Some states have already tried doing this, but Georgia is the only state that has an active system using work requirements to establish Medicaid eligibility — and recipients must report to the system once a month.

When she first started using the system, Tanisha Corporal, a social worker in Atlanta, wasn’t opposed to work requirements — in principle.

But when she left her job at a faith-based nonprofit to start her own project, the Be Well Black Girl Initiative, she needed health coverage. She soon came face-to-face with how daunting it can be to prove you are meeting the state’s work requirements.

“I would have never thought that I was going to run into the challenges that I did, with trying to get approved, because I’m like, I know the process,” Corporal said. “I’ve been in human services.”

Corporal has been a social worker for more than two decades in Georgia and was familiar with the state’s social service programs. For years, it had been her job to help others access benefit programs.

But her challenges with paperwork and the process had only begun.

Health advocates point to Georgia’s system as a sign that the new law will lead to excessive red tape, improper denials, and lost health coverage.

Beginning in 2027, the law will require adults on Medicaid who are under 65 to report how they engaged in at least 80 hours per month of work, education, or volunteer activities. Alternatively, these adults could submit documentation showing they qualify for an exemption, such as being a full-time caregiver.

Most states will have to set up verification systems similar to Georgia’s, which can be expensive to implement and run. In the two years since launching its program, Georgia has spent more than $91 million in state and federal funds, according to state data. More than $50 million of that was spent on building and operating the eligibility reporting system. Right now, just under 7,500 people are enrolled in Georgia.

For Corporal, 48, forgoing coverage wasn’t an option. She had been diagnosed with pre-diabetes and had other medical concerns.

“I have breast cancer in my family history,” she said. “So it was like, I gotta get my mammograms.”

On paper, it looked as if she qualified for Georgia’s program, called Georgia Pathways to Coverage.

It offers Medicaid to adults — who otherwise wouldn’t qualify for traditional Medicaid in Georgia — with incomes up to the federal poverty level ($15,650 per year for an individual, or $26,650 per year for a family of three), as long as they can show that for at least 80 hours a month they’re working, attending school, training for a job, or volunteering.

Corporal was eager to apply. She was already volunteering at least that much, including with the nonprofit Focused Community Strategies, and helping with other South Atlanta community improvement efforts.

She gathered up the various documents and forms needed to verify her duties and volunteer hours, then submitted them through Georgia’s online portal.

“And we were denied. I was like, this makes no sense,” said Corporal, who has a master’s degree in social work. “I did everything right.”

In the end, it took eight months fighting to prove that she and her son, a full-time college student in Georgia, qualified for Medicaid. She repeatedly uploaded their documents, only for them to bounce back or seemingly disappear into the portal. She went through numerous rounds of denials and appeals.

Corporal recently pulled up one of the denial notices on her cellphone to read aloud: “Your case was denied because you didn’t submit the correct documents. And you didn’t meet the qualifying activity requirement,” she read from the email.

When she tried to call the state Medicaid agency for answers, it was difficult reaching anyone who could explain what was wrong with her application paperwork, she said.

“Or, they’ll say they called you, and we look at our call log. Nobody called me,” she said. “And the letter will say, you missed your appointment, and it’ll come on the same day” as it was scheduled.

Corporal’s Pathways to Coverage application was finally approved in March after she spoke about her experience at a public hearing covered by Atlanta news outlets.

When asked about the delays and difficulties Corporal experienced, Ellen Brown, a spokesperson for Georgia’s Department of Human Services, emailed this statement: “Due to state and federal privacy laws, we cannot confirm or deny our involvement with any person related to a benefits case.”

Brown added that Georgia is implementing tech fixes to streamline the uploading and processing of participants’ documents. They include “rolling out a refresh to the Gateway Customer Portal in late July that will include easier navigation and training videos for users as well as built-in prompts to ask customers to upload required documents.”

Now that Corporal has coverage, she is having to recertify her volunteer hours every month using the same glitchy reporting system. It’s stressful, she said.

“It’s still a nightmare, even once I got through the red tape and got approved,” Corporal said. “Now maintaining it is bringing another level of anxiety.”

But she wonders how anyone without her professional background manages to get into the program at all.

“I think the system has to be simplified,” she said.

Because Georgia set up its work requirement before the recently passed law, it needed permission from the federal government through a special waiver.

It is now seeking an extension of that waiver to continue the Pathways program beyond its current expiration of September 2025. In the application, officials said they would reduce the frequency by which participants needed to reverify their hours from once a month to once per year.

