Rural clinic scrambles to provide care amid maternal death crisis

By Tamar Hallerman | Atlanta Journal-Constitution | February 21, 2020

Medicaid limit, OBGYN shortage in Georgia hamper efforts

JESUP — Kendra Davis was swollen and lethargic when she arrived at the emergency room in this southeast Georgia railroad town in late November, less than three days after delivering her baby.

Throughout her pregnancy, the 33-year-old Davis suffered from preeclampsia, a hypertensive disorder that’s one of the country’s leading causes of maternal death. Now her blood pressure was so high her doctors feared she was on the verge of a stroke.

The mother of three survived. In the moment, though, Davis recounted, “you could actually feel your eyes sinking.”

The U.S.’s maternal mortality rate is among the highest of the developed world. Georgia has consistently ranked among the worst of U.S. states and more often than not – 60% of the time, according to one recent state estimate – those deaths were preventable. Most fatalities happen not during childbirth, but in the months following.

Last month a bipartisan state House committee that studied the deepening crisis delivered 19 recommendations. Its top ask: for the state to extend Medicaid coverage for poor mothers to one year after childbirth, up from two months currently.

Several top Georgia officials, including Gov. Brian Kemp and House Speaker David Ralston, say the issue is a priority. But broader budget fights threaten to sideline it this legislative session. Negotiations to cut overall spending and competing priorities mean there could be even less funding available to tackle the problem.

While data are spotty, the recent state study estimated new mothers in Georgia were 52% more likely to die in the first year after giving birth than nationally, at 25.9 deaths per 100,000 live births compared with 17, based on 2012-14 data. The situation is far worse for women who live in rural parts of the state or are older than 35.

The most glaring disparity is by race. Black mothers in Georgia are three to four times more likely to die than white women, according to the study.

“It is important to consider the impact that the loss of a mother has on families and communities,” said Elise Blasingame, executive director of the Healthy Mothers, Healthy Babies Coalition of Georgia.

Those deaths don’t tell the whole story. Labor and delivery often leave mothers with significant long-term health problems if not properly monitored. Pregnancy-related issues such as postpartum depression, high blood pressure and cardiac conditions sometimes emerge more than 60 days after childbirth, by which time Medicaid has expired and many low-income mothers are without insurance.

The factors that have kept Georgia at the bottom of U.S. states are complex and interlocking.

A woman’s medical history and physical health prior to pregnancy play major roles — obesity is considered a compounding factor, as is diabetes and high blood pressure. Georgia’s reluctance to expand Medicaid to all of the state’s poor adults puts particular strain on uninsured mothers. A growing body of research suggests the stress associated with being a black woman is another factor, as well as biases among medical staff that downplay the pain experienced by women of color.

Then there is Georgia’s spiraling rural health care crisis. Half of the state’s 159 counties don’t have an OBGYN and hospitals that are struggling financially often eliminate their obstetric services first.

Monty Veazey, president of the advocacy group Georgia Alliance of Community Hospitals, estimated at least one in eight of Georgia’s 160 hospitals have cut their obstetric units over the last five years.

“It’s very specialized and expensive” for hospitals to maintain, said Veazey. “And then to recruit an OBGYN to a rural area is almost impossible because there’s not a demand for as many deliveries.”

The Medicaid cliff

Among those on the front lines is Dr. Jeffrey Harris, whose obstetrics and gynecology clinic in Jesup has treated many particularly vulnerable women, including Davis.

Roughly 40 miles northwest of Brunswick, the city of about 10,000 sprung up after the Civil War and has been struck by the same economic hardships that have plagued other stretches of rural Georgia. More than one-third of Jesup’s residents live in poverty.

In many respects, Jesup is in much better shape than its neighbors. Wayne County has three working OBGYNs who split on-call duties at the local hospital seven days a week. Harris said he’s not aware of any maternal deaths in the county since he first began practicing there in 2001.

Still, Harris’ hours are long and unpredictable. And finances can be tight: his staff spends hours on the phone every day battling with insurance companies whose reimbursement rates are often at or below cost.

“I see this as God’s work,” said Harris, an ex-Army doctor who as a child cut up his teddy bears so he could sew them back together.

Harris estimates that more than 80% of his obstetric patients are poor enough to qualify for Medicaid or other state subsidies. Pregnant women in households that earn less than 200% of the federal poverty level — or about $34,000 for a family of two and $52,000 for four — are eligible for Medicaid in Georgia, which covers doctors’ visits, prescription drugs and hospital services, including labor and delivery. But only for up to two months after they give birth.

That funding cliff helps shape the kind of coverage Harris gives and when, since many of his patients don’t otherwise have health care or have high-deductible plans that are unaffordable without Medicaid as a supplement. (Statewide, roughly half of Georgia’s births are covered by the safety net program).

Often, Harris and his colleagues race to coordinate medical procedures for new moms about to lose their Medicaid, including connecting them with specialists for procedures like removing gallbladders, which are more common after giving birth. Many of his patients disappear after the two-month postpartum window closes, unable to afford their health care bills.

