Georgia enjoys its image as the Empire State of the South, a leader among its Deep South neighbors, the first to have an Olympic city and the first to send a native son to the White House.
But for all of its firsts, the state is worst — or at least among the very worst — in a key measure: its rate of maternal mortality.
Federal officials define maternal mortality as the death of a woman from a cause related to her pregnancy during that pregnancy or within a year after its termination. But analysis of the issue is difficult because states keep records differently, and the length of time a woman is considered “postpartum” differs too. As a result not many organizations offer comparative listings, but a report issued by Amnesty International in 2010 ranked the state 50th in maternal mortality. Another group, the National Women’s Law Center, in 2006 ranked Georgia barely ahead of Michigan at the bottom of the pack.
State officials do not quibble about where Georgia ranks and note that the numbers have risen since 2010. And they vow to do something about it.This KHN story also ran in Governing magazine. It can be republished for free (details).
“It’s a public health crisis, and the first step is in making everyone aware,” said Dr. Michael Lindsay, who chairs the state’s Maternal Mortality and Review Committee created by the Georgia legislature. “We want to make sure that childbirth is safe for every woman in the state.”
According to figures from its own report, it has a way to go. Georgia’s maternal mortality rate was 28.7 per 100,000 live births in 2011, the most recent year for which figures are available, according the committee report.
That is considerably higher than the national rate. In 2012, the most recent year for which figures are available from the Centers for Disease Control, the U.S. had a maternal mortality rate of 15.9 per 100,000 births. That was a decline from a high in 2009 and 2011 of a rate of 17.8.
“These staggering rates and the underlying racial and ethnic disparities” led to the committee’s formation, according to the introduction to the report. It noted that maternal deaths were four times higher among blacks than whites.
So far, the committee has analyzed and issued a report on only one year, 2012, in which 25 pregnancy-related deaths were identified. It is now reviewing deaths from 2013.
The cases take a long time to review, Lindsay and other members said. The committee is looking at many factors: hospital and clinical medical records; prescription medication history; coroner and autopsy reports; emergency transport records and police reports.
Some trends have emerged, and a few changes have been made, such as providing tool kits for patients with high blood pressure.
Problems Before, During And After Pregnancy
The report identified postpartum hemorrhage as the leading cause of death among those who died from pregnancy-related deaths in 2012. That was followed by hypertension, cardiac problems, embolism and seizure. Suicide and depression were last.
The committee also identified deficiencies in care in treating many of those conditions.
Those included a lack of mental health services for pregnant and postpartum women; women not accessing high-risk care, possibly due to lack of referral or geographic challenges; rural hospitals possibly having limited stores of blood products; lack of diligent follow-up for women at risk for complications; and women with chronic health issues not having access to effective contraception — or even consistent health care.
“One of the real concerns — and the report supports this — women are in poorer health when they get pregnant, and are not getting proper care,” Dr. Brenda Fitzgerald, the state’s public health commissioner and an OB-GYN, wrote in an email. “Chronic health conditions like obesity, hypertension, diabetes and heart disease are more and more common in pregnant women, and those conditions make delivery more dangerous.”
Those point to an over-arching issue, according to a health care advocate in the state.
“It’s about women not having access to care along the continuum,” said Cindy Zeldin, executive director of Georgians for a Healthy Future.
More than 70 of the state’s 159 counties do not have an OB-GYN. Since 1994, 35 labor and delivery units, mainly in rural hospitals, have closed, said Pat Cota, executive director of the Georgia OBGYN Society. The closures have accelerated in recent years, Cota said, with at least three labor and delivery units closing each year.
And yet, Lindsay said that the review indicated that 70 to 80 percent of women who died had received pre-natal care. It’s not clear, however, how regular or extensive that care was. The report also says that only 35 percent began prenatal care in the first trimester.
In addition, Lashea Wattie, an OB-GYN nurse and a member of the review committee, notes this is not just a problem in rural areas. “To blame it all on one area is a little naive, being in denial a little,” said Wattie, who works in a metro Atlanta hospital. “There’s a statewide issue that needs to be addressed.”
Quality Of Care Is A Problem
The quality and consistency of that care could be a factor, the experts said. For example, a lack of referral for high-risk, hypertensive, diabetic or obese patients to OB-GYNs with expertise in those areas could play a role. Among the cases in which the weight of the woman was known, more than half — 58 percent — were overweight, obese or morbidly obese.
“Things pile up on top of one another,” said Wattie. “Yes, it’s lack of transportation, but it’s bad food, smoking, a lot of things together.”
While hemorrhage, the leading cause of death, can be hard to predict, the report suggested that more could be done to treat it during labor. Providers may not recognize hemorrhage during childbirth and thus may delay urgent care. Blood supplies may not be sufficient, especially in small or rural hospitals, the report said.
Also, women should be informed that they could still hemorrhage even after they leave the hospital.
“They may think ‘I’ve delivered the baby; I’m fine,’” said Wattie.
Georgia is not alone in its hemorrhage problem, as deaths from hemorrhage are a big problem nationally.
Georgia’s leaders said they are determined to go from worst to, if not first, much better.
“As a doctor and the mother of two, I’ve been in the delivery room and I know how one of the happiest times in life can change in an instant,” said Fitzgerald, the public health commissioner.
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