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On January 15, 2026, the State Board of Health approved rules establishing a statewide Mississippi Obstetrics ("OB") System of Care. After the meeting, the Mississippi State Department of Health ("MSDH") filed, then withdrew, and then on January 23, 2026, filed the final version of the rules with the Secretary of State. The rules become effective February 22, 2026 (30 days after January 23, 2026). Hospitals providing obstetric and/or newborn services will be designated into a tiered system: 1 of 4 maternal levels of care and 1 of 4 neonatal levels of care, with level-specific requirements.
If the "levels" concept sounds familiar, that is because Mississippi's State Health Plan ("SHP") has long used a similar four-level framework for perinatal services (Levels I–IV). The new OB System of Care rules build on familiar concepts but are significantly more detailed and operationally prescriptive (particularly around designation, surveys, governance and program infrastructure).
Maternal levels of care (Rule 1.2.5)
1. Level I (Basic): Level I facilities must have a triage process to identify high-risk patients for transfer, and the ability to initiate an emergency cesarean delivery within a time interval that best incorporates maternal and fetal risks and benefits. Transfers are expected (when possible) of stable mothers likely to deliver before 35 weeks or whose maternal/fetal condition is likely to require specialty services.
2. Level II (Specialty): Level II facilities must perform all Level I services, with a more stringent expectation to transfer stable mothers likely to deliver before 32 weeks or who are likely to require subspecialty services (maternal or neonatal) before delivery when possible. Level II must also have access to maternal-fetal medicine ("MFM") consultation and antenatal diagnostic technology, including fetal ultrasound.
3. Level III (Subspecialty): Level III facilities manage complex maternal and fetal illnesses before, during, and after delivery. They must maintain access to consultation and referral to MFM specialists.
4. Level IV (Comprehensive): Level IV facilities provide Level III capabilities and add on-site access to a full range of medical and surgical specialists, including on-site MFM. Level IV facilities also serve a broader system role, including facilitating maternal transport and providing outreach education.
Each OB Center must meet all applicable standards for the relevant level of care established by The Joint Commission Maternal Levels of Care Verification Program. Rule 1.3.5.
Neonatal levels of care (Rule 1.2.6)
1. Level I (Well Care): Level I neonatal facilities provide neonatal resuscitation at every delivery, evaluate and care for stable term newborns, and stabilize physiologically stable infants born at 35-37 weeks. They must stabilize ill infants and those born at less than 35 weeks until transfer.
2. Level II (Special Care): Level II facilities provide all Level I services and care for infants generally ≥32 weeks and ≥1500 grams who have conditions expected to resolve rapidly and are not expected to require urgent subspecialty services. Level II also provides convalescent care after intensive care and may provide brief mechanical ventilation (<24 hours) and/or CPAP. Level II must stabilize infants <32 weeks and <1500 grams until transfer and must have enhanced equipment and personnel to manage admitted infants and emergencies ( e.g., imaging and blood gas capabilities with adequate specialized staff).
3. Level III (Neonatal Intensive Care ("NICU")). Level III NICUs provide all Level I and II services and must have continuously available personnel and equipment to provide life support as long as needed. They provide comprehensive care for infants <32 weeks and <1500 grams and for critically ill infants of all gestational ages and weights. Level III requires prompt access to pediatric medical subspecialists and surgical specialists, advanced respiratory support, urgent advanced imaging capability, and robust family support services. The rule also emphasizes transport capabilities, quality improvement initiatives, and enrollment in the Vermont Oxford Network for monitoring outcomes.
4. Level IV (Advanced NICU). Level IV facilities provide all Level III capabilities and must be located within an institution capable of surgical repair of complex congenital or acquired conditions. They must maintain a full range of pediatric medical subspecialists, pediatric surgical subspecialists, and pediatric anesthesiologists at the site, and they play a regional role in transport facilitation and outreach education.
Each neonatal center must meet all applicable standards for the relevant level of care established by the American Academy of Pediatrics Standards for Neonatal Levels of Care. Rule 1.3.6.
Mandatory participation, survey, and three-year designation
Participation is mandatory for acute care facilities. Rule 1.3.2. The designation process includes an application and survey process with written results. Rule 1.3.1. Designation generally lasts three years (with a possible one-year extension), and facilities remain subject to review, including on-site inspection and required data submission. Rule 1.3.1. A facility may not market itself as MSDH-designated at a maternal or neonatal level unless it has been officially designated. Rule 1.1.1.
Program governance requirements administrators should prioritize
Beyond the level designation, the rules expect formal, documentable program infrastructure.
First, each facility must make a written, organization-wide commitment to its maternal and neonatal programs (typically through governing board action) with medical staff recognition and approval built into the process. See, e.g., Rules 3.1.2, 4.1.2.
Second, each hospital must develop written program plans describing services offered, resources, triage and transfer practices, core protocols, and training and competency expectations, with required review and approval steps. Rule 2.1.2.
Third, hospitals identify a maternal medical director and maternal program manager; neonatal services have parallel leadership roles. See, e.g., Rules 2.1.5, 2.1.6, 7.3.4, 7.3.5.
Fourth, each facility must maintain a multidisciplinary committee to oversee and lead the program. The committee is expected to support oversight, quality improvement, policy development, cross-departmental communication, and education through regular meetings and documentation. See, e.g., Rule 3.1.6. Committee expectations also increase with higher levels of care.
Finally, administrators should review the staffing and team requirements—particularly availability expectations, specialty coverage, and training and competency obligations. See, e.g., Rule 3.4.1.
Practical implications and preparing for a survey
Hospitals should start planning now for the gap between current operations and the requirements of a designation survey. Readiness often means formalizing roles and responsibilities, aligning coverage expectations with the intended level, and updating policies and training so they are operationally effective and survey-ready.
As practical next steps, hospital leadership should:
- Review the new OB System of Care requirements most applicable to your facility.
- Perform a self-assessment to confirm where the hospital currently fits and identify gaps.
- Determine the maternal and neonatal levels that the hospital intends to pursue.
- Schedule a governing board meeting to obtain the required approvals.
- Schedule a meeting with the Medical Executive Committee (and other medical staff leadership as appropriate) to align on the scope of services, coverage expectations, and program leadership roles.
- Enter or update maternal and/or neonatal medical directorship agreements.
- Review and update policies, procedures, transfer protocols, and related documentation to align with the requirements.
- Organize the required multidisciplinary committee(s), set a regular meeting cadence, and document actions.
- Educate clinicians and staff on the new program requirements and document training and competency.
A note on authority, rulemaking and economic impact
The OB System of Care rules cite existing statutory authority for MSDH rulemaking. However, questions have been raised as to whether that authority expressly supports the scope and mandatory nature of the system adopted by the MSDH. That question is underscored by the recent introduction of House Bill 1133, which would expressly authorize the State Board of Health to promulgate rules establishing standards for a statewide OB System of Care and designate MSDH as the lead agency.
If existing law did not clearly provide that authority, there is also a related question: whether MSDH's administrative rulemaking process should have included an economic impact statement under Mississippi's Administrative Procedures Act. Hospitals should be aware of this developing issue as the process continues.
Certificate of Need ("CON") considerations
The OB System of Care rules govern how MSDH designates levels of care and how a hospital may apply to change its designation. Separately, Section 403 of the SHP includes CON criteria that may apply when a hospital establishes, expands, or upgrades obstetrical services or neonatal special care services. Hospitals considering to establish, expand or change its level should seek guidance early on whether a CON is required.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.
