[dropcap]D[/dropcap]avid Ralston, Georgia’s Speaker of the House, has his share of problems. While his state leads as the “Top State for Business” for the sixth year in a row, it has failed miserably when it comes to maternal mortality — a tragedy no state wants to own.

The problem: Too many Georgia women are dying during or after their pregnancies, which places the state on par with Malaysia or Uzbekistan.

“For the most recent year of available data (2014), there were 65 maternal deaths per 100,000 live births,” states Nancy Nydam, spokeswoman for Georgia’s Department of Public Health. “Specific to pregnancy-related maternal deaths, there were 32.9 deaths from any cause related to or aggravated by pregnancy or its management per 100,000 live births.”

In addition, seven rural Georgia hospitals closed in the past decade, according to the Georgia Hospital Association. This dichotomy (a great place for business yet far too many maternal deaths) is “incompatible,” according to Ralston.

But it is also heartbreaking.

“Georgia’s maternal mortality rate is especially alarming for black women, who have a rate of 66.6 per 100,000 live births (compared to 43.2 for white women),” according to a June 2019 US News report.

The National Institutes of Health’s (NIH) Centers of Excellence (COEs) program has turned to Mercer University in Macon, Ga for help. Mercer has been designated as one of two Centers for Rural Health and Health Disparities as an NIH Center of Excellence. Although the focus, scope and origin can vary from one COE to another, the NIH selected two Mercer researchers to help identify and solve Georgia’s rural health challenges.

Warren and Smalley
Left to Right: Dr. Jacob Warren and Dr. Bryant Smalley

Dr. Jacob Warren has served as Rufus Harris Endowed Chair and director of the Center since 2013, and Dr. Bryant Smalley came to Mercer late last year as associate dean for research and accreditation. Together, they serve as joint principal investigators. Each has the distinction of winning the National Rural Health Association’s ‘Researcher of the Year’ award for previous work.

National COEs generally focus on a particular disease, a group of diseases or even a specific area of study, such as health disparities. But, for over ten years, these two prominent researchers have made Georgia’s rural health problems their primary focus.

Dr. Warren and Dr. Bryant sat down with RHQ together to talk about their exciting — and potentially life saving — new collaboration:



RHQ: The NIH Rural Health Centers have two locations, correct? Are they working on similar programs?

Warren: “Yes, one COE is here at Mercer University, Macon and the other is affiliated with Montana State University, Bozeman, Montana.” [Regarding the programs]: “It’s a little bit of a definitional issue. Some concerns may be similar, such as diabetes and hypertension.” Others, such as maternal mortality or the opioid crisis may vary.”

Your latest focus is on maternal mortality (or the number of deaths due to complications from pregnancy or childbirth). What led you to that research?

Warren: “Georgia is fiftieth in the nation for maternal mortality. The United States has the highest maternal mortality rate in the developed world. And Georgia is really the ‘epicenter’ of what’s happening [related to maternal mortality] as a country.”

How will you begin?

Warren: “We recently received funding to enact a comprehensive initiative to eliminate maternal mortality disparities in a seven-county rural region of southeast Georgia. The initiative, South Georgia Healthy Start, will hopefully change this trajectory. We’ve received funds to hire a nurse practitioner to expand access (specifically in one case) to the women’s health services side. We are looking at all medical health professions and how each level contributes to the system of care.”

What’s differentiates your approach to Georgia’s maternal mortality challenge?

Warren: “We believe our “full-system” approach will provide support to women before they become pregnant, all the way to 18-months postpartum; everything from clinical care, case management, health education, policy change, workforce development and the research associated with that. We also believe it’s relevant to rural counties everywhere; because what we see in Georgia — and other states — is that maternal mortality is much higher in our rural areas than in the larger urban cities.”

“…maternal mortality is much higher in our rural areas than in the larger urban cities.”

How were you able to start so quickly?

Warren: “A lot of this has really emerged from those partnerships we already had. I do think maternal health is a focal point. There’s a dire need in Georgia for maternal and infant health. In fact, we were recently asked to testify before the [Georgia] house maternal subcommittee that was convened by Speaker David Ralston. And we’ve had the chance to advocate directly with that committee.”

How did you describe the geographic problems to the committee?

Smalley: “When we only look at the geography — out of 159 Georgia counties, 120 of those are classified as rural. And of those we only have 27 that actually have labor and delivery available in the hospitals serving those counties. Just from those numbers, you see the significant need, the lack of access, which really trickles down to all areas of health care, such as  prenatal care, access to basic primary care and access to obstetrical (OB) services.”

What about ‘high risk’ health services for pregnant women?

Smalley: “We can’t even start talking about “high risk” OB services, because they are completely nonexistent in rural Georgia. I think that is considered a ‘hot topic’ across the nation, but particularly in Georgia. It’s the major issue that we’re hoping to help address.”

