Maternity Care in Rural Spain Through Inspired Lessons From North Carolina

Dear Editor,

We are two Spanish family medicine researchers working in Spain, and we write this letter in response to the article by Ruiz (2024) entitled “Closing the Gap: How a Community Effort Can Improve Rural Maternity Care” (1). We have followed this topic with close attention, as the challenges of providing quality maternity care in rural areas resonate strongly with the realities we face in our own communities. We appreciate the author’s clear presentation of a model that integrates family physicians, certified nurse midwives, and other professionals to support safe childbirth in an underserved environment. While our context in Spain differs in its funding mechanisms and governmental organization, we observe a common goal: improving maternal health outcomes through multidisciplinary collaboration, community engagement, and sustainable workforce strategies. We would like to expand on several points raised by this innovative project, offering reflections grounded in international comparisons, the importance of obstetric training for family physicians, midwife-physician collaboration, community participation, professional retention, the promotion of low-risk births in primary care centers, the reproducibility of similar models in depopulated Spanish areas, and the benefits of patient-centered continuity of care. In doing so, we also refer to relevant literature and experiences in both the United States and Spain that underscore the broader significance of these efforts.

We begin by examining how this rural maternity care model compares internationally, particularly when viewed alongside existing approaches in Spain. We then move on to highlight the need for robust obstetric training among Spanish family doctors to facilitate similar integrations. Next, we reflect on the ways midwives and family physicians can collaborate more effectively, a critical piece of the initiative described by Ruiz. We also discuss how community participation shapes the success of local health interventions in rural or underserved settings. This leads us to elaborate on the well-known difficulty of retaining health professionals in rural communities and how a model like the one in Chatham County addresses that concern. We then turn to the question of promoting low-risk births within primary care centers, aligning with several pilot initiatives in Spanish regions. We follow by considering whether such a framework could be reproduced in our depopulated areas, which face similar demographic and logistical challenges. Finally, we look at how patient-centered and continuous care underpins many of the outcomes depicted in the article, offering a compelling rationale for the integration of family medicine within maternity services. We are hopeful that a dialogue bridging these experiences will contribute to a wider understanding of rural maternity care and foster further developments in Spain, the United States, and beyond.

1. International Comparisons: Rural Maternity Care Models in the U.S. and Spain

The case in Chatham County, North Carolina, highlights that rural regions in the United States continue to face substantial maternal mortality and morbidity rates. According to MacDorman et al. (2), the United States has experienced a rise in maternal mortality over the past two decades, with pronounced inequities across race, ethnicity, and socioeconomic status. These trends align with what Ruiz describes in the original article, especially the disproportionate burdens faced by Black communities and Hispanic communities in rural areas. Despite differences in demographics, the Spanish context shows some parallels: while Spain’s overall maternal mortality is comparatively lower, certain rural or lower-income areas also see disparities in access to prenatal care, continuity of care, and transportation infrastructure. For instance, the World Health Organization (WHO) has repeatedly emphasized that any disruption in access to pregnancy-related services, such as the lack of close-by maternal facilities, can heighten risks for adverse outcomes, a situation faced by some remote areas in Spain where obstetric care is centralized in distant hospitals (3).

The Chatham County strategy of leveraging a Level 1 maternity care center led by family physicians, obstetricians, and certified nurse midwives is particularly interesting when viewed next to Spanish healthcare. In Spain, public healthcare is managed autonomously by each regional government, meaning that existing perinatal services can vary among Autonomous Communities (4). Generally, obstetric care takes place in specialized hospital settings, and family physicians coordinate routine antenatal check-ups, immunizations, and postpartum follow-ups. Because of this separation, rural Spanish women might need to travel 60 to 90 minutes or more to reach a reference hospital. This is reminiscent of the American situation in which individuals in remote areas may have to travel long distances to find a hospital with obstetric services (2). The shared challenge is ensuring a local facility can provide low-risk births without compromising safety or quality. Many of us in rural Spain have echoed the sentiment described in Ruiz’s account: centralizing all maternity services in urban hubs might yield short-term economic advantages but can undermine equity and community trust. Our experience supports the idea that smaller, well-equipped hospitals or health centers, staffed by a collaborative team, can meaningfully reduce travel barriers and improve patient satisfaction.

