Access to maternity care is essential for achieving optimal maternal health and maternal health equity while preventing poor maternal health outcomes (including severe maternal morbidity and maternal mortality).^1,2 The lack of access to risk-appropriate care contributes to the excess rate of maternal mortality in the United States relative to comparable nations and to the stark disparities in maternal health outcomes within the United States. Millions of U.S. women have limited or no access to maternal care, and access barriers are compounded among those of lower socioeconomic status, belonging to racial and ethnic minority groups, and residing in rural areas.^2,3

Georgia is among the states for which access to maternity care is challenging for a substantial portion of the birthing population. Recent research supports that the farther in distance an individual travels to receive maternity care, the greater the risk of adverse maternal and infant health outcomes.^4,5

In Georgia, 15.8% of women had no birthing hospital within a 30-minute drive (compared to 9.7% of U.S. women). Maternity care deserts are defined as U.S. counties that lack obstetrical care providers (obstetrician-gynecologists, family physicians who deliver babies, certified nurse midwives or other midwives) and without a birth center or hospital offering obstetric care.

In 2021, more than one-third of Georgia counties (34.6%) were classified as maternity care deserts (compared to 32.6% of U.S. counties).⁶ Sixty-three percent of Georgia’s rural hospitals do not provide obstetrical services.⁶ Not surprisingly, in Georgia’s rural areas, 61% of women live over 30 minutes from a birthing hospital compared to 13% of women in non-rural areas, and those in maternity care deserts traveled three times farther to access maternity care than did women living in areas with full access.⁶

In addition to distance to maternity care and the availability of maternity care providers, sociodemographic and cultural characteristics of the birthing population and the communities in which they reside provide greater context around barriers to receipt of appropriate care. According to the U.S. Maternal Vulnerability Index, a county-level measure that reflects 43 indicators across six themes relevant to maternal health (reproductive healthcare, physical health, mental health and substance abuse, general healthcare, socioeconomic determinants, physician environment),⁷ women living in 20.8% of Georgia counties have a very high or high vulnerability to adverse outcomes.

Across racial and ethnic groups, those living in areas of higher socioeconomic vulnerably are less likely to access adequate prenatal care than those living in areas of lower socioeconomic vulnerability. In particular, Georgia’s racial and ethnic minority women living in areas of higher socioeconomic vulnerability had an approximately 40% increased likelihood of inadequate prenatal care when compared to those living in areas of lower socioeconomic vulnerability.⁶

Access to maternity care has worsened in many areas of the United States in recent years, including in Georgia. Between 1994 and 2023, 41 labor and delivery units across Georgia closed. There were more closures in counties in which the majority of the population is Black, resulting in a quarter of Black women and a third of white women residing in counties with little or no access to maternity care.⁸

Factors contributing to the closure of obstetrical care units include financial strains related to low reimbursement or no reimbursement (in settings where deliveries are not covered by health insurance) and shortages of obstetrical care providers to staff delivery hospitals.^9,10

The U.S. has fewer obstetricians and midwives than other high-income countries (the number of midwives in the U.S. is 4 per 1,000 births vs. 25 to 68 per 1,000 births in comparable countries),¹¹ with ratios low in Georgia. ¹² Georgia’s scope of practice laws have been criticized for contributing to maternity care deserts, because Georgia is among the most restrictive states, requiring a written agreement between a physician and up to four certified nurse midwives that outlines overall prescriptive and practice authority and responsibilities that require physician supervision and/or approval.¹³ The Black Mamas Matter Alliance provides an in-depth policy brief on how the expansion of midwifery licensure and scope of practice in Georgia can improve access to appropriate care in rural and underserved areas, especially for racial and ethnic minority women.¹⁴

Similarly, Georgia’s certificate of need program, one of the most restrictive in the nation, has been criticized as contributing to maternity care deserts as the opening of labor and delivery units is burdensome and allows existing hospitals to file objections to new applications, while there are few regulations for closing such units.⁸ Another hospital-focused policy that could help address maternity care deserts include investing in community-based maternity services by improving the readiness of hospitals lacking maternity services to provide safe deliveries when needed.¹¹