But for now, Corporal’s experience remains typical. And many health advocates fear it will be replicated under Trump’s budget law with its new national Medicaid work mandate. 

“In Georgia, we have seen that people just can’t get enrolled in the first place. And some folks who do get enrolled lose their coverage because the system thinks they didn’t file their paperwork or there’s been some other glitch,” said Laura Colbert, who leads the advocacy group Georgians for a Healthy Future.

Another state, Arkansas, tried work requirements in 2018.

But it didn’t go any better there, said Joan Alker, who leads the Center for Children and Families at Georgetown University.

“A lot of the problems were similar to Georgia,” she said, “in terms of the website closed at night, people couldn’t get a hold of people.”

Some Republicans who backed the spending and tax legislation said the idea behind the national Medicaid work mandate was to ensure that as many people as possible who can work, do work. And to eliminate what the Trump administration deems waste, fraud, and abuse. 

“What we’re doing is restoring common sense to the programs in order to preserve them because Medicaid is intended to be a temporary safety net for people who desperately need it,” U.S. House Speaker Mike Johnson said during a June appearance on “The Megyn Kelly Show.” “You’re talking about the elderly, disabled, you know, young single pregnant moms who are down on their luck, right? But it’s not being used for those purposes because it’s been expanded under the last two Democrat presidents and to cover everybody. So, you’ve got a bunch of able-bodied young men, for example, who are on Medicaid and not working. So what we’re doing is restoring work requirements to Medicaid. OK, this is common sense.”

National work requirements are unlikely to actually boost employment, Alker said, because more than two-thirds of Medicaid recipients ages 19-64 already have jobs. The remainder includes students, or those who are too sick or disabled to work.

“Work requirements don’t work, except to cut people off of health insurance,” she said.

The logistical steps required to report one’s activities assume that a recipient has reliable internet or transportation to travel to an agency — things that low-income Georgians may not have.

The paperwork requirements to gain coverage are time-consuming, said one Medicaid recipient, Paul Mikell.

Mikell is a licensed truck driver but does not have coverage through that job. He’s also an electrician who currently does property maintenance in exchange for free housing.

Mikell has had Medicaid through Pathways for nearly two years and has had problems navigating the Pathways web portal. 

“And I know it wasn’t my device because I would go to the library and use the computer, I would try different devices, and I’ve had the same issues,” he said. “Regardless of the device, it’s something with the website.”

Another time, he said, his attempt to recertify his work hours was delayed because of paperwork issues.

“They said I was ineligible for everything because of a typo in the system or something, I don’t know what it was. I eventually was able to speak to someone and she fixed it,” he said.

This article is from a partnership with WABE and NPR.

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The case has drawn national attention to Georgia’s six-week abortion ban and its impacts on pregnancy care.

Adriana Smith was put on life support at Emory University Hospital in Atlanta in February. The then-30-year-old Atlanta nurse was more than eight weeks pregnant and suffering dangerous complications.

Her condition deteriorated as doctors tried to save her life, Smith’s mother told Atlanta TV station WXIA.

“They did a CT scan, and she had blood clots all in her head,” April Newkirk said. “So they had asked me if they could do a procedure to relieve them, and I said yes. And then they called me back and they said that they couldn’t do it.”

She said doctors declared Smith brain-dead and put her on life support without consulting her.

“And I’m not saying that we would have chose to terminate her pregnancy,” Newkirk said, “but what I’m saying is, we should have had a choice.”

Emory Healthcare declined to comment on the specifics of Smith’s case. After doctors removed Smith from life support, Emory issued a statement.

“The top priorities at Emory Healthcare continue to be the safety and wellbeing of the patients and families we serve,” the health system said. “Emory Healthcare uses consensus from clinical experts, medical literature and legal guidance to support our providers as they make medical recommendations. Emory Healthcare is legally required to maintain the confidentiality of the protected health information of our patients, which is why we are unable to comment on individual matters and circumstances.”

In a previous statement, Emory Healthcare said it complies “with Georgia’s abortion laws and all other applicable laws.”

Abortion Laws and Fetal Personhood

Georgia’s HB 481 — the Living Infants Fairness and Equality, or LIFE, Act — passed in 2019. It took effect shortly after the U.S. Supreme Court overturned Roe v. Wade with its ruling in Dobbs v. Jackson Women’s Health Organization on June 24, 2022.

The law bans abortion after the point at which an ultrasound can detect cardiac activity in an embryo. Typically, this occurs about six weeks into pregnancy, often before women know they’re pregnant.

The law also gave fetuses the same rights as people.

