Monday, November 2, 2015

Georgia ranks as the deadliest state in the country for women giving birth. Doctors practicing in the state's poor rural communities, where the population is often mainly black, detail the challenges they face at the heart of this health care crisis.

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Credit: Rae Z/A on Flickr, under Creative Commons

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ATLANTA (WOMENSENEWS)-- As an obstetrician-gynecologist

in southwest Georgia, Dr. Keisha Callins sometimes feels like she is working in the developing world. She compares her work in the state with the highest maternal mortality in the United State to working in Haiti.

"I tell people they don't have to get on a plane to Haiti to do mission work. Just do the public health thing here," Callins said by phone recently. "I have delivered 12-year-olds; 14-year-olds. I should not see that!"

One woman who gave birth in January 2015 became pregnant again within months. The young woman didn't have a ride to come back to the clinic for birth control after her first baby. "I don't know the home situation, but I work on repeats, so many repeats," Callins sighed, referring to women who come back to see her, with another pregnancy, shortly after giving birth.

Callins, born in Jamaica and a graduate of Atlanta's Morehouse School of Medicine, added that among the difficult circumstances her patients face, chronic medical issues are showing up a lot earlier. "It's not uncommon to see women in their 20s, even teens, who are hypertensive, diabetic and have had multiple pregnancies. And the number of pregnant patients with HIV would blow your mind," said Callins, who's a mother of two children.

The Centers for Disease Control and Prevention reports that the number of women with HIV giving birth in the United States increased approximately 30 percent between 2000 and 2006, rising from 6,000-7,000 women to 8,700.

Georgia ranked fifth among the 50 states in the number of HIV diagnoses in 2011, according to the CDC. Black women represent 75 percent of women with HIV in the state, says the Georgia Department of Public Health.

Chronic conditions, like HIV, can lead to tragic outcomes during a pregnancy. The risk of a stillbirth goes up. So do delivery complications such as preeclampsia, a pregnancy complication characterized by high blood pressure and possible damage to other organ systems, such as the kidneys.

"Last year we had three diabetic moms and babies that had major anomalies. The damage was done by the time I saw them, even in the middle of the first trimester. We've got to get people to manage their chronic medical problems," said Callins, who also holds a master's degree in public health.

Neglected Regions

Callins works at a nonprofit community health center, the Albany Area Primary Health Care, and her practice focuses on women's health and health behavior in southwest Georgia. Albany is in Dougherty County, population 92,000, and is 68 percent African American, with a median household income of $31,000, according to the Census Bureau.

Seventy-seven rural counties in the so-called black belt of Alabama and Georgia, and in the Delta of Mississippi, are among the most neglected regions in the nation, according to a report by the ,

The report found between 85 and 95 percent of black women in the rural counties studied lived in poverty, and they were also more likely to have lower median incomes than either black men or white women.

In Georgia, the state poverty rate for women is 10.6 percent, and in the rural counties studied, the rate is 38.7 percent. The U.S. official poverty rate in 2014 was 14.8 percent, which means there were 46.7 million people living in poverty, according to the Census Bureau.

Monica Simpson, executive director of SisterSong, a women of color reproductive justice collective, said the high rate of maternal mortality, especially among women of color in the South, "is astonishing to us. You think about third world countries with no running water, you don't think about the U.S.," she said.

She added that, "Health care is a human right, and the level of care has to be the same, whether you have millions in your bank account or no money in a bank account."

Simpson was one of the organizers of the "Black Mamas Matter" conference in June, to examine access to good quality health care as one of many components that put the bodies and lives of black men, women and children at risk.

Callins said the deck is stacked against many of her patients.

"Lots of what we deal with in rural, medically underserved areas plays into why we have our issues. Poverty! Albany has a high poverty rate, more than 40 percent. If you can't get a job, your decision-making goes down the drain," said Callins, who worked as a clinical researcher with the Minority Health and Health Disparities Research Center at the University of Alabama at Birmingham prior to medical school.

