ISSUE BRIEF

INPATIENT CARE LABOR AND DELIVERY

Maternal and neonatal levels of care designations for birthing centers and perinatal regionalization are nationally recognized, evidence-based strategies to improve maternal and perinatal outcomes. They improve outcomes, particularly infant mortality, by establishing coordinated systems among birthing facilities that provide different levels of maternal and neonatal care.^8,9 Such systems rely on the categorization of birthing facilities according to the services they offer to mothers and infants. Level I facilities meet the needs of women whose pregnancies are low-risk (>90% of births), and provide well-newborn nurseries for low-risk infants. As the level increases, so does the ability of the birthing facility to provide higher levels of specialized care and technology to care for mothers and infants with higher needs.^8,9 Perinatal regionalization builds on the levels of care designation by establishing systems that link lower level of care facilities to higher level of care facilities and guidelines for transfers between levels when mothers or infants need more specialized care.⁸ Such systems work to coordinate care and ensure that pregnant women and infants are cared for in “risk-appropriate” settings. While North Carolina has a system for assessing birthing facilities' level of care for infants, the guidelines have not been updated since 1996^a and do not match national best practice guidelines.

RECOMMENDATION 2.1:

Adopt National Maternal and Infant Risk-Appropriate Level of Care Standards

One of the beneficial aspects of the national levels of care system is the availability of a tool that allows a facility to objectively assess its capabilities and determine its true level of care. Through a partnership led by the Centers for Disease Control and Prevention (CDC), the Levels of Care Assessment Tool, or LOCATe, was developed to standardize assessments done by participating facilities on their neonatal and maternal levels of care.¹⁰

RECOMMENDATION 2.2:

Assess Levels of Care Utilizing the CDC LOCATe Tool

Under current North Carolina regulations, birthing facilities self-assess their neonatal level of care capabilities. To realize the full scope of advantages derived from implementing a regionalized perinatal system of care, the state should ensure birthing facilities are correctly identifying their level of care through external verifications.

RECOMMENDATION 2.3:

Require External Verification of Birthing Facilities' Maternal and Neonatal Level of Care Designations

Under the uniform national guidelines for neonatal and maternal levels of care, Level IV facilities not only provide care, but also act as regional leaders by facilitating collaboration among facilities, quality improvement activities, and education.⁸ For many years, North Carolina had a regional support system facilitated by a neonatal and perinatal outreach coordinator in each region; however, funding for these positions ended in 2009.¹¹

RECOMMENDATION 2.4:

Re-establish North Carolina's Perinatal and Neonatal Outreach Coordinator Program

PRECONCEPTION, PRENATAL, AND POSTPARTUM CARE

Access to and receipt of quality preconception and prenatal care is a critical step to improving maternal and birth outcomes. Adequate preconception and prenatal care are leading strategies to reduce infant mortality and pregnancy-related deaths.^12,13 Additionally, access to high-quality, consistent prenatal care is required in order to provide early and ongoing risk assessments, which make up the cornerstone of developing a risk-appropriate perinatal system of care. While the regional model of care is intended to help ensure that women have access to a well-integrated, risk-appropriate perinatal system of care, there remain structural, financial, and cultural barriers to care that must be eliminated in order to improve outcomes for women and infants.¹⁴ Access to care is particularly challenging for low income women and women that are undocumented immigrants.

RECOMMENDATION 3.1:

Expand Access to Health Care Services

Although most prenatal care is provided through individual office visits between pregnant women and their providers, there are other models of care that have been shown to positively impact maternal and infant outcomes for women, particularly women of color. In many cases, these models supplement the clinical prenatal care experience and facilitate community support and patient learning in environments women may find more supportive. Similarly, childbirth education models increase positive outcomes by simplifying the birthing process and decreasing rates of cesarean sections and prolonged labor periods.¹⁴

RECOMMENDATION 3.2:

Extend Coverage for Group Prenatal Care and Doula Support

RECOMMENDATION 3.3:

Increase the Utilization and Completion Percentages of Childbirth Education Classes

While data shows that the number of prenatal care providers across the state has been increasing in recent years, access to maternity care varies across the state, with some areas having few or no prenatal care providers.¹⁵ Women with low-risk pregnancies (>90% of pregnancies), meaning there are no complications or maternal or fetal factors that increase the risk of complications, can seek prenatal and labor and delivery care from many types of health care practitioners beyond gynecologists and obstetricians.⁸ Ensuring women have access to prenatal care is critical to improving the health and well-being of mothers and infants. One strategy used by many states to increase the number of providers of low-risk maternal care is allowing full practice authority for certified nurse-midwives, which allows them to provide care as independent providers.