It says that “unborn children are a class of living, distinct persons” and that the state of Georgia “recognizes the benefits of providing full legal recognition to an unborn child.”

Nineteen states now ban abortion at or before 19 weeks of gestation; 13 of those have a near-total ban on all abortions with very limited exceptions, according to the Guttmacher Institute, a nonpartisan research group that supports abortion rights.

Like Georgia, some of these states built their abortion restrictions around the legal concept of “personhood,” thus conferring legal rights and protections on an embryo or fetus during pregnancy.

Smith’s case has represented a major test of how this type of law will be applied in certain medical situations.

Despite mainly being unified in their opposition to abortion, conservatives and politicians in Georgia do not publicly agree on the scope of the law in cases like Smith’s.

For example, Georgia Attorney General Chris Carr, a Republican, said that the law should not restrict the options for care in a case like Smith’s and that removing life support wouldn’t be equivalent to aborting a fetus.

“There is nothing in the LIFE Act that requires medical professionals to keep a woman on life support after brain death,” Carr said in a statement. “Removing life support is not an action ‘with the purpose to terminate a pregnancy.’”

But Republican state Sen. Ed Setzler, who authored the LIFE Act, disagreed. Emory’s doctors acted appropriately when they put Smith on life support, he told The Associated Press.

“I think it is completely appropriate that the hospital do what they can to save the life of the child,” Setzler said. “I think this is an unusual circumstance, but I think it highlights the value of innocent human life. I think the hospital is acting appropriately.”

Mary Ziegler, a law professor at the University of California-Davis and author of “Personhood: The New Civil War Over Reproduction,” said the problem is that Georgia’s law “isn’t just an abortion ban. It’s a ‘personhood’ law declaring that a fetus or embryo is a person, that an ‘unborn child,’ as the law puts it, is a person.”

The legal concept of “personhood” has implications beyond abortion care, such as with the regulation of fertility treatment, or the potential criminalization of pregnancy complications such as stillbirth and miscarriage.

Under Georgia’s law, extending rights of personhood to a fetus changes how child support is calculated. It also allows an embryo or fetus to be claimed as a dependent on state taxes.

But the idea of personhood is not new, Ziegler said.

“It has been the goal for virtually everyone in the anti-abortion movement since the 1960s,” she said. “That doesn’t mean Republicans like that. It doesn’t necessarily mean that that’s what’s going to happen. But there is no daylight between the anti-abortion movement and the personhood movement. They’re the same.”

The personhood movement has gained more traction since the Dobbs ruling in 2022.

In Alabama, after the state’s Supreme Court ruled that frozen embryos are people, the state legislature had to step in to allow fertility clinics to continue their work.

“This is sort of the future we’re looking at if we move further in the direction of fetal personhood,” Ziegler said. “Any state Supreme Court, as we just saw in Alabama, can give them new life,” she said referring to personhood laws elsewhere.

Fetal Personhood Laws Can Delay Care  

In Georgia, dozens of OB-GYNs have said that the law interferes with patient care — in a state where the maternal mortality rate is one of the worst in the U.S. and where Black women are more than twice as likely to die from a pregnancy-related cause than white women. 

Members of Georgia’s Maternal Mortality Review Committee — who were later dismissed from the panel — linked the state’s abortion ban to delayed emergency care and the deaths of at least two women in the state, as ProPublica reported.

The personhood provision is having a profound effect on medical care, said Atlanta OB-GYN Zoë Lucier-Julian.

“These laws create an environment of fear and attempt to coerce us as providers to align with the state, as opposed to aligning with our patients that we work so hard to serve,” Lucier-Julian said.

Lucier-Julian said that’s what happened to Emory Healthcare in Smith’s case.

Cole Muzio, president of the Frontline Policy Council, a conservative Christian group, said the state’s abortion law shouldn’t have affected how Emory handled Smith’s care.

“This is a pretty clear-cut case, in terms of how it’s defined in the language of HB 481,” he said. “What this bans is an abortion after a heartbeat is detected. That is the scope of our law.”

“Taking a woman off life support is not an abortion. It just isn’t,” Muzio said.“Now, I am incredibly grateful that this child will be born even in the midst of tragic circumstances. That is a whole human life that will be able to be lived because of this beautiful mother’s sacrifice.”

A suit challenging Georgia’s law and its impact on public health is working its way through the courts. A coalition of physicians, the American Civil Liberties Union of Georgia, Planned Parenthood, the Center for Reproductive Rights, and other groups filed the suit.

