What Hospital Leaders Need to Know About Maternal Levels of Care

Several states have recently adopted maternal level of care designations to improve care standards. Learn about maternal leveling and how it can have a major impact on the maternal mortality rate in the U.S.
What Hospital Leaders Need to Know About Maternal Levels of Care
Featured Speakers:
Charles Jaynes, MD | Senior Director of Medical Operations
Dr. Charlie Jaynes joined Ob Hospitalist Group in 2011. He is a hospitalist at St. David's North Austin Medical Center and serves as the Senior Director of Medical Operations for our hospitalist programs nationwide. 

Learn more about Charles Jaynes, MD
What Hospital Leaders Need to Know About Maternal Levels of Care

Prakash Chandran (Host):  Several states have recently adopted maternal level of care designations to improve care standards. Learn about maternal leveling and how it can have a major impact on the maternal mortality rate in the US. Let’s talk about it today with Dr. Charles Jaynes, the Senior Director of Medical Operations at OB Hospitalist Group. This is the Obstetrics Podcast from OB Hospitalist Group. I’m Prakash Chandran. So, Dr. Jaynes, can you give us a little bit of background on your role with OB Hospitalist Group and your experience as an OB-GYN?

Charles Jaynes, MD (Guest):  Sure. I’ve been in practice now for about 42 years. And I work as a Senior Director for Medical Operations. I’m a Medical Director and I have direct oversight for multiple programs in the state of Texas and then I have some general oversight responsibility for OB Hospitalist Group as a role I work under a Chief Medical Officer Dr. Mark Simon out of Denver, Colorado.

Host:  Okay great. And I’d love to hear a little bit about your perspective on the current landscape of maternal care in the US.

Dr. Jaynes:  Sure, that – the current landscape I think is a disaster right now. Maternal mortality in the United States in 2018 was at a rate of about 20 per 100,000 deaths compared to industrial nations across the world with a rate of about 20 per 100,000. In Texas and specific where I live, and practice rate was 30.4 per 100,000 last year. And importantly the near miss rate which means women that almost died ended up with a serious event in the ICU was 195 per 100,000. So, we definitely have a real problem. We have a model we can follow and that’s the state of California and what they’ve done applying the same principles that are used in maternal level care designation and they’ve reduced their maternal mortality rate to 4.6 per 100,000 last year. Which is a phenomenally good rate and much better than industrial nations.

Host:  And just at a high level, what do you attribute this terrible maternal mortality rate to, especially in an industrial country like the US?

Dr. Jaynes:  I think that part of it is access to care. We don’t have a universal policy regarding obstetrics. I think part of it has to do with the level of training of medical staff. One issue is scalability of system and so it is not standardized to transport a patient that has a high risk pregnancy to a center capable of providing that care. And the fourth issue is the issue of a change in morbidity. Obesity, hypertension ate two huge factors in the increase in the maternal mortality rate.

Host:  You mentioned California. So, I’m curious as to what some states like California are doing to reduce their maternal mortality rate?

Dr. Jaynes:  Yeah in 2005, California realized that they had a real issue with their maternal mortality rate, and they applied really system solutions and so they – they mimic the airline industry in a way. They put in standardized protocols. Everybody is familiar with the California coop, UCM QCC and they’ve introduced multiple protocols that are standardized for the state. They are research based and they are updatable all of the time. And that is one of the issues. The second issue is accountability. The staff providing the obstetrical care from the nursing staff to the doctor staff and even the administrative staff has accountability and they are very carefully tracking outcomes and that is shared across the state, across the system.

And all of those are huge factors. I don’t know that they have really had an impact in terms of universal care, but the other factors have made a real difference and they are now the envy of the industrial world in terms of their maternal morbidity and mortality.

Host:  Yeah, I can see why that’s the case. We’re talking specifically around maternal levels of care today so, I’m curious as to what the levels are and what the purpose of these requirements are?

Dr. Jaynes:  In 2015, the American College of Obstetricians and Gynecologists in conjunction with the Society of Maternal Fetal Medicine introduced a joint statement that advocated for maternal level care and their system had five levels. In Texas, where I work, we have four levels. And basically is simply applying – it takes away the silo of care and gives you a scalable system across four levels where you have the lowest level of care which is certainly a good level of care which is appropriate for low risk pregnancies up to the highest level of care which is very specialized and has all of the attributes needed to address the worst cases but resources are focal in one small area. Because very few patients really need those resources.

