In 1976, the March of Dimes published a report titled "Toward Improving the Outcome of Pregnancy" (TIOP), and in 1993 they published "Toward Improving the Outcome of Pregnancy: The 90s and Beyond" (TIOP II). TIOP "stratified maternal and neonatal care into 3 levels of complexity and recommended referral of high-risk patients to centers with the personnel and resources needed for their degree of risk and severity of illness." TIOP was published when "resources for the most complex care were relatively scarce and concentrated in academic medical centers." TIOP II updated care complexity designations from levels I, II and III to basic, specialty and subspecialty, and the criteria were expanded.