Obstetric emergency readiness in rural emergency departments: a cross-sectional survey of birthing and non-birthing hospitals in Montana, USA

Background Rural emergency departments (EDs) increasingly serve as frontline providers of obstetric care due to widespread closures of labour and delivery (L&D) units. Building on a prior study that assessed hospital-level obstetric readiness using the WHO Emergency Obstetric Care (EmOC) Indicators, this study evaluates ED-specific preparedness for obstetric emergencies in a rural US state, with implications for similar settings globally. Methods A cross-sectional survey was conducted in Autumn 2024 involving ED medical and nursing staff from both birthing and non-birthing hospitals. The survey assessed hospital characteristics, staffing and nine domains related to emergency obstetric care. Descriptive statistics were used to summarise responses from 78 individuals across 45 EDs. Selected comparisons between birthing and non-birthing facilities were evaluated using Fisher’s exact tests. Results Most participating hospitals (87%) were in rural areas. Half of the EDs were in non-birthing facilities, many of which had previously had L&D units that closed. Key findings included inconsistent pregnancy screening and triage protocols, limited staff training and inadequate ED discharge and transport procedures. EDs frequently managed early pregnancy complications, postpartum emergencies and, in some cases, active labour and delivery. Conclusions Rural EDs function as critical safety nets but demonstrate important gaps in emergency preparedness, workforce readiness and transport systems. This assessment framework provides a practical approach for identifying facility-level vulnerabilities and informing targeted quality improvement, simulation training, referral-network strengthening and policy interventions. Readiness assessments such as this may help health systems improve preparedness for high-acuity, low frequency emergencies and promote equitable access to emergency care in rural and underserved communities.