“The clock is ticking,” Harris said. “Not only do you want to get the surgery done, you want to make sure there’s adequate time afterwards for follow-up in case there’s a complication.”

The fast-approaching Medicaid deadline was at top of mind of an exhausted-looking Joy Holder as she arrived at Harris’ office with her 16-day-old son, Prince, one recent rainy Thursday.

The 30-year-old will not have insurance once her Medicaid expires this spring — she quit her retail job before giving birth — and she was worried about losing the pricey medications the program has helped cover, as well as taking care of kidney stones that plagued her final months of pregnancy.

Holder was pensive when a nurse asked whether she wanted to have her tubes tied in the weeks ahead. State law requires a 30-day waiting period once mothers on Medicaid decide to have the procedure, leaving a small window for patients to make a decision postpartum. Not only that, but Holder feared the procedure’s recovery time would make it difficult to care for Prince.

“There’s quite a bit that I have going on, and I have to do all of that and raise a child alone,” said Holder.

Holder does not own a car and walks to all of her appointments from her apartment about a mile away. After her check-in at Harris’ clinic, she tucked Prince into his black and gray stroller, a polka dot diaper bag slung over her shoulder. Then she lingered outside the lobby for a rainstorm to pass before setting out.

Harris estimates that on any given day, about a quarter of his patients are no-shows, some of them due to lack of transportation, others because they can no longer afford his services after they lose their Medicaid.

‘Don’t want the debt’

In 2018, Georgia’s legislature began setting aside money to address the state’s higher maternal mortality rates. It allocated $2 million for hospitals in underserved areas to improve their maternal care.

The money has helped fund grants for rural hospitals to tackle the top causes of maternal death such as severe hypertension. And several Georgia universities, including Mercer, the Morehouse School of Medicine, Emory and the Medical College of Georgia, have begun devoting resources toward fighting the problem.

Still, the pinch is being felt at Jesup’s Wayne Memorial, which delivers about 60 babies a month and is the county’s only hospital.

“We’re picking up a heavier patient load with the same staff, the same providers. Our physicians have more pressure and more demands than they’ve ever had,” said Lois Hershberger, a perinatal nurse at the hospital. “In a rural area, that adds to a lot of stress and not a lot more income.”

The hospital recently won a public-private $100,000-year, five-year grant to implement best practices for some of the most preventable causes of maternal death. Hershberger has changed protocols to take the guessing out of measuring blood loss when a patient is hemorrhaging, and outfitted a cart with all the necessary supplies, medications and instructions to streamline care during such an emergency.

“We don’t have three layers of perinatal ICU” like bigger cities, she said. “So my protocols will look different than Atlanta’s or Savannah’s (hospitals).”

In the state Capitol, there appears to be some consensus around extending Medicaid for new moms, even among Republican leaders who have rejected expanding the program for the rest of Georgia’s population. Gov. Kemp, in a statement to The Atlanta Journal-Constitution, said the state’s maternal mortality statistics are “alarming and require action” but that “comprehensive solutions will take time.”

Cost remains the big factor as lawmakers weigh other big-ticket budgeting priorities that include a teacher pay raise and income tax cuts. That’s prompted some lawmakers to float a six-month postpartum Medicaid period as an alternative. The debate is expected to heat up in the weeks ahead as the state legislature begins drafting the budget for the 2021 fiscal year.

The reality in Harris’ clinic — its walls lined with photos of babies delivered and local sports leagues sponsored — is that many of its patients are at a higher risk of dying from pregnancy-related causes until changes are made because they can’t afford longer-term care.

Hariette Doomes, a 39-year-old patient, is in many ways a high-risk case. She’s an older mom, is overweight and had high blood pressure during her recent pregnancy. She’s visited the ER twice since delivering her daughter Promise in late December.

Doomes said she’s eligible for health insurance through her job as manager of a fast food restaurant, but that the rates are often unaffordable. Once her Medicaid runs out, she’ll likely forgo health care “until I have to go” because “I don’t want the debt,” she said.

Davis, meanwhile, is determined to avoid another emergency room stay even though she receives insurance through her job. She’s now closely watching her salt intake and trying to exercise more to lose weight and get her blood pressure under control. She said she feels reassured whenever she sees Harris.

Finding doctors like him, though, is becoming a growing challenge in rural Georgia.

The state has some tax breaks and incentives to fill positions in rural areas, but Veazey of the Georgia Alliance of Community Hospitals said more perks are needed to lure doctors to health care deserts.

Harris and his wife Antonia, a trained social worker who manages the office at the Jesup clinic, are in their early 60s and hoping to retire or at least scale back in the years ahead. But he’s not sure who would replace him.

“It doesn’t do any good for (legislators) to extend Medicaid to a whole year if we have nobody to deliver the care,” said Harris. Rural doctors, he said, are “either going to die or retire, and who’s going to be left to run the ship?”

Staff writer Ariel Hart contributed to this article.