Perinatal Regionalization Research Articles

Development and Application of a Delivery Infrastructure Collapse Risk Assessment Tool: A Focus on Metropolitan Metropolitan Areas

Purpose: This study aims to develop a tool to systematically assess the risk of collapse in the delivery infrastructure and apply it to 42 districts in Gyeonggi Province. The ultimate goal is to provide data for preventive and improvement strategies tailored to regional needs.Methods: Hospitals performing over 50 deliveries annually were identified. Regions were categorized as 'none,' 'one,' or 'more than two' delivery hospitals, with further subdivision by annual delivery volume. Regions were then classified into 5 categories: 'relatively stable,' 'low-risk,' 'moderate-risk,' 'high-risk,' and 'collapsed.'Results: Of the 42 districts, 23 were classified as relatively stable, 3 as low-risk, 1 as moderate-risk, 4 as highrisk, and 11 as collapsed. Notably, areas where the delivery infrastructure has collapsed or is at high risk of collapse accounted for approximately 36% of the total.Conclusion: Tailored strategies and urgent policy support are required for high-risk regions. While perinatal regionalization may be a future direction, stable infrastructure must be maintained until the maternal care delivery system is established.

Validation of a measure of hospital maternal level of care for the United States

BackgroundLack of a validated assessment of maternal risk-appropriate care for use in population data has prevented the existing literature from quantifying the benefit of maternal risk-appropriate care. The objective of this study was to develop a measure of hospital maternal levels of care based on the resources available at the hospital, using existing data available to researchers.MethodsThis was a secondary data analysis. The sample was abstracted from the American Hospital Association Annual Survey Database for 2018. Eligibility was limited to short-term acute general hospitals that reported providing maternity services as measured by hospital reporting of an obstetric service level, obstetric services, or birthing rooms. We aligned variables in the database with the ACOG criteria for each maternal level of care, then built models that used the variables to measure the maternal level of care. In each iteration, the distribution of hospitals was compared to the distribution in the CDC Levels of Care Assessment Tool Validation Pilot, assessing agreement with the Wilson Score for proportions for each level of care. Results were compared to hospital self-report in the database and measurement reported with another published method.ResultsThe sample included 2,351 hospitals. AHA variables were available to measure resources that align with ACOG Levels 1, 2, and 3. Overall, 1219 (51.9%) of hospitals reported resources aligned with Maternal Level One, 816 (34.7%) aligned with maternal level two, and 202 (8.6%) aligned with maternal level Three. This method overestimates the prevalence of hospitals with maternal level one compared to the CDC measurement of 36.1% (Mean 52.9%; 95% CI47.2%—58.7%), and likely includes hospitals that would not qualify as level one if all resources required by the ACOG guidelines could be assessed. This method underestimates the prevalence of hospitals with maternal critical care services (Level 3 or 4) compared to CDC measure of 12.1% (Mean 8.1%; 95%CI 6.2% – 10.0%) but is an improvement over hospital self-report (24.7%) and a prior published method (32.3%).ConclusionsThis method of measuring maternal level of care allows researchers to investigate the value of perinatal regionalization, risk-appropriate care, and hospital differences among the three levels of care. This study identified potential changes to the American Hospital Association Annual Survey that would improve identification of maternal levels of care for research.

Operationalizing risk-appropriate perinatal care in a rural US State: directions for policy and practice

