By David C. Bridges, Center for Rural Prosperity and Innovation and Kristy Thomson, Hometown Health
Recommendation. Georgia’s House Rural Development Council should recommend that the General Assembly take immediate action to increase access to obstetrical, labor, and delivery services in currently underserved areas of the State, by creating and funding Rural Maternal and Infant Health Centers of Excellence across the State. Details have been provided in a separate document, but the essence of the project would involve:
Providing stop-gap funding to a limited number of hospitals that currently provide labor and delivery services but which are doing so at a loss and are therefore at risk of ceasing services.
Providing incentives, financial and otherwise, to rural hospitals that do not offer L & D and physician communities serving those hospitals to partner with nearby hospitals that do offer labor and delivery.
Overview. During the past year, the Center for Rural Prosperity and Innovation has investigated the option for the State of Georgia to engage in a focused proof-of-concept project called the Hub Cities Project, the essence of which would be to invest strategically in several cities around the state that are currently experiencing some degree of prosperity. The underlying premise is that the development of a comprehensive plan created through a state, local, and private partnership aimed at improving healthcare, transportation, education, business environment, workforce, public safety, and quality of life would drive state, local, and private investment in a way that creates new and greater prosperity.
The Hub Cities Project will be a major undertaking, requiring cooperation between state and local governments and the private sector. It will require sustained commitment and cooperation over several years to bear fruit.
With this document, we are proposing a first step and proof of concept that is a bit more focused and maybe more attainable in the short term. Initially, we proposed a Hub Hospitals project, but now we think a more direct and identifiable name may be Rural Maternal and Infant Health Centers of Excellence.
Over the past 30 years, the State of Georgia has witnessed the closure of many rural hospitals, limiting access to much-needed healthcare. The challenge of recruiting doctors to rural communities is made almost impossible when there is no hospital. Furthermore, the loss of a hospital places a community in a very daunting position relative to future economic development.
While hospital closure is the ultimate blow to a community, the loss of obstetrical, gynecological, prenatal, and postnatal care is nearly as harmful. It often leads to the loss of labor and delivery services.
This paper, and the related recommendation for action, focuses on the need to improve all aspects of maternal and infant healthcare in underserved areas of the State of Georgia. Specifically, the goal of Rural Maternal and Infant Health Centers of Excellence project is to extend maternal healthcare, including labor and delivery, to currently unserved counties. We acknowledge and appreciate recent efforts by Georgia’s Rural Health Innovation Center, Mercer University College of Medicine, and others that are aimed a improving maternal and infant healthcare throughout the State.
Background and state of care. Maternal, fetal, and infant health in Georgia faces significant challenges. According to World Population Review, the state has one of the highest maternal mortality rates in the United States, with 30.2 pregnancy-related deaths per 100,000 live births (1). Georgia’s Department of Public Health routinely reports pregnancy-related deaths of more than 33 per 100,000 live births (2).
Limited, or lack of, access to prenatal, perinatal, postnatal, and labor and delivery services is a fact across much of the State, but it is particularly apparent in rural Georgia. Central and South Georgia fare poorly across all six measures. Data for each of the measures is presented by county in the appendices (Figure 1).
Inadequate access to OB/GYN services is among the greatest challenges. The Georgia Public Policy Forum (3) cites that 82 counties do not have an OB/GYN, and 65 counties do not have a pediatrician (Figure 2).
We estimate that mothers in approximately one third of Georgia counties live more than 45 minutes from a hospital that provides labor and delivery services. The lack of a hospital offering labor and delivery means that an OB/GYN that lives in that county either has no hospital or has a hospital that does not support labor and delivery. It requires the physician to commute, sometimes long distances, to deliver their patients’ babies.
Notables are the areas in a band from extreme southwest Georgia diagonally to the South Carolina border in east central Georgia. There are several other labor and delivery deserts, but in most of the remaining cases, mothers have labor and delivery options in hospitals in adjacent counties.
Figure 1. Six indicators of maternal and infant health in Georgia.
Figure 2. Counties without OB units (doctors).
The number of babies born each year in many of these underserved or unserved areas is relatively small, but it leaves thousands of mothers and their babies without a standard of care for these medical services (Figure 4). It is these areas that often contribute impactfully to Georgia’s poor standing in maternal and infant healthcare statistics.
