By Hope Burch, Candice Talkington, Annette Schnabel, Paula Lewis, Jacob Faries, Steven Brackeen, and Julie Wallace

Background

Launched in January 2023, the Rural Emergency Hospital (REH) designation is a provider type established by Congress that can help preserve access to essential healthcare services in rural communities.¹ Congress developed the REH designation in response to mounting financial pressures on rural hospitals, including declining patient volumes, reimbursement limits, and the high costs of operating comprehensive inpatient and specialty services. REHs receive enhanced reimbursement—an additional 5% for outpatient services² and a monthly facility payment³, helps ensure financial stability. This support enables REHs to maintain critical healthcare access in rural communities by focusing on emergency and outpatient care, rather than facing full closure.

Beginning in early 2023, with the approval of the first Rural Emergency Hospital. As of December 31, 2025, we have seen 44 struggling rural hospitals across the country complete their journey to obtain this new designation. The REH designation provided a pathway to stabilize operations in these rural hospitals and helped keep access to essential services in these communities. Unfortunately, a byproduct of an REH conversion is the closure of all inpatient units, including obstetric (OB) care. Despite this fact, the Rural Emergency Hospital plays a critical role in preserving access to OB care, both pre-natal and post-natal, and at times, emergent delivery services in these rural communities.

Introduction

Access to OB care remains a critical and an increasingly unmet need in rural communities across the United States. Nearly 59% of rural counties lack hospital-based OB services, leaving many pregnant individuals without nearby options for prenatal care or safe delivery. This access gap endangers maternal and newborn health and adds logistical, financial, and emotional stress to families forced to travel long distances for care.

Over the last decade, rural hospitals have increasingly discontinued OB services due to a combination of financial, workforce, and operational challenges.⁵ The financial pressures from rising malpractice insurance premiums, increasing volumes of Medicaid-covered deliveries coupled with low Medicaid reimbursement rates, and the operational cost of maintaining adequate staffing for an OB department have made labor and delivery services unsustainable for many rural facilities. According to the American Hospital Association (AHA), facilities with fewer than 300 births per year often struggle to cover fixed costs of an OB unit.⁶ Additionally, rural hospitals face persistent difficulties recruiting and retaining clinicians trained in OB care (e.g., physicians, nurses)⁷ and some hospitals have concerns about the cost of maintaining modern delivery suites and neonatal equipment.⁸

In many rural communities, the emergency department (ED) at a hospital is the only point of access for patients in labor.⁹ Like other hospitals, REHs are legally required to comply with the Emergency Medical Treatment and Labor Act (EMTALA), which mandates that all Medicare-participating facilities with an ED must:¹⁰

• Provide a medical screening exam to determine if the individual has an emergency medical condition and provide stabilizing treatment within their capability and capacity. This includes treatment for patients in active labor or experiencing pregnancy-related emergencies.
• Be prepared to conduct an emergency delivery if the patient cannot be safely transferred promptly.
• Establish protocols and have qualified staff and providers to manage OB emergencies and arrange for an appropriate transfer to a receiving facility with capability and capacity to provide obstetrical and/or neonatal care.

REHs, in accordance with federal law and regulatory requirements, are obligated to meet EMTALA law, reinforcing the importance of OB emergency readiness. In November of 2024, CMS released the 2025 Final Rule for the Medicare Hospital Outpatient Prospective Payment System (OPPS). This rule includes new Conditions of Participation for OB services, which are effective as of January 1, 2026. This change puts into place requirements to ensure that patients receive safe and effective patient care.

While REHs do not provide inpatient services, including OB care, their role in stabilizing patients and coordinating safe and appropriate transfers play a critical role in protecting maternal and newborn health. This underscores the importance of targeted OB emergency readiness and strong regional collaboration to help fill the gaps created by the loss of inpatient care capabilities. By prioritizing OB-specific training and forging strong partnerships with hospitals that offer OB services, REHs can effectively reduce maternal health risks and deliver timely, life-saving care during OB emergencies. An approach grounded in targeted clinical preparation and coordinated regional support enables REHs to protect community safety. It also reflects a broader, more sustainable strategy to balance urgent patient care needs with the long-term financial and operational challenges confronting rural healthcare systems.

