By Rachel Crumpler

A clear container of pink, blue and white beads sits on display at the nurses’ station of a five-bed rural maternity care unit in Siler City, the Chatham County seat. A label reads: “Legends are born.” 

As parents are discharged, they drop a bead inside.

As of Feb. 23, 894 beads had accumulated — one for each baby delivered at the UNC Health Chatham Maternity Care Center since it opened in September 2020, along with the few families who experienced a loss.

For Chatham County residents, the ability to give birth in their local community is a relatively new reality. That’s a stark contrast from many women in rural North Carolina — and across the country — where maternity care close to home is increasingly out of reach.  

Twenty counties in North Carolina are considered maternity care deserts, meaning they have no hospitals or birth centers offering obstetric care and no practicing OB-GYNs, certified nurse midwives, nurse midwives or family physicians delivering babies, according to a 2024 report by March of Dimes. Another 17 counties have low access to maternity care.

The loss of care is driven by years of financial pressure on rural hospitals, workforce shortages and low Medicaid reimbursement rates that make obstetric care difficult to sustain.

Between 2010 and 2022, eight rural hospitals lost maternity services in North Carolina. By the end of that period, 44 percent of rural hospitals in the state lacked obstetric services, compared with 27 percent of urban hospitals, according to a study published in Health Affairs. Closures have continued to occur.

Against this backdrop, UNC Health Chatham is the only rural hospital in North Carolina to restore maternity services — reopening care in a county that had gone nearly 30 years without it.

The unit serves low-risk mothers and newborns and is staffed by family physicians trained in obstetrics and surgery, along with midwives — a lower-cost model than one centered on OB-GYNs, who cost more to employ and are harder to recruit to rural areas. 

Births at the unit have increased each year since it opened, reflecting demand for local maternity care. Hospital leaders expect the center to reach 1,000 cumulative deliveries this year.

The impact has been tangible for providers and families choosing to deliver at the unit. Travel distances for labor and delivery have been cut roughly in half, and clinical outcomes are comparable to low-risk patients going to the larger UNC Health academic medical center in Chapel Hill, according to a study published in January evaluating its first three years in operation.

The unit has also earned national recognition. In its 2026 annual report, U.S. News & World Report named UNC Health Chatham among the best hospitals for maternity care.

Chatham’s experience could offer a potential blueprint for other rural hospitals. Facility leadership and researchers point to the unit’s staffing model as one approach that could help stabilize obstetric services at hospitals at risk of losing them — or make reopening care more feasible.

“Chatham is a template, but it’s not a copy-and-paste template,” said Jesus Ruiz, a family physician who has practiced at the Chatham Maternity Care since it opened. “It’s proof that a system can work if you have the right workforce, the right institutional commitment and the community trust. 

“This shows a way that rural maternity care can be built and sustained.”

Putting family physicians at the helm

Chatham Hospital eliminated maternity care in 1991, after struggling to staff the unit and keep it financially viable. At the time, the hospital — not yet part of UNC Health — was delivering about 300 babies a year, said Andy Hannapel, a family physician and chief medical officer at UNC Health Chatham.

Nearly three decades later, when hospital leaders decided to bring maternity care back, they concluded it would have to be done differently to be sustainable. 

This time, they put family physicians at the helm of the unit, not OB-GYNs. 

The idea originated in part with Cristy Page, then the chair of the UNC Department of Family Medicine, who is now CEO of UNC Health and dean of the UNC School of Medicine. While family physicians provide obstetric care in many parts of the country, particularly in the West and Midwest, the Chatham model was new to North Carolina: a maternity unit run by family physicians and midwives, with no OB-GYNs on staff.

It remains the only unit in the state structured that way.

Greg Griggs, head of the North Carolina Academy of Family Physicians, said more than 3,000 family physicians practice in the state. About 10 percent — roughly 300 — provide obstetric care, a figure he said has remained relatively flat over the years. Most work alongside OB-GYNs.

Margaret Helton, chair of the family medicine department, led implementation of the staffing model at the Chatham Maternity Care Center. She said family physicians are well-suited to small units with lower delivery volumes because of their versatility.

“Our family doctors at Chatham Hospital can also work on the inpatient side with adult medicine,” Helton said. “They just have a broader spectrum of practice, so that makes them more flexible and more cost effective too.”

Their salaries are also lower than those of OB-GYNs, meaning delivery volumes don’t need to be as high for the unit to be financially viable.

The unit currently averages about 15 to 20 deliveries a month, said Eric Wolak, UNC Health Chatham chief operating officer and chief nursing officer. 

Some days pass without a single delivery. On others, several patients arrive within hours. To manage that unpredictability, the unit maintains a fixed staffing ratio: two nurses and one provider — either a midwife or family physician — are always on duty. 

Three family physicians at the Chatham Maternity Care Center are trained to provide C-sections and serve as surgical backup for other staff members who don’t have that training. 

Birth volumes are trending upward, but Wolak said the unit is already operating sustainably. 

“We’re past that point of doing the numbers,” Wolak said. “We know we’re going to grow. The focus is on making sure patients get the best care possible.”

Griggs said family physicians are well positioned to help address maternity deserts because of where they practice.

“Family physicians are better distributed across the state than any other specialty,” Griggs said. “There’s a family physician in almost every county, whereas, if you look at OB, pediatrics or other specialties, there are a lot of counties without them.”