Newkirk said her daughter had initially gone to a different Atlanta-area hospital for help with severe headaches, was given some medicine, and was sent home, where her symptoms quickly worsened.

“She was gasping for air in her sleep, gargling,” she told WXIA in May. “More than likely, it was blood.”

Now, Newkirk said, the family is praying for her grandson to make it after the stress from months of life support. 

He is fighting, she said.

“My grandson may be blind, may not be able to walk, wheelchair-bound,” she said. “We don’t know if he’ll live.”

She added that the family will love him no matter what.

This article is from a partnership with WABE and NPR.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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The event, put together by Atlanta-area Democratic U.S. Rep. Nikema Williams, was attended mostly by union members and recently fired federal workers, including Ryan Sloane.

“I was fired by an anonymous email at 9 p.m. in the middle of a holiday weekend,” he said.

Sloane is still seeking reinstatement, but he feels he no longer has much to lose by speaking out.

“I’m only here today because they cannot fire me twice,” Sloane said.

When he received his termination notice, he was a few months into a job as a public affairs specialist at the Centers for Disease Control and Prevention.

At the CDC, his days were spent updating far-flung local TV, radio, and newspaper journalists about threats such as seasonal flu, measles, and food safety in their communities.

A judge has ordered the reinstatement of some fired federal employees, at least temporarily. But their jobs are still on the line.

Sloane said his former colleagues at the CDC whose jobs aren’t yet in limbo are scared.

“They are terrified that their life’s work is going to be deleted from servers and not backed up because it does not comport with the ideologies of the new administration,” he said. “No one is benefiting from this.”

From the end of January to mid-February, the Trump administration took offline some CDC webpages and froze external communications, including its widely read Morbidity and Mortality Weekly Report epidemiological digest.

The webpages that were removed included CDC public health reports, datasets, and guidance on infectious diseases and sexual health. After a court order, some agency information was restored, at least for now.

But even temporary disruptions to CDC communications could have big ripple effects.

It is information that state and local health departments, hospitals, university researchers, and others rely on to help them respond to outbreaks.

“CDC is there to provide technical information, provide funding, provide support, but it’s a collaborative work, working together to keep Americans safe,” said former CDC Director Tom Frieden, who headed the agency from 2009 to 2017. He is now president and CEO of the nonprofit organization Resolve to Save Lives. “In this country, we have a patchwork or network of public health. It’s really up to the local, city, and state health departments to get the job done.”

City and state health agencies also need the collaboration of CDC experts to help investigate local disease outbreaks and other threats to public health.

A clinician who has worked at the agency for more than two decades pointed to the CDC’s singular ability to send medical supplies and deploy highly specialized teams of scientists to help local communities identify and contain outbreaks. KFF Health News agreed not to use the clinician’s name because she fears she will be fired for airing these views publicly.

“A lot of them are assigned to state and local health departments, so really even beyond individual positions, any funding cuts that the agency takes are also passed on to state and local health departments,” the clinician said. “A lot of their budget comes from federal money as well.”

The Trump administration has attempted to terminate hundreds of employees from the CDC alone, along with hundreds more workers at the National Institutes of Health and other federal agencies with a U.S. health and safety role.

Many public health and science researchers are concerned about the cuts’ impacts on the nation’s ability to respond to threats — and about whether state and local public health departments will be able to keep communities healthy without the CDC’s partnership.

Billionaire Elon Musk has said his Department of Government Efficiency intends to keep cutting federal agencies’ budgets and staff, targeting what it calls “fraud.”

“Anytime someone gets fired, it’s always difficult. But with $36 trillion in debt, we have to reduce the size of the federal government,” Republican U.S. Rep. Marjorie Taylor Greene told WABE during a March visit to the Georgia State Capitol.

Her district includes parts of suburban Atlanta about 30 miles from CDC headquarters.

Greene also chairs a House subcommittee also called “DOGE,” for “Delivering on Government Efficiency.”

“Fortunately, with all the investments that are being brought back into the country under President Trump, I really hope that those federal workers are able to find new jobs,” she said.

She did not comment on whether local public health departments around the country would be able to work efficiently without the support of CDC experts who have been terminated.

But many U.S. public health experts are expressing concern.

The CDC has long been a key training ground for the next generation of U.S. public health researchers.

Emory University epidemiology professor Patrick Sullivan was one of them earlier in his career. The HIV expert previously worked at the CDC for about 15 years.

“When I started working in HIV prevention at CDC in the early 1990s, we didn’t have the treatments that essentially allowed people living with HIV to have a full, healthy, normal lifespan,” he said. “We didn’t have the treatments that essentially allowed people living with HIV to have a test that people could take home to test themselves.”

