Addressing the Maternal Health Crisis in Rural Georgia: Challenges, Disparities, and Pathways to Improvement

Abstract

The maternal health crisis in the United States, marked by alarming maternal mortality rates, necessitates a multidisciplinary response, including from surgical specialties. Despite a decline in maternal mortality rates in 2022, disparities remain, with Black women experiencing significantly higher risks of complications. In Georgia, the maternal mortality rate is notably elevated, particularly in rural areas lacking access to obstetric care. Effective initiatives, such as utilizing informative research to establish impactful community health programs and obstetrical rural residency tracks to address the rural obstetrical provider shortage, aim to bridge these gaps. By equipping local healthcare providers with advanced skills and utilizing telehealth, surgeons can enhance maternal care accessibility in rural communities. This collaborative approach is vital for improving maternal health outcomes and addressing systemic barriers, ultimately fostering health equity for all women.

The maternal health crisis in the United States is an ongoing battle that requires the collective effort of professionals across all fields, disciplines, and medical specialties. Surgeons, representing various subspecialities, are often at the forefront of managing complex medical-surgical conditions. They are frequently consulted in emergency rooms or by colleagues to assist with the surgical management of high-risk obstetrical cases, involving risks for severe maternal morbidity and mortality, both during and after delivery. Given this critical role, it is imperative that surgeons understand the systemic and contextual factors contributing to maternal health disparities in our country.

The United States’ maternal mortality rate is amongst the highest compared to other high-income nations.¹ Although maternal mortality rates decreased in 2022, following a significant increase in 2021 due to the COVID-19 pandemic, Black women remain 2 to 3 times more likely to die from pregnancy-related complications compared to White women, regardless of socioeconomic status.^1–5 Between 2018–2020, over 80% of pregnancy-related deaths were found to be preventable.^{1, 6, 7} Georgia’s maternal mortality rate is nearly 45% higher than the national average.² Data from 2019–2021 reveals that the primary causes of pregnancy-related deaths in Georgia included cardiovascular conditions, COVID-19, hemorrhage, mental health conditions, and embolism.⁸ These findings underscore the need for targeted interventions to address these critical health issues affecting maternal mortality in the state. Georgia’s efforts to address this crisis include initiatives and policy changes such as the Maternal Mortality Review Committee, expansion of telehealth services, the extension of postpartum Medicaid coverage to 12 months, and the implementation of group prenatal care models like the Centering Pregnancy^® Model.^8–14 Community health workers, doulas, and home visiting initiatives also play crucial roles in improving access and maternal health outcomes across the state.^15–17

Over 30% of Georgia’s 159 counties, many of which are rural, are classified as maternity care deserts- counties without birthing hospitals or obstetrical providers.¹⁸ Nearly 15% of other counties have low or moderate access to maternity care.¹⁸ Only 22 of Georgia’s 120 rural counties (18.3%) have Certificate of Need-authorized OB facilities or services, further complicating access.¹⁹ Approximately 5.5% of Georgia’s reproductive-aged women live in maternity care deserts, and 7.9% reside more than 50 miles from critical obstetric services, creating dangerous delays in accessing emergency care.²⁰ Furthermore, 38,202 women (2.0%) face the compounded challenge of living both in a maternity care desert and more than 50 miles from a critical care obstetric facility, exacerbating barriers to timely and comprehensive obstetrical care.^{19, 20}

Rural counties in Georgia face maternal mortality rates up to 2.5 times higher than urban areas, further complicated by the fact that over 60% of women in rural regions live more than 30 minutes from a birthing hospital, compared to 13% in urban areas.^{3, 9, 18, 21} Financial challenges over the past 20–30 years have led to multiple rural hospital closures, forcing pregnant individuals – especially Black women who bear a disproportionate burden - to travel 30–50 miles for essential care.²² The March of Dimes Report underscores the risks of long travel distances, linking them to higher rates of maternal morbidity and adverse infant outcomes, such as stillbirth and NICU admission.^{18, 23} Additional socioeconomic factors, such as poverty, unreliable transportation, low health literacy, and limited Medicaid expansion, further delay prenatal care and contribute to low postpartum follow-up rates.^{9, 24} These challenges ultimately result in increased mental health challenges as well as increased maternal and infant mortality.^{9, 24}

