Safer Births, Stronger Systems: The 25-Year Evolution of the OB Hospitalist Model
The History and Potential of OB Hospitalist Programs in the U.S.
Safer Births, Stronger Systems
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Executive Summary Twenty-five years after OB hospitalist medicine began as a novel concept in the United States, the model has made dramatic strides in maternal and fetal care. In nearly every state, OB hospitalist teams work closely with hospital leaders to improve processes, prevent complications, handle emergencies, reduce maternal mortality rates, and improve hospitals’ clinical, operational and financial goals. Yet significant work remains to improve maternal outcomes in the U.S. Rates of maternal morbidity in the United States have continued to rise since the 1990s, despite advances in medical technology and obstetric care. Maternal mortality is unacceptably high compared to high-income nations. Disparities in outcomes persist across racial, geographic, and socioeconomic lines. While more women require high-risk pregnancy care, hospitals face mounting challenges in maintaining safe, sustainable maternity services even at the most basic level: • An aging physician workforce • Clinician shortages • Rising malpractice costs • Financial pressure due to shrinking reimbursement rates and federal budget cuts • Closure of labor and delivery units in many communities
These converging pressures of rising demand for maternal-fetal medicine (MFM) alongside shrinking access require reimagining how obstetric care is delivered. The OB hospitalist model is one of the most significant solutions for maintaining and improving maternal care. These physicians partner with local providers to manage hospitalized obstetric patients 24/7. Today, these programs are integral to patient safety, emergency preparedness and interdisciplinary team performance. After 25 years of growth and expansion, OB hospitalist programs are positioned to tackle the mounting obstetrics challenges in the U.S. by leaning on a proven care model.
Safer Births, Stronger Systems
In the last few decades, pregnancy has become increasingly complex: • More pregnant women are diagnosed
with preexisting comorbidities, such as hypertension, diabetes and obesity • More pregnant women give birth at an older reproductive age. The average age of first-time mothers has increased from 26.6 years in 2016 to 27.5 years in 2023 • More women give birth to multiples. The twin birth rate rose 79% from 1980 (18.9 twins per 1,000) to 2014 (33.9). Rates have since declined steadily, but they remain high at 30.1 twins per 1,000 babies in 2024
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Introduction: A changing landscape for maternal care Advances in prenatal diagnostics, fetal monitoring, surgical techniques and critical care have transformed obstetric medicine, but maternal outcomes haven’t improved at the same pace. Instead, hospitals and healthcare systems simultaneously support increasingly complex patients while confronting persistent challenges, such as: • Maternal mortality Today's obstetric population differs • High premature birth rates significantly from previous generations. Each • Workforce shortages year, between 6% and 8% of women in the • Rural care deserts U.S. have high-risk pregnancies. • Shrinking budgets Age: The average age of first-time mothers was • Equitable access to care 27.5 years in 2023, compared to 21 in 1972 • Forward-looking solutions from Ob Hospitalist Group (OBHG) and Obtelecare Comorbidities: More pregnant women today have preexisting chronic health conditions Inequitable access to quality such as obesity, hypertension, diabetes and cardiovascular disease obstetric care Caring for high-risk pregnancies requires access to MFM specialists and coordinated multidisciplinary care that women across the United States can’t access equally. A 2024 JAMA study found that 537 U.S. hospitals lost obstetric services between 2010 and 2022, including 238 rural hospitals and 299 urban hospitals. Closures disproportionately affect rural and underserved communities. As access diminishes, pregnant women are forced to travel longer distances for prenatal care and delivery, increasing treatment delays, endangering women and their babies and placing additional strain on the hospitals that continue to provide obstetric services.
Mental health: Mental health conditions account for 27.7% of pregnancy-related deaths Substance use disorders: From 2010 to 2017, the number of women with opioidrelated diagnoses at delivery hospitalization increased by 131% Social determinants of health: Factors such as access to safe food, housing and environment, education and healthcare affect pregnancy outcomes
Challenges fuel innovation In response, hospitals are reevaluating long-standing inpatient obstetric care models. Best practices for modern maternity care require continuous clinical readiness, standardized evidence-based protocols, multidisciplinary collaboration and simulation training designed to help obstetric teams respond immediately to unpredictable emergencies. These realities have fueled growing interest in innovative care delivery models that strengthen patient safety while supporting physicians, nurses and hospital operations. Among the most influential is the OB hospitalist model. What started as a novel staffing approach in the 1990s is today a comprehensive strategy for improving emergency readiness, clinical outcomes, team performance and operational resilience. Understanding OB hospitalists’ role in today’s obstetric care model offers important lessons for improving maternal outcomes and strengthening the nation's maternity care system. Safer Births, Stronger Systems
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The problem: The U.S. maternal safety gap is an outlier among wealthy nations The challenges facing maternal healthcare result from multiple, interconnected forces reshaping obstetric practice. Despite the ability to offer the most advanced clinical care ever, maternal healthcare in the United States today is plagued by rising rates of severe maternal morbidity, increasingly complex pregnancies, persistent clinician shortages and rural care deserts. Together, these challenges have exposed the limitations of maternal care models developed for an earlier healthcare environment.
Since hitting a record low of about nine deaths per 100,000 births, the maternal mortality rate in the United States has been rising since the late 1990s.
1990
2024
10 deaths
17.9 deaths
per 100,000 births
per 100,000 births
Outcomes vary widely among people of color, with Black, American Indian and Alaska Native women more likely to die from pregnancy-related causes than white women. With rates of 42.2 maternal deaths per 100,000 live births among Black women in Mississippi, it’s safer to give birth in places like Cuba (35), Uruguay (15), Syria (20) and Kyrgyzstan (42). Complications and adverse outcomes are also increasing. A 2015 study found that 17% of adverse events in Labor & Delivery units were related to healthcare management and potentially preventable.
A 2020 BlueCross/Blue Shield analysis reveals that between 2014 and 2018:
Pregnancy complication rates rose more than 16%
Childbirth complication rates rose more than 14%
About seven out of every 1,000 pregnant women experienced both kinds of complications, a 31% increase
The OB hospitalist model emerged and is growing in response to these challenges. Many healthcare leaders now view hospitalists as a foundational component of modern obstetric care. Safer Births, Stronger Systems
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Before hospitalists: The traditional obstetric model Obstetric care in the United States historically centered on the physician-patient relationship and the “on-call” model. Most women selected a private obstetrician for prenatal care in the physician's office, expecting the same physician to manage labor, delivery and postpartum care. This model emphasized continuity, personal relationships and physician autonomy. Physicians typically practiced independently, hospitals served smaller geographic regions and patient clinical complexity was considerably lower than today. Physicians divided their time between outpatient clinics, scheduled procedures and deliveries. Overnight and on weekends, they remained on home call, traveling to the hospital when a patient went into labor or had an obstetric emergency. The financial structure of obstetric practice reinforced this model. Under a fee-for-service reimbursement system, physicians generated revenue primarily through office visits, deliveries, and procedures. Maintaining a busy outpatient practice was essential to financial sustainability, requiring physicians to shift between clinic responsibilities and hospital obligations continually. Today, this arrangement still offers professional autonomy, but it also requires physicians to be perpetually available to their patients, often with little separation between professional and personal life. While this maternal care model served generations of patients and physicians well, changing demographics, evolving clinical expectations and increasing demands on physicians exposed limitations that ultimately drove innovation in maternity care delivery.