Sullivan said the progress he has seen over the last several decades gave him optimism, and that advances in HIV treatment and prevention are a great example of the importance of federal support for public health work.

“Discovery science and pharmacy science really have given us the tools that we need to end the HIV epidemic in the United States,” he said.

But, to have those scientific tools without adequate public health staff or funding to use them, he said, will cost American lives.

This article is from a partnership that includes WABE, NPR, and KFF Health News.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Al evento, organizado por Nikema Williams, representante demócrata en el Congreso nacional, asistieron miembros del sindicato y también trabajadores federales recientemente despedidos, entre ellos Ryan Sloane.

“Me despidieron a través de un correo electrónico anónimo a las 9 pm en pleno fin de semana festivo”, declaró.

Sloane sigue peleando por su reincorporación, pero siente que ya no tiene mucho que perder alzando su voz.

“Estoy aquí hoy porque no pueden despedirme dos veces”, declaró Sloane.

Cuando recibió su notificación de despido, llevaba unos meses trabajando como especialista en información pública en los Centros para el Control y Prevención de Enfermedades (CDC).

En los CDC, dedicaba sus días a informar a periodistas locales de televisión, radio y periódicos sobre amenazas como la gripe estacional, el sarampión y la seguridad alimentaria en sus comunidades.

Un juez ha ordenado la reincorporación de algunos empleados federales despedidos, al menos temporalmente. Pero sus puestos de trabajo siguen en riesgo.

Sloane comentó que sus colegas de los CDC, cuyos puestos aún no están en el limbo, están asustados.

“Les aterra que el trabajo de toda una vida se borre de los servidores y no se respalde porque no se ajusta a las ideologías de la nueva administración”, declaró. “Nadie se beneficia con esto”.

Desde finales de enero hasta mediados de febrero, la administración Trump desconectó algunas páginas de internet de los CDC y congeló las comunicaciones externas, incluido su resumen epidemiológico, el Informe Semanal de Morbilidad y Mortalidad, un material muy leído y consultado.

Las páginas web eliminadas incluían informes de salud pública, conjuntos de datos y directrices sobre enfermedades infecciosas y de salud sexual. Tras una orden judicial, se restableció parte de la información de la agencia, al menos por ahora.

Pero incluso las interrupciones temporales en las comunicaciones de los CDC podrían tener un gran impacto.

Es información de la que dependen los departamentos de salud estatales y locales, los hospitales, los investigadores universitarios y otros para responder a brotes.

“Los CDC están ahí para proporcionar información técnica, financiación y apoyo, pero es un trabajo colaborativo, trabajando juntos para mantener a los estadounidenses seguros”, dijo el exdirector de los CDC, Tom Frieden, quien dirigió la agencia de 2009 a 2017.

Actualmente, Frieden es presidente y director ejecutivo de la organización sin fines de lucro Resolve to Save Lives. “En este país, tenemos una red fragmentada de salud pública. Depende de los departamentos de salud locales, municipales y estatales hacer el trabajo”.

Las agencias de salud municipales y estatales también necesitan la colaboración de los expertos de los CDC para ayudar a investigar brotes locales de enfermedades y otras amenazas de salud pública.

Una médica que ha trabajado en la agencia durante más de dos décadas destacó la singular capacidad de los CDC para enviar suministros médicos y desplegar equipos de científicos altamente especializados para ayudar a las comunidades locales a identificar y contener brotes. KFF Health News acordó no revelar su nombre por temor al despido por opinar públicamente.

“Muchos de ellos están asignados a departamentos de salud estatales y locales, así que, incluso más allá de los puestos individuales, cualquier recorte de fondos que implemente la agencia también se traslada a esos departamentos”, declaró la médica. “Gran parte de sus presupuestos también proviene de fondos federales”.

La administración Trump ha intentado despedir a cientos de empleados de los CDC, junto con cientos de trabajadores de los Institutos Nacionales de Salud (NIH) y otras agencias federales con funciones en materia de salud y seguridad.

Muchos investigadores de salud pública y ciencia están preocupados por el impacto de los recortes en la capacidad del país para responder a amenazas, y sobre si los departamentos de salud pública estatales y locales podrán mantener la salud de las comunidades sin la colaboración de los CDC.

El multimillonario Elon Musk ha declarado que su Departamento de Eficiencia Gubernamental (DOGE) tiene la intención de seguir recortando presupuestos y personal de las agencias federales, combatiendo lo que denomina “fraude”.

