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, to birth spacing and any number of other factors including the social determinants of health in which individuals are born, grow, live, work and age. Improving women’s health throughout the lifespan is an essential component to improving the health and wellness of Georgia’s women. The MCH Women-Maternal Health programs promote and support a myriad of efforts to improve the health of all women. Over the past year the Women-Maternal Health programs 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. All-encompassing is the goal to promote health equity for all Georgians, which is emphasized throughout all domains, and 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 aimed at helping to promote 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.

 

MCH hosted the Third Annual MCH Conference at the University of Georgia in Athens on June 3-4, 2019 to provide professional development, dialogue and networking to Georgia’s MCH workforce with 400 people in attendance. The conference’s keynote address presented by Dr. Fleda Mask Jackson, leader and creator of Save 100 Babies, focused on maternal mortality prevention highlighting social determinants and asset-based approaches for eliminating racial disparities in birth outcomes. A Pre-Conference session was held on June 2, 2019 to provide an opportunity for MCH workforce, stakeholders and partners to learn about current trends, state and national initiatives, and how Georgia can improve maternal mortality outcomes. Two nationally recognized speakers, Mr. Charles Johnson and Dr. Joia Crear-Perry presented. Mr. Johnson, shared his personal experience with maternal mortality and his mission to advocate for improved maternal health policies and regulations through his nonprofit 4Kira4Moms. Dr. Crear-Perry is the Founder and President of the National Birth Equity Collaborative presented opportunities to reduce black maternal and infant mortality through research, family-centered collaboration and advocacy.

 

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 Georgia Maternal Mortality Review Committee (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 these deaths. The bill provides 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. The analysis of 2014 case review findings and draft report were completed in 2018. The final report has been published and disseminated statewide. During the review of 2014 maternal deaths in Georgia, the MMRC adopted the CDC-developed Committee Decision Form which was critical and necessary to collect additional data about factors related to the maternal death. The MMRC findings help direct and lead initiatives to impact maternal birth outcomes.

 

 

Figure 1: DPH Collaboration in Reducing Maternal Mortality

 

 

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. In the reporting year, DPH launched an initiative to designate hospitals according to the level of maternal and neonatal care the facility is capable of providing. The purpose of a hospital designation is to encourage risk-appropriate care for Georgia’s women and infants and to more accurately assess the capabilities of Georgia’s hospitals. 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 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 new 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 also established to assist the Maternal and Neonatal Advisory Council on the designation requirements. These subcommittees are comprised of physicians, nurses and hospital administrators from hospital systems throughout the state and represent a variety of specialties. The committees were formed in July 2018 and meet monthly.

 

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; 5) assisting hospitals with quality improvement activities, data collection protocols, and quality assurance policies and procedures.

 

During the reporting period, the Women’s Health Program continued strategies to increase awareness of the RPCs with the goal of increasing utilization of perinatal regionalization with Level I and Level II birthing hospitals in the southernmost region of the state. A summary of site visits that were completed in 2018 was presented at the RPC meeting at the annual GOGS conference. RPC outreach educators completed a formal educational needs assessment for their respective perinatal regions. Each educator created an educational plan using SMART goals for the year. The assessment highlighted some of the areas of educational need to be NAS, hemorrhage simulation, thermal regulation, and maintaining blood sugars. Several committees were designated to focus on data collection, transportation, oversight and branding. The branding committee was responsible for outreach materials designed to promote knowledge of the regionalized system. The six RPCs are located in Albany, Atlanta, Augusta, Columbus, Macon, and Savannah.

 

Alliance for Innovation on Maternal Health (AIM) Bundles
In response to the MMRC reports, Georgia applied to the Alliance for Innovation on Maternal Health (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 and the AIM Severe Hypertension in Pregnancy Bundle. During the reporting period, under the leadership of DPH and in collaboration with the GaPQC, hospitals were enrolled to participate in the AIM Obstetric Hemorrhage Bundle over two enrollment periods, resulting in over half (42) of the state’s delivering hospitals enrolled by the end of the reporting year. Hospitals identified their respective implementation teams, and were provided structure and process measures to implement. GaPQC provides support to hospitals including monthly collaboration webinars, individualized technical calls, and data collection, analysis and reporting. In 2018 the Georgia General Assembly provided two million dollars to implement quality improvement projects in rural birthing hospitals. Sixteen hospitals receive funding and are among the birthing hospitals working to implement the AIM hemorrhage bundle initiative.

 

Priority Need: Promote Oral Health Among All Populations

 

NPM 13: Preventive Dental Visit

 

In the reporting year, the Oral Health program served 1,118 pregnant women in an effort 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.

