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Objectives Movements to stem abortion accessibility and provision are underway across the southern United States. Preserving access to safe abortion requires a steady maternal health workforce. Targeted laws and limiting environments have contributed to a regional dearth of abortion providers. This study evaluates the consequences of restrictive environments for the abortion workforce to inform strategies to reduce the provider shortage in the South. Methods We recruited twelve physicians using purposive sampling and interviewed them on their motivations and experiences practicing in the South. We employed grounded theory analysis to translate their perspectives into recommendations for provider recruitment and retention. Results Abortion providers identified challenges relating to restrictive legislation, institutional separation of abortion from other medical services, training unavailability, safety concerns, identity struggles, and marginalization within their profession. This contributed to providers widely experiencing stigma and isolation within their work and life environments. Their motivations for practicing in the South despite these challenges included wanting to be impactful in areas of high need, combating health access disparites, and having personal ties to the region. Providers' suggested increasing regional networking and training opportunities, creating an information clearinghouse, and offering additional compensation to better support their work. We conceptualized these findings into a framework detailing the challenges, impacts and opportunities for abortion provision in the southern United States. Conclusions for Practice Our recommendations for provider recruitment and retention include cooperation between professional organizations, training programs, and healthcare institutions to create opportunities for training and networking and encourage abortion-supportive organizational and policy environments., Author(s): Pari Chowdhary [sup.1] , Anna Newton-Levinson [sup.2] , Roger Rochat [sup.2] Author Affiliations: (1) grid.423462.5, 0000 0001 2234 1613, Health Equity and Rights Team, CARE USA, , Atlanta, GA, [...]

Background Obstetric provider coverage in rural Georgia has worsened, with nine rural labor and delivery units (LDUs) closing outside the Atlanta Metropolitan Statistical Area from 2012 to 2016. Georgia consistently has one of the highest maternal mortality rates in the nation and faces increased adverse health consequences from this decline in obstetric care. Objective This study explores what factors may be associated with rural hospital LDU closures in Georgia from 2012 to 2016. Methods This study describes differences between rural Georgia hospitals based on LDU closure status through a quantitative analysis of 2011 baseline regional, hospital, and patient data, and a qualitative analysis of newspaper articles addressing the closures. Results LDUs that closed had higher proportions of Black female residents in their Primary Care Service Areas (PCSAs), of Black birthing patients, and of patients with Medicaid, self-pay or other government insurance; lower LDU birth volume; more women giving birth within their PCSA of residence; fewer obstetricians and obstetric provider equivalents per LDU; and fewer average annual births per obstetric provider. Qualitative results indicate financial distress primarily contributed to closures, but also suggest that low birth volume and obstetric provider shortage impacted closures. Conclusions for Practice Rural LDU closure in Georgia has a disproportionate impact on Black and low-income women and may be prevented through funding maternity healthcare, financing LDUs, and addressing provider shortages., Author(s): Anna E. Carson Daymude [sup.1] , Joshua J. Daymude [sup.2] , Roger Rochat [sup.1] Author Affiliations: (1) grid.189967.8, 0000 0001 0941 6502, Rollins School of Public Health, Emory University, [...]

Objectives The aim of this study was to identify key challenges and opportunities to better support non-clinician clinic staff at family planning centers in Southern US states. Methods We conducted qualitative interviews with 15 individuals in clinic staff and leadership positions at family planning centers in seven Southern states. Results Turnover had negative impacts on both clinic functioning as well as patient care. Participants identified several challenges related to recruitment and retention in family planning health centers in the South, including the conservative contextual landscape, the perceived value of support staff, gaps in communication, and rural locations. In response to these challenges, staff also identified key strategies to better support and retain health center workers. These included prioritizing investment in management, creating career advancement opportunities, prioritizing staff retention, and creating space for self-care. Health center staff and leadership who used these strategies to support and retain staff noted improvements in the effectiveness of staff work as well as increases in patient volume. Conclusions for Practice Study findings provide key areas for intervention including providing development opportunities, commitment from leadership to recognize and invest in staff and supporting self-care. Focusing on ensuring internal organizational justice for staff may also facilitate resilience to external challenging environments. Better supporting clinic staff is likely also important for quality services and ensures the full workforce involved in providing family planning care can work at full capacity., Author(s): Anna Newton-Levinson [sup.1] [sup.2] , Megan Higdon [sup.1] [sup.2] , Roger Rochat [sup.1] Author Affiliations: (1) grid.189967.8, 0000 0001 0941 6502, Hubert Department of Global Health, Rollins School of [...]

