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.
The United States’ rate of maternal mortality is worse compared with other high-income countries, according to the Organization for Economic Cooperation and Development.
Recent data shows the U.S. averaged 23.8 deaths due to complications during pregnancy or delivery per 100,000 live births in 2022. The country with the second-highest maternal mortality rate was New Zealand, with 13.6 maternal deaths per 100,000 live births.
Maternal mortality trends are more alarming when comparing rural areas to other geographic areas. The same federal data shows that from 2016-18, the maternal mortality rate in rural America was 77 percent higher than the mortality rate in the country’s urban areas.
Racial disparities in maternal care
The data also shows that Black women have the highest maternal mortality rates of any racial group across all demographics with 41.5 deaths in Black women per 100,000 live births. For white women, the rate is 13.7 deaths per 100,000 live births.
“Racial inequities have more of a burden on (rural residents) for sure,” Dixon said.
Women of color are more likely to be dismissed by health care professionals than white women, research shows. Many health experts argue that pregnant people of color experience poor health as a result of historical socioeconomic disadvantages.
Since rural patients already have a higher risk of maternal health complications, Dixon said, racial inequity compounds the issue in WNC.
Nonprofits throughout the state and OB/GYN researchers at UNC Chapel Hill have spearheaded programs to address racial inequities in maternal health, but many say government and public assistance could be the only option for real reform.
How did WNC get to this point?
Nearly 100 rural hospitals across the nation have closed their labor and delivery units since 2010, the National Rural Health Association found.In WNC, four labor and delivery units have closed since 2015.
“It’s already difficult for people (in rural areas) to access (prenatal) services,” said Mekhala Dissanayake, a doctoral student in epidemiology at UNC Chapel Hill. “So, when further closures happen, it just really puts a strain on (access to the) the health care system.”
The strain, she said, occurs when private OB/GYNs leave an area because there isn’t a nearby hospital to practice in. Since 2015, five WNC counties, Jackson, Macon, McDowell, Rutherford and Yancey, lost OB/GYNs, according to UNC’s Cecil G. Sheps Center for Health Services Research,
Rachel Urrutia, OB/GYN and UNC School of Medicine professor, said this doctor flight could be the result of doctors not being trained to practice in rural areas.
“For physicians, most of our training programs are not in rural areas. Residents may get a little bit of exposure to rural health, but they’re not rotating with the people who are providing care in those places most of the time. So, one, they may not have the desire because they haven’t been exposed to it,” Urrutia said.
Out of North Carolina’s nine residency programs for aspiring OB/GYNs, only one, MAHEC, is in the western part of the state, and none are in rural hospitals.
“When (medical students) are graduating, they’ve only done care in these places with lots of resources,” Urrutia said. “They’ve never practiced medicine in a place that is lower resource, so they may feel unprepared to do that.”
Dwindling numbers of rural OB/GYNs not only means pregnant people lose prenatal care, Dixon said, but they also no longer have access to postpartum care, contraceptive services and preventive care, such as cancer screenings.
“Those services are also lost when a labor and delivery unit closes,” Dixon said.
How do we address WNC’s maternal care situation?
Because WNC’s current maternal health situation has multiple causes — from social inequalities to topographical barriers — solving it will require innovative solutions, the doctors said.
Ensuring general physicians in rural areas have continued training in the basics of prenatal, delivery and postnatal care could be a start to mending the care deficits. Hospitals typically determine training requirements, UNC’s Urrutia said.
Efforts like MAHEC’s Maternal-Fetal Medicine Program are looking to make these training sessions more accessible, Dixon said.
Doctors in the program offer monthly presentations to teach general providers in rural areas how to respond to high-risk prenatal, delivery and postnatal situations.
The presentations are available via Project ECHO, a model of medical education that started in New Mexico in 2003 to help providers in remote areas learn from colleagues. Project ECHO operates like medical rounds at teaching hospitals, where residents meet with a medical team to discuss a patient’s plan of care.
During a session, providers present anonymized patient cases to each other. They discuss the case and help each other refine their plans of care. Research suggests that Project ECHO’s model improves health care in rural communities.
“It allows (providers) to stay up to date with continuing medical education,” Dixon said.
MAHEC also has a satellite office in Macon County, where OB/GYNs from Asheville work a few days a week to provide prenatal care for pregnant people in nearby rural areas, like Moss’ neighboring home of Clay County.
“We’re working on trying to increase the number of access points for prenatal care and to bolster the social determinants of health that will help people get that care,” Dixon said about the satellite clinics, which started in 2018.
Expanding satellite clinics and equipping all doctors with basic OB/GYN knowledge is the start to addressing the gaps in prenatal care uptake, Urrutia said, which could improve the region’s maternal morbidity rate.
These actions could be the first step to mending WNC’s maternal health crisis and ensure that women like Moss have smoother pregnancy experiences than they currently do.
The post-delivery drive back to rural WNC
Sitting at a picnic table on a mild November day, Moss reflected on her 2018 post-delivery drive back to Clay County from Asheville.
That December day, she buckled a healthy baby girl in the back seat before embarking on the two-hour journey home, when Moss winced as each mountain curve and bump shot pain into her sore body
When she remembers the chilly day she brought her second child into the world, Moss doesn’t just recall the love and joy she felt. She also remembers feeling forgotten and ignored by the health care industry.
“Women’s health is not a priority,” she said. “It is a very clear message to me.”
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