Priority Need: Prevent Maternal Mortality

 

NPM 1: Well-Woman Visits

 

The factors impacting women's health are complex and varied, ranging from social-emotional issues, environmental impact, health insurance status, access to health care, birth spacing, and any number of other factors, which include the social determinants of health, or the conditions in which individuals are born, grow, live, work and age. Improving women’s health throughout the lifespan is an essential component to bettering the health and wellness of Georgia’s women. The Women’s Health program promotes and supports a myriad of efforts to improve the health of all women. Over the past year, the Women’s Health program continued to focus on improving access to health care, including access to the most effective forms of contraceptives and preconception health to promote women's health prior to pregnancy. The all-encompassing goal to promote health equity for all Georgians, which is emphasized throughout all domains, is reflected in the Women-Maternal Health section of this application.

 

Well-woman visits are important to a woman’s overall health and well-being. One of the many benefits of these visits is the opportunity for women to discuss their health and to prevent and/or help identify serious health concerns before they become life threatening. Programmatic activities and strategies undertaken during the reporting year promoted routine well-woman visits to support the mental and physical health needs of women.

 

Maternal mortality was identified as a priority need for Georgia in 2015 with a strategic focus on increasing the percentage of women who receive a preventive health care visit. Due to the critical need to reduce maternal mortality in Georgia, the Title V program focused on strategies that reduce maternal mortality. Understanding those factors associated with maternal mortality and morbidity is essential for improving maternal health outcomes.

 

Maternal Mortality Review Committee

The support of the Governor and the Georgia Legislature with the passage of SB 273 in 2017 laid the foundation for the ability for the MMRC to identify pregnancy-associated deaths, review those caused by pregnancy complications and other selected deaths and identify problems contributing to the deaths and interventions that may reduce deaths. The bill provided legal protections for committee members and the review process, ensuring confidentiality of the review process, and providing the committee with the necessary authority to collect data for case review.

 

During the reporting year, the MMRC completed its review of the 2015 and 2016 cases and began the review of the 2017 cases, with the goal of reviewing cases within two years of the date of death. DPH received $200,000 in state funding to fund two additional case abstractors through the Georgia Obstetrical and Gynecological Society.

 

The MMRC worked to improve processes and the quality of the recommendations. The committee membership was updated to ensure that needed perspectives were represented and members who had met or exceeded the three-year term limit were released. In December 2020, an orientation with all MMRC members was conducted to ensure the understanding of the Committee Decisions Form. A non-clinical Co-Chair position was developed to assist with guiding the discussion on preventability, contributing factors, and recommendations. Members were added to ensure the committee includes clinical and non-clinical disciplines and is diverse with respect to race, geographic location, and specialty. The MMRC reviewed the 2016 cases and completed the entire Committee Decisions Form for pregnancy-related and pregnancy-associated, but not related cases. A recusal policy and conflict of interest policy was developed and implemented.

 

The quality of the MMRC review was enhanced with the addition of a Co-Chair to facilitate the discussion on social determinants of health. Additional members with expertise in mental health, substance use, and non-clinical disciplines were added to ensure racial diversity and representation from rural areas of the state.

 

In January 2020, DPH published a 2012-2015 Fact Sheet that included data on pregnancy-associated, but not-related, and pregnancy-related cases. This fact sheet was used by maternal health advocates in the 2020 legislative session to advocate for maternal health, including the extension of Medicaid coverage up to one year postpartum. HB 1114 passed in June 2020, which allows the Department of Community Health (DCH) to apply for an 1115 Waiver to extend Pregnancy Medicaid to six months after delivery.

 

Efforts continued to enhance case identification and abstraction. MCH Epidemiology linked hospital discharge data with 2016 death certificates to strengthen case identification and provide further information on known cases. The effort identified eight potential cases from 2016 and was included in the case identification process. DPH developed a data sharing process with Medicaid to receive Medicaid information for known cases, including dates of coverage and providers seen to assist abstractors in making records request.

 

DPH implemented a process to complete Informant Interviews to enhance the quality of the case review for pregnancy-associated deaths. Informant Interviews provided qualitative information surrounding pregnancy-associated deaths, including a decedent’s feelings and stressors, experiences with healthcare, and use of social services. This information provided greater context around social determinants of health and other events leading up to a pregnancy-associated death. The information obtained from Informant Interviews facilitated a more comprehensive maternal mortality case review with enhanced learning of contributing factors of pregnancy-associated death and more effective recommendations for prevention. DPH hired a Licensed Clinical Social Worker to conduct interviews with family members and other close contacts on pregnancy-associated deaths in June 2020. The interviews were conducted using an interview guide, created based on the Informant Interview Guide for Maternal Mortality Review Committees that was developed by CDC and the CDC Foundation. Informants were asked questions about the decedent’s physical health, emotional health, experiences with healthcare providers, stressors, social history, and other questions specific to the circumstances. The interview notes were compiled into a summary, which was included in the case narrative and provided to the committee members for the case review.

