Kayla Dominick of Meridian knew something was not right – her periods were irregular and she felt constant pressure in her pelvis. She found a local OB-GYN who accepted Medicaid, and he performed an ultrasound of her uterus.
When it was recommended she undergo follow-up testing, including a uterine biopsy, she called the office to ask the doctor or nurse some questions and share concerns about the procedure. After leaving several messages and never hearing back, she decided to find another doctor.
But that didn’t prove simple: There are only 11 licensed OB-GYNs in Lauderdale County, home to Meridian, and its surrounding five counties, according to data from the Office of Mississippi Physician Workforce. Of those 11, only six reportedly practice obstetrics, or deliver babies.
At the same time, almost 28,000 women of reproductive age are living in that six-county area, according to U.S. Census data.
By comparison, in Rankin County, also home to about 28,000 women of reproductive age, there are 42 licensed OB-GYNs.
Mississippi as a whole is experiencing a shortage of these specialists. A recent WalletHub study ranked Mississippi as the worst state to have a baby. It came in 50th in the “midwives and OB-GYNs per capita” category, which it used data from the U.S. Bureau of Labor Statistics to determine. It also incorporated the state’s maternal and infant mortality rates – some of the worst in the nation – into the ranking.
More than half of Mississippi counties are considered maternity care deserts, or have no hospitals providing obstetric care, no OB-GYNs and no certified nurse midwives.
But the small number of OB-GYNs – particularly those still practicing obstetrics – in a metropolitan area like Meridian shows how tenuous the current workforce landscape is.
Dr. Norman Connell, market medical director for the OB Hospitalist Group and a Vicksburg-based OB-GYN, said about five years ago, the Meridian area had around 12 or 13 obstetric providers, most of them with privileges at both hospitals. Now, there are six providers on staff at both Ochsner Rush and Anderson Regional Medical Center.
In 2021, as a result of the drop in providers, both hospitals signed an agreement with Connell’s company to supply OB-GYN hospitalists, or providers from across the state, or even out of state, who work solely in an inpatient hospital setting.
“The population of Meridian didn’t shrink, but the area lost over half of the OB providers in a few short years,” Connell said.
Connell said the doctors at his company allow the local OB-GYNs to stay in their clinics more often and see patients they need to see.
“In addition to that, we’re also the doctor for patients who don’t have physicians on staff there … and for people who haven’t gotten prenatal care and show up with an obstetric problem,” he explained.
The group also has contracts with seven other hospitals all over the state, from Magnolia Regional Health Center in Corinth to Mississippi Baptist Medical Center in Jackson.
For Dominick, finding another doctor who accepts Medicaid and who would perform the procedure was a challenge – a surprising one for the native of New Orleans, where health care services are abundant.
“In the New Orleans area, we have an urgent care (clinic) on almost every corner, open 24/7,” she said of the abundance of health care services.
Dominick, like many other women in Meridian, took to a Facebook group for Meridian moms to ask for OB-GYN recommendations. There are several posts in the group from women looking for OB-GYN recommendations, either because they need a new one or because the one they’ve been seeing is too busy for routine appointments like check-ups.
“Best obgyns to go to im tired of waiting to get an appointment at my doctors office I shouldn’t have to sit there for three hours when there’s 3 people in the waiting room or waiting 6 months to even get in,” one woman wrote.
Dominick eventually landed an appointment with Dr. Virginia Nelson, who has been an OB-GYN in the area for more than 20 years. Nelson, however, recently quit practicing obstetrics after spending the prior two years on call at the hospital 24 nights a month.
Nelson was absolutely exhausted, scrambling from the hospital to the clinic and back.
She remembers one night when several other OB-GYNs at the hospital were out of town, and she was sick with the flu. She wound up working anyway.
Anywhere from 40% to more than 75% of OB-GYNs experience burnout, studies show – in the middle to upper one-third of medical specialties.
On top of the physical and mental burnout from around-the-clock work, she had many high-risk patients to see in her clinic – patients who required a lot of time, she said, and often with insurance that did not reimburse well. About half of her patients were on Medicaid, she said.
Medicaid payments for physician services are well below Medicare payments, which are below commercial insurance rates. Mississippi also has one of the lowest average commercial reimbursement rates for both inpatient and outpatient services in the nation, according to a Milliman white paper.
