This blog series takes a closer look at targeted health priorities being advanced by states in their Rural Health Transformation program (RHTP) applications. As authorized under the One Big Beautiful Bill Act (OBBBA), the Centers for Medicare and Medicaid Services (CMS) will provide states with $50 billion over 5 years to strengthen and modernize health care in rural communities. Each state developed a plan in their applications to expand health care access, strengthen workforces, build infrastructure and technology, and support care delivery innovation within rural communities. CMS has awarded RHTP funds to states for the first year, ranging from $147 to $281 million.
Rural Health Resources
Pregnant women, children, and families living in rural communities can experience persistent and well-documented health disparities as compared to their non-rural counterparts. Maternity care workforce shortages disproportionately affect rural communities, where maternal health outcomes are often worse and more than half of counties lack hospital-based obstetric services.1 Consequently, women living in the most rural counties face significantly higher pregnancy-related mortality ratios (24.2 per 100,000 live births) compared to women in large metropolitan counties (14.8 per 100,000 live births).2 In response, states are expanding and strengthening access to care in rural areas for these populations.
Additionally, nearly one in five children in the United States lives in a rural county, where access to care and health outcomes are also statistically worse than those in urban areas.3 Child health workforce shortages further exacerbate health disparities for these children, as more than half of rural counties and 90.4 percent of completely rural counties currently lack a general pediatrician.
State Trends
The Rural Health Transformation Program (RHTP) offers a new opportunity for states to improve health care access in rural communities. An analysis of applications offers insights into state priorities to address maternal and child health in rural areas through the RHTP.
Over two-thirds of states (35 state applications) include a focus on maternal and/or child health in their RHTP applications. Most of these states are prioritizing maternity care access; some states are also prioritizing child health initiatives, including addressing youth behavioral health and chronic disease management. Key areas in which states propose to address maternal and child health include:
Increasing Access to Maternity Care
States are using a range of strategies to address maternity care deserts — places with no hospitals or birth centers offering obstetric care and no obstetric providers — in both urban and rural areas across the country.4 Studies show that hospital closures in both rural and urban communities can harm maternal health, worsening delivery outcomes and increasing disparities.5 As part of the RHTP, some states are proposing to support new or enhanced care delivery models to improve access to maternity care in rural areas, including regional health collaboratives or hub and spoke health care delivery models. Some states are also proposing to establish birthing centers in rural areas and expand community-based maternity care options and networks through collaboration with rural clinics, pharmacies, and mobile providers.
- California proposes a statewide hub-and-spoke model that has a particular focus on maternal and primary care. This model would involve hospitals as hubs and federally qualified health centers, rural health centers, Tribal health programs, county behavioral health, birth centers, rural hospitals, community-based organizations, and local health jurisdictions as spokes. These hub-and-spoke models will feature telehealth nodes to further increase access to care.
Expanding the Maternal Health Workforce
States have longstanding priorities in addressing the maternal health workforce shortage through recruitment and retention efforts, as well as providing Medicaid reimbursement for a range of clinical and non-clinical providers. As part of the RHTP, many states are prioritizing rural health care workforce development. This includes specific initiatives to establish new training and credentialing programs for various maternal health providers, such as community health workers, midwives, doulas, and lactation consultants.
- New York’s proposed workforce development initiative, “Rural Roots,” places a significant emphasis on addressing maternal care deserts in rural communities. It will offer advanced training in pregnancy support, lactation counseling, and simulation-based obstetrics training for emergency medical technicians, nursing, and medical students.
Strengthening Community-Based Behavioral Health Programs and Services for Pregnant and Postpartum Women, Children, and Youth
Maternal and pediatric behavioral health have been longstanding priorities as states address heightened mental health needs and limited access to appropriate behavioral health treatment and services for children and families, particularly in rural areas. States are proposing a range of strategies to improve rural access to behavioral health services, many of which are focused on strengthening existing community-based service delivery systems. State plans include integrating screenings for behavioral health conditions in home visiting programs for pregnant and postpartum women and their families, expanding school-based health centers and access to mental health services and curricula in educational settings, strengthening care coordination for behavioral health services, and implementing specialized perinatal and child behavioral health programs (e.g., train-the-trainer models for parents).
- Connecticut proposes expanding its ACCESS Mental Health model, which offers real-time consultation support to address mental health and substance use needs identified during pediatric and prenatal care, into school settings. The state also plans to develop a model of specialized trainings, partnerships, and improved referrals for rural school districts to serve youth with high-acuity behavioral health needs. In addition, Connecticut plans to extend its Family Bridge nurse home visiting program, offering comprehensive behavioral health screenings and additional care to mothers and new babies in rural communities.
Incorporating Technology-Enabled Strategies Into Maternal Health Initiatives
States expanded the use of technology-enabled care models during the COVID-19 pandemic to maintain access to key maternal health services. Many states have continued to build on these efforts to address persistent access barriers, particularly in rural and underserved communities. Strategies include deploying mobile health units in rural areas, providing obstetric carts in rural hospitals, and expanding telehealth and remote patient monitoring programs.
