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Maternal comorbidity and the feasibility of regionalization of maternity care
Abstract Number: S1A-1
Abstract Type: Original Research
Introduction: Regionalization of maternity care by referring high-risk women to hospitals equipped to manage their comorbidities is a strategy proposed to reduce maternal mortality. Little evidence supports the feasibility of this approach. We sought to describe the current landscape of regionalization and examine risk factors associated with delivery at an inappropriately low-level center.
Methods: We linked the 2014 American Hospital Association (AHA) survey to the State Inpatient Databases (SID) from 7 representative states. We used national guidelines to identify maternal comorbidities in the SID and assign each patient to an appropriate level of care hospital. We then used the obstetric levels of care designated within the AHA survey (level 1 or basic care, level 2 or specialty care, and level 3 or subspecialty care) to define hospitals' resources and capacities. We compared maternal comorbidities to hospital level and classified each delivery as occurring at an appropriate or inappropriate center. We used multivariable logistic regression to define the independent association between patients' comorbidities and the likelihood of delivery at an inappropriate low-level center.
Results: There were 751,773 deliveries in 449 hospitals with 18% (n=135,036) at the 168 level 1 centers, 29% (n=215,600) at 134 level 2 centers, and 53% (n=401,137) at 147 level 3 centers. Ninety-seven percent of all deliveries were at appropriate centers. The strength of the association with delivering at an inappropriate facility varied by medical condition from an adjusted odds ratio (aOR) of 1.11 (95% confidence interval (CI) 0.91-1.36) for preterm chronic hypertension to an aOR of 38.22 (95% CI 34.84-41.94) for epilepsy (Table). Women with compounding diseases like previa with prior cesarean were more likely to be delivered at an inappropriate center than those with isolated comorbidities like previa alone.
Conclusion: Overall, only 3% of patients delivered at inappropriately low level center, suggests that regionalization is feasible without dramatic changes in the organization of contemporary obstetric practice. However, approximately a third of women with certain high-risk medical conditions or compounding diseases delivered at facilities suboptimally equipped to address their needs. Targeting women with these indications for referral will be an important and attainable component of the strategy to optimize regionalization and decrease maternal morbidity and mortality.