In addition to geographical parallels, the two countries share organizational lessons. The United States typically involves public and private funding models, whereas Spain relies on a predominantly public scheme with complementary private options. Yet in both settings, cost considerations often dominate discussions on maintaining rural obstetric units. The Chatham County example underscores that sustainability is not merely a matter of finances but also hinges upon political and social will, something we have observed in Spanish local governments. One impetus for expanding local maternity care in certain Spanish rural areas is the depopulation crisis, which has spurred councils to explore creative approaches to healthcare delivery. We were particularly encouraged that the initiative in North Carolina included advocacy and collaboration with local authorities, nonprofits, and community members, creating a synergy that appears to be a decisive factor in garnering adequate political and financial support for such a center. As we monitor these developments, we believe that replicating such synergy might help Spanish municipalities ensure the viability of rural maternity units. The potential for knowledge exchange is significant, and we encourage further comparative research that captures the cost-effectiveness, clinical outcomes, and patient-reported experiences of these cross-national models.

2. Obstetric Training for Family Physicians in Spain

Another salient aspect of the Chatham County case is the role family physicians play in managing low-risk pregnancies and, in certain cases, performing cesarean sections or other obstetrical interventions. In Spain, specialized obstetricians oversee the majority of deliveries within public hospitals, while family doctors predominantly provide antenatal check-ups and postpartum care at the primary care level. Historically, a more integrated approach existed. Studies such as Eden et al. (5–7) described the successful involvement of well-trained family physicians in obstetric care, pointing out that adequate education and ongoing practical experience were key to ensuring safety. Over the past few decades, however, obstetric training has become less routine for family physicians in Spain. The Family and Community Medicine residency program typically offers limited exposure to deliveries, with many trainees rotating through obstetrics wards only briefly. This leaves newly qualified family physicians without the confidence or credentials to provide full-scope obstetric services, particularly in rural communities that might benefit most from such versatility.

We believe that revisiting these training opportunities could help address gaps in rural maternity care. The Chatham County model suggests that, when family doctors receive structured training and maintain competencies in obstetrics and neonatal resuscitation, they can effectively reduce the load on tertiary centers, offer continuity to pregnant individuals, and develop trusting relationships that might otherwise be lost in an overburdened system. In Spain, implementing such a shift would entail reforms at several levels. Residency programs might expand their rotations in obstetric and perinatal wards. Health authorities could establish credentialing pathways allowing family physicians to perform specific procedures once they meet set standards of competence. There is growing evidence that such policy changes can create positive outcomes in maternal and neonatal health, especially when combined with supportive telemedicine approaches (8–12). While family physicians would not replace obstetricians, their broader skill set could be especially valuable for normal or low-risk deliveries.

Incentives are also important. Some Autonomous Communities in Spain, such as Aragón and Castilla y León, have begun offering financial and professional incentives to attract and retain doctors in rural areas. However, these measures often lack direct linkage to the upskilling of physicians in maternity care. We propose that targeted funding and protected time for continuing education in obstetrics be made available to family physicians practicing in smaller communities, building on ideas that Boerma et al. (13) outline regarding strategic investment in primary care. Such incentives might incorporate partial salary supplementation, subsidized housing, or career progression benefits for those who demonstrate proficiencies in rural obstetrics. This would potentially draw more physicians to areas that struggle with access to specialized services (14). Although operational challenges exist, including the need for strong collaboration with obstetrics departments, the case from North Carolina supports the feasibility of incorporating doctors from other specialties into maternity care, as long as training is thorough and aligned with safety standards. We see this as an opportunity for Spanish policymakers and medical societies to advocate for more robust primary care teams in perinatal health. If the achievements in Chatham County can be adapted to local Spanish conditions, it might help fill the gaps in coverage while promoting continuity for expectant mothers, who would otherwise face distant hospital journeys for basic obstetric procedures.