BackgroundRisk-appropriate care improves outcomes by ensuring birthing people and infants receive care at a facility prepared to meet their needs. Perinatal regionalization has particular importance in rural areas where pregnant people might not live in a community with a birthing facility or specialty care. Limited research focuses on operationalizing risk-appropriate care in rural and remote settings. Through the implementation of the Centers for Disease Control and Prevention (CDC) Levels of Care Assessment Tool (LOCATe), this study assessed the system of risk-appropriate perinatal care in Montana.MethodsPrimary data was collected from Montana birthing facilities that participated in the CDC LOCATe version 9.2 (collected July 2021 – October 2021). Secondary data included 2021 Montana birth records. All birthing facilities in Montana received an invitation to complete LOCATe. LOCATe collects information on facility staffing, service delivery, drills, and facility-level statistics. We added additional questions on transport.ResultsNearly all (96%) birthing facilities in Montana completed LOCATe (N = 25). The CDC applied its LOCATe algorithm to assign each facility with a level of care that aligns directly with guidelines published by the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG), and Society for Maternal-Fetal Medicine (SMFM). LOCATe-assessed levels for neonatal care ranged from Level I to Level III. Most (68%) facilities LOCATe-assessed at Level I or lower for maternal care. Close to half (40%) self-reported a higher-level of maternal care than their LOCATe-assessed level, indicating that many facilities believe they have greater capacity than outlined in their LOCATe-assessed level. The most common ACOG/SMFM requirements contributing to the maternal care discrepancies were the lack of obstetric ultrasound services and a physician anesthesiologist.ConclusionsThe Montana LOCATe results can drive broader conversations on the staffing and service requirements necessary to provide high-quality obstetric care in low-volume rural hospitals. Montana hospitals often rely on Certified Registered Nurse Anesthetists (CRNA) for anesthesia services and telemedicine to access specialty providers. Integrating a rural health perspective into the national guidelines could enhance the utility of LOCATe to support state strategies to improve the provision of risk-appropriate care.

American Indians travel great distances for obstetrical care: Examining rural and racial disparities

Rural, American Indian/Alaska Native (AI/AN) people, a population at elevated risk for complex pregnancies, have limited access to risk-appropriate obstetric care. Obstetrical bypassing, seeking care at a non-local obstetric unit, is an important feature of perinatal regionalization that can alleviate some challenges faced by this rural population, at the cost of increased travel to give birth. Data from five years (2014–2018) of birth certificates from Montana, along with the 2018 annual survey of the American Hospital Association (AHA) were used in logistic regression models to identify predictors of bypassing, with ordinary least squares regression models used to predict factors associated with the distance (in miles) birthing people drove beyond their local obstetric unit to give birth. Logit analyses focused on hospital-based births to Montana residents delivered during this time period (n = 54,146 births). Distance analyses focused on births to individuals who bypassed their local obstetric unit to deliver (n = 5,991 births). Individual-level predictors included maternal sociodemographic characteristics, location, perinatal health characteristics, and health care utilization. Facility-related measures included level of obstetric care of the closest and delivery hospitals, and distance to the closest hospital-based obstetric unit. Findings suggest that birthing people living in rural areas and on American Indian reservations were more likely to bypass to give birth, with bypassing likelihood depending on health risk, insurance, and rurality. AI/AN and reservation-dwelling birthing people traveled significantly farther when bypassing. Findings highlight that distance traveled was even farther for AI/AN people facing pregnancy health risks (23.8 miles farther than White people with pregnancy risks) or when delivering at facilities offering complex care (14–44 miles farther than White people). While bypassing may connect rural birthing people to more risk-appropriate care, rural and racial inequities in access persist, with rural, reservation-dwelling AI/AN birthing people experiencing greater likelihood of bypassing and traveling greater distances when bypassing.

“I Gave Birth”—An Initiative to Improve Postpartum Care

New families need support, information, and resources to navigate their postpartum recovery. The “I Gave Birth” initiative educates communities to improve outcomes in Perinatal Region VI and across North Carolina. Evaluation of the initiative demonstrated that health care system and community-wide awareness of maternal warning signs leads to early recognition and treatment of maternal complications.

Levels of neonatal care among birth facilities in 20 states and other jurisdictions: CDC levels of care assessment toolSM (CDC LOCATeSM).

Describe discrepancies between facilities' self-reported level of neonatal care and Centers for Disease Control and Prevention Levels of Care Assessment ToolSM (CDC LOCATeSM)-assessed level. CDC LOCATeSM data from 765 health facilities in the United States, including 17 states, one territory, one large multi-state hospital system, and one perinatal region within a state, was collected between 2016 and 2021 for this cross-sectional analysis. Among 721 facilities that self-reported level of neonatal care, 33.1% had discrepancies between their self-reported level and their LOCATeSM-assessed level. Among facilities with discrepancies, 75.3% self-reported a higher level of neonatal care than their LOCATeSM-assessed level. The most common elements contributing to discrepancies were limited specialty and subspecialty staffing, such as neonatology or neonatal surgery. Results highlight opportunities for jurisdictions to engage with facilities, health systems, and partners about levels of neonatal care, and to collaborate to promote standardized systems of risk-appropriate care.

