In 2015, the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) outlined Levels of Maternal Care as an important strategy to decrease severe maternal morbidity and mortality and eliminate inequities in poor obstetric health outcomes.

The Levels of Maternal Care concept (similar to Neonatal Levels of Care) relies on developing collaborative relationships between hospitals of differing levels of maternal care within a region. This integration of relationships enables the referral of birthing people with high-risk comorbidities to hospitals equipped with the resources and personnel to manage their unique needs.

Risk-appropriate care is not synonymous with transferring patients to tertiary care centers; rather, it ensures that birthing people have equitable access to services and resources that will optimize their birth experiences and meet their care needs. 

“Moms are not just vessels for babies; they need their own safety levels.”
– Dr. Ronald Iverson, PNQIN Co-Chair

Frequently Asked Questions

The ACOG/SMFM guidelines provide a framework for the resources available at a given level of care and examples of patient comorbidities. However, these recommendations left the designation of hospital levels of care and implementation of the paradigm in the hands of the state.

PNQIN is leading this initiative in Massachusetts to underscore the importance of the collaborative nature of this statewide effort and to help implement processes in hospitals that will identify areas for potential program augmentation.

PNQIN and The Betsy Lehman Center for Patient Safety took the first step to assess the resources available in our state by implementing the CDC Levels of Care Assessment Tool (LOCATe®), in collaboration with the Massachusetts Department of Public Health (MDPH) and the Centers for Disease Control and Prevention (CDC).

LOCATe® asks hospitals about their available services, which provides a preliminary suggestion of a birthing hospital’s level of maternal care.

Each level reflects a hospital’s capabilities, physical facilities, and medical and support staffing. Higher levels of care include and build on the capabilities of the lower levels.

This survey was developed by the CDC and has been implemented by 23 other states (including Maine, New Hampshire, and Vermont). Massachusetts added a set of additional questions to the LOCATe® tool to ensure that the results capture information on disparities in care and opportunities to increase health equity.

Accredited Birth Center

  • Care for low-risk patients with uncomplicated pregnancies and an anticipated uncomplicated birth.

Level I (Basic Care)

  • Care of people with low- to moderate-risk pregnancies with the ability to detect, stabilize, and initiate management of unanticipated maternal-fetal or neonatal problems until the patient can be transferred to a facility for specialty maternal care.

Level II (Specialty Care)

  • Level I facility plus care of appropriate moderate- to high-risk antepartum, intrapartum, or postpartum conditions.

Level III (Subspecialty Care)

  • Level II facility plus care of more complex maternal medical conditions, obstetric complications, and fetal conditions.

Level IV (Regional Perinatal Health Care Centers

  • Level III facility plus on-site medical and surgical care of the most complex maternal conditions and critically ill pregnant people and fetuses.

In 2021, PNQIN asked all 40 birthing hospitals in the state to complete the LOCATe® survey to better understand the systems of care serving birthing people, parents, and infants—including how those services respond to the unique needs of a diverse population.

A physician and nurse dyad completed the survey for each hospital, based on the CDC’s recommendation and to enhance accuracy.

Our goal was 100% participation from MA birthing hospitals in order to provide the most informative assessment of maternal care capacity in our state. 

We are proud to say that we reached our goal, and we sincerely thank each and every one of our hospitals for their participation!!!

LOCATe® responses were collected using the online secure platform REDcap and housed at the Betsy Lehman Center for Patient Safety (BLC), a non-regulatory state agency that already houses data for many of PNQIN’s existing projects. 

CDC analyzed the LOCATe® data for the state of Massachusetts and reported back the assessed level of maternal care for each hospital. BLC created individual summary reports for each hospital that PNQIN shared with the survey submitters and department leadership.


  • 48% of hospitals self-reported a higher level than their LOCATe®-assessed level.
  • Of the 19 hospitals that over-reported their Level of Maternal Care, most did so by only one level, but several hospitals over-reported by two levels. There were no discrepancies of more than two levels.

PNQIN convened a Levels of Maternal Care Task Force in 2019, comprised of state and hospital stakeholders, to guide the implementation of and access of this project — including how the LOCATe® results are stored, analyzed, and distributed.

Our hope is that hospitals and stakeholders are willing to engage in follow-up steps for this initiative in order to confirm their results and discuss strategies for improving care for their unique patient populations using the resources available.

PNQIN is committed to working collaboratively and honestly with all hospitals to accomplish your care goals.

With funding from the HRSA State Maternal Health Innovation & Data Capacity Program, BLC will conduct several activities, including:

  1. Further analyze the LOCATe® hospital-level data collected in 2021 and link LOCATe®-determined levels to hospitals’ severe maternal morbidity (SMM) data.
  2. Analyze data from the MA-specific LOCATe® supplemental questions and hospital-level data on processes and structures related to perinatal health equity.
  3. Establish and convene a LoMC Implementation Steering Committee composed of clinical and administrative stakeholders from MDPH, PNQIN, hospitals, and other state organizations to inform a strategic plan for implementing LoMC in MA through a voluntary, quality improvement process.
  4. Map the geographic distribution of maternity care resources and regionalization activities in MA and develop a strategy for inter-hospital transfer and consulting arrangements following the LoMC model.
  5. Pilot a learning collaborative and engagement approach with hospitals to inform a technical assistance support model for operating at their goal Level.
  6. Develop tools and resources to address barriers to regionalization of care in MA and identify examples and best practices for successful implementation of a levels of care system.

Levels of Maternal Care Webinar Series

In 2021, PNQIN and BLC co-hosted a series of webinars about implementing Levels of Maternal Care. Watch the videos below to learn more!

February 9th, 2021: The first webinar introduced the CDC’s Levels of Care Assessment Tool (LOCATe®), the timeline for its administration, and its intended use in Massachusetts.

March 2nd, 2021: The second webinar reviewed LOCATe® and MA-specific Equity measures and includes a large Q&A with project leads.

October 12th, 2021: The third webinar shared statewide LOCATe® and supplemental Equity results with participating hospitals and provided an opportunity to ask questions about results, upcoming individualized reports, and the future of LoMC in Massachusetts.