A new consensus report from the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) recommends a regionalized maternity care system, by classifying and ranking levels of services for mothers. This report follows on the tails of a UK study and the NICE guidelines, recommending that women be encouraged to utilize midwifery care in all settings. This has sparked an active public dialogue here in the US about ways in which more midwifery care can be incorporated into our maternity system. The new report describes the current system’s focus “almost entirely on the newborn,” and outlines a “complementary but distinct,” set of designations based on care for the pregnant woman, including a highlighted role for birth centers:
The proposed classification system for levels of maternal care pertains 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 regionalized maternal care is for pregnant women at high risk to receive care in facilities that are prepared to provide the required level of specialized care, thereby reducing maternal morbidity and mortality in the United States.
The paper defines facilities, scope and services at each level with an emphasis on communication and referrals between professionals depending on the needs of women and babies. The authors cite the American Association of Birth Centers’ (AABC) definition of “a homelike facility existing within a healthcare system with a program of care designed in the wellness model of pregnancy and birth,” and discuss certified nurse-midwives (CNMs), certified midwives (CMs), certified professional midwives (CPMs), and licensed midwives as appropriate providers for this type of care.
Level I basic care facilities “have the capability to perform routine intrapartum and postpartum care that is anticipated to be uncomplicated,” and are staffed by “midwives, family physicians, or obstetrician-gynecologists,” along with “adequate numbers of registered nurses.” The authors recommend that level I care may be appropriate for “women with term twin gestation, women attempting trial of labor after cesarean delivery, women expecting an uncomplicated cesarean delivery; and women with preeclampsia without severe features at term.”
Level II specialty care ranked facilities are those prepared to care for “women with severe preeclampsia and women with placenta previa with no prior uterine surgery.” At facilities ranked level III, providers must be prepared for “comprehensive management of severe maternal and fetal complications,” and at level IV intensive care must be onsite for treatment of “pregnant women with severe maternal cardiac conditions, severe pulmonary hypertension, or liver failure; pregnant women in need of neurosurgery or cardiac surgery; or pregnant women in unstable condition and in need of an organ transplant.”
The paper recommends that “higher-level facilities should provide training for quality improvement initiatives, educational support… for lower-level hospitals,” and describes how within a region, community outreach needs to be part of the system. One strength of the report is that the proposed ranking system recognizes that an uncomplicated pregnancy need not take place in a higher level facility. The recommendations open the door for a fluid system of maternity care, where communication and cooperation among maternity providers allow a woman to move both up to a higher level of care (a common practice in our current system) or down to a lower level of care when appropriate. Acknowledging the benefits of baby-centered care on perinatal outcomes, this shifted focus on maternal health will hopefully have the same effect for women. Beyond simply classifying and labeling facilities, this system will facilitate data collection and quality improvement: values shared by Maternity Neighborhood and made possible by the work we do.