Intensity, stratification, and risk in perinatal care: redefining problems and restructuring levels

Inappropriate intervention and inequitable access are well known, but inadequately understood, issues in US perinatal care. Both are related to the structure of the perinatal system; this paper focuses on their connection with levels of care. Professional and regulatory policies and reform efforts (in conjunction with market forces) have shaped a system of levels differentiated according to specialist and technological capacity. Expansion of "higher" levels has contributed to their excessive supply and discriminatory use. The concept of risk offers a justification for levels of care, but it also reflects the structure of levels. In order to address inappropriate intensity and stratified access, we must not just redefine concepts, we must also restructure levels of perinatal care.