Although the Calendar Year 2023 Final Outpatient Prospective Payment System (OPPS) Rule permits REHs to provide low-risk labor and delivery services,¹¹ the absence of inpatient beds presents operational challenges for offering comprehensive OB care. As REHs navigate their new designation, many are still determining how to provide labor and delivery services safely and sustainably within these constraints.

This paper explores how three REHs approach delivering OB-related care in an REH. Each facility has adopted strategies to serve their communities while overcoming financial limitations, workforce barriers, and regulatory demands. By examining their approaches, this brief aims to highlight both the lessons learned and promising practices in rural OB care under the REH designation and ensuring compliance with the new CoPs.

Methodology

To inform this resource, the Rural Health Redesign Center (RHRC) conducted interviews with hospital leaders at three REHs: (1) Parkland Health Center in Missouri, (2) St. Bernard’s Five Rivers Medical Center in Arkansas, and (3) Progressive Health of Helena in Arkansas, who are navigating the realities of providing OB-related care under the REH designation. RHRC supplemented these firsthand accounts using industry research and publicly available data on OB service trends in rural hospitals. This mixed-methods approach helps ensure the findings reflect both on-the-ground experience and a broader national context.

Addressing Obstetric Care in an REH

As rural hospitals transition to the REH model, many are developing innovative approaches to manage OB care without full labor and delivery services. By focusing on emergency readiness, transfer coordination, and community education, these facilities are working to ensure maternal and newborn safety despite resource constraints. The following outlines the challenges and strategies of three REHs.

Progressive Health of Helena: Financial Strain and Staffing Shortages

Progressive Health of Helena offers a clear example of the financial and workforce challenges rural hospitals face in sustaining OB services. Prior to REH conversion, the hospital discontinued its OB program due to mounting losses and persistent staffing barriers.

Challenges:

Progressive Health of Helena eliminated its OB program prior to converting to an REH, citing an annual loss of nearly $1 million attributed to high staffing costs, elevated malpractice insurance premiums, and persistently low Medicaid reimbursement rates. With approximately 85% of OB patients covered by Medicaid and reimbursement rates unchanged for over 21 years, the OB program was no longer sustainable. Staffing was also a major challenge, as the hospital faced difficulties recruiting physicians and nurses for a low-volume, high-risk OB model.

Strategies:

Now operating as an REH, Progressive Health focuses on emergency stabilization and rapid transfer of OB patients to larger facilities 35–45 minutes away. The facility maintains essential OB supplies and has implemented emergency protocols in the emergency department to manage deliveries when immediate transfer is not possible. They also engage the community through public education campaigns to ensure patients understand where and how to access OB care.

St. Bernard’s Five Rivers: Low Volume and Provider Access

St. Bernard’s Five Rivers illustrates how REHs are adapting to the loss of traditional OB services by emphasizing emergency readiness and patient safety. Though full OB care is no longer available, the facility has implemented targeted strategies to manage urgent situations and ensure timely transfers to higher-level care.

Challenges:

St. Bernard’s Five Rivers discontinued formal OB services prior to its REH conversion due to unsustainable costs. High malpractice premiums and low Medicaid reimbursements made it financially unfeasible to support a full OB program. The hospital’s low annual birth volume and small population base compounded the issue. Additionally, the limited number of deliveries made it difficult to recruit and retain OB providers, who typically seek higher-volume environments to maintain their skills.

Strategies:

Despite not offering full OB services, the facility maintains a basic set of OB supplies and evidence-based clinical protocols to guide staff through emergency deliveries. The REH offers routine staff training to stabilize high-risk patients and coordinate timely transfers to higher-level OB care facilities within the St. Bernard’s system, located about 45 minutes away. These protocols maximize safety in the absence of on-site delivery services.

Parkland Health Center: Coordinated OB Services Across Campuses

Parkland Health Center demonstrates how REHs can preserve access to OB care through system-level coordination and resource sharing. By leveraging services at a nearby full-service campus and preparing REH staff for emergency scenarios, Parkland ensures continuity of care across its rural service area.