Key state and national programmatic and policy initiatives have been implemented to address disparities and enhance maternal health outcomes. The Biden-Harris administration initiated the American Rescue Plan Act (ARP, 2021) and the Consolidated Appropriations Act (CAA, 2023) that solidified federal funding for states to offer extension of Medicaid coverage through 12 months postpartum, up from 60 days.^{25, 26} As of mid-2024, 40 states, including Georgia, provide for 1 year of comprehensive, continuous postpartum coverage, ensuring access to preventive care and chronic condition management, including mental health, between pregnancies.^26–28 Efforts like these, along with initiatives such as the White House Blueprint for Addressing the Maternal Health Crisis (2022), championed by U.S. Vice President Kamala Harris, are crucial for fostering healthier outcomes for mothers and infants.²⁹ The expansion and diversification of the perinatal workforce, designed to alleviate provider shortages and mitigate the effects of maternal care deserts, is a key strategy in ensuring access to comprehensive maternal care.²⁹

According to the 2019–2020 State of Georgia Physician Workforce data, a striking number of counties lack access to essential medical and surgical specialists, with 50.3% of counties having no general surgeon and 51.6% lacking an Obstetrics and Gynecology (OB/GYN) physician.³⁰ Even more alarming, 45.3% of counties have neither a general surgeon nor an OB/GYN, leaving vast regions without critical care for both surgical and reproductive health needs.³⁰ This shortage highlights severe disparities in healthcare access, particularly in rural and underserved areas, where the absence of these specialists puts patients at heightened risk for poor outcomes.⁹ The dual lack of surgical and obstetric expertise further amplifies barriers to comprehensive, life-saving care, exacerbating health inequities across the state.

Surgical and obstetrical training programs are vital in enhancing access to care in underserved communities, particularly in rural areas. By equipping these trainees with the skills and knowledge needed to serve in these populations, these programs directly address the shortage of healthcare providers. Programs like the newly minted Rural Track within Morehouse School of Medicine’s Department of Obstetrics and Gynecology Residency Program focuses on training residents in rural communities, ensuring the delivery of quality obstetrical care where it is most critically needed. Launching its inaugural resident in November 2024, this program emphasizes collaboration with other medical professionals and community health workers, including doulas as part of its core training. This track, the first of its kind in the state of Georgia, not only trains residents to provide essential reproductive care in southwest Georgia but also establishes a pathway to mitigate physician shortages over time. By fostering collaboration among various healthcare providers, the program enhances the overall quality of care and improves health outcomes for rural populations.

While the demand for surgeons spans across 14 specialties, the role of rural surgeons is particularly crucial in enhancing healthcare access. Rural tracks within surgical residency programs can significantly contribute to addressing the maternal health crisis. A well-trained rural surgeon with OB/GYN experience can perform approximately 66% of all inpatient operations in a rural hospital, highlighting the importance of integrated training programs.³¹ Both program directors and graduates of surgery programs with a rural focus have emphasized the necessity of additional OB/GYN training to enhance preparation for rural practice.³² Surveys of general surgery program directors have also indicated a pressing need for OB/GYN training, especially in key procedures like salpingo-oophorectomy, dilation and curettage, hysterectomy, tubal ligations and Caesarean deliveries.³¹ By integrating these specialties, we not only strengthen the capabilities of rural surgeons but also create a network of providers committed to improving maternal health outcomes in their communities.^{31, 32}

Morehouse School of Medicine has been a leader in recognizing and addressing health disparities in Georgia. In response to the state’s maternal health crisis, Morehouse School of Medicine founded the Center for Maternal Health Equity (CMHE) in 2019. The CMHE aims to pursue equity in maternal health by reducing maternal morbidity and mortality locally, nationally, and globally by building and strengthening community-academic partnerships, developing a competitive translational research program, and offering interdisciplinary and professional training. As a National Institutes of Health (NIH) Center of Excellence in Maternal Health Research (Grant number U54HD113292), the CMHE stewards multiple federally funded research grants, addressing issues such as Black maternal mental health, cardiovascular risk assessment, and fertility inequity among women of color.

