Pregnant women in rural communities that lose obstetric services face a number of challenges, including transportation difficulties, childcare issues, and other obstacles to care. Because each rural community experiencing a labor and delivery (L&D) unit closure faces its own set of challenges, however, we focused our study on New Hampshire, which has lost more than half of its rural L&D units over the last two decades. We sought to understand how L&D closures in New Hampshire affected the providers and patients in these communities. We conducted key informant interviews with more than 30 stakeholders, including hospital administrators and obstetric providers at hospitals that have experienced an L&D closure, hospitals that have remained open but are the receiving hospital for communities that have experienced a closure, and hospitals that are at risk for losing obstetric services. We also conducted a focus group and small group interviews with women living in communities that have experienced a closure. To supplement this case study work, we fielded a web-based survey of hospital executives in the state. We found that financial challenges and quality and safety concerns were the most cited reasons for L&D unit closures in rural New Hampshire. We also found that women in communities with a closure faced transportation challenges and benefitted from maintaining prenatal care in their community. Recommended strategies to ensure access to safe and secure pregnancies and deliveries after closures included strategic regionalization of maternity care, third party oversight of L&D closures, in-community prenatal and postpartum care, and hiring and retention of interdisciplinary maternity care teams.