Hospital designation of maternal care levels has been suggested as a way to combat rising maternal morbidity and mortality by ensuring access to adequate facilities. Our objective is to evaluate whether women with conditions that place them at high risk of severe morbidity have better outcomes when cared for at hospitals with a higher maternal level-of-care designation (MLOCD).
We conducted a telephone survey of birth hospitals in nine states as identified in 2012 State Inpatient Databases. Based on responses, MLOCD were assigned following criteria in the SMFM-ACOG “Maternal Levels of Care” document. The primary outcome was the rate of severe maternal morbidity overall and among high-risk subgroups of patients (ie, placenta previa, pre-eclampsia/eclampsia). Associations between MLOCD and maternal morbidity were evaluated. Final multivariable models adjusted for potential confounders.
Overall, 90 hospitals, accounting for over 135,000 births were categorized into one of four levels of care. High-risk medical conditions were more prevalent in Level 4 hospitals. The overall frequency of severe maternal morbidity was 1.9%, although the frequency was 8.5% among high-risk women. After adjustment, there was no significant association between the MLOCD and composite maternal outcome.
No association between MLOCD and maternal morbidity was detected. However, level 4 hospitals have a higher proportion of patients with pre-existing comorbidities, and even multivariable adjustment may not account for potentially important confounding. Prospective designation of hospital level and evaluation with patient outcomes is necessary to truly determine the impact of MLOCD and regionalization on maternal outcomes.