“Cada vez que despiden a alguien, es difícil. Pero con una deuda de $36 mil millones, tenemos que reducir el tamaño del gobierno federal”, declaró la representante republicana Marjorie Taylor Greene a WABE durante una visita al Capitolio estatal de Georgia en marzo.

Su distrito incluye zonas suburbanas de Atlanta, a unos 48 kilómetros de la sede de los CDC. Greene también preside un subcomité de la Cámara de Representantes, también llamado DOGE.

“Afortunadamente, con todas las inversiones que se están reincorporando al país bajo la presidencia de Trump, espero de verdad que esos trabajadores federales puedan encontrar nuevos empleos”, afirmó.

No comentó si los departamentos locales de salud pública de todo el país podrían trabajar eficientemente sin el apoyo de los expertos de los CDC que han sido despedidos.

Pero muchos especialistas en salud pública están expresando su preocupación.

Los CDC han sido durante mucho tiempo un centro de formación clave para la próxima generación de investigadores de salud pública del país.

Patrick Sullivan, profesor de epidemiología de la Universidad Emory, fue uno de ellos al principio de su carrera. Este experto en VIH trabajó en los CDC durante unos 15 años.

“Cuando comencé a trabajar en la prevención del VIH en los CDC a principios de la década de 1990, no contábamos con los tratamientos que permitieran a las personas con VIH tener una vida plena, saludable y normal”, dijo. “No contábamos con los tratamientos que permitieran a las personas con VIH llevarse un kit a casa para hacerse la prueba ellos mismos”.

Sullivan afirmó que el progreso que ha visto en las últimas décadas le generaba optimismo, y que los avances en el tratamiento y la prevención del VIH son un gran ejemplo de la importancia del apoyo federal al trabajo de salud pública.

“La ciencia del descubrimiento y la ciencia farmacéutica realmente nos han proporcionado las herramientas que necesitamos para acabar con la epidemia de VIH en Estados Unidos”, afirmó.

Pero agregó que, sin esas herramientas científicas, sin financiación y sin personal de salud pública, se perderán vidas.

Este artículo es parte de una colaboración que incluye a WABE, NPR y KFF Health News.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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It wasn’t the vaginal birth Clark had hoped for during her pregnancy.

“I was freaking out. That was my first child. Like, of course you don’t plan that,” she said. “I just remember the gas pulling up to my face and I ended up going to sleep.”

She remembered feeling a rush of relief when she woke to see that her baby boy was healthy.

Clark, a 33-year-old nursing student who also works full-time in county government, had another C-section when her second child was born in 2020. This time, the cesarean was planned.

Clark said she’s grateful the physicians and nurses who delivered both her babies were kind and caring during her labor and delivery. But looking back, she said, she wishes she had had a doula for one-on-one support through pregnancy, childbirth, and the postpartum period. Now she wants to give other women the option she didn’t have.

Clark is a member of Morehouse School of Medicine’s first class of rural doulas, called Perinatal Patient Navigators.

The program recently graduated a dozen participants, all Black women from southwestern Georgia. They have completed more than five months of training and are scheduled to begin working with pregnant and postpartum patients this year.

“We’re developing a workforce that’s going to be providing the support that Black women and birthing people need,” Natalie Hernandez-Green, an associate professor of obstetrics and gynecology at Morehouse School of Medicine, said at the doula commencement ceremony in Albany, Georgia.

Albany is Morehouse School of Medicine’s second Perinatal Patient Navigator program site. The first has been up and running in Atlanta since training began in the fall of 2022.

Georgia has one of the highest rates of maternal mortality in the country, according to an analysis by KFF, a health information nonprofit that includes KFF Health News. And Black Georgians are more than twice as likely as white Georgians to die of causes related to pregnancy.

“It doesn’t matter whether you’re rich or poor. Black women are dying at [an] alarming rate from pregnancy-related complications,” said Hernandez-Green, who is also executive director of the Center for Maternal Health Equity at Morehouse School of Medicine. “And we’re about to change that one person at a time.”

The presence of a doula, along with regular nursing care, is associated with improved labor and delivery outcomes, reduced stress, and higher rates of patient satisfaction, according to the American College of Obstetricians and Gynecologists.

Multiple studies also link doulas to fewer expensive childbirth interventions, including cesarean births.

Doulas are not medical professionals. They are trained to offer education about the pregnancy and postpartum periods, to guide patients through the health care system, and to provide emotional and physical support before, during, and after childbirth.