 

Center for Black Women’s Wellness Health Equity Lab

The MCH Director participated in the Center for Black Women’s Wellness Health Equity Lab and worked with design teams to develop tangible ways to support efforts to change birth outcome experiences. The Action Lab provided opportunities to collaborate with subject matter experts to explore the contribution of racism on adverse outcomes for black women and leverage findings to strategize solutions and identify the most high-leverage work to improve the system for black women. Development of the Shared Awareness and Leadership Evaluation Logic Model began to influence changes in health care delivery systems to address systemic racism as the root of morbidity and mortality among Black mothers in Georgia. The logic model included process inputs, activities, and outputs as well as short, intermediate, and long term anticipated outcomes. A Respectful Care Survey was developed to assess care provided by organizations for women to ensure adequate care was being provided in a manner that maintains dignity, privacy and confidentiality, freedom from harm and mistreatment, and enabled informed choice and continuous support during labor and childbirth.

 

Priority Need: Prevent Maternal Mortality

 

NPM 3: Risk-appropriate Perinatal Care

 

Maternal and Neonatal Levels of Care

Perinatal Levels of Care Legislation became effective July 1, 2018, to create a mechanism for levels of care designation and ongoing site verification of Georgia birthing hospitals. DPH launched an initiative to designate hospitals according to the level of maternal and neonatal care the facility can provide. The purpose of a hospital designation is to encourage risk-appropriate care for Georgia’s women and infants and to assess the capabilities of Georgia’s hospitals more accurately. In Georgia, hospitals receive a certificate of need authorizing them to provide a level of perinatal care through the Georgia Department of Community Health. However, there has not been a mechanism to verify that hospitals are meeting the requirements for the level of care they have been authorized to provide through their license. According to the Levels of Care Assessment Tool (LOCATe) survey conducted by the CDC, nearly half of Georgia hospitals that completed the survey were assessed at a lower level of care than their self-assessed level. Through this program, hospitals may voluntarily apply for a designation from DPH. To achieve a designation, hospitals must demonstrate through document submission and an onsite review that they meet the requirements for their license, as well as additional requirements based on the recommendation from the American Academy of Pediatrics (AAP), the American College of Gynecology and Obstetrics and the Society for Maternal-Fetal Medicine. A Neonatal Subcommittee and a Maternal Subcommittee were established to assist the Maternal and Neonatal Advisory Council on the designation requirements. The subcommittees are comprised of physicians, nurses, and hospital administrators from hospital systems throughout the state and represent a variety of specialties.

 

Perinatal Regionalization

The MCH Regional Perinatal Center (RPC) program promotes access to risk appropriate perinatal care to pregnant women and their infants through regional quality improvement activities. Program activities include: 1) facilitating local perinatal advisory councils to provide regional planning, coordination, and recommendations to ensure appropriate levels of care; 2) performing regional and statewide hospital surveys and perinatal assessments; 3) developing communication networks among agencies, providers, and individuals; 4) disseminating educational materials and producing a statewide summary of findings; and 5) assisting hospitals with quality improvement activities, data collection protocols, and quality assurance policies and procedures.

 

The Maternal and Neonatal Center Designation program planning and implementation continued in the reporting year and the rules outlining the requirements for designated centers became effective in November 2019. A contract was established with the AAP to use the AAP Verification program for the application and site survey process for Level II and Level III Neonatal Center Designations. Although there were barriers to implementation due to COVID-19, five hospitals worked on an agreement with AAP to begin their verification process. The Maternal and Neonatal Center Designation program was piloted with two hospitals in the Fall of 2020.

 

To strengthen the system of regionalization, meetings and conference calls continued to increase communication with RPC stakeholders, medical directors, and outreach educators in the six RPCs located in Albany, Atlanta, Augusta, Columbus, Macon, and Savannah.