- Alabama details efforts to address maternity care deserts through digital regionalization and mobile screening models. The “Maternal and Fetal Health Initiative” uses telehealth and other digital tools to link rural hospitals with maternal-fetal specialists and improve access to advanced ultrasound services. It aims to address gaps in obstetric care in underserved areas and reduce serious health risks for mothers and infants. The program also expands a pilot that equips rural hospitals with emergency labor-and-delivery carts, helping staff stabilize patients until they can be transferred to higher-level care facilities.
Supporting Chronic Disease Detection and Management
Chronic disease detection and management are particularly critical during the prenatal and postpartum periods, when conditions such as hypertension and maternal mental health disorders adversely affect maternal and infant health outcomes.6 Many states appear to be advancing strategies that align with the priorities of the Make America Healthy Again (MAHA) Commission, including efforts to address and better manage chronic conditions. States are proposing to address chronic disease among maternal and child health populations through screenings, school-based programs, mobile chronic disease management services, and deployment of consumer-facing technologies to support chronic disease management.
- Arizona proposes expanded screening efforts and evidence-based interventions for chronic disease and maternal–fetal health. The state’s strategy focuses on deploying the “Priority Health Initiatives Grants Portfolio,” which emphasizes chronic disease prevention and management alongside maternal–fetal care. This approach supports targeted funding for chronic disease programs and advances the statewide adoption of the Alliance for Innovation on Maternal Health (AIM) maternal safety bundles to improve maternal health outcomes.
- Maryland and Ohio propose efforts to expand the capacity of rural school-based health centers and focus on integrated chronic disease prevention and treatment. Maryland intends to improve access to school-based chronic disease management, including support for students’ asthma action plans, while Ohio plans to pilot the use of a new school-based technology that screens youth for autism spectrum disorder.
Expanding Nutrition Support and Prevention-Focused Lifestyle Initiatives
Consistent with federal priorities advanced through the Make America Healthy Again (MAHA) Commission to address chronic disease, states are proposing to support nutritional and prevention-focused lifestyle initiatives. Specifically, states are targeting Food is Medicine programs and diabetes and obesity management services, including specific efforts for infants, children with chronic and complex needs, and pregnant women.
- Kansas describes efforts to develop and expand Food is Medicine infrastructure through a joint “Accountable Food is Medicine and Community Health Worker Deployment Program.” As this program progresses, community health workers will engage local families in early childhood healthy eating and physical activity by leading community workshops, presenting cooking demonstrations, and distributing family-focused resources.
Note: The summary is based on publicly available state RHTP applications. These strategies may continue to evolve, as states finalize plans and begin implementation of activities in the coming months.
Other blog posts in this series:
- CMS Announces Rural Health Transformation Awards to States
- Rural Health Transformation Program: State Focus on Community Health Workers
- Rural Health Transformation Program: State Focus on Aging
- Rural Health Transformation Program: State Focus on Behavioral Health
- Rural Health Transformation Program: State Focus on Primary Care
Notes
1U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Report to Congress: Maternal Health (Washington, DC: U.S. Department of Health and Human Services, July 2024), https://aspe.hhs.gov/sites/default/files/documents/688063d3176311f3b2ee6c14f02bf4e4/rtc-maternal-health.pdf.
2U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Report to Congress: Maternal Health (Washington, DC: U.S. Department of Health and Human Services, July 2024), https://aspe.hhs.gov/sites/default/files/documents/688063d3176311f3b2ee6c14f02bf4e4/rtc-maternal-health.pdf.
3Jessica L. Bettenhausen, Courtney M. Winterer, and Jeffrey D. Colvin, “Health and Poverty of Rural Children: An Under-Researched and Under-Resourced Vulnerable Population,” Academic Pediatrics 21, no. 8 (November 2021): S126–33, https://doi.org/10.1016/j.acap.2021.08.001.
4Staren, Dakota. 2024. “State Strategies to Addressing Maternity Care Deserts – NASHP.” NASHP. December 2, 2024. https://nashp.org/state-strategies-to-addressing-maternity-care-deserts/.
5Kozhimannil, Katy Backes, Julia D. Interrante, Caitlin Carroll, Emily C. Sheffield, Alyssa H. Fritz, Alecia J. McGregor, and Sara C. Handley. 2025. “Obstetric Care Access Declined in Rural and Urban Hospitals across US States, 2010–22.” Health Affairs 44 (7): 806–11. https://doi.org/10.1377/hlthaff.2024.01552.
6Garovic, Vesna D., Ralf Dechend, Thomas Easterling, S. Ananth Karumanchi, Suzanne McMurtry Baird, Laura A. Magee, Sarosh Rana, Jane V. Vermunt, and Phyllis August. 2021. “Hypertension in Pregnancy: Diagnosis, Blood Pressure Goals, and Pharmacotherapy: A Scientific Statement from the American Heart Association.” Hypertension 79 (2). https://doi.org/10.1161/HYP.0000000000000208.
Acknowledgments
The authors would like to thank Karen VanLandeghem for providing guidance and review of this blog. This product is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under the Supporting Maternal and Child Health Innovation in States Grant No. U1XMC54191; $396,167. This information, content, and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government.
