When Clare Shirley went into labor late one night, she faced a 2 1/2 hour drive to get to the nearest hospital with a delivery room.

COOK COUNTY, Minn. — The pain started at midnight.

Clare Shirley shuffled through the darkness to the bathroom. The pain, pulsing through the pit of her stomach, came again and again, taking her breath away. She could barely move.

Two days from her due date, Clare quickly realized what was happening. She woke her husband, Dan. Their first baby was coming — fast. But to deliver safely, they’d have to make it through a 2 1/2 hour journey across a rugged landscape to the big-city hospital in Duluth.

There was a closer hospital. But it had shut its labor and delivery service just before Clare became pregnant, unable to afford to renovate or hire enough staff to meet modern clinical standards.

It is a common story in rural America. Financial pressures, insurance problems, and doctor shortages forced more than 200 hospitals to close their birthing units between 2004 and 2014, according to the University of Minnesota’s Rural Health Research Center. That’s left millions of women of reproductive age facing longer drives to deliver babies — who sometimes arrive en route.

The long drives, understandably, increase anxiety. They also make mothers and babies less safe; studies show these distances bring with them increased rates of complications and infant deaths, as well as longer stays in neonatal intensive care units.

But many women have no choice.

In Texas, for instance, just 70 of the state’s 162 rural hospitals still deliver babies. More than two-thirds of rural counties in Florida, Nevada, and South Dakota do not have obstetric services. Sixteen percent of Minnesota’s rural counties lost those services in just the past decade.

In Cook County, where the Shirleys live, the only path to life runs down Highway 61, a two-lane road that hugs the shoreline of Lake Superior.

The winding drive to the distant city of Duluth is as beautiful as it is treacherous. Views of the lake are framed by spindly white birches and towering pines. Deer and moose roam freely, especially at night — and often stray onto the roads.

The Shirleys live at the end of the Sawbill Trail, a 24-mile road that snakes through Superior National Forest in the northeastern corner of the state. It takes about 40 minutes just to get to Highway 61, and another two hours to get to the hospital in Duluth. There is no cell service. GPS doesn’t work.

Clare, 29, and Dan, 32, co-own and manage a seasonal canoe outfitting business along Sawbill Lake. In the last weeks of her pregnancy, they were living in a remote cabin with no working phone. So when Clare started having contractions, Dan hopped on his bike and rode to his in-laws’ house nearby. He dialed Clare’s doctor in Duluth, who told him to get on the road as soon as possible.

Dan and Clare hustled into their black station wagon and drove into the darkness, the tires crunching over the gravel road that connects their camp to the highway. It was early May and unusually warm.

Because of the distance, doctors advise patients in the region to leave for the hospital at the first sign of labor, when contractions are 20 minutes apart.

Clare’s were already much closer. “They were five minutes from the get-go,” she said. “We skipped right over the 20 minutes. It was like, ‘OK, what do we do now?’”

Dan and Clare Shirley with their daughter, Kit. The couple operates a canoe and camping business at the end of the Sawbill Trail, a 24-mile road through Superior National Forest.

Risk shifts from hospitals to expectant moms

The Shirleys’ local hospital closed its birthing unit in the summer of 2015, after a long struggle to keep it open.

Cook County North Shore Hospital had been delivering babies in the town of Grand Marais — population 1,350 — since it opened, largely for that purpose, in 1958. The county-owned hospital, about an hour drive from the Shirleys’ home, has 16 beds and an emergency room.

Its labor and delivery unit wasn’t high-tech. It didn’t have the staff to offer epidurals for pain relief, or an operating room to provide C-sections. If patients wanted those services, they had to travel to Duluth. Many did. In recent years, North Shore Hospital has only delivered 10 of the roughly 45 babies born in the county each year.

And the service was becoming increasingly difficult to provide. The hospital lost money on births — about $16,000 a year, according to a hospital board member. Worse, some doctors and nurses said they were struggling to keep up their skills. They worried about being able to handle complications or the unpredictable turns that births often take.

“We would talk amongst ourselves about how scared we were,” said Christine Kunze, a nurse who worked at the hospital for 23 years before moving to the adjacent Sawtooth Mountain health clinic. “We continued to get more training. But as we got more training, we got less patients. It became so stressful.”

