Motherhood in the U.S. can be dangerous. The nation spends more on healthcare than any other high-income country. But women giving birth here — particularly Black women, and particularly in Georgia — are more likely to die in childbirth. A big reason for this maternal mortality crisis is a lack of access to obstetric care.
“Georgia has a problem with access to care — the whole country does,” said Meghan Meredith, a fourth-year Ph.D. student in the H. Milton Stewart School of Industrial and Systems Engineering (ISyE) who has spent much of her academic career studying the problem, which is particularly acute in rural, lower-income places.
Many of these places have been designated “maternity care deserts” by the March of Dimes. If a county doesn’t have any obstetric care or providers, it’s considered a desert. Another commonly used measure is whether a pregnant woman lives within 50 miles of critical care obstetrics (CCO).
These measures are often referred to in academic literature and popular media to highlight a lack of healthcare access, and by public policy leaders trying to address the issue. But it’s become evident to Georgia Tech researchers that they just don’t add up.
“These measures don’t capture the complete picture,” said Meredith. “They aren’t an accurate representation of access to care.”
And that’s what concerns Meredith and her faculty advisor, ISyE Assistant Professor Lauren Steimle.
“We’ve been interested in access to maternal care for a long time, and in countless news stories, the maternity care desert measure is reported on,” Meredith said. “We recognized the limitations, so we thought, ‘Let’s write a paper that explains how this measure is not a complete representation of access.’”
They published their work recently in the journal BMC Health Services Research.
Modeling the Landscape
To study these measures of access, Meredith and Steimle used the same kind of computer-based mathematical model that helps companies decide where to place a new distribution center, retail outlet, or even electric car charging stations: a facility location model.
“This model helps us determine where to place facilities, so demand is sufficiently covered with the fewest number of facilities,” said Steimle. “There are tons of potential applications for this model, but we’re using it for healthcare.” For this study, they used the model to identify where Georgia would need to expand healthcare facilities to improve access under the commonly used measures.
Here’s some of what the researchers found:
• Of the 1,910,308 reproductive-age women in Georgia, 104,158 (5.5%) live in maternity care deserts, while 150,563 (7.9%) live more than 50 miles from CCO services; 38,202 live in both situations.
• Fifty-six counties in Georgia meet current “maternity care desert” measures, which means eliminating these deserts would require 56 new obstetric hospitals. That would increase the number of obstetric hospitals statewide from 83 to 139 (a 67% increase).
• Strategically expanding 16 hospitals (a 19% increase) would reduce the number of reproductive-age women living in deserts by half.
• 82% of reproductive-age women designated as living in maternity care deserts live within 25 miles from an obstetric hospital.
The researchers conclude that policymakers should be warned: Using the maternity care desert measure alone as a basis for where and how to invest in healthcare resources isn’t a great idea.
“If we really want to improve pregnancy outcomes, our measures of access should promote risk-appropriate and regionalized care systems,” Steimle said.
Turns out, Georgia is already headed in that direction.
Counting Counties: One Size Doesn’t Fit All
To illustrate the problems with the maternity care desert measure, Steimle compared Georgia with a very different state on the opposite side of the U.S.: Nevada.
“A major problem with the maternity care desert measure is its emphasis on county-by-county infrastructure,” she said. “It’s a one-size-fits-all approach that doesn’t tell the whole story about access to care.”
For example, Georgia has 159 counties and more than three times the population of Nevada. Meanwhile, Nevada has twice the square mileage of Georgia — and 16 very large counties.
At 18,147 square miles, Nye County is Nevada’s largest, and it’s been labeled a maternity care desert. There’s also lots of actual desert in Nye, which is larger than nine U.S. states. So, it’s difficult to accurately compare a vast jurisdiction like Nye with, say, central Georgia’s Lamar County. Lamar, also labeled a desert, is a mere 185 square miles in size. It's also surrounded by counties that are veritable oases of care.
“A lot of people in Georgia may be falsely labeled as not having access, at least geographically speaking, when in fact they have services nearby,” noted Steimle. “Meanwhile, in a state like Nevada, some women may be labeled as having access, but might be very far from obstetric hospitals in their county.”
Steimle also point out that measuring access on a county-by-county basis ignores efforts to coordinate care across the whole state. “The maternity care desert model doesn’t hold up. And it doesn't reflect Georgia’s approach to a regionalization system.”
Since 2009, the Georgia Department of Public Health has organized the state into six geographic perinatal regions (the perinatal period covers pregnancy, childbirth, and early postpartum). The idea is to coordinate the delivery of health services to ensure people in all regions have access to risk-appropriate maternal care.
Build a Better Model
Each of Georgia’s perinatal regions has a “hub” — a major care center serving as an administrative unit to enable the coordination and delivery of maternal care services. For example, The Emory Perinatal Regional Center at Emory University Hospital is the coordinating center for the 39-county metro Atlanta region.
This regionalization strategy also tries to address the problem of hospital closures, a troubling trend that leads to more deserts. In Georgia, 12 hospitals have closed since 2013; 18 rural hospitals are currently at risk of closure. And this new Georgia Tech study indicates that Georgia would somehow need to add 56 new facilities to eliminate the state’s maternity care deserts — at least by the standards used by the March of Dimes.
“Eliminating maternity care deserts in Georgia would mean adding a larger number of obstetrics facilities to make sure every county has an obstetric hospital,” Steimle said. “But this is likely unrealistic with the current economic forces pushing hospitals to close their obstetric units. With that many facilities in Georgia, some facilities would have a very small number of deliveries, which is not economically sustainable.”
In other words, eliminating maternity care deserts in Georgia wouldn’t sufficiently address the larger problems related to access to care. Instead, Steimle and Meredith advocate for approaches that simultaneously consider the different dimensions of an ideal maternal healthcare system, not just access alone.
For this initial study, Steimle and Meredith just focused on spatial access. They haven’t yet addressed the complex issues of racial disparities, insurance access, or other hurdles facing reproductive-age women in Georgia. That may be coming.
“This is a start,” Steimle said. “Our future work entails thinking about how to come at this with the goal of maximizing or improving outcomes for women.”
And as policy leaders across the country begin to address the maternal mortality crisis, Steimle believes her team’s approach using more sophisticated tools can be helpful. So far, they’ve shared their results with the Centers for Disease Control and Prevention, and members of the Georgia, Iowa, and Nevada departments of public health.
“How do we make measurements that point us toward our end goals? Our tools as mathematical modelers can really help us think through the system holistically and think through strategies before trying them in the real world,” Steimle said. “Think of it as a policy sandbox.”
CITATION: Meghan Meredith, Lauren Steimle, and Stephanie Radke. “The implications of using maternity care deserts to measure progress in access to obstetric care: a mixed-integer optimization analysis.” BMC Health Services Research (June 2024)
doi.org/10.1186/s12913-024-11135-4
