By Rachel Crumpler
In the past decade, 14 rural hospitals in North Carolina have stopped providing maternity care. Betsy Johnson Hospital in Harnett County shuttered its labor and delivery unit in October — the most recent closure.
Maintaining labor and delivery services at rural hospitals across North Carolina and the nation has become increasingly difficult as costs stay high, birth volumes stay low and staff gets harder to recruit and retain. More units are closing their doors, leaving women without a place to give birth close to home.
Chatham County is bucking that trend.
Chatham Hospital — a 25-bed Critical Access Hospital in Siler City that is part of the UNC Health System — opened a new Maternity Care Center in September 2020.
The five-bed maternity unit serves low-risk mothers and newborns and is staffed mostly by family physicians trained in obstetrics and surgery, rather than OB/GYNs, who cost more to employ.
Family physicians providing maternity care is commonplace in many rural hospitals across the United States, particularly in the West and Midwest, but not in North Carolina.
Operations at the maternity unit got off to a rocky start. It was a challenge to staff and operate the unit at the height of the worldwide COVID-19 pandemic, not to mention the expected pressures of providing rural maternity care.
Staffing shortages resulted in monthslong partial closures of the unit. The closures meant they delivered fewer babies, which eroded the community’s confidence in the unit as a reliable place to give birth. In fall 2022, community members and UNC Health leaders raised concerns about the unit’s financial and operational sustainability.
Community members pulled together to support keeping the maternity care center open, emphasizing the value of providing care to a fast-growing county that’s projected to add tens of thousands of residents in the next 10 years. A community task force assembled to brainstorm how to chart a more sustainable path for the unit.
Now, over three years after opening, the Chatham Hospital Maternity Care Center has found a solid footing, reporting a consistent staff and 24/7 operations since March 2023.
“We still have a lot of work to do but, for today, we really should celebrate where we are — and that we’re still here,” Margaret Helton, chair of UNC’s Department of Family Medicine, said at a Jan. 30 community task force meeting to review the three-year track record of the maternity care center.
It’s a path that offers promise for rural maternity care elsewhere, said Ellen Chetwynd, a researcher who helped lead a three-year evaluation funded by The Duke Endowment of the Chatham Maternity Care Center. Chetwynd added that local, state and national entities are watching to see what can be learned from the Chatham Maternity Care Center.
Filling community need
Before the unit opened, Chatham County had been a maternity care desert for nearly three decades. Maternity care deserts are counties without a hospital or birth center offering obstetrics care and without any obstetrics providers — a phenomenon that is becoming increasingly prevalent across the nation and North Carolina.
Twenty-one counties in North Carolina are designated as maternity care deserts, and another 17 counties have low access to maternity care, according to March of Dimes. This affects an estimated 342,738 women of childbearing age living in those counties.
To close the maternity care gap, Chatham Hospital, UNC Family Medicine, Chatham County Health Department, federally qualified health care centers, nonprofits and other entities joined forces to open a maternity care center.
Jesus Ruiz, a family physician who has been delivering babies at the Chatham Maternity Care Center since it opened in 2020, said the benefit of accessible maternity care is already evident from patient experiences.
“They’re truly appreciative of being able to deliver close to home,” Ruiz said.
In three years — from Sept. 8, 2020, to Sept. 7, 2023 — 402 babies were born at Chatham Hospital, according to data from the researchers’ evaluation. Each year, birth volume has gradually increased.
There also were 1,120 obstetric triage visits during that time period, signaling demand for accessible care.
The presence of the labor and delivery unit has brought care closer to home for thousands of birthing women in the area, cutting median travel distances in half. That’s poised to improve health outcomes, since traveling long distances during labor is associated with increased perinatal morbidity — including preterm birth and out-of-hospital births.
Families traveled a median 16 miles to deliver at the Chatham maternity unit, according to evaluation data. However, if the 402 families had to travel to UNC Chapel Hill to give birth, the median distance would have been 35 miles.
Care closer to home is a good thing, particularly as Chatham County’s population is projected to balloon in the coming years as the new Chatham Park housing development is built. Two major economic development projects — Wolfspeed’s manufacturing facility for silicon carbide chips and VinFast’s electric vehicle and battery production facility — will also spur growth, bringing thousands of jobs and likely families to the county.
Additionally, the unit is serving a predominantly Hispanic birthing population. Of the total births, 42 percent of patients preferred to speak Spanish. Ruiz said Chatham Hospital is providing linguistically and culturally competent care to these patients.
“When my patients see me and they see that I look like them and speak like them, they immediately feel relieved,” Ruiz said. “I’ve worked in bigger places where not all the providers speak Spanish, and they have to use an iPad or an interpreter — and some things get lost in the literal translation.”
Compared with the rest of North Carolina and the United States, Chatham County fares worse in maternal and infant health indicators and outcomes, and Black and Hispanic communities in particular are disproportionately affected by infant mortality and low birth weights.
