How New York’s Perinatal Care System Works and What It Means for Families

New York State runs one of the oldest and most detailed systems for organizing pregnancy and newborn care in the country. This isn’t just bureaucracy. It’s a framework designed to make sure that when complications arise during pregnancy or birth, families have access to the right level of medical expertise at the right time.

Understanding how this system works can help explain why certain transfers happen, why some hospitals can handle certain complications while others cannot, and how the medical infrastructure surrounding your pregnancy and delivery is organized. For families dealing with birth injuries, this context often clarifies what happened, why decisions were made, and where potential gaps in care might have occurred.

What Is a Regionalized Perinatal Care System?

New York organizes its maternal and newborn services into a tiered system. The basic idea is straightforward: not every hospital needs to handle the most complex, high-risk cases, but every hospital needs to know when to transfer patients to facilities that can.

This system, regulated by the New York State Department of Health under 10 NYCRR Part 721, divides hospitals into four levels based on their capabilities, staff expertise, equipment, and experience handling high-risk situations. The regulations apply to all hospitals with maternity and newborn services caring for pregnant women at any stage, women in labor, women up to six weeks after delivery, and infants 28 days old or younger (or any age if they weigh less than 5.5 pounds).

The goal is to match the complexity of a pregnancy or newborn’s condition with the appropriate level of hospital capability. When that match doesn’t happen, whether because complications develop unexpectedly or transfers don’t occur when they should, the risk of birth injuries increases significantly.

The Four Levels of Perinatal Centers in New York

Level I Perinatal Centers Handle Routine Pregnancies and Births

Level I hospitals provide care for normal, low-risk pregnancies and healthy newborns. They don’t operate neonatal intensive care units.

These facilities handle routine deliveries and provide continuing care for healthy pregnancies expected to deliver at 36 weeks or later, and healthy newborns weighing 2,500 grams (about 5.5 pounds) or more. When complications arise, Level I hospitals are responsible for evaluating and stabilizing patients, consulting with higher-level facilities, and arranging timely transfers.

Level I hospitals also care for babies who were initially treated at higher-level facilities but are now stable enough to be transferred back for continued care closer to home.

Level II Perinatal Centers Provide Moderate Risk Care

Level II hospitals care for women and newborns at moderate risk and operate neonatal intensive care units. They offer everything Level I hospitals provide, plus the capability to manage moderately high-risk pregnancies and newborns.

To maintain Level II designation, these hospitals must provide at least 1,200 high-risk newborn patient days annually and at least 150 high-risk maternal patient days annually. These volume requirements exist because managing complex cases requires not just equipment but ongoing practice and expertise.

Level III Perinatal Centers Handle Complex Cases

Level III hospitals provide care for patients requiring increasingly complex medical intervention. They operate NICUs with more advanced capabilities than Level II facilities.

These hospitals must handle at least 2,000 high-risk newborn patient days each year and at least 250 high-risk maternal patient days annually. New York currently has 34 hospitals designated as Level III Perinatal Centers.

Regional Perinatal Centers Are the Highest Level of Care

Regional Perinatal Centers, or RPCs, represent the most advanced level of care in New York’s system. These 17 facilities operate the most sophisticated NICUs and serve as referral centers for the most serious obstetric and neonatal complications in their geographic regions.

RPCs must provide at least 4,000 high-risk newborn patient days and at least 400 high-risk maternal patient days each year. They’re also required to provide quality improvement services to affiliated hospitals representing at least 8,000 births annually.

The concentration of the most complex cases at RPCs serves a purpose beyond just having the right equipment. When specialists regularly handle the most challenging situations, they maintain and enhance their expertise. This volume also justifies the substantial expense of maintaining the most advanced neonatal intensive care units and having subspecialists available around the clock.

What Regional Perinatal Centers Do Beyond Patient Care

Regional Perinatal Centers aren’t just hospitals. They function as hubs for an entire region’s perinatal care system, with responsibilities that extend well beyond their own patients.

Clinical Consultation and Transport Services

RPCs provide 24-hour consultation to affiliated hospitals for obstetrical and neonatal emergencies. When a community hospital faces a complicated case, they can call the RPC for guidance. RPCs also coordinate transfers, finding appropriate beds and arranging specialized neonatal ambulance transportation.

These aren’t ordinary ambulances. Modern neonatal transport vehicles, like the one operated by Buffalo’s John R. Oishei Children’s Hospital, can carry automatic lifts for 300-pound isolette units, enough equipment to simultaneously care for two babies, and room for four specialized team members. That facility alone averages 300 transports of premature or critically injured babies every year.

