The provision of safe obstetric care requires a commitment to lifelong learning and maintenance of knowledge and skills. Rural settings, low-volume settings, or both, may present challenges in maintaining clinician and nursing skills because of limited volume and, therefore, limited opportunity to participate in various aspects of care. The ability to maintain skills and patient safety in low-volume obstetric facilities may be improved by the following activities:

  • Maximize the number of health care providers (nursing and delivering staff) who attend a delivery in order to leverage the available experience for all health care providers.
  • Periodically rotate health care providers to larger, higher volume, regional facilities to facilitate clinical experience. Ideally, funding to support this clinical experience would be provided.
  • Provide a structured orientation program for all health care providers who are new to the practice setting. This program should include local and regional practices and standards.
  • Frequently conduct structured multidisciplinary drills and simulations.
  • Participate in a regional integrated delivery system with ready access to consultation and referral when needed, outreach education from regional perinatal centers, and regional analysis and evaluation of regional data (facilitated by regional perinatal centers)1.
  • Ensure that an established agreement with policies and procedures for timely transport is in place, where a woman who needs urgent or emergent delivery (cesarean delivery) can be expeditiously transported to an accepting physician and facility in accordance with a fully established regional perinatal care plan1.
  • Have essential obstetric medications and supplies available (such as magnesium sulfate, antenatal corticosteroids, and tocolytics) in low-risk birthing centers. Ideally, blood banking and ready access to at least limited obstetric ultrasonography also should be available (if level of maternal care is level 1 or higher)1.

Additional options also could be implemented to reinforce patient safety as well as clinical support for health care providers in low-volume settings. Telemedicine and teleconsultation capabilities may be beneficial to coordinate care. The Obstetric Care Consensus document, Levels of Maternal Care, provides further information regarding regionalization and integration1. Importantly, support of health care providers in rural settings, low-volume settings, or both, should be a shared responsibility among the community, government, payers, and health care facilities. Each must be committed to retaining obstetric services in the community and to contributing to the programs and activities designed to maintain the skills of the health care team.


  1. Levels of maternal care. Obstetric Care Consensus No. 9. American College of Obstetricians and Gynecologists. Obstet Gynecol August 2019;134(2):e41-e55

Approved by the Executive Board: May 2016
Reaffirmed: July 2018
Reaffirmed: March 2021