A pivotal moment arrives every time a pregnancy test turns positive at public health departments across the state.

The new mother could walk out the doors, overwhelmed and underprepared, never to return again. She could receive little or no prenatal care before delivery. She could possibly die.

Or, she could pay absolutely nothing for prenatal care, delivery and 60 days of postpartum care. Not to mention, childbirth and parenting classes, one year of Medicaid for her newborn child, family planning services, and even emotional support and advice throughout the pregnancy.

It’s a moment that nurses at Haywood and Jackson County health departments don’t take lightly.

“That’s where we grab them,” said Vicki James, maternal care coordinator for Haywood for the past 11 years.

“We really have the nurse literally come knock on my door as they get their positive pregnancy test,” said Courtney McLaughlin, Jackson’s maternity care coordinator. “As soon as we get them, we connect them to all these services.”

North Carolina has come a long way in providing support to low-income women, bringing them closer to the reality of an uncomplicated pregnancy and a healthy baby.

Moreover, Medicaid for Pregnant Woman extends generous financial aid to women who don’t usually qualify for regular Medicaid.

Yet a study released this month by Amnesty International, a human rights group, shows a major gap still exists in care given to pregnant women across the state.

The report states 15.7 percent of women in North Carolina still receive delayed or no prenatal care, equivalent to about one in six women. That number jumps to nearly one in four among women of color.

Amnesty International claims that women who do not get prenatal care are three to four times more likely to die than women who do.

With 11.4 mothers dying per 100,000 live births, North Carolina ranks 37th in the nation for maternal mortality. In comparison, Maine, the top-ranked state, has 1.2 mothers dying for every 100,000 live births.

The reasons for the disparity are manifold, but major culprits include lack of health insurance, lack of access, and lack of education and awareness.

Nevertheless, lawmakers in Raleigh have already made significant cuts to the Baby Love program, which provides nursing and social work to low-income women. They are considering doing away with the program altogether — an idea that causes deep worry for health officials across the state.

“We’re not sure where these clients will go if that program ceases to exist,” said Debbie Sprouse, adult health supervisor in Haywood County.

Logical disconnects

Julie Guffey, a 28-year-old Waynesville resident, says she can’t fathom why those who need prenatal care aren’t receiving it. Guffey qualified for Medicaid for Pregnant Women when she gave birth to twin girls almost a decade ago and easily obtained it again after learning she was pregnant late last year.

Medicaid for Pregnant Women covers all pregnancy-related costs, even those that result from complications. It also provides one year of Medicaid coverage for the newborn child automatically.

Guffey says the entire application process is very simple, and the care she’s received has been excellent. Nurses have sent her home with thick educational packets to prepare her again for pregnancy, and she’s taken advantage of free birthing classes at Haywood Regional Medical Center in the past.

“If the services are available, and if you qualify for Medicaid, I don’t see why they don’t use it,” said Guffey. “Anyone who’s not getting prenatal care, it’s their own fault.”

It is relatively easy for low-income women to receive Medicaid for Pregnant Women, commonly called “Pink” Medicaid because its ID card had been pink at one point.

Income requirements are significantly more relaxed than those that exist for regular Medicaid.

For example, a family of four must make no more than $594 each month to qualify for Medicaid for families, while they can qualify for Pink Medicaid if they make up to $3,400 each month. Unborn children are included in the family count.

But even such a generous eligibility requirement can leave those who need financial aid floundering. Pregnancies in Western North Carolina can run up bills from $4,000 to $8,000. Ultrasounds cost $500 and up, and most women need at least two per pregnancy.

Having health insurance doesn’t necessarily shelter expecting mothers from the burden of financial worries. It’s not uncommon for policies to exclude prenatal care and to consider pregnancy a pre-existing condition.

Katie Martin, a 35-year-old Waynesville mother of two, said she paid nearly $2,500 in pregnancy-related costs, despite having state health insurance.

Martin says she’s not sure many of her friends could meet the Medicaid cutoff requirement even though they’d struggle to pay for prenatal care.

Because her own pregnancy was completely normal and she didn’t take any drugs during delivery, Martin was shocked when she set her eyes on such steep bills.

“I can’t even imagine if we had issues, how expensive the delivery would be,” Martin said.

Some of her bills had to be paid upfront, but Martin was able to set up a payment plan for the rest.

“Her birth is paid for now,” said Martin of her 1-year-old daughter, laughing. Of course, countless other expenses have piled up since then.

“From conception on, they cost a whole lot more than you would think,” Martin said.

Countless barriers to care

Charlene Carswell, prenatal clinic coordinator, understands that no matter how much she and her co-workers preach, some women will always insist that they don’t need prenatal care.

They’ll say “My sister didn’t have a low birth weight baby, and she smoked a pack a day,” said Carswell.

Others adamantly argue that no one received prenatal care a hundred years ago, so there’s no need for it now.

But late or no prenatal care can be detrimental to both the mother and the baby. It can lead to preterm births, dangerously low birth weights, gestational diabetes, and babies that haven’t fully developed.

Many of the women who don’t receive prenatal care do not have health insurance. Even those who have Medicaid may have trouble tracking down doctors who accept it.

Women who can’t afford medical care often put off early prenatal care to save up for the costs that’ll greet them in the third trimester. They pick and choose which tests they’ll get done and which they’ll skip. Even though it’s recommended that pregnant women get a check-up at least once a month, they’ll pass on those as well.

