Essentia Health Services recently announced that it plans to end labor and delivery services at its hospital in Fosston, a town of 1,400 people in northwest Minnesota. 

The closure of the delivery ward means that mothers in Fosston and surrounding towns will now have to travel 45 minutes west to Crookston or east to Bemidji to find an obstetric unit that delivers babies. 

It’s the latest in a longstanding trend of rural hospitals shuttering their obstetrics departments in the face of staffing and other challenges. Twenty years ago, more than 110 hospitals in the state offered birth services, according to the Minnesota Department of Health. Today that number stands at 76, with the closures hitting especially hard in communities in the rural northern reaches of the state.

In Grand Marais, on the North Shore, women face a two-hour drive to get to the nearest birthing center in Duluth. Mothers in Ely (pop. 3,200) need to drive an hour to get to Virginia after the local hospital ended delivery services in 2014. Virginia is also the nearest delivery hospital for residents of International Falls, a city on the Canadian border with a population of more than 5,000 people. It’s one hour and 45 minutes away by car.

Minnesotans living on reservations and tribal lands are especially likely to face difficulties in finding a nearby birthing hospital, as the map above shows. Infant mortality rates for Indigenous Minnesotans are more than double what they are for white babies, according to state data, and the maternal mortality rate is nearly 8 times higher.

Chartis, a private health care consulting firm, recently found that Minnesota had the nation’s highest number of rural obstetrics closures from 2011 through 2021, although this is partly because it has more rural hospitals than other states. A March of Dimes report found that 14% of Minnesota moms have to drive a half hour or more to reach a birthing hospital, compared to 10% nationwide.

When rural delivery wards close, “our research has shown increased risks of emergency room births as well as preterm births, especially in the more remote rural communities which are not adjacent to urban areas,” said Katy Kozhimannil, a University of Minnesota health policy professor. “We have also found that rural communities that lose obstetrics are less likely to offer other evidence-based services and supports for families, like childbirth education or lactation support.”

Rural hospitals in Minnesota have often cited staffing challenges as a driver of maternity ward closures. It can be expensive to keep staff and supplies on hand for procedures that happen infrequently. 

“For obstetric services the fixed costs of staffing, equipment, and facilities are difficult to cover with volume based revenues when facilities and clinicians have few pregnant patients,” Kozhimanill explained in an opinion published in BMJ last year. “This leads to workforce shortages and unit closures in more remote, less populated areas.”

Essentia Health in Fosston, for instance, only delivered 38 babies in the 12-month period ending in June of 2022, according to state data. The hospitals in the communities of Olivia and Granite Falls saw fewer than 20 deliveries in their most recently reported years. Both have since ceased offering those services.

Kozhimanill also noted that nearly half of American births are financed by Medicaid, which “reimburses at substantially lower rates than private insurers, so facilities and clinicians caring for lower income patients in remote rural areas face exceptional challenges in generating revenue for obstetric services.”

The closure of an obstetrics unit can become part of a self-perpetuating cycle of rural decline. Young families in need of maternal and infant care may decide to move elsewhere, shrinking the local economy and making it harder for the community to fund services for those who remain. 

The March of Dimes recommends expanding Medicaid eligibility and coverage as a way to reverse these trends, but Kozhimanill says policymakers should think bigger and consider ambitious investments in community public health.

“Policy solutions need to focus squarely on the structural injustices and systemic failures that have created and reproduced the statistics that alarm us,” she wrote last year. “As the closest place to give birth becomes further and further away for many people, these facts should no longer be surprising.”