Plenty of senior doctors remained committed to the service, and loved providing it. They had been trained in residency to deliver babies without pain medications — and without specialists waiting in the wings. “Everybody was willing to do this model of care and back each other up,” said Dr. Jenny Delfs, who handled deliveries at the hospital for 20 years and now provides pre- and postnatal care at the Sawtooth clinic.

But following an inspection in late 2014, the hospital’s malpractice insurer, Coverys, determined that North Shore no longer met several clinical standards. The biggest issue was that it could not provide its patients with a C-section within 30 minutes, a guideline established by the American College of Obstetricians and Gynecologists.

That guideline, while meant to protect patients, left no room for babies to be delivered in a place like Cook County, where it is difficult to attract surgeons or provide the volume of patients needed for them to establish and maintain competency.

It is a problem that results in part from a rejection of risk. Insurers don’t want it, and rural hospitals cannot afford it.

But in health care, risk is a force as real as running water. When it is blocked in one spot, it simply falls somewhere else, in this case on the backs of patients who must endure harrowing late-night rides to distant hospitals. Or give birth at home.

The Sawtooth Mountain Clinic and adjacent North Shore Hospital in Grand Marais, Minn.

A bitter blow for a self-sufficient town

North Shore’s administrator, Kimber Wraalstad, said meeting the guideline for C-sections would have required the hospital to build an operating room, hire both a surgeon and an anesthesiologist, and provide new equipment and training for nurses. Operating expenses alone would top $1 million a year. That simply was not feasible for a hospital that was already barely breaking even, with an annual budget of about $14.4 million.

Beyond the finances, Wraalstad said, the low birth volumes presented a real safety issue. “We have an obligation to make sure we have the best situation for moms and babies,” she said. “As much as this decision hurts your heart, it would be horrible if something happened to them.”

“We have an obligation to make sure we have the best situation for moms and babies. As much as this decision hurts your heart, it would be horrible if something happened to them.” Kimber Wraalstad, hospital administrator

The planned closure prompted an outcry in the community, which is situated along Lake Superior and at the edge of a vast federal wilderness area. Grand Marais, a former logging and fishing hub, is the seat of Cook County and its only municipality. Its economy is driven by tourists and seasonal visitors who flock to the artsy town for its breathtaking scenery and recreation. The people who live here year-round take a certain pride in living independently. Many built their own homes, started their own businesses, and take care of their own problems.

The hospital serves a vast area, including several unincorporated territories whose residents live on dirt roads more than three hours from Duluth.

Some worried the closure of the labor and delivery services would disproportionately harm low-income families without the means to spend several nights in the city and take extra time off work. More women might decide to give birth at home, despite the inherent dangers. And it would certainly force more women in labor to make the long drive to Duluth. In cases where they couldn’t make it, they would still have to rely on local doctors, whose skills would be diminished from handling fewer and fewer births.

During a packed community meeting in early 2015, many residents also fretted about something more fundamental — the inability of this remote county to remain independent and support life on its own.

“It’s already hard to make a living in Cook County,” resident Betsy Jorgenson said, according to a recording of the meeting posted on Facebook. “Now you can’t even be born here.”

County board members appeared sympathetic. But if it kept its labor and delivery service open, the hospital could lose its its medical malpractice coverage. The entire facility would be forced to shut down.

They decided to cease deliveries in July 2015.

Clare Shirley became pregnant a month later.

A scene along the Sawbill Trail. Dan and Clare Shirley operate a canoe outfitting business at the end of the trail, where campers and hikers set off on excursions through the federally-protected Boundary Waters Canoe Area Wilderness.

A longer drive and a higher risk of complications

Clare and Dan took a roundabout path to their cabin in the woods. Dan was a chemist who helped to start a renewable chemicals business after graduating from the University of Montana. Clare became a lawyer. While she was completing a clerkship for a federal judge in Montana, the couple began thinking about changing gears.

They wanted to start a family and live near relatives. So they decided to move to Minnesota, where they could become the third-generation owners of Sawbill Canoe Outfitters, which helps plan excursions into the Boundary Waters Canoe Area Wilderness. The company was started by Clare’s grandparents in 1957.

Clare hated the idea of having her baby in Duluth. Aside from the inconvenience, it also broke with tradition. Clare had been born in the little hospital in Grand Marais, and so had her mother.

“It was upsetting,” she said. “To have so many generations of your family born in this place and be so deeply rooted to it — to not have [local birth] as an option was sad.”

