ATLANTA — On Aug. 16, 2022, Amanda Jones logged on to Facebook to share the good news. She posted pictures of a positive pregnancy test, a grainy black-and-white ultrasound image and test results confirming that she was expecting a second girl.
Jones had been a stay-at-home mother in Macon since she and her partner, Donald Tullius, welcomed their first child, Katie, two years earlier. That December, Jones gave birth to Miranda during a planned cesarean section.
“She was doing great. Fine. She had no real problem, other than her blood pressure was a little high,” Tullius said.
In the next several months, Jones’ legs began to swell and hurt. The couple looked online for the side effects of the blood pressure medication she was prescribed after the birth and scheduled an appointment with Jones’ doctor. Then, early one morning in June 2023, Jones went into the kitchen to prepare a bottle of formula for the baby.
“She dropped,” said Tullius, who called 911. “She passed out.”
Later that morning, Jones was pronounced dead. Doctors determined she had a blood clot in her right lung.
Jones and other women who die during pregnancy or within a year after giving birth are closely studied by state health officials. Policymakers have worked in earnest for a decade to improve pregnancy outcomes, yet Georgia remains one of the least safe states in the country for women to give birth.
Georgia women are dying from pregnancy-related causes at the highest rate that has been documented by the state in the past decade. Each year, between 35 and 40 mothers die, recent state health data show.
“These deaths are very complex. It’s not that these are people who just died during childbirth because they received bad care. It’s often that there are really complex social determinants of health contributing to the death,” said Katie Kopp, director of maternal programs for the Department of Public Health.
Under the Gold Dome this session, the House has passed a bill to study maternal and infant health services and lawmakers may propose expanding Medicaid. If passed, the expansion could be the state’s most effective tool in helping women access health care prior to becoming pregnant, which could lower maternal mortality in the state, advocates said.
For the families who have lost mothers, life is never the same.
Tullius watched with his 3-year-old and 6-month-old daughters as the ambulance took Jones to the hospital. In less than two hours, his whole world changed when doctors were unable to revive the mother of his children. Tullius said it never crossed his mind that he would be a single parent or face raising their girls alone.
In Katie’s bedroom, there is a picture of Jones, and the 3-year-old still has memories of her mom.
“Every now and then, because mommy went to the doctor, she says, ‘When mommy gets better, can I see her?’ And I have to explain again that mama can’t come back,” Tullius said.
For Tullius, the realization on his daughter’s face each time he explains Jones’ death has been the hardest part.
“It hurts me to break her little heart,” Tullius said.
A decade of research
Maternal mortality has been a perplexing problem in the United States for decades.
In 2010, the human rights group, Amnesty International, identified maternal mortality as a national health care crisis. The group issued a report that said women in the U.S. had a greater lifetime risk of dying from pregnancy-related complications than 40 other nations. More than two women were dying each day in America from pregnancy-related causes, the report said.
The group ranked Georgia last among the states — 50th in country — for its high maternal mortality rate. Only the District of Columbia ranked worse.
Four years after the report, the legislation that created Georgia’s Maternal Mortality Review Committee noted that the deaths of mothers were a “serious public health concern” with “tremendous family and societal impact.”
The committee’s research paints a stark picture of who these missing mothers are. The vast majority of those lost during and after pregnancy have a high school education or less. Many are poor. They are disproportionately Black. And most of the deaths were preventable, the mortality review committee found.
Georgia’s climbing maternal death rate is happening amid the flight of obstetricians from the state, with some counties having no obstetrical services.
Despite the urgency coming from the General Assembly to identify the root causes of maternal mortality and to provide updates “on a routine basis” to lawmakers and later annual reports to the governor’s Office of Health Strategy and Coordination, the committee has been slow to release information. Four reports were published in nine years, and the data lagged years behind. That made it challenging to assess the effectiveness of actions the General Assembly took to address maternal health.