State Medicaid policy is also recognized as an important lever for improving access to maternity care.¹ Medicaid expansion under the Affordable Care Act (adopted by all but 10 states, with Georgia being among the non-expanding states) achieves expanded coverage of more women of reproductive age prior to pregnancy and postpartum and is linked to improved access to healthcare and economic benefits for states, hospital systems and healthcare providers (especially in areas where substantial proportions of the population fall into the coverage gap between eligibility for low-income Medicaid and Affordable Care Act plans).^15.

In 2021, a provision of the American Rescue Plan Act gave states the option to extend Medicaid postpartum coverage through 12 months to enhance coverage stability and to help address racial disparities in maternal health outcomes. As of March 2024, 46 states and Washington, D.C., including the state of Georgia, have implemented a 12-month Medicaid postpartum extension.¹⁶ Enhancing the reimbursement for Medicaid-covered maternity care services (to be more similar to private health insurance) and the amending of state Medicaid plans to assure coverage of midwifery and doula care as well as services at home and in freestanding birthing centers are other Medicaid policy strategies viewed as important for addressing maternity care deserts and, in particular, for improving accessibility of culturally competent and culturally congruent care. ^11,17

Telehealth services, which have expanded with the growth of broadband services, show great promise for improving access to maternal healthcare, especially for socioeconomically marginalized populations^18,19 However, existing studies of the delivery of maternal care via telehealth have mostly focused on low-risk patient populations, so additional implementation and evaluation research is needed with higher-risk patient populations.²⁰

A recent brief outlines the great potential to expand maternity care telehealth in Georgia, highlighting the work of the Georgia Health Information Network, which recently received a $1-million grant to promote rural healthcare services, is partnering with a regional health information exchange to assess and securely share vital medical information electronically; the Georgia Rural Health Innovation Center, established in 2018 at the Mercer School of Medicine; and the Georgia Health Policy Center, which is providing evaluation support in collaboration with the coalition of Maternal Telehealth Access Project partners for a project that focuses on promoting healthy conception, pregnancy and delivery, particularly for Black, Native American and Latina women, and women who live in rural and frontier communities.²¹

Education and training policies that offer scholarships and loan forgiveness for obstetrician and midwifery trainees and graduate education funding for institutions that develop obstetrical residency and nurse midwifery programs serving rural hospitals are important for addressing maternity care deserts. Further, it is increasingly recognized that workforce approaches should also attend to the expansion and diversification of the perinatal workforce as a strategy for enhancing maternal healthcare access, accessibility and equity.¹¹

Both child birthing centers and midwife models of care as a hallmark include the provision of continuous support during labor, which is associated with shorter labor, lower rates of instrumental vaginal deliveries and cesarean deliveries, and higher newborn Apgar scores.^22,23 Growing data support that when a midwife is part of an integrated network of care, midwife-attended deliveries have comparable outcomes with in-hospital births for low-risk women.²⁴

Emerging data support that the incorporation of racially concordant, community-based patient navigators, community health workers and doulas in maternal care enhances the cultural-competence of care while addressing discrimination, systemic racism and institutional barriers to quality care and that such transformational models offer promise for improving patient experiences, outcomes and costs.^25,26 The use of doulas is growing, including through Healthy Start funding of community-based doula initiatives.²⁶

In summary, the assurance of adequate and accessible perinatal and birthing care for the U.S. birthing population is essential for achieving improvements in maternal health outcomes and maternal health equity. Strategies to improve access to care include expanding scope of practice, the extension and expansion of Medicaid, increased telehealth services and a greater investment in training for maternal health providers. The availability of resources and the political will to enact change are increasingly available within the state of Georgia to achieve these ends.

