For the third year in a row, the March of Dimes gave the state a D+ for its record of ensuring healthy pregnancies and providing adequate access to prenatal care.
The March of Dimes this month released its annual report card on maternal and infant health, and North Carolina yet again earned a grade that would have gotten you grounded in high school.
North Carolina has some of the premier hospitals and medical schools in the world, but for the third year in a row, the state got a D+ for its record of protecting new mothers and their babies. North Carolina ranks worse than the national average on many important measures of health.
And the rest of the country’s grades, the report card shows, are bad enough.
The United States remains “one of the most dangerous high income countries in the world” for pregnant women, Dr. Michael Warren, the March of Dimes’ chief medical officer, told Cardinal & Pine in a recent interview. But the problem is especially stark in North Carolina, where pregnancies and childbirth are more dangerous for both mothers and babies than most of the rest of the country.
In 2023, 834 babies in North Carolina died before their first birthdays, the report card found. Only 8 states in the country had a higher infant mortality rate.
North Carolina also has a higher rate of premature births than the United States on average.
Those are abysmal numbers, especially for a state that pitches itself as prime for families and relocation.
There are several reasons the state performs so poorly every year and progress remains so elusive, Warren said, but two stand out. And each of them highlights how entangled the state’s healthcare issues can be and how difficult it is to separate one from another.
‘It’s not surprising’
North Carolina has high rates of chronic disease and too many many parts of the state have limited access to adequate healthcare, including prenatal care.
Warren, a Sampson County native, has North Carolina roots, graduating undergrad at Wake Forest University and from East Carolina University’s medical school.
“The state is near and dear to my heart … and one of the things that jumps out to me for North Carolina is the high rate of chronic disease, particularly before pregnancy,” Warren said.
“This includes women who have high blood pressure, women who have an unhealthy weight or diabetes, or women who smoke.”
Those are all risk factors that can contribute to pre-term births, he said.
And with the number and size of healthcare deserts getting worse in the state, many women in rural areas have limited access to prenatal care that can help mitigate these factors, he said.
“Fewer women in North Carolina start prenatal care in that first trimester or those first few months of pregnancy compared to the rest of the country,” he said.
“Fewer women get adequate prenatal care, meaning all of the prenatal visits that they should have in addition to starting early.”
Prenatal care is not a luxury for a healthy pregnancy and birth, he said, it’s essential. Women who are able to start prenatal care on time and attend every recommended check up have far better outcomes than those who cannot, Warren said.
“Those prenatal visits are such an important opportunity to assess how that pregnant woman is doing, and if any chronic diseases like diabetes or high blood pressure are … managed well,” he said.
He added: “Between high rates of chronic disease and challenges with access, unfortunately it’s not surprising that we still continue to see this bad grade in North Carolina.”
Racial and rural disparities
The risks and consequences of the state’s dismal record, however, are not born equally.
The numbers are far worse in rural, low-income communities, and for Black and brown women.
Black women in the United States are three times more likely to die from pregnancy-related complications than white women.
“The infant mortality rate among babies born to Black moms is 1.7 [times] the state rate,” the report says. Black mothers are nearly two times as likely as white mothers to lack access to adequate prenatal care, while Hispanic mothers are more than twice as likely as white moms to be unable to get the care they need.
The disparities are just as stark for rural areas.
A 2025 study by the National Institutes of Health found that residents in rural areas had higher rates of high blood pressure, cardiovascular disease, obesity, and diabetes than residents who lived in or near cities. North Carolina has the second largest rural population in the country.
“These issues are inextricably linked,” Warren said.
While North Carolina has languished at just above a failing grade for the past few years, the D+ was still an improvement. Next year’s report card could be much worse.
North Carolina could be headed for an F
In 2022, North Carolina got a D. The grade jumped half a letter grade in 2023 and held steady in 2024 because North Carolina finally expanded Medicaid, increasing people’s ability to pay for the prenatal care they need even if access remained a challenge. But with federal cuts to Medicaid on the horizon at the end of 2026, and with the Republican-led legislature’s failure to pass a new budget that fills current funding shortfalls, North Carolina is in danger of erasing that small but significant progress.
“Those are very real threats in North Carolina and in many other states,” Warren said. “Medicaid clearly is a vital source when we think about maternal and infant health.”
Medicaid paid for nearly 36% of all births in the state in 2024, the March of Dimes report card shows.
If the federal cuts go into effect as currently planned, “state Medicaid directors, governor’s offices, [and] legislatures are gonna have to make some very difficult decisions,” Warren said.
“As the dollars are decreasing, one of the very real concerns we have is that access is actually going to get worse. Now is not the time for us to be taking our foot off the gas. We need to be really leaning into this and making sure that every woman has access to care even before she’s pregnant, so we can have the best possible chance for a healthy pregnancy and a healthy start for that baby.”
Now what?
“There is a strong component of political will here,” Warren said.
“We know the things we need to do, we just need to lean in and do them.”
The to-do list starts with protecting Medicaid access, but the report also made several other recommendations for the state, including calling for lawmakers to reimburse doula services, improve paid family leave, and increase funding for postpartum mental health screenings.
The March of Dimes will also continue its efforts, Warren said, not just to give out grades, but help improve them by lobbying for better Medicaid policies and working to provide better access to rural healthcare.
“We are working to fill in some of those gaps with our mom and baby mobile health units to go into communities that are underserved,” he said.
“We’ve gotta keep the fight going.”
And while the divide between North Carolina’s promise and performance is glaring, it also means there is more room for improvement, Warren said.
“In North Carolina you have a really strong public health infrastructure in place.”
He continued: “Having grown up in the Tar Hill state, I know people can do hard things, and I know you can really move this needle and improve birth outcomes.”