 

Alliance for Innovation on Maternal Health (AIM) Bundles

Georgia applied to the AIM program and was accepted as an AIM state in October 2017 to lead the Georgia Perinatal Quality Collaborative’s (GaPQC) initiative to implement the use of AIM hemorrhage and hypertension patient safety bundles in the state’s birthing hospitals. The two-maternal safety bundles that were selected for implementation were the AIM Obstetric Hemorrhage Bundle (HMG) and the AIM Severe Hypertension in Pregnancy Bundle (HTN). GaPQC continued to implement the HMG and HTN bundles. Forty-four hospitals participated in the HMG initiative and 42 hospitals participated in HTN. Forty-four out of 54 (81 percent) of AIM hospitals submitted data for structure/process measures. During the reporting year, 100 percent of the AIM hospital quarterly outcome Severe Maternal Morbidity (SMM) measures were collected, analyzed, and uploaded into the AIM data portal and sent to participating hospitals. Fifteen of the 44 hospitals participating in the AIM hemorrhage initiative are rural hospitals and received state funding to support perinatal quality improvement in their rural facilities. Ten rural hospitals participated in the HTN bundles. The Women’s Health program staff worked closely with the remaining six hospitals to recruit them into the Hypertension bundle.

 

In the fall of 2019, a statewide needs assessment was conducted to identify priority needs of our HMG and HTN maternal teams. Training for simulation drills and debriefs were identified as a priority among respondents. To meet this need, five regional clinical simulation drill and debrief trainings were scheduled. Each were planned in collaboration with the six maternal Regional Perinatal Center Outreach Educators who would have served as trainers for the trainings in the southeast, southwest, middle, northwest, and northeast regions of the state. All birthing facilities in the state were invited to participate. Over 100 participants were registered to attend the sessions in total. Due to the COVID-19 pandemic, only one training was conducted. The sessions will be rescheduled once schedules and operations return to normal. In partnership with the Georgia OB/GYN Society, an environmental scan of the maternal and neonatal participating hospitals was created and disseminated in December 2020 to identify improvement opportunities for all initiatives and future direction. The results will be analyzed and presented in the first quarter of 2021 to guide future directions. Teams enrolled in the HTN initiative began reporting on new process measures which involved case identification and time to treatment. Technical assistance was ongoing to support hospital teams with the new reporting measures and initiatives overall.

 

To improve health equity education, the Reducing Peripartum Disparities Bundle was implemented in the reporting year and a requirement for hospital providers and nurses to complete implicit bias training was added to HMG and HTN process measures. Race was also included in the chart review data collected and reported in the HTN bundle. Hospitals began reporting the number of providers and staff receiving implicit bias training in their quarterly reports. GaPQC launched the Health Equity and Implicit Bias learning series in the summer of 2020 featuring two national speakers, Dr. Joia Crear-Perry and Dr. Uche Blackstock. GaPQC members, Women’s Health, and several MCH staff attended the training. The SPEAK UP Against Racism training through the Institute for Perinatal Quality Improvement was also offered. The 2020 GaPQC Annual Conference was cancelled due to the COVID-19 pandemic. Training efforts were focused on monthly webinars and supporting hospitals with their initiatives.

 

Maternal Mental Health

In the reporting year, the Perinatal Psychiatry Access program connected providers treating pregnant and postpartum women with training on managing perinatal mood and anxiety disorders with real-time consultations from a perinatal psychiatrist. The Women’s Health program established contracts with Georgia Healthy Mothers Healthy Babies and the Emory Clinic to operate the program. Postpartum Support International, Georgia Chapter, conducted training to increase the number of mental health providers with a Certification in Perinatal Mental Health. Lifeline4Moms collaborated with Women’s Health to provide consultation services on program development and monthly webinars and program manager conference calls.

 

Priority Need: Promote Oral Health Among All Populations

 

NPM 13: Preventive Dental Visit

 

Oral Health

In the reporting year, the Oral Health program served 1,245 pregnant women to reduce some of the contributing factors to low birth weight (LBW) infants. Education was provided to women of childbearing age about Neonatal Abstinence Syndrome (NAS) and the need for good nutrition, prenatal, and dental care. The Oral Health Director recorded a series of six short public service announcement videos focused on key messages on oral health geared towards pregnant women and caregivers of young children. The videos were placed on the DPH YouTube page and were shared with partners for cross promotion. The Oral Health program participated in a Georgia Healthy Mothers Healthy Babies pregnancy oral health work group to improve the number of pregnant women in Georgia receiving oral health care. Three key priority areas were developed, which included improving oral health literacy through awareness efforts for pregnant women, increasing oral health literacy through awareness efforts geared towards perinatal providers, and reducing administrative burden for participating as a provider in the state Medicaid program.

