Maternal mortality, near misses, and severe morbidity: lowering rates through designated levels of maternity care.

An increase in the prevalence of obesity, hypertension, diabetes, and abnormal placentation, among others, has fueled the recent rise in maternal mortality, "near misses" and severe morbidity. In 1976, the March of Dimes published a report, "Toward Improving the Outcome of Pregnancy," which included recommendations for levels of perinatal care. Although the original intent was to address the needs of both mother and neonate, implementation in the ensuing years focused mostly on the latter. Currently, there are no well-defined nationally accepted levels of maternal care similar to those adopted by the American Academy of Pediatrics for neonatal intensive care units. When discussing regionalization of perinatal care, the needs of the mother are frequently overlooked. We propose that it is time to address this deficiency and develop levels of care that are specific to the mother. We expect that improving maternal care will also improve neonatal outcome. We call on various organizations and agencies to establish national standards and levels of maternity care much as our colleagues in neonatology have already successfully done. We canvassed the available publications by states and other countries and found a number of noteworthy examples. We propose that the goal would be an integrated maternal-fetal-neonatal care network, a model similar to what is done in stroke or emergency care. In addition to accepting transfers, the central facility functioning at the highest level would also be responsible for education, evidence-based best practices, policy development, and quality review and improvement within the network.