title: Challenges faced in providing safe care in rural perinatal settings.
abstract: OBJECTIVE
  To examine and describe neonatal resuscitation preparedness, presence of connections to wider systems of care, continuing education activities, presence of trained staff, and other indicators of high performance in rural perinatal microsystems.
  
  
  METHODS
  A nonexperimental, retrospective, descriptive, cross-sectional design was utilized. Rural hospitals (n = 124) providing perinatal services in five southern states were invited to participate. Nurse managers completed the Hospital Neonatal Resuscitation Survey, describing policies, healthcare team members, educational activities, organizational culture, system connections, and process improvement. Descriptive data were also collected.
  
  
  RESULTS
  A total of 44 (35.1%) hospitals participated. Annual birth volume ranged from 22 to 1,614 (M = 515.53; SD = 336.27). Low birth volume hospitals (<125 births per year) had significantly lower levels of preparedness than high volume hospitals (>125 births per year). Preparedness was not influenced by rurality. One-third (34.1%) did not identify relationships with Level III NICUs. Support of continuing education was universal. Efforts to increase interdisciplinary teamwork were common. Medical provider shortages were prevalent (n = 25: 56.8%), and the presence of midwifery services was infrequent (n = 12; 27.2%). Hospital nursing shortages (n = 35; 81.8%) were widespread.
  
  
  CONCLUSIONS
  Challenges faced by rural hospitals and healthcare professionals in the delivery of perinatal care emphasize the importance of creating and maintaining high performance microsystems that are responsive to the changing needs of providers and the populations they serve. Lower levels of preparedness and the lack of established relationships with level III NICUs is concerning.
authors.affiliation: University of Alabama at Birmingham, AL, USA. jukkalaa@uab.edu
authors.forename: Angela M
authors.initials: AM
authors.lastname: Jukkala
authors.forename: Russell S
authors.initials: RS
authors.lastname: Kirby
mesh_terms: D015331:Cohort Studies; D004509:Education, Nursing, Continuing; D005260:Female; D006780:Hospitals, Rural / Q000706:statistics & numerical data*; D006801:Humans; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal / Q000706:statistics & numerical data*; D008880:Midwifery / Q000592:standards; D020380:Needs Assessment; D018743:Perinatal Care / Q000592:standards*; D011247:Pregnancy; D012189:Retrospective Studies; D012423:Rural Health; D019035:Rural Health Services / Q000592:standards*; D014481:United States; D000078329:Workforce