---

References

1. Brigance C, Lucas R., Jones, E., Davis, A., Oinuma, M., Mishkin, K. , Henderson, Z. Nowhere to Go: Maternity Care Deserts Across the U.S. (Report No. 3). March of Dimes; 2022. Accessed March 15, 2024. https://www.marchofdimes.org/maternity-care-deserts-report
2. Hernandez ND, Aina AD, Baker LJ, et al. Maternal health equity in Georgia: a Delphi consensus approach to definition and research priorities. BMC Public Health. Mar 30 2023;23(1):596. doi:10.1186/s12889-023-15395-3
3. Tikkanen R, Gunja, M.Z., FitzGerald, M., Zephyrin, L.C. Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries. The Commonwealth Fund; 2020. Accessed March 15, 2024. https://www.commonwealthfund.org/publications/issue-briefs/2020/nov/maternal-mortality-maternity-care-us-compared-10-countries
4. Roa L, Uribe-Leitz T, Fallah PN, et al. Travel Time to Access Obstetric and Neonatal Care in the United States. Obstet Gynecol. Sep 2020;136(3):610-612. doi:10.1097/aog.0000000000004053
5. Minion SC, Krans EE, Brooks MM, Mendez DD, Haggerty CL. Association of Driving Distance to Maternity Hospitals and Maternal and Perinatal Outcomes. Obstet Gynecol. Nov 1 2022;140(5):812-819. doi:10.1097/aog.0000000000004960
6. Fontenot J, Lucas, R, Stoneburner, A, Brigance, C, Hubbard, K, Jones, E, Mishkin, K. Where You Live Matters: Maternity Care Deserts and the Crisis of Access and Equity in Georgia. . March of Dimes; 2023. 2023. Accessed March 15, 2024. https://www.marchofdimes.org/peristats/reports/georgia/maternity-care-deserts
7. Ventures S. Getting hyperlocal to improve outcomes & achieve racial equity in maternal health: the US Maternal Vulnerability Index. 2021. Accessed March 15, 2024. https://surgoventures.org/resource-library/getting-hyperlocal-to-improve-outcomes-achieve-racial-equity-in-maternal-health-the-us-mvi
8. Snipe M. Black Women Are Losing Access to Maternity Care. This Law Is Partly to Blame. . Capital B News; 2023. March 9, 2023. Accessed March 15, 2024. https://capitalbnews.org/dangerous-deliveries-maternal-care-deserts/
9. Kozhimannil KB, Interrante JD, Admon LK, Basile Ibrahim BL. Rural Hospital Administrators’ Beliefs About Safety, Financial Viability, and Community Need for Offering Obstetric Care. JAMA Health Forum. Mar 2022;3(3):e220204. doi:10.1001/jamahealthforum.2022.0204
10. Daymude AEC, Daymude JJ, Rochat R. Labor and Delivery Unit Closures in Rural Georgia from 2012 to 2016 and the Impact on Black Women: A Mixed-Methods Investigation. Matern Child Health J. Apr 2022;26(4):796-805. doi:10.1007/s10995-022-03380-y
11. Sonenberg A, Mason DJ. Maternity Care Deserts in the US. JAMA Health Forum. Jan 6 2023;4(1):e225541. doi:10.1001/jamahealthforum.2022.5541
12. Nurse-Midwives ACo. Midwifery Fact Sheet: Georgia. 2023. 2023. https://www.midwife.org/acnm/files/cclibraryfiles/filename/000000009080/Georgia.pdf
13. MidwifeSchooling.com. States that Allow CNMs to Practice and Prescribe Independently vs those that Require a Collaborative Agreement. MidwifeSchooling.com. Accessed March 15, 2024. https://www.midwifeschooling.com/independent-practice-and-collaborative-agreement-states/
14. Black Mamas Matter Alliance PD. Issue Brief: Expanding Midwifery Licensure in Georgia. 2022. https://reproductiverights.issuelab.org/resources/42612/42612.pdf
15. Gurth M, Diep, K. What does the recent literature say about Medicaid expansion? Impacts on sexual and reproductive health. 2023. June 29, 2023. https://www.kff.org/affordable-care-act/issue-brief/what-does-the-recent-literature-say-about-medicaid-expansion-impacts-on-sexual-and-reproductive-health/