Challenges:

Parkland Health Center has maintained OB services within its broader system by coordinating between two campuses. The Bonne Terre campus, which operates as an REH, does not provide deliveries, while the Farmington campus continues to offer full OB services. Bonne Terre staff previously faced challenges maintaining OB-specific clinical skills due to infrequent provision of care. Further, managing equipment, staff, and clinical resources across two sites added further operational complexity.

Strategies:

The Bonne Terre REH team now receives biannual OB emergency training, including the Neonatal Resuscitation Program (NRP) certification,¹² and stocks key OB equipment such as neonatal warmers and delivery kits. They are prepared to initiate emergency deliveries, when necessary, before transferring patients to the Farmington campus. Parkland also collaborates with a nearby primary care provider who offers prenatal care for up to 36 weeks of gestation, minimizing travel burdens for expectant mothers until delivery at the Farmington location.

Common Strategies Across Rural Emergency Hospitals

Several shared strategies emerged to support OB care in settings without traditional labor and delivery services across the three facilities highlighted in this document.

• Emergency readiness: All three REHs maintain basic OB supplies and implement step-by-step emergency policies and protocols.
• Training and drills: Staff undergo regular training (e.g., obstetric training and NRP) to be prepared for unexpected deliveries.
• Transfer coordination: Each facility relies on clear, pre-established transfer agreements—as required by REH law and regulation that focus on appropriate transfers with nearby hospitals offering full OB services.
• Community education: Hospitals use social media, community meetings, and direct outreach to educate residents on available OB services and where to seek appropriate care.

These adaptive strategies illustrate how REHs can continue supporting maternal health while managing the financial and operational realities of rural healthcare delivery.

As more rural hospitals transition to the REH designation, ensuring readiness for OB emergencies remains a critical priority, particularly for facilities no longer offering full OB care. REHs must have formal transfer agreements in place, and the ability to stabilize and safely transfer patients experiencing OB complications is essential to protecting maternal and newborn health. To support non-birthing facilities in this effort, the AIM Obstetric

Emergency Readiness Resource Kit,¹³ funded by HRSA, offers practical tools and training resources to help staff deliver safe, timely care. In addition, newly released simulation scenarios for non-OB settings provide realistic case-based exercises to help teams prepare for high-risk situations, such as postpartum hemorrhage or shoulder dystocia, when immediate delivery or stabilization is necessary.¹⁴ These resources are valuable for REHs striving to maintain emergency readiness and patient safety without traditional labor and delivery services.

Conclusion

As rural hospitals confront the complex realities of declining resources and continuing maternal health needs, the REH designation offers a viable path to preserve access to emergency and outpatient services. The loss of inpatient capacity in REHs, including OB care, presents some limitations on Obstetric care. REHs are strategically focused on emergency readiness, ongoing clinical training, transfer agreements that focus on timely response, and proactive community education to preserve maternal and newborn health.
The experiences of Progressive Health of Helena, St. Bernard’s Five Rivers, and Parkland Health Center reveal that even in the absence of full OB departments, REHs can effectively respond to obstetric emergencies and ensure safe continuity of care through coordination with regional partners. Leveraging national tools such as the AIM Obstetric Emergency Readiness Resource Kit and simulation scenarios for non-OB settings can further strengthen their capacity. By continuing to invest in training, protocols, and partnerships, REHs can help rural communities navigate maternal health with resilience, responsiveness, and patient safety at the forefront.

Get Connected

If you are interested in hearing more about Obstetric Care and Emergency Readiness in REH Hospitals, as well as other updates and key learnings from the REH Technical Assistance Center, visit the RHRC website. To receive support from the REH Technical Assistance Center, contact us at REHSupport@rhrco.org. 

