Maternal Mortality: Spotlight Georgia
“The risk of death from pregnancy and child birth varies greatly by state, more than is explained by mere demographics, which suggests that this risk of death is not a ‘natural’ distribution, but that state-by-state policies are implicated.” -- When the State Fails: Maternal Mortality & Racial Disparity in Georgia, 2018
What’s the state got to do with it?
Anyone and everyone reading this post is aware of the now (thankfully) much repeated statistics around maternal mortality in the United States: That we have the only rising maternal death rate in the ‘developed’ world, and that Black women are 3-4x more likely to die in or immediately following childbirth than white women. As informed birthworkers, we are aware of the fact that it is not biologically driven factors undergirding these disparities, but cultural biases. That’s true in the reality that 60% of US maternal deaths are considered preventable, meaning that maternal deaths amongst all birthing people here are largely a factor of culture and medical access, and that is even more apparent in explaining the vast gaps in treatment leading to maternal morbidity and mortality (as well as poor infant outcomes) when factoring in race.
What is not often meted out in even our education is how this is divided amongst individual states within the United States, which is an important component of understanding and addressing this issue as advocates; as supporters or critics of doula legislation packages; and for any of us engaging in conversations around diverse realities of birthing options in the US including freebirthing, access to midwifery care, Black maternal health policy; Medicaid expansion efforts; etc. It is essential that we take both a narrowly focused microscope to our immediate community issues around birth, as well as a wide shot of what disparities exist across the United States in order to understand the way forward.
In that vein, let’s take a look at Georgia. The state of Georgia has one of the lowest numbers of obstetrical practitioners per capita in the country and one of the highest maternal mortality rates (48th in the US as of 2017). Additionally, according to the PeriStats compiled by March of Dimes, the rate of severe maternal morbidity in Georgia was nearly 78 per 10,000 live births in 2016 and 73 per in 2017 as compared to those same years in South Carolina 67 and 69 cases per 10,000; 54 and 58 per 10,000 in Maine; and 60 and 65 per 10,000 in Oregon, respectively*. Georgia also has a preterm birth rate of nearly 12% overall and that number parses out to over 14% for Black birthing women versus 10% for white women. The maternal mortality rate in the state in 2016 was 40.8 per 100,000 live births but parsed is 27.1 for white women and 62.1 for Black women, making it one of the least safe places in the country to give birth.
Georgia and low access to obstetrical care
Part of the reason for this is due to the wide lack of medical coverage, both in providers and in insurance coverage across the state. Georgia did not expand Medicaid coverage under the Affordable Care Act, which has left many of its residents in a coverage gap, where they make too much to be considered low income and receive medical benefits, but don’t make enough for them to actually afford supposedly affordable health coverage. It’s estimated that nearly 2 million people in the US fall into this coverage gap, thanks to states like Georgia, Texas, North Carolina, and Wyoming not expanding Medicaid coverage.
Georgia is the 5th poorest state in the US and over half the births in the state are covered by Medicaid. As the Yale Law report from 2018 When the State Fails: Maternal Mortality & Racial Disparity in Georgia notes, “although Georgia presumes Medicaid eligibility for pregnant women in order to speed them through the enrollment process, it can still take weeks to start receiving coverage,” and that coverage only extends into 60 days postpartum.
It is worth noting that one of the reasons cited for the increased rates of maternal morbidity and mortality over the past five years is due to better reporting measures and an increased focus on finding and addressing the data and root causes, however, the rise in these stats is not solely from reporting changes. Georgia is a prime example of this matter and why there needs to be a continued focus on the systemic issues facing the pregnant and birthing populations in that state which lead to the dismal outcomes.
Is anyone on this plane a doctor!?
Across the country, there is a trend of doctors aging out of obstetrical practice and not enough medical students specializing in obstetrics to fill the gaps. Additionally, there is a particular shortage of obstetrical care in rural regions in all US states. Add to that the fact that though nurse midwifery is now legal in all fifty states, there exists such a broad range of intentionally imposed limitations around midwives practicing in most states, as well as major barriers for access to their care for many families.
This leaves the majority of families in places like rural Georgia without an obstetrical care provider, including a midwife, or a hospital with a labor and delivery unit within an hour of their homes. That number decreases again when considering which hospitals and obstetrical/midwifery practices take Medicaid clients. We see yet another reduction in options when also looking at where birthing people of color can find a Black doctor or midwife to care for them in that state.
It’s estimated that around 60% of maternal deaths are preventable, which means that there is a broad factor blend leading to mortality rates that go beyond biology. This is abundantly true when considering the higher Black maternal death rate, when it’s been proven that systemic bias in care is at the cause of the rate disparity when factoring out economic status, educational background, insurance coverage, and age when looking into the high rates of poor outcomes amongst Black mothers.
Another factor causing there to be such a divide in outcomes not only amongst Black birthing people in the US, but more broadly as compared with other countries is in the prevalence of Crisis Pregnancy Centers, which are fronts for actual medical establishments which push pregnant people away from seeking an abortion without offering actual early pregnancy medical care like adequate screenings, tests, education, nutritional support, or means to find and finance a provider for birth. They may confuse these centers for medical care and not seek out a care provider at all.
