When Nikki Johnson heard Mayo Clinic Health System was closing its labor and delivery unit at her local clinic in Fairmont, Minnesota, she was shocked. It was 2024, and she was 33 weeks pregnant. Instead of giving birth in her small rural town, she was suddenly faced with having to drive to Mayo's Mankato clinic about an hour away when she went into labor.
"I asked the doctor, so what happens if I go into labor and it goes pretty fast and I have to pull over on the side of the road on the way to Mankato?" Johnson recalled. "I was like, that would be terrifying. Giving birth is scary to begin with."
Johnson's experience isn't unique. Labor and delivery units have been closing across the state and the nation in recent years. The latest data from the University of Minnesota Rural Health Research Center shows that in 2010, 56% of U.S. counties had at least one hospital with obstetrics services. 14 years later, that dropped by 9% — almost 300 counties had lost hospital-based obstetrics services and rural areas had been hardest hit.
Labor and delivery units require 24/7 staffing since births can happen at any time. That makes it expensive. Rural hospitals see more low-income patients on Medicaid, which offers lower reimbursement, and they see fewer births, so labor and delivery units rarely pay for themselves. They tend to have fewer resources for simulation training and telemedicine support.
Katy Kozhimannil, co-director of the Rural Health Research Center, said when rural units close, it can make giving birth more dangerous.
"Certainly in rural areas, for every hospital that closes its obstetric unit or closes entirely, the nearest place to give birth gets further and further away, and that distance is associated with poor outcomes for moms and for babies," Kozhimannil explained.
She said many pregnant people are forced to give birth in under-resourced rural emergency rooms, in ambulances, or even on the side of the road, leading to more instances of pre-term birth and infant mortality.
Bucking the trend
However, there's one rural hospital birthing center that is thriving, and its success could offer a template for others. Minnesota's United Hospital District runs a small critical access hospital and three clinics in rural counties. Johnson gave birth to her daughter Sylvie at the hospital. It's located in Blue Earth, Minnesota. 3,000 people live in the town and the hospital is the only one in the county.
"We're the last one here," said United Hospital District CEO Richard Ash. "If we're not doing OB, there's a big desert here, and there's a lot of people that are going to either have to move or take the risk."
Ash said during much of his time leading the hospital, about 50 babies a year were born at the facility in Blue Earth. However, since 2020 there's been an increase every year and in 2025, they delivered 178 babies. He said the hospital's on track to follow suit this year.
Ash says has United Health District implemented a few different tactics to remain open. It joined Headwaters, a clinically integrated network of rural hospitals in Minnesota. That gave the hospital more negotiating power in purchasing supplies and allowed them to lower other costs. The hospital is also able to offset financial losses in labor and delivery by providing other services, like outpatient surgery, that bring in more money.
UHD's Chief Medical Officer Aaron Johnson said cross training is also crucial to balancing the hospital's budget.
"The biggest thing, I think, that allows us to keep our head above water, is that people can do multiple things," Johnson said. "If our labor and delivery staff were just L&D nurses it wouldn't work. There's no way it would work."
Building close relationships with patients is key
Maija Whitefeather Manning and her husband chose to give birth to both their sons in Blue Earth instead of other larger hospital system affiliates nearby because of the rave reviews she heard from her colleagues.
"I mean, we live in a world of technology, right?" Whitefeather Manning said. "And you can look at reviews, and you can read all these things. But also, when you live in a small community, what people say is true and has a lot of weight."
Both Whitefeather Manning and Johnson said they feel heard and understood at the Blue Earth hospital. They also recalled little homey touches that stood out: seasonally-inspired baby hats crocheted by church volunteers in town; the gift basket the hospital sent them home with; and a special multi-course meal for the new parents during their last night at the hospital.
"They gave us a little menu, it was like, steak or chicken breast and dessert and a bottle of sparkling grape juice," Johnson said jokingly that was not the sort of thing she'd come to expect with hospital care. "Like they are not setting up a little romantic meal for you and your husband."
Kozhimannil, co-director of the Rural Health Research Center said the hospital's strategy is a textbook example of what some rural hospitals are doing in order to succeed. And staying open and building capacity to serve more patients is crucial to improving the delivery of health care in rural areas.
For many of those who work at United Hospital District, the commitment to keeping the labor and delivery unit open feels personal.
"I mean for us, these are our neighbors," chief medical officer Aaron Johnson said. "These are our family members. These are the people that we go to church with, go to school with, go to football games with. We want to provide the best care for them."
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