Innovations in Rural Obstetrics to Maintain Access to Care 

The closures of rural hospitals and obstetric services has created an urgent need for innovative approaches to maintaining high-quality obstetrics care in these areas. In the past 10 years, over 200 rural hospitals have discontinued providing labor and delivery services; now less than half of rural hospitals provide this care.  

In March 2024, leaders from six maternity programs providing sustainable obstetrics care to rural communities gathered for a Rural Obstetrics Innovation Summit in Texas. The summit, organized by the TLL Temple Foundation, in partnership with the National Rural Health Association, Federal Office of Rural Health Policy, and rural health care consultancy Stroudwater Associates, highlighted solutions from six very different rural obstetrics delivery sites from across the country that capitalized on each program’s particular unique circumstances and opportunities. Participants included Fairview Hospital in Massachusetts, Goodall-Witcher Healthcare in Texas, Mahaska Health in Iowa, Southcentral Foundation in Alaska, Sterling Regional Medical Center in Colorado, and University of North Carolina Health Chatham in North Carolina. Below, we describe each unique approach to sustaining quality maternal care taken by these facilities.  

Six Innovative Approaches 

1. Partnerships: Fairview Hospital (Great Barrington, Mass.) 

In 2007, Fairview Hospital, a critical access hospital in the Berkshire Health System, partnered with a federally qualified health center (FQHC) to integrate the hospital’s OBGYN practice into the FQHC, which removed the significant $200,000 per provider cost of medical malpractice liability coverage from the hospital as the physicians could thereby be covered by the Federal Tort Claims Act. This partnership allowed the hospital to continue to provide comprehensive maternity care services despite pressure from the health system to discontinue these service lines due to financial sustainability concerns. The maternity care unit has reported high patient experience scores for the past 10 years, meeting the community preference for local, high-quality maternity care.  

2. Community-centered care: Goodall-Witcher Healthcare (Clifton, Texas) 

In 2018, financially strapped Goodall-Witcher Hospital transitioned from the Goodall-Witcher Healthcare Foundation to a municipal hospital district supported by an elected board of community members with the authority to impose property taxes to fund the hospital. Goodall-Witcher invested in updating their facilities and recruiting family medicine physicians with surgical obstetric training to staff deliveries and deliver care across multiple clinical services. These investments have reduced provider turnover, increased patient satisfaction, and improved community perception. The critical access hospital is recognized for providing personalized and comprehensive care; now many patients choose to travel to the hospital for obstetric care. Goodall-Witcher views maternity care to generate long-term patients across its service lines.  

3. Quality Initiatives: Mahaska Health (Oskaloosa, Iowa) 

Mahaska Health is a critical access hospital with a strong culture of being physician and nurse led. The hospital received a state grant that helped expand maternity care services and in recent years has started to provide perinatal mental health care in addition to general and specialty maternal and obstetric care. As a part of the Iowa Perinatal Quality Collaborative, the birthing center has standardized protocols for postpartum hemorrhage and preeclampsia management to provide high quality care. The birthing hospital is a designated regional trainer for Advanced Life Support in Obstetrics (ALSO) and provides certifications to nurses and physicians. Mahaska Health has reported volume increases driven by patients attracted to its emphasis on high quality care.  

4. Culturally competent care: Southcentral Foundation (Anchorage, Alaska)  

Southcentral Foundation (SCF) provides maternity health care services to the Alaska Native Community from across Alaska. The Tribal Health System in Alaska relies on a team-based approach to obstetric care that leverages the expertise of community health aides, doulas, nurse midwives, family medicine physicians, OB-GYN and maternal fetal medicine physicians, nurse case managers, and other specialists to provide coordinated care for pregnant women from across the state. To overcome the access barriers related to the remoteness of the region, SCF partners closely with providers from regional Tribal Health Organizations to help provide care in rural settings. If a woman is considered to have a high-risk pregnancy, she will be transferred to a higher level of care in Anchorage. SCF is dedicated to being culturally aligned with the Alaska Native Community. For example, SCF supports indigenous birth practices by providing no-cost Indigenous doula services through a community grant. 

5. Rural workforce development: Sterling Regional Medical Center (Sterling, Col.)  

Sterling Regional Medical Center is an acute hospital part of Banner Health’s multi-state initiative, Rural Maternity Optimization Model (RMOMs), which coordinates care across 10 rural sites in six states. The initiative relies on team-based care from physician or midwife and nurse dyads who meet remotely together monthly to standardized care, establish patient care plans, and share knowledge and resources. Sterling Medical Center is part of the Northern Colorado Family Medicine Residency Program that trains family medicine residents in rural obstetrics. This residency program has led to the successful recruitment and retention of residents in rural areas; six of the ten graduates have practiced rural obstetrics with four continuing to practice surgical obstetrics. The Medical Center recognizes training physicians in rural settings as a key strategy for maintaining rural obstetrics care. 

6. Framing maternity care as an equity issue: University of North Carolina (UNC) Chatham Hospital (Siler City, N.C.)  

In 2020, the UNC Chatham Hospital Maternity Care Center (MCC) reopened as a Level 1 maternity care center certified to provide low risk perinatal and maternal care after the original labor and delivery unit closed in 1991. UNC Chatham is a critical access hospital that features a community-integrated model that includes full-spectrum family medicine and OB/GYN care, leveraging partnerships with the larger UNC system, local health services, and community health care organizations and focusing on culturally competent care to address disparities in maternal health outcomes. To address maternal and infant morbidity and mortality, the MCC created EMBRACe (Equity for Moms and Babies Realized Across Chatham) to assess the needs of the community and coordinate community health initiatives.  

While these sites leveraged different creative solutions to financing and staffing challenges, the conference underscored that all were driven by innovative leadership and dedication to providing high-quality care that was responsive to the needs of the local community. To learn more about these sites and their innovations, see the Site Innovation Report on the Rural Health Information Hub. Stay tuned for a related issue brief that will provide a deeper examination of the models of care delivery and opportunities for states to support them.