The true impact of WNC’s maternal desert on rural women

By Shelby Harris and Sarah Melotte

This story is a collaboration between Carolina Public Press and The Daily Yonder. The Daily Yonder provides news, commentary and analysis about and for rural America.

As her husband drove through Western North Carolina’s winding mountain roads in December 2018, Katlyn Moss repeated instructions to him in case something went wrong. 

It was nighttime and snowing, and Moss was nine months pregnant. At the time, she was also a OB/GYN nurse. 

As her husband drove through the snowy terrain of North Carolina’s mountain region, Moss rehashed their plan for what to do if she went into labor during the 107-mile drive from her home in rural Clay County to Mission Hospital in Asheville. 

“I had a conversation with my husband, like, ‘If we deliver on the side of the road, this is what you’re responsible for, and this is what we’re going to do, and this is who you should call,’” Moss said.

Recounting her experience last November on a mild morning in Hayesville, Moss said she knows several women from rural parts of the state who have similar delivery stories. 

Her long-distance drive to give birth is not uncommon for some women in the western part of the state, based on data showing little- to no access to maternal care in the region. Of the 16 medical facilities that serve the region, only half provide prenatal care and delivery for WNC’s roughly 153,000 women ages 18-44, according to the March of Dimes, a maternal health advocacy nonprofit that tracks health data across multiple federal agencies. 

The consequence of a lack of access to maternal care services, research shows, is that women living in rural areas often forgo prenatal, emergency and delivery care — which can have serious health consequences, such as severe hypertension and hemorrhaging. 

Beyond the health risks associated with living in a maternal care desert, rural women say they also grapple with feeling that their health needs are forgotten, regardless of how critical the situation becomes. 

“It is offensive that we are not thought of enough and prioritized enough that (traveling to get maternal care) is just a common thing,” Moss said. “It’s very demeaning to me to not have the services that we need.”

Sparse access to prenatal care for rural WNC 

Three years earlier, Moss delivered her first baby at Angel Medical Center, 40 miles away in neighboring Macon County. That wasn’t an option with her second pregnancy, as Angel Medical Center’s labor and delivery unit closed in 2017.

Though Angel Medical Center was closer than Mission Hospital, Moss still had to buckle a seat belt over her protruding belly and drive 45 minutes to the next county every time she needed an ultrasound, bloodwork or other routine prenatal care.

Living in rural WNC can make these regular journeys to prenatal care difficult, said Suzanne Dixon, an obstetrician/ gynecologist (OB/GYN) with Asheville-based Mountain Area Health Education Center, or MAHEC. 

“Even though (patients) have a carefully laid plan to get to the hospital of choice for delivery, they might have to totally change that plan if there’s an ice storm,” Dixon said. “That’s one of the big differences between our area and the metropolitan areas of North Carolina.”

Each of WNC’s 14 counties without labor and delivery units is classified as rural, or not in a market area containing a city with at least 50,000 residents, by the N.C. Department of Health and Human Services. 

WNC’s four urban counties, Buncombe, Burke, Haywood and Henderson, house five of the region’s eight hospitals with labor and delivery units. The other units are in rural counties: Jackson, McDowell and Rutherford. Five of these counties — Graham, Swain, Madison, Mitchell and Polk — are “maternity care deserts,”  or areas where there are “no hospitals providing obstetric care, no birth centers, no OB/GYN and no certified nurse midwives.”

There are 21 counties in North Carolina classified as maternity care deserts by the March of Dimes. Only one, Stokes County, is urban — indicating that the state’s maternal care crisis uniquely impacts rural pregnant people.  

The disparity between maternal care in urban and rural areas could have serious consequences, Dixon said — the worst of which includes more maternal deaths and fewer pregnant people getting necessary prenatal care. 

“I think if you talk to providers of maternal care all over the country, we are seeing an increase in outcomes that are less desirable,” Dixon said.

Low prenatal care uptake, high maternal mortality rates 

Health care professionals, including Moss who researches maternal health in Western North Carolina for MAHEC, say these mortality rates are often the result of medical issues not addressed due to the lack of access to prenatal and delivery care.

Moss said patients would come into the office when they’re pregnant, and “their blood pressure is through the roof because they had chronic hypertension, but they didn’t know that,” she said.

After stabilizing the patient’s blood pressure, Moss would work with the doctors to establish a plan for the hypertension, a condition that could have been diagnosed with earlier prenatal care. 

“If (her hypertension) changes during the pregnancy, is it because of the pregnancy? Or have we not gotten her chronic hypertension under control? What’s going to happen when she goes home?”

Women who received either late or no prenatal care delivered 6.2 percent of live births — 1-in-16 infants — nationwide in 2020, according to the March of Dimes, which defines late prenatal care as care that begins in the third trimester (seven to nine months).  

In North Carolina, women who didn’t receive care or received it in the third trimester made up 8 percent of total live births — the highest it has been in the last decade. In 2011, the percentage was 5 percent. 

That means women who received late or no prenatal care gave birth to 1-in-12 babies across the state in 2020. 

In Swain County, 9 percent of women received late or no prenatal care, greater than the state’s baseline of 8 percent in 2020. 

The frequency of prenatal visits is also important. According to the March of Dimes, inadequate prenatal care is care that begins in the fifth month or later, or when someone receives fewer than 50 percent of the recommended 15 prenatal visits for a low-risk pregnancy.

In Swain County, 21 percen percent of women received inadequate prenatal care, compared with the statewide average of 17 percent, or 1-in-6 births.

As the number of births from people who did not receive prenatal care rises, so does the number of people dying while pregnant or after giving birth, or the maternal mortality rate. 

In 2021, North Carolina’s maternal mortality rate was 27.6 deaths per 100,000 live births, according to federal data. That’s 16 percent higher than the national rate of 23.8 deaths per 100,000 live births.