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Obstetrics
Cross-sectional survey of California childbirth hospitals: implications for defining maternal levels of risk-appropriate care

https://doi.org/10.1016/j.ajog.2015.07.014Get rights and content

Objective

Measures of maternal mortality and severe maternal morbidity have risen in the United States, sparking national interest regarding hospitals’ ability to provide maternal risk-appropriate care. We examined the extent to which hospitals could be classified by increasingly sophisticated maternal levels of care.

Study Design

We performed a cross-sectional survey to identify hospital-specific resources and classify hospitals by criteria for basic, intermediate, and regional maternal levels of care in all nonmilitary childbirth hospitals in California. We measured hospital compliance with maternal level of care criteria that were produced via consensus based on professional standards at 2 regional summits funded by the March of Dimes through a cooperative agreement with the Community Perinatal Network in 2007 (California Perinatal Summit on Risk-Appropriate Care).

Results

The response rate was 96% (239 of 248 hospitals). Only 82 hospitals (34%) were classifiable under these criteria (35 basic, 42 intermediate, and 5 regional) because most (157 [66%]) did not meet the required set of basic criteria. The unmet criteria preventing assignment into the basic category included the ability to perform a cesarean delivery within 30 minutes 100% of the time (only 64% met), pediatrician availability day and night (only 56% met), and radiology department ultrasound capability within 12 hours (only 83% met). Only 29 of classified hospitals (35%) had a nursery or neonatal intensive care unit level that matched the maternal level of care, and for most remaining hospitals (52 of 53), the neonatal intensive care unit level was higher than the maternal care level.

Conclusion

Childbirth services varied widely across California hospitals, and most hospitals did not fit easily into proposed levels. Cognizance of this existing variation is critical to determining the optimal configuration of services for basic, intermediate, and regional maternal levels of care.

Section snippets

Materials and Methods

This is a cross-sectional assessment of childbirth hospital services designed to determine the extent to which hospitals can be classified by increasingly sophisticated maternal levels of care. Information was obtained from a survey of labor and delivery nurse managers for childbirth hospitals in California that included an array of items regarding hospital services, resources, and patient care activities. The study was approved by the Cedars-Sinai Institutional Review Board (protocol

Results

The survey response rate was 96% (239 of 248 hospitals). Nine hospitals (ie, four integrated delivery system and 5 community hospitals) did not respond. The majority of respondents were administrative directors and nurses (n = 141; 59.0%), followed by clinical directors or nurse managers (n = 85; 35.6%), and others (n = 13; 5.4%). The mean (SD) number of years working at the current hospital was 12.4 (10.1) (median, 11.0; range, 0.1–46 years), and the mean (SD) number of years in the current

Comment

National efforts to examine and stem the rise in severe maternal morbidity have encouraged interest in strategies to classify childbirth hospitals by their resources and patient care activities and thus develop systems for maternal risk-appropriate care, or maternal levels of care.14, 16 However, our data demonstrated that given the wide variation in childbirth services that exists, only one third of hospitals could be assigned to a maternal level of care category using a scheme that had been

Acknowledgments

We are grateful to the many individuals and organizations that have contributed to this effort, including the staff of all of the participating hospitals. We want to specifically acknowledge the Regional Perinatal Programs of California for their assistance in providing introductions and contact information for participants and Kevin Van Otterloo of the Community Perinatal Network in Yorba Linda, CA, for his assistance with recruitment and scheduling participant interviews.

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    The funding sources had no involvement in the conduct of the research or in the preparation of the manuscript.

    This study was supported by Agency for Healthcare Research and Quality grant 5 R01 HS020915 (all investigators except D.S.F.). Additional support was provided by the March of Dimes (L.M.K., M.F., and D.L.B.) and by the American Congress of Obstetricians and Gynecologists/Duchesnay USA Research Award in Quality Improvement in Maternity Care (D.S.F.).

    The authors report no conflict of interest.

    Cite this article as: 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;213:527.e1-12.

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