Thank you to the many rural leaders, clinicians, and partners who continue to make time—amid already stretched capacity—to engage in honest conversations about the future of perinatal care in Colorado. Those conversations are remarkably consistent, and increasingly urgent.

At the Colorado Perinatal Care Quality Collaborative (CPCQC), we partner with every birthing hospital in the state to advance safe, high-quality, and equitable care—no matter who someone is or where they live. Over the past several years, rural maternity care has emerged not just as a priority, but as a defining challenge for the state’s health system.

A recent report from The Commonwealth Fund captures the national reality with striking clarity: rural hospitals are being asked to sustain high-cost, low-volume obstetric services in environments where even small disruptions—a provider departure, rising liability costs, or financial losses—can trigger collapse. More than 100 rural hospitals nationwide have closed labor and delivery units in just five years.

Colorado reflects—and in some ways intensifies—this trend.

Since 2020, five rural labor and delivery units have closed across the state, including two in early 2025 alone. Interviews with rural hospital leaders and clinicians reveal a system under strain: facilities losing up to $1 million annually to maintain obstetric services; teams operating with minimal staffing redundancy; and growing concern about maintaining clinical competency in low-volume settings.

But the most important insight is this: these closures and constraints are not inevitable.

A recent multi-site case study of rural Colorado hospitals, led by CPCQC, Colorado Hospital Association (CHA), Dr. Mark Deutschman, and Dr. Kelly Bogaert, found that sustainability challenges are driven less by volume alone and more by structural misalignment—between payment models, workforce realities, and the fixed costs of maintaining readiness. Obstetric care is not an elective service; it must be staffed and prepared 24/7, regardless of whether there are two deliveries a day or two a week. Yet reimbursement remains largely volume-based.

At the same time, workforce fragility has emerged as the most immediate threat. In many hospitals, the loss of a single clinician can destabilize an entire program, triggering a cascade of staffing gaps, reliance on temporary providers, rising costs, and ultimately, closure decisions. Providers describe this as a “death spiral”—and one that can often be prevented with earlier intervention and stronger alignment between leadership and care teams.

As the country is learning, when local labor and delivery units close, the health system does not eliminate risk—it redistributes it. Emergency departments and EMS providers become the front line for obstetric care, often without the training, equipment, or protocols needed to safely manage complications. Patients face longer travel distances, disrupted continuity of care, and increased risk during emergencies.

Despite these challenges, there is a clear path forward—not through a single sweeping solution, but through practical, building-block strategies that strengthen the system now while longer-term policy evolves.

Several opportunities stand out:

• Invest in obstetric emergency readiness outside of L&D units. As closures occur, emergency departments and EMS must be equipped to stabilize and manage perinatal emergencies. Mobile simulation programs, standardized protocols, and targeted training can create a reliable safety net across rural communities. 
• Establish a statewide Maternal Levels of Care framework. Transparency about each facility’s capabilities—paired with strong transfer networks—ensures patients receive care in the right setting at the right time and allows EMS and providers to plan proactively. 
• Strengthen workforce sustainability through regional models. Shared call pools, cross-credentialing across hospitals, and rotational training programs between low- and high-volume settings can stabilize staffing and maintain clinical competency. 
• Expand access through innovation. Remote patient monitoring and maternal-fetal medicine hub-and-spoke models can reduce travel burdens and improve monitoring for high-risk patients. Partnerships between hospitals and community-based providers, including FQHCs, offer additional pathways to distribute cost and care delivery. 
• Pilot and evaluate new models through existing mechanisms. Programs like the Rural Health Transformation Program (RHTP) offer an opportunity to test scalable solutions—even within current fiscal constraints. 
• Start building the pathway to restructured payment. Assess the options and opportunities to build differential payments that maintain essential services and cover fixed “readiness” costs.  
• Sustain data systems and monitor impact. A shifting policy landscape requires vigilant monitoring of care patterns. Changes resulting from the One Big Beautiful Bill Act, the 2027 transition to fee-for-service maternity coding, and the Rural Hospital Transformation Program may significantly impact rural care delivery. Proactive monitoring of claims data, distance to care, and provider distribution is essential to understanding these shifts and determining how best to respond.

Ultimately, sustaining rural maternity care requires a fundamental shift in how we define value. These services are not just cost centers—they are essential infrastructure, foundational to community health, economic stability, and long-term trust in the healthcare system.

Colorado has an opportunity to lead by acknowledging both the complexity of the challenge and the feasibility of near-term action. The conversations happening today are no longer just about identifying the problem—they are about building a path forward.

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

CPCQC is actively advancing these solutions while working to mitigate the challenges facing rural communities. This includes building targeted strategies to support emergency departments as they increasingly serve as the front line for obstetric care and convening with emergency medical services leaders across the state to better understand and respond to perinatal and infant-related calls. Together, this work is helping to surface critical insights—ranging from call frequency and clinical severity to transfer patterns and travel times between facilities.

These efforts represent an important first step toward a more coordinated and resilient system. By strengthening data visibility, aligning training, and fostering collaboration across hospitals, EMS, and community providers, Colorado can build the infrastructure needed to better protect the health and safety of patients during pregnancy and throughout the first year postpartum.

CPCQC has also developed a set of practical tools to support rural hospitals in advancing this work:

The Quick Care Card addresses this gap by ensuring birthing people, first responders, and healthcare teams have shared, easily accessible information at the point of care. Developed by the Colorado Perinatal Care Quality Collaborative, the program includes an alert card with QR codes, educational resources, and key warning signs of pregnancy and postpartum complications. The initiative supports patient safety, continuity of care, and awareness across emergency response systems.

The Maternal Quality and Safety Toolkit for Rural Hospitals provides practical, adaptable resources to support perinatal safety across care settings. CPCQC recommends the Alliance for Innovation on Maternal Health (AIM) patient safety bundles as condition-specific resources and provides this toolkit, designed to be flexible, relevant to multiple initiatives, and grounded in the realities of rural practice.Initial scoping and curriculum development for an Obstetric Emergency Readiness Initiative tailored to the needs of rural hospitals and built around the needs of pregnant people. The program design focuses on equipping hospitals and first responders with the tools and protocols needed to address obstetrical emergencies.