Are high-risk pregnancies receiving the appropriate level of care?

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One strategy proposed to reduce the maternal mortality rate is to refer high-risk women to medical centers which are more equipped to properly care for their comorbidities. However, it is not clear how effective this strategy has been for ensuring these women are receiving the proper level of care. A recent study in Obstetrics & Gynecology sought to estimate the degree to which women at high risk for developing severe maternal morbidity deliver at appropriate levels in maternal care centers.

The cross-sectional study linked 2014 American Hospital Association survey and State Inpatient Database data from seven representative states to assign a level of maternal care to each hospital. Each woman in the study was assigned a minimum required level of maternal care (I to IV) based on her unique medical and obstetric comorbidities. Level I hospitals are those designed to care for uncomplicated pregnancies with the ability to detect, stabilize, and initiate management of un anticipated medical comorbidities. Level II care reflected the possible need for availability of medical consultants beyond the scope of a general ob/gyn to guide management during the delivery hospitalization. Level III care indicated a potential need for subspecialty care including the availability of cardiologists, neurologists, or the possibility of dialysis. Level IV reflected a possible need for surgical subspecialists including cardiac surgeons, neurosurgeons, or transplant surgeons.

The primary outcome of interest was delivery at a hospital with an inappropriate level (too low-level care for the woman’s needs) of maternal care based on obstetric risk and presence of comorbid conditions.

The analysis included 845,545 deliveries occurring at 56 hospitals. The majority of women had risk factors appropriate for delivery at level I or II hospitals (85.1% and 12.6%, respectively). Most women delivered at level II or III hospitals (33.8% and 36.0%) with a lower percentage of deliveries at level I and IV hospitals (12.3% and 17.9%), respectively. Overall rates for comorbidities necessitating delivery at level III hospitals were low (2.4%).

An overwhelming majority of women (97.6%) delivered at a hospital with an appropriate level of maternal care, with just 2.4% of women delivering at a hospital with inappropriate care. However, of the 19,988 high-risk patients whose comorbidities warranted delivery at a high-risk hospital (level III or level IV), 43.4% delivered at level I or level II. Furthermore, women with comorbidities who would have benefitted from delivering at a hospital with specialized care had high rates of delivery with an inappropriate level of maternal care. Rates of delivery at inappropriate centers were highest for women with chronic medical conditions such as maternal cardiac disease (68.2%).

The authors believe that while only 2.41% of deliveries included in the study occurred at hospitals with an inappropriate level of maternal care, a substantial number of women at risk for maternal morbidity delivered at hospitals potentially unequipped to manage the delivery. Despite this, the authors believe that the absolute number of women warranting referral and transfer to risk-appropriate care appears to be manageable without overhauling the entire maternity system. They argue that targeting women with high-risk medical conditions for transfer and risk-appropriate care should be a relatively simple step to improve outcomes.