A Constant Challenge

Callins practices in Albany because she was selected as a National Health Service Corps Scholar, getting medical school expenses paid for in exchange for working in an underserved area. She said rural medicine is a constant challenge, without the resources and specialists available in a big city.

Sometimes her patients' combined hardships--lack of transportation, lack of a family support system and ambulance company regulations--add up to enormous frustration.

For example, she said, one of her patients had contracted HIV and was pregnant. The plan was to deliver the baby a little bit early, at 38 weeks, to have a controlled situation to dramatically reduce the possibility of HIV transmission to the baby. That involves administering an IV drug as quickly as possible to the mom, no later than three hours after labor begins. But the patient's water broke at 2 a.m. one day during her 37th week. The ambulance she called would not transport her other young child with her, so she had to wait until 5:30 am to get child care and a ride to the hospital.

"Now we have to wait six months to see if the baby will be okay [HIV negative] just because they couldn't ride in the ambulance. Could I have put a letter in her hand, 'Here is a special condition, you must transport this mom and her other child to the hospital?'" said Callins.

These are some of the constant, unpredictable circumstances Callins faces. "In rural areas, you've got to be comfortable with your skills, because you are going to see some stuff. And you are it. You have to figure it out real quick, and do it well."

Women in other underserved parts of the state often lack access to a physician with either the training or compassion of Callins. Or, any ob-gyn at all.

"Some of these counties don't have any!" said Georgia State Sen. Renee Unterman during an interview in her office at the Georgia State Capitol in Atlanta. "Zero, none. Patients may have to go three counties over to get care."

In fact, 79 of Georgia's 159 counties, or more than half, have no practicing obstetrician-gynecologist, according to the Georgia Board for Physician Workforce. The board also reports that 15 additional counties have only one doctor specializing in obstetrics and gynecology.

Maternity care is just one of many health services in short supply in rural, often poor areas of the state, many with large African American populations.

"Obstetric services are right up there with mental health services. Last year, nine different areas with access to obstetric services closed within the state," said Unterman, who is also a cardiac nurse and a social worker.

Urban Health Prioritized

Whether it is on the state or federal level, rural health care providers said they are sometimes shortchanged by urban-focused health care policymakers.

"I was the only doctor in this county for four years, and because of that, I have dealt with emergency situations, with births. The police would pick up a woman in labor and bring her to my office," said internist Dr. Jean Sumner by phone from her office in Wrightsville. The town, with a population of around 3,700 is in Johnson County in central Georgia.

Sumner is a third-generation country doctor. Her grandfather, father and brothers have taken care of families in the region from cradle to grave. She sees rural communities across Georgia often getting marginalized or misunderstood by politicians when it comes to health care.

"They forget there are two Georgias, clearly there are urban areas and rural areas. And people who are policymakers, and I respect them and I think they care about us, but they try to impose Atlanta solutions to rural areas, and it doesn't fly," she said.

She said, for example, medical centers in larger cities used to send specialists, like obstetricians-gynecologists out to rural county health departments on a regular basis. "And that isn't happening anymore. They put people in vans and drive them 80 or 90 miles and you know, if you're poor, or pregnant, or trying to keep a job, or you have children at home, driving for eight hours a day doesn't fly, particularly when you are pregnant. And it's just impossible," she said. "So we really need to re-do that care and bring it back out here. We don't need an ob-gyn every day; we need one twice a month at most to see pregnant women."

Sumner said the shortage of health care professionals is quite real in Georgia. Sixty-three counties have no pediatrician; 66 have no general surgeon.

Like Callins, she said a doctor in a small town has to have a wide range of skills. "You can't send a weakly trained practitioner to a rural area and expect quality medicine because of the breadth of what we do, and the need," said Sumner.

"If you call a code in this county, it's me and the public health nurse that come. I used to tell the Methodist preacher that she needed to learn CPR, because the ambulance service is good and the EMTs are good, but they're short staffed as well," said Sumner.

This story is part of a larger project on African American maternal and infant health nationwide funded by the W.K. Kellogg Foundation.