One of the CMHE’s most impactful projects is a Community-Based Perinatal Patient Navigation Program, funded by the NIH’s National Institute of Nursing Research (Grant Number: R01NR020756). This pragmatic randomized controlled trial (RCT) integrates community-based patient navigators into maternal care to improve maternal outcomes through meeting social needs, providing behavioral health support, and improving access and utilization of care for 500 Black women in a safety-net hospital system in Atlanta, GA. In this RCT, community-based patient navigators are integrated into the continuum of maternal care starting prior to mid-pregnancy and continuing through one-year of birth to discern effectiveness in reducing maternal morbidity and mortality. Also, we have recently expanded to Albany, GA to implement our approach in a rural Georgia community.

The CMHE leads a Health Resources and Services Administration (HRSA)-funded research center (Grant Number: UR6MC50349) focused on advancing maternal health in Georgia’s rural areas through innovative, community-based interventions. Concentrating on five of the state’s six perinatal regions—Augusta, Macon, Columbus, Savannah, and Albany- our work addresses the unique challenges of underserved communities by integrating clinical research with local community-based efforts to improve health outcomes. This approach ensures that clinicians, healthcare systems, and communities are aligned in delivering high-quality, culturally responsive maternal care.

Guided by a Community Accountability Board, the CMHE will develop a Black maternal health Research Agenda in collaboration with Black women, families, and the community-based organizations. This agenda will identify 10 key research priorities and the 10 most significant barriers and facilitators to engaging in maternal health research, based on insights gathered from ongoing community listening sessions. These sessions center the voices and experiences of Black women and families, ensuring that our strategies are rooted in lived experiences.

Our goal is to influence clinical practice by examining the social and structural determinants of maternal health and challenging the dominance of traditional healthcare models that are centered around white, mainstream experiences, which often overlook the needs of marginalized communities. By fostering antiracist, culturally sensitive care, training providers, and advocating for policy changes, we aim to create equitable healthcare environments and improve maternal health outcomes for Black women across Georgia.

Given the significant maternal morbidity and mortality rates in the United States, particularly in rural areas, surgeons can play a vital role in addressing the healthcare challenges faced in maternal care deserts and rural communities. Surgeons have a critical role in addressing the complex challenges associated with maternal morbidity and mortality. By actively engaging in training and mentoring with local providers- including obstetricians, nurse practitioners, and midwives – surgeons can enhance skills and foster collaboration in maternal care. This approach not only improves access to essential care but also helps to create a cohesive healthcare network that prioritizes the needs of patients.

Together with advocacy, collaboration, and research, these efforts are vital in addressing disparities in obstetrical care access and outcomes.^{15, 33, 34} Given the severe lack of access to quality care in rural areas, it is crucial for surgical professionals to actively engage in efforts with OB/GYN that enhance maternal health equity and improve outcomes, especially for vulnerable populations like Black women. Together, these efforts can pave the way forward in the fight against maternal morbidity and mortality in Georgia and beyond.

Key Take-Aways.

• The maternal health crisis in the United States is marked by alarming disparities, including in underserved and rural communities, necessitating urgent action from healthcare providers across all specialties, including surgeons.

• Targeted initiatives, such as expanding the perinatal workforce and community-based programs, are essential to mitigating maternal health disparities and improving overall maternal and infant well-being.

• Collaborative surgical and obstetrical training programs can play a vital role in enhancing maternal health by fostering the training and mentorship of local healthcare providers in rural areas.