The maternity unit is serving this population and providing positive birth experiences and outcomes, said Chetwynd — an important step to help improve equitable outcomes in the community.
The total cesarean section rate is about 12 percent, compared with about a third of births nationwide.
Of the 402 births evaluated, only 4 percent of babies were born low or very low birth weight, compared to the 9.4 percent born that way in all of Chatham County. Breastfeeding rates at discharge were also high, with 90 percent either exclusively breastfeeding or using a combination of formula and breast milk.
Additionally, because the unit is staffed primarily by family physicians — many of whom also work at community health centers — providers can continue to see patients and their babies after delivery, building connections with patients to foster improved health engagement and outcomes. Ruiz said he particularly enjoys this continuity of care aspect of his role.
“One case that sticks out to me … is a patient that I actually delivered at Chapel Hill. She ended up getting a C-section and, unfortunately, her baby ended up passing away. And that was the first time I met her,” Ruiz said.
“She lives near our clinic, and I offered to take her on as my patient. I followed her through the grief, the depression. She was able to get pregnant again. I followed her through her pregnancy, and she asked me to deliver her at Chatham. She knew me, she trusted me and she trusted the service — and now she has a very healthy, 2-month-old that I see.”
More births needed to improve sustainability
While it’s an accomplishment that the unit has survived for over three years, challenges lie ahead.
Jeff Strickler, president of UNC Health Chatham, told NC Health News that the biggest issue facing the maternity care center is covering the standby costs needed to operate the unit.
There always need to be enough nurses, midwives and physicians ready to handle an increased caseload, increasing costs. Right now, the 24/7 costs of the unit outpace the volume and reimbursement of deliveries, he said.
Chatham Hospital’s link to the larger UNC Health System sustains it despite these costs. Without the system support, Strickler said it wouldn’t work.
Strickler said he will feel more assured of the long-term sustainability of the unit once birth volume rises enough to cover the standby costs — a goal hospital leadership are working to achieve and one that feels attainable.
Eric Wolak, chief operating officer and chief nurse officer at UNC Health Chatham, said his hope is for there to be a birth every day. Currently, there are about 15 births per month.
To bring in more patients, outreach to community members and community providers is underway, Wolak said, including in neighboring Alamance and Randolph counties.
Wolak said the hospital is working to increase ways that expecting mothers can connect to the unit. For example, the Chatham County Health Department offers birthing classes onsite at Chatham Hospital that include a tour of the maternity unit. Ultrasounds during pregnancy are also conducted at the maternity care center. The hope is that greater exposure to the unit and its environment may lead more women to choose to deliver there.
Additionally, Kelly Holder, medical director at Chatham Maternity Care Center, said she is working to build a strong prenatal pipeline by establishing more relationships with community providers, midwifery practices and pediatricians who feel comfortable referring patients to the unit for delivery.
Holder said she also wants to position the Chatham Maternity Care Center as a place that can accommodate some of the low-risk patients seeking care at UNC Chapel Hill.
“One of the things that they struggle with in Chapel Hill is capacity issues,” Holder said. “We want to be a resource to them, as well, so that they can see the high-risk patients that really need to be seen in Chapel Hill, and they can then direct and filter other patients towards Chatham.”
“My hope is that the community will see Chatham Maternity Care Center as a place to deliver — the place that they want to be,” Holder added.
Jen Medearis Costello, a member of the operational leadership team of Equity for Moms and Babies Realized Across Chatham (EMBRACe), which seeks to ensure successful and equitable birth outcomes for women and babies in the county, said she hopes the hospital also pursues outreach through trusted messengers like community organizations, churches and women with positive birth experiences.
“You’re not going to get people into the hospital unless they trust,” Costello said.
An energizing bright spot
Chetwynd hopes that other rural hospitals and communities can be inspired by the efforts in Chatham County to bring back maternity care to the area.
The journey has been difficult — and will continue to be — but worthwhile.
Chetwynd said surveys revealed that the maternity care staff’s belief in the care model grew over time as the unit got more stable, and it’s patients’ outcomes fulfilled the vision of the unit.
Ruiz was motivated to join the unit to improve outcomes in the county, and he said his patients reaffirm that purpose every day.
“Hopefully we can show that this is an investment in the community itself, and that with time it’ll pay not just about the number of deliveries that we do, but it’s about the workforce that you’re able to recruit, the resources, the attention and bringing up those health disparities that exist within the community,” Ruiz said.
There are lessons to be learned from Chatham Maternity Care Center’s experiences, such as the need for collaboration between hospitals and the communities they serve, embracing innovation and the perils of a new unit in uneven economic times.
But Chetwynd cautioned that rural communities are all different and will require tailored solutions.
“We’re in a maternity care crisis,” Chetwynd said. “We’ve got mothers and babies at risk. It takes vision. It takes commitment. It takes an openness to finding creative, individual ways that it can work in various communities — not cookie cutter.”
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