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Emerging limitations of the traditional maternal care model The traditional model of care is increasingly difficult to sustain. Pregnancies are more medically complex, hospitals have higher expectations for standardized protocols and physicians face growing clinical and administrative demands. Relying on community physicians to lead hospital teams makes it harder to maintain consistent communication, standardized protocols and continuous clinical leadership in labor and delivery. The following are some specific challenges to the traditional model of obstetric care: Obstetric emergencies Emergencies, such as postpartum hemorrhage, shoulder dystocia, umbilical cord prolapse, placental abruption and eclampsia, develop rapidly and require immediate intervention. After being notified of an emergency, a physician has limited time to travel to the hospital. Physician workload and burnout Physician workload has expanded considerably. Due to financial pressures and the shift toward valuebased care, obstetricians increasingly manage larger patient panels. They’re balancing office visits, scheduled surgeries, hospital rounds, deliveries, administrative responsibilities, electronic health record documentation and after-hours calls. Maintaining continuous availability for labor and delivery has become more challenging. The increasing workload, mounting malpractice insurance costs and emotional strain have led to growing rates of physician burnout. A review of studies found burnout rates among OB/GYNs ranging from 40% to more than 75%. Staffing shortages Physician burnout and an aging workforce are contributing to a physician shortage that’s not unique to OB/GYN. Nearly half of all U.S. practicing physicians are over 55, and 35% are expected to reach retirement age within the next five years.
In a January 2026 study published in Obstetrics & Gynecology, researchers assessed the adequacy of the number of OB/GYNs across all U.S. states to predict changes in the next decade: 2025: The national supply met 93.4% of the demand, with significant geographic disparities
2035: All but six states are projected to have an OB/ GYN shortage
Rural areas are expected to experience a particularly severe shortfall.
Already today, hospitals face increasing difficulty ensuring continuous physician presence on labor and delivery units. Especially in rural areas, it’s difficult to staff fluctuating delivery volumes for obstetric emergencies that demand an increasingly rapid response. A model dependent on physicians traveling to the hospital from home or outpatient offices no longer consistently meets modern expectations for patient safety, quality and operational efficiency. Combined, these challenges represent a growing mismatch between a model designed for an earlier era of maternity care and today’s obstetric realities. The OB hospitalist has become a necessity. Safer Births, Stronger Systems
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The Solution: The OB hospitalist model The traditional model of obstetric care was already being tested in the 1990s by forces that extended well beyond maternity services. Even then, hospitals were treating increasingly complex patients, quality expectations were rising and physicians faced growing demands. Across service lines, these changes gave rise to the hospitalist.
The first hospitalists “Hospitalist” was a concept first introduced in 1996 by Robert Wachter, MD, and Lee Goldman, MD, to describe physicians whose primary professional focus was caring for hospitalized patients, rather than dividing their time between office practice and inpatient responsibilities. Their constant presence allows them to respond immediately to patients’ needs, coordinate multidisciplinary care and lead quality improvement initiatives. The model first spread rapidly across internal medicine, aligning with increasingly complex inpatient care. As hospital medicine matured into a recognized specialty, healthcare leaders began asking whether similar benefits could be realized in other clinical areas. A 2002 follow-up analysis by Drs. Wachter and Goldman found hospitalist programs significantly reduced resource use, such as hospital costs (average decrease, 13.4%) or average length of stay (average decrease, 16.6%). Obstetrics was an obvious expansion opportunity for this novel care model. Labor and delivery patients can deteriorate rapidly, emergencies require immediate intervention and effective care depends on close collaboration among physicians, nurses, anesthesiologists and neonatologists.
Introducing the "laborist" In 2003, Louis Weinstein, MD, introduced the concept of the "laborist" in the American Journal of Obstetrics and Gynecology, proposing a physician role whose primary responsibility is managing hospitalized labor and delivery patients rather than maintaining an outpatient practice while covering inpatient responsibilities remotely. Instead of viewing labor and delivery as one component of a physician's broader practice, the laborist model recognized inpatient obstetrics as a distinct area of expertise requiring continuous physician presence and specialized focus. The goal was to reduce emergency response times, enhance communication with clinical staff and relieve the growing burden on community obstetricians.
1989
1996
2002-2003 Turning Point
The first OB hospitalist program
The hospitalist model is named
The "laborist" concept is introduced
Alta Bates Medical Center in Berkeley, California, launches what is recognized as the first dedicated obstetric hospitalist program, years before the term itself existed.
Robert Wachter and Lee Goldman describe the emerging "hospitalist" role in the New England Journal of Medicine, establishing the broader hospital-based physician model that obstetrics would later adapt.
