Labor Pains: Rural Access to Maternal Care in Georgia

Her story is far from unique. According to the Center for Healthcare Quality and Payment Reform, a nonprofit think tank, only 34% of the state’s rural hospitals offer labor and delivery services. The most recent closure happened in Lavonia in Northeast Georgia, where St. Mary’s Hospital shuttered its labor and delivery unit last October.

A 2024 report from The March of Dimes pegged 42.1% of Georgia counties as maternal care deserts – lacking a hospital or center offering obstetric care and without an OB-GYN, family doctor who delivered babies, or a nurse midwife. Another 12.6% had low or moderate access to maternal care.

The lack of rural access contributes to Georgia’s terrible scores on infant and maternal mortality. Another March of Dimes report in 2025 ranks the state 36th out of 48 in maternal mortality – slightly better than past years, when Georgia was at the very bottom.

“Georgia was 50 out of 50,” says Glenda Grant, executive director of the Georgia Rural Health Innovation Center at Mercer University School of Medicine in Macon. “We were No. 1 to do business and No. 50 to have a baby. It just doesn’t seem right.”

There are no easy or quick ways to make it right. But a dedicated community of maternal health advocates are coming up with innovative ways to address rural access and geographic disparities.

More Than Medicine

Linda Randolph – the certified nurse midwife who sees patients two days a week at Jefferson Hospital – is part of a rural health access collaboration between Wellstar MCG Health Medical Center and Jefferson Hospital to offer women’s health services in Louisville two days a week. (Randolph sees patients at Wellstar MCG in Augusta on the other days.) Wellstar’s recently launched women’s Rural Health Program is more extensive, covering an additional eight counties in East Georgia and offering prenatal, perinatal and postpartum support via rural doulas and community partners.

Prenatal and Postpartum Help: Midwife Linda Randolph and doula Jennifer Verdery offer their services to patient ShaQuanda Buford, as part of a collaboration between Wellstar MCG Health Medical Center and Jefferson Hospital to offer women’s health services in Louisville two days a week. Photo credit: Hillary Rumsey

Unlike midwives, doulas do not provide clinical services. Instead they act as a support system for moms during and after childbirth, including being a patient advocate and birthing coach if desired. Keisha Mays, director of the Rural Health Access Program for Wellstar MCG Health in Augusta, dubs them “birth besties.” Studies have shown that doula care during pregnancy and delivery is associated with better outcomes, including lower cesarean and preterm birth rates. Expecting moms in Wellstar’s rural access program see a doula about every four weeks, in person or virtually, Mays says. The program is free for participants and includes a year of postpartum care.

A similar Wellstar program in West Georgia grew out of Wellstar’s initial doula program – the first hospital-based doula program in the state, launched as a pilot in 2023 to serve Cobb and Douglas counties. The following year, Wellstar used a federal grant to create a more expansive Healthy Start Program, which offers clinical and community services to women (and family members) in Spalding, Troup and Butts counties. The only requirement is that participants either live in or see a healthcare provider in one of the three counties; they do not have to or be patients of Wellstar itself, and they could even live across the state line in Alabama. There is no income requirement, and participation in the program is free.

Through the program, women and family members who are caregivers of infants up to 18 months old have access to a nurse navigator, doula, case manager and health educators. Khristen Flennoy, director of the Healthy Start Program for Wellstar Health System, says having the support of doulas has been both popular and necessary.

Both Flennoy and Mays note the importance of being community-based programs and offering wraparound services that address housing, transportation, food insecurity and mental health – all factors that play a huge role in the health of women and infants. As Mays says, “If a mom doesn’t have access to the food she needs, can she really have a healthy pregnancy?”

Navigating the Systems

When Natalie Hernandez’s grandfather was dying from cancer, one of the most important people in their lives was a patient navigator. Hernandez, who is the executive director of Morehouse School of Medicine’s Center for Maternal Health Equity, recognized the benefit a perinatal patient navigator could have for Black moms-to-be, too.

