Summary
- Rural labor and delivery providers have made improvements as part of an IHI Collaborative. They shared insights about how rural settings come with advantages despite resource limitations.
“I've had shifts where I take care of a patient on hospice and see them take their last breath. And then later in the shift, I deliver a baby. You see the whole lifespan throughout your days in this setting.” Kayla Paulsen, RN, BSN, CLC, Birth Center Manager at Orange City Area Health System in Orange City, Iowa, reflected on the profoundly human dimension of providing healthcare in a small, rural community. Like many who work in rural settings, she told us she finds her work deeply rewarding — despite resource limitations and a sense of marginalization within the larger medical community.
In September 2025, IHI launched a Collaborative focused on reducing NTSV (Nulliparous, Term, Singleton, Vertex) cesarean birth rates at 13 hospitals. With generous funding from Merck for Mothers and partnerships with the Iowa Perinatal Quality Care Collaborative (IPQCC) and Alabama Perinatal Quality Collaborative (ALPQC), IHI convened hospital teams in peer learning, quality improvement coaching, and testing change ideas. Teams used a data platform called AdaptX to track metrics and measure progress in real time.
The Collaborative included participants from small rural hospitals, large urban academic medical centers, and everything in between. We identified three rural hospitals in Iowa that have been making impressive strides in their improvement work. To learn what they are doing well and how their rural settings impact care, we sat down with hospital leaders, who shared five important lessons.
1. Rural providers develop skills across many specialties
Rural hospitals often lack the highly specialized services that larger hospitals offer. As a result, providers become adept at a wide range of services. Said Paulsen, “We're not as specialized, but I would argue that we sometimes have more skill sets than some higher acuity facilities, because we have to know a little bit of everything.”
Elizabeth Reedy, BSN, RN, Inpatient Services Director at Palo Alto County Health System in Emmetsburg, Iowa, shared that her hospital does not have respiratory therapy (RT) around the clock. Instead, they have trained their hospital-based ambulance teams. “Instead of RT being our airway, we've trained our EMS [emergency medical services] and our critical care paramedics to be our airway. It's about knowing what you have and what training you can give to maximize every possible person in house.”
Similarly, Alicyn McVey, BSN, RN, Director of Inpatient Services at Cass County Memorial Hospital in Atlantic, Iowa, shared, “Nobody's coming to your rescue, so you become the best that you can be and work to the very top of your scope. You become a well-oiled machine and you know exactly who is best at which skill.” Over and over, we saw that rural care teams took on challenges across disciplines to meet the needs of those they serve.
2. Simulations prepare teams for high-risk scenarios
While rural providers have the chance to become skilled across specialties, they also have fewer opportunities to practice rare, high-risk birth scenarios. Paulsen said of her colleagues, “They're very much jacks of all trades, which is awesome. They have great clinical judgment. But they may only see one high-risk obstetric situation each year. So we do a lot of simulations to help them stay competent.” McVey also shared that simulations, particularly those run by IPQCC, have been hugely beneficial to her team, though she was hesitant to lead simulations at first. Her advice is to “get comfortable with simulation, get comfortable with practicing.” That includes approaches that range from role playing to using a wearable tool that simulates giving birth. She has seen these simulations pay off many times through successful birth outcomes in high-risk situations.
3. Standard recommendations and guidelines need adaptations for different settings
Hospitals are held accountable to many target metrics for safety and quality. However, these are often not created with the constraints of rural facilities in mind. Reedy acknowledged that her hospital’s NTSV c-section rate is above the Healthy People 2030 goal of 23.6 percent, and she attributes some of this gap to the realities of rural care. “Our resources could potentially be 30 minutes away, and that definitely plays a factor in how early we’re willing to call a C-section. We’re still trying to stay up to date with best practices and going off evidence-based guidelines, but those guidelines are made for bigger hospitals that have more resources at their disposal.” Risks and benefits are different when specialized support is farther away.
When it comes to measuring improvement over time, IHI advises tracking data at least monthly, if not more frequently. However, we found that hospitals with low volumes are not well-served by such frequent analysis because they have so few cases. Instead, they may do better to look at quarterly trends. McVey shared that she felt discouraged by some of her data and needed to “not let one month where my C-section rate was higher get to me. To see your C-section rate be 50 percent or 40 percent in a month can be a little disheartening.” While a 50 percent rate at a large hospital could indicate hundreds of C-sections, it might reflect only one or two at a low volume facility. Looking at data over time has helped her gain a more balanced view and a stronger understanding of her system.
4. Smaller teams can spread change rapidly
In quality improvement, testing change ideas through Plan-Do-Study-Act (PDSA) cycles is key to improvement. Many larger hospitals run into barriers getting providers and leaders on board when implementing changes. Smaller teams have a greater degree of autonomy. After a Collaborative learning session, McVey reflected that it seemed these large systems “had more hoops to jump through. They have to take it to their admin team. They have to take it to different councils. And then they've got providers delivering from outside clinics to get on board. Whereas if I want to make a change in how we practice or how we run oxytocin or our C-section metrics, I can just do them. Most things I don't have to run through admin. They let me use my best judgment and evidence-based medicine.”
She concluded that for staff at large urban medical centers, “Their ability to drive change is so much harder than mine.” We often think about smaller, lower resourced hospitals learning from larger facilities. However, in this Collaborative, larger hospitals had a chance to learn from the rural hospitals about empowering frontline leaders to more rapidly spread improvement.
5. Small communities contribute to uniquely meaningful provider-patient relationships
The three providers we spoke to all shared a sense of heart that goes far beyond the delivery room in their rural communities. Reedy summed up these feelings: “We strive to provide the absolute best care we can with the resources that we have. Just because we don't have this laundry list of providers or specialists available, it does not mean that our patients or the babies that we deliver are shortchanged by any means.”
She continued, “Our nurses that deliver these babies, they watch them grow up. Kids that I delivered, I see in the grocery store. They're on my kids’ T-ball team. Their mom is still like, ‘Oh yeah, don't you remember, Liz was in the delivery room when you were born!’ The stories that our patients remember and the warm and fuzzy feelings that they have from that relationship with us are amazing.”
Learning from and supporting one another
Ultimately, our communities need both large and small facilities so that everyone can access the care they need. When asked about what resources she wished were available, Reedy answered that what she needs most is continued support from large hospitals. She sees a reciprocal relationship with larger facilities that makes the entire healthcare ecosystem stronger. “We want to be able to take some of those well moms and those well babies off their hands so they can focus on the high-risk moms and the high-risk babies. It goes back to allocation of resources and who can take care of whom.” In this way, it helps us all — providers and patients alike — to be supportive, respectful, and open to learning more about the unique challenges and needs of rural healthcare.
Sophia Cunningham is a Project Manager at IHI. Deborah Bamel is a Project Director at IHI.
Photo by Jimmy Conover on Unsplash
You may also be interested in: