Guest blog by Rebecca Alderfer, MPP from CPCQC

Thank you to the many rural leaders, clinicians, and partners who continue to make time in their busy schedules to have honest conversations about the future of perinatal care in Colorado. Those conversations point to the same concerns, and they are increasingly urgent.

At the Colorado Perinatal Care Quality Collaborative (CPCQC), we work with every hospital that delivers babies. Our goal is to make sure care is safe, high-quality, and equitable, no matter who someone is or where they live. Over the past several years, maternity care in rural areas has become not just a priority, but one of the biggest challenges facing Colorado’s health system.

A recent national report from The Commonwealth Fund paints a clear picture: rural hospitals are being asked to keep running expensive maternity programs, even when they don’t deliver many babies. When small problems come up, like a provider leaving, insurance costs rising, or financial losses, a hospital may have no choice but to shut down its maternity unit. More than 100 rural hospitals across the country have shut down their labor and delivery units in just five years.

Colorado reflects and intensifies this trend.

Since 2020, five rural labor and delivery units have closed in Colorado, including two that shut down in early 2025. Conversations with hospital leaders and clinicians in rural areas reveal a system under pressure. Some hospitals lose up to $1 million every year just to keep maternity services running. Many work with little staff backup. And there is growing concern about how doctors and nurses can stay skilled when they don’t deliver many babies.

But the most important insight is this: these closures don’t have to happen.

Recently, CPCQC worked with the Colorado Hospital Association (CHA), Dr. Mark Deutschman, and Dr. Kelly Bogaert on a case study of rural hospitals in Colorado. They found that the number of patients is not the main reason hospitals struggle. The bigger problem is a mismatch between how hospitals get paid, how hard it is to keep staff, and the costs of being ready to deliver services at any hour. And obstetric care is not optional. Hospitals must be staffed and ready around the clock, whether they deliver two babies a day or two babies a week. But payment is still largely based on how many patients a hospital sees.

At the same time, workforce instability has become the most immediate threat. In many hospitals, losing even one doctor or nurse can put an entire maternity program at risk. One loss could start a chain reaction of staffing gaps, reliance on temporary providers, rising costs, and eventually, closure. Providers call this a “death spiral.” The good news is that these situations can often be prevented with early action and better coordination between leadership and care teams.

As the country is learning, when local labor and delivery units close, the risk doesn’t go away. It just shifts. Emergency departments and EMS providers become the front line for maternity care. They often do this without the training, equipment, or protocols needed to handle complications safely. Patients must travel farther, their care gets disrupted, and the risk goes up during emergencies.

There is a clear path forward despite these challenges. It won’t happen through a single sweeping solution, but through practical, step-by-step strategies that make the system stronger now, while bigger policy change takes shape over time.

Here are some key opportunities:

• Invest in preparing emergency rooms and ambulance teams labor and delivery services. As maternity unites close, emergency departments and EMS crews need training to stabilize and manage pregnancy-related emergencies. Mobile simulation programs, consistent protocols, and targeted training can create a dependable safety net across rural communities.
• Create a statewide Maternal Levels of Care framework. Being transparent about what care each hospital can provide and creating strong transfer networks ensures patients get care in the right place at the right time. This also allows EMS and emergency providers to plan ahead.
• Strengthen workforce sustainability through regional models. Hospitals can share on-call schedules, allow staff to work across hospitals, and rotate staff between busy and less busy settings to maintain skills and avoid burnout.
• Expand access to care through innovation. Tools like patient monitoring can track and improve care for high-risk patients. Hub-and-spoke models can connect rural hospitals to specialists and reduce travel burdens. Partnerships with local health centers and community-based providers, including federal qualified health centers, offer additional ways to share cost and care.
• Test and evaluate new models through existing programs. The Rural Health Transformation Program (RHTP) gives hospitals a chance to try out scalable solutions, even within the budget is tight.
• Work toward more effective payment models. Explore options for payment models that support essential services and cover the fixed costs of being ready to deliver care.
• Collect data about what’s happening and monitor impact. New laws and policy changes requires close monitoring of care patterns. The One Big Beautiful Bill Act, the 2027 transition to fee-for-service maternity coding, and the Rural Hospital Transformation Program may significantly affect rural care delivery. Proactively tracking claims data, distance to care, and provider distribution is essential to understanding these shifts and responding effectively.

In the end, keeping rural maternity care alive means change how we think about its value. These services are not just a line item in a budget. They are essential infrastructure, foundational to community health, economic stability, and long-term trust in the health care system.

Colorado has a chance to lead by being honest about how complex this problem is and taking action in the short-term. The conversations happening today are no longer just about identifying the problem. They are about building a path forward.

And that path, while not easy, is within reach.

CPCQC is actively working toward solutions while help rural communities deal with today’s challenges. This includes building targeted strategies to support the emergency departments that serve as the front line for maternity care. It also involves bringing EMS leaders across the state together to better understand and respond to pregnancy- and newborn-related calls. This work gives us valuable information: from how often calls happen and how serious they are, to transfer patterns and travel times between facilities.

These are important first steps toward a system that is more connected and resilient. Colorado can build the infrastructure we need to better protect patient health and safety during pregnancy and throughout the first year postpartum. This requires making data visible, aligning training, and strengthening collaboration across hospitals, EMS, and community providers.

CPCQC has also created a set of practical tools to help rural hospitals in this work:

The Quick Care Card makes sure patients, first responders, and health care teams all have the same, easy-to-find information when they need it most. CPCQC developed this program to include an alert card with QR codes that link to educational resources and key warning signs of pregnancy and postpartum complications. This helps keep patients safe, continue their care, and inform emergency teams on how to respond.

The Maternal Quality and Safety Toolkit for Rural Hospitals gives hospitals practical, adaptable resources to improve safety for pregnant patients. CPCQC recommends using the Alliance for Innovation on Maternal Health (AIM) safety bundles alongside this toolkit, which is built to work in real rural settings.

The Obstetric Emergency Reading Initiative is currently in its early design phase. CPCQC is designing a training program built around the needs of rural hospitals and the patients they serve. The program focuses on preparing hospitals and first responders with the tools and protocols needed to handle obstetric emergencies.

Read the Full Case Study to Learn More