Clinical and Community Services: Khristen Flennoy, director of the Healthy Start Program for Wellstar Health System. Photo credit: Wellstar Health System

Although Georgia’s maternal mortality rate is among the highest in the country, the situation is even worse for Black women, who have a maternal mortality rate twice that of white women. The goal of the grant-funded Perinatal Patient Navigator Program was to address those disparities in two locations – one urban, in Atlanta, and one rural, in Southwest Georgia – by training navigators from within the community they will then serve.

“It’s a three-month intensive training program for laypersons who have lived experience and are really passionate about this work, because that’s what makes a navigator effective. They have to love this work,” says Hernandez. Similar to doulas (plus with a strong community health worker approach), the perinatal patient navigators help coordinate care and can do everything from monitoring blood pressure to providing childbirth education. They also assess non-clinical needs such as housing, food and transportation.

“They provide social support while identifying the patient’s needs, including around all of those non-medical drivers of health,” Hernandez says. “Then they connect patients with community-based resources to overcome those obstacles to care because … these non-medical drivers of health make up 60% of the issues people experience.”

In fact, Hernandez says food insecurity is one of the biggest issues, along with transportation. She estimates about 40% of women, when asked by the navigator, said they experienced moderate to severe food insecurity. About 30% said they missed a healthcare appointment because of transportation issues.

“The most significant challenge for us is getting them the housing they need,” Hernandez says. “We have been looking for partners to help with that, and we have found some in Atlanta, but we’re trying hard right now in Southwest Georgia to figure out who is the equivalent.”

In addition to addressing these kinds of social determinants of health, perinatal patient navigators can act as advocates during prenatal appointments. “Over and over, we heard that women felt like they were not listened to,” Hernandez says. “So the navigator [can] attend doctor’s visits with them and if they don’t understand something, the navigator can translate things in layman’s terms or say, ‘Here are questions we think you should ask your doctor.’”

The first class of navigators in the grant-funded program graduated in 2024. “It’s a lot of training,” Hernandez says. “Maternal health-focused community health worker training, community-based doula training, peer lactation training and patient navigation training … and they shadow a maternal-fetal medicine doctor, anesthesiologists, anyone involved in a clinical care team.”

Better Outcomes: Keisha Mays, director of the Rural Health Access Program for Wellstar MCG Health, surrounded by fresh produce and other items for moms in the program who may be food insecure or need baby supplies. Photo credit: Hillary Rumsey

In Southwest Georgia, navigators worked with the Albany Area Primary Health Care, a nonprofit, community-based Federally Qualified Health Center that offers comprehensive healthcare to underserved, low-income and vulnerable populations. Hernandez says that navigators will also be integrated into the Phoebe Putney Health System soon. (Morehouse School of Medicine has a longstanding partnership with Phoebe.) “We actually have a waiting list [of potential navigators] and people keep calling us about when they’ll be able to train,” says Hernandez.

Making More Matches

The partnership with Phoebe extends to training medical students, too. All third-year MSM students focusing on pediatrics complete core rotations in Phoebe’s neonatal ICU. In 2025, the partnership took another step as a resident in MSM’s OB-GYN program started training at Phoebe for a year. Another resident will do the same in 2026, and other OB-GYN residents will rotate through for shorter periods.

To Grant, who heads the Georgia Rural Health Innovation Center about an hour-and-a-half northwest in Macon, that initiative and a similar one between the innovation center and MSM get to the heart of the matter: access to obstetricians.

“Georgia was 50 out of 50. We were No. 1 to do business and No. 50 to have a baby. It just doesn’t seem right.” – Glenda Grant, executive director, Georgia Rural Health Innovation Center, Mercer University School of Medicine

Grant says the center worked on different pilot projects and quickly came to that realization. “We’re never going to come up with the one thing that’s going to fix it unless we build a pipeline for physicians – and get rural physicians,” she says. It’s one reason she says Mercer’s School of Medicine preferentially accepts rural Georgians as students.

“In the United States, less than 5% of medical students are from rural communities – then it’s no surprise [that] when they graduate, they don’t go rural, because they don’t know it,” she says. “But people who grew up in those communities, they’ve seen their mom or aunt or sisters or cousins have to drive outside their county to get prenatal care or deliver their baby. And they’ve seen the struggle their local hospital goes through because they can’t afford to keep the doors of the labor and delivery unit open.”

