2014 American Journal of Obstetrics & Gynecology 13

http://www.ajog.org/article/S0002-9378%2813%2900744-8/fulltext

http://www.ajog.org/article/S0002-9378%2813%2900744-8/fulltext

http://www.uptodate.com/home/grading-guide

000

14 Am

Levels of maternal care
This document was developed jointly by the American College of Obstetricians
and Gynecologists and the Society for MaternaleFetal Medicine with the

assistance of M. Kathryn Menard; Sarah Kilpatrick; George Saade; Lisa M.

Hollier; Gerald F. Joseph Jr; Wanda Barfield; William Callaghan; John Jennings;

and Jeanne Conry

erican Journal of Obstetrics & Gynecology MONTH 2014