Maternity care deserts in North Carolina

Explainer of Sugg et al. (2025), The Journal of Rural Health. Not the journal article.

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) Free PDF

Award: NRHA Article of the Year, 2026

Facts¶

Main finding¶

Increased driving distance to obstetric/gynecological providers was significantly associated with worse maternal and infant health results 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, social and economic status emerged as a stronger driver of provider access than racial composition in North Carolina.

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, social and economic factors - not race/ethnicity - emerged as the primary driver 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.

Policy hook¶

Access to maternity care is declining across the U.S. despite rising maternal deaths and adverse results. 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.

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 measures calculated from residential areas to nearest OB/GYN providers

• Time period: 2016-2021 (study period); separate pre- and post-COVID-19 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 results, 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.

PDF or DOI¶

DOI · Free PDF

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 results. 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 social and economic vulnerability - not just rurality - drives these gaps in North Carolina. Importantly, the study identifies specific health results most sensitive to access barriers: severe maternal morbidity shows the strongest gradient, followed by cesarean delivery and preterm birth. These granular geospatial findings are critical for targeting programs. 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.