High rates of preterm birth, low birth weight, and late initiation of prenatal care can be signs of poor health and high levels of social risk factors in a community. Better-than-expected birth outcomes and early entry into prenatal care, on the other hand, can signal a supportive community environment. The Urban Institute identified six counties in North Carolina with better-than- and worse-than-expected birth outcomes among Medicaid members, compared with Healthy People 2020 goals. This report draws on interviews with public health officials and health care and social service providers in Bladen, Catawba, Cumberland, Halifax, Orange, and Wayne counties to examine community-level strengths and challenges to optimal maternal and infant health.

Across all counties, key informants described high unmet social needs among Medicaid members, such as for transportation, stable and affordable housing, and child care, that county social services and community resources were often inadequate to meet. A major concern key informants noted was a lack of consistent health insurance coverage, especially outside of pregnancy and among immigrant populations. Further, informants described limited access to care—often county health departments are the only source of prenatal care for Medicaid members but struggle to meet the need because of insufficient funding, staff turnovers and shortages, and limited ability to provide interpretation services. But informants also noted several local efforts to support maternal health, including collaborative partnerships between local health departments and maternity care clinics, midwives, and hospitals.

Our findings suggest that structural barriers such as poverty and limited resources to meet one’s basic needs for food, shelter, transportation, and health care pose challenges to maternal and infant health. Reforming clinical approaches or improving the coverage of and access to Medicaid-funded maternity care services are, alone, likely not enough to improve health and eradicate disparities in birth outcomes. Serious, systemic, and large-scale changes are also needed at the local, state, and federal levels to address structural inequalities and inequities that contribute to poor population health and affect maternal and infant outcomes.