 

The Oral Health program disseminated the message of drinking fluoridated water at all ages to pregnant and parenting women through the Georgia Oral Health Collation, Healthy Mothers and Healthy Babies, and Home Visiting. The Oral Health program collaborated with the Tobacco program in the DPH Chronic Disease section to distribute toolkits geared to dental providers focused on patient tobacco cessation strategies and tips. Approximately 1,900 Oral Health Pregnancy Resource Bags were distributed to pregnant and new mothers through partnerships with district oral health staff, district Women, Infants, and Children Special Supplemental Nutrition program (WIC) nurses, district DPH nurses, home visitors, DPH perinatal case managers, and others. The Oral Health Director continued efforts to educate professional organizations through presentations to OBGYN residents and disseminating a monthly newsletter to Georgia Obstetrics and Gynecology Society members on oral health.

 

Priority Need: Increase Access to Family Planning Services

 

SPM 1: Family Planning (2015-2020)

 

Family Planning

Georgia’s Family Planning program provided leadership, guidance, and resources to Georgia’s 18 public health districts in the development and provision of resources that increase the access of family planning services to women. The Family Planning program offers patient-centered, comprehensive health care services designed to provide women support to plan the birth of their children, reduce unintended pregnancies, determine effective birth control methods, and improve the well-being of families statewide.

 

In the reporting year, the Family Planning program completed site visits which provided unique insight into the successes and challenges of each public health district. Site visits provided information concerning daily operations and provided billing, clinical and administrative technical assistance. Best practices including billing third party payers to maximize reimbursement, thus generating income, and the implementation of a health educator/navigator model to promote access to family planning services continue to be explored.

 

The Family Planning program conducted nine weeklong women’s health courses for new public health registered nurses to provide the training required to practice in an expanded roll according to nurse protocol. The expanded role skills are needed for family planning service delivery in local health departments.

 

The COVID-19 pandemic resulted in clinic closures and reduced availability of face-to-face visits. Prior to the pandemic, all family planning encounters were conducted in clinic settings. The program developed guidance for clinics in providing remote interviews for the continuation of oral contraceptives and much of the Depo Provera visit. The pandemic also required the program to postpone the remaining program site visits to Athens, Gainesville, Clayton, and Dalton health districts, women’s health trainings, and Long-Acting Reversible Contraceptives (LARC) training courses due to concerns over COVID-19.

 

Other Women/Maternal Health Programs

 

Centering Pregnancy

Centering Pregnancy is an evidenced-based model of group prenatal care combining health assessment, interactive learning, and community building to help support positive health behaviors. Centering Pregnancy empowers patients, strengthens patient/provider relationships, and builds communities through health assessment, interactive learning and community building. During the reporting year, Women’s Health continued to collaborate with partners to provide education and resources to Centering Pregnancy participants. In collaboration with the Oral Health program, dental kits and an Oral Health During Pregnancy webinar were provided to Centering Pregnancy participants. Albany Area Primary Health Care, a Federally Qualified Health Center (FQHC), provided staff support to the Centering Pregnancy program in Albany and was interested in adopting the program. The program collaborated with United Way to provide the next Basic Facilitator’s training to the Albany district to ensure training of replacement staff and continuity of care in the district.

 

Augusta’s Centering Pregnancy program hosted a virtual reunion for delivered participants. Previous program participants shared their experiences and expressed their appreciation of the Centering Pregnancy program. Discussions centered around the individual birthing experience, contraceptives, and birth spacing. Activities included playing games, winning prizes, and a certificate of completion for the program was given. The Microsoft Teams virtual meeting format was utilized to provide Centering Pregnancy meetings during the COVID-19 Pandemic.

 

Perinatal Case Management

Perinatal Case Management (PCM) is a voluntary program that is implemented in the public health departments. PCM allows for a case manager to assist a pregnant woman with identifying her special needs and helps her gain access to medical, nutritional, social, psychosocial, educational, and other services to improve health outcomes of mother and baby. In the reporting year, 111 county health departments provided PCM services in the state of Georgia. PCM collaborated with the Child Occupant Safety Program (COSP) to increase participation in the car seat program for all counties. PCM also collaborated with the Oral Health program to provide dental kits to the pregnant women entering the county health department for PCM enrollment and a webinar educating the Perinatal Case Managers on the importance of oral health during pregnancy. Collaboration continued with the HIV Prevention Project with internal partners of the HIV program. Education was developed and provided to women on the importance of early treatment in pregnancy and lowering the incidence of congenital syphilis and HIV occurrence. The project was placed on hold due to the COVID-19 pandemic.

 

Planning for Healthy Babies

Planning for Health Babies (P4HB) is a family planning demonstration waiver program issued by DCH to assist DPH in reducing the number of low birth weight (LBW) and very low birth weight (VLBW) infants in Georgia. Women who meet Medicaid eligibility criteria and/or have had a VLBW baby may be eligible under the expansion policy to receive family planning services, Inter-pregnancy Care (IPC), Case Management, and/or Resource Mother program services. The program is intended to bridge health care for underinsured and uninsured women of high need. Efforts to increase enrollment into P4HB were continued with DCH and other partners.