“They say ‘If I’m going to have to pay for the delivery, I’ll save for the delivery, not monthly visits to doctors,’” said Tania Connaughton-Espino, Latina program manager for the North Carolina Healthy Start Foundation, a nonprofit devoted to reducing infant death and illness.

Since Pink Medicaid applications can take up to 45 days to be approved, some patients who qualify for the aid skip out on appointments until it is formally approved.

Other barriers include lack of access to treatment, whether it’s not owning a car to drive to the health department or not being able to take off from work to make an appointment. Mothers might also not be able to line up childcare for their other kids while they are visiting the doctor.

And sometimes, it can be hard to even get an appointment with the recession sending waves of newly uninsured people to local health departments.

According to Connaughton-Espino’s experience, some women just might not see why prenatal care is necessary. They wonder why they’ve given up several hours of work time to wait for a 15 minute appointment with a nurse who measures their belly and takes their temperature.

“We just need to makes sure that moms understand that they can make that appointment important for them and ask questions,” said Connaughton-Espino.

According to Connaughton-Espino, the best route to a solution is through education. Some expecting mothers just don’t know when they’re supposed to take a prenatal vitamin or how often they should visit the doctor.

A whole other category of women who are not receiving prenatal care are undocumented workers. Because citizenship is a requirement for Pink Medicaid, illegal immigrants who are expecting often are left behind.

They do have the option of applying for presumptive eligibility Medicaid, which provides care until an application is formally approved or denied. However, this kind of Medicaid promises only a maximum of two months of care. It allows only minimal contact with a doctor and does not cover the cost of delivery.

At most public health departments, undocumented workers pay on a sliding scale based on their income. Even though the cost of care might be within reach, undocumented immigrants are afraid to even show up on the health department’s doorstep.

“They fear that they’re going to be arrested or shipped back to Mexico,” said Adrienne Maurin, a licensed therapist at Jackson County’s health department.

“Some of them come in later for care, some decline testing doctors recommend,” said McLaughlin, who tries to schedule ultrasounds and any other major tests within the few weeks that undocumented workers gets Medicaid coverage.

Children of undocumented workers who are born in the U.S. automatically get American citizenship, but they might still receive inadequate care because of their mother’s illegal status.

Carswell doesn’t think that that’s fair.

“It’s not the baby’s fault, whoever is pregnant,” said Carswell. “You just have to have good prenatal care.”

For many low-income women, pregnancy can lead to more stress than excitement. Most of the expecting mothers who visit local health departments are facing unplanned pregnancies.

Maternal care coordinators across the state have experienced firsthand all possible emotions along with the patients they support.

“I have a box of Kleenex in my office that I just leave here,” said Courtney McLaughlin, maternal care coordinator for Jackson County.

As part of the Baby Love program, maternal care coordinators contact patients once a month to check in throughout the pregnancy and up to two months after the mom delivers.

“Nine times out of 10, you’re their support system,” said Vicki James, maternal care coordinator for Haywood County. “You talk to them just like you do your own kid.”

Often times the father of the baby isn’t involved or the parents have turned their back on their pregnant daughter. So James picks up the slack and provides advice like a mother would.

She advises women on where to buy cribs, tells them how often they should see their doctor, and answers questions about what is or isn’t normal during a pregnancy.

James has made a lot of friends through her work, but the job comes with many ups and downs.

“It’s very rewarding, it’s very frustrating,” said James.

Jackson County, one of the few counties in the area to have a high-risk prenatal clinic, routinely sees extreme social work cases. Some expecting mothers are dealing with weighty issues, like sexual and physical abuse.

“You don’t know until you make a home visit what this pregnant girl is going through,” said Charlene Carswell, prenatal clinic coordinator for Haywood County.

Adrienne Maurin, a licensed therapist at Jackson’s health department, said she’s recently treated a pregnant woman who was just recovering from a substance abuse problem while simultaneously battling a mental illness.

Others have no psychological issues but come to Maurin just to vent their frustrations.

“They say, ‘I’m pregnant, and I don’t have a job, and I can’t get a job because I’m pregnant,’” said Maurin. “That causes a lot of stress for most of the ladies.

Of course, not all women who visit the health department have unhappy endings to their stories.

Carswell recalled a teenager who was petrified about her mother discovering that she was pregnant.

“Several of us cried with her,” said Carswell. “She was in a state.”

But when her mother found out, she was supportive, and to top it off, the baby’s father re-entered the picture.

James remembered one Hispanic woman who prepared a generous meal for her when she paid a visit, even though the woman had little to feed her own family.

“We had already ate, but we ate again,” said James, who was touched by the kind gesture.

James has seen women from all backgrounds, education and income levels and says there’s no stereotype for the kind of woman who takes advantage of the health department’s services, especially since the economic downturn.

Many who come in are finding it difficult to purchase basic baby supplies, like diapers, carseats and cribs — none of which is covered by Medicaid for Pregnant Women. Maternal care coordinators help provide some of those supplies, though their resources are quickly drying up.

“I’ve seen moms who have slept a baby in a laundry basket or a drawer,” said McLaughlin. Others share a bed with their baby, sometimes leading to cases of suffocation.

Maurin said she worries about her patients quite a bit, especially about the risks of post-partem depression.

“They are more prone to it because of the level of poverty,” said Maurin.