Georgia lawmakers budgeted millions during that time to expand Medicaid coverage for women up to 12 months after the birth of a child and piloted multiple initiatives, including home visits in rural counties, echocardiograms for pregnant women, and remote maternal and fetal heart monitoring programs for high-risk mothers.
The lag in data is unavoidable, said Nancy Nydam, spokeswoman with the Department of Public Health. She said the committee aims to publish reports more frequently. The next maternal mortality report covering 2019 to 2021 is expected to be published in the spring.
A one-page description of the upcoming report’s findings shows that the state’s maternal mortality rate has increased again. Kopp, the state’s maternal programs director, attributed Georgia’s rising maternal mortality rate to improved data collection and not more women dying. Still, she expects there will need to be more long-term investment from the state to address the problem.
“There is not one intervention that we can do that is going to lower the number tomorrow, unfortunately,” Kopp said.
A positive outcome of the review committee’s work is that it has started conversations about maternal health that weren’t possible a decade ago, said Ky Lindberg, the leader of the Healthy Mothers, Healthy Babies Coalition of Georgia and a member of the review committee.
“One could argue that it may not be enough, but it’s a start,” Lindberg said. “… We couldn’t have this conversation 10 years ago, and we are now. And we have both sides of the aisle’s attention on it, so we need to really honor that.”
Dr. Anthony Kondracki with the Mercer University School of Medicine in Savannah, has independently analyzed some of the state’s data. He said maternal deaths are going up and doubted that the increase was only due to better data collection.
“The only thing I know for sure is that maternal mortality is a huge issue in this state,” Kondracki said.
Barriers to accessing health care
About half of the pregnant women in Georgia are on Medicaid at the time they give birth, according to a Kaiser Family Foundation estimate.
For many women, pregnancy can be the first time they qualify for state assistance with health insurance. That includes mothers like Jones, who despite working, did not have health insurance. She was obese and did not have a primary care physician before she became pregnant and received Medicaid.
“Part of the challenge, too, is when these women become pregnant and become Medicaid eligible, they were not healthy when they got pregnant,” said Anna Adams with the Georgia Hospital Association, which lobbies for medical facilities across Georgia.
The majority — 60% — of pregnancy-related deaths occurred to women receiving Medicaid at the time of delivery, the state’s latest mortality review committee report said.
Rep. Teddy Reese, a Democrat from Columbus, has witnessed the side effects of inaccessible health care in ways many in the General Assembly have not. His constituents and surrounding communities in Georgia’s West Central Health District are burdened with the state’s highest maternal mortality rate.
That’s one of the reasons he is pushing for full Medicaid expansion. Republicans may propose a bill to fully expand Medicaid this session. This is a notable shift, he said, because expansion used to be unmentionable in the Capitol. He could not give his blanket support without first seeing the bill and time to debate a bill is running short, he said.
Without it, many women will not have affordable access to health care, he said.
“You can’t prevent maternal mortality if the mother is not seeing a doctor, and a mother can’t go to the doctor if she doesn’t have adequate access,” to health insurance, Reese said.
Maternal mortality is increasing across the United States, but one recent study found that it increased much less in states that had expanded Medicaid than those that had not fully expanded the program.
Georgia partially expanded Medicaid in July 2023 to provide health insurance to some low-income residents who did not qualify for traditional Medicaid. The program has not helped as many people as originally estimated.
Rep. Sharon Cooper, R-Marietta, has not seen a draft of a bill to further expand Medicaid, and she is starting to doubt one will submitted this session.
“We have Medicaid expansion,” said Cooper, who has a master’s degree in nursing and chairs the House Public Health Committee. “If the governor wants to entertain a different kind of program, I certainly would consider it.”
Shifting focus to moms who survive
As the state continues to work on reducing maternal mortality, advocates and lawmakers say the focus should not solely be on the women who die, but also those who came close to death and survived.