Morehouse School of Medicine’s program is among a growing number of similar efforts being introduced across the country as more communities look to doulas to help address maternal mortality and poor maternal health outcomes, particularly for Black women and other women of color.

Now that she has graduated, Clark said she’s looking forward to helping other women in her community as a doula. “To be that person that would be there for my clients, treat them like a sister or like a mother, in a sense of just treating them with utmost respect,” she said. “The ultimate goal is to make them feel comfortable and let them know ‘I’m here to support you.’” Her training has inspired her to become an advocate for maternal health issues in southwestern Georgia.

Grants fund Morehouse School of Medicine’s doula program, which costs $350,000 a year to operate. Graduates are given a $2,000 training stipend and the program places five graduates with health care providers in southwestern Georgia. Grant money also pays the doulas’ salaries for one year. 

“It’s not sustainable if you’re chasing the next grant to fund it,” said Rachel Hardeman, a professor of health and racial equity at the University of Minnesota School of Public Health.

Thirteen states cover doulas through Medicaid, according to the Georgetown University Center for Children and Families.

Hardeman and others have found that when Medicaid programs cover doula care, states save millions of dollars in health care costs. “We were able to calculate the return on investment if Medicaid decided to reimburse doulas for pregnant people who are Medicaid beneficiaries,” she said.

That’s because doulas can help reduce the number of expensive medical interventions during and after birth, and improving delivery outcomes, including reduced cesarean sections.

Doulas can even reduce the likelihood of preterm birth. 

“An infant that is born at a very, very early gestational age is going to require a great deal of resources and interventions to ensure that they survive and then continue to thrive,” Hardeman said.

There is growing demand for doula services in Georgia, said Fowzio Jama, director of research for Healthy Mothers, Healthy Babies Coalition of Georgia. Her group recently completed a pilot study that offered doula services to about 170 Georgians covered under Medicaid. “We had a waitlist of over 200 clients and we wanted to give them the support that they needed, but we just couldn’t with the given resources that we had,” Jama said.

Doula services can cost hundreds or thousands of dollars out-of-pocket, making it too expensive for many low-income people, rural communities, and communities of color, many of which suffer from shortages in maternity care, according to the March of Dimes.

The Healthy Mothers, Healthy Babies study found that matching high-risk patients with doulas — particularly doulas from similar racial and ethnic backgrounds — had a positive effect on patients. 

“There was a reduced use of pitocin to induce labor. We saw fewer requests for pain medication. And with our infants, only 6% were low birth weight,” Jama said.

Still, she and others acknowledge that doulas alone can’t fix the problem of high maternal mortality and morbidity rates.

States, including Georgia, need to do more to bring comprehensive maternity care to communities that need more options, Hardeman said.

“I think it’s important to understand that doulas are not going to save us, and we should not put that expectation on them. Doulas are a tool,” she said. “They are a piece of the puzzle that is helping to impact a really, really complex issue.”

In the meantime, Joan Anderson, 55, said she’s excited to get to work supporting patients, especially from rural areas around Albany.

“I feel like I’m equipped to go out and be that voice, be that person that our community needs so bad,” said Anderson, a graduate of the Morehouse School of Medicine doula program. “I am encouraged to know that I will be joining in that mission, that fight for us, as far as maternal health is concerned.”

Anderson said that someday she wants to open a birthing center to provide maternity care. “We do not have one here in southwest Georgia at all,” Anderson said.

In addition to providing support during and after childbirth, Anderson and her fellow graduates are trained to assess their patients’ needs and connect them to services such as food assistance, mental health care, transportation to prenatal appointments, and breastfeeding assistance.

Their work is likely to have ripple effects across a largely rural corner of Georgia, said Sherrell Byrd, who co-founded and directs SOWEGA Rising, a nonprofit organization in southwestern Georgia.

“So many of the graduates are part of church networks, they are part of community organizations, some of them are our government workers. They’re very connected,” Byrd said. “And I think that connectedness is what’s going to help them be successful moving forward.”

This reporting is part of a fellowship with the Association of Health Care Journalists supported by The Commonwealth Fund. It comes from a partnership that includes WABE, NPR, and KFF Health News.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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“I’m having two boys, twins. It’s my first pregnancy,” she said.

Carter knows the pregnancy risks she could face as a Black woman, especially in Georgia, where data shows Black women are more than twice as likely as white women to die during or within a year after a pregnancy.

“I take care of my body during the pregnancy, but, yeah, I’m very aware,” Carter said. “And I just try to stay positive.”

In 2021, women made up about 17% of the U.S. military’s active-duty force. And women are the fastest-growing group of veterans in the country, according to the Department of Veterans Affairs.

