State Implementation

Levels of Maternal Care: State Implementation

The ACOG/SMFM Levels of Maternal Care Obstetric Care Consensus defines the required minimal capabilities, physical facilities, and medical and support personnel for Levels of Maternal Care, including level I (basic care), level II (specialty care), level III (subspecialty care), and level IV (regional perinatal health care centers). By focusing on obstetric criteria, we aim to improve the quality and safety of maternal care and improve health outcomes for mothers.

There is much variation in states’ implementation of Levels of Maternal Care. ACOG collected the following information for each state:

LoMC guidelines: Published state guidelines that deﬁne hospital levels of maternal care by specifying minimum capabilities and personnel for every level. Maternal guidelines are further defined as:
1. “Distinct maternal and neonatal criteria” whereby maternal criteria by level is separate from neonatal criteria.
2. “Maternal and neonatal criteria not distinct” whereby maternal criteria by level is blended with neonatal criteria. Maternal criteria may be included in documents titled, “Perinatal Guidelines” or “Neonatal Levels of Care Guidelines.”
Please note: We did not evaluate if states’ guidelines are aligned with the criteria and definitions in the Levels of Maternal Care Obstetric Care Consensus.
Legislation: State has passed a specific legislative bill to establish level of care designation for hospitals that provide maternity care. If maternal-specific designation is not specified, this is noted.
State regulation: Levels of Maternal Care criteria by hospital level is specified in regulations that govern hospitals in the state. If regulations exist, states specify if designation is a mandatory or voluntary requirement.
Entity that sets criteria: Organization that sets the criteria for each level designation.
Method of designation: Method in which the level of care is determined. If a state reported self-designation by hospitals but has no maternal guidelines and no structured process to capture the designation, this is not considered a method of designation.
Frequency of designation: How often the level of care designation is reviewed.
LOCATe assessed: State has begun collecting CDC’s Levels of Care Assessment Tool (LOCATe) data. If state requires a LOCATe assessment, this is noted.
Independent Hospital Verification: One or more hospitals in the state has had an onsite survey and been verified by the ACOG/Joint Commission Maternal Levels of Care Program. See the Joint Commission website for the list of hospitals by state. Please note that health systems that use their own verification program are not included at this time.

Of note, ACOG would like to emphasize these important points in the Levels of Maternal Care Obstetric Care Consensus:

Criteria for levels of maternal care should be separate and distinct from levels of neonatal care.
Maternal and neonatal level designations within a facility do not need to match. For example, a freestanding children’s hospital might be neonatal care level IV, with maternal capabilities and personnel consistent with level II designation.
Specific to capabilities of higher-level facilities, it is critical that all level III and level IV facilities have an ICU that accepts pregnant and postpartum patients. While this analysis didn’t include evaluation of the criteria in states’ guidelines, it was apparent in our review that multiple guidelines did not include this requirement.

