Background: The Rural Surgical Obstetrical Networks (RSON) project was developed in response to the persistent attrition of rural maternity services across Canada over the past two decades. While other research has demonstrated the adverse health and psychosocial consequences of losing local maternity services, this paper explores the impact of a program designed to increase the sustainability of rural services themselves, through the funding of four “pillars”: increased scope and volume, clinical coaching, continuous quality improvement (CQI) and remote presence technology. Methods: We conducted in-depth, qualitative research interviews with rural health care providers and administrators in eight rural communities across British Columbia to understand the impact of the RSON program on maternity services. Researchers used thematic analysis to generate common themes across the dataset and interpret findings. Findings: Participants articulated six themes regarding the sustainability of maternity care as actualized through the RSON project: safety and quality through quality improvement opportunities, improved access to care through increased surgical volume and OR backup, optimized team function through innovative models of care, improved infrastructure, local innovation surrounding workforce shortages, and locally tailored funding models. Conclusion: Rural maternity sites benefited from the funding offered through the RSON pillars, as demonstrated by larger volumes of local deliveries, nearly unanimous positive accounts of the interventions by health care providers, and evidence of staffing stability during the study time frame. As such, the interventions provided through the Rural Surgical Obstetrical Networks project as well as study findings on the common themes of sustainable maternity care should be considered when planning core rural health services funding schemes.

Introduction The continued attrition of maternity services across rural communities in high resource countries demands a rigorous, systematic approach to determining population level need, including a clear understanding of feasibility issues that may constrain achieving and sustaining recommended levels of services. The Rural Birth Index (RBI) proposes a robust and objective methodology to determine such need along with attention to the feasibility of implementation. Background Predictions of appropriate levels of maternity care in rural communities require consideration of the feasibility of implementation. Although previous work has focused on essential considerations that impact feasibility, there is little research documenting the barriers to implementation from the perspective of rural care providers and administrators. Methods We conducted in-depth, qualitative research interviews with rural community health care administrators and providers (n = 14) to understand the challenges of offering maternity care in 10 rural communities across British Columbia (BC). Results Participants articulated three thematic challenges to providing maternity services in their communities: maintaining clinical skills and financial stability in the context of low procedural volume, recruitment and retention of care providers and challenges with patient transport. Conclusions Current models of compensation for maternity care are inadequate and inflexible and underscore many of the challenges to implementing a level of care that is based on population need. Re-thinking provision of care as a social obligation to actualize our system commitment to equity instead of working to achieve economies of scale is the first step to use equitable care. Addressing remuneration will provide the groundwork for solving other barriers to sustainable care.