Rural maternity care has faced growing challenges in recent years. Since the end of 2020, more than 120 rural hospitals across the U.S. have closed their labor and delivery units, and 41 have closed in Iowa alone since 2000. As local options disappear, pregnant patients — particularly those seeking home births — are increasingly forced to travel farther for care if complications arise. At Boone County Hospital (BCH), we’ve seen this impact firsthand.
Our 25-bed Critical Access Hospital in Boone, Iowa, began experiencing an increase in transfers from home birth patients who had “risked out” of their level of care. These patients reported positive experiences with BCH, attracting a growing number of patients from a wider region, including the greater Des Moines area.
Combating home birth stigma and prioritizing patient care
Recognizing this growing population and shortages in labor and delivery services across the state, we focused on our role as a central source of care and support for patients in our community. We established intentional collaboration with local home birth providers and midwives to discuss expectations with home birth transfers, review Boone’s level of care, and determine which patients could safely be cared for at a level 1 low-risk obstetrics service.
Meeting with our providers allowed community midwives to ask questions and share previous transfer experiences. After learning that home birth patients were not always well-received at larger facilities and often didn’t feel heard, we made it a priority to address the stigma around home births. At BCH, we are dedicated to maintaining open communication with all patients, especially those transferred from home births, to ensure their voices are always heard. After discharge, patients can continue to reach out and connect with caregivers via their MyHealth portal.
Collaborating with midwives and ensuring safe transfers
To ensure communication remains open, BCH now meets annually with a group of midwives and has integrated post-delivery debriefing into our workflows to ensure smooth transitions of care when a transfer is necessary. We further solidified our collaboration with local midwives by joining the “Step Up Together” collaborative to review and improve safe transfer processes. Over a three-to-four-month period, participants in this collaborative reviewed processes for safe transfers from home to the hospital and vice versa, using webinars, simulations, and discussions with home birth providers throughout the community.
The simulations helped the providers at BCH better understand the equipment and capabilities of home birth providers, while EMS teams gained clarity around the extensive training of certified nurse midwives — reducing safety concerns and stigma around home births. The most recent multidisciplinary simulation, completed in January 2026, successfully walked through the full emergency transfer process from a 911 call to transport and admission to the OR. This simulation gave our labor and delivery nurses and providers hands-on experience and useful training for when emergencies arise.
Elevating safety and supporting better outcomes through statewide quality care initiatives
Our focus on quality and safety extends beyond local collaboration and into statewide initiatives. In 2020, Iowa received a Health Resources and Services Administration (HRSA) grant to focus on maternal morbidity and mortality. BCH has participated in each of the yearly initiatives supported by the Iowa Perinatal Quality Care Collaborative, specifically focusing on improving patient safety and outcomes:
- NTSV Reduction (Nulliparous, Term, Single, Vertex): Implemented improvement processes and algorithms to prevent the first C-section in low-risk, first-time mothers, reducing our rate from 38% to 21.9%, and conducting multi-disciplinary case reviews.
- Obstetrical Hemorrhage: Standardized protocols for quantitative blood loss (QBL) across the hospital, including the OR, and performs risk assessments at admission, during labor, and postpartum.
- Severe Hypertension: Developed algorithms and committed to monthly simulations in obstetrical emergencies, which led to a life-saving process for safely completing C-sections when anesthesia is not immediately in-house.
- Hypoxic Ischemic Encephalopathy (HIE): Improved processes for newborns at risk, consistently performing cord gases, assessing neurological status, and notifying the NICU for higher-level care when needed.
By continuing to align our services with our community’s needs, Boone County Hospital has experienced meaningful growth and improved the patient experience. Looking ahead, we remain focused on sustaining that momentum by deepening communication, expanding collaboration, and continuing to deliver safe, high-quality care through ongoing quality collaboratives and improvement initiatives. With consistently positive patient feedback and survey responses, BCH is committed to ensuring every patient leaves feeling supported, fulfilled, and confident in the care they received.
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