RECOMMENDATION 3.4:

Full practice Authority for Certified Nurse-Midwives

While many women have mental health- and substance use-related needs during pregnancy, these needs may not be identified and adequately treated.^16–18 In North Carolina, most pregnant and postpartum women are screened for depression and substance use; however, services for those who screen positive vary widely.^19,20

RECOMMENDATION 3.5:

Standardize Screening and Treatment for Perinatal Mental Health and Substance Use

RECOMMENDATION 3.6:

Expand Perinatal Access to Mental Health Services

Efforts to improve health care typically focus on improving access to care and quality of care. Quality improvement (QI) activities involve analyzing current systems and processes for areas where changes could lead to improved outcomes and can happen at the state, regional, payor, health care system, practice, and individual provider level. Although QI has become a standard part of health care over the past 30 years, QI efforts have not been widely used to address the disparities seen across health care measures.³ The increase in maternal mortality in the United States, the slow rate of improvement in infant mortality, and the large disparities in outcomes for women and infants of color all point to the need for quality improvement efforts focused on perinatal care.

RECOMMENDATION 4.1:

Collect and Report Data on Maternal and Infant Outcomes by Race and Ethnicity

RECOMMENDATION 4.2:

Engage Insurers in Quality Improvement Efforts that Address Racial and Ethnic Disparities in Care

RECOMMENDATION 4.3:

Engage Birthing Facilities in Quality Improvement Efforts to Address Racial and Ethnic Disparities in Care

National guidelines recommend establishing relationships among birthing facilities to facilitate a risk-appropriate regional perinatal system of care; however, such a system does not account for the fact that most maternal care is provided in outpatient clinics.¹⁵ Just as women and infants will benefit as connections between birthing facilities providing different levels of care are improved and supported, they would also benefit from better connections between prenatal care providers, particularly among those providing low-risk prenatal care and those providing high-risk prenatal care or specialty care for pregnant women.

RECOMMENDATION 4.4:

Support Outpatient Risk-Appropriate Perinatal System of Care

Because of the potential for improved health outcomes and patient satisfaction, patient and family engagement has emerged as a critical strategy for improving the performance of our health care system. Creating opportunities throughout health care organizations for patients and family members to influence decisions, such as through patient and family advisory councils, can help ensure health care organizations are meeting the needs of the communities they serve.

RECOMMENDATION 4.5:

Create Patient and Family Advisory Councils

RECOMMENDATION 4.6:

Align Perinatal Care Regional Maps with Medicaid Transformation Maps

POSTPARTUM CARE

Improving maternal and infant outcomes does not end with delivery. While healthy birth outcomes are a critical step, they are not the end of the journey for women, infants, and families. Children who are born preterm, low birth weight, or with other health challenges often have lengthy neonatal intensive care unit (NICU) stays. Families with infants in the NICU often experience heightened stress and anxiety both during and after their infant's stay in the NICU.²¹ Parent navigators can help parents understand how the NICU works, what to expect, and how to advocate for their infants, both in the hospital and after they go home. Parents who have worked with NICU parent navigators report lower levels of stress, depression, and anxiety; increased confidence and well-being; and feel more empowered to interact with and care for their infants.²²

RECOMMENDATION 5.1:

Develop Parent Navigator Programs in Birthing Facilities

The weeks and months following birth are a critical period for families, setting the stage for long-term health and well-being. More than half of pregnancy-related maternal deaths occur after delivery, the majority of which are preventable.^23,24 However, many women go without health care after the 60-day postpartum period due to cost.¹⁵

See Recommendation 3.1: Expand Access to Health Care Services

IMPACT OF SOCIAL DETERMINANTS OF HEALTH ON PERINATAL HEALTH

The health and well-being of women and infants begins in their families and communities, and is largely determined by the social and economic contexts in which they grow up, live, work, and age; the health behaviors that those contexts make easier or harder to perform²; and their physical environments. Community health workers can serve as vital members of a health care team to address health-related social needs.

RECOMMENDATION 6.1:

Use Community Health Workers to Support Pregnant Women in Their Communities

Workplace environments and activities have a tremendous impact on pregnant women and their infants. The availability of pregnancy and breastfeeding accommodations, paid family and sick leave, affordable child care, and other benefits that support working mothers can improve health outcomes for women and babies.

RECOMMENDATION 6.2:

Implement Family-Friendly Workplace Policies