Clare Shirley, 30, and her husband Dan, are just days away from giving birth to their second child. But they’re hoping for a less harrowing experience than when she delivered their first child, Kit, two years ago.

“She was born at 2:30 A.M,” Clare Shirley said. “It was a very fast delivery.” The then-first-time parents phoned both their pre-natal doctor in Grand Marais, and their doctor in Duluth for advice. The Shirleys live surrounded by wilderness on the edge of the Boundary Waters Canoe Area. They run a seasonal business as canoe outfitters, a 45-minute drive on a partially-gravel road away from Highway 61 — which then is still a two-hour drive to Duluth, or a 30-minute drive to North Shore Hospital in Grand Marais.

“There’s no cell service between us here and Tofte, Minn. (at Highway 61),” Shirley explained. “We told them we’re going to head out to Tofte and we’d call them when we get to Highway 61. At that point, we’d have to make a split-second decision.”

The Shirleys had to make an anxiety-ridden choice. If they elected to turn right to make the long journey to Duluth, they’d be guaranteed their delivery would have the best obstetrics care available, to access to an epidural, anesthesia, a surgeon and staff accustomed to doing frequent deliveries. If they instead went left to Grand Marais, the shorter drive might get them to North Shore Hospital, but staff and the facility might not be able to handle a birth with complications.

In 2015, North Shore Hospital made a “difficult” but controversial decision to stop scheduling deliveries. Instead, the facility would still accept women in labor, but only admit them as an emergency. That’s because its insurer determined the facility didn’t have the ability to administer a C-section birth, or to address any other complications that might develop.

“It’s very hard to say we weren’t meeting the standard of care,” Kimber Wraalstad, hospital administrator, said. “And when [the insurer] said ‘this is what you need to do to meet the standard of care and be insured,’ that put the whole organization at risk.”

State data shows women who live in Cook County had 393 births from 2008-2017. Less than 20 percent of those births took place there, however. The majority of expectant mothers were already by choice traveling to Duluth to give birth, years before the local hospital stopped scheduling deliveries. But there isn’t a chart to show the number of births that would have occurred at the local hospital if it had a state-of-the art obstetrics unit and trained staff on hand. Until 2015, local family physicians familiar with obstetrics, had been overseeing low-risk births at North Shore Hospital.

Some would have continued with that practice, even today. Dr. Jenny Delfs practices family medicine at the federally-funded Sawtooth Mountain Clinic in Grand Marais. She and others had been willing to deliver babies. Now, she is limited to providing pre-natal care and will deliver a baby in an emergency.

“Society has dismantled something that will take decades to rebuild,” Delfs said.

Researchers are also concerned that disappearing access to healthcare services, like obstetrics, in rural America will contribute to negative outcomes in the future. Groundbreaking research shows that women in rural counties that lost obstetrics units were more likely to deliver pre-term births and more likely to give birth in places that didn’t have adequate care, said Carrie Henning-Smith, one of the authors of the research. And more than half of all rural counties in the United States don’t offer obstetrical services — a decrease of nine percent from 2004-2014.

Henning-Smith said the solution will have to come from a variety of areas, including federal aid and community support for initiatives like more paid time off, low-cost short-term residences for expectant mothers and their families who have traveled great distances and changes in Medicare payments. For now, they hope the research will help start discussions. For expectant mothers and their families in places like Cook County, it means taking on more of the birthing risk, and potentially making split-second decisions in the middle of the night.