New York Medicaid directly reimburses Regional Perinatal Centers for neonatal ambulance transportation costs between community hospitals and RPCs (ground transportation only, established in 1992). This policy ensures financial considerations don’t delay necessary transfers. Air transportation for neonates and any maternal transportation require separate authorization.

This represents significant evolution from 1948, when New York City launched the nation’s first organized neonatal transportation program, the New York Premature Infant Transport Service.

Quality Improvement Across Affiliated Hospitals

RPCs implement quality improvement programs not just within their own facilities but across their network of affiliate hospitals. They participate in New York State Department of Health quality improvement activities and help implement initiatives at community hospitals.

This includes conducting outreach support visits to affiliated facilities, essentially serving as consultants to help smaller hospitals improve their perinatal care practices.

Training the Next Generation of Specialists

RPCs work to train the next generation of high-risk obstetrical and neonatal providers. They participate in regional Perinatal Forums and provide education and consultation to affiliated hospitals.

The ultimate goal is improving maternal and infant outcomes by promoting access to appropriate care levels, implementing quality improvement programs, and assisting with Department of Health quality initiatives.

How Hospital Affiliations Work in New York’s Perinatal System

Every hospital designated as Level I, Level II, or Level III must have a written affiliation agreement with a Regional Perinatal Center. These aren’t casual relationships. The affiliation agreements formalize referral relationships, consultation protocols, and transfer procedures that make the regionalized system function.

Geographic access standards require that surface travel time to reach a Level II hospital, Level III hospital, or RPC under usual travel conditions cannot exceed two hours. Transfer decisions must be based on the appropriate level of perinatal care required, with care provided at a facility offering appropriate services that’s accessible and convenient to the mother’s residence whenever feasible.

Why Volume Requirements Matter for Hospital Designations

To maintain their designation level, hospitals must meet minimum volume standards. This isn’t arbitrary bureaucracy. There’s substantial evidence that facilities and providers who regularly handle specific conditions achieve better outcomes than those who encounter them rarely.

Hospitals failing to meet volume standards must present evidence that they’ll achieve the required volumes within one year. The Department of Health can waive these requirements if doing so will improve access while maintaining high-quality care, recognizing the geographic realities of serving rural or underserved populations.

These volume standards exist to ensure both service capability and staff competence. A team that regularly manages premature births, obstetric hemorrhages, or newborns requiring intensive care maintains skills that teams encountering these situations once or twice a year simply cannot match.

When and Why Transfers Happen During Pregnancy and After Birth

The perinatal regionalization system operates on risk-stratified transfer protocols designed to match patient complexity with facility capabilities. Understanding these protocols helps explain why certain transfers occur and when they should happen but don’t.

Maternal Transfers Before Delivery

When complications arise or are anticipated during pregnancy, women should be transferred to higher-level facilities before delivery whenever possible. This is preferable to transferring a critically ill newborn after birth, though that’s not always possible.

Conditions that typically prompt maternal transfer include:

• Gestational age less than 36 weeks, especially less than 32 weeks for RPC transfer
• Anticipated birthweight less than 2,500 grams
• Known fetal anomalies requiring immediate specialized care after birth
• Severe maternal complications such as preeclampsia, hemorrhage, or cardiac complications
• Multiple gestations with complications
• Fetal distress or signs of compromise

The decision to transfer should happen early enough that the mother arrives at the appropriate facility with time to stabilize before delivery. Delayed transfers, or failures to transfer when indicated, sometimes contribute to birth injuries.

Neonatal Transfers After Birth

When infants are born at facilities unable to provide necessary care, the Regional Perinatal Center is responsible for finding an appropriate hospital bed and arranging specialized neonatal ambulance transportation to the RPC.

At discharge, the RPC arranges transfer of the infant back to the community hospital when appropriate. This “back transfer” allows families to receive ongoing care closer to home once the most critical period has passed.

How New York Collects and Uses Perinatal Data

A cornerstone of New York’s perinatal quality improvement infrastructure is the Statewide Perinatal Data System, or SPDS. This web-based system collects detailed information about every birth in the state.

What Information the Statewide Perinatal Data System Captures

SPDS consists of several modules:

The Core Module includes enhanced electronic birth certificate data collected for all women giving birth and their newborns. For births in New York City, this has been in place since January 1, 2007.

The Supplemental Module adds maternal and newborn health data elements beyond what’s on birth certificates.

The High-Risk Obstetric Module captures data on high-risk maternal conditions and interventions.

