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The number of rural hospitals offering labor and delivery services has been declining across the United States for decades. As a part of this trend, labor and delivery services at Cook County North Shore Hospital in Grand Marais, Minnesota were discontinued in July 2015. The closure necessitates that patients now travel to Duluth, 110 miles away, for hospital-based delivery services. Partnership between Duluth’s regional campus medical school and this rural community has grown to incorporate researching the effects of this closure on the Cook Country region including the community of Grand Marais. A prior study undertaken evaluated patients’ perspectives on this loss of local obstetrical services. The present study’s purpose was to characterize the utilization and clinical outcomes of obstetrical care for patients before and after local labor and delivery services were discontinued. Retrospective chart review compared measures before and after delivery services were discontinued locally. Although not statistically significant, patterns since closure include an increased percentage of inductions, home births, and cesarean deliveries for women in Cook County. Introduction There has been a significant decline over the past couple of decades in the number of rural communities providing obstetrical services throughout the United States, Canada, and elsewhere.1–4 According to the United States Census Bureau statistics from 2010, nearly 18 million reproductiveaged women live in rural counties. Up to 40% of counties housing these rural women lack a qualified healthcare provider.5 It has also become increasingly clear that there is an association between loss of hospital-based obstetrical services and birth outcomes in rural counties.6–8 One of the limitations discussed in Kozhimannil et al’s 2016 national analysis is that county data is the only available unit of analysis, but that counties vary considerably. It was suggested that future work assess the associations between obstetrical service loss and individual outcomes. Our study focuses on patients seen at the Sawtooth Mountain Clinic (SMC) in Grand Marais, Minnesota. Grand Marais has a population of 1,351 and is the county seat of Cook County. Cook County has a median household income of $51,793, a poverty rate of 10.1%, a population of foreignborn residents of 4.7%, and a percentage of the population over 25 years of age with a bachelor’s degree or higher of 39.6%.9 In addition to patients in Cook County and surrounding areas, SMC also partners with the Grand Portage Band of Lake Superior Chippewa Health Services to provide some services for Band members in Cook County and on the Grand Portage Indian Reservation. Cook County North Shore Hospital (CCNH) in Grand Marais discontinued local obstetrical services in July of 2015. For decades prior to this closure, CCNH did not have epidural or surgical capabilities. Local providers would assess women during prenatal care and determine whether they were low-risk, thus candidates for local delivery. Surgical or higher risk patients were referred to regional providers for collaborative prenatal care between local and regional providers, with deliveries planned for a regional hospital. No regular home birth providers practiced in the area, so these patients did not have care coordinated by SMC providers either prior to or post closure. Since the closure of local obstetrical services, hospital management of labor and delivery now requires travel to a regional hospital in Duluth, Minnesota, 110 miles away. St. Mary’s and St. Luke’s Hospitals are located within a mile of each other on the same central hillside in Duluth, making the slight difference to each of them from CCNH insignificant. Only emergent deliveries are currently done at CCNH. Grand Marais serves as one of the longitudinal Rural Medical Scholars Program (RMSP) preceptorship sites for medical students from the University of Minnesota Medical School’s Duluth campus. Given the campus’s mission to improve healthcare outcomes in rural Minnesota and American Indian communities by educating medical students, creating strong regional partnerships, and fostering research, a closer look at the local effects of obstetrical service closure was felt to be relevant not only to the affected community, but to the

Changes in Labor and Delivery Patterns and Outcomes after Rural Obstetrical Service Closure