PURPOSE To evaluate differential mortality outcomes in rural Alabama counties with or without access to a local labor and delivery (L&D) unit. METHODS This retrospective cohort study used county-level data from the Alabama Department of Public Health. Rural counties in Alabama were categorized into those with an L&D unit and those without. The 2 groups were compared based on infant mortality rate, perinatal mortality rate, neonatal mortality rate, and low birth weight. RESULTS The infant mortality rate from 2003-2017 in the rural counties in Alabama with no local obstetrical care was 9.23 per 1,000 live births, whereas the infant mortality rate during the same period in the rural counties with continuous access to local obstetrical units was 7.89 (relative risk [RR] = 1.1679; 95% CI, 1.0643-1.2817, P = 0.0011). The percentage of low birth weight babies from the time period 2003-2014 in the rural counties in Alabama with no local obstetrical care was 10.61%, compared with 9.86% in the rural counties with continuous access to local L&D services (RR = 1.0756; 95% CI, 1.0424-1.1098, P <.0001). The perinatal mortality rate in counties with no active L&D was 10.82 per 1,000 still + live births compared with 8.89 in counties with an active L&D (RR = 1.2149; 95% CI, 1.1147-1.3242; P <.0001). The neonatal mortality rate during this period was 5.67 per 1,000 live births in counties with no active L&D, vs 4.74 in those counties with L&D services (RR = 1.1953; 95% CI, 1.0609-1.3466; P = 0.0034). CONCLUSION Access to local obstetrical care in a rural area is associated with better infant outcomes.