Louis Weinstein, MD, coins the term "laborist" in the American Journal of Obstetrics and Gynecology, proposing a physician whose sole focus is the care of the laboring patient. The same year, Frigoletto and Greene ask whether a broader shift in ob-gyn practice is underway.
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First-generation programs The earliest laborist programs emerged primarily within academic medical centers and high-volume hospitals, where patient volumes and clinical complexity made continuous physician presence both practical and increasingly necessary. From the start, these programs were designed to complement –– not replace –– community obstetricians. Laborists assumed responsibility for unassigned patients, obstetric emergencies, and inpatient care when primary physicians were unavailable, while private practitioners continued to provide prenatal care and deliver many of their own patients. Early programs demonstrated that dedicated inpatient obstetric physicians could strengthen both clinical operations and physician satisfaction without eliminating the essential role of community obstetricians. Their success laid the foundation for a much broader transformation in maternity care delivery. This was the hope of Christopher Swain, MD, who founded Ob Hospitalist Group in 2006 after a middle-of-the-night epiphany. “Private OB/GYNs not only suffered from the inconvenience of being disturbed at all hours, but also took risks by managing patients' care over the phone without actually seeing them. Delays in care at this time can be serious. It was my 'aha' moment," says Dr. Swain.
Becoming a national model What began as a novel approach to improving labor and delivery coverage has today evolved into a widely adopted inpatient obstetric care model. In the past two decades, OB hospitalist programs have expanded from a small number of academic medical centers to hospitals of varying sizes and in every state, from metropolitan areas to rural communities. As the model matured, so too did the role.
Expanding responsibilities The responsibilities of OB hospitalists have expanded considerably since the earliest laborist programs. Today’s OB hospitalists contribute benefits beyond emergency coverage, such as:
Improving communication among multidisciplinary teams
Safer Births, Stronger Systems
Helping standardize clinical protocols
Supervise residents
Assuming leadership roles in patient safety and quality improvement initiatives
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Standardizing the specialty Adoption increased as maternal care became more complex and hospitals faced increasing workforce shortages. Today, OB hospitalists are more standardized across the U.S., through the efforts of organizations like the Society of OB/GYN Hospitalists (SOGH), Ob Hospitalist Group (OBHG) and the American College of Obstetricians and Gynecologists (ACOG). As an integral part of the OB care model, OB hospitalist programs deliver the following and more: Immediate OB availability: 24/7 on-site coverage, enabling rapid response to obstetric emergencies
Improved team coordination: Continuous physician presence strengthens communication and collaboration among the labor and delivery care team
Greater workforce sustainability: Inpatient coverage reduces the burden of community physicians, helping hospitals recruit and retain physicians while mitigating burnout
Standardized, evidencebased care: OB hospitalists lead clinical protocols, simulation training and quality improvement initiatives
Enhanced hospital performance: OB hospitalists support efficient labor and delivery operations, strengthen risk management and provide clinical leadership that improves the safety and stability of maternity services
Introducing the OB Emergency Department In 2006, Chris Swain, MD, founder of OBHG, introduced a 24/7 obstetric emergency department (OBED), based on the internal medicine hospitalist model. Historically, nurse triage in the labor and delivery department evaluated unscheduled obstetric patients and corresponded with a clinician by phone. This method made labor and delivery the only emergency location in the hospital where a qualified clinician didn’t consistently see patients. With an OBED, a physician or certified-nurse midwife and an OB nurse see any patient presenting with an emergency condition at any stage of pregnancy, including the postpartum year. An OB/GYN with critical care training quickly addresses emergent issues. The OBED model improves patient safety and reduces the burden on community OBs.
An OBED also helps hospitals meet financial and operational goals:
•
For patients with an assigned obstetrician, the OB hospitalist stabilizes the patient, then coordinates ongoing care with her primary obstetrical clinician.