The High-Risk Neonatal or NICU Module collects data on all neonates entering special care or intensive care nurseries for longer than four hours.

The Medicaid Eligibility Module uses mother’s Medicaid information to determine newborns’ Medicaid eligibility.

Information captured includes maternal demographics and insurance status, when prenatal care began and whether weight gain was adequate during pregnancy, prenatal education received and maternal risk factors, preterm labor and labor or delivery complications, newborn outcomes and birthweight, breastfeeding in the early postpartum period, NICU admission reasons and interventions, and outcomes.

How Perinatal Data Gets Used to Improve Care

All hospitals and freestanding birthing centers providing perinatal services must participate in SPDS. All live births must be entered into the system.

This data supports multiple functions. It enables public health surveillance of birth outcomes. It allows quality improvement at hospital, regional, and state levels. Hospitals can benchmark their performance against similar hospitals, regional performance, and national Healthy People goals. The data informs policy development and resource allocation decisions. Researchers use it to study maternal and child health trends, disparities, and intervention effectiveness.

Hospital birth registrars and quality improvement staff generate standardized reports monthly. Authorized individuals at each hospital can access record-level data via secure Department of Health website extraction. De-identified aggregate data allows comparison to other similar hospitals in the region, regional performance overall, and national benchmarks.

This comprehensive data collection makes New York’s maternal and infant health challenges visible and measurable, which is the first step toward addressing them.

How New York Reviews Maternal Deaths

New York State established comprehensive Maternal Mortality Review Board systems in 2019 through legislation signed by Governor Andrew Cuomo. This law created state and New York City maternal mortality review boards and advisory councils to review all maternal deaths and severe maternal morbidity, disseminating findings, recommendations, and best practices to prevent future deaths.

What Maternal Mortality Review Committees Do

New York City convened its Maternal Mortality Review Committee in January 2018 to conduct multidisciplinary reviews of all pregnancy-associated deaths among New York State residents who died in New York City, starting with deaths from 2016.

The committee brings together diverse expertise, including clinical specialties like midwifery, family medicine, nursing, psychology and psychiatry, anesthesiology, maternal-fetal medicine, and obstetrics and gynecology. It includes community services representatives from doula services, patient advocacy, social work, home visiting, and violence prevention. It includes systems expertise in health systems and addiction treatment.

Seventy percent of committee members self-identify as Black or Hispanic, the two groups most affected by maternal deaths. Sixty-five percent identify as clinical while thirty-five percent identify as nonclinical. The NYC Health Department uses the same standards and protocols developed by the Centers for Disease Control and Prevention that most states use.

How New York Identifies and Tracks Maternal Deaths

New York maintains linked files between statewide Vital Records, including death and birth files, and the Statewide Planning and Research Cooperative System, or SPARCS, hospital discharge data.

Staff identifies potential pregnancy-associated deaths through a complex linkage algorithm using New York State death records of women ages 10 through 65 years, birth records, and SPARCS hospital discharge records. Staff also gained direct access to the Office of Mental Health’s Psychiatric Services and Clinical Knowledge Enhancement System, or PSYCKES, which provides behavioral health information related to pregnancy-associated death cases.

This data infrastructure allows comprehensive identification and review of maternal deaths, making it possible to identify patterns, preventable factors, and opportunities for system improvement.

Current Maternal and Infant Health Outcomes in New York

Despite comprehensive infrastructure, significant challenges and disparities persist in New York’s perinatal outcomes.

Maternal Mortality Rates and Racial Disparities

New York’s maternal mortality rate was 22.4 deaths per 100,000 live births in 2023, slightly above the national average. The state ranks 23rd nationally for maternal mortality rate.

New York City’s pregnancy-associated mortality ratio was 66.4 deaths per 100,000 live births in 2022, the highest since 2016. The pregnancy-related mortality ratio was 32.2 per 100,000.

While New York’s overall maternal mortality rate has declined from its peak, racial disparities persist dramatically. Maternal deaths are 4.6 times more likely for Black women compared to White women during the 2017 through 2019 timeframe. Non-Hispanic Black women have a pregnancy-related mortality rate five times higher than non-Hispanic White women in New York.

One significant success story demonstrates what’s possible with focused effort. New York achieved a dramatic 50 percent reduction in maternal hypertension deaths through the Perinatal Quality Collaborative led by the Department of Health. The initiative trained all birthing facilities on hypertension awareness, implemented standardized treatments through the Safe Motherhood Initiative hypertension bundle, and achieved participation from the majority of birthing facilities statewide.