A recent report from Rand Corp. outlines some of the ways the health needs of women differ from men’s, including pregnancy and childbirth. And health researchers have said women veterans may be at heightened risk for pregnancy complications, compared with their civilian counterparts.

A few years ago, the Atlanta VA Clinic got creative with its outreach to pregnant patients. It began throwing surprise baby showers for small groups of patients. The goal is to cement relationships with the clinical staff, make sure pregnant veterans get to all their regular and specialist appointments, and help ensure pregnant people have the supplies they need as they near delivery. A trained maternity care coordinator manages each pregnant veteran’s care.

After the covid-19 pandemic emerged, the VA transformed the showers into low-contact “drive-thru” events, which occur about every three months, and serve roughly 20 pregnant veterans each time.

At a shower in February, volunteers set up in front of the main entrance of the Atlanta VA. The building is concrete, beige, and bland. But the volunteers created a celebratory atmosphere by decorating a folding table and stacking it high with free diaper bags and other baby supplies.

A car pulled up to the table and a volunteer with a clipboard began hyping up the small crowd, which then burst into applause and cheers.

“Thank you for your service!” they called out. “Congratulations!”

The pregnant veteran behind the wheel looked surprised at first. Then she broke into a big smile. She rolled down her car window.

Volunteers and VA staff members clustered around the car and offered her a tiara of green, white, and pink flowers.

“Would you like to wear it?” one asked. “Stunning! Remind us what you’re having?”

“I’m having a girl,” the woman said.

While they chatted through the open window about her due date and health, other volunteers rushed forward with supplies. Some piled boxes of diapers into the back seat. The final, parting gesture was a $100 gift card.

Kathleen O’Loughlin, who manages the women veterans program at the Atlanta VA, said the events offer “last-minute baby needs.”

“Because we know there’s a lot,” she said.

O’Loughlin said the health center can’t invite every pregnant veteran to these group baby showers, so they focus on women with higher-risk pregnancies, including veterans carrying multiples or those who have a disability related to their military service.

“Now, a lot of the women have different musculoskeletal issues because of their service, [or] a lot of service-connected disabilities that civilian women aren’t exposed to because they don’t have those same job responsibilities,” O’Loughlin said. “This is an extra set of eyeballs on them. Are you making sure you’re taking your blood pressure medicines? Are you getting all of your appointments, are you meeting with your doctors?”

U.S. maternal mortality rates increased again during the pandemic years of 2020 and 2021, according to the Centers for Disease Control and Prevention.

Physical and psychological injuries linked to military service can increase the risk of poor maternal outcomes, according to Jamya Pittman, an internist and the medical director for the women veterans program in Atlanta.

“A lot of our women veterans have the diagnoses of anxiety, depression. They may also have PTSD, in addition to a myriad of other diagnoses like hypertension and diabetes,” Pittman said. “We also know that pregnancy in itself can be a stressor on the body.”

The Atlanta VA designed the baby showers to boost veterans’ well-being, she explained. Program volunteers are predominantly also women veterans.

“This visible showing of support, this community engagement, this celebration,” she said, “is our way of helping to decrease stress and allow the woman veteran to know that she has a partner in her health care and with the arrival of the baby.”

Nationally, the Department of Veterans Affairs is focusing on women’s health at all life stages.

The Atlanta women veterans program serves more than 24,000 veterans in the region, and about 9% of them are pregnant at any time.

Two years ago, Congress passed bipartisan legislation mandating a national study of pregnancy outcomes among veterans, including any racial disparities.

“There has never been a comprehensive evaluation of how our nation’s growing maternal mortality crisis is impacting our women Veterans, even though they may be at higher risk due to their service,” wrote co-sponsor Sen. Tammy Duckworth (D-Ill.) on the day the bill was introduced.

The law, called the Protecting Moms Who Served Act, also provided $15 million to support maternity care coordination programs at VA facilities.

The Atlanta VA is using some of its share of that money to make sure pregnant veterans receive ongoing medical care for a full year after giving birth.

Carter, the Navy veteran who stopped by the baby shower, said she appreciated the outreach from the VA.

“Just checking on the women, supporting them, making sure that they have everything that they need for the baby,” she said, “because a lot of people don’t have that support, they don’t have family, they’re doing this on their own.”

Carter gave birth to her twins on Feb. 25. She and the babies are doing well, she said. The women veterans program’s maternity care coverage continues for 12 months after the twins’ birth.

This article is from a partnership that includes WABE, NPR, and KFF Health News.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).