The weeks and months leading up to baby’s arrival are filled with decisions. From choosing nursery colors to selecting the best diapers and bottles, expectant parents spend countless hours preparing for this life-changing event.
An even more critical decision for soon-to-be mothers is where to give birth. Expectant moms in larger cities often have multiple options, including birthing centers and community hospitals. It’s a different story entirely for many pregnant women living in rural Texas who have few—if any—nearby options for safely delivering their babies.
According to the March of Dimes report “Where You Live Matters: Maternity Care in Texas,” nearly half of Texas counties lack a hospital offering obstetric care, a birth center or adequate access to maternity providers. These conditions create “maternity care deserts” in many rural communities, leaving women without a safe, local facility to give birth.
The Center for Healthcare Quality & Payment Reform (CHQPR) reports higher risks of complications and death for both mothers and infants in communities without local maternity care services. The farther a woman must travel to receive maternity care, the greater her risk of maternal morbidity and adverse infant outcomes, including stillbirth and NICU admission.
Why rural labor and delivery units are closing
There are several reasons for the discrepancy in maternity care in rural communities compared to larger cities. One major factor is cost. Providing obstetric care—whether in urban or rural facilities—is expensive. Labor and delivery units must be staffed with specialized personnel around the clock. In addition, reimbursement rates from private insurance plans and Medicaid programs often do not cover the high cost of delivering safe, high-quality maternity care.
Urban hospitals are often able to offset labor and delivery expenses with revenue generated from other service lines such as orthopedics, cardiology and oncology. Rural hospitals, however, serve smaller patient populations and receive less overall revenue, making the financial burden of supporting a labor and delivery department especially challenging. As a result, these departments are often the first to be eliminated in rural hospitals.
Together, these factors point to a growing maternal health care crisis in Texas.
Innovative solutions for immediate impact
While health care professionals, policymakers and governmental agencies continue working toward long-term solutions, expectant mothers in rural communities are frequently forced to rely on the nearest emergency room for delivery or pregnancy-related complications, according to the National Rural Health Association. Many rural emergency departments (EDs), however, are not equipped to manage obstetric emergencies due to limited exposure to these cases.
Recognizing the need for immediate action, Texas A&M Health—with funding from the 89thTexas Legislature through the Rural Engagement Program—has developed an innovative, practical solution to train emergency room personnel to care for expectant mothers in rural Texas. This initiative is the first in the state to develop this type of training specifically for rural health care facilities.
“While there are other simulation-based maternal safety programs, most efforts are centered in urban or tertiary settings,” said Jacquelyn Alvarado, DNP, director of rural maternal health at the Texas A&M Health Rural and Community Health Institute. “We are offering the training to rural EDs in communities without maternity care and those rural hospitals that have a low-volume labor and delivery unit (less than 100 births per year). Texas A&M’s initiative is among the first in Texas to scale this type of training for rural hospitals and critical access facilities.”
The training was developed with the Texas A&M College of Nursing and is multidisciplinary. It’s designed for emergency room physicians, advanced practice providers, registered nurses, emergency medical services and other staff who may be the first to respond to an obstetric emergency, Alvarado said. All members of the care team participate together, which strengthens communication and teamwork.
Hands-on training, delivered locally
Because rural health care providers often cannot travel to metropolitan areas for training, Alvarado brings mobile simulation directly to emergency departments across Texas. Her hands-on approach strengthens providers’ ability to respond quickly and effectively to obstetric emergencies, helping hospitals stabilize and manage critical patients within facilities that may not have been expressly designed to handle obstetrics.
“Our model is unique because the training takes place locally where teams can practice in their own environment,” Alvarado said. “This allows for highly realistic, team-based drills. Because the training is tailored to the local context, staff walk away with practical, immediately applicable lessons.”
Each session involves directed simulations with anatomically correct obstetric mannequins—MamaNatalie Birth Simulator. These advanced models have realistic pelvises, replaceable cervices and internal structures which allow medical professionals to engage in emergency scenarios and delivery complications.
Teams work through scenarios in real time, followed by a structured debriefing session. Trainings typically last four to six hours, though some hospitals opt for two-day intensives to allow for more staff rotations and multiple runs of each scenario.
The goal of these simulation drills is to increase confidence among emergency room staff and improve their ability to quickly recognize and stabilize life-threatening conditions.
Prepared in Pearsall
Cassandra DuBose, chief nursing officer for Frio Regional Hospital (FRH) in Pearsall—approximately 55 miles southwest of San Antonio—was among the first to schedule training with Alvarado. She wanted her nurses and emergency staff to be better prepared for maternal care cases that might arrive at their door. She said that Alvarado’s training greatly exceeded her expectations.
“She talked through real-life scenarios and visually demonstrated the best ways to handle complications,” DuBose said. “What we learned were things we could not have learned from watching a video.”
One particular emergency scenario Alvarado demonstrated to the FRH emergency staff was how to deliver a baby presenting with shoulder dystocia—a complication that occurs when the baby’s shoulder gets stuck behind the mother’s pubic bone or sacrum. Alvarado showed how to properly and safely facilitate this kind of delivery. She then encouraged the participants to practice the procedure on the training mannequin. As a result, the staff members left the training feeling confident in their ability to identify such an obstetric emergency and provide the proper care, DuBose said.
Overall DuBose was impressed with Alvarado’s genuine passion for preparing emergency room staff to manage a variety of maternal health complications.
“She created a safe environment for participants to ask questions and provided numerous references and materials,” she said.
DuBose and her staff have committed to participate in quarterly virtual refresher sessions to reinforce skills and review real-life case applications.
Keeping maternal care within reach
To date, Alvarado has completed six OB Emergency Simulation Trainings in cities across Texas, including Mitchell, Knox City, Ward, Haskell and Seymour. Each site received a MamaNatalie birth simulator mannequin for continued practice and training.
The goal, according to Alvarado, is to build a rotating calendar so rural hospitals across the state can be reached systematically, with quarterly refresher training to ensure sustained readiness.
“We’re not just responding to a crisis; we’re building a blueprint for sustainable maternal care in rural Texas,” Alvarado said. “Every mother deserves access to quality care, regardless of her ZIP code. Our mission is to make equitable, evidence-based care a reality in every rural community.”
ABOUT TEXAS A&M HEALTH
Texas A&M University Health Science Center (Texas A&M Health) comprises five colleges and schools (dentistry, medicine, nursing, pharmacy and public health), integrated University Health Services, several research centers and institutes, and numerous outpatient clinics with a shared mission of advancing health care for all. We serve the state and beyond with campuses and locations in Bryan-College Station, Dallas, Houston, Round Rock, Kingsville, Corpus Christi, McAllen and Navasota. Learn more at health.tamu.edu or follow @TAMUHealth on X (née Twitter).
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