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

Am J Obstet Gynecol. 2015 Oct;213(4):527.e1-527.e12. doi: 10.1016/j.ajog.2015.07.014. Epub 2015 Jul 18.


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.

Keywords: childbirth hospital services; hospital staffing; maternal health; maternal levels of care; risk-appropriate care.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Anesthesia, Obstetrical / statistics & numerical data
  • California
  • Cesarean Section / standards*
  • Cross-Sectional Studies
  • Female
  • Health Services Accessibility / standards*
  • Hospitals / standards*
  • Humans
  • Infant, Newborn
  • Intensive Care Units, Neonatal / statistics & numerical data
  • Maternal Health Services / standards*
  • Medical Staff, Hospital / statistics & numerical data
  • Nurseries, Hospital / statistics & numerical data
  • Nursing Staff, Hospital / statistics & numerical data
  • Obstetrics / statistics & numerical data
  • Parturition*
  • Pediatrics / statistics & numerical data
  • Pregnancy
  • Quality of Health Care
  • Surveys and Questionnaires
  • Time Factors
  • Ultrasonography / statistics & numerical data