3. Integration of Midwives and Family Physicians

One of the most promising dimensions of the Chatham County initiative is the seamless collaboration between certified nurse midwives and family physicians. The article describes how CNMs and FM physicians share responsibilities for antenatal check-ups, deliveries, and postpartum follow-ups, with obstetricians providing additional support for high-risk or more complex pregnancies. In Spain, midwives are highly regarded professionals who typically work alongside obstetricians in hospital labor wards or follow low-risk pregnancies in primary care units. Family physicians, for their part, are frequently engaged in general follow-ups and postpartum care, but structured interaction with midwives remains limited. While midwives often coordinate with nurses and pediatricians in child health programs, we have found that forging robust alliances between midwives and family doctors could optimize the care pathway by allowing both professionals to operate at the top of their skill sets.

De Vries et al. (15) observed how midwife-led models of care across Europe can improve patient satisfaction and outcomes, partly because midwives provide education, counseling, and emotional support within a consistent care framework. When this approach merges with a family physician’s capacity for holistic care and the early identification of risk factors beyond pregnancy, the potential benefits multiply. From our viewpoint, the North Carolina example demonstrates a practical plan for integrating these roles in a rural environment. We see parallels in Spanish rural clinics, where the shortage of obstetricians could be mitigated by empowering midwives to manage most of the pregnancy pathway, while family physicians remain involved as coordinators of broader healthcare. Such a setup might reduce fragmentation and the sense of isolation that mothers in remote areas sometimes experience.

To move in that direction, policy changes would be needed. Midwives already have specialized training that allows them to handle normal and low-risk deliveries safely. Family physicians often maintain strong bonds with patients throughout their life cycles. However, administrative barriers and cultural norms may hinder closer collaboration. The Chatham County center overcame these hurdles by actively recruiting midwives, providing comprehensive training opportunities, and creating an environment in which each professional’s expertise was respected. A similar approach might prove valuable in Spain. Pilot programs could allocate joint budget lines to family medicine and midwifery teams, establishing care protocols with clearly delineated responsibilities and referral pathways for high-risk cases. Another essential piece would be ensuring adequate infrastructure, including birthing rooms in local health centers that meet safety standards defined by national guidelines, such as those suggested by the WHO (3,16). In our experiences, once women experience a supportive team composed of family doctors and midwives, they frequently express higher satisfaction and are more engaged in their own care. We thus believe that promoting the synergy between these two professional groups is a practical way to enhance outcomes in rural maternity services, reflecting what Ruiz (1) describes as the value of inclusive, multidisciplinary care.

4. Community Participation in Maternal Health Initiatives

A further aspect of the Chatham County intervention that resonates with our experiences is the strong reliance on community participation. Ruiz (1) notes that efforts to maintain the new maternity center found considerable support from local stakeholders, including patients, clinicians, health departments, and nonprofits. We have seen that engaging community members can shift the focus from mere financial viability to broader questions of health equity and long-term investment in local well-being. This aligns with the principles of community-oriented primary care, as advocated by the Pan American Health Organization (PAHO), wherein local input plays a pivotal role in identifying needs, planning interventions, and evaluating outcomes (13).

In Spain, rural communities often possess tight social networks that can be powerful advocates when mobilized for a common cause. This is especially true in areas undergoing depopulation, where sustaining a local school, pharmacy, or basic health service is considered essential for community survival. By involving municipalities, civic associations, and local media, public health projects gain visibility and can accumulate the critical mass of public backing needed to sway political decision-making. We have witnessed successful instances in which primary care teams collaborated with local town halls to organize open workshops on pregnancy, childbirth, and newborn care. These events allowed future parents, grandparents, and other community members to voice their concerns about transportation difficulties, mental health resources, or language barriers for immigrants. When these dialogues are genuinely integrated into service planning, the result is a sense of shared ownership that mirrors what the Chatham initiative describes. The role of local radio, community newsletters, or social media cannot be overstated in generating broader awareness. Once the community sees the maternity center or local birth unit as “theirs,” they are more inclined to defend it, even in the face of budgetary constraints.