 

In the reporting year, P4HB convened a working group with the purpose of increasing utilization and participation in P4HB. The MCH Director and Title V Deputy Director participated in the working group to create a statewide marketing and communications plan in collaboration with the four Care Management Organizations (CMOs), provider organizations and community-based organizations that serve the MCH population eligible for P4HB in Georgia to amplify efforts by DCH and CMOs toward increasing the knowledge, understanding, and utilization of P4HB services toward reducing Georgia’s LBW and VLBW rates, unintended pregnancies, and lowering Medicaid costs. Working groups were held in December 2019, February, June, and August 2020. The P4HB Waiver program services for eligible women was drafted and barriers around patient awareness were identified and marketing materials development was discussed.

 

Maternal and Child Health Information and Resource Center

In the reporting year, the Women’s Health program worked with the existing Maternal and Child Health Information and Resource Center that operates the MCH resource hotline and website to include resources and referrals to resources that identify and treat chronic illnesses such as hypertension, heart disease, obesity, and diabetes.

 

Current Year: Oct 2020-Sept 2021

 

Priority Need: Prevent Maternal Mortality

 

NPM 1: Well-Woman Visits

 

Preventive Medical Visit

In the current year, Women’s Health collaborated with the Breast and Cervical Cancer Program (BCCP) district and contracted providers to improve preventative care for women by meeting or exceeding the CDC Guidelines for breast and cervical cancer prevention services annually. Strategies to increase opportunities to provide well-woman or preconception visits were developed so women could receive recommended clinical preventive services, such as screening, counseling, and immunizations, which can lead to appropriate identification, treatment, and prevention of diseases to optimize the health of women before, between, and beyond potential pregnancies. Prevention, screening, and management of chronic conditions, such as diabetes, counseling to achieve a healthy weight, and smoking cessation, can be advanced with a well-woman visit to promote women’s health prior to and between pregnancies and improve subsequent maternal and perinatal outcomes.

 

Although COVID-19 impacted public health services at local health departments the Women’s Health program continued plans to support activities to meet or exceed the CDC guideline for the percent of initial cervical screening tests that are conducted among women who have never been screened or not screened within the last 10 years.

 

Maternal Mortality Review Committee

During the current year, the MMRC reviewed 65 cases from 2018 and continue working towards reviewing cases within two years of the date of death. Data entry on 2017 cases was completed. The MMRC continues to improve processes and quality of the recommendations that were made and implemented to meet this goal.

 

Efforts continue to enhance case identification and abstraction while working with Medicaid to develop a data sharing process to receive Medicaid information for known cases, including dates of coverage and providers seen. Knowing the providers seen ensures that abstractors know where to request records and expand the abstraction beyond obstetric providers. As of June 30, 2021, all abstraction responsibilities were transitioned to DPH staff.

 

In the current year, Key Informant Interviews continue as part of the review process. The Key Informant Interviewer interviews friends, family members, and other individuals who were close to the woman’s life. Having qualitative information provides contextual information on the woman’s life, pregnancy, and events surrounding her death, which helps the committee better identify contributing factors and recommendations for prevention. Women’s Health worked with a graphic designer to develop a softer design for outreach materials.

 

The Georgia Maternal Health Extension for Community Healthcare Outcomes (ECHO) was launched to enhance knowledge, interprofessional collaboration, and dissemination of resources to directly address Georgia’s maternal mortality and severe maternal morbidity rate. The ECHO collaborative learning model is used to help implement Georgia Maternal Mortality Review Committee (MMRC) recommendations for provider education. Each Maternal Health ECHO session is composed of a brief content presentation followed by community discussion of resources and guidelines available to guide care. The collaborative launches September 14, 2021, with a Perinatal Mental Health session. Future sessions will occur on the third Wednesday of each month. Upcoming topics include Hypertensive Complications of Pregnancy and Cardiac Complications of the Perinatal Period.

 

Related legislation: GA Code § 31-2A-16 became effective July 1, 2014, authorizing DPH to conduct case review of maternal deaths. The legislation provides protection for the case review process and authorizing access to case information.

 

House Bill 684 included $2,000,000 in annual funding under DPH’s Adolescent and Adult Health Promotion Program to implement perinatal quality improvement initiatives in rural birthing hospitals to improve maternal outcomes. The funding became effective July 1, 2018, and provides needed infrastructure for smaller, rural facilities to participate in perinatal improvement initiatives.