This demonstrates that when preventable maternal deaths are identified and standardized interventions are introduced across the state, dramatic improvements are achievable. It also raises the question of why similar progress hasn’t been achieved for other preventable causes of maternal death and severe morbidity.

Severe Maternal Morbidity Rates Across New York

Severe maternal morbidity, or SMM, refers to unexpected outcomes of labor and delivery that result in significant short-term or long-term consequences to a woman’s health. In New York City, severe maternal morbidity occurs in 284 per 10,000 live births, or roughly 2.8 percent of deliveries.

Statewide in 2018, the severe maternal morbidity rate for White women was 191 per 10,000 deliveries. The rate for Black women was 447 per 10,000 deliveries, 2.3 times the rate for White women. Hispanic women experienced approximately 1.7 times the rate for White women at 325 per 10,000. Asian women experienced approximately 1.5 times the rate for White women at 283 per 10,000.

These disparities persisted from 2011 through 2018 and exist across all regions of the state, though the magnitude varies by geography. Long Island had the highest severe maternal morbidity rate for Black women at 519 per 10,000 deliveries, or roughly 5.2 percent. New York City had the highest rate for Hispanic women at 362 per 10,000 deliveries, or roughly 3.6 percent.

These numbers represent real women experiencing life-threatening complications, many of which are preventable with appropriate care. The persistent disparities suggest systemic issues beyond individual hospital quality.

Infant Mortality Rates and Trends

New York’s infant mortality rate was 4.3 per 1,000 live births in 2023, with 478 infant deaths. New York City’s infant mortality rate was 4.0 per 1,000 live births in 2021.

From 2008 to 2016, infant mortality declined 9 percent for non-Hispanic Whites to 3.45 per 1,000, declined 28 percent for non-Hispanic Blacks to 7.85 per 1,000, and declined 3 percent for Hispanics to 3.6 per 1,000. Non-Hispanic Asian and Pacific Islanders had the lowest rate at 2.87 per 1,000.

Despite these improvements, Black families still experience infant mortality about 2.4 times the state average. Leading causes of infant death include prematurity, congenital malformation, and sudden unexpected infant death.

Preterm Birth Rates in New York

New York’s preterm birth rate was 9.6 percent in 2023, representing 1 in 10 babies. About 8.6 percent of births were low birthweight.

Prematurity remains one of the leading causes of infant death and contributes significantly to birth injuries and long-term developmental challenges. Preterm birth rates are not evenly distributed across populations, with Black women experiencing significantly higher rates than White women.

Birth Centers in New York and How They Fit Into the System

New York has historically maintained one of the nation’s most stringent regulatory frameworks for freestanding birth centers, requiring Article 28 facility licensure as a condition for Medicaid reimbursement.

Why So Few Birth Centers Operate in New York

Birth centers fall under the same Certificate of Need, or CON, application process administered by the Public Health and Health Planning Council as hospitals. The CON and licensure process in New York is recognized as the most onerous and expensive in the United States, with most applicants hiring consultants to complete it. While other states exempted birth centers from CON processes, New York did not.

Despite the state allowing midwife-led birthing centers since 2016, not a single prospective birth center completed the application under the original regulations issued in June 2020.

After months of activism, the Midwifery Birth Center Bill passed the Legislature in May 2021 and was signed into law by Governor Kathy Hochul on December 31, 2021. The legislation sought to streamline licensing by relying primarily on national standards from the Commission for the Accreditation of Birth Centers. However, chapter amendments maintained Department of Health authority to impose additional licensing criteria, including evidence of capability to fund renovations and construction costs, as well as life, safety, and building standards.

As of the 2025 legislative session, only eight birth centers operate across New York State.

Transfer Protocols for Birth Centers

Transfer protocols require birth centers to maintain written plans and procedures for transfer of patients to obstetrical or pediatric services of receiving hospitals when complications arise.

The birth center must initiate transfer when risks are identified, including prolonged labor, fetal distress, need for spinal or epidural anesthesia, or possibility of operative or cesarean birth.

The limited number of birth centers means that families seeking this option have few choices, and in many parts of the state, no nearby access to birth center care.

Recent and Proposed Changes to Improve Maternal Health Equity

Recognizing persistent disparities, New York has implemented and proposed multiple initiatives targeting maternal health equity.

Implicit Bias Training Requirements

Proposed legislation, S6983/A4018, would establish the New York Dignity in Pregnancy and Childbirth Act, requiring hospitals and facilities providing perinatal care to implement evidence-based implicit bias programs for all healthcare providers involved in perinatal care.