Introduction Integration of routine infant immunization and family planning services (FP/EPI) seeks to create opportunities for increased uptake of postpartum contraception. This evaluation assessed the implementation of a combined service provision model and experiences of postpartum women seeking services at integrated FP/EPI facilities in Benin. Methods We used a mixed qualitative methods design to conduct a process evaluation of services at eight facilities supported by CARE's HIN NOU VIVO! project. We facilitated focus group discussions with 56 postpartum women who attended integrated sessions, divided into family planning users and non-users. Using grounded theory methodology, we explored women's experiences with the integrated services. We conducted 159 patient flow analyses and evaluated fidelity to the integration model. Results Focus group participants responded positively to FP group education sessions during integrated FP/EPI days, but found the referral process confusing. Contraceptive use was motivated mainly by a desire for birth spacing, whereas fear of side effects and lack of spousal engagement were cited as reasons for contraceptive non-use. In four out of eight facilities, staffing shortages prevented FP group education sessions and referrals. Discussion Integrated FP/EPI services are feasible and accepted by postpartum women, but require consistent implementation across facilities. To achieve service integration goals, projects need to ensure availability of trained staff, supportive supervision, clear referral processes, and activities addressing the role of spouses and other stakeholders in reproductive health decisions., Author(s): Blake Erhardt-Ohren [sup.1] , Heidi Schroffel [sup.2] , Roger Rochat [sup.1] Author Affiliations: (1) grid.189967.8, 0000 0001 0941 6502, Emory University Rollins School of Public Health, , Atlanta, GA, [...]

Objectives To determine trends for Georgia and contiguous state residents seeking abortions in Georgia between 1994 and 2016. Methods We analyzed aggregate vital statistics data, collected in Georgia, on Georgia residents (n = 675,995) and contiguous state residents (Alabama, Florida, North Carolina, South Carolina, Tennessee) (n = 76,232) obtaining abortion and delivery services in Georgia between 1994 and 2016. We examined demographic, pregnancy, and abortion characteristics using counts, ratios, and [chi].sup.2 tests of proportion. Results Of the data analyzed, 10.1% of all abortions were for contiguous state residents. The number of abortions in Georgia for contiguous state residents increased 35.3% from 1994 to 2016 (from n = 3115 to n = 4216) while it decreased for Georgia residents by 11.1% (from n = 32,934 to n = 29,264). Contiguous state residents exhibited a higher abortion ratio (1115) compared to Georgia women (224). These populations exhibited statistically significant differences across all variables and time points. Both populations demonstrated similar trends in ethnicity, race, education, marital status, and age. However, contiguous state residents were more likely to obtain an abortion at [greater than or equal to] 20 weeks gestational age (13.8%) and obtained a lower proportion of suction curettage abortions (60.0%) and a higher proportion of dilation and evacuation procedures (31.9%). They were also less likely to be primigravid. Conclusions for Practice Women from neighboring states seek abortions in Georgia later in gestation and may therefore lack affordable, safe, early abortion care in their home states. Understanding trends in travel for abortion can allow providers and policymakers to better respond to the needs of patients., Author(s): Rachel Shapiro [sup.1] , Blake Erhardt-Ohren [sup.1] , Roger Rochat [sup.1] Author Affiliations: (1) grid.189967.8, 0000 0001 0941 6502, Emory University Rollins School of Public Health, , Atlanta, GA, [...]

Purpose The purpose of this study is to assess whether Maternal and Child Health (MCH) graduate programs address abortion content in their programs' foundational courses, elective courses, and general curricula. Description Between January and March 2017, we conducted a descriptive study with faculty from the 13 Centers of Excellence in Maternal and Child Health Education, Science and Practice (COEs). We reviewed syllabi and discussed foundational and elective course content via email and key informant interviews with COE faculty. We categorized abortion coverage in foundational courses as 'transparent' or 'tangential' depending on inclusion of the word 'abortion' in course syllabi. We identified electives addressing abortion as 'electives including abortion' and courses that focus on abortion as 'abortion-specific electives.' Assessment Evidence demonstrated that most programs do not transparently address abortion in required course curricula. Only one of 13 COEs transparently addresses abortion in the foundational course(s); seven COEs tangentially include abortion in foundational courses; and all programs address abortion in some capacity though no standard exists to ensure its inclusion. Despite barriers, including avoidance of controversy and fear of losing funding, COEs could address abortion by establishing shared curricular standards, facilitating values clarification and attitude transformation activities, utilizing information-sharing networks, strengthening relationships between MCH programs and abortion-related organizations, and using professional societies. The scope of our study does not allow us to conclude why abortion content is lacking nor the quality of current content. Conclusion MCH programs should transparently incorporate abortion content in foundational and electives courses to educate students on how to engage with complex and sometimes stigmatized public health issues., Author(s): Meredith Burns [sup.1] [sup.2] , Roger Rochat [sup.3] , Amy G. Bryant [sup.4] , Kathryn Andersen [sup.2] Author Affiliations: (Aff1) 0000000122483208, grid.10698.36, Gillings School of Global Public Health, University [...]