For Spain, the lesson is that bottom-up approaches can complement the top-down organization of regional health services. While the central or autonomous governments often allocate resources, it is the local communities who must provide grassroots support. This dynamic has been documented in other European rural health projects, which found that community-driven demand for services can significantly influence political priorities (17). By building on these observations, Spanish clinicians and health planners could adapt the collaborative blueprint from Chatham to their own contexts, partnering with local stakeholders to develop culturally and linguistically tailored services. The fruit of this engagement process, be it in the form of improved accessibility, better patient education, or heightened awareness of maternal health disparities, represents a major factor in sustaining any new or existing maternity care resource in remote settings.

5. Challenges of Retaining Health Professionals in Rural Settings

As Ruiz (1) highlights, maintaining staffing levels in a rural maternity center is an ongoing concern, amplified by the COVID-19 pandemic and the inherent difficulties of recruiting clinicians to less populated regions. This challenge resonates in Spain, where certain provinces chronically struggle to attract and retain doctors, nurses, midwives, and other allied health professionals (14). We believe that focusing only on economic incentives is insufficient (18). The Chatham County experience suggests that a combination of supportive work environments, local political commitment, and a strong sense of community buy-in can collectively enhance recruitment and retention.

From our own experience, many family physicians in rural Spain find their work deeply rewarding because it allows for comprehensive patient follow-up and the development of enduring relationships with families. However, when facilities lack basic resources, an extensive area falls under the responsibility of a single team (even a single physician), or when administrative burdens overshadow patient care, burnout rates climb, and turnover becomes high. Some Autonomous Communities have introduced measures like guaranteed housing or improved salaries for remote postings, which partially alleviate the problem (4). Yet, these measures do not always incorporate specific attention to obstetric or perinatal competencies. If clinicians perceive an absence of professional development opportunities, particularly in obstetrics or neonatal emergency care, they may opt for urban centers where specialized training is more easily accessible.

The Chatham County initiative, on the other hand, leverages a cohesive team and alignment between hospital and community-based services, allowing professionals to practice at their full scope. We find that more robust integration of family physicians, midwives, and even nurse anesthetists, as described by Ruiz, can offer a dynamic clinical environment that appeals to practitioners who seek a broader skill set and deeper community involvement. This resonates with prior research indicating that professional satisfaction increases when physicians can maintain varied clinical roles and exercise autonomy within a multidisciplinary network (19,20). A further point is that supportive governance structures at both county and state levels in North Carolina appear to have played a part in stabilizing funding and fostering an environment conducive to staff retention. Spanish regional health authorities can take note, considering the possibility of forging stronger alliances with local councils or regional development agencies. By doing so, they may create a more stable system that not only attracts committed professionals but also encourages them to remain, thus reducing the chronic staffing shortages that hinder service continuity.

6. Promotion of Low-Risk Births in Primary Care Centers

In Spain, discussions about whether low-risk deliveries could take place in enhanced primary care centers have gained momentum, reflecting a desire to reduce unnecessary medicalization and to bring childbirth closer to patients. The approach outlined in Chatham County indicates how such an arrangement might be realized in a rural context without jeopardizing patient safety. According to the WHO (3), low-risk pregnancies can often be managed effectively by midwife-led units or family medicine-led units, provided clear transfer protocols are in place and the staff is adequately trained in emergency procedures. Ruiz’s (1) description of a Level 1 maternity care center emphasizes that local deliveries can be safe and appreciated by patients who prefer giving birth within their own communities, avoiding the anxiety and cost of long-distance travel.

