Brandi Eversole was in the Swainsboro home she shared with her husband and three sons last December when she felt water trickling down her legs.
She was pregnant and knew well that when the amniotic sac that surrounds the fetus breaks, it releases a colorless fluid that signals labor is near. But Eversole was four weeks short of a full-term baby.
The fluid turned out to be blood, a bad sign. “Thank goodness we live only seven minutes from the hospital,” she said.
Infant Caden was delivered by C-section at Emanuel Medical Center. “If we hadn’t been so close, I could have had to bury my own son,” said Eversole, who experienced a condition called placental abruption. “Or they might have had to bury me.”
Women who face similar emergencies in Swainsboro will not have that option after June 30.
More than 30 small-town hospitals in Georgia have shuttered their labor and delivery units over the years, and Emanuel Medical is slated to become one of them. The closings have escalated in the past five years to about two a year, said Pat Cota, executive director of the Georgia OBGyn Association.
If plans to close Emanuel Medical’s birthing unit proceed, Swainsboro women will have to travel roughly 30 miles or more — to Dublin, Vidalia or Statesboro — to get to the nearest OB-GYN.
It’s a trend that threatens the health of pregnant women in the state, critics say. Georgia ranks dead last in the rate of maternal deaths, with a larger percentage of women dying here from pregnancy or pregnancy-related complications than in any other state in the nation, according to the Association of Women’s Health, Obstetric and Neonatal Nurses. And of Georgia’s 159 counties, 79 do not have an OB-GYN, in line with a national trend that has seen women’s reproductive health specialists retreat from less populated, rural areas, according to Cota.
While women in labor or life-threatening obstetric situations could still go to an emergency room, those who lack transportation to another town could lose prenatal care unless there’s a plan to provide at least a doctor to visit the area once a week, or a midwife or nurse at a local clinic.
Small-town hospitals face a financial challenge in keeping birthing centers open, hospital executives say. Often there are not enough patients in a small town to support a birthing center. Even more often, as in Swainsboro, a town about 175 miles southeast of Atlanta, there are not enough patients with health insurance to reimburse the hospital for birthing costs.
Swainsboro has been told Emanuel Medical will close its labor and delivery unit on June 30. About the same time, Barrow Regional Medical Center in Winder, about 45 miles east of Atlanta, intends to pull the plug on its birthing unit.
The double whammy will bring to 33 the number of rural Georgia hospitals opting out of the birthing business.
At least 85 percent of the babies born in Swainsboro are Medicaid deliveries, said Mel Pyne, southeast region president of ER Hospitals, a Utah-based hospital management company. Medicaid, the federal-state program that provides coverage to poor children, pregnant women and those with disabilities between the ages of 19 and 64, does not reimburse at the rate of private insurance. And while the state Legislature recently granted OB-GYNs a bump in Medicaid reimbursement rates, that increase does not extend to hospitals, which must cover the cost of nursing staff, anesthesiologists, supplies and space.
It all forces Georgia’s rural hospitals, already struggling because their patients are largely poor and uninsured, to look at service lines that are not making money. Birthing centers, in many cases, are at the top of the list.
“We clearly have a problem,” said Dr. Ben Cheek of Columbus, who has delivered more than 5,000 babies and serves on the executive board for the American Congress of Obstetricians and Gynecologists.
Cota agreed. “It doesn’t matter if you’re rich or poor. When you are having an obstetrical emergency, time matters,” she said. “Studies show that being less than 40 minutes away does make a difference.”
Yet hospital executives argue that in exiting the labor and delivery business, they are merely doing what they must to stanch the financial hemorrhaging.
Closing the Barrow birthing unit will allow that medical center to focus on “better ER, orthopedics and primary care,” said Chad Conner, a Barrow spokesman. Meanwhile, pregnant women in Winder will have nearby options to deliver their babies, such as Clearview Regional Medical Center about 15 miles away in Monroe, Conner said.
As for Emanuel Medical, in 2013 it entered into a joint management agreement and lease with ER Hospitals LLC, described on LinkedIn as a “hospital operations company focused on turning around distressed and under performing organizations.”
Pyne, of ER Hospitals, said his company is doing its best to save Emanuel Medical, which in 2014 beat out 70 rural Georgia and Florida facilities to be named “Hospital of the Year” by HomeTown Health LLC, an organization of small and rural hospitals throughout the Southeast that pursues ways to help members survive.
Health care providers, community leaders and consumer advocates say expanding the state’s Medicaid program under the Affordable Care Act would go a long way toward helping rural hospitals remain financially afloat and continue delivering key services, such as maternity care.
