Over the past decade, rural communities have steadily lost access to maternal care. Since 2020, more than 130 rural hospitals closed their labor and delivery units, leaving many rural counties without any hospital-based obstetric services. Today, more than 2.4 million women ages 15 to 44 live in counties without an obstetrician or local delivery services.
At the same time, many rural hospitals and health systems are demonstrating innovation and commitment to providing maternal health care. The American Hospital Association is leading an initiative called Opportunities for Innovations in Rural Maternal Care to examine how rural hospitals sustain or expand access to maternal care. In 2025 and 2026, we spoke with 160 leaders from 92 hospitals serving rural communities across 37 states.
Our conversations with rural hospital leaders underscore that decisions to retract maternal care are rarely made lightly. Three interconnected pressures often contribute to these decisions:
- Workforce shortages reflect a persistent lack of essential maternal care clinicians, including ob/gyns, labor and delivery nurses, anesthesiologists, pediatricians, and sonographers residing and practicing in rural communities.
- Low birth volumes make it hard for clinicians to maintain skills for obstetric emergencies.
- Reimbursement may not cover the fixed cost of care, especially for rural hospitals with low birth volumes and those with a high proportion of patients on Medicaid, which often reimburses below the cost of care.
Strategies to Sustain Rural Maternal Care
Despite variation in geography and other attributes, consistent themes emerged from these conversations that point to the foundations of a resilient rural maternal care ecosystem.
Solidify leadership commitment and strategic alignment.
Leadership commitment is essential to sustaining maternal care. This commitment often reflects a deeper understanding that local maternal care access is tied to the organization’s mission, trust between hospitals and communities, and long-term health for families and communities.
Build a skilled and sustainable workforce.
Workforce is the foundation of rural maternal care. Hospitals are taking a multifaceted approach to staffing and skill development, which includes:
- Multidisciplinary care teams. Care extends beyond obstetricians to include labor and delivery nurses, family physicians with obstetric specialization, midwives, emergency medical services, doulas, and community health workers.
- Maintaining skills despite low birth volume. Hospitals are investing in simulation training, drills, and partnerships with higher-volume centers to ensure teams remain prepared for high-risk scenarios.
- Telehealth support. Telehealth connections between obstetrics, neonatal intensive care units, and hospitals provide real-time guidance for complex cases.
- Workforce pipelines. Some hospitals are “growing their own” workforce by uptraining local providers or partnering with rural-focused education programs.
Strengthen regional and community partnerships.
Partnerships can extend capacity and connect hospitals to additional expertise. These partnerships can take several forms:
- Hospital-to-hospital collaboration. Some smaller facilities partner with larger medical centers to support higher-acuity care when needed, while others form regional networks to share resources and expertise.
- Community-based care networks. Partnerships with primary care providers, public health agencies and community-based organizations can extend maternal care beyond the hospital. These partnerships can help establish coordinated prenatal care, referral pathways for high-risk patients, telehealth services, and postpartum follow-up in the community.
Extend care into the community.
Meeting patients where they are can improve access and outcomes. Communities are investing in:
- Technology-enabled care. Remote patient monitoring supports high-risk patients at home while tele-maternal-fetal medicine connects patients to specialized services locally.
- Mobile and home-based care. Mobile clinics, community paramedicine, and home visits bring services directly to remote patients.
- Care coordination. Shared care plans, clear referral pathways, and communication across clinicians and community providers help create a patient-centered experience from pregnancy through postpartum.
Address behavioral health and social needs.
Hospitals emphasized that maternal health outcomes are closely tied to behavioral health and social conditions. Many are integrating:
- Behavioral health services for conditions like substance use disorder and postpartum depression.
- Social supports to address transportation, housing, food access, and other aids to a healthy pregnancy.
Support financial sustainability.
Rural hospitals are exploring new payment models and funding opportunities to support maternal services. Initiatives such as the Center for Medicare and Medicaid Services’ Transforming Maternal Health Model offer one pathway toward more sustainable financing, while longer-term solutions will require payment that better reflects the true cost of providing maternal care in rural communities.
What’s Next
The challenges facing rural maternal care are significant — but so is the innovation emerging from communities determined to keep care close to home.
There is no single solution. Resilient rural maternal care depends on a combination of strong leadership, a supported workforce, flexible care models, strategic partnerships, and sustainable financing.
What works will look different in every community. But the goal is the same: build on local strengths and reinforce the connections, resources, and support needed to keep high-quality maternal care within reach.
