Extra-legal abortion and post-abortion care knowledge, attitudes, and practices among obstetrician-gynecologist clinicians and medical residents in San José, Costa Rica: a qualitative study.

BACKGROUND: Induced abortion in Costa Rica is illegal in all cases except to save the life of the pregnant person. Despite severe restrictions to legal abortion, individuals in Costa Rica still induce abortions outside of the formal healthcare system. These individuals and those with spontaneous abortions, also known as miscarriages, occasionally need medical care for complications. In Costa Rica, an estimated 41% of unintended pregnancies end in abortion, yet there is very little published literature exploring the perspectives of healthcare providers on abortion in Costa Rica. METHODS: We interviewed ten obstetrician-gynecologist clinicians and five obstetrician-gynecologist medical residents in San José, Costa Rica about their beliefs and practices related to extra-legal abortion and post-abortion care (PAC) using a Spanish language in-depth semi-structured interview guide. After transcription and translation into English, analysis team pairs used a combination of deductive and inductive coding to identify themes and sub-themes within the data. RESULTS: Obstetrician-gynecologist clinicians and medical residents were aware of the presence of extra-legal abortion, and particularly, medication abortion, in their communities, but less familiar with dosing for induction. They expressed the desire to provide non-judgmental care and support their patients through extra-legal abortion and PAC journeys. Study participants were most familiar with providing care to individuals with spontaneous abortions. When discussing PAC, they often spoke about a policy of reporting individuals who seek PAC following an extra-legal abortion, without commenting on whether or not they followed the guidance. CONCLUSIONS: This study contributes to a gap in research about the knowledge, attitudes, and practices of Costa Rican obstetrician-gynecologist clinicians and medical residents around extra-legal abortion and PAC. The results reveal an opportunity to train these healthcare providers as harm reduction experts, who are able to accurately counsel individuals who are seeking abortion services outside of the healthcare system, and to provide training to improve care for individuals needing PAC.

"No One Does This for the Money or Lifestyle": Abortion Providers' Perspectives on Factors Affecting Workforce Recruitment and Retention in the Southern United States.

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.

Supporting Staff in Southern Family Planning Clinics: Challenges and Opportunities.

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.

Labor and Delivery Unit Closures in Rural Georgia from 2012 to 2016 and the Impact on Black Women: A Mixed-Methods Investigation.

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.

Factors associated with postpartum contraception in Togo, West Africa.

The health benefits of postpartum contraception are well established. Using 2013/14 Togo Demographic and Health Survey (DHS) data, we examine the association between contraceptive use among women who gave birth within 24 months of the DHS and four health service use indicators - antenatal care, institutional delivery, postpartum care, and immunization of the last child - in addition to socio-demographic factors. Factors associated with postpartum contraceptive use in Togo included having their last birth in a health facility, having a postnatal check within two months of birth, youngest child receiving the first diphtheria-pertussis-tetanus vaccine, wanting to space children more than two years from last birth or not have more children, living outside the Savanes region, husband's desire for number of children agreeing with the woman's, and increasing breastfeeding duration. These findings highlight the need for programming which strengthens the integration of contraception into reproductive and immunization services in Togo.

"I'd Rather Use a Refuse Bag:" A Qualitative Exploration of a South African Community's Perceptions of Government-Provided Condoms and Participant-Preferred Solutions.

Despite South Africa experiencing one of the largest HIV epidemics in the world, condom use has decreased since 2008. However, condoms are the only low-cost HIV prevention technology widely available in South Africa. This study aims to explore a South African community's perceptions of condoms, recent condom use decrease, and suggestions for increasing condom use. In 2014, we conducted seven focus groups (n = 40 men) and 20 in-depth interviews (n = 9 men, n = 11 women) with participants aged ≥ 18 years recruited from four urban settlement health clinics in Cape Town, South Africa. Data were collected, coded, and analysed using a general inductive approach. Participants perceived government-provided condoms negatively, with themes including "disgust" for condom physical properties, concerns with social status associated with free condoms, and performance concerns. There was an intersection of themes surrounding masculinity, condom use, and sexual pleasure. Solutions to increase condom use included improving the quality and variety of free condoms and rebranding free condoms. Participants suggested that condoms are distributed with novel attributes (e.g., more colors, smells/flavors, sizes, and in-demand brands) and that government programs should consider offering all brands of condoms at no or low cost. This study suggests a substantial rethinking of condom branding for government-provided condoms. Our findings suggest that condom dissemination and promotion programs should proactively address public concerns regarding condoms. Existing societal and structural norms such as hegemonic masculinity must also be addressed using gender-transformative interventions. We also strongly suggest the creation of a Male Condom Acceptability Scale to understand condom users' needs.

