The United States is facing a profound maternal health crisis, characterized by alarming mortality rates, widespread severe complications, and a systemic erosion of perinatal care infrastructure. Against the backdrop of a national crisis that sees hundreds of pregnancy-related deaths annually—more than 80 percent of which are deemed preventable by the Centers for Disease Control and Prevention (CDC)—individual states are being forced to confront the collapse of their rural healthcare safety nets. Colorado has emerged as a stark microcosm of this national fragility. A recent comprehensive study conducted by public health research organization JSI for the Colorado Department of Public Health and Environment (CDPHE) sheds light on the cascading impacts of rural birth facility closures, exposing a healthcare ecosystem in urgent need of structural reform, workforce training, and targeted legislative intervention.
The Scope of the National Maternal Health and Care Access Crisis
To understand the gravity of Colorado’s current situation, one must examine the broader national landscape of maternal mortality and morbidity. Annually, between 650 and 700 women in the United States die from pregnancy-related complications. Furthermore, as many as 60,000 women suffer from severe maternal morbidity—a classification that encompasses unexpected labor and delivery outcomes carrying severe short- or long-term health consequences. The tragedy of these statistics lies in their preventability; the CDC estimates that over four out of five pregnancy-related deaths could be averted with timely, appropriate clinical care.
Compounding this clinical challenge is a severe contraction in physical access to care. The United States is currently navigating a perinatal care access crisis driven by the accelerating closure of hospital labor and delivery units. Between 2010 and 2023, a staggering 641 hospital obstetrics units closed their doors nationwide. These closures create dangerous geographical and temporal voids in the healthcare continuum. Patients are routinely forced to travel significantly greater distances to access time-sensitive labor, delivery, and postpartum care, thereby exponentially increasing maternal and infant health risks.
As dedicated labor and delivery units disappear from rural and low-resource areas, an increasing number of pregnant and postpartum patients are turning to non-traditional and emergency settings for obstetric care. Emergency departments and emergency medical services (EMS) personnel are increasingly acting as the primary point of contact for acute perinatal events. However, these entities are rarely structured or resourced to manage complex obstetric emergencies, creating a dangerous mismatch between patient need and clinical capability. Furthermore, this contraction of services, compounded by nationwide perinatal workforce shortages, severely limits patient choice and drastically elevates stress levels for expectant families.
Colorado’s Fragile Health Ecosystem: Maternity Care Deserts and Rural Pressures
Colorado mirrors this fragile national ecosystem, struggling with a persistent wave of birth facility closures that has fundamentally compromised access to quality care. The consequences of these closures are quantified in alarming metrics: roughly 40 percent of Colorado’s counties are currently classified as maternity care deserts, lacking even a single hospital obstetric unit or birth center. More critically, an overwhelming 98 percent of Coloradans now reside in geographic areas characterized by an inadequate supply of prenatal health care.
Recognizing the severity of these systemic vulnerabilities, the CDPHE commissioned JSI in 2025 to execute an in-depth study focusing specifically on perinatal care access in rural regions and the localized impacts of birth facility closures. The investigation aimed to capture the lived experiences of rural residents, healthcare providers, and emergency responders, translating qualitative accounts and quantitative data into actionable policy recommendations.
The human and logistical toll of these closures became immediately apparent through the study’s findings. Caitlin Hungate, Senior Associate at JSI and co-investigator and co-author of the study, detailed the profound disruptions experienced by rural families. "Study participants shared that the primary consequence of a birth facility closure was increased travel time to care," Hungate explained. "In rural Colorado, that is often exacerbated by weather, mountain passes, and wildlife on the roads. The increased travel time can be financially and logistically burdensome for women and families, given transportation needs and the implications on childcare and employment leave time."
Beyond the logistical and financial strains placed on expectant mothers, the study revealed a dangerous systemic shift in how obstetric emergencies are handled. When local labor and delivery units shutter, the immediate burden of managing complex obstetric crises shifts directly to local hospital emergency departments and emergency medical services. Unfortunately, these entities are frequently ill-equipped to handle the specialized demands of childbirth complications. Staff in rural emergency departments often lack the clinical training, ongoing exposure, and specialized experience required to manage acute labor and delivery scenarios, and many facilities operate without appropriate specialized obstetric equipment.
Implications for System Readiness and Workforce Training
The empirical findings of the Colorado study underscore an urgent, non-negotiable imperative: healthcare systems and clinical workforces must be systematically strengthened to handle obstetric emergencies, particularly in regions experiencing acute gaps in perinatal care access.
