BACKGROUND: To determine the knowledge, attitudes and self-reported usage of emergency contraception (EC) in rural western North Carolina women. METHODS: Using a cross-sectional survey, with a convenience sample, participants self-administered the survey in waiting rooms of eight medical clinics in three counties in western North Carolina. Participants included 401 English-speaking women of childbearing age (18-44 years old) presenting for routine medical care during a three-month period in 2004. RESULTS: Of the 70.5% who responded, almost all (97%) were sexually active and most (92%) perceived an unintended pregnancy to be a problem. A majority of the participants (72%) were aware of EC, but only 7.5% of women reported usage in the last year. More than 80% of the surveyed women were uncertain if EC was the same as the abortion pill, RU-486. While only 16% of respondents indicated they had discussed EC with a doctor or another health professional, most women (89%) reported that doctors or other health professionals would be their first choice for accurate information about EC pills. CONCLUSIONS: Among western North Carolina women of childbearing age, EC is rarely used, perhaps because of confusion about its mechanism of action. Furthermore, EC is infrequently discussed with doctors. Since women indicate that health care providers would be their preferred choice for accurate information about EC, improved patient education by physicians about EC would be a first step in increasing knowledge among patients.