Objectives In 2011, a workforce assessment conducted by the Georgia Maternal and Infant Health Research Group found that 52 % of Primary Care Service Areas outside metropolitan Atlanta, Georgia, had an overburdened or complete lack of obstetric care services. In response to that finding, this study's aim was twofold: to describe challenges faced by providers who currently deliver or formerly delivered obstetric care in these areas, and to identify essential core components that can be integrated into alternative models of care in order to alleviate the burden placed on the remaining obstetric providers. Methods We conducted 46 qualitative in-depth interviews with obstetricians, maternal-fetal medicine specialists, certified nurse midwives, and maternal and infant health leaders in Georgia. Interviews were digitally recorded, transcribed verbatim, uploaded into MAXQDA software, and analyzed using a Grounded Theory Approach. Results Providers faced significant financial barriers in service delivery, including low Medicaid reimbursement, high proportions of self-pay patients, and high cost of medical malpractice insurance. Further challenges in provision of obstetric care in this region were related to patient's late initiation of prenatal care and lacking collaboration between obstetric providers. Essential components of effective models of care included continuity, efficient use of resources, and risk-appropriate services. Conclusion Our analysis revealed core components of improved models of care that are more cost effective and would expand coverage. These components include closer collaboration among stakeholder populations, decentralization of services with effective use of each type of clinical provider, improved continuity of care, and system-wide changes to increase Medicaid benefits., Author(s): Meredith Pinto[sup.1] , Roger Rochat[sup.1] , Monique Hennink[sup.1] , Adrienne D. Zertuche[sup.1] [sup.2] , Bridget Spelke[sup.2] Author Affiliations: (1) Emory University Rollins School of Public Health, Atlanta, GAUSA (2) [...]

Purpose Despite having an obstetrician/gynecologist (ob/gyn) workforce comparable to the national average, Georgia is ranked 50th in maternal mortality and 40th in infant mortality. The Georgia Maternal and Infant Health Research Group (GMIHRG) was founded in 2010 to evaluate and address this paradox. Description In the several years since GMIHRG's inception, its graduate allied health student researchers and advisors have collaborated with community partners to complete several requisite research initiatives. Their initial work demonstrated that over half the Georgia areas outside metropolitan Atlanta lack adequate access to obstetric services, and their subsequent research evaluated the reasons for and the consequences of this maldistribution of obstetric providers. Assessment In order to translate their workforce and outcomes data for use in policymaking and programming, GMIHRG created reader-friendly reports for distribution to a wide variety of stakeholders and prepared concise, compelling presentations with targeted recommendations for change. This commitment to advocacy ultimately enabled them to: (a) inspire the Georgia Study Committees on Medicaid Reform and Medical Education, (b) influence Georgia General Assembly abortion bills, medical scholarship/loan legislation, and appropriations, and (c) motivate programming initiatives to improve midwifery education and perinatal regionalization in Georgia. Conclusion GMIHRG members have employed inventive research methods and maximized collaborative partnerships to enable their data on Georgia's maternal and infant outcomes and obstetric workforce to effectively inform state organizations and policymakers. With this unique approach, GMIHRG serves as a cost-efficient and valuable model for student engagement in the translation of research into advocacy efforts, policy change, and innovative programming., Author(s): Adrienne D. Zertuche[sup.1] [sup.2] [sup.3] , Bridget Spelke[sup.2] , Zoë Julian[sup.2] [sup.3] , Meredith Pinto[sup.3] , Roger Rochat[sup.3] Author Affiliations: (1) Department of Gynecology and Obstetrics, Emory University School [...]