One of those pushing this idea is Rep. Lauren Daniel, R-Locust Grove, who often does her legislative work while carrying her youngest child, Zane, in a sling across her chest.
Daniel, 29, had her own near-death experience when she was diagnosed with preeclampsia – a life-threatening form of high blood pressure that if uncontrolled can cause seizures – at age 17 while pregnant with her first child. Then, last year, she hemorrhaged and lost a large amount of blood after an emergency c-section to deliver Zane.
Her hospital room at Piedmont Henry Hospital, where she gave birth, had a specialized medical cart, and the staff participates in a nationally recognized program to rapidly address this kind of life-threatening bleeding. The Maternal Mortality Review Committee recommends that all hospitals implement this program.
“It literally saved my life,” Daniel said.
Daniel submitted HB 1037 this year, which would create a Commission on Maternal and Infant Health to give the public and lawmakers more real-time information about health services for women and babies. Daniel said her aim is for the committee to quantify how many women have been saved, and to reduce fears some women have about giving birth in Georgia.
Her bill was passed unanimously by the House of Representatives on Feb. 13.
“One of the things that we should always seek for is for women to have good experiences in terms of how they give birth and the way that they feel in that process, because that does carry over afterward,” Daniel said.
Making birth safer for mothers and babies in Georgia is a shared goal, particularly among Black women who historically face worse pregnancy outcomes.
They are twice as likely to die from pregnancy-related causes than white women in Georgia, while the national rate is even worse, data show.
“Black maternal mortality is a public health crisis that demands a public outcry and action. Each death represents a tragic loss to a family and a community,” said Wanda Barfield, director of the division of reproductive health with the U.S. Centers for Disease Control and Prevention, speaking at a press briefing this month.
Dr. Maya Eady McCarthy, a pediatrician in Atlanta, feared she would be another statistic while pregnant with her daughter in 2020.
From the beginning, it was not a simple pregnancy. McCarthy was obese at the time and had chronic hypertension and asthma. Her blood pressure was high and needed to be monitored at home.
“I wasn’t thinking about my own health, because I was just excited to even be pregnant in the first place,” McCarthy said.
At a routine check-up halfway through her pregnancy, McCarthy was diagnosed with preeclampsia and HELLP syndrome — which can cause the liver to swell — and she was admitted to the hospital. The medical staff was unable to get her blood pressure under control, and McCarthy said she wasn’t sure she would live to see her unborn daughter. In a hospital bed, she recorded a video for her just in case.
“Not only was I having end-of-life conversations with my husband, but I was FaceTiming my family, friends, coworkers, parents essentially just telling them goodbye,” she said.
McCarthy had an emergency c-section and gave birth to her daughter, Charlotte, at just 25 weeks gestation. Her baby weighed just 1 pound and 13 ounces and was taken to the neonatal intensive care unit. Today Charlotte is 3 years old.
During a rally outside the state Capitol in January, McCarthy proposed a bold goal: Make Georgia the safest place in the country to give birth.
She said in an interview that she believes it is possible, but will require funding for medical research into the causes of maternal mortality. There also needs to be a shift in public policy to aid mothers with transportation, child care and time off work to access health care, she said.
“We are moving the needle, but there’s more that needs to be done,” McCarthy said.
Birthday’s missed, a family’s loss
Back in Macon, life has fallen into a new rhythm for the family Jones left behind.
Tullius still wakes at 5 a.m., but now it’s up to him to dress both girls and drop them off at daycare. Then it’s off to work, until it’s time for afternoon pick-up.
As a single dad, he said he is doing his best to pick up where Jones left off. He cooks dinner each night like she did, “but there’s some nights I just do what I can,” Tullius said.
Their girls have grown in the eight months since Jones’ death.
Miranda, their youngest, was just starting to roll over last June. Now she says “dad” and is walking. She drinks milk instead of formula and eats whole foods. She celebrated her first birthday.
“Amanda missed all that,” Tullius said.