Abortion Trends in Georgia Following Enactment of the 22-Week Gestational Age Limit, 2007-2017.

Objectives. To measure trends before, during, and after implementation of Georgia House Bill 954, a limit on abortion at 22 or more weeks of gestation passed in 2012, in total abortions and abortions by gestational age and state residence.Methods. We analyzed aggregate year-level induced termination of pregnancy data from the Georgia Department of Public Health from 2007 to 2017. We used linear regression to describe annual trends in the number of abortions and χ2 analyses to describe changes in proportions of abortions by gestational age (< 20 weeks, 20-21 weeks, and > 21 weeks) across policy implementation periods (before, partial, and full implementation) for Georgia residents and nonresidents.Results. Although the total number of abortions and abortions at 21 weeks or less remained stable from 2007 to 2017, the number of abortions at more than 21 weeks declined (P = .02). The decline in number of abortions at more than 21 weeks was steeper for nonresidents (31/year; Β = -31.3; P = .02) compared with Georgia residents (14/year; Β = -13.9; P = .06).Conclusions. Findings suggest that implementation of Georgia's 22-week gestational age limit has effectively limited access to needed abortion services in Georgia and beyond. (Am J Public Health. Published online ahead of print May 21, 2020: e1-e5. doi:10.2105/AJPH.2020.305653).

Integrated Family Planning and Routine Child Immunization Services in Benin: A Process Evaluation.

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.

Comparison of Women from Georgia and Contiguous States Who Obtained Abortions in Georgia, 1994-2016.

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 χ2 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 ≥ 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.

Methodology for sampling women at high maternal risk in administrative data.

BACKGROUND: In population level studies, the conventional practice of categorizing women into low and high maternal risk samples relies upon ascertaining the presence of various comorbid conditions in administrative data. Two problems with the conventional method include variability in the recommended comorbidities to consider and inability to distinguish between maternal and fetal risks. High maternal risk sample selection may be improved by using the Obstetric Comorbidity Index (OCI), a system of risk scoring based on weighting comorbidities associated with maternal end organ damage. The purpose of this study was to compare the net benefit of using OCI risk scoring vs the conventional risk identification method to identify a sample of women at high maternal risk in administrative data. METHODS: This was a net benefit analysis using linked delivery hospitalization discharge and vital records data for women experiencing singleton births in Georgia from 2008 to 2012. We compared the value identifying a sample of women at high maternal risk using the OCI score to the conventional method of dichotomous identification of any comorbidities. Value was measured by the ability to select a sample of women designated as high maternal risk who experienced severe maternal morbidity or mortality. RESULTS: The high maternal risk sample created with the OCI had a small but positive net benefit (+ 0.6), while the conventionally derived sample had a negative net benefit indicating the sample selection performed worse than identifying no woman as high maternal risk. CONCLUSIONS: The OCI can be used to select women at high maternal risk in administrative data. The OCI provides a consistent method of identification for women at risk of maternal morbidity and mortality and avoids confounding all obstetric risk factors with specific maternal risk factors. Using the OCI may help reduce misclassification as high maternal risk and improve the consistency in identifying women at high maternal risk in administrative data.

"Regardless, you are not the first woman": an illustrative case study of contextual risk factors impacting sexual and reproductive health and rights in Nicaragua.

BACKGROUND: Rape, unintended pregnancy, and abortion are among the most controversial and stigmatized topics facing sexual and reproductive health researchers, advocates, and the public today. Over the past three decades, public health practicioners and human rights advocates have made great strides to advance our understanding of sexual and reproductive rights and how they should be protected. The overall aim of the study was to understand young women's personal experiences of unintended pregnancy in the context of Nicaragua's repressive legal and sociocultural landscape. Ten in-depth interviews (IDIs) were conducted with women ages 16-23 in a city in North Central Nicaragua, from June to July 2014. CASE PRESENTATION: This case study focuses on the story of a 19-year-old Nicaraguan woman who was raped, became pregnant, and almost died from complications resulting from an unsafe abortion. Her case, detailed under the pseudonym Ana Maria, presents unique challenges related to the fulfillment of sexual and reproductive rights due to the restrictive social norms related to sexual health, ubiquitous violence against women (VAW) and the total ban on abortion in Nicaragua. The case also provides a useful lens through which to examine individual sexual and reproductive health (SRH) experiences, particularly those of rape, unintended pregnancy, and unsafe abortion; this in-depth analysis identifies the contextual risk factors that contributed to Ana Maria's experience. CONCLUSIONS: Far too many women experience their sexuality in the context of individual and structural violence. Ana Maria's case provides several important lessons for the realization of sexual and reproductive health and rights in countries with restrictive legal policies and conservative cultural norms around sexuality. Ana Maria's experience demonstrates that an individual's health decisions are not made in isolation, free from the influence of social norms and national laws. We present an overview of the key risk and contextual factors that contributed to Ana Maria's experience of violence, unintended pregnancy, and unsafe abortion.

