In many parts of rural North Carolina, giving birth means driving farther, waiting longer and arriving sicker.
As Erin Fraher, PhD, of the University of North Carolina’s Sheps Center told lawmakers in March, North Carolina does not have a maternity care supply problem; it has a distribution problem. The numbers appear to bear her out. Over the past 19 years, North Carolina has added more than 200 obstetricians, yet many now work part time, and 28 rural counties still have no local delivery care options.
Births and clinicians in North Carolina are concentrated along the same Interstate 40 corridor between the Research Triangle and Charlotte, where just 10 counties contain 60 percent of the state’s obstetrical workforce.1 Clinicians cluster where population density, professional infrastructure and financial stability make practice sustainable. From a market perspective, that distribution is rational, but the result is unmistakable: Many rural parts of the state have no local maternal care.
This distribution did not happen by chance. It reflects three forces that markets are poorly equipped to correct.
The first is structural. The U.S. healthcare system rewards volume, not coverage. A labor and delivery unit must maintain highly trained clinicians, specialized equipment and 24/7 readiness whether it manages 300 births a month or 30. Those costs do not shrink because a community is small. In North Carolina, Medicaid reimbursement largely fails to account for the higher per-patient cost of providing maternity care in rural communities, where hospitals must sustain 24/7 obstetric coverage and recruit and retain scarce clinicians while spreading those costs across fewer births. For rural hospitals already operating on thin margins, this financial reality can determine whether a labor and delivery unit remains open. The result is a troubling paradox: Rural hospitals are expected to provide the same lifesaving care as their urban counterparts, yet reimbursement often falls short of the actual cost of maintaining that care. When payment does not reflect the cost of preserving access, labor and delivery units close — not because communities no longer need them, but because the economics no longer work. The consequences extend far beyond the hospital’s balance sheet. The burden is borne by mothers, babies and entire rural communities placed at greater risk.
The second is a workforce pipeline built for urban practice. Most residency training occurs in urban centers and teaches in environments with subspecialty backup, tertiary care resources and technologies such as robotics that are unavailable in smaller hospitals. Graduates can leave training dependent on the same environment. The maternal workforce may be growing on paper, but training and practice incentives steer physicians toward urban settings.
The third is geography. Maternity care cannot be centralized. A woman in labor is fixed at her point of need, not where the market has decided care is profitable. In North Carolina, longer travel times have been linked to higher cesarean rates, severe maternal morbidity, preterm birth and gestational diabetes. In a normal market, unmet demand attracts new entrants, but the barriers are too high for that to correct this clinician imbalance. Years of training, heavy call burdens and the need for 24/7 coverage in low-volume settings are steep barriers to new entrants. Add an aging workforce, and it is unrealistic to expect the problem to correct itself.
For the woman in labor, a closed unit is not an accounting decision. It is another hour in a car and another layer of risk at the worst possible time. If North Carolina wants maternity care to exist outside its urban crescent, it will have to support that access deliberately. That is not a distortion of the market; it is an acknowledgment that markets alone will not solve this problem.
Some solutions are already in place. At ECU Health, we added a rural-specific OB-GYN residency position, developed an obstetrical fellowship for family medicine physicians and expanded midwifery independence. We are also building a regional coverage model that allows obstetricians based at the medical center to work at regional labor and delivery units.
But regional health systems cannot solve a statewide market failure alone. Payment should reward access, not just volume. That means the state must help solve these challenges by addressing their root causes. This can be accomplished by shifting from a financing model that pays for births to one that pays for rural OB capacity: establishing readiness payments that recognize the fixed costs of maintaining 24/7 obstetric services in rural areas; enhancing Medicaid reimbursement for rural hospitals that commit to preserving access to labor and delivery services; and investing in rural obstetric workforce incentives to recruit and retain the physicians, midwives, nurses and other clinicians needed to provide rural obstetric care.
If North Carolina believes maternity care is essential, it cannot leave access to the invisible hand.
Dr. James Whiteside is fellowship trained and board certified in female pelvic medicine and reconstructive surgery. He serves as Chief of Service at ECU Health Medical Center in Greenville, N.C.
1. Fraher E. Distribution of Maternal Health Care Providers in North Carolina. Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill; presented to the North Carolina General Assembly Joint Legislative Oversight Committee on Health and Human Services, March 10, 2026.
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