By Shelby Harris and Sarah Melotte for The Daily Yonder.
Broadcast version by Nadia Ramlagan for North Carolina News Service Service for the Public News Service/Daily Yonder Collaboration

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 an 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 low- 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 aged 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 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 Dr. Suzanne Dixon, an 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 Resources.

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 North Carolina'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 because of 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 patient's 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% 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% of total live births - the highest it has been in the last decade. In 2011, the percentage was just 5%.

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

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

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

In Swain County, 21% of women received inadequate prenatal care, compared to the statewide average of 17%, 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 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% higher than the national rate of 23.8 deaths per 100,000 live births.

The United States' rate of maternal mortality is worse compared to 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 to 2018, the maternal mortality rate in rural America was 77% 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 the University of North Carolina at 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 the University of North Carolina at Chapel Hill (UNC). "So, when further closures happen, it just really puts a strain on (access to the) the healthcare 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,

OB-GYN and UNC School of Medicine professor Dr. Rachel Urrutia 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 in rural hospitals. None are in rural cities.

"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 pregnant people lose prenatal care, Dixon said, but they also no longer have access to postpartum care, contraceptive services and preventative 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 hourlong 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."

Shelby Harris and Sarah Melotte wrote this article for The Daily Yonder.


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Voters in Arizona overwhelmingly supported and approved Proposition 139 last week, which enshrines abortion rights into the state's constitution.

The measure will allow abortions up to fetal viability, which is about 24 weeks.

But Fatima Goss Graves - president and CEO of the National Women's Law Center - said while ballot measures expanding access to abortion won in seven of the ten states this election, she contended there are still countless ways to restrict and upend abortion access even further, including nationwide.

"There is a long list of ways to target birth control, to target fertility treatments, to target our ability to control our own bodies, and to be fully equal in this society," said Graves. "We know that road will be long and hard."

Over the weekend Arizona was officially called for former President Donald Trump, awarding him the state's 11 electoral college votes.

Graves said Trump has promised to veto a national abortion ban, and to distance himself from the conservative playbook Project 2025.

She said reproductive rights advocates, like herself, expect the next administration to deliver on those campaign promises.

The state has a number of abortion restrictions and laws that directly conflict with Prop 139.

Until the election results are officially certified by Gov. Katie Hobbs later this month, pro-choice advocates say they'll likely file legal challenges to deem those current restrictions unconstitutional.

In a statement, the It Goes Too Far Campaign - a group opposing the measure - says "the fight against extreme abortion laws will continue."

Monica Simpson is the executive director of the SisterSong Women of Color Reproductive Justice Collective.

She said while all eyes need to stay on the Trump administration, advocates must also continue to lift up "powerful programs."

"I want us to be able to find a balance in doing that," said Simpson, "and work together as the organizations and entities that we are, to be able to make sure that we give ourselves the power and the fuel that we need over these next four years."

Simpson said while it is crucial to keep an eye out at the policy level, advocacy will also be a key part of the fight moving forward.

Support for this reporting was provided by the Carnegie Corporation of New York.

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Oregon has the third highest percent of women in city government, according to a new report from Rutgers University.

It may be proof of the success of organizations working to support and encourage women to run.

Groups like Emerge Oregon and Vote Run Lead Action train women and nonbinary people to run for office - and win.

Emerge Oregon alums currently hold more than 100 elected positions on city councils, school boards and in the legislature.

Beyond campaigning and fundraising, women receive support to overcome gender-based barriers.

The group's outgoing director, Annie Ellison, noted that the political system wasn't designed with women - particularly women of color - in mind.

"This is a system that was built - like, pretty immaculately - to keep women and women of color out, even if it's not the intention now," said Ellison. "When do we have city council meetings? You know, most of these city council meetings are unpaid, and they're at 7:00 at night. If you're a caregiver, that's bedtime."

But research shows that female elected officials bring more money back to their districts, pass more bipartisan legislation, and get more done overall.

State Director of Vote Run Lead Action, Becca Phelps, said the challenge isn't just getting more women into office - it's keeping them there.

She said in the past few years, several women in the Oregon Legislature have had to leave prematurely or not run again, citing the low pay and added responsibilities of daily life.

This is where organizations can step in to fill these gaps - advocating for higher pay, helping with childcare and transportation costs, even providing emotional support.

"Sometimes," said Phelps, "it's that personal care of having a friend check in on you to see how you're doing when you're an elected leader."

After Tuesday's election, 15 graduates of Emerge Oregon programs may be in the Oregon House and four may hold seats in the Senate.

Ellison added that the biggest barrier women face in running for office is confidence.

"If he can do it, you can do it," said Ellison. "And here's how you're going to do it, and we're going to help you."




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A federal nutrition program for low-income moms and babies now includes canned fish and beans, whole grains such as quinoa and cornmeal, and more money for fruits and vegetables.

Theda Simpson, a former participant in the Special Supplemental Nutrition Assistance Program for Women, Infants and Children from Metcalfe County, said she relied on the funds for extra help paying for supplemental formula for her daughter and sons, who had milk allergies as infants. She found out about the program through her local health department and stressed it was a lifesaver for preventing her children from going hungry.

"I hope that every mother finds out about it, knows about the program, is able to access and get the help that they need to be able to feed their children," Simpson emphasized.

Under the new changes, children ages 1-4 will now receive $24 per month, pregnant and postpartum women will now receive $43 per month and breastfeeding women will now receive $47 per month, under recent USDA updates.

Research has shown the WIC program helps improve pregnancy outcomes, including lower incidences of premature births, infant mortality and low-birthweight babies.

Karena Cash, data and research director for Kentucky Youth Advocates, said WIC is not reaching every available mom or mom-to-be in the state, although advocates have been doing work to reach more households, especially in Latino communities and among kinship caregivers. The data show two of every eligible five families are not participating in the program.

"About 96% of infants in Kentucky are enrolled, whereas only about 60% of women and 51% of eligible children one to five," Cash reported. "We see some pretty big discrepancies."

Tanya Torp, executive director of the nonprofit Step By Step in Lexington serving young, single mothers and their babies, said a major barrier is a lack of understanding among grocery stores about how WIC works and what products are covered under the program.

"For us, being able to work with some of the stores is going to be really important," Torp explained. "To train the employees at the stores so that they will be able to help when someone comes in and asks questions about WIC."

Advocacy groups have developed an online toolkit for local communities and leaders, and professionals who serve young children to help get the word out about the WIC program. Nationwide, more than 6 million women and children rely on WIC each month.


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