As her husband sped toward University Hospital in Augusta, more than an hour from their home in Wilkes County, Sarah Smith just had to hang on and hope the contractions didn’t come sooner and that the jostling wouldn’t speed things up.
“That car ride – every time Saul, my husband, would take a turn I would say, (gasp) ‘Slow down! Don’t shake me!’” she said from her hospital bed at University. “It was an adventure.”
Eleanor Lynn Smith came in at 8 pounds, 1 ounce without incident hours later Aug. 14. Despite the distance, the family is loyal to University and its doctors and doesn’t mind traveling to get care at the hospital, Sarah Smith said.
“There was no question that we were going to come here,” she said.
But for many women in Georgia, the options for where to give birth have been dwindling rapidly as more hospitals close labor and delivery units or shut down altogether, particularly in rural areas.
The number of doctors who will deliver babies has also become increasingly scarce outside major metropolitan areas, and many of those are getting close to an age when obstetricians typically stop doing deliveries. A looming physician shortage nationwide and in Georgia will not help to reverse what some see as already disturbing trends for mothers and babies in the state and in other rural areas across the country.
There was a lot of anecdotal evidence this was happening but Pat Cota, the executive director of the Georgia OBGyn Society, didn’t have evidence she could present to the state Legislature.
“She didn’t have any data to support all of those anecdotes,” said Dr. Adrienne Zertuche, an OB/GYN resident at Emory University.
Cota convinced Zertuche to look into it in 2010, calling programs and gathering evidence on labor and delivery hospitals and obstetricians.
What Zertuche found was unnerving.
“We knew there was going to be some issues,” she said. “But the fact that in our first study, over half of the areas outside metropolitan Atlanta were underserved or completely devoid of obstetric practitioners was shocking.”
Worse, when they began to look in 2011 at who was still delivering babies in these areas, many were on the verge of stopping or would be in the next few years because of their age. The study predicted that within five to 10 years, the number of underserved areas in the state would increase from 52 percent to 75 percent or that three-quarters of Georgia would be without adequate services.
Birthing centers have been closing at an accelerated pace. Five have closed just within the past two years, including those in Burke and Emanuel counties, and 34 have closed over the past 20 years, “which is just incredible,” Zertuche said.
That is affecting not only pregnant women, who must travel greater distances to get prenatal care or possibly go without, but also new mothers who need care after the birth, said Dr. Chad Ray, the OB/GYN residency director at Georgia Regents Medical Center. As a result, once rare complications are now becoming more commonplace, he said.
For instance, if a mother delivers, is not on contraception and gets pregnant again right away, the placenta might overgrow and invade nearby organs, creating the possibility for potentially life-threatening problems such as a hemorrhage.
“We’re seeing more complications such as that,” Ray said, “which should be quite a rare complication and we’ve seen it four or five times (in the past year).”
It is not just rare complications that are becoming more common at those centers that are still delivering babies, Zertuche said.
“Patients are coming in with things that could have been prevented or at least could have been better controlled if they had access to appropriate services,” she said.
Georgia Regents works with some family practice doctors in Burke County to provide prenatal care, and there are scattered providers such as a midwife in other counties that can help, Ray said. But there isn’t much else in this area of the state.
“I’m not exactly sure where those folks are getting their prenatal care if they’re not traveling to Augusta or Savannah or Statesboro,” Ray said. “Certainly there are more patients that are not having prenatal care because of the distance. We know that’s true; we see a number of patients who have had limited prenatal care.”
That can also put pressure on obstetricians in those urban hospitals to induce early – a practice many organizations and hospitals say should be avoided if possible – because the mother lives an hour or more away.
“You’re always taking a risk sending them out of your office that they are not going to make it to 39 weeks” or full term, Ray said. Studies have found that risk of prematurity is 1.5 times higher if the mother has to drive an hour or more to deliver, he said, and premature babies can face lifelong consequences.
Ultimately, Ray said, the effect of this could be seen in the maternal mortality rate, defined as the death of a mother during pregnancy or the first year after birth. Georgia’s rate led the nation in 2011 and the Augusta health district had the highest rate within Georgia, according to a previous analysis by The Augusta Chronicle. And that was before the most recent round of closures.
Lack of OB/GYNs affects women throughout their lives, Cota said. If women aren’t getting good health care overall, they will be in worse shape if they become pregnant, and that also has a big effect on outcomes, she said.
“We’re not able to counsel them, coach them, get their hypertension under control, get their diabetes under control, get their health in good shape to become pregnant,” Cota said.
There was some good news earlier this year. The Georgia OBGyn Society was able to present Zertuche’s work to the Legislature and got a slight increase in Medicaid payments, the first in about 14 years, Zertuche said.
“But we have a long way to go on that,” Cota said. “First you have to have a hospital, so we have to stem the tide of the obstetrical units closing. Someone needs to take a look at that. Then incentivize (obstetricians) to practice there.”
With the physician shortage looming over a state that is already wanting, Ray doesn’t try to sugarcoat his vision of the future, particularly for those already struggling rural areas.
“Yeah, it is going to get worse,” he said. “I think it is just the tip of the iceberg. We don’t know quite yet how those closures are going to affect us. The workforce shortage is going to be bad.”