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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
MCHbest. Risk-Appropriate Perinatal Care.

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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. A 2014 Neonatal assessment identified 22 states that had a policy on regionalized care. Levels vary in consistency with the American Academy of Pediatrics. (AAP) Policy.[1] A 2018 Maternal assessment identified 17 states that are incorporating maternal care policies. Levels vary in consistency with the Society for Maternal-Fetal Medicine. (SMFM)/American College of Obstetricians and Gynecologists. (ACOG) guidelines.[2]

Evidence. Moderate Evidence. Strategies with this rating are likely to work. These strategies have been tested more than once and results trend positive overall; however, further research is needed to confirm effects, especially with multiple population groups. These strategies also trend positive in combination with other strategies. (Clarifying Note: The WWFH database calls this "some evidence").

Access the peer-reviewed evidence through the MCH Digital Library or related evidence source. (Read more about understanding evidence ratings).

Source. Peer-Reviewed Literature

Outcome Components. This strategy has shown to have impact on the following outcomes (Read more about these categories):

  • Safety of Care. This study promotes avoidance of preventable harm to patients during healthcare delivery.
  • Morbidity Reduction. This strategy addresses factors that can decrease the incidence or prevalence of diseases and illnesses.
  • Mortality Prevention. This strategy addresses factors that are associated with preventing death, particularly premature death from preventable causes.

Detailed Outcomes. For specific outcomes related to each study supporting this strategy, access the peer-reviewed evidence and read the Intervention Results for each study.

Intervention Type. Policy Development and Enforcement (Read more about intervention types and levels as defined by the Public Health Intervention Wheel).

Intervention Level. Population/Systems-Focused

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.

Sample ESMs. Here are sample ESMs to use as models for your own measures using the Results-Based Accountability framework (for suggestions on how to develop programs to support this strategy, see The Role of Title V in Adapting Strategies).

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

PROCESS MEASURES:

  • Number of states that adapted AAP and ACOG/SMFM guidelines to address unique local needs while maintaining core standards. (Assesses alignment with evidence-based approaches)
  • Number of hospitals that incorporated health literacy principles in their level-of-care designation communications. (Evaluates use of health literacy principles)

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

PROCESS MEASURES:

  • Percent of hospitals adhering to national quality benchmarks for their designated level of care. (Evaluates adherence to quality standards)
  • Percent of level-of-care verification process that included representation from community partners. (Assesses authentic engagement)

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

PROCESS MEASURES:

  • Number of cross-facility training programs established to support providers in meeting level-specific care requirements. (Shows provider training and capacity)
  • Number of state perinatal quality collaboratives that integrated level-of-care standards into their improvement initiatives. (Assesses integration into existing plans)

OUTCOME MEASURES:

  • Number of maternal and neonatal complications prevented through appropriate level-of-care placement. (Measures clinical impact)
  • Number of policy changes implemented to support risk-appropriate care based on standardized levels. (Assesses system-level improvements)

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

PROCESS MEASURES:

  • Percent of rural and urban hospitals assessed for level-of-care designation, disaggregated by community socioeconomic status. (Evaluates reach in assessment)
  • Percent of state perinatal quality collaboratives that integrated level-of-care standards into their improvement initiatives. (Assesses integration into existing plans)

OUTCOME MEASURES:

  • Percent reduction in gaps for adverse maternal and neonatal outcomes, stratified by key characteristics. (Measures impact)
  • Percent improvement in risk-appropriate care access for various communities compared to baseline. (Assesses strategic deployment of resources)

Note. When looking at your ESMs, SPMs, or other strategies:

  1. Move from measuring quantity to quality.
  2. Move from measuring effort to effect.
  3. Quadrant 1 strategies should be used sparingly, when no other data exists.
  4. The most effective measurement combines strategies in all levels, with most in Quadrants 2 and 4.

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

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.