“It’s already hard to make a living in Cook County. Now you can’t even be born here.” Betsy Jorgenson, local resident

It also significantly raised the risk of complications.

A 2011 study of 50,000 births in rural British Columbia found that infant mortality rates increased by as much as three times for women who had to travel several hours to get to the hospital. It also found that more travel was associated with longer stays in intensive care units and that unplanned, out-of-hospital deliveries were highest for mothers located one to two hours from the hospital.

Kristin DeArruda-Wharton holds birthing classes for expectant mothers at the Sawtooth Mountain Clinic, where she is a registered nurse. She said discussions are dominated by concerns about the drive.

“It’s the biggest thing on people’s minds,” she said. “People literally say to me, ‘I’m not even worried about the birth. I just want to get to Duluth.’”

The 110-mile drive between Grand Marais and Duluth winds along the shore of Lake Superior, through long sections of wilderness. Deer, moose, and other wildlife often wander onto the roads at night.

A quick decision with no margin for error

Dan Shirley was trying to keep his eyes on the road. His wife was in distress beside him, but he was focused on avoiding the deer that frequently cross Sawbill Trail at night.

When they hit Highway 61, they stopped at a cafe where a sheriff’s deputy was waiting for them. They had to make a quick decision with no margin for error: head to Duluth, still two hours away, or drive 25 miles in the opposite direction for an emergency delivery in Grand Marais.

Since cell service works on 61, they were able to speak to Delfs, Clare’s local physician. Clare told her the pressure was getting intense. She felt the urge to push. “Apparently, those were the magic words,” Clare said. “Because she told us to head to Grand Marais.”

Clare and Dan got back on the road, trailed by the deputy. Fearing time was running out, Delfs got in an ambulance and told the driver to meet the couple on the highway. The deputy blocked the road while Clare hustled into the ambulance. It was about 1:30 a.m.

Delfs told Dan she would have the ambulance driver pull off the road if Clare was going to deliver the baby before they arrived. She closed the back doors, and the ambulance sped off.

Dan hopped back in his car and tried to catch up. He noticed fresh blood on the road from deer strikes but pressed his speed to 80 mph. Still, the ambulance faded from view. He figured it was going about 100.

Inside, Clare was strapped down and in immense pain. Delfs leaned close, telling her not to push. It was the one thing Clare wanted to do most.

Dan arrived just in time to see Clare getting wheeled into the hospital. There was no delivery room, so she ended up in an ordinary patient room.

Delfs was backed up by Dr. Sandy Stover, who had known Clare from childhood and delivered countless babies over the years. The bed had no stirrups, so Dan held one of Clare’s legs, Stover the other.

“[My contractions] were five minutes from the get-go. We skipped right over the 20 minutes. It was like, ‘OK, what do we do now?’” Clare Shirley

Clare said she remembers the unusual quiet of the empty hospital at night. There was no bustle. No beeping monitors. No voices. Then she heard a nurse say something about a drop in the baby’s heart rate. A rush of anxiety. “I thought, ‘OK, we’re not going down this path,’” Clare recalled. “This baby is coming on the next push.’”

Within 25 minutes of her arrival at the hospital, at 2:32 a.m., her daughter, Kit, was born. It took a few seconds to get the umbilical cord off her legs, but she was healthy and so was her mom. The hospital room cleared out. “All of a sudden we were just alone,” Clare said. “It was great.”

Dan and Clare Shirley hold their daughter, Kit, in the living room of their home.

On a recent morning, Kit — now 11 months old with curls of dark hair and bright brown eyes — zipped along the floor of the Shirleys’ home on Sawbill Lake, pulling up on the furniture and stairs. She seemed ready to walk any day. Looking back on her birth, the Shirleys said it could not have worked out better: Clare delivered a healthy baby whose certificate lists Grand Marais as the place of birth.

But they’re already considering how they would handle the delivery of a sibling for Kit. And wondering whether they could go through the anxiety and the drama again.

Clare has been thinking about taking classes on how to give birth at home. “I don’t want to have a home birth,” she said. “But in the event that it happens, I want us to know what we’re doing.”

Clarification: North Shore Hospital has 16 beds and is part of a county-owned entity that also operates a 37-bed skilled nursing facility on the same property. A prior version of the story imprecisely described how the beds are allocated.