LoMC Implementation by State

State	LoMC Guidelines, as of September 2025	Legislation	State Regulation	Sets Criteria	Method of Designation	Frequency of Designation	LOCATe Assessed	Independent Hospital Verification
Alabama	None	No	No	N/A	N/A	N/A	Yes	No
Alaska	None	No	No	N/A	N/A	N/A	No	No
Arizona	Yes: Maternal and neonatal criteria not distinct Not publicly available	No	No Voluntary implementation	Arizona Perinatal Trust	Onsite survey	Every 3 years	No	No
Arkansas	Yes : Maternal and neonatal criteria not distinct	No	No Voluntary implementation	Arkansas Board of Health	Level I & II: self-designation (on hold) Level III+: onsite survey	Level III+ every 2 years	Yes	No
California	None	No	No	N/A	N/A	N/A	Yes	Yes
Colorado	None	No	No	N/A	N/A	N/A	No	No
Connecticut	None	No	No	N/A	N/A	N/A	No	No
Delaware	None	No	No	N/A	N/A	N/A	Yes	No
District of Columbia	None	No	No	N/A	N/A	N/A	No	No
Florida	None	No	Yes Voluntary Implementation	ACOG/JC Verification Program	Levels I-IV: onsite survey	Every 3 years	No	Yes
Georgia	Yes: Distinct maternal and neonatal criteria	Yes: Maternal designation not specified	Yes Voluntary implementation	State health department	Levels I-IV: onsite survey	Every 3 years	Yes	Yes
Hawaii	Status unknown	Status unknown	Status unknown	Status unknown	Status unknown	Status unknown	Status unknown	No
Idaho	Status unknown	Status unknown	Status unknown	Status unknown	Status unknown	Status unknown	Status unknown	No
Illinois	Updated guidelines in process	Yes	Yes Mandatory implementation	State health department	Onsite survey	Every 3 years	Yes	No
Indiana	Yes: Distinct maternal and neonatal criteria	Yes	Yes Mandatory implementation	State health department	Onsite survey	Every 3 years	No	No
Iowa	Yes: Distinct maternal and neonatal criteria	No	Yes Voluntary implementation	State health department	Level I: self-designation only Level II & III: onsite survey by state perinatal care team or external organization Level IV: onsite survey by external organization only	Every 3 years	Yes State requires LOCATe assessment	No
Kansas	Status unknown	Status unknown	Status unknown	Status unknown	Status unknown	Status unknown	Status unknown	No
Kentucky	Status unknown	Status unknown	Status unknown	Status unknown	Status unknown	Status unknown	Status unknown	Yes
Louisiana	Yes: Distinct maternal and neonatal criteria	No	Yes Mandatory implementation	State health department	Self-designation	N/A	No	Yes
Maine	Yes: Maternal and neonatal criteria not distinct	No	No	State health department	N/A	N/A	Yes	No
Maryland	Yes: Maternal and neonatal criteria not distinct	No	Yes Mandatory implementation Level III/IV only	State health department	Level I/II: self-designation Level III/IV: onsite survey	Every 5 years	No	No
Massachusetts	Yes: Maternal and neonatal criteria not distinct	No	Yes Mandatory implementation	State health department	Self-designation	Every 2 years	Yes	No
Michigan	None	No	Yes Voluntary Implementation	ACOG/TJ Verification Program	Levels I-IV: onsite survey	Every 3 years	Yes (within perinatal region)	Yes
Minnesota	Status unknown	Status unknown	Status unknown	Status unknown	Status unknown	Status unknown	Status unknown	No
Mississippi	Updated guidelines in process	No	Yes Mandatory implementation	State health department	Onsite survey	To be determined	Yes	No
Missouri	None: Uses LoMC Obstetric Care Consensus	Yes	Yes Mandatory implementation	State health department	Onsite survey by external organization optional	Every 3 years	Yes State requires LOCATe assessment	Yes
Montana	None	No	No	N/A	N/A	N/A	Yes	No
Nebraska	None	No	No	N/A	N/A	N/A	Yes	No
Nevada	None	No	No	N/A	N/A	N/A	Yes	No
New Hampshire	None	No	No	N/A	N/A	N/A	Yes	No
New Jersey	Status unknown	Status unknown	Status unknown	Status unknown	Status unknown	Status unknown	Status unknown	Yes
New Mexico	Status unknown	Status unknown	Status unknown	Status unknown	Status unknown	Status unknown	Status unknown	No
New York	Yes: Maternal and neonatal criteria not distinct*#	No	Yes Mandatory implementation	State health department	On hold	To be determined	No	No
North Carolina	None	No	No	N/A	N/A	N/A	Yes	No
North Dakota	None	No	No	N/A	N/A	N/A	No	No
Ohio	Yes: Maternal and neonatal criteria not distinct	No	Yes Mandatory implementation	State health department	Onsite survey	Every 3 years	No	Yes
Oklahoma	None	No	No	N/A	N/A	N/A	No	No
Oregon	None	No	No	N/A	N/A	N/A	No	No
Pennsylvania	None	No	No	N/A	N/A	N/A	No	No
Rhode Island	None	No	No	N/A	N/A	N/A	No	No
South Carolina	Yes: Maternal and neonatal criteria not distinct#	No	Yes Mandatory implementation	State health department	Onsite survey	Annual	No	No
South Dakota	None	No	No	N/A	N/A	N/A	No	No
Tennessee	Yes: Maternal and neonatal criteria not distinct	No	No Voluntary implementation	State health department	Self-designation	Annual	Yes	No
Texas	Yes: Distinct maternal and neonatal criteria	Yes	Yes Mandatory implementation	State health department	Level I: self-designation Level II/III/IV: onsite survey by external organization only	Every 3 years	No	No
Utah	None	No	No	N/A	N/A	N/A	Yes	No
Vermont	None	No	No	N/A	N/A	N/A	Yes	No
Virginia	None	No	No	N/A	N/A	N/A	Yes	Yes
Washington	Yes: Maternal and neonatal criteria not distinct	No	No Voluntary implementation	State health department	N/A	N/A	Yes	No
West Virginia	None	No	No	N/A	N/A	N/A	Yes	No
Wisconsin	None: Uses LoMC Obstetric Care Consensus	No	No Voluntary implementation	Wisconsin Association for Perinatal Care	Self-designation	N/A	Yes	No
Wyoming	None	No	No	N/A	N/A	N/A	Yes	No

*State is updating guidelines.
#State guidelines do not include language that level III/IV facilities must have an ICU that accepts pregnant and postpartum patients.

Acknowledgements

ACOG would like to thank the following individuals for their contributions to this project: Sarah Kilpatrick, MD, PhD, M. Kathryn Menard, MD, MPH, David Goodman, MS, PhD, Catherine Vladutiu, PhD, MPH, Andrea Catalano, MPH, and Katie Lichter, MD, MPH.

State Implementation

Levels of Maternal Care: State Implementation

LoMC Implementation by State

Acknowledgements

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