16. Foundation KF. Medicaid Postpartum Coverage Extension Tracker. . Kaiser Family Foundation; 2024. March 8, 2024. Accessed March 15, 2024. https://www.kff.org/medicaid/issue-brief/medicaid-postpartum-coverage-extension-tracker/
17. Alliance BMM. Issue Brief: Black Maternal Health. 2022. April 2022. Accessed March 15, 2024. https://blackmamasmatter.org/wp-content/uploads/2022/04/0322_BMHStatisticalBrief_Final.pdf
18. Butler Tobah YS, LeBlanc A, Branda ME, et al. Randomized comparison of a reduced-visit prenatal care model enhanced with remote monitoring. Am J Obstet Gynecol. Dec 2019;221(6):638.e1-638.e8. doi:10.1016/j.ajog.2019.06.034
19. Marko KI, Ganju N, Krapf JM, et al. A Mobile Prenatal Care App to Reduce In-Person Visits: Prospective Controlled Trial. JMIR Mhealth Uhealth. May 1 2019;7(5):e10520. doi:10.2196/10520
20. Ukoha EP, Davis K, Yinger M, et al. Ensuring Equitable Implementation of Telemedicine in Perinatal Care. Obstet Gynecol. Mar 1 2021;137(3):487-492. doi:10.1097/aog.0000000000004276
21. Saravanana S. How tele-health can prevent maternity care deserts. Capital Corner. 2024. February 14, 2024. Accessed March 15, 2024. https://www.spencerfrye.com/how-tele-health-can-prevent-maternity-care-deserts/
22. Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Rev. Apr 28 2016;4(4):Cd004667. doi:10.1002/14651858.CD004667.pub5
23. Bohren MA, Hofmeyr GJ, Sakala C, Fukuzawa RK, Cuthbert A. Continuous support for women during childbirth. Cochrane Database Syst Rev. Jul 6 2017;7(7):Cd003766. doi:10.1002/14651858.CD003766.pub6
24. Hutton EK, Reitsma A, Simioni J, Brunton G, Kaufman K. Perinatal or neonatal mortality among women who intend at the onset of labour to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: A systematic review and meta-analyses. EClinicalMedicine. Sep 2019;14:59-70. doi:10.1016/j.eclinm.2019.07.005
25. Zephyrin LC, Seervai, S., Lewis, C., Katon, J.G. Community-Based Models to Improve Maternal Health Outcomes and Promote Health Equity. The Commonweath Fund; 2021. March 4, 2021. Accessed March 15, 2024. https://www.commonwealthfund.org/publications/issue-briefs/2021/mar/community-models-improve-maternal-outcomes-equity
26. Van Eijk MS, Guenther GA, Kett PM, Jopson AD, Frogner BK, Skillman SM. Addressing Systemic Racism in Birth Doula Services to Reduce Health Inequities in the United States. Health Equity. 2022;6(1):98-105. doi:10.1089/heq.2021.0033

---

Dr. Anne Dunlop

Dr. Dunlop is a public health-oriented physician whose research focuses on understanding the biological, social and clinical underpinnings of racial and ethnic disparities in adverse birth, maternal and infant health outcomes and evaluating practice and policy solutions for ameliorating these. She is board certified in family medicine and preventive medicine and is a gynecology and obstetrics professor at the Emory School of Medicine. She provides clinical services and performs clinical research within Emory and Grady Health systems.

Dr. Erin Poe Ferranti

Dr. Ferranti is an assistant professor of nursing at the Nell Hodgson Woodruff School of Nursing with additional appointments in the Department of Gynecology and Obstetrics, Emory School of Medicine and in the Nutrition and Health Sciences Program at Emory University. She is a Fellow of the American Academy of Nursing, the American Heart Association and the PreventiveCardiovascular Nurses Association,