 

House Bill 1114 passed in June 2020, which allows DCH to apply for an 1115 Waiver to extend Pregnancy Medicaid to six months after delivery. In April 2021, the state’s Georgia Postpartum Extension section 1115 demonstration waiver was approved by Centers for Medicare and Medicaid Services (CMS) extending Medicaid state plan benefits from 60 days to six months to postpartum women with incomes up to 220 percent of the federal poverty level.

 

NPM 3: Risk-appropriate Perinatal Care

 

Maternal and Neonatal Levels of Care

Two hospitals worked on completing their application process for the maternal center designation pilot. A position was posted to hire a full-time nurse to conduct the site visits. Five hospitals are in the application process with Georgia Chapter of the American Academy of Pediatrics (GA AAP).

 

Perinatal Regionalization

Efforts to continue strengthening the system of Regionalization and communication with RPC stakeholders includes having meetings with RPC medical directors and outreach educators, as well as conference calls with finance staff and data coordinators. Work with the six RPCs located in Albany, Atlanta, Augusta, Columbus, Macon, and Savannah continues.

 

Related legislation: House Bill 1114 Pregnancy Medicaid Coverage to Six Months Postpartum was passed by the Georgia General Assembly to allow Medicaid to extend to six months post-delivery.

 

In 2018, the Georgia General Assembly passed HB909 which authorizes DPH to designate hospitals for maternal and neonatal care. The legislation was signed into law and became effective July 1, 2018.

 

Alliance for Innovation on Maternal Health Bundles (AIM)

In the current year, GaPQC continued to implement the obstetric hemorrhage (HMG) and severe hypertension (HTN) in pregnancy AIM patient safety bundles with 44 hospitals participating in HMG initiative and 42 hospitals participating in HTN. All of the AIM hospitals continue to submit quarterly data for structure/process measures, but there was a noted decrease in 2021 reporting due to the pandemic’s impact on hospital teams. During the current year, 100 percent of the AIM hospitals quarterly outcome Severe Maternal Morbidity (SMM) measures were collected, analyzed, and uploaded into the AIM data portal and sent to participating hospitals. Hospital teams participating in the Hypertension QI Initiative began reporting on two process measures by race and ethnicity – time to treatment and treatment with Magnesium Sulfate.

 

Women’s Health began a formal partnership with the AIM Community Care Initiative. AIM CCI builds on existing quality improvement efforts in hospital settings and focuses on using maternal safety bundles in non-hospital settings. GaPQC is also partnering with more AIM states, Louisiana and Texas, as plans to prepare continue for the 2022 launch of cardiac related conditions AIM bundle.

 

To improve health equity education, the Reducing Peripartum Disparities Bundle was implemented in the reporting year 2020 and a requirement for hospital providers and nurses to complete implicit bias training was added to HMG and HTN process measures. Race was also included in the chart review data collected and reported in the HTN bundle. Hospitals began reporting the number of providers and staff receiving implicit bias training in their quarterly reports. Two additional SPEAK UP trainings to provide health equity education were offered in May and July 2021 with the goal to support hospitals in translating knowledge into action through the completion of hospital specific action plans. The 2020 GaPQC Annual Conference was rescheduled for October 14-15, 2021.

 

In the current year, in an effort to reduce disparities in severe maternal morbidities and adverse maternal and early child health outcomes in Georgia, the MCH Director serves  as a member of several advisory groups that include a diverse team of clinicians, health service researchers, health economists, medical providers, and epidemiologist who are committed to studying the complex array of individual, health care system, community and societal level factors that culminate in disparities in access to care and maternal health outcomes. The Advisory Boards include:

• Center for Black Women’s Wellness (CBWW) Health Equity Lab- The Health Equity Lab develops tangible ways to support efforts to change birth outcome experiences. The Action Lab provides opportunities to collaborate with subject matter experts to explore the contribution of racism on adverse outcomes for black women and leverage findings to strategize solutions and identify the most high-leverage work to improve the system for black women. A Respectful Care Survey was developed to assess care provided by organizations for women to ensure adequate care was being provided in a manner that maintains dignity, privacy and confidentiality, freedom from harm and mistreatment, and enabled informed choice and continuous support during labor and childbirth.