Disclaimer

The Rural Health Redesign Center (RHRC) provides technical assistance to organizations on behalf of the Health Resources and Services Administration (HRSA). While RHRC strives to offer accurate and up-to-date guidance, the information provided in this resource is for general informational purposes and should not be considered legal, regulatory, or financial advice. Hospitals and healthcare providers are responsible for ensuring compliance with all applicable federal, state, and local regulations, including those set forth by the Centers for Medicare & Medicaid Services (CMS), state health departments, and other governing bodies. RHRC does not assume responsibility for an organization’s compliance status or guarantee regulatory approval, and healthcare facilities are encouraged to consult with legal, regulatory, and financial professionals for advice.

As a technical assistance provider to rural stakeholders, the Rural Health Redesign Center provides access to a wide range of resources on relevant topics. Inclusion on the Rural Health Redesign Center’s webpage or presentations does not imply endorsement of, or agreement with, the contents by the Rural Health Redesign Center or the Health Resources and Services Administration.  

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Resources

[i]  Centers for Medicare & Medicaid Services. (2024, September). Rural Emergency Hospitals. U.S. Department of Health & Human Services. Retrieved from: https://www.cms.gov/files/document/rural-emergency-hospitals-factsheet-september-2024.pdf 

[ii]  Social Security Act §1834(x)(1), 42 U.S.C. §1395m(x)(1)

[iii]  Social Security Act §1834(x)(2), 42 U.S.C. §1395m(x)(2)

[v] Ashley, M. (2025, April 17). “100 rural hospitals have closed labor and delivery in 5 years: Report. ” Becker’s Hospital Review. Retrieved from https://www.beckershospitalreview.com/finance/100-rural-hospitals-have-closed-labor-and-delivery-in-5-years-report/?utm_source=chatgpt.com 

[vi]  Hung, P., Henning-Smith, C., Casey, M. M., & Kozhimannil, K. B. (2017). “Closure of Hospital Obstetric Services Disproportionately Affects Less-Populated Rural Counties.” Health Affairs, 36(9), 1663–1671.

[vii] American College of Obstetricians and Gynecologists (ACOG). (2022). Obstetric Care in Rural America – highlighting a shortage of OB providers in rural areas.

[viii] Kozhimannil, K. B., Hung, P., Prasad, S., Casey, M., & Moscovice, I. (2015). “Rural Obstetric Unit Closures and Maternal and Infant Health.” Health Affairs, 34(5), 765–772.

[ix] Kozhimannil, K. B., et al. (2018). “Access to Obstetric Services in Rural Counties Still Declining, With 9 Percent Losing Services,” 2004–14. Health Affairs, 37(1), 63–70.

[x]  Centers for Medicare & Medicaid Services. (2022). 42 CFR § 485.514 – Condition of participation: Compliance with EMTALA. Retrieved from: https://www.ecfr.gov/current/title-42/section-485.514 

[xi]   Centers for Medicare & Medicaid Services. (2022, November 1). CY 2023 Medicare hospital outpatient prospective payment system and ambulatory surgical center payment system final rule with comment period (CMS‑1772‑FC) [Fact sheet]. Retrieved from: https://www.cms.gov/newsroom/fact-sheets/cy-2023-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center-2#:~:text=CMS%20is%20finalizing%20its%20proposal%20to%20require%20that%20payment%20for,remotely%20by%20hospital%20clinical%20staff. 

[xii]    American Academy of Pediatrics and American Heart Association. Neonatal Resuscitation Program (NRP). 8th ed. Itasca, IL: American Academy of Pediatrics, 2021. Retrieved from: https://www.aap.org/en/patient-care/neonatal-resuscitation-program. 

[xiii] Alliance for Innovation on Maternal Health. (n.d.). AIM Obstetric Emergency Readiness Resource Kit. Retrieved from: https://saferbirth.org/aim-obstetric-emergency-readiness-resource-kit/. 

[xiv] Alliance for Innovation on Maternal Health (AIM) at the American College of Obstetricians and Gynecologists. (January 7, 2025). AIM Obstetric Simulation Scenarios for Non‑OB Settings [Interactive PDF]. Funded by the Health Resources and Services Administration, designed to help non‑birthing facilities simulate and prepare for obstetric emergencies. Retrieved from: https://saferbirth.org/wp-content/uploads/AIM_OBSimulationScenarios_Non-OBSettings_010725_Interactive.pdf.