Spain’s public health system provides a framework for universal coverage and standardized care, but differences arise between regional health services in terms of how primary care is resourced. Some communities have begun experimenting with birthing units run by midwives, though many remain tied to large hospitals. We see a strong parallel with Chatham County’s reasoning: geographical obstacles, especially in mountainous or sparsely populated areas, can lead to significant delays if a hospital is located several hours away. The local midwife-physician collaboration model can mitigate these delays for low-risk births, allowing immediate postpartum care and breastfeeding support in a setting that is more familiar and personalized.

However, implementing a similar model in Spain requires addressing logistical, regulatory, and cultural factors. On a logistical level, primary care centers would need structural adjustments: designated rooms, basic obstetric equipment, and infection control measures consistent with national guidelines. At a regulatory level, health authorities would need to define clear risk-assessment protocols, ensuring that only individuals meeting specific low-risk criteria are eligible for out-of-hospital deliveries. Cultural acceptance also matters, as some Spanish families may feel more secure in a hospital environment. Nevertheless, surveys conducted in certain Autonomous Communities have shown that many women would consider an out-of-hospital birth setting if safety could be guaranteed (15). This correlates with the positive reception reported in Chatham County, where women expressed gratitude and a sense of empowerment in being able to give birth near their homes. We believe an incremental approach—perhaps piloting a few well-equipped rural centers—might confirm whether the benefits described by Ruiz can be replicated in Spain, opening a path for broader adoption if outcomes and patient experiences remain favorable.

7. A Reproducible Model for Depopulated Regions in Spain

Depopulation has become a pressing concern in large swathes of rural Spain, including areas of Aragón, Castilla y León, and Extremadura. These regions struggle with decreasing birth rates, which in turn undermine the sustainability of local schools, businesses, and healthcare services. The Chatham County example, in our view, provides insights into how a maternity center can act as a linchpin for community resilience by offering tangible, local healthcare access. While the two contexts differ, the underlying premise (that a combined effort of public entities, nonprofits, and professional teams can secure resources for a community-based maternity service) feels broadly applicable. Local governments in Spain have been searching for innovative strategies to counteract the cycle of depopulation, recognizing that the availability of key health and education services influences families’ decisions to stay or relocate.

If we apply the Chatham model to a Spanish setting, we envision a structured partnership involving the regional health authority, local councils, and private or philanthropic organizations, similar to the arrangement described by Ruiz (1). For instance, a small hospital or enhanced primary care center could be classified as a Level 1 maternity unit, staffed by family doctors with additional obstetric training, midwives, and rotating specialist obstetricians. This team would handle routine deliveries, antenatal classes, and postpartum support. Regional governments might finance equipment and provide stable contracts to attract qualified staff. Private or nonprofit partners could contribute through grants or community development funds. The collaborative aspect is central, as we have observed that purely top-down initiatives often falter if the local population does not actively support them.

The potential advantages are not limited to maternal health alone. A well-functioning rural maternity center could generate broader benefits, including improved child health services and a positive ripple effect on local economies. By focusing on evidence-based practices and continuous evaluation, as exemplified in North Carolina, Spanish programs could systematically address quality concerns and gather data on outcomes. The success stories might help convince policymakers who remain skeptical about the cost-effectiveness of small-scale obstetric units. Research from MacDorman et al. (2) suggests that outcomes in such community settings can be comparable to larger hospitals, provided risk criteria are followed and timely referrals for complications are guaranteed. This evidence-based perspective could be decisive in swaying public opinion and ensuring that resources are allocated effectively. With appropriate adaptations for Spanish legal and administrative frameworks, the strategies described in Ruiz’s article could indeed provide a blueprint for revitalizing certain low-density areas, offering hope that healthcare can become part of a sustainable rural future rather than a casualty of declining populations.