The Oral Health program partnered with DPH’s Chronic Disease team for the Oral Health/Tobacco Program collaborative. Three separate three-hour continuing education courses were presented in October and November 2017, to oral health providers on pregnancy in oral health, the role of oral health providers in tobacco cessation for pregnant women, and promoting cross referrals between perinatal healthcare workers and dentists. A toolkit entitled Tobacco Cessation for Oral Health Professionals geared towards tobacco cessation for pregnant women was also developed and disseminated through several statewide coalitions, organizations, and conferences during the reporting year.

 

The Oral Health program presented to approximately 70 family medicine and internal medicine physician residents on the medical provider’s role in oral health. A portion of the presentation was geared towards assessing pregnant women’s oral health, providing education on the importance of oral health, and making referrals to dental providers.

 

The Executive Director of Healthy Mothers Healthy Babies (HMHB) partnered with Oral Health to present at the Georgia Oral Health Coalition (GOHC) meeting about pregnant women and oral health and the efforts HMHB is taking to provide access to dental care for pregnant women. Oral Health presented a webinar for the First Steps Organization providing information to approximately 30 state-wide community health coordinators to educate and provide anticipatory guidance on the importance of oral health for pregnant women and children.

 

Oral Health attended the HMHB Coalition’s annual stakeholder meeting and participated in an interactive feedback session regarding HMHB priority legislative updates as well as provided subject matter input and suggestions related to two of their performance measures on oral health, both for pregnant women. Agenda items included 2018 legislative recap, what to expect in 2019 – threats, challenges and opportunities, partner priorities impacting maternal and child health, and planning for Infant Mortality Awareness Day at the Capital. The Oral Health Director agreed to be on an ongoing work group related to Oral Healthcare during Pregnancy and Prenatal Education.

 

The Oral Health program helped lead the Georgia Oral Health Coalition meeting with DPH Oral Health District Programs, Children’s Hospital of Atlanta (CHOA), accredited Georgia Dental Hygiene Programs, child advocacy organizations such as Georgia Voices, the Council on Aging, Emory, the Georgia Tobacco Program, and Medicaid payers. The Emory Center for Maternal Substance Abuse and Child Development spoke about substance abuse during pregnancy and the effects on the developing fetus.

 

To assist in combating the opioid epidemic, the Oral Health program participated in the Opioid Taskforces Prescription Drug Monitoring Program (PDMP) work group to assess, evaluate and improve the PDMP registry.

 

The Oral Health program applied for and was chosen to participate in a partnership project being developed from the National Maternal and Child Oral Health Resource Center(OHRC) (COHSII project). The application involves a partnership agreement with the State Oral Health Program and the Albany Primary Care Health Center (APCHC), a Federally Qualified Health Center in Albany. APCHC is working to integrate medical and dental services, and currently has a dental operatory in their OBGYN clinic staffed with a dentist one day a week, a hygienist a separate day a week, and a dental assistant a half day a week to provide education and outreach in the OBGYN waiting room. Georgia was one of five states selected by the OHRC at Georgetown University to participate with Illinois, Maryland, Michigan, and Rhode Island. Primary care health professionals will integrate oral health care into primary care by completing risk assessments and screenings, providing preventive interventions and oral health education, and conducting interprofessional collaborative activities. The populations of focus include pregnant women, infants, children, adolescents, and young adults. Project settings include community health centers, a local public health department, and a university-based women’s health clinic.
 

Priority Need: Increase Access to Family Planning Services  

 

SPM 1: Family Planning

 

In the reporting year, 60,784 women were served through DPH’s family planning program. Georgia’s Family Planning program provided leadership, guidance and resources to Georgia’s 18 health districts in the development and provision of resources that increase the access of family planning services to Georgia’s women offering comprehensive health care services designed to provide women with support to plan the birth of their children, reduce unintended pregnancies, determine effective birth control methods and improve the well-being of families statewide. The Family Planning program offers comprehensive health care services designed to provide women support with planning when to have children, reduce unintended pregnancies, determine effective birth control methods and improve the wellbeing of families statewide. Because of the proven effectiveness of LARCs, Georgia’s efforts to reduce unintended pregnancies focused on encouraging the use of LARCs by educating providers, health educators and women.

 

During the reporting year, the Family Planning Advisory Group, consisting of district representatives and state program staff, engaged to discuss strategies that would support increasing access to family planning. The Family Planning Advisory Group identified modifications to the electronic health record that were implemented to improve clinical flow and efficiency. The Advisory Group was key in developing tools to be utilized for district site monitoring by state staff.

 

Program staff engaged stakeholders and developed messaging and graphics for the statewide family planning campaign launched in three phases. Phase I launched in March 2018 and focused on the southern region of the state. The initial phase included Albany, Valdosta, Waycross, Savannah and Augusta. During Phase I (January – December 2018) 3,600 unique page views were captured. Phase II will include Dublin, Macon, Rome Dalton and Gainesville.

