Background: Obstetrical care has been declining in rural communities. We examined patient choices and perspectives from two rural northern Minnesota communities who lost their local obstetrical services in July 2015. Our purpose was to characterize obstetrical use patterns through the years leading to and following the closure and to explore the effects of the closure on these communities. Methods: Information introducing the project and providing access to the survey was mailed to women who received prenatal care in the communities of interest. Responses were analyzed quantitatively and qualitatively. Findings: Two hundred and one participants completed the survey with 356 deliveries reported from 1990 to 2016. Before the closure, there was a trend toward an increasing percentage of women electing regional delivery (P <.001); however, women were still 1.6 times more likely to choose local (62%) than regional (38%) delivery. Reasons for choosing delivery location changed over the decades. While birth experiences remained positive or extremely positive, anxiety about getting to the hospital rose 10-fold from 1990 to 2016 (5%-51%, P <.001). Women voiced substantial concern about the lack of local obstetrical services. Qualitative analysis revealed significant negative emotional reactions and concerns for the consequences of this loss for the viability of their rural communities. Conclusions: Choices and opinions about obstetric care have significantly changed from 1990 to 2016 in rural Minnesota. Understanding these changes can help address shifting risks and costs to rural communities here and elsewhere in an effort to support and sustain healthy, viable rural communities.