 

• Black Maternal and Child Health Program and Policy Environmental Scan Advisory Board- CBWW, Emory University, and Healthcare Georgia Foundation works with the Advisory Board to better understand the needs, opportunities, and gaps for maternal and child health (under the age of three) in Georgia. The Advisory Group is working to identify programs, policies, and services that best address Black maternal and child health. Focus groups that will be conducted among Black mothers with lived experiences throughout the state. These focus groups will be conducted to determine the importance of racism as a cause of health disparities. Six focus groups will be conducted with women who live in both rural and urban locations throughout the state and who represent different levels of socio-economic status. A focus group will also be conducted with teen mothers and one focus group will be with partners or support persons (e.g., grandparents). An electronic survey will be administered to identified representatives of programs and organizations that provide services to women, mothers, infants, and children through age three in Georgia. The purpose of the e-survey is to collect information about (1) the target population for the programs or services, (2) the content of the programs or services, (3) whether the programs or services are perceived to meet the needs of Black women, infants, and children, (4) how programs or services might be improved to better meet the needs of Black women, infants, and children, and (5) whether the programs and/or organizations address workforce development or trainings, such as implicit bias or health disparities. Informant Interviews will be conducted. A select number of interviews will be with the representatives who participated in the electronic survey to elicit more in-depth information and detail of the programs and services. The Advisory Board will also make recommendations to close the gaps in MCH to include the LGBTQ+ community.

 

• Minding the Gap– Minding the Gap (MTG) is a five-year mixed method, multi-stage study that combines a statewide assessment of racial disparities in severe maternal morbidities and other adverse maternal health outcomes in the context of Georgia’s Medicaid Inter-pregnancy Care Program and a randomized trial of a comprehensive postpartum care system in an urban safety-net hospital (Grady Memorial Hospital). Funded by the National Institutes of Health (NIH), the MTG project brings together a diverse team of clinicians, health services researchers, health economists, and epidemiologists that are committed to studying the complex array of individual, health care system, community, and societal level factors that culminate in women’s lack of access to and engagement with postpartum care. The overarching goal of the MTG study is to fill critical gaps in knowledge regarding policy and health system approaches for reducing disparities in maternal morbidity and mortality.

 

Challenges/barriers: Workforce shortages were reported from Regional Perinatal Centers during annual site visit due to COVID-19. Initiatives were paused at the hospital level to focus on COVID-19. Women’s Health is prepared to provide support to assist hospitals in moving forward as the situation allows.

 

Maternal Mental Health

Women’s Health, in collaboration with the Emory Brain Health Center, launched the PEACE (Perinatal Psychiatry, Education and Community Engagement) for Moms program which seeks to support the mental health of women before and after childbirth. The program provides expert consultation and education to physicians, physician assistants, nurse midwives, and nurse practitioners. The PEACE for Moms program aims to:

• Engage with clinicians caring for mothers and mothers-to-be and provide one-time evaluations, when needed, with women to direct care decisions.
• Educate caregivers about the resources available to patients in their communities.
• Provide health professionals with information so they can best treat their patients.
• Train medical professionals to recognize and treat psychiatric illness in their patients and help them plan for future pregnancies.
• Educate physicians in training on how to best address the needs of this vulnerable population.

 

PEACE for Moms works with care providers to determine appropriate treatment options and support for patients, especially in rural areas where access and coverage are critical. Of the state’s 159 counties, it is estimated only eight possess an adequate number of mental health practitioners. Currently there are 132 providers enrolled in the program and a therapist referral database has been developed. The program is currently hiring for a Clinical Psychologist position and a Community Advisor. The program has seven peer support facilitators.

 

Priority Need: Promote Oral Health to All Populations

 

NPM 13: Preventive Dental Visit

 

Oral Health

In the current year, the Oral Health program screened pregnant women to reduce some of the contributing factors to low birth weight (LBW) infants. Education was provided to women of childbearing age about NAS and the need for good nutrition, prenatal care, and dental care. During the current year the previously developed Public Service Announcement (PSA) oral health videos were boosted on social media platforms Instagram and Facebook for 30 days. This created a Facebook “REACH” of 164,708 and 194,871 “IMPRESSIONS” and an Instagram “REACH” of 19,460 and 22,473 “IMPRESSIONS”.

 

The Oral Health program continued to work with DPH Epidemiology with the PRAMS program to add four state supplemental questions on oral health for pregnant or recently pregnant women to the PRAMS survey. The supplemental questions gain additional data on “having dental problems during pregnancy,” “seeing the dentist for that problem during pregnancy,” “whether anything made it difficult to see a dentist for problems during pregnancy,” and if respondents “have seen the dentist since their most recent delivery.”

 

During the current year, pilot projects funded by HRSA grants to the National Oral Health Resource Center (ORHC) out of Georgetown University Center for Oral Health Systems Integration and Improvement will be completed. To focus on medical and dental integration with a local primary care center, the Oral Health Program partnered with Albany Primary Care (APC), an FQHC network in Albany, and built upon existing Medicaid/dental integration to incorporate a full-time dental hygienist in the primary care medical facility. A single dental operatory was built into the APC Women’s Health clinic. An APC dentist sees OBGYN patients for their dental care needs one day a week and a dental hygienist sees women on a separate day within the Women’s Health Clinic. One half day per week, a dental assistant offers oral health education in the Women’s Health Clinic waiting room. Midwives and nurses were cross trained by oral health staff to provide oral health education, caries risk assessments, and enter referrals/care coordination into their electronic health records for follow up at the APC dental clinics. All medical staff were cross trained with the online Smiles for Life program for medical providers.