Without it, they argue, hospitals will be forced to cut more services and jobs. But Gov. Nathan Deal and other conservative lawmakers have remained steadfastly opposed to expansion, saying Georgia simply can’t afford it.
Pyne said Emanuel lost $700,000 from its birthing unit in 2014, delivering 120 babies that year. While the number of deliveries needed to break even varies from facility to facility, doctors and administrators in the medical field said a hospital needs to deliver several hundred babies each year to stay in the black.
Worth noting, said Pyne, is that 240 Emanuel County babies were delivered in 2014 at hospitals other than Emanuel Medical Center, an indication that pregnant women with the financial means elected to go elsewhere.
“But there’s been double-digit growth in our emergency room usage, and we’re developing a general psych unit. We’re re-allocating to programs that are more sustainable,” Pyne said.
Critics decry that way of thinking, contending it reduces to profits and losses an issue that should be about life, death and community values, particularly as it pertains to low-income patients with few transportation options.
“It’s sad,” said Dr. Roslyn Banks-Jackson, who works at Emanuel Medical and is the sole OB-GYN in Emanuel County. Many of her low-income patients suffer from obesity, diabetes and high blood pressure — the latter a risk factor for preeclampsia and eclampsia, pregnancy disorders that are dangerous, and in rare instances even fatal, for mother and baby. Women need prenatal care that’s close by, she said.
“If you ask a person what’s the most important time in their lives, it’s often about having their children. This is a weird devaluing of life,” said Banks-Jackson, who delivered Eversole’s son Caden by emergency C-section last December.
Two petitions and a Facebook page have been started in Swainsboro to let hospital administrators know the town wants Emanuel Medical’s birthing unit to stay open.
“I’m not happy that they’re gonna close that unit,” said state Rep. Butch Parrish, R-Swainsboro, who sits on the House Appropriations committee. “Any time you do that, you cut access.”
Still, he recognizes the “margins are razor thin” at the not-for-profit hospital, which needs to survive to serve the town both medically and as its second-largest employer.
“When a hospital pulls out, it becomes a downward spiral,” Parrish said.
Legislators and leaders in Swainsboro will seek ways to ensure pregnant women are offered prenatal care close to home, he said.
Cota, of the Georgia OBGyn Association, wants a state-level task force. “We have to find a way that we preserve access to health care,” Cota said. “It’s a public health issue.”
Georgia’s ranking as worst in the nation in the rate of maternal deaths is a call to action for Dr. Brenda Fitzgerald, commissioner of the Georgia Department of Public Health.
Fitzgerald, an OB-GYN who has spent decades providing prenatal and post-natal care, said she is determined to improve care for Georgia women. Here’s what’s being done:
» Georgia is working with the Centers for Disease Control and Prevention to collect and analyze data to make sure officials have accurate information.
» The Department of Public Health has established a review board to analyze maternal deaths. Fitzgerald said the analysis for 2012-2013 suggests 60 of the 122 maternal deaths may have been related to something other than pregnancy. The review board will continue to meet to assess maternal deaths in Georgia, she said.
» The review board learned that hemorrhaging during childbirth was the leading cause of maternal death in Georgia, Fitzgerald said. Such a major emergency typically requires a highly experienced OB-GYN. Sometimes, there may not even be enough blood in a nearby blood bank to replenish the bleeding, she said. Making sure small towns have ample blood supply may be one solution.
» The state is intensifying efforts to revive medical scholarships to get OB-GYNs to practice in rural parts of the state.
What’s next: The Department of Public Health is awaiting a report late this month from Georgia's Maternal Mortality Review Committee that may indicate whether the state has improved, Fitzgerald said. The MMRC was established during the 2013 legislative session to identify and review pregnancy-associated deaths in Georgia and develop interventions.
The OB-GYN workforce is aging, the average number of work hours is declining, and a large number of OB-GYNS are retiring from obstetrics early or not practicing obstetrics altogether because of high malpractice premiums.
There has been essentially no increase in the number of OB-GYNs trained since 1980, while:
» The population of women in the United States has increased by 26 percent since that time, and will increase another 36 percent by 2050.
» The number of OB-GYNs retiring will soon equal the number of resident graduates.
» The anticipated shortage of OB-GYN physicians will be 18 percent (9,000) by 2030 and 25 percent (15,723) by 2050.
» Despite many attempts, no meaningful medical liability reform has been achieved at the federal level, leading to continued high medical liability premiums that discourage many from entering or remaining in the physician workforce, particularly within the OB-GYN field.
SOURCE: The American Congress of Obstetricians and Gynecologists’ 2014 workforce fact sheet