Despite huge health care expenditures, many rural areas of the United States are without adequate access to basic maternity services. Hospital closures and changes in reimbursement have created new threats, even in areas with functional systems of delivering maternity care. New models of care must be developed that take advantage of attributes of low-volume rural maternity units, increase the number of collaborative practices among various providers of maternity services, and judiciously apply new technologies to bring perinatal expertise into the rural hospital when appropriate. Local access to maternity care in rural communities is essential to improve birth outcomes and lower costs. Standardization of management of obstetric emergencies and advances in telecommunication technology may make these low-technology, isolated communities safer than they have been in the past. Changes in health care financing, particularly managed care with capitation, may further support these changes.