Basic perinatal services include comprehensive obstetric care through neonatal newborn services. Additionally, Georgia has six Regional Perinatal Centers, specially qualified hospitals, which are designated to specific geographic regions that provide the most advanced care for high risk mothers and infants. (MAP SOURCE: Georgia Department of Public Health)

RHQ: How do you explain the high risk need in Georgia?

Smalley: “Out of the 120 rural counties we have, there are 93 that have no labor and delivery unit at all. And then, of those rural counties, none have a high-risk OB specialist. In the vast majority of our underserved communities, you can’t even access a labor and delivery unit. This is a very real and serious systemic issue — nearly half the rural labor and delivery units closed in the last 20 years. That remains an active problem.”

Is that why there are so few OB clinicians in rural Georgia?

Warren: “In our meetings, we’ve asked that very same question. It’s a part of discussions that we constantly have. It appears to come down to the difficult financial decisions that are made. When speaking with hospital executives, our rural communities don’t have the number of births required to afford an OB. Once a labor and delivery unit closes, it’s hard for an OB to stay within the area.”

You refer to yourselves as ‘participatory researchers’ – can you expound on that?

Smalley: “We [Warren and I] are both researchers, but we fully engage the community. It’s not us coming in to say: This is what you should do.” Instead, it’s “what are your goals as a community and how can we help?” We believe that approach has allowed for success in addressing some of the most pressing public health-related problems.”

Would you mind sharing something about your earlier work with our readers?

Smalley: “[Children’s health] was identified by the communities as being a pressing issue. As part of that, we actually created the first school-based health center in South Georgia, because they had lost their pediatrician and there was no access to a pediatric services in the area. With the schools and community support, today we have a [county] school-based, health center.”

You also developed Project EDUCATE – how does that fit in?

Smalley: “Yes, that was part of our initial NIH funding. It helped us develop a telephone-delivered intervention for individuals with diabetes or hypertension, for rural patients specifically.”

Warren: “The money for Project EDUCATE came from NIH’s National Institute on Minority Health and Health Disparities.”

Smalley: “By building Project EDUCATE from the ground up — [and] being rural focused — gave us the best results.”

Do you see a specific reason for Georgia’s problem with health disparity in the rural areas?

Warren: “There’s not a single reason; it is really a cumulative effect with overall shift in health care delivery, hospital stability and social determinants of health. We’ve seen hospital closures in rural Georgia at a rate higher than almost any other state in the nation, so it’s a larger system issue, I would say. I don’t think it’s traceable back to any one political process or policy. It’s an accumulation of multiple changes.”

How does policy come into play?

Warren: “Part of what we’re working on is policy change. That has become a core area for us. We want to know what barriers we face. We are asking what systemic issues can be addressed immediately, or even over time, that may help reduce these barriers, particularly for those in rural areas?”

Can you share an example for RHQ readers?

Warren: “Certain provisions exist in some policies that immediately cut funding for insurance coverage for women prior to national guidelines. We are advocating, and have been advocating for some time, to make changes in this particular policy. In fact, that’s part of what we recently presented to a Georgia maternal health subcommittee. We are also looking at ways to strategically place services within rural regions, because unfortunately, and it makes sense, not every county can sustain an OB unit.”

In the metro-Atlanta area, a couple of counties share health care costs: Gwinnett, Newton and Rockdale, as well as Cobb and Douglas. Are you familiar with those relationships?

Smalley: “That’s exactly what we’re looking at. How can we have shared resources, as well as shared financial responsibility, cutting across county lines. What can we do strategically to place services to allow for greater access within certain Georgia regions — and not necessarily [only] within one county?”

Are you also looking at technology?

Smalley: “Within our region where our ‘Healthy Start Program’ is located, the closest major hub is Savannah. Instead of driving to Savannah, which could be about an hour and a half drive for a potentially major health issue, we are examining ways to bring services closer. To that end, we are also exploring the use of technology — perhaps additional telehealth — to increase access to certain services, such as high-risk OB services as one example.”

Any other news to share with RHQ?

Warren: “One additional thing, as a part of this program, is somewhat innovative and hasn’t been done across the country yet. That’s because of existing barriers having to do with [resident] physician rotations. Previously, a lot of barriers stood in the way — primarily because of ‘supervision’ of those residents. Today, we are actually in the process of requesting a waiver from the national organization to use tele-supervision. In other words, instead having it be in person, OB residents could rotate through our region and not require their attending [physician] be right there physically. But they would have immediate access if needed.”

How does this work fit within your COE?

Smalley: “All of the work we’ve discussed is housed within the Center for Rural Health and Health Disparities located at Mercer University’s School of Medicine. And it’s that Center that was designated as a NIH Center of Excellence. Dr. Warren and I are highly collaborative in the community-based work we do — related to rural health concerns and health disparities — within Georgia.”


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Judi Kanne, a registered nurse and freelance writer, combines her nursing and journalism backgrounds to write about public health. She lives in Atlanta.