 

Figure 2: Statewide Family Planning Marketing Campaign

 

 

Other Women/Maternal Health Programs

 

Centering Pregnancy

Centering Pregnancy is an evidenced based model of group prenatal care. The centering model combines health assessment, interactive learning and community building to help support positive health behaviors; improve patient care and drive better health outcomes by increasing access to prenatal education and the community and empowering women to take an active role in their prenatal care. Centering Pregnancy empowers patients, strengthens patient/provider relationships, and builds communities through health assessment, interactive learning and community building.

 

In the reporting year, MCH in collaboration with the Centering Healthcare Institute hosted five Centering Pregnancy Information Sessions around Georgia’s Public Health Districts. These districts have an increase in infant mortality rate and preterm births. The Centering Pregnancy Information Session was a one-day seminar to learn more about centering group care and to understand what is needed for successful implementation and long term sustainability. MCH utilized the funding provided by March of Dimes to allow staff from three Public Health Districts to attend the Basic Facilitators Workshop hosted by the Centering Healthcare Institute designed to help facilitative leaders gain confidence through a variety of skill building and interactive activities. In May 2018, the East Central Health District (Augusta) hosted their Centering Pregnancy kickoff and implemented their first prenatal group session in June at the Richmond County Health Department. Implementing the program remains a challenge among hospitals, District Health Directors and private OBs due to funding. Funding for Centering Pregnancy was a topic of interest during the 2018 Legislative sessions and the General Assembly allocated funding to the Department of Community Health to establish expanded reimbursement for Centering Pregnancy. during the 2018 legislation.

 

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 mom and baby.

 

During the reporting year, the Georgia Department of Community Health (DCH), DPH and Harris Public Health Solutions launched the VHN Perinatal Case Management Module, an automated process of transmitting documents between the Care Management Organizations (CMO’s) and DPH. A PCM curriculum was developed and a one-day interactive training was provided to case managers in the public health departments. There have been 14 trainings around the state with 278 participants. The number of county health departments providing PCM services have increased from 88 to 107 exceeding DPH’s strategic goal of 104. The PCM partnership between DPH, DCH, Harris Public Health Solutions and CMOs have been successful in streamlining the PCM module to reduce health department workload and improve coordination of care covered by Medicaid.

 

PCM also collaborated with the Sexually Transmitted Disease (STD) program in two local health departments to provide services aimed to reduce the incidence of congenital syphilis through a referral system for early treatment. Guidance and technical assistance were provided with the Southeast District as they hosted a district wide PCM training in May and Northeast District who hosted in September.

 

To expand PCM services, a brochure and postcard fact sheet were developed to provide education and increase awareness of PCM services in the health department.

 

Planning for Healthy Babies

Planning for Health Babies (P4HB) is a family planning demonstration waiver program issued by DCH to assist the 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. 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.

 

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 2018-Sept 2019

 

Priority Need: Prevent Maternal Mortality  

 

NPM 1: Well-Woman Visits

 

Maternal Mortality Review Committee

In the current year, the MMRC completed case reviews of 2012, 2013 and 2014 maternal deaths. Analysis of 2014 case review findings and report were completed. The 2014 Maternal Mortality Report was published and disseminated statewide. The MMRC began reviewing 2015 case findings.

 

Georgia was one of eight states invited to participate on the National Governors Association’s Roundtable on State Strategies to Address Maternal Morbidity and Mortality. The purpose of the session was to discuss strategies available to states to reduce maternal morbidity and mortality and improve maternal health outcomes across states.

 

Contracts were established with 16 rural birthing facilities to provide funding for participation in perinatal quality improvement initiatives.

 

The Women’s Health team presented the poster, State Investments: Advancing Maternal and Neonatal Care In Georgia at the 2019 Annual AMCHP Conference.

 

Challenges/Barriers: The time required for abstraction of many cases and limited number of abstractors presents a challenge for the MMRC.

 

NPM 3: Risk-appropriate Perinatal Care

 

Perinatal Regionalization

To strengthen the system of Regionalization, there has been continued work on increasing communication with RPC stakeholders to include 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.