"I have no choice": Influences on Contraceptive Use and Abortion among Women in the Democratic Republic of the Congo.

In 2015, the Democratic Republic of the Congo (DRC) recorded an estimated maternal mortality ratio of 693/100,000 live births. Strict abortion laws, high fertility rates, low contraceptive prevalence, and lack of emergency obstetric care all contribute to the high maternal mortality ratio. This study explored influences on contraceptive use and abortion in the DRC. Qualitative in-depth interviews were conducted with 32 women and 10 healthcare providers in four provinces. Participants were recruited at health centers and households in the study communities. Thematic analysis was used and identified that Congolese women's contraceptive decision-making was shaped by a range of external influences rather than their own independent decisions. Non- autonomous decisions and strict abortion laws influenced the methods used to abort a pregnancy, exposing risks of infection, complication, and fatality. These findings highlight that Congolese women's decisions about their fertility and family planning are constrained by policy and socio-cultural influences.

Is Abortion Included in Maternal and Child Health Curricula in the United States?

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.

Decline in semen parameters from 2000 to 2016 among Bangladeshi men attending a tertiary care hospital.

INTRODUCTION: The objective of this study was to analyze longitudinal changes in sperm parameters of Bangladeshi men. We hypothesized that semen parameters declined for this population. METHODS: We retrospectively analyzed semen data from men aged 18-64 years who sought care for general sperm quality or updates on fertility status at an infertility clinic in Dhaka, Bangladesh, from January 2000 to June 2016 (n = 13,953). Samples with incomplete data were excluded (n = 143). The WHO normal criteria and semen analysis procedures were used to evaluate parameters of the remaining 13,810 specimens. Samples with missing values on sperm concentration (n = 6187) were excluded from concentration analyses. Age and duration of abstinence at testing were recorded and adjusted for. Data were imported into SAS® 9.4 statistical software. Temporal significance was investigated using one-way ANOVA for motility parameters and Chi-square test for raw concentration. Logistic regression analyzed the effects of confounders on azoospermia and raw concentration, while median regression modeling adjusted confounders for concentration, total motility, and rapid linear (RL) motility. RESULTS: Age distribution was significantly correlated with annual parameter changes (concentration, total motility, and RL motility [P < 0.0001]). Adjusted total motility and RL motility declined by 20% from their maximum values to end of the study (P < 0.0001). Raw concentration lacked clear trends and was unaffected by adjustment. Azoospermia increased by 18% between the 2000-2010 and 2011-2016 participants (odds ratio = 0.16 [0.14-0.16]). CONCLUSION: In agreement with the hypothesis, Bangladeshi males attending this clinic have experienced decline in semen parameters (total motility and RL motility) and increased frequency of azoospermia.

Physician opinions concerning legal abortion in Bogotá, Colombia.

Since the decriminalisation of abortion in 2006, women in Colombia have continued to seek clandestine abortions, endangering their health and contributing to maternal mortality and morbidity. The goal of this study was to explore physicians' opinions towards and knowledge about legal abortion in Bogotá, Colombia, and key barriers to the legal abortion access. We conducted 13 key informant interviews followed by a survey with a probability sample of 49 doctors working in public hospitals in Bogotá. Interview and survey data showed lack of technical experience in the provision of abortion and nuanced opinions towards its practice. Key informants described ignorance and lack of abortion training in medical schools as key barriers to provision. In the survey, 16/49 respondents had performed an abortion, 24/49 had referred a woman for an abortion and only 33/49 showed correct knowledge of the law.

Commentary on Obstetric Care in Rural Georgia.

This is an invited commentary on five articles on obstetric care in rural Georgia.

Obstetric Provider Maldistribution: Georgia, USA, 2011.

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 < 144), "at risk" (144 ≤ AABP ≤ 166), or "deficient" (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.

Georgia Maternal and Infant Health Research Group (GMIHRG): Mobilizing Allied Health Students and Community Partners to Put Data into Action.

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.

Bridging the Gaps in Obstetric Care: Perspectives of Service Delivery Providers on Challenges and Core Components of Care in Rural Georgia.

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.

Obstetric Provider Trainees in Georgia: Characteristics and Attitudes About Practice in Obstetric Provider Shortage Areas.

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.