Participating States & Success Stories
As of May 2022, a total of 25 states (Alabama, Arkansas, California, Colorado, Delaware, Georgia, Illinois, Iowa, Maine, Massachusetts, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New Mexico, North Carolina, Oklahoma, Tennessee, Utah, Vermont, Washington, West Virginia, and Wyoming), the southeast perinatal region of Michigan, and Puerto Rico have successfully implemented CDC LOCATeSM.
The rate of severe maternal morbidity in Massachusetts has increased over time, with notable racial and ethnic disparities. Levels of Maternal Care is one strategy to reduce morbidity by ensuring pregnant and birthing people have equitable access to delivery centers that appropriately address their level of risk. The Perinatal-Neonatal Quality Improvement Network of Massachusetts (PNQIN) assembled a task force to implement CDC LOCATeSM to understand available resources by hospital and region across Massachusetts.
The Betsy Lehman Center for Patient Safety, a nonregulatory state agency focusing on safety and quality, administered CDC LOCATeSM to the 40 hospitals providing obstetric services in Massachusetts. In addition to the standard CDC LOCATeSM questions, the assessment included questions about hospital training and quality improvement practices relevant to health equity and patient safety. All 40 hospitals participated on a voluntary basis. As a result of their involvement with CDC LOCATeSM, each hospital received a detailed report of their results and were invited to discuss quality improvement opportunities offered by PNQIN, including a discussion of discrepancies between hospital self-reported Level of Maternal Care and CDC LOCATeSM-assessed Level of Maternal Care when applicable. These efforts help optimize equitable risk-appropriate obstetric care for patients and families.
Montana implemented CDC LOCATeSM to assess levels of maternal and neonatal care and collect data about facility capacity and service delivery in the state. The Montana Obstetrics and Maternal Support (MOMS) program was initiated by a 5-year grant awarded to the Montana Department of Public Health and Human Services from the Health Resources and Services Administration to reduce maternal morbidity and mortality in the state.
Because of the unique geographic landscape of Montana, addressing challenges associated with rural obstetric care requires statewide coordination of all available perinatal care. MOMS facilitates quality improvement in maternal care through the Montana Perinatal Quality Collaborative and the Alliance for Innovation in Maternal Health initiative.
MOMS also established Montana’s Maternal Mortality Review Committee and implemented the CDC LOCATeSM assessment as part of a broader effort to identify areas for improvement. CDC LOCATeSM contributes to these initiatives by providing Montana’s maternal health partners and facilities with important information related to health care preparedness and risk-appropriate care. Montana added a module to the end of the CDC LOCATeSM assessment to gather additional information on provider training, transport, medical products, and accessibility.
As a result of participating in CDC LOCATeSM, Montana launched an emergency obstetric services assessment to assess capacity and preparedness in critical access hospitals without an obstetric unit (i.e., facilities that do not participate in CDC LOCATeSM). Paired with CDC LOCATeSM, this assessment will contribute to statewide conversations on perinatal regionalization. Moving forward, Montana will focus on linking CDC LOCATeSM data to maternal hospital discharge data, birth certificate data, and infant death certificate data to identify opportunities for improving risk-appropriate care in the state.
Georgia Department of Public Health staff wanted to use CDC LOCATeSM to compare hospitals’ self-assessment of levels of maternal and neonatal care to national guidelines. In addition, staff aimed to learn about the distribution of resources across the state for maternal and neonatal care. Health Department staff sent letters to all birth hospitals encouraging participation and then emailed the CDC LOCATeSM assessment link to nursing leadership. CDC analyzed the data and the Georgia Department of Public Health staff provided results to participating hospitals and to a research group to examine the role of level of care among maternal outcomes. As a result of participation in CDC LOCATeSM, stakeholders working in maternal and infant health started conversations about the need for a standardized state levels of care certification program. In 2018, the GA Legislature passed a level of care bill that established a voluntary program for assessment of levels of care.
The Illinois Department of Public Health was motivated to use CDC LOCATeSM to compare their state’s perinatal system to the AAP and ACOG guidelines for levels of care. Additionally, staff wanted to use CDC LOCATeSM results to inform policy decisions to improve care for mothers and infants. Health Department staff obtained buy-in from various stakeholders before proceeding with CDC LOCATeSM, including Department of Health leadership, nurse administrators that oversee the 10 perinatal centers, and the state Perinatal Advisory Committee. Department of Health staff emphasized the results would be used to evaluate the state system, not to assign levels of care to individual hospitals or for any regulatory/designation purposes. The state perinatal administrators helped distribute the materials to the hospitals and assured assessment completion for their network hospitals, resulting in a 100% response rate from the state’s 120 birthing hospitals. Following completion of CDC LOCATeSM, a state epidemiologist performed several analyses including describing current hospitals’ neonatal and maternal levels of care, the potential impact of changing levels of care to current national guidelines, as well as neonatal mortality across and within levels of care. The findings from these analyses assisted the state of Illinois in the adoption of the current AAP guidelines for neonatal levels of care.
Since 2007, the Department of Health (DOH) in Puerto Rico has worked to assess levels of care of their birth facilities, but discovered the tools they developed were not sufficient. Staff at DOH worked with CDC to translate CDC LOCATeSM into Spanish and to train the regional directors and health educators to complete the assessment in person at each facility. An analysis of maternal and neonatal outcomes by level of care and by hospital capabilities or protocols was performed. The findings were discussed with each participating hospital and recommendations for quality services according to their level of care was provided. With this information combined with the Maternal and Neonatal Care Guidelines, facilities now have the necessary tools to evaluate their performance and improve their services according to their level of care. The implementation of CDC LOCATeSM encouraged conversations around emergency preparedness, highlighting the need for inclusion of the maternal and neonatal units in facility protocols and drills and the importance of breastfeeding for mother and infant.
In order to obtain a better understanding of the services available to Utah’s mothers and infants, and to ensure that the most vulnerable infants are cared for in the most appropriate facilities, the Maternal and Child Health Bureau at the Utah Department of Health chose risk-appropriate perinatal care as a state priority for their Title V Maternal and Child Health Block Grant. Aided by Utah Administrative Rule and a variety of communication techniques (i.e., sending letters and making phone calls to follow up on hospitals’ progress and any questions related to the CDC LOCATeSM assessment link), state staff were able to achieve a 99% response rate. To help improve outcomes for Utah women and babies, state staff work continuously to build and maintain relationships with nursing and medical directors in the various health systems in Utah. As part of the Department’s relationship with the participating hospitals, a written report of CDC LOCATeSM assessment results were provided to all participating hospitals in Utah by Bureau staff. As a result of participation and statewide implementation of the CDC LOCATeSM assessment, the Utah Perinatal Mortality Review incorporates CDC LOCATeSM levels of maternal and neonatal care into their case review for maternal and infant deaths. Additionally, the Maternal and Infant Program will be developing a report to include maternal complications associated with tertiary and non-tertiary birth locations.