When emergency departments and EMS providers are thrust into the front lines of maternity care without adequate preparation, the risk of adverse outcomes skyrockets. Addressing these vulnerabilities requires a multi-layered strategic approach. First, rural and non-obstetric healthcare facilities must implement continuous simulation training and advanced educational modules. These programs are essential for ensuring that emergency clinicians maintain the competence and confidence required to respond effectively to high-acuity, low-frequency events such as emergency department births or complex neonatal and maternal emergency transfers.
Second, the study highlights a critical need for dedicated funding streams directed toward the acquisition of modern, specialized medical equipment tailored to emergency obstetric care. Rural hospitals, often operating on razor-thin financial margins, cannot absorb the costs of specialized carts, fetal monitors, and emergency resuscitation gear without targeted state and federal support.
Finally, the study emphasizes the necessity of enhanced coordination and formal collaboration between community-based birth providers—such as licensed midwives and doulas—and local emergency medical services. In many rural communities, community birth providers are the primary source of continuous perinatal support. Establishing robust, streamlined pathways for emergency communication and transfer between community settings and regional hospitals can mean the difference between life and death during a catastrophic hemorrhage, eclampsia, or shoulder dystocia event.
Legislative Action and Strategic Policy Recommendations
Armed with the comprehensive data gathered from the investigation, JSI authored a pivotal legislative report designed to guide state policymakers. The document outlines a series of strategic recommendations aimed at reinforcing Colorado’s perinatal system of care, safeguarding maternal health, and guaranteeing equitable access to safe, reliable, and high-quality clinical services regardless of geography.
The legislative report serves as an operational roadmap for lawmakers, healthcare executives, and public health officials. Key focus areas within the recommendations include establishing sustainable funding mechanisms for rural maternity care models, expanding telehealth infrastructure for prenatal and postpartum monitoring, creating regionalized networks of perinatal care that facilitate seamless emergency transport, and mandating standardized obstetric emergency training across all acute care facilities in the state.
Public health advocates and healthcare administrators argue that adopting these legislative recommendations is essential for reversing the tide of maternal morbidity in Colorado. By proactively preparing emergency systems for obstetric crises and supporting the remaining perinatal workforce, the state can mitigate the worst impacts of rural facility closures.
National Initiatives and the Path Forward
While state-level policy changes are critical, Colorado’s challenges are part of a broader national dialogue regarding maternal safety and quality improvement. Across the United States, large-scale initiatives are working to bridge the gaps in perinatal care access through evidence-based protocols and clinical standardization.
A cornerstone of this national effort is the Alliance for Innovation on Maternal Health (AIM), a national, cross-sector commitment funded by the Health Resources and Services Administration (HRSA). AIM is explicitly designed to support the adoption of patient safety bundles—structured collections of evidence-based clinical practices—that make birth safer, improve overall maternal health outcomes, and ultimately save lives.
The AIM Technical Assistance Center, managed by JSI, plays a pivotal operational role in this mission. By supporting the implementation of maternal safety bundles across 51 U.S. states and jurisdictions, the center reaches over 2,095 birthing facilities, accounting for approximately 74 percent of all delivery locations nationwide. Through this extensive network, AIM facilitates the rapid dissemination of best practices aimed at reducing preventable maternal mortality and severe morbidity.
Recognizing that closures and maternity care deserts force deliveries into non-traditional settings, the AIM TA Center has also developed specialized resources tailored to lower-resource and non-obstetric environments. Tools such as the AIM Obstetric Emergency Readiness Resource Kit and the AIM Community Birth Transfer Resource Kit provide practical, evidence-based guidelines for emergency departments, EMS agencies, and community birth attendants. These resources offer standardized protocols for recognizing maternal warning signs, managing unexpected deliveries outside of traditional labor and delivery units, and executing safe, efficient patient transfers to higher levels of care.
Looking toward the future, public health experts emphasize that Colorado and the nation as a whole must prioritize proactive investments in maternal health infrastructure. Preventing obstetric emergencies requires a dual-track approach: actively working to preserve and support existing perinatal care access points while aggressively preparing emergency and community systems for the inevitable scenarios where local care is unavailable.
As rural birth facilities continue to face economic and operational pressures, the insights provided by the Colorado JSI study and national frameworks like AIM offer a clear path forward. By combining targeted legislative action, enhanced workforce training, robust equipment funding, and seamless inter-facility communication, policymakers and healthcare leaders can build a resilient perinatal care system capable of protecting mothers and infants across every zip code.
Stakeholders, healthcare providers, and policymakers interested in a detailed breakdown of the state’s strategic roadmap can access the full legislative report through JSI’s publication portal. The comprehensive document provides an in-depth summary of qualitative findings, policy recommendations, proposed action steps, and best practice guidelines designed to navigate the ongoing challenges of birth facility closures and safeguard the future of maternal health in Colorado.