So, it’s about learning how to scale that to identify patients who are at high risk and have a basic level of emergency response for stabilization at the lowest level moving up through the different levels to a transport when necessary to the highest level care that has the resources to deal with the worst complications. And it takes as you can imagine, it takes coordination at the state level. It’s takes cooperation at the hospital level. It has an impact on the finances of the hospital because they’re going to be sending out patients that they may have tried to keep before but that they really didn’t have the ability to manage appropriately. So, it’s going to take something that occurs over a period of time. But California has demonstrated well that it can be done. They have reduced their mortality rates by a factor of 4 over the last 15 years.

Host:  Got it so using California as a template, I’m assuming that you believe this holistic approach can really impact the national maternal mortality crisis, right?

Dr. Jaynes:  Absolutely. And when you couple maternal level of care to something called the AIM program, the AIM bundles, which are – AIM stands for the Alliance for Integration of Maternal Health. When you put those bundles which are modeled after the California protocols and they include things like acute hypertensive crisis management, pot partum hemorrhage management, opioid reduction management, those kinds of protocols and you couple those with the maternal level of care; you have protocol training at every level one through four in the state of Texas. Right now we have over 230 hospitals in Texas that are participating in implementing of the AIM protocols.

At the same time, you have to have leadership instill protocols that are standardized and the American College of OB-GYN in conjunction with the Nursing National leadership AWON, have come up with standardized protocols in something called the Alliance for Initiative of Maternal Health the AIM protocols and in Texas, the state department of health is instituting those AIM protocols at the same time and on an independent track that we are going with the maternal level of care designation. You put those two things together and over 230 hospitals in the state at any level of designation you are going to have standardized protocols that can help address, stabilize and treat the issues that are causing increased maternal morbidity and mortality and then in conjunction with that you have a scalable system with reporting and reporting lack of data across the entire system that allows you to refer the identified high risk patients to the highest level of care.

And when you put those two together, that’s exactly the kind of systemic change that California made that lead to their significant improvement in maternal mortality.

Host:  And you know Dr. Jaynes, I’d love to learn a little bit more about what specifically the levels are. You talked about the lowest to the highest and where those different protocols fit in, but what exactly are the levels and what happens at each of them?

Dr. Jaynes:  Yeah let me give you the from 2015 the joint statement from ACOG and Society of Maternal Fetal Medicine. They actually have five levels. The first level is the level of a birthing center which is controlled by federal legislation and is uniform across the country for the requirements of having a birthing center. The second level is a community hospital that may be staffed by board certified OB-GYN doctors, it may also be staffed by Family Practitioners who are doing OB. It may be staffed by certified nurse midwives in conjunction with the other two. Then you have a level above that where you have a specialty hospital where you have primarily OB-GYNs, sometimes Family Practitioners in conjunction working at a specialty level and those contain units which a high level neonatal nursery designation and they have an ICU and they have the bells and whistles to do 98% of what needs to be done on these patients.

Above that, you have what’s called the level four which is you have a doctor on the deck 24/7. So, there’s an OB-GYN doctor specifically there to act as emergency first responder for any patient that walks through the door whether or not you have a relationship with them. They also have advanced care in terms of medical specialties. They can help take care of ill patients. They have surgical specialists such as oncologists that are involved and they have high level intensive care units. Then you go to the highest level which the analogy would be the medical center level which can provide care for any level of disease both neonatal and maternal and has all of the appropriate staffing from maternal fetal medicine, oncologists, intensivists in the ICU, hospitalists on the deck including pediatric hospitalists, OB hospitalists. They have the full range of specialties to help care for the patient and the neonate.

Host:  Yeah, I can really see how this first and foremost drives awareness but secondly, following these comprehensive set of procedures within each level can really reduce that maternal mortality crisis in this country. So, as we wrap up here, I’ve heard that hospitals in many rural areas are actually closing their labor and delivery units and I’m curious as to how the maternal level of care standardization can help women in these areas?

Dr. Jaynes:  The attention of maternal level of care specifically as it maintains those hospitals because as I said earlier, part of the initiative is to help develop protocols that identify women at high risk. And having identified that small segment of the population, allow those patients to be sent on for a high level of care before they become an emergency. And then giving the capability through things like AIM protocols to teach the staff how to stabilize these worst events that occur so they can be sent to a high level when they occur spontaneously in the middle of the night and that involves the transport system, it involves regional coordination and all of those things now in Texas are moving towards a unified direction because of this maternal level of care designation that was laid out by the state legislature as early as 2013.

So, I’m really confident that by 2025, you’ll see a significant reduction in maternal mortality beginning in the state of Texas.

Host:  All right Dr. Jaynes. Well I really appreciate your time today. that’s Dr. Charles Jaynes, Senior Director of Medical Operations at OB Hospitalist Group. Thanks for checking out this episode of the Obstetrics Podcast. To find out more about a potential OBHG partnership, visit www.obhg.com/hospitals. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. Thanks and we’ll talk next time.