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There are currently 54 birthing hospitals in Iowa.Iowa uses a level system to identify what types of specialists and equipment are available at birthing hospitals, so that women and infants with complex medical conditions can receive care at the right facility for their specific needs. Pregnant women may be advised to deliver their baby at a higher level of care based on potential complications, or they or their newborn may be transferred to a facility with a higher level of care if complications arise during labor and delivery. Iowa assigns a level for maternal and neonatal care.Facilities may have different levels for each – for example, a hospital may be a Level I for maternal care and a Level II for neonatal care.
Level I hospitals must have a provider of basic obstetrical care. They must be able to perform routine care and begin an emergency cesarean delivery within the appropriate timeframe. Level I hospitals may have midwives, family practice physicians, or obstetrician-gynecologists, and providers must be able to provide neonatal resuscitation and postnatal care. They must also have a provider who can perform an emergency cesarean delivery and an anesthesia provider. Level I hospitals must have obstetrical ultrasonography, laboratory testing, and blood bank supplies, as well as corresponding protocols for available supports.
Level II hospitals must have all the required criteria of a Level I hospital, as well as specialty care providers. For example, a Level II hospital must have an attending obstetrician-gynecologist available at all times, access to a maternal-fetal medicine subspecialist for consultation, a board-certified or board-eligible OBGYN as the director of obstetric services, and a board-certified or board-eligible anesthesiologist available for consultation. They must also have more advanced medical imaging and additional support for more complex patients.
Level III hospitals must meet all required criteria of a Level II facility in addition to having various subspecialists available on site, by telephone, or by telemedicine to assist in providing care for complex maternal and fetal conditions. The subspecialists include, but are not limited to, an obstetrician-gynecologist with inpatient privileges on site at all times and a maternal-fetal medicine physician with inpatient privileges, available at all times either on-site, by telephone, or telemedicine. A level III hospital will have a board-certified anesthesiologist with special obstetric training on site at all times. Level III hospitals will contain an intensive-care unit with critical care providers and maternal-fetal medicine specialists on site at all times. These facilities include specialty equipment and personnel to ventilate and monitor women in the labor and delivery unit until transferred to the intensive care unit
In addition to meeting criteria for a Level III hospital, Level IV hospitals provide care to the most complex and critically ill pregnant women throughout antepartum, intrapartum, and postpartum periods. Level IV hospitals require specialties such as fetal surgery, advanced neurosurgery, transplant, and advanced cardiovascular care. In addition to having an on-site intensive care unit, Level IV hospitals must have a maternal-fetal medicine care team with expertise in critical care. The team will be on site, at all times, for critical care obstetrics, consultation, and management. Teams of medical and surgical specialists to collaborate for maternal-fetal complications are also on site and available at all times.
Neonatal Care Levels
A Level I hospital provides basic neonatal care for those who have no complications. A Level I facility has the capabilities to provide neonatal resuscitation at any type of delivery. This facility also provides postnatal care to stable and term newborn infants born between 35 and 37 weeks of gestation. These teams identify any early risk factors in the event that the infant needs a higher level of care. A Level I facility also includes a variety of allied health professionals and services such as pharmacists, social workers, radiology, and laboratory services.
Level II hospitals provide management of certain high-risk neonates with selected complications. These facilities care for neonates born at or greater than 32 weeks of gestation and weighing more than or equal to 1500 grams. Level II hospitals can provide mechanical ventilation and are able to stabilize infants born before 32 weeks and weighing less than 1500 grams until transfer of care. These facilities will have a neonatologist or pediatrician on staff as well as allied health professionals, including internal medicine, radiology and pathology, respiratory therapy, x-ray, and ultrasound technicians. Level II hospitals also contain a perinatal care committee to develop perinatal policies to ensure adequate patient care.
A Level III hospital manages high-risk neonates, including those born at less than 32 weeks’ gestation and weighing less than 1500 grams. Level III facilities provide life support, comprehensive care, and have consultative agreements with higher-level hospitals in the event of critical illness. Level III hospitals have a neonatal intensive care unit on-site with available medical personnel, including neonatologists, neonatal nurses, respiratory therapists, social workers, x-ray technologists, and ultrasound technicians. These facilities also provide advanced imaging on an urgent basis, including computed tomography, magnetic resonance imaging, and echocardiography. Additionally, level III hospitals maintain a specialized neonatal transport team for transfer of care and a perinatal care committee.
A level IV hospital provides care to the highest risk neonates and has additional professional staff with experience providing complex and critical care. Professionals at these hospitals can provide surgical repairs of complex conditions in the neonate patient. These facilities require on-site neonatologists in addition to subspecialist physicians who are immediately available, along with specialty neonatal nurses. A level IV hospital has transport capabilities for neonatal patients via ground or air with transport teams who have specialty training. Lastly, level IV hospitals maintain a perinatal care committee and analyze data on long-term outcomes to evaluate the effectiveness of health services for perinatal services.
Iowa Statewide Perinatal Care Team
The Iowa Statewide Perinatal Care Team, established in 1973, provides education, development of standards/guidelines of care, consultation to regional and primary providers, and evaluation of the quality of perinatal care delivered in Iowa with the goal of reducing the mortality and morbidity of mothers and infants. Through a contract between HHS and the University of Iowa College of Medicine, these services are offered to all Iowa hospitals providing delivery services. The Statewide Perinatal Care Program provides verification site visits to birthing hospitals participating in Iowa’s Regionalized System of Perinatal Care, as outlined in Iowa Administrative Rule 641 Ch. 150.
The Statewide Perinatal Care Team ensures birthing hospitals align with national standards through the formal verification process for maternal and neonatal levels of care using the CDC’s Levels of Care Assessment Tool (LOCATe). The LOCATe tool was developed to assess risk appropriate care to improve health outcomes for pregnant women and infants. The team conducts verification site visits to Level I – III hospitals participating in the regionalized system of perinatal care every six years. Level IV hospitals require an alternate team to verify the level of care assessed.
