Do Hospitals with a Higher Level of Maternal Care Designation Have Better Maternal Outcomes?

Abstract

Background A recent document by the American Congress of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine introduced the concept of uniform levels of maternal care (LMCs).

Objective We assessed LMC across hospitals and measured their association with maternal morbidity, focusing on women with high-risk conditions.

Study Design We collected data from hospitals from May to November 2015 and linked survey responses to Statewide Inpatient Databases (SID) hospital discharge data in a retrospective cross-sectional study of 247,383 births admitted to 236 hospitals. Generalized logistic regression models were used to examine the associations between hospitals' LMC and the risk of severe maternal morbidity. Stratified analyses were conducted among women with high-risk conditions.

Results High-risk pregnancies were more likely to be managed in hospitals with higher LMC (p < 0.001). Women with cardiac conditions had lower odds of maternal morbidity when delivered in level I compared with level IV units (adjusted odds ratio: 0.29; 95% confidence interval: 0.08–0.99; p = 0.049). There were no other significant associations between the LMC and severe maternal morbidity.

Conclusion A higher proportion of high-risk pregnancies were managed within level IV units, although there was no overall evidence that these births had superior outcomes. Further prospective evaluation of LMC designation with patient outcomes is necessary to determine the impact of regionalization on maternal outcomes.

Keywords

maternal morbidity - levels of care - regionalization - maternal outcomes

Note

This study was presented at the 2016 Society for Maternal–Fetal Medicine Meeting.

• References

• 1 Creanga AA, Berg CJ, Ko JY. , et al. Maternal mortality and morbidity in the United States: where are we now?. J Womens Health (Larchmt) 2014; 23 (01) 3-9
• 2 Callaghan WM, Creanga AA, Jamieson DJ. Pregnancy-related mortality resulting from influenza in the United States during the 2009-2010 pandemic. Obstet Gynecol 2015; 126 (03) 486-490
• 3 Cousens S, Blencowe H, Stanton C. , et al. National, regional, and worldwide estimates of stillbirth rates in 2009 with trends since 1995: a systematic analysis. Lancet 2011; 377 (9774): 1319-1330
• 4 Janakiraman V, Lazar J, Joynt KE, Jha AK. Hospital volume, provider volume, and complications after childbirth in U.S. hospitals. Obstet Gynecol 2011; 118 (03) 521-527
• 5 Kyser KL, Lu X, Santillan DA. , et al. The association between hospital obstetrical volume and maternal postpartum complications. Am J Obstet Gynecol 2012; 207 (01) 42.e1-42.e17
• 6 Snowden JM, Cheng YW, Kontgis CP, Caughey AB. The association between hospital obstetric volume and perinatal outcomes in California. Am J Obstet Gynecol 2012; 207 (06) 478.e1-478.e7
• 7 Kozhimannil KB, Thao V, Hung P, Tilden E, Caughey AB, Snowden JM. Association between hospital birth volume and maternal morbidity among low-risk pregnancies in rural, urban, and teaching hospitals in the United States. Am J Perinatol 2016; 33 (06) 590-599
• 8 Wright JD, Herzog TJ, Shah M. , et al. Regionalization of care for obstetric hemorrhage and its effect on maternal mortality. Obstet Gynecol 2010; 115 (06) 1194-1200
• 9 Yeast JD, Poskin M, Stockbauer JW, Shaffer S. Changing patterns in regionalization of perinatal care and the impact on neonatal mortality. Am J Obstet Gynecol 1998; 178 (1 Pt 1): 131-135
• 10 Callaghan WM. Overview of maternal mortality in the United States. Semin Perinatol 2012; 36 (01) 2-6
• 11 Menard MK, Kilpatrick S, Saade G. , et al; American College of Obstetricians and Gynecologists and Society for Maternal–Fetal Medicine. Levels of maternal care. Am J Obstet Gynecol 2015; 212 (03) 259-271
• 12 Kuklina EV, Whiteman MK, Hillis SD. , et al. An enhanced method for identifying obstetric deliveries: implications for estimating maternal morbidity. Matern Child Health J 2008; 12 (04) 469-477
• 13 Bateman BT, Mhyre JM, Hernandez-Diaz S. , et al. Development of a comorbidity index for use in obstetric patients. Obstet Gynecol 2013; 122 (05) 957-965
• 14 Korst LM, Feldman DS, Bollman DL. , et al. Cross-sectional survey of California childbirth hospitals: implications for defining maternal levels of risk-appropriate care. Am J Obstet Gynecol 2015; 213 (04) 527.e1-527.e12
• 15 Phibbs CS, Baker LC, Caughey AB, Danielsen B, Schmitt SK, Phibbs RH. Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants. N Engl J Med 2007; 356 (21) 2165-2175
• 16 Myers SR, Branas CC, French B, Nance ML, Carr BG. A national analysis of pediatric trauma care utilization and outcomes in the United States. Pediatr Emerg Care 2016 Doi: 10.1097/PEC.0000000000000902
• 17 Clement RC, Carr BG, Kallan MJ, Wolff C, Reilly PM, Malhotra NR. Volume-outcome relationship in neurotrauma care. J Neurosurg 2013; 118 (03) 687-693