Levels of maternal care This document was developed jointly by the American College of Obstetricians and Gynecologists and the Society for MaternaleFetal Medicine with the assistance of M. Kathryn Menard, MD, MPH; Sarah Kilpatrick, MD, PhD; George Saade, MD; Lisa M. Hollier, MD, MPH; Gerald F. Joseph Jr, MD; Wanda Barfield, MD; William Callaghan, MD; John Jennings, MD; and Jeanne Conry, MD, PhD The information reflects emerging clinical and scientific advances as of the date issued, is subject to change, and should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice. Objectives  To introduce uniform designations for levels of maternal care that are complementary but distinct from levels of neonatal care and that address maternal health needs, thereby reducing maternal morbidity and mortality in the United States  To develop standardized definitions and nomenclature for facilities that provide each level of maternal care  To provide consistent guidelines ac- cording to level of maternal care for use in quality improvement and health promotion  To foster the development and equitable geographic distribution of full-service maternal care facilities and systems that promote proactive integration of risk-appropriate an- tepartum, intrapartum, and post- partum services Background In the 1970s, studies demonstrated that timely access to risk-appropriate neonatal and obstetric care could reduce perinatal mortality. In 1976, the March of Dimes and its partners first articulated the concept of an inte- grated system for regionalized per- inatal care in a report titled Toward Improving the Outcome of Pregnancy . 1 This report included criteria that stra- tified maternal and neonatal care into 3 levels of complexity, and recom- mended referral of high-risk patients to higher-level centers with the appro- priate resources and personnel needed to address their increased complexity of care. After the publication of the March of Dimes report, 1 most states devel- oped coordinated regional systems for perinatal care. The designated regional or tertiary care centers pro- vided the highest levels of obstetric and neonatal care, while serving smaller facilities’ needs through edu- cation and transport services. Numerous studies have validated the concept that improved neonatal out- comes were achieved through application of risk-appropriate ma- ternal transport systems. 2,3 A com- prehensive metaanalysis has shown increased odds of neonatal mortality for very low birthweight (very LBW, also commonly known as VLBW) infants (<1500 g) born outside of a level III hospital (38% vs 23%; adjusted odds ratio, 1.62; 95% con- fidence interval, 1.44e1.83). 4 Data indicate higher neonatal mortality for very low birthweight infants born in hospitals that are staffed by neonatologists in the absence of a more complete multidisciplinary team (level II), compared with those born in level III centers. 5 Since the March of Dimes report 1 was published, the conceptual frame- work of regionalization of care of the woman and the newborn has changed to focus almost entirely on the newborn. 6,7 The American College of Obstetricians and Gynecologists (ACOG) and the The authors report no conflict of interest. This article is being published in the February 2015 issue of Obstetrics & Gynecology (Obstet Gynecol 2015;125:502-15). Copyright February 2015 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2014.12.030 In the 1970s, studies demonstrated that timely access to risk-appropriate neonatal and obstetric care could reduce perinatal mortality. Since the publication of the Toward Improving the Outcome of Pregnancy report, more than 3 decades ago, the conceptual framework of regionalization of care of the woman and the newborn has been gradually separated with recent focus almost entirely on the newborn. In this current document, maternal care refers to all aspects of antepartum, intrapartum, and postpartum care of the pregnant woman. The proposed classification system for levels of maternal care pertains to birth centers, basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV). The goal of regionalized maternal care is for pregnant women at high risk to receive care in facilities that are prepared to provide the required level of specialized care, thereby reducing maternal morbidity and mortality in the United States. ACOG/SMFM Obstetric Care Consensus ajog.org MARCH 2015 American Journal of Obstetrics & Gynecology 259