1.4: Perinatal Care- Regional and Levels of Care and Transport
By the end of this section, you will be able to:
- Recognize reasons for regionalization of perinatal health-care services
- Discuss community-based care
- Distinguish between community health nursing and community-based nursing
Perinatal care is provided in many different settings. Some settings, such as a regional care facility, are safest for a high-risk pregnancy. Community settings are designed for low-risk pregnancies. By identifying the level of care available and required, health-care providers can collaborate with their patients to make informed decisions on where a person’s perinatal care should take place. Not all states have adopted this model.
Community health nurses and community-based nursing both support people in the community and neighborhoods. Community health nurses become aware of issues in the community and develop education to address those issues. Community-based nurses provide hands-on nursing care to different populations for specific disorders. The nurse is an integral part of the care of low- and high-risk pregnant persons and people in the community.
Regionalization of Perinatal Health Care Services
Regionalization of health care refers to matching the patient’s needs with the hospital capable of providing the appropriate level of care. According to Kunz et al. (2020), regionalization began in the United States in the 1970s after the March of Dimes published “Improving the Outcomes of Pregnancy,” which focused on preterm infants being born in facilities with high-level neonatal intensive care unit s (NICUs). In turn, regionalization has decreased neonatal complications, increased survival, and reduced morbidity and mortality.
Regionalization of maternal care services began in 2015 with ACOG’s “Levels of Maternal Care Obstetric Care Consensus” (reaffirmed in 2019), which showed that higher-risk patients who gave birth in low-acuity facilities had higher rates of severe maternal morbidity than those who birthed at higher-acuity facilities (Kilpatrick et al., 2019). Therefore, hospitals were labeled by the level of acuity they could safely treat, and higher-risk persons were transferred to the appropriate facilities for the continuation of their care. The levels of maternal care include level 1 through 4, with the higher levels of care treating the greater risks of acuity (Kilpatrick et al., 2019). All facilities, regardless of level, should be able to stabilize a perinatal person prior to transfer to a higher level of care. Table 1.2 summarizes further information on levels of maternal care.
| Level of Care | Definitions | Capabilities | Health-Care Providers |
|---|---|---|---|
| Birth center | Care for low-risk pregnant persons with uncomplicated singleton term vertex pregnancies | Capable of providing low-risk care | Nurse-midwives, midwives, doctor of medicine (MD), doctor of osteopathic medicine (DO) |
| Level 1: Basic Care | Care of low to moderate risk pregnancies, able to stabilize unanticipated problems until the patient can be transferred | Capable of beginning an emergency cesarean birth, limited ultrasound, support services readily available, ability to initiate massive transfusion protocol | Nurse-midwife, family physician, or OB-GYN; trained RNs; certified registered nurse anesthetists (CRNAs) or anesthesiologists available at all times |
| Level 2: Specialty Care | Level 1 PLUS care of moderate to high risk antepartum, intrapartum, and postpartum conditions | Level 1 PLUS ability for computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, non-OB ultrasounds, echocardiogram |
Level 1 PLUS
board-certified OB-GYN available at all times; maternal-fetal medicine (MFM) available via phone, telemedicine, or on-site; anesthesiologist, internal medicine specialist, and general surgeon readily available at all times |
| Level 3: Subspecialty Care | Level 2 PLUS more complex maternal medical conditions, OB complications, and fetal conditions | Level 2 PLUS in-house availability of all blood components; ability to perform CTs, MRIs, Doppler studies, specialized OB ultrasounds, interventional radiology; on-site ventilation; on-site ICU; accept maternal transfers | Level 2 PLUS nursing leaders and adequate number of RNs who are specially trained for complex OB complications; board-certified OB physically present at all times; MFM readily available; anesthesiologist physically present at all times; and full complement of subspecialties |
| Level 4: Regional Perinatal Health Care Center | Level 3 PLUS on-site medical and surgical care of the most complex maternal conditions; critically ill pregnant person and fetus | Level 3 PLUS on-site medical and surgical care of complex conditions including ICU; co-management with MFM and ICU specialists; perinatal system leadership and collaboration with other facilities in the region | Level 3 PLUS MFM team and MFM provider readily available; nursing service line leadership with advanced degrees and national certifications; continuous availability of adequate RNs; anesthesiologist physically present at all times; at least one available: neurosurgery, cardiac surgery, or transplant |
Community-Based Care
Low- to moderate-risk pregnant persons are provided perinatal care in their communities. Most U.S. pregnant persons fit into this category (Kunz et al., 2020). Community hospitals offer basic care for those in rural and underserved communities and defer to higher-acuity facilities to care for high-risk patients. Research has shown that community-based care can reduce health inequities and improve maternal and neonatal clinical outcomes (Rayment-Jones et al., 2021).
Community-based care has been shown to reduce the cost of maternity care and improve patient experiences, especially for people of color and those with low income (Zephyrin et al., 2021). Because community-based care is tailored to low-risk pregnancies, care can include the use of nurse-midwives, family practice providers, nurse practitioners, and birth center s (Figure 1.4).
Community Health Nursing
A nurse who provides education and health promotion outside the hospital setting, directly to the public, is called a community health nurse (Galan, 2022). Responsibilities of a community health nurse may include
- being a community advocate;
- providing referrals;
- encouraging health promotion through nutrition, wellness, and disease prevention;
- providing health screenings; and
- providing family planning education (Galan, 2022).
Community health nurses develop trusting relationships and become aware of social factors that influence the health of people in the community. Strategies for care can be developed around social determinants of health related to health inequities in that community (Heath, 2020). Education and dissemination of information to the community at large and to specific at-risk populations are the ways a community health nurse cares for their patients and community. Their responsibilities include advocacy, referrals, health promotion, screenings, and family planning education.
Community-Based Nursing
The delivery of care in the community is called community-based nursing . Mobile health clinics are an example of community-based nursing. By walking to a mobile health clinic parked at a church or community center, people in the community can access care without traveling. Many times these citizens will trust the care providers because the community allows them in the neighborhood (Heath, 2020). Community-based care can reach people who cannot afford care, do not have transportation, and may feel marginalized by previous health-care experiences (Heath, 2020). The visit is done in the home or at a local site where patients can be seen.
Community-based nursing delivers care to the community. The focus of community health is broad, while the focus of community-based nursing care is more specific (e.g., diabetes, hypertension). Both types of care help the people in the community by providing low-cost, local, individualized care.
Watch this video explaining the difference between community health nursing and community-based nursing from Level Up RN.