By Rachel Crumpler
One in six North Carolina counties has no local obstetric care, meaning families have to travel long distances to deliver their babies — and, in some cases, even for routine prenatal and postpartum appointments.
Of the state’s 100 counties, 18 are considered maternity care deserts, according to an August report from the March of Dimes. That’s defined as an area having no hospitals or birth centers offering labor and delivery services and no practicing OB-GYNs, nurse midwives or family physicians who reported delivering babies. Another 12 counties have only one obstetric clinician.
About 61,000 women ages 15 to 44 live in these maternity care deserts in North Carolina, affecting an estimated 4,000 births annually. Tens of thousands more women live in areas with low access to care.
The distance to care for rural patients is not only a logistical hurdle, but has been associated with higher rates of cesarean deliveries, preterm births and maternal complications.
Pat Campbell, director of March of Dimes’ maternal and infant health initiative in North Carolina, said addressing these gaps will take a bigger maternity care workforce.
“It’s a huge issue if there’s not someone that can provide prenatal care and deliver a baby in a county,” Campbell said.
The scarcity and uneven distribution of maternity care providers has prompted a new initiative that will work to bring prenatal and postpartum care closer to patients in rural areas by training and supporting more family physicians to provide it.
Perinatal Access to Care and Health in North Carolina (PATCH-NC) will use a “shared care” model to help improve maternity care access in 10 rural counties that are classified as maternity care deserts or low-access areas. Ideally, prenatal care, delivery and postpartum care are all delivered by the same practitioner or clinical team, but the shared care model is a way to replicate that continuity when local providers cannot provide all three. Pregnant women go to a local clinician — often a family physician — for prenatal and postpartum care, and a partner provider farther away delivers the baby.
The three-year initiative, funded by $2.8 million from the Charlotte-based Leon Levine Foundation, will help rural family physicians at community health centers start providing consistent prenatal and postpartum care.
“One of the ways we can help women get access to ‘early and often’ prenatal care is to bring it closer to home for them,” said Shannon Dowler, a family physician leading the PATCH-NC initiative. “If we can have the medical homes in these rural communities provide that pregnancy and postpartum care, in partnership with the delivering provider who’s at the hospital that’s going to catch the baby and make sure the baby is okay, then it’s a win-win.”
Leveraging family physicians
Shared maternity care isn’t a new model, said physician Betsey Tilson, a former state health director who is now executive director of Nurture NC, a nonprofit working to improve maternal and infant health across the state. Some health departments, community health centers and health system satellite clinics already practice this form of “shared care.”
“This is just leveraging the model strategically and financing it so we can get more sites to be doing that model to address maternity deserts,” Tilson said, noting that North Carolina has the second-largest number of rural residents in the United States.
Decades ago, rural practices provided more maternity care, with family physicians often taking the lead, Dowler said.
Then that started to dwindle.
“The liability costs for malpractice skyrocketed in the late ’90s and early 2000s, and so a lot of doctors stopped doing pregnancy care because the cost of their malpractice became so high, even if they weren’t delivering the babies,” Dowler explained. “Then we had tort reform in North Carolina, which helped with that, but meanwhile, we lost that sort of institutional memory.
“The other thing that happened is that health systems came in and bought up practices in rural communities and bought up rural hospitals — and then the scope that they were allowing their doctors to provide in those rural communities got narrowed.”
Dowler, a member of the board of directors for the American Academy of Family Physicians, sees family physicians as a promising way to help address maternity care deserts. As part of residency, all family physicians get training and education in maternity care.
Providing prenatal and postpartum care is within a family physician’s scope of practice, she said, and they are often more prevalent in rural areas than OB-GYNs.
In 2025, 3,429 family physicians practiced across the state, according to the North Carolina Health Professions Data System, compared with 1,566 OB-GYNs.
“We train … family doctors to have maternity care skills and pregnancy care skills, and then often they go into a practice where they’re not allowed to use them,” Dowler said. “Creating space where they can really do that full scope of care is really important for dealing with our crisis of access in rural areas and reducing burnout for the full healthcare team.”