Statewide transfer policy impact for parturients with severe features of hypertensive disorders of pregnancy

To address increases in severe maternal morbidity (SMM) and mortality, systematic improvements in the care of high-risk parturients at facility and population levels have been advocated. Part of this effort involves levels of maternal care which account for perinatal regionalization and risk-appropriate maternal care for high-risk patients. In 7/2019, the Ohio Department of Health’s Maternity Licensure requirements established transfer of patients ≥37 weeks from Level 1 and ≥34 weeks from Level 2 to Level 3 or 4 perinatal centers for hypertensive disorders of peripartum with severe features (HDP-SF).

CDC LOCATe: discrepancies between self-reported level of maternal care and LOCATe-assessed level of maternal care among 463 birth facilities.

Describe sources of discrepancy between self-assessed LoMC (level of maternal care) and CDC LOCATe®-assessed (Levels of Care Assessment Tool) LoMC. CDC LOCATe® was implemented at 480 facilities in 13 jurisdictions, including states, territories, perinatal regions, and hospital systems, in the U.S. Cross-sectional analyses were conducted to compare facilities' self-reported LoMC and LOCATe®-assessed LoMC. Among 418 facilitiesthat self-reported an LoMC, 41.4% self-reported a higher LoMC than their LOCATe®-assessed LoMC. Among facilities with discrepancies, the most common elements lacking to meet self-reported LoMC included availability of maternal-fetal medicine (27.7%), obstetric-specializing anesthesiologist (16.2%), and obstetric ultrasound services (12.1%). Two in five facilities self-report a LoMC higher than their LOCATe®-assessed LoMC, indicating discrepancies between perceived maternal care capabilities and those recommended in current LoMC guidelines. Results highlight an opportunity for states to engage with facilities, health systems, and other stakeholders about LoMC and collaborate to strengthen systems for improving maternal care delivery.

Impact of regionalisation and case-volume on neonatal and perinatal mortality: an umbrella review.

ObjectiveThis umbrella review summarises and critically appraises the evidence on the effects of regulated or high-volume perinatal care on outcome among very low birth weight/very preterm infants born in countries with neonatal mortality <5/1000 births.Intervention/expositionPerinatal regionalisation, centralisation, case-volume.Primary outcomesDeath.Secondary outcomesDisability, discomfort, disease, dissatisfaction.MethodsOn 29 November 2019 a systematic search in MEDLINE and Embase was performed and supplemented by hand search. Relevant systematic reviews (SRs) were critically appraised with A MeaSurement Tool to Assess systematic Reviews 2.ResultsThe literature search revealed 508 hits and three SRs were included. Effects of perinatal regionalisation were assessed in three (34 studies) and case-volume in one SR (6 studies). Centralisation has not been evaluated. The included SRs reported effects on ‘death’ (eg, neonatal), ‘disability’ (eg, mental status), ‘discomfort’ (eg, maternal sensitivity) and ‘disease’ (eg, intraventricular haemorrhages). ‘Dissatisfactions’ were not reported. The critical appraisal showed a heterogeneous quality ranging from moderate to critically low. A pooled effect estimate was reported once and showed a significant favour of perinatal regionalisation in terms of neonatal mortality (OR 1.60, 95% CI 1.33–1.92). The qualitative evidence synthesis of the two SRs without pooled estimate suggests superiority of perinatal regionalisation in terms of different mortality and non-mortality outcomes. In one SR, contradictory results of lower neonatal mortality rates were reported in hospitals with higher birth volumes.ConclusionsRegionalised perinatal care seems to be a crucial care strategy to improve the survival of very low birth weight and preterm births. To overcome the low and critically low methodological quality and to consider additional clinical and patient-reported results that were not addressed by the SRs included, we recommend an updated SR. In the long term, an international, uniformly conceived and defined perinatal database could help to provide evidence-based recommendations on optimal strategies to regionalise perinatal care.PROSPERO registration numberCRD42018094835.

Improving perinatal regionalization: 10 years of experience with an Arkansas initiative.

