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 2012-2016. 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 2012-2016. 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, selfpay 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 and addressing provider shortages.

Background:The 2003 revision of the standard United States death certificate included a set of "pregnancy checkboxes" to ascertain whether a woman was pregnant at the time of her death or within the preceding year. Studies validating the pregnancy checkbox have indicated a potentially high number of errors, resulting in inflated maternal mortality rates. In response to concerns about pregnancy checkbox data quality, four state health departments implemented a quality assurance pilot project examining the accuracy of the pregnancy checkbox for 2016 deaths. Methods: State staff conducted searches for birth or fetal death reports that matched a death certificate, within a year of death. If a pregnancy checkbox was marked, but no match was found between certificates, confirmation of the pregnancy was attempted through active follow-up with the death certifier. From December 2017 to January 2018, the quality assurance pilot was evaluated through three focus groups with key stakeholders. The evaluation aimed to describe opportunities and challenges to implementation, sustainability, and lessons learned. Results: Opportunities for implementing the pilot included written documentation of the quality assurance process, improved certifier response, improved data quality, and increased data timeliness for Maternal Mortality Review Committees. Challenges included initial delays in certifier response, staff turnover, high caseloads in relation to resources, and lack of pilot prioritization in the health department. All four pilot states plan to sustain the pregnancy checkbox quality assurance process in some capacity. Conclusions: Implementing quality assurance processes for the pregnancy checkbox may ultimately improve state and national maternal death data quality.

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 2012–2016. 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 2012–2016.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 and addressing provider shortages.