8. Patient-Centered Care and Continuity in Rural Maternity Services

Finally, we wish to underscore the principle of patient-centered continuity of care (21), which emerges as a cornerstone in the Chatham County model. The article points out how expectant individuals value the possibility of giving birth within their own community, guided by professionals they trust and who understand their cultural or linguistic context. This resonates with established findings that continuity of care can contribute to better health outcomes, as well as higher rates of patient satisfaction (13). In our own practice in rural Spain, many patients express relief and gratitude when they can see the same team of family physicians and midwives throughout pregnancy, childbirth, and the postpartum period. It fosters a sense of comfort and reduces potential anxieties associated with transferring care to unfamiliar hospital staff.

In the Spanish healthcare context, continuity of care is often interrupted by fragmented pathways, where the pregnant individual might alternate between a family physician for basic antenatal follow-ups, an obstetrician for specialized scans, and perhaps a midwife for antenatal classes, all situated in different facilities. While the system ensures coverage, it can sometimes lack cohesion. The strategy depicted by Ruiz (1) highlights how embedding maternity care in a small local hospital or health center permits deeper personal connections and timely follow-up, improving the capacity to detect psychosocial or environmental factors that might not surface in a brief hospital appointment. This aligns with the perspective that family physicians, by virtue of their training, are equipped to address a variety of health and social needs simultaneously. By collaborating closely with midwives, they can create a supportive atmosphere that respects patient preferences and cultural needs, as indicated by Freed et al. (17).

Furthermore, patient-centeredness extends to postpartum support. In many rural areas of Spain, as in Chatham County, postpartum depression, breastfeeding difficulties, or other mental and physical challenges may go unnoticed if there is no integrated follow-up system. Here, the family physician-midwife team could readily identify and address these issues early, offering referrals to psychologists or social workers if needed. This comprehensive style of care is made possible by the personal familiarity that often develops between providers and families in a rural environment. By drawing on the continuity-based successes from the North Carolina initiative, Spanish practitioners and policymakers might reinforce the idea that small maternity centers can be catalysts for holistic care. We believe that adopting this patient-centered paradigm, rather than focusing strictly on cost and volume metrics, can reshape how rural maternity services are structured, leading to better maternal well-being, as well as improved neonatal and early childhood outcomes.

9. Conclusion

In closing, we wish to express our appreciation for the article by Ruiz (1) and the valuable insights it offers to clinicians and policymakers operating in rural settings. The challenges facing Chatham County reflect realities that many Spanish regions also experience: demographic shifts, limited resources, and the persistent need for equitable and culturally sensitive maternity care. The model described (centering on Level 1 maternity care, integration of family physicians and midwives, community engagement, and a focus on continuity) underscores the impact of collaborative effort. Our reflections have illustrated how similar approaches could enrich Spain’s public healthcare structure, especially for those living in sparsely populated rural provinces. We have touched upon the importance of robust obstetric training for family doctors, the dynamic integration of midwives, the power of grassroots community advocacy, the multifactorial nature of professional retention, the feasibility of low-risk births in primary care centers, the potential of such a model to revitalize depopulated areas, and the value of patient-centered care in strengthening outcomes.

While Spain and the United States differ in their funding mechanisms, insurance structures, and administrative organization, the need to secure accessible, high-quality maternity services in underserved places bridges these differences. The experiences documented in North Carolina offer a compelling case for why local governments, health institutions, and communities might benefit from forging tighter partnerships around rural obstetric care. We believe that further research comparing the implementation and results of similar models in both countries could yield fruitful data, guiding evidence-based decisions on workforce training, infrastructure investment, and the design of patient-focused services. As family physicians with firsthand knowledge of rural Spanish healthcare, we are encouraged by the pragmatic strategies described in Ruiz’s work. We see the potential for these strategies to inform broader efforts not only to reduce health inequities, but also to sustain rural life and culture in regions that risk losing vital social services. We therefore hope that this letter expands on the original article’s message and encourages ongoing dialogue, both within the pages of this journal and in the varied and often challenging contexts where dedicated professionals strive to offer safe and compassionate maternity care to all.

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