Patients access to obstetric care has been falling in the U.S. even as maternal deaths keep rising. And the drop has been even deeper in rural areas where fewer than half of rural hospitals offered obstetric care in 2022.

LDI Senior Fellow Sara C. Handley knows these gaps well. Only about a quarter of the highest risk OB patients received appropriate care in the rural areas of four states, according to a recent study Handley led with LDI Senior Fellow Scott Lorch in JAMA Health Forum. 

Distance was the strongest barrier for patients in Oregon, Michigan, Pennsylvania, and South Carolina, said Handley, a Children’s Hospital of Philadelphia neonatologist. But other factors were associated with poor access, including younger age, Hispanic ancestry, lower educational attainment and lack of insurance.

Handley saw the travails of rural health long before she conducted research. A native Minnesotan, she has relatives living across the state. She also graduated from the University of Minnesota Medical School and collaborates with the university’s Rural Health Research Center. The challenges to get care in remote areas “are familiar,” she said, with a touch of Midwestern understatement.

Handley is perhaps best known for her work persuading clinicians to treat birth parents and infants as a single entity to improve care. Measures around childbirth fail to give the full picture unless they include information from both parents and infants, her 2023 Health Affairs study found.

Handley says we need to create regional care networks that can deliver high-risk care more widely. We should also expand payments for maternal transport and give hospitals incentives to move patients out of their facility when they lack the needed capabilities.

Many observers assume that telehealth is usable everywhere, but Handley says that’s untrue in many parts of the U.S.

Arkansas High-Risk Pregnancy Program, she notes, has done an excellent job coupling better broadband with a telehealth effort supporting high-risk care.

Sara answers more questions about her work below:  

Can you summarize the current conditions for high-risk OB care in rural areas? 

Handley: Of course, hospital-based obstetric care is declining in the U.S. in both urban and rural areas. Compared to urban areas, the percentage of rural hospitals that have obstetric services is lower and continues to decline over time. Nationally in 2010, about 57% of rural hospitals offered obstetric services and by 2022 only 48% offered obstetric services. Access to high-risk obstetric care is generally located in urban areas, making it harder for rural residents to reach. We can appreciate this by looking at the median distance to risk-appropriate obstetric care for rural residents with different levels of risk, about 11 miles for the lowest-risk patients in this study and about 66 miles for the highest-risk patients. 

What’s happening to high-risk patients OB patients in rural areas?

Handley: People who live in rural areas experience a higher burden of pre-existing and pregnancy-related conditions. One example is high blood pressure, which can complicate pregnancy. This condition benefits from regular visits for diagnosis, monitoring, and treatment when indicated. For context, in this study almost half of rural residents had some indication of higher medical or obstetric risk warranting a specific level of obstetric care. 

What are the most important points for policymakers in your study of high-risk OB care?

Handley: There are real, structural barriers for rural residents to reach risk-appropriate obstetric care at the time of childbirth. We found a number of barriers, such as age, race, ethnicity, education, insurance, and distance, which was the strongest factor. These highlight opportunities to improve the organization of our health care systems. Given the influence of distance, thinking geographically about how far pregnant patients may need to travel to reach essential care, can inform how readers, clinicians, and policymakers think about maintaining or introducing services at specific hospitals to maintain access for rural communities. 

Is the impact of high-level care on outcomes more of an expert consensus or do these care levels create better outcomes?

Handley: The initial maternal level of care guidelines were consensus based, though published empiric evidence is ongoing. The parallel, which is neonatal levels of care for newborns and infants, shows strong evidence over decades that high risk newborns—those born very small or very early and those with congenital anomalies—have much better outcomes and fewer complications and better survival when they are born in hospitals with risk-appropriate care. Many have assumed such relationships would also be seen in obstetric care, and some recent data out of Massachusetts shows that higher risk patients who give birth at a hospital with an inappropriate level of maternal care had a significantly higher risk of severe complications. I anticipate additional evidence will continue to be published that supports higher level care for higher risk patients. 

What key inequities did you find for high-risk OB care in rural areas?

Handley: It was notable that residents who identified as American Indian or Alaska Native as well as those missing race—which is rarely random—had higher odds of not receiving risk-appropriate care. This highlights how accessing care is not just about geography and distance, but also about the community in which you live. About 20% of rural residents identify as Black, Indigenous, and people of color (BIPOC) and for those living in rural areas, the combination of these structural challenges (related to race and rurality) seem to compound the issues of getting the necessary care. 

What are the most important limitations of your study on high-risk care in rural areas?

Handley: We conducted this analysis using data from four very different states and while I imagine many of the barriers we identified to reaching risk-appropriate obstetric care may be experienced by pregnant people across the U.S., this was not a nationwide study. Health care systems, organizations, and policies differ among states and what results in impactful change may vary. 

What recommendations do you have for policymakers and regulators to encourage regional care systems, telehealth and other fixes?

Handley: Given the influence of geography as a barrier to risk-appropriate care, it is important to think creatively about how to design and incentivize regional care systems that support high quality obstetric care for those in rural communities. Expanding reimbursement for maternal transports and incentivizing hospitals to transport obstetric patients out of their facility when they lack the necessary capabilities—versus keeping the patient and billing for the birth—would be an important step in prioritizing the needs of rural obstetric patients. With respect to telehealth, especially in the post-COVID era, I think many assume it is an accessible form of health care regardless of location. But this is not the case in rural parts of the U.S. Arkansas has done a noteworthy job of expanding broadband alongside a telehealth program designed to reach and support care for high-risk obstetric patients. 

Where is your research going next?

Handley: Our team is hoping to build on this work both in looking at how rural obstetric unit and/or hospital closures over time change access to risk appropriate care and what this ultimately means for both maternal and infant outcomes. 

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The article, “Risk-Appropriate Childbirth Care Among Higher-Risk Pregnant Rural Residents,” was published on November 21, 2025 in JAMA Health Forum. Authors include Sara C. Handley, Brielle Formanowski, Molly Passarella, Maggie L. Thorsen, Julia D. Interrante, Clara E. Busse, Scott A. Lorch, and Katy B. Kozhimannil.

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