Advancing Obstetric Readiness through Innovative Policies and Programs
By Association of State and Territorial Health Officials (ASTHO)
The United States is facing a maternal mortality crisis largely driven by limited access to care. In 2023, 18.6 women per 100,000 live births died from maternal causes, despite more than 85% of pregnancy-related deaths being preventable. Timely, high-quality medical care plays a major role in reducing maternal deaths, especially in obstetric emergencies. Yet, over 2.3 million reproductive-aged women live in areas without access to essential services, and more than 35% of counties are classified as maternal care deserts, exacerbated by the rise in hospital closures. The resulting long travel times or lack of transportation to reach services worsen geographic barriers to care, delaying responses to obstetric emergencies and further intensifying the maternal mortality crisis.
As the landscape of maternal health continues to evolve, state and territorial health officials are uniquely positioned to explore and support innovative policies and programmatic initiatives that broaden telehealth access, improve maternity care access, and better leverage emergency care resources.
Telehealth
Expanding telehealth can mitigate geographic barriers to obstetric care and support the management of high-risk pregnancies through remote patient monitoring and specialist consultations. While the COVID-19 pandemic led many states to implement broad telehealth programs and policies, targeted efforts focused on maternal care can further improve access in areas without obstetric services.
For example, in 2024, New York enacted S 7690, which expanded Medicaid coverage to include remote ultrasounds and fetal non-stress tests. These types of policies expand access to telehealth consultation for pregnant Medicaid recipients, helping to prevent complications and emergencies.
The University of Arkansas for Medical Sciences and the Arkansas Department of Human Services launched the High-Risk Pregnancy Program to expand access to high-risk obstetric services. This program connects patients with maternal-fetal medicine specialists and emergency teams through a comprehensive telehealth network, ensuring timely, high-quality care for obstetric emergencies, regardless of geographic barriers.
Telehealth is an evidence-based approach and a valuable tool for expanding access to care. However, it may be less accessible in communities without reliable broadband and should not be viewed as a full replacement for in-person services. Telehealth is most effective when integrated with other strategies to strengthen obstetric readiness. Additional policies supporting broadband and digital infrastructure are needed to ensure all communities can access telehealth services.
Maternal Health Workforce
A nationwide shortage of OB-GYNs exacerbates current barriers to accessing maternity care. This highlights the need to adopt innovative programs and policies that bridge the gaps caused by these shortages. By strategically leveraging alternative providers, such as Certified Professional Midwives (CPMs) and Family Medicine Physicians, and through targeted accessibility and scope-of-practice policies, states can improve access to maternity care.
In 2024, the Governor of Massachusetts signed legislation to expand access to midwifery care. This legislation creates a formal state licensure pathway for CPMs and requires coverage of midwifery services under MassHealth. Since each state sets its own regulations for certified professional midwives (CPMs), those that recognize CPMs and offer a defined licensure process are better positioned to support a midwifery workforce that meets communities’ needs. Supporting Medicaid reimbursement and inclusion of CPMs in Medicaid managed care plans and private insurance plans also expands financial access to midwifery services for patients.
A recent bill (SB 213) directs the Arkansas Medicaid Program to reimburse prenatal, delivery, and postpartum services separately, rather than as a lump payment. By reimbursing these services separately, the policy strengthens the financial feasibility of family medicine physicians to provide maternal health services, increasing the number of providers who can deliver prenatal and postpartum care in underserved areas. This expands access points, especially in maternity care deserts, by leveraging family medicine physicians as vital sources of care for obstetric emergencies.
Policies such as these are a good start at improving access to maternity care as OB-GYN shortages continue. As such, it is increasingly important to empower and train non-obstetric providers further to ensure obstetric readiness.
Emergency Medical Services and Emergency Departments
Maternity care deserts and rural hospital closures have led more pregnant women to deliver at home, en route to a hospital, or at nearby facilities without a maternity ward. Emergency Medical Services (EMS) and Emergency Department (ED) providers actively manage obstetric emergencies as geographic barriers to care increase. Strengthening obstetric readiness through programs and policies is essential to ensuring safe, high-quality maternal care.
As states acknowledge the importance of non-obstetric providers, EMS is becoming a key component of coordinated maternal health care systems. Maryland has a perinatal levels of care system in which the Maryland Institute for Emergency Medical Services System regulates higher levels of care. In contrast, most other states’ systems are structured through the health department or Perinatal Quality Collaboratives. The institute regulates this system to ensure that maternal-neonatal transport is conducted appropriately across all geographic areas, ensuring that pregnant women receive timely, high-quality care during critical moments.
Beyond regulation, State Perinatal Quality Collaboratives are providing guidance and training on triaging pregnancy complications in emergency settings to strengthen obstetric readiness. For example, Missouri developed a flowchart to guide EDs in managing maternal hypertension as well as an Emergency Triage and Care Resource Workbook, and Florida has numerous emergency resources to support training to prevent maternal mortality.
On a national level, the Indian Health Service released its Obstetric Readiness in the Emergency Department Manual in response to the increase in obstetric unit closures in rural hospitals affecting American Indian/Alaska Native populations. They designed this manual to build the capacity of EDs to provide proper maternal care to American Indian/Alaska Native populations, address obstetric emergencies, and ensure patient access to risk-appropriate care.
Despite limited data on obstetric response in emergency settings, integrating EMS into maternal care coordination and strengthening training and resources for emergency care settings are promising practices that should be formalized into policy to improve obstetric readiness.
Conclusion
These strategies highlight that improving maternal outcomes requires not only clinical interventions but also coordinated state‑level programs and policies to expand obstetric readiness. Initiatives to improve maternal health demonstrate a strong return on investment and lay the groundwork for comprehensively improving access to maternal care. Sustainable progress will also depend on integrating community involvement, addressing transportation and broadband barriers, and increasing consumer awareness.
While significant progress has been made in improving obstetric readiness, the postpartum period continues to require a similar level of attention, support, and care. Maternal mortality remains a persistent challenge during this critical time, and limited access to postpartum services is a major barrier to achieving better outcomes. Applying strategies to advance obstetric readiness, with an emphasis on postpartum needs, can help close gaps and improve maternal health across the continuum.
