Delivery at an inadequate level of maternal care is associated with severe maternal morbidity

Abstract

BackgroundImplementing levels of maternal care is one strategy proposed to reduce maternal morbidity and mortality. The levels of maternal care framework outline individual medical and obstetric comorbidities, along with hospital resources required for individuals with these different comorbidities to deliver safely. The overall goal is to match individuals to hospitals, so all birthing people get appropriate resources and personnel during delivery to reduce maternal morbidity. ObjectivesThis study examined the association between delivery in a hospital with an inappropriate level of maternal care and the risk of experiencing severe maternal morbidity. Study designThe 40 birthing hospitals in Massachusetts were surveyed using the Centers for Disease Control and Prevention’s Levels of Care Assessment Tool. We linked individual delivery hospitalizations from the Massachusetts Pregnancy to Early Life Longitudinal data system to hospital-level data from the Levels of Care Assessment Tool surveys. Level of maternal care guidelines were used to outline 16 high-risk conditions warranting delivery at hospitals with resources beyond those considered basic (level I) obstetric care. We then used the Levels of Care Assessment Tool assessed levels to determine whether delivery occurred at a hospital that had the resources to meet an individual’s needs (i.e., if a patient received risk-inappropriate care).We conducted our analyses in two stages. First, multivariable logistic regression models predicted whether an individual delivered in a hospital that did not have the resources for their risk condition. The main explanatory variable of interest was whether the hospital self-assessed their level of maternal care to be higher than their Levels of Care Assessment Tool -assessment. We then used logistic regression to examine the association between delivery at an inappropriate level and the presence of severe maternal morbidity at delivery. ResultsAmong 64,441 deliveries in Massachusetts from January 1 to December 31, 2019, 33.2% (21,415/64,441) had one or more of the 16 high-risk conditions suggesting delivery should occur at a center designated as a level I or higher. Of the 21,415 individuals with a high-risk condition, 13% (2,793/21,415) or 4% (2,793/64,441) of the entire sample delivered at an inappropriate level of maternal care. Birthing individuals with high-risk conditions delivering at a hospital with an inappropriate level had elevated odds (aOR: 3.34, 95% CI: 2.24, 4.96) of experiencing severe maternal morbidity after adjusting for patient comorbidities, demographics, average hospital severe maternal morbidity rate, hospital level of maternal care, and geographic region. ConclusionsBirthing people who delivered in a hospital with risk-inappropriate resources were significantly more likely to experience severe maternal morbidity. Delivery in a hospital with a discrepancy in their self-assessment and Levels of Care Assessment Tool assessment significantly predicted delivery in a hospital with an inappropriate level of maternal care, suggesting inadequate knowledge of hospitals’ resources and capabilities. Our data demonstrate the potential for the levels of maternal care paradigm to decrease severe maternal morbidity while highlighting the need for robust implementation and education to ensure everyone receives risk-appropriate care.