To examine the impact of Antenatal and Neonatal Guidelines, Education and Learning Systems (ANGELS) on neonatal intensive care unit (NICU) preterm delivery rates. In this longitudinal observational study, linked vital records and Medicaid claims records for 29,124 preterm births (April 2001-December 2012) to Medicaid covered women were used to examine factors predicting whether deliveries occurred at hospitals with neonatology-staffed NICUs. The factors associated with delivery are estimated and compared for baseline and three post-implementation periods. Rates for NICU preterm deliveries increased from 28 to 37% over the time period. Compared to baseline, adjusted NICU delivery rates in the middle and late implementation periods were statistically significant (p < 0.001). Negative impacts of long travel times were reduced, while impacts of obstetrician prenatal care changed from negative to positive association. Findings validate the ANGELS initiative premise: academic specialists, working with community-based care providers, can improve perinatal regionalization.

Perinatal regionalization system: efficiency analysis

The first principles and fundamental elements of perinatal regionalization were formulated more than 40 years ago. Over the past years this organizational model was substantially complicated and modernized. Numerous large, population-based studies describe and analyze the effects of perinatal regionalization, propose and study the possible directions of its development. It has been proven that the bed capacity of the obstetric hospital and the flow of extremely premature newborns in the hospital largely determine the outcome of the premature newborn, morbidity, mortality, long-term results, affecting important population indicators, neonatal and infant mortality. The review summarizes the data on available population studies, outlines the basic principles of the formation and development of the perinatal regionalization system.

Time of Birth and the Risk of Severe Unexpected Complications in Term Singleton Neonates.

To assess whether there is a relationship between evening, night, and weekend births and severe unexpected neonatal morbidity in low-risk term singleton births. We conducted a population-based, cross-sectional analysis. Severe unexpected neonatal morbidity as defined by the National Quality Forum specification 0716 was derived from linked birth certificate and hospital discharge summaries for 1,048,957 low-risk singleton term Californian births during 2011 through 2013. The association between the nursing shift (7 am-3 pm vs 3-11 pm and 11 pm -7 am) and weekday compared with weekend birth and the risk of severe unexpected neonatal morbidity was estimated using mixed effects logistic regression models. Severe unexpected neonatal morbidity was higher among births during the 3-11 pm evening shift (2.1%) and the 11 pm-7 am night shift (2.1%), compared with those during the 7 am-3 pm day shift (1.8%). The adjusted odds ratios (ORs) were 1.10 (95% CI 1.06-1.13) for the evening shift and 1.15 (1.11-1.19) for the night shift. The adjusted ORs of severe unexpected neonatal morbidity were increased only on Sunday, as compared with other days (adjusted OR 1.08, 95% CI 1.02-1.14). When our analysis was by perinatal region, the increase was seen in four of the nine perinatal regions. After risk adjustment, the risk of severe unexpected morbidity in the low-risk singleton California birth cohort was significantly increased on Sundays and births during evening and night shifts. These elevations were detected in only four of California's nine perinatal regions. Further analysis at the individual hospital level is warranted.

The changing landscape of perinatal regionalization

Regionalization, which emphasizes matching patient needs with the capabilities of the hospital in which care is provided, has long been a recommended approach to reducing neonatal morbidity and mortality. Over the past decade, research methods surrounding the measurement and evaluation of such programs have improved, thus strengthening arguments for implementation of these strategies. However, regionalization policies vary widely across regions and between countries, with potential impacts on neonatal outcomes as well as costs of care. It is important to account for geographic and other regional differences when determining the feasibility of regionalization for a specific region, as certain areas and populations may need particular consideration in order for regionalization policies to be successful.

Quality and Safety of Pediatric Inpatient Care in Community Hospitals: A Scoping Review.

