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By Hannah Critchfield

The news during 2020 was filled with tragic scenes of families visiting their senior loved ones through windows, health care professionals breaking down over the lonely deaths of patients in intensive care wards, and funerals carried out without families receiving the caresses and comfort of loved ones. 

There have been some points of hope. For one thing, the Tar Heel state still experienced more births than deaths overall last year, according to provisional resident data provided by the North Carolina Department of Health and Human Services. In total, 115,076 residents of North Carolina were born, while 87,987 community members died.

But the numbers belie a grim reality that for the first time in a century – perhaps ever – more people died than were born in 64 of North Carolina’s 100 counties, driven by the novel coronavirus pandemic. 

The actual number may be higher. Local data suggests even more communities may have been impacted by this troubling trend.

The North Carolina data mirrors an increased rate of death at the national level. In 2020, approximately 3,358,814 resident deaths occurred in the United States, compared to 2,854,838 deaths in final data for the previous year. It’s unclear how many people were born in the country last year, as the CDC is still gathering data.

Provisional death data suggests the country’s death rate increased by 16 percent from what it was in 2019, with COVID-19 as the third leading cause of death behind heart disease and cancer, completely pushing suicide out of the top 10 causes of death. 

Age-adjusted death rates for the 10 leading causes of death in 2019: United States, 2018 and 2019. Data/ graph: National Center for Health Statistics/ Centers for Disease Control and Prevention

In the United States overall, the Centers for Disease Control and Prevention has reported an excessive number of deaths last year, which the agency largely attributed to the impact of COVID-19. Provisional death data suggests the country’s death rate increased by 16 percent from what it was in 2019.

Looking local

Part of the reason for the uncertainty around each county’s death rates has to do with bookkeeping. Most North Carolina counties track death and birth information by place of occurrence – where the person was at the time of the event – rather than by the person’s place of residence. 

“How birth and death works is that you can live in a county all your life, have a house and a family there, but the county where you are born is where that birth certificate will be recorded – and wherever you die is the same way,” said Crystal Gilliard, register of deeds for Union County. “Because that’s never going to change.”

In contrast, state health departments and the CDC collect this information by county of residence –  which can be a bit more murky, county recorders who deal with death and birth records on the local level said. Existing state-level data additionally does not include people with out-of-state residency.

In Union County, among the 10 largest counties by population, 1,562 people died and just 914 people were born. In Gaston County, another top-10 jurisdiction, 2,658 people died, while 1,794 were born. On the state DHHS data, both counties are listed as having more births than deaths, however.

“We’re kind of a bedroom community to Charlotte,” explained Gilliard. “A lot of people, especially on our western side, go to Charlotte for their doctor’s appointments or to have children, but they live in Union County. If Atrium Hospital here in Union cannot accommodate a person, if they need a little bit more help than they could give them here, they would be taken to Mecklenburg County to one of their hospitals. You have a lot of that dynamic as well.”

For many rural counties with aging populations, it’s become normal to see more deaths than births in a given year, especially as the average age of the population increases. This was the case for Union County as well, but according to Gilliard, the trend significantly worsened in the last year, with a sharper uptick in deaths than usual.

“Our number of deaths does increase a little bit each year, by about 30 annually,” she said. “From 2019 to 2020, it went up by 248 people. According to the Union County Health Department, 206 of those deaths were from COVID.”

‘I don’t think it accurately reflects the strain’

Other counties experienced this excess loss of life for the first time. 

Buncombe County, a western area containing the large HCA-run Mission Hospital in Asheville, also reported more deaths than births for the first time in its recorded history. That didn’t even occur during the 1918 flu pandemic, according to the county register of deeds, Drew Reisinger.

“It took a pretty substantial event for that to happen,” Reisinger said. “In Buncombe County alone, our excess deaths were entirely made up of COVID deaths.”

The county had 4,114 people die within their jurisdiction in 2020, according to his office’s data, while 4,055 people were born. The state figures also show there were more deaths than births in Buncombe County, but report a significantly smaller number of each – with just 2,312 births and 2,671 deaths – assigning those other deaths to the decedents’ home counties.

“The CDC and public health departments break it down by county of residence, which is frustrating,” said Reisinger. “Because I see a lot of COVID deaths happen in Buncombe County, and then they get traced back to being a Florida death, or a Connecticut death.”

In addition to North Carolinians, people from Tennessee, Wisconsin, Georgia, West Virginia, Ohio and Washington died in Buncombe County last year, according to death certificates reviewed by North Carolina Health News.

The county has the largest health system in western North Carolina, meaning many in-state residents from other counties found their way to Buncombe for more complex care during the pandemic – a phenomenon that has been the case for births among people with high-risk pregnancies in years past. 

COVID-19 placed an unprecedented burden on the county, however, Reisinger said.

“When they’re complicated COVID patients, they often got sent to the regional hub that has more specialists, better heart doctors, and a bigger ICU with more beds,” he said. “Locally, Mission Hospital and our local health care providers saw a massive uptick in deaths that were instead reported back to other counties.

“I don’t think it accurately reflects the strain that we’re seeing on our local nurses and our local health systems in these metropolitan areas that have these big hospitals,” Reisinger added.

Defining someone’s place of death or birth by the place that they reside can be subjective.

A University of North Carolina student may die within Orange County, for example, but their parents may live out-of-state. Funeral directors and physicians filling out death certificates often take their cues from family members, county registrars of deeds said, who may opt to list their loved one’s place of residence as whatever they view as their more “permanent” home.

“We see different funerals draw up death certificates in different ways,” said Reisinger. “But it’s usually how the decedent’s family views it.”

Looking to 2021

Early in the pandemic, jokes about a “baby boom” as a result of sheltering in place flourished. But an influx of “corona-babies” in 2021 is unlikely. This year will likely see trends of lower births, according to early research by economists and pollsters. 

A June 2020 report from the Guttmacher Institute found that almost half of surveyed cisgender women of childbearing age changed plans to have children due to the pandemic. A third said they wanted to get pregnant later or have fewer children. A Brookings analysis conducted in December of that year, which looked at the rising unemployment rate during the pandemic, predicted 206,000 fewer births in 2021 in the U.S.

“We incorporated this into our forecast by examining the experience of the 1918 Spanish Flu,” authors Melissa S. Kearney and Phillip B. Levine wrote in the study. “Back then, every spike in the death rate attributable to the flu was associated with a dramatic reduction in births nine months later.”

The availability of safe vaccines that appear to be effective against existing COVID-19 variants will hopefully stem the rise in deaths experienced over the last year. It’s thus hard to predict if similar trends will continue in North Carolina into 2021.

State-level data for North Carolina is provisional – meaning we won’t know the true death and birth toll for last year until DHHS has finished gathering all official certificates filled out in 2020. 

This process will likely take a good deal of time, as North Carolina still relies on a paper-based death and birth registry system, one of just three states to still do so. 

Hannah Critchfield

Critchfield is NC Health News' Report for America corps member. Report for America is a national service program that places talented emerging journalists...