•
Decreases the potential for harm due to early assessment and team-based interventions
•
Aligns billing with evaluation and treatment services, patient acuity and emergency center
For patients without a primary obstetrician, the OB hospitalist cares for the patient from arrival through discharge.
•
Supports training, hiring, retention, liability and compliance
•
Since the OB hospitalist model launched, hundreds of U.S. hospitals have adopted OB hospitalist programs, many with an OBED. Safer Births, Stronger Systems
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The Results: Evidence suggests OB hospitalists are a proven model of better care Today’s OB hospitalists are "maternal safety champions," serving as change agents who work closely with administrators, community providers and patients to identify potential health problems and risk factors earlier, when medical interventions can be effective. “Our data shows that two-thirds of risk and medical malpractice events on the unit occur when the OB hospitalist is not the primary physician or midwife. There’s clear opportunity for OB hospitalists to become involved in care earlier to improve safety across the unit,” says Mark Simon, MD, OBHG chief medical officer. In OBHG’s HERAld assessment, the highest-scoring hospitals consistently focus on patient care with the mentality that every physician, midwife and nurse on the unit shares responsibility for patient outcomes. In these hospitals, OB hospitalists make a difference as the maternal safety champions of the entire labor and delivery unit. The following are ways the OB hospitalist model has improved maternal care in the United States.
Research on maternal outcomes Studies have examined the relationship between OB hospitalist programs and a range of clinical outcomes, including severe maternal morbidity, cesarean delivery rates, hypertensive disorders, postpartum hemorrhage management, neonatal intensive care unit (NICU) admissions and patient satisfaction. Many report improvements in maternal mortality and morbidity, emergency response, adherence to evidence-based protocols and team communication. •
A Journal of Patient Safety study, Use of Obstetric and Gynecologic Hospitalists is Associated with Decreased Severe Maternal Morbidity in the United States, concludes hospitals with 24/7 OB hospitalist coverage have lower levels of severe maternal morbidity than those that use non-hospitalist providers (1.7 versus 2.0, P = 0.014).
•
A study, Impact Of An Obstetrical Hospitalist Program On Safety Events In A Mid-Sized Obstetrical Unit, showed a statistically significant decrease in OB safety events in a mid-sized OB unit after implementing the OB hospitalist program.
•
A case study found a dedicated, full-time OB/GYN hospitalist service was associated with a 27% reduction in cesarean delivery rate compared with the traditional model of care. Quality results (vs Year 1: Aug 2021-Jul 2022)
500
severe maternal morbidity (SMM) cases avoided* due to improved patient outcomes
$4.4 M
in avoided medical and societal costs* * SMM and preterm birth figures are “improvement impact” vs Year 1 and are not added into the $812.7M total impact.
1,036
19.6%
preterm births prevented*
C-section rate across OBHG-supported hospitals
$40M in
7 percentage points
avoided medical and societal costs*
below the 26.6% national average, linked to
$8.7M in savings
OBHG 2025 Maternal Health Impact Report
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Improving equitable outcomes Because OB hospitalists are payer-agnostic and not dependent on individual patient panels, reimbursement concerns don’t influence care decisions. The result is standardized, evidence-based care applied consistently across populations. Quality and equity are embedded into the care model. At OBHG-supported hospitals, RGS found C-section rates significantly below national averages:
19.6%
overall C-section rate
22.4% C-section rate for Black patients
vs
26.6% national average
vs
30%
These are more than rate differences They point to care that is safer, more consistent, and more respectful of patients' needs–regardless of race, background, or which clinician happens to be on call.
national average
These results suggest that better C-section practices can improve safety and help close outcome gaps across racial groups.
Operational outcomes Research on the OB hospitalist impact on hospital operations has demonstrated improvements in physician response times, multidisciplinary collaboration, protocol compliance and clinician satisfaction. “Having a physician physically present in the hospital at all times allows us to respond immediately when a patient needs care, which is critical in obstetrics where conditions can change rapidly,” says Dr. Simon. Hospitals have also reported benefits in quality improvement efforts, patient safety initiatives and support for community physicians through reduced call burden and continuous inpatient coverage. Financially, OB hospitalist programs demonstrate measurable return on investment. Analyses of successful hospitals with full-time OB hospitalists noted that the programs pay for themselves many times over in reductions in liability and compensation costs.
