The US has the worst maternal mortality rate of any high-income nation in large part due to the socioeconomic and racial disparities. The urban-rural divide is one such example, as rural-dwelling mothers suffer nearly double the mortality rate as those who live in urban areas. In particular, mothers giving birth at rural hospitals with low-volume obstetrics departments experience the greatest rates of morbidity, as these hospitals are less equipped to deal with complicated pregnancies and less able to transfer high-risk patients to better-resourced hospitals nearby, compared to urban hospitals. However, the closure of obstetric service lines, especially in rural areas, is also associated with worse maternal outcomes. Rural mothers are therefore caught in a vicious cycle, in which rural hospitals with low-volume obstetrics departments that produce poor outcomes for mothers choose to shutter their underperforming service lines to help with their thin margins. In the last twenty years, nearly 200 rural hospitals have closed altogether, an undeniable crisis that is only expected to worsen with impending Medicaid cuts. Those that manage to stay open may join the more than half of rural hospitals without obstetrics departments.
 
This dynamic is not unique to rural obstetrics, although it presents there acutely. Rural health is fundamentally about infrastructure and access. The clinicians, facilities, and systems are what make care possible across every service line. Without that foundation, maternal health can’t improve and neither can cancer outcomes, mental health, or chronic disease management in rural populations. Rather than helplessly witnessing further disinvestment from rural populations, we should be doubling down on clinician training, finding ways to improve basic access through mobile clinics and telehealth, and connecting rural “spokes” to larger “hub” centers for specialty access. But even these steps may only be salves to rural healthcare’s ailing system of payment and provision, which is in need of a complete overhaul.