Remembering Mom: The Use of Maternal Levels of Care to Prevent Mortality and Morbidity

Blog | July 28, 2021

By Amanda Gomez


In the 1970s, the March of Dimes Committee on Perinatal Health published its seminal “Toward Improving the Outcome of Pregnancy” guidance, which outlined a model for perinatal health regionalization to address maternal, fetal, and neonatal deaths.1 In this model, regionalized perinatal systems assign hospitals levels of care based on their birth volume, resources, and staff specializations; ensure women give birth in risk-appropriate facilities; and facilitate emergency maternal and neonatal transport. These designations indicate increased capacity to care for patients with high-risk conditions and/or severe complications that arise during pregnancy, birth, and postpartum.


While these strategies have primarily focused on neonatal care, a growing number of professional organizations and health providers have recognized the need for distinct maternal levels of care to adequately address maternal health.2-4


In 1976, North Carolina established 6 perinatal care regions.5 In 1994, the North Carolina Administrative Code documented requirements for facilities seeking neonatal levels of care designations.6 The state does not, however, have formal regulations that define maternal levels of care. The adoption of maternal levels of care was recommended in NCIOM’s April 2020 Healthy Moms, Healthy Babies Report and is currently being explored by the NCIOM Task Force on Maternal Health.7


 Many studies have shown the association between risk-appropriate neonatal placement and/or maternal transport and improved neonatal outcomes. For example, a 1982 study of low-birth-weight infants in New York showed a dramatically lower mortality rate for low-birth-weight babies born in hospitals with Level III neonatal intensive care units (128.5 deaths per 1,000 live births) compared to those born in hospitals with Level II (168.1) and Level I (163) neonatal intensive care units.8 Other studies demonstrate that very low-birth weight (VLBW, <1500 grams) infants especially benefit from Level III NICUs.9-11


Similarly, there is evidence that women with high-risk conditions are best served in high-level facilities with specialty and subspecialty services. One study found that women with high-risk health conditions had about nine times the risk (relative to women who did not have high-risk conditions) of severe maternal morbidity in hospitals that have a small proportion of high-risk patients.12 Comparatively, hospitals that have a large proportion of high-risk patients only had about six times the risk of poor maternal health outcomes. Other studies suggest that hospital birth volume, facility level (or rating), and provider density are correlated with maternal health outcomes.13-16


In 2015, the American College of Obstetrics and Gynecologists and the Society for Maternal-Fetal Medicine published the first comprehensive framework for defining maternal levels of care. The most recent version of this obstetric care consensus was published in 2019, further clarifying designation criteria and applying lessons from states that had begun implementing levels of care specific to maternal health needs.2 Since 2010, 16 states have published guidelines defining at least three levels of maternal care. Four of these states (Georgia, Illinois, Indiana, and Texas) have formalized these guidelines in state legislation.17 Thirteen states regulate maternal levels of care designations through state agencies, and nine of these states mandate designation in some way. For instance, while Illinois authorized a public act that requires the establishment of a classification for maternal care, Texas included a section in its administrative code that predicates Medicaid reimbursement on each hospital receiving a maternal level of care designation.18,19


Perinatal care encompasses maternal, fetal, and neonatal health. While systems of perinatal regionalization have made incredible strides in reducing mortality and morbidity for the most fragile newborns, it is important to remember and address the medical needs of pregnant and birthing women. While the method of implementation among states may vary, applying a regionalization framework specific to maternal risk can support improved maternal health outcomes.




  1. Ryan GM Jr. Toward improving the outcome of pregnancy Recommendations for the regional development of perinatal health services. Obstet Gynecol. 1975;46(4):375-384
  2. Levels of Maternal Care: Obstetric Care Consensus No, 9 Summary. Obstet Gynecol. 2019;134(2):428-434. doi:10.1097/AOG.0000000000003384
  3. Catalano A, Bennett A, Busacker A, et al. Implementing CDC's Level of Care Assessment Tool (LOCATe): A National Collaboration to Improve Maternal and Child Health. J Womens Health (Larchmt). 2017;26(12):1265-1269. doi:10.1089/jwh.2017.6771
  4. The Massachusetts Perinatal Quality Collaborative. MA Levels of Maternal Care Initiative. Retrieved from:
  5. Pettiford B. Maternal and infant mortality in North Carolina. North Carolina Medical Journal 2020; 82: 3. Retrieved from:
  6. North Carolina Administrative 10A Code NCAC 14C.
  7. Healthy moms, healthy babies: building a risk-appropriate perinatal system of care in North Carolina. 2020. Retrieved from:
  8. Paneth N, Kiely JL, Wallenstein S, Marcus M, Pakter J, Susser M. Newborn intensive care and neonatal mortality in low-birth-weight infants: a population study. N Engl J Med 1982;307:149–55.
  9. Gortmaker S, Sobol A, Clark C, Walker DK, Geronimus A. The survival of very low-birth weight infants by level of hospital of birth: a population study of perinatal systems in four states. Am J Obstet Gynecol 1985;152:517–24.
  10. Menard MK, Liu Q, Holgren EA, Sappenfield WM. Neonatal mortality for very low birth weight deliveries in South Carolina by level of hospital perinatal service. Am J Obstet Gynecol 1998;179:374–81.
  11. Lasswell SM, Barfield WD, Rochat RW, Blackmon L. Perinatal regionalization for very low-birth-weight and very preterm infants: a meta-analysis. JAMA 2010;304:992–1000.
  12. Clapp MA, James KE, Kaimal AJ. The effect of hospital acuity on severe maternal morbidity in high-risk patients. Am J Obstet Gynecol 2018;219:111.e1–7.
  13. Kyser KL, Lu X, Santillan DA, Santillan MK, Hunter SK, Cahill AG, et al. The association between hospital obstetrical volume and maternal postpartum complications. Am J Obstet Gynecol 2012;207:42.e1–17.
  14. Janakiraman V, Lazar J, Joynt KE, Jha AK. Hospital volume, provider volume, and complications after childbirth in U.S. hospitals. Obstet Gynecol 2011;118:521–7.
  15. Ananth CV, Lavery JA, Friedman AM, Wapner RJ, Wright JD. Serious maternal complications in relation to severe pre-eclampsia: a retrospective cohort study of the impact of hospital volume. BJOG 2017;124:1246–53.
  16. Sullivan SA, Hill EG, Newman RB, Menard MK. Maternal-fetal medicine specialist density is inversely associated with maternal mortality ratios. Am J Obstet Gynecol 2005;193:1083–8.
  17. Levels of maternal care: state implementation. Retrieved from:
  18. 20 ILCS 2310-223.
  19. Texas Administrative Code, Title 25, Chapter 133, Subchapter K. Retrieved from:$ext.ViewTAC?tac_view=5&ti=25&pt=1&ch=133&sch=K&rl=Y.