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Reducing burnout and improving retention The OB hospitalist model separates inpatient care from outpatient productivity pressures so that OB/GYNs are no longer overextended. An ACOG survey of 1020 OB/GYNs found that OB hospitalists and laborists reported high rates of career satisfaction. At Ob Hospitalist Group, full-time physicians work 24-hour shifts 5-8 times per month. Rather than continuous on-call periods layered onto clinic schedules, they have plenty of time for work-life balance.
Keeping obstetric services local and reliable For rural hospitals struggling with OB/GYN shortages and overextended community physicians, OB hospitalists provide reliable coverage that helps keep maternity services open. By supplementing local physicians with dedicated inpatient coverage, hospitalists strengthen the OB/GYN workforce and help more women access local obstetric care instead of traveling long distances. For example, the OBHG 2025 Maternal Health Impact Report found the following obstetric care access results:
36,278
3,000+
36,814
prenatal visits for patients in maternity care deserts
deliveries supported in high-need communities
additional patients served in low-access maternity care counties
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Moving Ahead: Ongoing maternal care challenges, but unlimited opportunity Of the millions of childbirths in the U.S. annually, almost all occur within the hospital setting. It’s imperative that hospitals are positioned to provide the best possible maternal care. This is no small undertaking. Virtually all hospitals face rising expenses, shrinking operating margins, rising labor costs and ongoing financial challenges. Obstetric service line closures due to financial pressure disproportionately affect rural Americans while also signifying a general shortage that pregnant women experience in every state, including in metropolitan areas. These challenges are even more acute amid recent federal cuts to Medicare and Medicaid. The need is great, but so are the opportunities supported by OB hospitalists and supporting programs. OB hospitalist programs are expanding in every state, from rural hospitals to large metropolitan ones. With OB/GYNs and certified nurse midwives (CNMs) working as team-based clinicians, more women are accessing expert maternity care close to home. Beyond expanding OB hospitalists in more sites, the next step for the OB hospitalist model is to bring high-risk maternity care to women, no matter their ZIP code. The following program is expanding access to maternalfetal medicine.
TeleMFM Programs like Obtelecare remove geographic barriers by expanding access to the country’s limited MFM specialists, who are typically concentrated in academic medical centers. Between 6% and 8% of women in the U.S. have high-risk pregnancies per year. Virtual MFM connects rural hospitals to large metropolitan health systems, integrating more high-risk specialists directly into their clinical teams. As obstetric care moves into the next decade, OB hospitalist programs have proven their value in clinical and operational outcomes and offer greater promise for the future. As the clinical workforce changes and hospitals continue to face constraints over the next decade, OB hospitalist programs are positioned to help hospital partners improve the trajectory of the maternal mortality rate and raise the standard of women’s healthcare in the United States. “The more we expand hospital partnerships across the country, the more community OB/GYNs and OB hospitalists can work together to advance evidence-based practices that improve outcomes for mothers and infants, while also ensuring hospitals maintain quality obstetric services amid provider shortages,” says Lisa Bukovac, DO, chief clinical officer of OBHG. Ob Hospitalist Group (OBHG) is the nation’s largest and only dedicated provider of customized women’s health solutions, focused on improving access to care and ensuring all women receive prompt, unconditional obstetric care. Our team partners with hospitals nationwide to improve maternal safety and outcomes and reduce physician burnout. As part of our dedicated women’s health focus, we coordinate care so every pregnant woman presenting to labor and delivery with unscheduled medical needs receives timely, expert care from a skilled clinician. Our 2,000+ clinicians partner closely with local OB/GYN physicians, providing collaborative, non-competitive support. Together, we deliver great patient care and clinicians passionate about their role in caring for pregnant women. OBHG is headquartered in Greenville, SC. For more information, visit www.OBHG.com. Safer Births, Stronger Systems
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