The persistent racial disparities in maternal mortality and severe maternal morbidity, even after controlling for socioeconomic factors, suggest that implicit bias in how symptoms are assessed and responded to may contribute to worse outcomes for Black and Hispanic women.

Enhanced Maternal Depression Screening

Proposed legislation, S7012/A7448, would require healthcare providers to facilitate screening for maternal depression within the first six weeks of birth, with insurance coverage mandated. Current law requires informational leaflets to include information on maternal depression.

Maternal mental health conditions contribute significantly to pregnancy-associated deaths, particularly in the postpartum period. Enhanced screening aims to identify at-risk mothers earlier.

Increased Transparency About Hospital Outcomes

Proposed legislation, A4272, would require maternity information leaflets to include statistics on childbirth complications, fetal losses, and other injuries, broken down by age and race of the mother.

This responds to concerns about inadequate transparency regarding hospital-specific outcomes. Currently, families often lack access to comparative data that would help them make informed decisions about where to deliver.

Community Based Programs Addressing Social Determinants

New York City launched a Neighborhood Stress-Free Zone pilot program in Brownsville in September 2024, providing free parenting workshops, cooking classes, social groups, diaper distributions, mental health screenings, and massages to combat maternal mortality rates driven by overdoses and suicides.

The initiative aims to reduce the city’s maternal death rate by 10 percent by 2030. This approach recognizes that clinical interventions alone cannot address maternal health disparities rooted in social determinants of health.

Expanding Access to Doula Care

In April 2018, New York launched a Doula Pilot Program expanding Medicaid to cover doula services in Brooklyn and parts of Buffalo. The program faced challenges recruiting doulas due to state certification requirements, low reimbursement rates, and billing processes requiring up to six months for reimbursement.

Evidence suggests that continuous labor support from doulas improves outcomes and reduces intervention rates, particularly for women of color. Addressing the barriers that limit doula availability could improve care access.

What Families Have the Right to Know Under New York Law

New York law, Public Health Law Section 2803-j, requires every hospital and birth center to prepare and distribute an informational leaflet to prospective maternity patients at pre-booking and upon request to the general public.

The leaflet must include brief definitions of maternity-related procedures and practices, the hospital’s perinatal designation level and brief definition, explanation of special provisions relating to maternity care coverage under insurance law, information on physical and mental health after discharge including maternal depression, and statistics on annual percentage of maternity procedures performed and maternal outcomes at that facility.

The informational leaflet must be made available in the top six languages spoken in the state other than English. The Commissioner makes information contained in the leaflet available on the Department’s website and presents annual statistical information for the most recent five years.

In practice, many families don’t receive these leaflets or don’t review them carefully before delivery. Awareness of this right can help families access important comparative information.

What This System Means for Families Dealing With Birth Injuries

First, it clarifies whether care was provided at the appropriate level facility for the pregnancy’s complexity. When high-risk conditions are managed at Level I or Level II facilities that lack the expertise or resources for those situations, the risk of adverse outcomes increases.

Second, it raises questions about whether appropriate transfers occurred when indicated. Delayed or failed transfers, whether due to system failures, communication breakdowns, or clinical misjudgments, sometimes contribute to preventable birth injuries.

Third, it highlights the importance of consultation. Even when transfer isn’t possible due to timing, lower-level facilities should be consulting with Regional Perinatal Centers for guidance on managing complex situations. Documentation showing whether such consultation occurred can be relevant in understanding what happened.

Fourth, the comprehensive data collection through SPDS means that detailed information about what occurred during pregnancy, labor, delivery, and the immediate postpartum period exists in state databases. This data, combined with medical records, provides a complete picture of events.

Finally, understanding the quality improvement infrastructure and maternal mortality review processes helps families understand how systemic problems get identified and addressed. While this doesn’t change what happened to an individual family, it provides context for how their experience might contribute to preventing similar situations in the future.

New York’s comprehensive, data-driven, and equity-focused approach to perinatal regionalization represents one model for organizing maternal and child health services. The persistent disparities in outcomes, despite this infrastructure, underscore that infrastructure alone isn’t sufficient. Implementation, accountability, and addressing the social and systemic factors that drive disparities remain critical challenges.

For families navigating pregnancy, understanding this system helps them advocate for appropriate care. For families dealing with birth injuries, understanding this system helps them understand what should have happened, identify where gaps or failures might have occurred, and place their experience within the broader context of how perinatal care is organized in New York.