Objectives In 2010, Georgia had the nation's highest maternal mortality rate, sixteenth highest infant mortality rate, and a waning obstetrician/gynecologist (ob/gyn) workforce. Statewide ob/gyn workforce data, however, masked obstetric-specific care shortages and regional variation in obstetric services. The Georgia Maternal and Infant Health Research Group thereby assessed each Georgia region's obstetric provider workforce to identify service-deficient areas. Methods We identified 63 birthing facilities in the 82 Primary Care Service Areas (PCSAs) outside metropolitan Atlanta and interviewed nurse managers and others to assess the age, sex, and expected departure year of each delivering professional. Using accepted annual delivery rates of 155 per obstetrician (OB), 100 per certified nurse midwife (CNM), and 70 per family medicine physician (FP) we converted obstetric providers into 'OB equivalents' to standardize obstetric services available in any given area. Using facility births and computed OB equivalents (contemporary and 2020 estimates), we calculated current and projected average annual births per provider (AABP) for each PCSA, categorizing its obstetric provider workforce as 'adequate' (AABP 166). We mapped results using ArcGIS. Results Of 82 surveyed PCSAs, 52 % (43) were deficient in obstetric care; 16 % (13) had a shortage and 37 % (30) lacked obstetric providers entirely. There were no delivering FPs in 89 % (73) of PCSAs and no CNMs in 70 % (56). If Georgia fails to recruit delivering providers, 72 % (58/77) of PCSAs will have deficient or no obstetric care by 2020. Conclusions Obstetric provider shortages in Georgia hinder access to prenatal and delivery services. Care-deficient areas will expand if recruitment and retention of delivering professionals does not improve., Author(s): Bridget Spelke[sup.1] , Adrienne D. Zertuche[sup.2] , Roger Rochat[sup.2] [sup.3] Author Affiliations: (1) Emory University School of Medicine, 1648 Pierce Dr NE, 30307, Atlanta, GAUSA (2) Emory Department of [...]

Objectives Georgia has the highest rate of maternal mortality in the United States, and ranks 40th for infant mortality. The Georgia Maternal and Infant Health Research Group was formed to investigate and address the shortage of obstetric care providers outside the Atlanta area. Because access to prenatal care (PNC) can improve maternal and infant health outcomes, we used qualitative methods to identify the access barriers experienced by women who live in rural and peri-urban areas of the state. Methods We conducted semi-structured, in-depth interviews with 24 mothers who gave birth between July and August 2013, and who live in either shortage or non-shortage obstetric care service areas. We also conducted key informant interviews with four perinatal case managers, and analyzed all data using applied thematic analysis. We then utilized Thaddeus and Maine's 'Three Delays to Care' theoretical framework structure to describe the recognized barriers to care. Results We identified delays in a woman's decision to seek PNC (such as awareness of pregnancy and stigma); delays in accessing an appropriate healthcare facility (such as choosing a doctor and receiving insurance coverage); and delays in receiving adequate and appropriate care (such as continuity of care and communication). Moreover, many participants perceived low self-worth and believed this influenced their PNC exchanges. Conclusion As a means of supporting Georgia's pregnant women who face barriers and delays to PNC, these data provide a rationale for developing contextually relevant solutions to both mothers and their providers., Author(s): Erika Meyer[sup.1] , Monique Hennink[sup.1] , Roger Rochat[sup.1] [sup.2] , Zoë Julian[sup.1] [sup.2] , Meredith Pinto[sup.1] , Adrienne D. Zertuche[sup.1] [sup.2] [sup.3] , Bridget Spelke[sup.1] [sup.2] , Andrew Dott[sup.4] [...]

Objectives In Georgia, 52 % of the primary care service areas outside metropolitan Atlanta have a deficit of obstetric providers. This study was designed to identify factors associated with the likelihood of Georgia's obstetric trainees (obstetrics and gynecology (OB/GYN) residents and certified nurse midwifery (CNM) students) to practice in areas of Georgia that lack obstetric providers and services, i.e. rural Georgia. Methods Pilot-tested electronic and paper surveys were distributed to all of Georgia's OB/GYN residents (N = 95) and CNM students (N = 28). Mixed-methods survey questions assessed characteristics, attitudes, and incentives that might be associated with trainee desire to practice in areas of Georgia that lack obstetric providers and services. Surveys also gathered information about concerns that may prevent trainees from practicing in shortage areas. Univariate and bivariate analyses were performed, and qualitative themes were abstracted from open-ended questions. Results The survey response rate was 87.8 % (108/123). Overall, 24.4 % (19/78) of residents and 53.6 % (15/28) of CNM students expressed interest in practicing in rural Georgia, and both residents and CNM students were more likely to desire to practice in rural Georgia with the offer of any of six financial incentives (P < 0.001). Qualitative themes highlighted trainees' strong concerns about Georgia's political environment as it relates to reproductive healthcare. Conclusions Increasing state-level, rurally-focused financial incentive programs and emphasizing the role of CNMs may alleviate obstetric provider shortages in Georgia., Author(s): Elizabeth A. Smulian[sup.1] , Leilah Zahedi[sup.2] , Julie Hurvitz[sup.2] , Abigail Talbot[sup.1] [sup.2] , Audra Williams[sup.1] [sup.2] , Zoë Julian[sup.1] [sup.2] , Adrienne D. Zertuche[sup.1] [sup.2] [sup.3] , Roger [...]

Byline: Nusrat. Mahmud, Eshita. Sharmin, Md.. Mamun, Zayan. Shamayeen, Natalie. Rivadeneira, Roger. Rochat, Akanksha. Mehta Introduction: The objective of this study was to analyze longitudinal changes in sperm parameters of [...]