 

The second project focused on developing Quality Indicator metrics on oral health for MCH populations. Five pilot states, including Georgia, worked with a national stakeholder and subject matter expert group to provide state level feedback on feasibility and implementation factors for including the quality indicators in the state oral health surveillance and for quality improvement. The Oral Health Director participated in several meetings of the Healthy Mothers Healthy Babies (HMHB) Oral Health and Pregnancy workgroup. The group includes a diverse range of stakeholders and seeks to carry out three priority areas: (1) improve oral health literacy in pregnant women throughout the state, (2) improve oral health literacy in perinatal providers throughout the state, and (3) reduce administrative burdens for providers to participate in the Medicaid provider network in Georgia. Oral Health in pregnant women training was provided to approximately 50 OBGYN residents.

 

Six virtual fluoridation trainings were provided in the current year to community water plant operators across the state to ensure that Georgia remains one of the top states in the country in terms of access to optimally fluoridated water. Currently almost 96 percent of Georgia residents on community water systems have access to optimally adjusted fluoridation through community water fluoridation programs. CDC has shown community water fluoridation can reduce dental decay in communities by up to 25 percent.

 

Other Women/Maternal Health Programs

 

Family Planning

During the current year, the COVID-19 pandemic continued to result in clinic closures and reduced availability of face-to-face visits.  The Georgia Maternal Child Health Coordinator Locator on the DPH website was available and provided real time service availability in the public health clinics for adjusted COVID-19 services. Women’s Health continued to provide guidance for clinics in providing remote interviews for the continuation of oral contraceptives and much of the Depo Provera visit.

 

Centering Pregnancy

During the current year, in-person Centering Pregnancy group sessions were not offered due to COVID-19 concerns for client safety and traditional prenatal care was provided. The Augusta site gathered information and attended training sessions involving hosting virtual centering pregnancy sessions to improve capacity for providing virtual care. Staff attended Centering Healthcare Institute’s latest Basic Facilitators Workshop via virtual mode.

 

Challenges/barriers: Sustainability and staffing continue to be a challenge. Some Centering Pregnancy staff assisted in supporting the needs in the community and working specimen point of collection (SPOC) locations. Some clinics suffered staffing shortages due to positive testing of COVID-19.

 

Perinatal Case Management

In the current year, there continues to be 111 county health departments providing PCM services in the state of Georgia. Some districts are providing limited services due to COVID-19. The PCM objective by 2022 is to increase the number of County Health Departments providing PCM services to 115.

 

PCM trainings were conducted throughout the current year via telehealth. PCM training via face-to-face mode was cancelled during the summer months due to constraints with COVID-19. The production of the PCM post card and pamphlet has been placed on hold due to the pandemic. PCM collaborated with the Oral Health Program to provide dental kits to the pregnant women entering the county health department for PCM enrollment and a webinar educating the Perinatal Case Managers on the importance of oral health during pregnancy. Collaboration continues with the HIV Prevention Project with internal partners of the HIV program. PCM plans to continue its collaboration with the Child Occupant Safety Program post-pandemic to increase participation in the car seat program for all counties.

 

Planning for Healthy Babies (P4HB)

The P4HB working group continued with the purpose of increasing utilization and participation in P4HB. The MCH Director and Title V Deputy Director participate in the working group to create a statewide marketing and communications plan in collaboration with the four Care Management Organizations (CMOs), provider organizations, and community-based organizations that serve the MCH population eligible for P4HB in Georgia. Efforts by the Department of Community Health (DCH) and CMOs are being amplified to increasing the knowledge, understanding and utilization of P4HB services toward reducing Georgia’s LBW and VLBW rates, unintended pregnancies, and lowering Medicaid costs.

 

Working groups were held in December 2020, March, May, and August 2021. The mutual goal to increase the awareness and utilization of the P4HB Waiver program services for eligible women was drafted. Barriers around patient awareness were identified and marketing materials development was discussed.

 

Maternal and Child Health Information and Resource Center

In the current year, the Women’s Health Program continued work with the existing Maternal and Child Health Information and Resource Center that operates the MCH resource hotline and website to include resources and referrals that identify and treat chronic illnesses such as hypertension, heart disease, obesity, and diabetes.