Pregnant people who wind up getting this subpar and non clinical care in the first trimester may have a large gap in coverage of care when they do carry their pregnancies to term, are typically getting mostly medical misinformation, and may be delaying access to diagnostic tools to prevent and treat conditions of pregnancy that may eventually result in poor outcomes for their babies and their own bodies, including fatal ones. Many states, including Georgia, help fund these Crisis Pregnancy Centers at the state level through grants.
Across the pond.
In returning to the issues around reporting maternal mortality data, the Yale Law report notes that although Georgia’s maternal death reporting system meets the basic requirements within the US in terms of reporting methods, it only meets the minimum requirements on the reporting side and has failed to turn those findings into meaningful policy changes. This is true of many states across the US, and is partly why there has been a push at the federal and state levels for more “MOMNIBUS” bills which seek to take the key findings of many of these maternal mortality review committees (MMRCs) to advocate for productive legislative initiatives.
According to a ProPublica piece from 2017, “Why Giving Birth Is Safer in Britain Than in the U.S.” by Kate Womersley, the UK has seen a reduction in maternal mortalities following committed action steps taken following their robust and thorough maternal mortality commission reportings. There was a time where the US and the UK had matching mortality stats, but inaction in the US (amongst other factors) has caused our mortality rates to surge even after improvements to reporting where action in the UK has produced better outcomes nation-wide. Though, of course in hindsight we see that it isn’t all stars and roses in the UK either. There have been a number of scandals in the UK around an increase in maternal and infant trauma as a result, supposedly, of a push to reduce cesarean births at all costs.
We can look, as usual, to Robbie Davis-Floyd’s warnings around the technocratic model of birth as the dominant narrative, even in cases where there is midwifery care that’s more medicalized and integrated into the medical industrial system, can cause as many problems, if different problems, as what they seek to replace. The NICE Induction Guideline draft citing routine induction at 39 weeks as a method of improving maternal outcomes for Black, Asian, and aged over 35 years old persons as one such example of this six one way - half a dozen the other mode of seeking to address a problem with a problem. Some argue that putting more women obstetricians into practice alone, or putting more doctors of color into the same system that’s failing is as equally shallow and likely ineffective as keeping the status quo (just spend a day on Twitter or Instagram and you’ll see just that conversation…).
It’s the systems
Clearly, the issue within Georgia and elsewhere in the US, the core of the problems are deeply systemic. We cannot argue towards the need to fill gaps in obstetrical coverage while not advocating for changes in midwifery legislation while also having battles against midwifery legislation from the pro-midwife side.
This, in part, adds fuel to the fire against drives for fully autonomous midwifery practice (that is, midwives being permitted to practice without obstetrician guidance), even and maybe especially when these arguments are strangely backed by such far-Right free market think tanks as the Heritage Foundation and the American Enterprise Institute.
Even ACOG has put out statements around expanding access to midwifery care (of course, just obstetrically supervised, nurse-midwifery care) in rural places to meet the demands OBGYN’s are unable to fulfill. Though this is clearly not a full addressing of the problems in the obstetrical model and for-profit hospital model, it is a small way forward in making meaningful progress.
Obviously, medical school needs to address their underlying biases around the standard ideas of birth and birth complications, the deep misogyny that exists in the very foundations of obstetrical knowledge, the anti-primitiveness that pervades modern medical thought, the legacy of eugenics and it’s particularly deep roots in obstetrical care especially, and other compounding matters of racial and class bias throughout medicine. Hospital policy needs to reflect those concerns as well. We need greater access to autonomous midwifery care, including more birth centers and home birth midwives who are licensed in such a way that they have access to life-saving supplies and are faced with bias which prevents the possibility of safe transfer of care in the case of emergency -- that includes insurance providers, including Medicaid and state funded insurance which pays independent midwives for care even after a transfer. There needs to be more Black midwives and obstetricians broadly, and particularly in areas where there is a large practice population of Black birthing people. We need universal health care.
What can doulas do?
I am a strong advocate for birth workers making horizontal career moves in order to help move us forward in addressing these issues. What I mean by that is, when faced with the typical cycles of burn out that exist amongst midwives and doulas after 2.5-5 years of attending births, a move to working in government, in training in social work, working in insurance companies and HR departments, non-profit and NGO work at organizations like the National Health Law Partnership and Black Mama’s Matter Alliance, etc. will likely do more to advocate for the necessary and dire changes needed in maternal and infant mortality in the US than a compromised doula practice based around shift work or simply serving wealthy clients privately for another 5 years.
I believe more doula training organizations owe their students a frank discussion around that fact, too, so we can destigmatize the idea of needing to leave this grueling profession and offer light into how a move into the structures that are making our work a reality can help to break down barriers from the inside.
Much of political work is unglamorous and requires compromise, which is not just a matter of truth of systemic oppression, but also just the realities of working within major institutions which seek to govern so many people at once. It sucks. We can change it.
*Of note: Every state I looked at from Colorado to Missouri to Connecticut saw a significant increase in severe maternal morbidity between 2016 and 2017. New Mexico had a shocking stat of over 80 per 10,000 live births resulting in severe maternal morbidity in those years, meaning that nearly 1% of births in that state result in near-fatal outcomes for birthing people.