OBSTETRICS Cross-sectional survey of California childbirth hospitals: implications for defining maternal levels of risk-appropriate care Q2 Lisa M. Korst, MD, PhD; Daniele S. Feldman, MD; D. Lisa Bollman, RN, MSN; Moshe Fridman, PhD; Samia El Haj Ibrahim, MPH; Arlene Fink, PhD; Kimberly D. Gregory, MD, MPH 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. Key words: childbirth hospital services, hospital staffing, maternal health, maternal levels of care, risk-appropriate care Cite this article as: Korst LM, Feldman DS, Bollman DL, et al. Cross-sectional survey of California childbirth hospitals: implications for defining maternal levels of risk-appropriate care. Am J Obstet Gynecol 2015;213:xx-xx. W orsening measures of maternal mortality and severe morbidity have begun to gain national attention. 1 From 1987 to 2009, the pregnancy- related mortality ratio rose steadily from 7.2 to 17.8 deaths per 100,000 live births, 2 and recent studies have esti- mated that at least 40% of maternal deaths appear to be preventable. 3-6 Recent publications have also recog- nized steadily increasing rates of severe obstetrical complications 6-9 showing substantial racial disparity, with eleva- tions among African-Americans and women of Hispanic ethnicity. 3,9,10 Ac- cording to Kuklina et al, 6 renal failure, pulmonary embolism, adult respira- tory distress syndrome, shock, blood Q1 From Childbirth Research Associates, North Hollywood (Dr Korst); Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Burns Allen Research Institute (Drs Feldman and Gregory and Ms El Haj Ibrahim); AMF Consulting (Dr Fridman); Division of General Internal Medicine and Health Services Research, Department of Medicine (Dr Fink), and Department of Obstetrics and Gynecology (Dr Gregory), David Geffen School of Medicine at UCLA; and Departments of Health Policy and Management (Dr Fink) and Community Health Sciences (Dr Gregory), Fielding School of Public Health at UCLA, Los Angeles; Community Perinatal Network, Yorba Linda (Ms Bollman); and Langley Research Institute, Pacific Palisades (Dr Fink), CA. Received April 16, 2015; revised May 20, 2015; accepted July 13, 2015. The funding sources had no involvement in the conduct of the research or in the preparation of the manuscript. This study was supported by Agency for Healthcare Research and Quality grant 5 R01 HS020915 (all investigators except D.S.F.). Additional support was provided by the March of Dimes (L.M.K., M.F., and D.L.B.) and by the American Congress of Obstetricians and Gynecologists/Duchesnay USA Research Award in Quality Improvement in Maternity Care (D.S.F.). The authors report no conflict of interest. Corresponding author: Kimberly D. Gregory, MD, MPH. gregory@cshs.org 0002-9378/$36.00  ª 2015 Elsevier Inc. All rights reserved.  http://dx.doi.org/10.1016/j.ajog.2015.07.014 MONTH 2015 American Journal of Obstetrics & Gynecology 1.e1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 FLA 5.2.0 DTD  YMOB10528_proof  28 July 2015  9:51 pm  ce Research ajog.org