All family physicians receive obstetrics training during residency, Griggs said, and those who choose to provide maternity care can pursue additional training, including fellowships for C-section training. Outcomes for family physicians delivering babies are positive, he added. 

“Innovative models like Chatham, I think, are a really good solution to our maternity crisis in the state,” Griggs said. 

Measuring what happens when care comes back

A January study published in the International Journal of Environmental Research and Public Health evaluating the center offers early evidence of success, finding low-risk patient outcomes comparable to those at the larger UNC Health hospital in Chapel Hill. 

Katie Wouk, a maternal and child health epidemiologist and an associate research scientist at the Pacific Institute for Research and Evaluation in Chapel Hill, led the study.

She said most research on rural maternity care has focused on closures, finding declines in access and poorer outcomes. Far less attention has been paid to what happens when services are opened or restored. 

The reopening in Chatham County offered that opportunity.

Researchers analyzed data from the unit’s first three years — 402 births — and found it served predominantly low-income, Hispanic families near their homes. 

They found similar outcomes among key birth measures — including delivery type, epidural use, birthweight and infant feeding status — when comparing the center’s patients to a geographically similar, low-risk comparison group who gave birth at UNC Health in Chapel Hill in the three years before the Chatham Maternity Care Center opened.

Nearly one-third of patients delivering at the Chatham maternity unit lived within five miles, while fewer than 1 percent of patients in the comparison cohort lived that close to the Chapel Hill labor and delivery unit. 

“The travel burden really mattered,” Wouk said.

Qualitative interviews revealed high levels of patient satisfaction. Many described positive relationships with staff and a sense of shared, supportive care. One patient told of delivering within 15 minutes of arriving at the hospital.

“If [the Chatham Maternity Care Center] had not been there, I would have had my baby in a car,” she said. 

Dana Iglesias, medical director of the UNC Health Chatham Maternity Care Center who delivers babies there, said that patients repeatedly cite the unit’s proximity.

“Transportation issues are real,” Iglesias said.

Ruiz, who delivers babies at the center and practices at a federally qualified health center in Siler City, said the unit’s model allows family physicians to follow patients throughout pregnancy, delivery and then continue treating both parent and child.

“That’s another component that can be missed from the discussion of outcomes,” Ruiz said. “Delivering locally with physicians that you trust, enhances continuity of care. It enhances follow up for moms after delivery and follow up for the newborn.”

Wouk said rural maternity care is often framed from a lens of deficits with the assumption that larger, higher-resourced institutions always provide better care and patients will bypass local, rural options. 

“But I think our study shows that with the right team and appropriate scope of care, that maternity services are not only safe and high quality, but they’re perceived as patient centered as the kind of right-sized care that the patient is seeking,” Wouk said.

‘The most beautiful thing’

Reestablishing maternity care in Chatham County wasn’t easy. 

The unit launched in late 2020 in the middle of the COVID pandemic. Birth volume was initially low, and by fall 2022 staffing turnover — especially among nurses — put the unit on the brink of closing.

A community task force assembled to recommend strategies to improve sustainability. 

Since then, the center has found a solid footing, built a stable core staff and gradually increased delivery volumes. 

Beverly Carpenter, the maternity care center’s manager, started in October 2022 as a travel nurse. She planned to stay temporarily but fell in love with the unit. Now she commutes an hour each way.

Staff described a passion in serving a rural population and helping shape a new maternity care model. 

“Being able to practice what I would call my values and the mission of what I think is the core of family medicine, of providing care in the context of the community, is just a beautiful thing to be a part of,” Iglesias said.

Staff say earning the community’s trust and providing a place that they want to deliver has been meaningful. For example, recognizing that many of its patients speak Spanish, the unit has hired bilingual staff and prioritized offering in-person interpreting services.

Initially, some patients were hesitant to deliver at the new unit. Now, people seek it out — and come back. 

“There’s multiple people that I’ve delivered their babies for the second time or done their C-section for the second time,” Ruiz said. “I’ve seen the 5-year-old come in and then come in with their little newborn sibling in the clinic. That’s the most beautiful thing.” 

Hannapel, a family physician working at the unit and the hospital’s chief medical officer, recalled a family who experienced a fetal loss at the unit. Eighteen months later, they returned for another delivery. 

“That trust is remarkable,” Hannapel said. “You have to earn it every day.”

Will the model spread?

With more than five years of experience and evidence of positive outcomes, leaders wonder whether the Chatham model can spread in North Carolina to help fill the gaps in maternity care.

Wolak, chief operating officer at UNC Health Chatham, said he’s fielded calls from other community hospitals — within and outside the UNC Health system — asking about the family medicine-driven model and Chatham’s implementation. 

He said he recently spoke with an executive at a hospital whose maternity unit closed several years ago because they weren’t able to retain OB-GYNs.

“They have everything in place — they have the unit, they have the C-section rooms — but they don’t have providers to be able to do that work,” Wolak said. “I spoke with them at length about what has worked for us.”

Hospital leaders and family physicians have also presented the model at multiple conferences, sharing lessons learned about staffing, community engagement and sustainability. 

Ruiz and others involved hope that the Chatham Maternity Care Center isn’t a one-off. 

“I think it can be reproducible in other areas,” Ruiz said. “Wherever the next reopening or the next opening of maternity care is, it’s not a one-size-fits-all. They have to adjust to the needs of that community.”

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