Massachusetts will designate hospital “Levels of Maternal Care” to improve health outcomes for higher-risk patients

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To help patients with high-risk pregnancies receive care at hospitals that are staffed and equipped to deliver care appropriate to their needs, the Department of Public Health will require licensed birthing hospitals to use a system called Levels of Maternal Care. The system classifies hospitals based on their capacity to meet the needs of patients with a range of potential complications during childbirth.

The impetus is the rising levels of severe maternal morbidity, large racial disparities in outcomes, and concerns that higher-risk patients who deliver in hospitals that over-estimate the level of care they are able to provide are more likely to experience complications.

Levels of care describe a hospital’s physical facilities, capabilities and staffing, indicating its ability to serve people giving birth across a range of medical needs. For example, Level 1 is appropriate for low-risk patients with uncomplicated pregnancies, including twins and labor after cesarean delivery. To that group, Level II adds patients with poorly controlled asthma or hypertension and other higher-risk conditions. Subsequent levels include patients at increasingly high risk of complications, up to Level IV, which is appropriate for patients with severe cardiac disease, those who need organ transplant and others.

Established by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine in 2015, the classification system is one tool used by states across the country to improve maternal health and birthing outcomes.

Designating levels of maternal care facilitates planning for individual patients, regional planning, and development of facilities’ capabilities in underserved areas.

DPH acknowledges that a public awareness and education effort may be needed to explain that higher levels of maternal care do not equate to higher quality. The goal is to provide safe, risk-appropriate care at high quality at all levels.

Risk-appropriate care helps address maternal health inequities

Classifying levels of care may also help address inequities in maternal health outcomes. Data released by the state last year show that the rate of severe maternal morbidity — unexpected complications with significant consequences to the health of the birthing person — doubled in Massachusetts from 2011 to 2020. This troubling trend is especially acute for demographic subgroups, with non-Hispanic Black patients consistently at the highest risk. In 2020, the rate among non-Hispanic Black birthing people was 2.5 times higher than that of non-Hispanic whites, a gap that had increased 25 percent in 10 years.

Five-year collaboration leads to new approach

The recommendation to use the levels of maternal care classification system in licensure is incorporated into a comprehensive 2023 Review of Maternal Health Services, initiated by Governor Maura Healey, and comes after five years of collaboration with the Betsy Lehman Center and the state’s Perinatal Neonatal Quality Improvement Network of Massachusetts. In 2023, the Center convened a Maternal Care Implementation Committee comprising relevant state agencies, payers, community organizations, provider organizations, transport service providers and people with lived experience, whose work informed the recommendation to the governor.

In addition, in 2021, all birthing hospitals in the state participated in a voluntary, confidential survey designed to assess each facility’s capacity to manage deliveries at different levels of risk. Survey results showed that 47% of hospitals overestimated the highest level they are able to provide. This finding contributed to recommendations for a regulatory approach to maternal care capacities.


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