Maternity care deserts in North Carolina

Publication id: sugg-2025-maternity-care-deserts-nc
Status: verified Published: 2025, Vol. 41: e70020 in The Journal of Rural Health
Award: NRHA Article of the Year, 2026

Citation: Sugg, M., Shakya, S., Ulrich, S., Tyson, J. S., & Runkle, J. (2025). Mapping maternity care deserts: Driving distance and health outcomes in North Carolina. The Journal of Rural Health, 41, e70020. Sugg et al. (2025) Download PDF

Facts¶

Policy hook¶

Access to maternity care is declining across the U.S. despite rising maternal deaths and adverse outcomes. Between 2006 and 2020, over 400 maternity services closed, with disproportionate impact on Black women. Maternity care deserts—geographic areas with limited or no maternal health services—affect 2.3 million women and up to 150,000 births nationally according to the March of Dimes. Understanding which areas and populations are most affected by declining access is an emerging research priority as maternal mortality rates continue to rise.

Main finding¶

Increased driving distance to obstetric/gynecological providers was significantly associated with worse maternal and infant health outcomes in North Carolina. Women in the lowest access areas experienced higher rates of gestational diabetes (aOR: 1.15), preterm birth (aOR: 1.18), hypertensive disorders of pregnancy (aOR: 1.03), cesarean delivery (aOR: 1.23), and severe maternal morbidity (SMM20: aOR 1.09; SMM21: aOR 1.61). Rural and low-income areas had significantly fewer providers, longer travel times, and longer driving distances. Notably, socioeconomic status emerged as a stronger determinant of provider access than racial composition in North Carolina.

Data and setting¶

• Data sources: National Plan and Provider Enumeration System (NPPES) from Centers for Medicare & Medicaid Services (2016–2021); North Carolina inpatient hospitalization records for pregnant persons (2016–2021)

• Population: Residents of North Carolina with pregnancy-related hospitalizations (2016–2021)

• Geographic scale: Zip Code Tabulation Areas (ZCTA) with travel metrics calculated from residential areas to nearest OB/GYN providers

• Time period: 2016–2021 (study period); separate pre- and post-COVID-19 pandemic analysis

• Provider identification: Obstetrics and Gynecology providers (OBGYNs) identified using NPPES taxonomy codes

Research design (plain language)¶

Retrospective secondary data analysis using geographic information systems (GIS). Researchers geocoded OB/GYN provider locations and calculated driving distance (miles) and driving time (minutes) from population-weighted residential zip codes to nearest obstetric providers. They then employed generalized linear mixed models to examine associations between accessibility measures and five maternal/infant health outcomes, adjusting for individual factors (age, race/ethnicity, insurance type) and community-level factors (rural-urban classification, income segregation, racial segregation using the Index of Concentration at the Extremes). Geographic clustering was accounted for using random intercepts by residential ZCTA.

One caveat¶

The analysis included only OB/GYN providers and excluded other critical maternal healthcare providers—notably midwives and family physicians—who deliver approximately 10% of babies in rural settings. This omission may have overlooked a significant component of actual maternal care accessibility. Additionally, the NPI database relies on self-reported provider data, and providers may retire or relocate without updates, affecting accuracy. Importantly, socioeconomic factors—not race/ethnicity—emerged as the primary determinant of provider shortages in North Carolina, likely reflecting the state’s unique Appalachian geography and demographics; these findings may not generalize to other U.S. regions.

PDF or DOI¶

Download PDF · DOI: Sugg et al. (2025)

Why it matters¶

This study moves beyond county-level categorizations to map maternity care deserts at smaller geographic scales, linking provider accessibility directly to maternal outcomes. The findings are alarming: women traveling far to reach obstetric care experience substantially higher rates of dangerous complications including severe maternal morbidity. The research reveals that socioeconomic vulnerability—not just rurality—drives these disparities in North Carolina. Importantly, the study identifies specific health outcomes most sensitive to access barriers: severe maternal morbidity shows the strongest gradient, followed by cesarean delivery and preterm birth. These granular geospatial insights are critical for targeting interventions. The research also highlights that current policy lacks clear national standards for obstetric access (unlike stroke response time standards), leaving communities without benchmarks for adequate maternal healthcare infrastructure.