Although the majority of children are hospitalized in nonchildren's hospitals, little is known about the quality and safety of pediatric care in community hospitals. The aim of this study was to conduct a scoping review and synthesize literature on the quality and safety of pediatric inpatient care in United States community hospitals. We performed a systematic literature search in October 2016 to identify pediatric studies that reported on safety, effectiveness, efficiency, timeliness, patient-centeredness, or equity set in general, nonuniversity, or nonchildren's hospitals. We extracted data on study design, patient descriptors, and quality outcomes and assessed the risk of bias using modified Newcastle-Ottawa Scales. A total of 44 articles met the inclusion criteria. Study designs, patient populations, and quality outcome measures were heterogeneous; only three clinical domains, (1) perinatal regionalization, (2) telemedicine, and (3) imaging radiation, were explored in multiple studies with consistent directionality of results. A total of 30 studies were observational, and 22 studies compared community hospital quality outcomes with other hospital types. The remaining 14 studies reported testing of interventions; 12 showed improved quality of care postintervention. All studies reported an outcome addressing safety, effectiveness, or efficiency, whereas timeliness, patient-centeredness, and equity were infrequently addressed. Risk of bias was moderate or high for 72% of studies. Literature on the inpatient care of children in community hospitals is limited, making it difficult to evaluate healthcare quality. Measures of timeliness, patient-centeredness, and equity are underrepresented. The field would benefit from more multicenter collaborations to facilitate the application of robust study designs and to enable a systematic assessment of individual interventions and community hospital quality outcomes.

Obstetric Care Consensus #9: Levels of Maternal Care: (Replaces Obstetric Care Consensus Number 2, February 2015)

Maternal mortality and severe maternal morbidity, particularly among women of color, have increased in the United States. The leading medical causes of maternal mortality include cardiovascular disease, infection, and common obstetric complications such as hemorrhage and vary by timing relative to the end of pregnancy. Although specific modifications in the clinical management of some of these conditions have been instituted, more can be done to improve the system of care for high-risk women at facility and population levels. The goal of levels of maternal care is to reduce maternal morbidity and mortality, including existing disparities, by encouraging the growth and maturation of systems for the provision of risk-appropriate care specific to maternal health needs. To standardize a complete and integrated system of perinatal regionalization and risk-appropriate maternal care, this classification system establishes levels of maternal care that pertain to basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV). The determination of the appropriate level of care to be provided by a given facility should be guided by regional and state health care entities, national accreditation and professional organization guidelines, identified regional perinatal health care service needs, and regional resources. State and regional authorities should work together with the multiple institutions within a region, and with the input from their obstetric care providers, to determine the appropriate coordinated system of care and to implement policies that promote and support a regionalized system of care. These relationships enhance the ability of women to give birth safely in their communities while providing support for circumstances when higher level resources are needed. This document is a revision of the original 2015 Levels of Maternal Care Obstetric Care Consensus, which has been revised primarily to clarify terminology and to include more recent data based on published literature and feedback from levels of maternal care implementation.

Volume of Neonatal Care and Survival without Disability at 2 Years in Very Preterm Infants: Results of a French National Cohort Study

To investigate the relation between neonatal intensive care unit (NICU) volume and survival, and neuromotor and sensory disabilities at 2years in very preterm infants. The EPIPAGE-2 (Etude Epidémiologique sur les Petits Âges Gestationnels-2) national prospective population-based cohort study was used to include 2447 babies born alive in 66 level III hospitals between 24 and 30 completed weeks of gestation in 2011. The outcome was survival without disabilities (levels 2-5 of the Gross Motor Function Classification System for cerebral palsy with or without unilateral or bilateral blindness or deafness). Units were grouped in quartiles according to volume, defined as the annual admissions of very preterm babies. Multivariate logistic regression analyses with population average models were used. Survival at discharge was lower in hospitals with lower volumes of neonatal activity (aOR 0.55, 95% CI 0.33-0.91). Survival without neuromotor and sensory disabilities at 2years increased with hospital volume, from 75% to 80.7% in the highest volume units. After adjustment for gestational age, small for gestational age, sex, maternal age, infertility treatment, multiple pregnancy, principal cause of prematurity, parental socioeconomic status, and mother's country of birth, survival without neuromotor or sensory disabilities was significantly lower in hospitals with a lower volume of neonatal activity (aOR 0.60, 95% CI 0.38-0.95) than in the highest quartile hospitals. These results suggest that lower neonatal intensive care unit volume is associated with lower survival without an increase in disabilities at 2years. These results could be useful to generate improvements of perinatal regionalization.

