ACOG, SMFM propose definitions for maternal care sites



In a first-time consensus document, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine have proposed a new classification system for maternal care facilities that includes minimum standards for each level of care.

Implementing these definitions nationally could help decrease maternal and fetal morbidity and mortality, improve regional availability of care for high-risk pregnant women, and enhance the collection of related data, according to the two organizations. The consensus document appears in the February issue of Obstetrics & Gynecology (Obstet. Gynecol. 2015;125:502-15).

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The classification of maternal facilities mirrors the model already in use for neonatal care facilities and comes as U.S. maternal mortality rates have climbed. The United States now ranks 60th in the world for maternal mortality, the document notes.

“It is essential to remember that, when we are addressing obstetrical outcomes, we have two very important patients: mother and child,” Dr. Sarah J. Kilpatrick, chair of the department of obstetrics and gynecology at Cedars-Sinai Medical Center in Los Angeles and lead author of the document, said in a statement. “Our goal for these consensus recommendations is to create a system for maternal care that complements and supplements the current neonatal framework in order to reduce maternal morbidity and mortality across the country.”

The consensus document defines five categories of maternal care centers:

Level 1 (basic care) facilities have the same capacities as birth centers but also can perform common emergency procedures, such as unplanned cesarean deliveries and massive transfusions. They must have the appropriate blood products and analgesia and anesthesia services. Unlike birth centers, level 1 facilities can readily handle term deliveries of twins, preeclampsia at term that is not severe, and uncomplicated cesarean deliveries. Managers of these facilities are able to create formal protocols for transferring high-risk patients, as well as education and quality improvement programs.

Level 2 (specialty care) facilities are able to handle moderately complex cases, such as severe preeclampsia or placental previa without prior uterine surgery. These facilities have an attending ob.gyn. available at all times, plus in-person or remote access to a maternal-fetal medicine subspecialist. They also have basic ultrasound equipment, equipment for obese women such as bariatric beds, and CT scanning equipment. They ideally have MRI scanning and interpretation, according to the consensus document.

Level 3 (subspecialty care) facilities meet level 2 criteria and also have continuous, on-site intensive care, maternal-fetal medicine services that are led by a maternal-fetal subspecialist, and advanced imaging and ventilator equipment. These facilities may act as regional referral centers and are appropriate for women with suspected placenta accreta or placenta previa with prior uterine surgery, suspected placenta percreta, adult respiratory syndrome, or severe eclampsia at less than 34 weeks’ gestation.

Level 4 (regional perinatal health care) facilities offer medical and surgical care for the most critical cases, including severe pulmonary hypertension; liver failure; and conditions that require organ transplantation, neurosurgery, or cardiac surgery. These facilities have continuously available maternal-fetal medicine care teams that are highly experienced in handling pregnant and postpartum women in critical condition. Level 4 facilities also coordinate referral and transport, provide outreach education for local facilities and providers, and help collect and analyze regional data for quality improvement programs.

Leaders at these facilities should understand their sites’ capabilities and limitations and have a “well-defined threshold for transferring women to health care facilities that offer a higher level of care,” ACOG and SMFM wrote. The organizations also called on state and regional authorities to partner with maternal care facilities to coordinate a system of care.

The new consensus statement does not address high-risk neonatal care, but such care must be coordinated with maternal care, ACOG and SMFM officials wrote.

Several groups endorsed the consensus definitions, including the American Association of Birth Centers; the American College of Nurse-Midwives; the Association of Women’s Health, Obstetric and Neonatal Nurses; and the Commission for the Accreditation of Birth Centers. The authors reported having no financial disclosures.

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