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Inter-facility maternal transport

Stephanie R Martin, DO
Section Editor
Vincenzo Berghella, MD
Deputy Editor
Kristen Eckler, MD, FACOG


Transfer of the complicated pregnant patient to a facility with appropriate medical, surgical, obstetric, or pediatric resources can reduce maternal, fetal, and/or neonatal morbidity and mortality. The most common reason for maternal transfer is availability of neonatal tertiary care; transferring the undelivered woman is preferable to neonatal transport and should be a primary goal [1]. Maternal transfers are also performed for maternal medical or surgical conditions, to accommodate family request, to comply with insurance contract requirements, or when a pregnant woman seeks emergency care at a facility without obstetrical services.

Although most hospitals are not expected to provide obstetric units or tertiary neonatal care, they should be prepared to stabilize obstetric patients who present for emergency care or who have complicated pregnancies. This preparation includes having a prearranged transfer agreement that identifies the preferred receiving obstetric care facility, mode of transport, and method of clinician-to-clinician contact. Transport may occur by ground (ambulance), helicopter, or fixed wing plane. An obvious concern is the possibility of delivery during transport, when minimal resources are available.

A general guide for inter-facility patient transfer has been published by the National Highway Traffic Safety Administration (NHTSA) and is available through their website (http://www.nhtsa.gov/people/injury/ems/interfacility/index.htm). However, this guide does not specifically address pregnant patients. The Society of Obstetricians and Gynecologists of Canada has published a Maternal Transport Policy Statement [2].


In the United States, only 1.4 percent of all births are very low birthweight babies (VLBW, <1500 g); however, a large proportion (51 percent) of neonatal mortality occurs in this group [3,4]. In part for this reason, the March of Dimes published a document entitled "Toward Improving the Outcome of Pregnancy," which stimulated the development of regionalized perinatal care systems and maternal transport programs. One of the primary purposes of regionalization was to clearly define the scope of neonatal care available at hospitals and increase the number of high-risk and premature births occurring at appropriate level facilities rather than transferring neonates to these facilities after birth. The benefit of this approach was subsequently illustrated by a meta-analysis that evaluated neonatal outcomes for VLBW or very preterm babies and found neonatal mortality significantly increased if delivery occurred outside of highly specialized (level III) hospitals [5]. In the United States, 74 percent of VLBW deliveries between 2000 and 2008 occurred in high-risk facilities, but with wide variation among the states [6]. Oregon had the highest rate of inborn VLBW neonates at 99.4 percent, compared with 32 percent in Mississippi. Only five states (Oregon, Nevada, Iowa, Rhode Island and Vermont) exceeded 90 percent.

Although most maternal transports go to a facility with a well-defined level of neonatal care and for neonatal indications, some maternal transfers are for maternal indications. A national effort to standardize maternal levels of care has been initiated in an effort to improve maternal morbidity and mortality and decrease "near-misses" [7]. In 2015, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine issued a joint care consensus document on levels of maternal care [8]. This guideline is intended to develop standards for designations of maternal care that are complimentary to, but distinct from, neonatal levels of care. The authors propose a framework for levels of maternal care from birth centers, basic care (level I), specialty care (level II), subspecialty care (level III) and regional perinatal healthcare centers (level IV). According to the consensus document, "Each facility should have a clear understanding of its capability to handle increasingly complex levels of maternal care, and should have a well-defined threshold for transferring women to health care facilities that offer a higher level of care. To ensure optimal care of all pregnant women, all birth centers, hospitals, and higher-level facilities should collaborate to develop and maintain maternal and neonatal transport plans and cooperative agreements capable of managing the health care needs of women who develop complications; receiving hospitals should openly accept transfers." Subsequently, the Centers for Disease Control and Prevention launched the voluntary Levels of Care Assessment Tool (CDC LOCATe). As of August 2017, 12 states (California, Colorado, Georgia, Illinois, Michigan, Mississippi, New Mexico, North Carolina, Oklahoma, Tennessee, Utah, and Wyoming) and Puerto Rico are participating in CDC LOCATe [9]. This process is intended to create standards for assessing maternal and neonatal levels of care.

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Literature review current through: Oct 2017. | This topic last updated: Sep 28, 2017.
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