Impact of Rural Hospital Closures on Patient Outcomes in a Perinatal Region of Georgia [4E

Impact of Rural Hospital Closures on Patient Outcomes in a Perinatal Region of Georgia [4E

Incidence and risk factors for moderate and severe bronchopulmonary dysplasia in very low birth weight infants in two Croatian perinatal regions – a retrospective cohort study

Introduction: Bronchopulmonary dysplasia (BPD) is a significant cause of mortality and morbidity in preterm infants. The incidence of BPD varies widely between centers and is found in 20% to 40% of very low birth weight (VLBW) infants. Our work aimed to examine the incidence and risk factors for moderate and severe BPD in a population of VLBW infants. Materials and methods: Demographic data, risk factors, incidence and severity of BPD were analyzed for 178 VLBW infants treated in two Croatian perinatal regions (2 level III neonatal units, 2 level II neonatal units and 5 level I neonatal wards) in the period from January 1, 2014 to December 31, 2016. Results: The rate of BPD was 59.6% (106/178) which is significantly higher than reported earlier. Mild BPD accounted for 65.1% (69/106) and moderate/severe BPD is found in 34.9% (37/106) infants. Among infants with ≤ 28 weeks of gestation, the rate of moderate and severe BPD was 40.5% (30/74). Ultimate risk factors for the development of moderate/severe BPD were late-onset sepsis (p = 0.03; OR [95% CI]: 4.76 [1.22-18.5]), and higher initial neonatal risk as expressed by Critical Risk Index for Babies (CRIB) score (p < 0.001; OR [95% CI]: 1.73 [1.32-2.29]). Conclusion: The incidence of moderate and severe BPD in our study group is higher than previously reported, and the majority of affected infants are < 29 weeks of gestation. The factors that had the strongest influence on the development of moderate and severe BPD were a higher initial neonatal risk as expressed by CRIB score and late-onset sepsis.

687: Rural obstetrical unit closures and preterm delivery rates at a regional perinatal center in georgia

To determine if rural obstetrical unit closures within our perinatal region from 2012-2015 impacted rates of preterm delivery at Augusta University Medical Center, which functions as the designated regional perinatal center. A retrospective chart review was conducted within the Department of Obstetrics and Gynecology at Augusta University Medical Center in Augusta, Georgia. The National Institute of Health’s (NIH) Informatics for Integrating Biology and the Bedside (I2B2) software was used to identify charts corresponding to patients seen at our institution for obstetrical services between the period of January 1, 2010-December 31, 2011 to January 1, 2015-December 31, 2016. Clinical outcomes between the January 1, 2010-December 31, 2011 cohort and January 1, 2015-December 31, 2016 cohort were compared. The I2B2 software was able to extrapolate 2562 charts corresponding to the 2010-2011 period and 3534 charts corresponding to the 2015-2016 period for a total of 6096 charts. 1501 charts from the 2010-2011 period were found to be appropriate for study inclusion. This amounted to 74.60% (1501/2012) of our total hospital deliveries during that period. 2071 charts from the 2015-2016 period were found to be appropriate for study inclusion. This amounted to 71.17% (2071/2910) of our total hospital deliveries during that period. Gestational age at time of delivery were categorized as: early preterm (< 34.0 weeks), late preterm (34.0-36.6 weeks), early term (37.0-38.6 weeks), full term (39.0-40.6 weeks), late term (41.0- 41.6 weeks), and post-term (> 42.0 weeks). As seen in table 1, rates of early and late preterm deliveries remained relatively unchanged at 8.00% to 7.79% and 10.27% to 10.21%, respectively. The rate of early term deliveries decreased from 33.20% to 27.59%. The rate of full term deliveries increased from 46.0% to 50.7%. The rate of late and post term deliveries remained relatively constant. The differences of proportions among gestational age categories for years 2010-11 and 2015-2106 were found to be statistically significant (p=0.0038). The rate of preterm delivery at Augusta University Medical Center does not appear to have been impacted by rural obstetrical unit closures in the 2012-2015 time period.

A State Level Analysis of Factors Impacting Very Preterm Births at Non-Level III Hospitals

Background: The national Collaborative Improvement and Innovation Network to Reduce Infant Mortality set a national goal that 90% of very preterm (VPT, < 32 weeks gestation) infants be delivered at a hospital with a level III neonatal intensive care unit (NICU). Illinois has employed perinatal regionalization since the 1970s but still has not met the national goal for risk-appropriate care. This study aimed to identify factors associated with birth of VPT babies at inappropriate levels of care. Methods: Each Illinois non-Level III perinatal hospital was asked to complete review forms for VPT live births occurring at their facility during …