The TRUST Framework: A Model for Safe, Sustainable Rural Maternity Care

Rural maternity unit closures have narrowed access to health services for families across the United States, yet evaluative frameworks remain focused on rural deficits, financial viability, and short-term clinical outcomes. In a recent evaluation of the reopening of a rural Level I maternity care unit in North Carolina published as part of this Special Issue, we found that outcomes for low-risk birthing patients were comparable to those at a larger academic medical center for matched cases, median travel distances were reduced by approximately half, and patient satisfaction was high. However, these findings do not fully capture the relational, structural, and contextual conditions that made the model possible and sustainable. In this commentary, we argue for a broader evaluative approach that incorporates community trust, culturally and linguistically responsive care, interprofessional collaboration, political and institutional alignment, and models of care grounded in population need rather than volume-based revenue logic. We introduce the TRUST Framework as a conceptual starting point to guide policy, practice, and research toward more holistic assessment and support of rural maternity care systems. By centering strengths as well as challenges, this framework reframes rural maternity care as a coordinated system rooted in relationships, accountability, and place.