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Strengthening the evidence base for maternal and child health programs

New: MCH Best strategies database for sample ESMs

Evidence Tools
MCH Best. NPM 3: Risk-Appropriate Perinatal Care

MCH Best Logo finger touching the foot of a small newborn in an incubator

Strategy. Adopt Standard Definitions for Hospital Level of Care

Approach. Define Hospital Levels of Neonatal care and Levels of Maternal Care using AAP and ACOG/SMFM guidelines.*

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Overview. Perinatal Regionalization of care ensures that mothers and newborns who are at highest risk for morbidity or mortality deliver at birthing facilities that are equipped with appropriate personnel, resources, and capabilities to meet their needs.

Evidence. Moderate. Evidence suggests that uniform definitions and consistent standards are necesary to implement and monitor regional systems. A 2014 Neonatal assessment identified 22 states that had a policy on regionalized care. Levels vary in consistency with the AAP Policy.1 A 2018 Maternal assessment identified 17 states that are incorporating maternal care policies. Levels vary in consistency with the SMFM/ACOG guidelines.2 (Read more about understanding evidence ratings).

Target Audience. Hospitals.

Outcome. Percent of Very Low Birth Weight (VLBW) infants born in the hospital within a Level III hospital + NICU.

Examples from the Field. Access descriptions of ESMs that use this strategy directly or intervention components that align with this strategy. You can use these ESMs to see how other Title V agencies are addressing the NPM.

In addition, the Texas DHHS has made the following advances in adopting standard definitions for hospital level of care:

Role of Title V. Title V agencies can design, fund, and manage implementation of perinatal systems in partnership with hospitals and perinatal profesionals:

For additional suggestions on how to develop programs to support this strategy, see The Role of Title V in Adapting Strategies.

Sample ESMs. Using the approach "Define Hospital Levels of Neonatal care and Levels of Maternal Care using AAP and ACOG/SMFM guidelines,” here are sample ESMs you can use as a model for your own measures using the Results-Based Accountability framework:

Quadrant 1:
Measuring Quantity of Effort
("What/how much did we do?")

  • Number of hospitals that have a defined care level based on AAP and ACOG/SMFM guidelines.

Quadrant 2:
Measuring Quality of Effort
("How well did we do it?")

  • Percent of hospitals that have a defined care level based on AAP and ACOG/SMFM guidelines.

Quadrant 3:
Measuring Quantity of Effect
("Is anyone better off?")

  • Number of hospitals that have a defined care level based on AAP and ACOG/SMFM guidelines that is clearly accessible to the provider community and the public.

Quadrant 4:
Measuring Quality of Effect
("How are they better off?")

  • Percent of hospitals that have a defined care level based on AAP and ACOG/SMFM guidelines that is clearly accessible to the provider community and the public.

Note. ESMs become stronger as they move from measuring quantity to measuring quality (moving from Quadrants 1 and 3, respectively, to Quadrants 2 and 4) and from measuring effort to measuring effect (moving from Quadrants 1 and 2, respectively, to Quadrants 3 and 4):

Learn More. Read how to create stronger ESMs and how to measure ESM impact more meaningfully through Results-Based Accountability.


Note and References:

* American Academy of Pediatrics (AAP), American College of Obstetricians and Gynecologists (ACOG), and Society for Maternal-Fetal Medicine (SMFM).

1 Kroelinger CD, Okoroh EM, Goodman DA, Lasswell SM, Barfield WD. Comparison of state risk-appropriate neonatal care policies with the 2012 AAP policy statement. J Perinatol 2018;38:411-420.
2 Vladutiu CJ, Minnaert JJ, Sosa S, Menard MK. Levels of Maternal Care in the United States: An Assessment of Publically Available State Guidlines.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.