Echos of the Past Are Louder Than You Think
For many, the idea of an American woman dying in childbirth lurks as a foggy echo from the recesses of history. With rapid advancements in medicine and technology, how could a country as modern as the United States still be dealing with a seemingly unmodern tragedy? Yet today, if you were to ask 10 random people in Georgia, one would personally know someone who died during pregnancy, childbirth, or shortly after. A loved one dying from pregnancy complications is currently a reality for a large portion of the state.
Georgia’s tremendously high maternal mortality rate (MMR) provides a grim overview of this widespread problem. As defined by the Centers for Disease Control and Prevention (CDC), maternal mortality rate includes not only deaths during pregnancy and childbirth but also deaths during the postpartum period or ‘42 days after the end of the pregnancy.’ Nationwide, the United States possesses the worst maternal mortality rate amongst developed countries, with our average MMR in 2020 (21 deaths per 100,000 live births) being equal to countries such as Grenada, Malaysia, and Lebanon. Some states have it worse than others, with Georgia having a MMR of 30.2 deaths per 100,000 live births, putting the state on par with countries like Syria and Sri Lanka.
The most heartbreaking fact is that 89% of these deaths in Georgia are preventable.
That’s no mistake. Out of every 10 women that die in Georgia due to pregnancy or postpartum complications, 9 of these women could still be alive today with their loved ones and children.
So then, what’s at the root of increasing maternal deaths in Georgia, and what can be done to prevent a further decay of women’s health?
Access Denied - Nowhere to Turn
When most non-Georgians first think of the state, the hustle and bustle of Atlanta often pops into mind. However, the densely urban Atlanta in Fulton County is the exception to the rule as 120 of Georgia’s 159 counties are considered rural. For these rural counties, access to OB-GYN resources for prenatal care and childbirth is an uphill battle as the number of facilities dwindles and the distance to care only skyrockets.
Nearly four in 10 GA counties are considered ‘maternity deserts,’ meaning the county has no obstetric hospitals, birth centers, and obstetric providers. In fact, rural Georgia only has 7.1 OB-GYN physicians per 100,000 residents when the standard per state is 121.32 OB-GYNs per 100,000 residents. When it comes to childbirth, 93 rural counties have no hospital with a labor and delivery unit.
With no nearby access to obstetric care, 83% of rural women are forced to travel hundreds of miles to the nearest OB-GYN or hospital with a labor and delivery unit. These trips are often nearly impossible for many of the rural women who live in health transportation shortage areas or who have a caretaking role with their children or relatives and cannot leave them for hours on end to travel. As such, many of these women forgo prenatal care and the chance to catch health complications early due to these barriers to access.
While many discussions focus on care during pregnancy, the access to care problem extends beyond impacting prenatal care and childbirth, as 52% of maternal deaths happen either within the postpartum period or up to a year after birth. A woman is just as likely to die from complications in the days, weeks, and months following pregnancy as she was during it.
The top causes of postpartum deaths vary amongst demographics with the leading factors being cardiac and coronary conditions for non-Hispanic Black women, mental health conditions for Hispanic and non-Hispanic White women, and hemorrhaging for non-Hispanic Asian women. Access to necessary primary and mental health care facilities is vital in supporting women post-pregnancy against these conditions. Yet, as with OB-GYNs, many rural Georgians are locked in healthcare deserts inhibiting that access to care.
And even if a woman can reach an obstetric, primary, or psychiatric care provider, 1 in 6 Georgia women are uninsured and cannot afford the costs associated with pregnancy and childbirth, often having to turn said care away.
Who You Are Can Also Devastate Your Quality of Care
Limitations in access are not the only factors contributing to the state’s high maternal mortality rate. In Georgia, rural Black women are twice as likely to die from giving birth as rural White women, and Black infants are twice as likely to be born with a low birthweight than White infants. The inequalities in these statistics can be derived from the healthcare inequalities Black women face due to long-lasting systemic discrimination in many former Jim Crow states like Georgia.
In an Emory University of Medicine survey, half of Black female respondents reported racism as a major obstacle in achieving equitable maternal health outcomes. In healthcare, racism often appears as the dismissal of the medical concerns of Black women by providers, from currently practicing ones all the way to medical students. A 2016 study of first and second year medical students revealed 40% of them believed Black people’s skin was thicker than White people’s. Many students in this survey also even believed Black people felt less pain than White people, a false notion that can attest to why Black patients are 22% less likely to be prescribed pain medicine than White patients.
