Beyond birth: The missing postpartum care putting North Carolina mothers at risk

Giving birth is just the beginning—and in North Carolina, many mothers have nowhere to turn after leaving the hospital.

“Postpartum just isn’t valued enough here,” said North Carolina resident Selena Williams. “We have so much support when we’re pregnant, or in the hospital. But once you have the baby, that support abruptly stops.”

It’s a problem she and her business partner set out to address when they founded Ziva Postpartum Retreat in Charlotte.

The Black- and women-led retreat center is North Carolina’s first of its kind. It provides critical postpartum services to new mothers and newborns, such as around-the-clock doula care, postpartum classes, lactation and feeding support, and mental health services during a stay of three to seven days. These are resources that many hospitals don’t offer once a mother is discharged.

In the US, postpartum recovery is often overlooked by the health care system, and North Carolina is no exception. While the state has expanded Medicaid to provide 12 months of postpartum coverage, it still lacks direct investment and support many mothers need in the weeks and months after childbirth.

For those who can afford spending around $1,318.83 per day, on average across all stay lengths, Ziva offers an alternative. 

READ MORE: A state task force on child fatalities wants Medicaid to cover doulas in NC

The retreat was created after Williams and co-founder Lauren Hall, shared their different birthing experiences. Hall, who had her first child in South Carolina, said she had received plenty of help from family and friends. But after moving to North Carolina for work, her usual support system disappeared, leaving her vulnerable to postpartum depression.

As a single mother by choice, Williams said she had heard of a postpartum retreat in New York, which inspired her to create one in North Carolina. However, accessibility remains a challenge.

“We advertise the retreat as luxury, because it’s not something that is covered by insurance and affordable, but I think that that’s just the default,” Williams said. “Just having that community is nice, and it just doesn’t seem like a luxury when you’re in it. It seems like, ‘Wow, this is something I totally needed.’”

Hall agreed, saying postpartum care in the country is a systemic issue, not just a personal one. As a private-sector care center, aside from therapy and some doula reimbursements, many of Ziva’s amenities are not covered by insurance or Medicaid.

RELATED: NC Medicaid recipients say Republicans’ proposed cuts will ‘doom’ them to ‘early deaths’

“We wish there was a way that this is accessible to everyone,” Hall said, noting that she hopes Ziva can help build momentum for a demand for better postpartum care within the health care system. 

“You need to blame your health care system, your congressman, the people that vote on this stuff,” she said. “This is covered in other places…but here in the United States, it’s just not.”

Historical gaps in maternal care

North Carolina’s maternal health issues have deep historical roots. In the early 20th century, midwives—many of whom were Black—played a vital role in maternal and newborn care, particularly in rural communities. But as hospitals and professional obstetrics expanded, midwifery declined.

“The biggest law regulating midwives happened in 1935, which is a permitting system,” said Jenesis Nwainokpor, a Yale student researching the history of midwifery regulation in North Carolina. “In order to practice, they had to go to the State Board of Health or their local county board of health and receive sanction to practice. And that sanction could be taken away at any time for really any infraction.”

RELATED: NC midwives might be the key to the Black maternal health crisis

Instead of training midwives to provide safer care, the state slowly phased them out. 

“What the State Board of Health did was essentially wait for all the older midwives to die off, or they would retire them forcibly. And then they wouldn’t give permits to the new midwives who would traditionally have taken those places,” Nwainokpor said.

This left many Black and rural families in North Carolina without access to culturally competent maternal care. 

“Before, they would have had this Black provider who worked in their community, who knew them, who understood them and their health problems. Now they’re being sent to a hospital, often outside of their community. It’s far more expensive than it was before. And now the midwife is kind of not this community figure that she once was. She’s this kind of other actor of government intervention in their communities.”

In a recent March of Dimes report, 21% of North Carolina counties were classified as maternity care deserts—meaning they have no hospitals or birth centers offering obstetric care and no OB/GYN or certified nurse midwife providers per 10,000 births. Additionally, 13.4% of women in North Carolina have no birthing hospital within 30 minutes of their home—a gap that disproportionately affects rural communities.

READ MORE: ‘You don’t know what you don’t know’: A Q&A with a NC doula on making maternal care affordable and accessible

North Carolina postpartum retreats like Ziva, and postpartum doulas, like Emerald Doulas, Central Carolina Doulas, and Doulas of Raleigh, aim to provide the post-birth care that midwives once offered.

Legislative efforts for change

Some lawmakers are working to address the gaps in care. Senator Natalie Murdock, a Democrat representing Durham who has championed maternal health initiatives, said that while the state’s 12-month Medicaid expansion for postpartum care was a critical step, many mothers still struggle to access care.

“The delivery is the beginning,” Murdock said. “It’s not the end where you go home and just figure it out. But before the 12-month [Medicaid] extension, after 60 days, you were kicked off of Medicaid. So getting that expansion was huge.”

However, Murdock noted that not all mothers qualify for Medicaid, leaving many without affordable postpartum care options.

Murdock has co-sponsored several bills aimed at improving maternal health in North Carolina:

• Senate Bill 247 – Focuses on expanding Medicaid coverage for doula services, recognizing the role doulas play in improving maternal health outcomes.
• Senate Bill 294 – Seeks to increase funding for maternal health programs.
• Senate Bill 467 – The state’s Momnibus Act; would fund community-based maternity health programs and expand transportation access for postpartum mothers.
• Senate Bill 469 – Aims to improve access to midwifery care by reducing restrictive regulations on certified nurse midwives.
• Senate Bill 614 – Establishes a statewide maternal health task force to address racial disparities in maternal mortality rates.

Despite the introduction of these bills, most remain stalled in committee since 2023. And despite having a Democratic governor, Republicans control both chambers of North Carolina’s state government.

“Our current budget outlook is far more bleak as a result of Hurricane Helene and how unstable federal funding is because of Donald Trump,” Murdock said. “I hate that that’s the space that we’re in, but it’s the reality. So quite frankly, we’ll be fighting just to hold on to Medicaid at current levels.”

The Trump administration previously endorsed a budget proposal that would slash $880 billion from Medicaid, which could lead to more uninsured individuals and limited access to maternal care, particularly in rural and low-income areas.

RELATED: Here’s how the GOP push to cut Medicaid would impact rural North Carolina

Murdock said this uncertainty in federal funding makes it difficult to expand programs like postpartum recovery services, which already receive limited state support.

“It took all this work to expand [Medicaid], but I definitely think that there are programs such as Healthy Opportunities that are pilot programs across the state,” she said. “So I definitely think in addition to a lot of the maternity care centers across the state, if they wanted to add on, they could say, ‘Hey, in addition to this, we have these retreat centers that are available.'”

She also suggested that a mix of public and private funding could help postpartum retreat models like Ziva become more accessible.

The path forward

Murdock said that continued advocacy from North Carolina residents is needed to make sure maternal health remains a legislative priority.

“People have every right to reach out to their House members, their state senators, to say this is something they care about,” she said. “We have to continue to say, ‘Not on our watch.’”

READ MORE: Here are the ways you can improve maternal health care in NC