So when Alicia Williams, a Mercer med student at the time, told the Georgia Rural Health Innovation Center staff that students needed to meet rural doctors and patients and see what it was like to practice in a rural county, that idea inspired the launch of the Maternal Health Observership Summer Program in 2021. Over six weeks, rising second-year med students from Mercer and Morehouse shadow doctors in rural OB-GYN offices around the state.

“They interact with the doctors and ask them questions, because it is also a practical research project,” Grant says. “We need practical solutions to real-world problems.” Participants work with the doctors to understand the issues in rural maternal care and conduct literature reviews and interviews, then author a translational research poster. Grant says students have presented their posters to the U.S. Department of Health and Human Services and the Centers for Medicare & Medicaid Services, and several funders have shown interest in piloting two of the students’ projects.

From the initial cohort of four students, Williams matched into an OB-GYN residency after graduating from medical school. The following year, two of four in the program matched after graduation. And from the 2023 cohort of six, all matched into OB-GYN residencies.

“These young people come from rural spaces, and they want to go back – they just don’t know how,” Grant says. “It’s up to us to find the ways to send them home. … To us, they’re the hope. We really put all our eggs into this basket because we think expanding the workforce and eliminating maternal health deserts are going to be the answer.”

Home Advantage

Dr. Kathleen Toomey, commissioner of the Georgia Department of Public Health, has worked in the state for more than three decades. So when she describes DPH’s Home Visiting Program as “probably the single most exciting thing I have done in my career in Georgia,” it carries some weight.

Addressing Disparities: Natalie Hernandez, executive director of Morehouse School of Medicine’s Center for Maternal Health Equity. Photo credit: Ben Rollins

Toomey acknowledges Georgia’s dismal maternal health record. “This is not a new problem,” she says, recalling that it has even been part of past economic development discussions. “There was concern that our maternal and infant outcomes were going to affect the ability of the state to bring in new business,” she says. What’s different now, according to Toomey, is “uniform engagement” from Gov. Brian Kemp, the state legislature and community groups to improve those outcomes.

The expansion of Medicaid to cover 12 months postpartum is one example. The home visitation program is another, begun as a pilot program in 2023 with funds from the legislature. The initial program covered 21 counties and has been expanded to 75 counties, with continued annual legislative funding and an emphasis on rural areas.

The program offers support between doctor appointments to expecting moms who have high-risk pregnancies. Registered nurses and community health workers screen participants for any warning signs, such as severe headaches or swelling, and also screen for mental health issues. They perform clinical checks on blood pressure, weight and fetal heart tones, and help connect moms to any needed resources such as transportation or WIC nutrition support. The program includes prenatal as well as postpartum visits for one year after giving birth. Moms can self-refer or be directed to the program by a doctor or community groups; there is no income requirement to participate in the program.

“We are identifying the highest-risk pregnancies,” Toomey says. “We take all comers who have a need and could potentially have a poor outcome. It embraces a much broader group of individuals than many of the federally funded home programs do.”

Data from the pilot program showed that 75% of enrolled moms delivered at term, and 75% delivered babies with a normal birth weight – both measures of maternal and infant health. Then there are the case studies, like the mom who started having vision changes, severe headache and swelling, and knew from the education her home visitor had provided that she should call 911. At the hospital, she was treated for pre-eclampsia, a condition that can be life-threatening if not treated promptly. But thanks to the home visitation program, this mom acted quickly and was able to avoid complications.

“This program is making the state better and healthier,” Toomey says, noting that the Department of Public Health is working with Emory University on a formal evaluation of outcomes. And she says that other Southern states are interested in adopting the model.

These programs haven’t solved the maternal health crisis in Georgia – that will take systems-wide change, says Hernandez – but they are helping to improve outcomes in some rural areas. Hernandez acknowledges the economic development boost as well as the health benefits, saying of the patient navigator program, “We’re hoping we can integrate this into health systems across the state to serve all mamas who deserve the best possible care – and that can be enticing for more people to move to Georgia.”

It turns out that moving up from being No. 50 to have a baby can also help Georgia keep that coveted No. 1 to do business ranking.