Closer to home
Richard Lord, a family physician in Winston-Salem, helped launch a shared care program in Stokes County in 2009. At the time, Lord was leading the maternity care program at the Wake Forest University School of Medicine’s Department of Family Medicine. He noticed that many women from Stokes County were traveling to Winston-Salem to give birth — and many hadn’t had consistent prenatal care.
Lord established a partnership with the Stokes County Health Department to operate a weekly prenatal clinic. The clinic still operates, Lord said — every Tuesday at the health department office.
“The idea was just that these women weren’t going to drive 45 minutes to Winston on a weekly basis,” Lord said. “They didn’t have the resources.”
Lord, now chairperson of the Department of Family and Community Medicine, said the shared care model has meant that more women have gotten prenatal care throughout their pregnancies rather than only occasional visits.
“For many of them, it makes a difference in getting more prenatal visits in, less time away from work, less barriers,” Lord said.
Lord said the Wake Forest University School of Medicine also has physicians who work in Yadkin, Davie, Wilkes and Forsyth counties in partnership with local health departments or federally qualified health centers to make maternity care more accessible.
Some studies have shown shared care not only improves access to prenatal care, it increases appointment attendance and continuity of care. And early and regular prenatal care has been shown to improve outcomes for mother and baby.
In 2024, about 1 in 5 infants — 18.6 percent of live births in North Carolina — was born to a woman who didn’t get adequate prenatal care, according to March of Dimes.
“If you only see a woman every two months or three months, you miss the chance to do all that surveillance and also to intervene,” Dowler said.
Regular visits give clinicians opportunities to identify mental health, substance use or other concerns with the mother and baby.
“Not having a regular source of care has just tremendous consequences for [pregnant women],” Dowler said. “We want them to have a safe, trusted place of care in their communities.”
Dowler said community health centers are often that place; the PATCH-NC grant funding focuses on boosting access there.
For example, Piedmont Health Services, a federally qualified health center operating in Caswell, Orange, Alamance, Chatham and Lee counties, offers prenatal and postpartum care at all but one of its 10 clinic locations.
Adrian Mancheno, chief medical officer at Piedmont Health Services, said the service is important for the clinic’s goal of keeping as much health care as possible all in one place for patients. In 2025, Piedmont Health Services served about 45,000 patients, including just over 1,000 prenatal patients, he said.
“The patient would prefer to do the prenatal care in the local community and go and deliver somewhere else, even if they have to have to drive, as long as they know that the records are going to be transferred and that they’re going to have all that information,” Mancheno said about patients’ response to the shared care model.
For many of the clinic’s low-income patients, the time away from work and cost of gas can make travel for prenatal care impossible, Mancheno said.
In addition to meeting patients’ needs, he said offering prenatal care is beneficial for the community health center overall because it improves continuity of care and adds newborns to the patient pool.
Spreading shared maternity care
While some places are already providing shared maternity care, Dowler sees a key opportunity to expand.
That’s the work PATCH-NC will take on. Bringing shared care to new communities requires more than identifying a willing family physician.
Providers and clinics may need additional training, equipment and new workflows. They’ll also need to form partnerships with clinicians and hospitals that provide labor and delivery and can accept referrals for high-risk patients who need a more intensive level of care.
The 10 counties and sites selected to get funding through the PATCH-NC initiative are expected to be announced by the end of October, Dowler said. By the first quarter of 2027, the sites are expected to begin offering pregnancy care in communities where it had not been available before.
“This isn’t a ‘think about it for 18 months and then start doing it,’” Dowler said. “We really want there to be more pregnancy care available around our state pretty quickly.”
The initiative will track outcomes to help map out expansion across the state, including how early in pregnancy patients got their first prenatal visit and the number of women who attend an appointment after the baby’s born, something that many new parents skip. Dowler hopes those are two of the measures where shared care can bring “rapid improvements.”
Restoring labor and delivery services in rural communities is a much larger undertaking. Only one rural North Carolina hospital — UNC Health Chatham in Siler City — has bucked the trend of closing labor and delivery units. They reopened maternity services in September 2020.
What PATCH-NC is doing is “a bite-sized piece” of filling maternity care gaps, Dowler said. “Trying to open up a rural hospital to provide pregnancy care again is like the whole meal. This is one small thing that a practice can do.”
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