In recent years, maternal mortality rates in North Carolina have trended in the wrong direction, with rural communities facing some of the steepest challenges. Missed appointments and unmanaged chronic conditions can contribute, but they’re often symptoms of needs related to non-medical drivers of health like food insecurity and a lack of transportation.

Scotland Health, a member of the North Carolina Healthcare Foundation‘s Maternal Health Action Network (MHAN) since September 2024, launched its Maternal Nurse Navigator program in response to ensure high-risk expecting moms and babies don’t fall through the cracks. The MHAN serves as a collaborative space for hospitals to explore opportunities to close gaps in care for new or expecting mothers.

“We were hearing from our OB-GYN providers that they had real problems finding patients and navigating them to the right follow-up appointments,” said Jamie Cicali, Executive Director of Population Health. “Making sure they’re following through on their care plan, that’s where things were breaking down.”

As a solution, Scotland Health built a program rooted in clinical expertise and human connection. A registered nurse experienced in labor and delivery guides high-risk patients through pregnancy and postpartum care.

Maternal Nurse Navigator Heather Dunn, BSN, RN, RNC-OB, C-EFM, serves as a liaison and advocate for patients and care providers. From coordinating specialist care and attending appointments to providing emotional support, Dunn ensures patients understand their care plans after they leave the exam room.

“Sometimes you can leave an appointment and think, ‘What just happened?’” Dunn said. “I’m that second set of ears.”

“Our focus in rural health is about touchpoints,” Cicali explained. “That you meet patients at physician’s offices, you talk to them in person and make that connectivity.”

For many patients, that persistent presence builds trust and improves consistency with care plans, two critical components of quality and safety.

“We had a patient with several no-shows. When we went to her home, we found out she didn’t have a phone, she didn’t have transportation,” Dunn shared. “So how could she have come to her appointment.”

Instead of labeling the patient as noncompliant, the team intervened. Nurse navigators work closely with Scotland Health’s community health workers to identify and resolve access barriers such as transportation, food insecurity, and lack of access to communication. “Now she has transportation, she has appointments, and she’s following up,” Dunn said.

In some cases, this intervention can be lifesaving. Dunn shared an experience with a postpartum patient with dangerously high blood pressure who refused care due to a lack of trust and support. Through consistent outreach and relationship-building, the team convinced her to seek treatment. She was ultimately diagnosed with postpartum cardiomyopathy and transferred for higher-level care.

“Had we not caught that… I don’t even want to think of the outcome,” Dunn said.

Since launching the Maternal Nurse Navigator role, the data provided by Scotland Health has shown its impact.

• The rate of inadequate prenatal care dropped from 30% in October 2024 to 24% in September 2025.
• Postpartum no-show rates have also improved, decreasing from 21.5% in 2024 to 17.71% in 2025.

For quality and safety, nurse navigators alongside community health workers offer a powerful example of bridging clinical care, community resources, and patient trust. Scotland Health didn’t just identify a problem; they built a model that adapts to patient needs in real time.

“I always say rural health may not have unique problems, but we have to come up with unique solutions,” Cicali said.

Scotland Health also has nurse navigators for transitions of care, lung health, breast health and oncology. As the system looks to expand the model, its early success shows how healthcare systems can improve health outcomes by meeting patients where they are and ensuring no one navigates care alone.

Learn more about Scotland Health Care System’s nurse navigators here.