Figure 3. Counties with hospitals that provide labor and delivery to rural patients.
Figure 4. Births by county.
We carefully considered travel distances, number of births, and recent county statistics and identified ten (10) hospitals that could significantly improve access if they offered labor and delivery services (Figure 5). However, adding labor and delivery services at rural Georgia critical access hospitals will be very challenging.
Labor and delivery programs necessitate coverage 24 hours per day year around. Hence hiring a single OB/GYN will not make for a sustainable unit. It takes two and a significant support staff.
Recruiting OB/GYNS to serve in these small hospitals with limited support personnel and infrastructure will be challenging.
Relatively small numbers of patients, many of whom are uninsured, receiving assistance, or who may be cases requiring indigent care, makes the financial situation untenable for already struggling hospitals.
Many rural, critical access hospitals are already experiencing significant financial stress and will not willingly take on additional financial burdens.
For these and other reasons, bringing on new, stand-alone labor and delivery services may be unlikely. However, we believe that there are two tenable options to improve access.
Figure 5. Counties with hospitals that could consider adding L & D (red).
Tenable Strategy #1 - Stop further losses
We believe the most important and essential step for the State of Georgia is to minimize the potential for additional labor and delivery closures. We have reviewed labor and delivery numbers, financials, areas of unduplicated service, and potential travel distances to identify hospitals that are “at risk” of closing labor and delivery. We have identified six (6) hospitals for which closure of labor and delivery could happen and for which there would be a significant further reduction in access to labor and delivery for Georgia mothers (Figure 6). A seventh (7th) county, Wayne County, could be considered, as its leadership has indicated that they are having a very difficult time recruiting additional physicians[1]. Subsidizing these hospitals and ensuring against their closure will prevent significantly expanding the labor and delivery desert in Georgia.
Among considerations for subsidy were:
Geographic location within the State – meaning that their service is not duplicated in the region.
Labor and delivery revenue, which is a small portion of total revenue (or net revenue).
Loss of access should the hospital cease L & D – the additional number of unserved births that will result from closure.
Anticipated inability to restart L & D should the hospital discontinue L & D.
Figure 6. Hospitals that should be considered for subsidy (green).
Tenable Strategy #2 – Increase access by collaboration and partnership
Assuming that new L & D sites will be difficult to establish, especially in the short term, the State can increase access by promoting collaboration and partnerships. The State should provide incentives, financial and otherwise, to rural hospitals that do not offer L & D and to physician communities serving those hospitals to partner with nearby hospitals that do offer L & D. Physicians, and other providers, in the non-L&D communities would provide prenatal and postpartum care. Furthermore, they would be afforded referral and admission privileges to the L & D-providing hospital. This would improve access to prenatal and postpartum care and drive business towards L & D-providing hospitals, achieving a degree of economy of scale.
Among the high priority hospitals to seek collaboration with would be those that are situated within a 45-minutes’ drive time from unserved counties. The number of unserved and underserved mothers in the State can be substantially reduced if hospitals and physicians in communities without L & D will partner with nearby hospitals that do. The easiest solution is for hospitals with L & D to partner with adjacent counties. This would dramatically reduce the unserved area.
These strategies will produce the following results:
Closure of L & D services will stop.
The efficiency and effectiveness of the remaining L & D hospitals will improve.
Access to maternal healthcare, fetal, and infant healthcare will increase.
Maternal, fetal, and infant health indicators will improve over time.
In addition to these benefits, there will be significant cost avoidance for underserved and uninsured patients, for those who face financial and transportation challenges, for hospitals, and for the State of Georgia.
References
2024. World Population Review. Maternal Mortality Rate by State – 2024. https://worldpopulationreview.com/state-rankings/maternal-mortality-rate-by-state
2024. Georgia Department of Public Health. Maternal Mortality. https://dph.georgia.gov/maternal-mortality.\
2022. Georgia Public Policy Forum. Addressing Georgia’s Healthcare Shortage. https://www.georgiapolicy.org/news/addressing-georgias-healthcare-shortage/.
[1] Wayne Memorial consider ending labor and delivery. https://www.wtoc.com/2024/11/22/wayne-memorial-hospital-considers-ending-labor-delivery-services/