In addition, it’s not hard to see how prevalent internal bias and racism can be within healthcare when analyzing the demographics of the healthcare workforce. Black physicians only represent 5% of total physicians in the United States and black female physicians represent just 2%. For black women, finding a physician or OB-GYN with a shared cultural and social background is an extremely difficult experience.
And while rural black women with lower income fight a compounded challenge of securing reliable and unbiased care, the problem of discrimination entraps Black women of any socioeconomic status, such as for Olympic Gold Medalist Tori Bowie, who in 2023 died from pregnancy complications at just 32 years old.
How Can We Prevent Maternal Deaths?
While there’s no single magic action to reverse a systematic issue like maternal mortality, taking a systematic approach to finding solutions is the key to improving maternal health. For major changes to be actualized, government entities, health plans and providers, adjacent support organizations, and mothers must work cross-functionally.
This idea was the grounds for creation of the Georgia Perinatal Quality Collaborative (GaPQC), a group of key stakeholders formed to research, find, and implement data-backed solutions to the state’s high MMR. Some key members include the Georgia Department of Public Health, The American Hospital of Gynecologists and Obstetricians, March of Dimes, multiple hospitals across the state, and organizations such as the Black Mamas Matter Alliance and Healthy Mothers, Healthy Babies Coalition of Georgia. Their first annual Symposium to Address the Maternal Health Crisis in Georgia last November brought all these stakeholders in one place to align their efforts and interview mothers impacted by the crisis. A coalition like GaPQC has proven results before with California’s version, the CMQCC, slashing the state’s maternal mortality rate in half with its efforts.
With stakeholders aligned on key objectives, they can implement solutions across their fields to support mothers. On the legal side in 2023, multiple policies with supported evidence on potential impact for maternal mortality were proposed to the Georgia state government. While many policies did not pass, the most impactful enacted policy removed the five-year waiting period for Medicaid-eligible pregnant women and children, increasing Medicare coverage for immigrant women with lawful permanent residence status during their pregnancies and postpartum periods. Georgia also implemented its own Maternal Mortality Review Committee (MMRC) to further research the major factors of MMR in Georgia and provide further evidence for policy necessity and implementation. Progress is igniting, but continued policy enactment will be necessary to improve maternal health, especially for Black mothers.
On the provider side, an increase of available midwives for low-risk pregnancies could also help fight the state’s high MMR. Common in other developed countries like the UK, midwives are licensed medical professionals that provide medical and psychosocial support across a pregnancy. An increase in midwives for low-risk pregnancies allows for an already strained pool of OB-GYNs in Georgia to focus on monitoring and treating high-risk pregnancies.
As far too many GA residents do not have access to a nearby OB-GYN, all healthcare providers should communicate early with expecting women about symptoms of common pregnancy complications. The early identification of comorbid conditions that pose further risk for pregnancy-related complications like preeclampsia and postpartum depression could further save lives. The acknowledgement of unconscious biases is another step providers should take, making sure they listen carefully to mothers of color. Transformative learning theory (TLT) and implicit bias recognition and management (IBRM) are techniques used in identifying and retraining unconscious bias amongst providers to instead foster sound decision-making associated with higher health outcomes.
No set of systematic solutions would be complete without addressing the access to care issue stemming from the maternal and primary care deserts across Georgia. Healthcare providers and health plans offering telehealth and non-emergency medical transportation (NEMT) options provide mothers connection to healthcare providers despite distance. Telehealth, however, can often fail due to the lack of internet in some rural areas, so transportation access is key in ensuring women do not miss vital appointments in the pregnancy and postpartum periods.
Digital solutions like MedTrans Go allow healthcare providers to organize ambulatory, wheelchair, and stretcher rides from anywhere, including rural communities, that assist women to and from their medical appointments and procedures. For pregnant and postpartum women without access to a vehicle, transportation arranged by their healthcare provider can save their lives.
There is no acceptable reason why pregnancy, childbirth, and the postpartum period should still carry this level of risk in the US. When we acknowledge that 89% of maternal deaths in the state are preventable, we are also acknowledging that we can do better by the women of Georgia. By working together, we can truly close the book on this chapter in history of high maternal mortality rates and provide a safer future for women across the state.
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