“It’s expensive to do OB here. I ran my numbers one month – if every one of my OB patients had been Medicaid … I would not have been able to pay my overhead with my nurses, and that’s with me working for free, totally taking my salary out of it,” she said. “I would have been about $100,000 short.”
In her clinic now, she treats Medicaid patients when they are referred to her clinic and, on a case-by-case basis, unreferred patients. She said because the clinic is not designated a “rural health clinic” by the federal government, Medicaid reimbursements for services are very low.
“The (gynecology) side is very low reimbursement for general services if you don’t have a rural health clinic designation,” she explained.
Further compounding the issue is how sick the patient population in the area – and across the state – is.
“We have the sickest patient population, so they’re litigious, time consuming – I did a lot of high-risk pregnancies. It’s a lot of coming up at two in the morning to check on people who are super sick,” she said.
Mississippi leads the nation in areas such as obesity, high blood pressure and diabetes – all conditions that make pregnancy more dangerous and require more time and services from OB-GYNs and other maternal health practitioners. These conditions often lead to worse outcomes for women and babies.
As OB-GYNs stop practicing or retire, both in Mississippi and nationwide, they aren’t being replaced at the same rate. And it’s unknown how last year’s Dobbs decision that overturned Roe v. Wade is affecting the OB-GYN workforce in Mississippi, though other states with similar restrictive abortion laws have seen providers leave because of enhanced legal risks.
Dr. Michelle Owens, a maternal fetal medicine specialist who worked at the University of Mississippi Medical Center for nearly 20 years, said she suspects because the state’s laws have always been so restrictive in regards to abortion, Dobbs is not having an immediate effect on providers who live here.
“I think if anything, if people are concerned about the restrictive nature of practice of obstetrics and gynecology as it pertains to terminations services, that it (Dobbs) would probably be more influential on preventing people who want to provide that care. Those people aren’t going to come here (to Mississippi),” she said.
In a state with such a severe shortage, one must consider the ramifications of that, she said.
“The more we say we're in favor of allowing or condoning government interference in exam rooms, we have to also recognize there are some unintended consequences to those decisions – they don’t just happen in a vacuum,” she said.
There’s currently only one OB-GYN residency program in the state at the University of Mississippi Medical Center, and the program graduates six residents each year. Of the most recent graduates, only two stayed in Mississippi – prior years’ numbers average about the same.
On top of that, there have been changes in how OB-GYNs work over the last decade nationally. Traditionally OB-GYNs worked at private clinics and had privileges at hospitals. Now, however, many OB-GYNs are hospitalists, or OB-GYNs who work solely in the inpatient setting, according to Dr. Elizabeth Lutz, associate professor of obstetrics and gynecology and the residency program director at the University of Mississippi Medical Center.
And more OB-GYNs today wind up completing fellowships, or going into a subspecialty such as maternal fetal medicine.
“Nowadays, closer than 30 to 40% of OB-GYN residents go into fellowship – that’s grown dramatically,” said Lutz, associate professor of obstetrics and gynecology and the residency program director at the University of Mississippi Medical Center.
Both Ochsner Rush, where Nelson previously had privileges, and Anderson in Meridian began contracting with the OB Hospitalist Group in 2021 to fill in the gaps created by the shortage. About eight OB-GYNs from across the state – and even some from out of state – work shifts at both hospitals.
Anderson averages about 1,020 births per year, according to a hospital spokesperson. Ochsner Rush averages just under 1,000 births annually.
“Due to a shortage of OB-GYN’s in east central Mississippi, Anderson Regional Health System partners with a OB Hospitalist group to supplement our three practicing OB-GYN’s in providing 24-hour obstetrics coverage every day,” said Dr. Keith Everett, chief medical officer at Anderson Regional Health System.
Both hospitals also employ advanced practice nurses called certified nurse midwives – Ochsner Rush has four on staff – who manage the care of low-risk patients. The midwives are also skilled at counseling and education of patients in areas such as nutrition, childbirth preparation and breastfeeding.
The use of certified nurse midwives in Mississippi is rare: there are fewer than 30 in the state, and only a few hospitals, including the two in Meridian, allow them to deliver babies.
Connell said he thinks the company’s role in the area – and in the state – will only continue to grow.
“I think Meridian paints a picture of (why this work is important),” he said. “... It’s a work in progress. We’re at the very beginning of making things better.”
Correction 9/18/2023: This story has been updated to reflect Dr. Virginia Nelson's correct first name.