 

Alliance for Innovation on Maternal Health Bundles
During the fall of 2017 the structure, membership and initiatives of GaPQC were revised. Advisory Committee membership was updated to reflect inclusion of specialty providers and agencies focused on improving the health and outcomes of mothers and babies. Subcommittees were established for maternal, neonatal, data and operations. The Maternal Subcommittee is leading the work of AIM bundle implementation in birthing hospitals. In January 2018, a letter was sent from the DPH Commissioner to all 76 birthing hospitals in Georgia encouraging their participation in the AIM bundle initiative. Enrollment packets and readiness assessment surveys were sent to 41 birthing hospitals that had expressed interest in participating in the AIM bundle initiative. Hospital support continues for implementation of the Obstetric Hemorrhage Bundle. Outreach efforts continued to increase awareness of GaPQC and availability of the maternal safety bundle initiatives. The AIM Hypertension Hospital Bundles launched during the current year. The Second Annual GaPQC Meeting was held in Atlanta on April 25-26, 2019 with over 200 paid participants in attendance.

 

Challenges/barriers: Rural birthing hospitals may lack sufficient staff to work on quality initiatives.

 

Priority Need: Promote Oral Health to All Populations

 

NPM 13: Preventive Dental Visit

 

In the current year, a media campaign was created focusing on pregnant women and children, with key points related to prevention and oral health literacy. This campaign included thirty second radio spots and billboards in six public health districts over the late spring and early summer.

 

The COHSII medical dental integration project continued with lessons learned and results reviewed to be reviewed in summer. The Director of Oral Health wrote an article on the medical provider’s role in prenatal and infant oral health and be published in the Georgia Academy of Family Physicians monthly newsletter.

 

Oral health education was provided at the 2019 Maternal and Child Health Conference where a variety of MCH topics were discussed, including presentations on maternal mortality, signs and indications of oral sexual abuse in children, and practical implementation of school-based sealant programs.

 

Challenges/barriers: Some oral health providers are uncomfortable treating pregnant women either due to lack of understanding of clinical implications or the added liability they assume, therefore, access to providers remains difficult. Medicaid, a widely used means of coverage for pregnant women in Georgia, is often not accepted by oral health providers.

 

Priority Need: Increase Access to Family Planning Services  

 

SPM 1: Family Planning

 

More Georgia women are planning their pregnancy which helps to insure healthier birth outcomes. Processes and procedures have been streamlined and training systems that support access to family planning and LARCs have been improved. Family Planning’s budget of 1.3 million dollars is earmarked for the LARC project. Funds are used to purchase additional pharmaceuticals and provide support to districts to hire Advanced Practice Registered Nurses (APRN) to provide LARC related services.

 

In the current year, the focus is to promote and increase access to family planning services, particularly LARCs. In addition to the marketing campaign, the budget also included purchasing additional pharmaceuticals and providing support to districts to hire APRN staff to provide LARC related services. Phase II of the marketing campaign launched to target the northern districts. Phase II (January-June 2019) has received over 24,000 unique page views. Site visits are being conducted in each district to provide understanding of their unique challenges and to provide technical support.

 

Other Women/Maternal Health Programs

 

Centering Pregnancy

During the current year, Women’s Health collaborated with external stakeholders, Harris Solutions, to review the prenatal care process and streamline the data collection and flow chart design. Monthly meetings continue among County Health Districts 6 and 8-2 that provide Centering Pregnancy in their clinics. Discussions are underway for Macon-Bibb County Health Department to start Centering Pregnancy in the reporting year.

 

Challenges/barriers: Challenges surrounding incorporating the Centering Pregnancy model are related to a lack of adequate space to host group prenatal care sessions in OB practices and county health departments. Lack of commitment from hospitals, district health directors, and private OB physicians to implement Centering Pregnancy at their facility presents a challenge, as does reimbursement issues related to providing the Centering Pregnancy program. Both districts recognize retention and increasing enrollment of the patients as a challenge.

 

Perinatal Case Management

In the current year, the number of county health departments providing PCM services increased from 92 to104. PCM continues the quest to provide PCM training and technical assistance to counties in implementation of PCM programs. Efforts to establish communication between DPH and county health departments Electronic Medical Record (EMR) partners improve communication between Medicaid Care Management Organization (CMO’s) in the PCM reimbursement process continues. PCM plans to continue collaboration with EMR partners to develop a method of extracting data from the PCM Module for monthly reporting, percentages of Presumptive Eligibility and PCM enrollment.

 

Challenges/barriers: Several Georgia obstetricians have patients with identified CMOs which makes it difficult for the patient to be perinatally case managed through the health department system.

 

The self-reporting monthly electronic data reporting system presents a need for an electronic data retrieval system. Decreased number of staff available to provide PCM services at the county health departments and communication between District IT and the Perinatal Case Managers at the county health departments also present challenges.

Better communication is needed between District IT and the Perinatal Case Managers at the health department in maneuvering through the EMR PCM Module.

 

Planning for Healthy Babies

Planning for Health Babies (P4HB) is a family planning demonstration waiver program issued by the Georgia Department of Community Health (DCH) to assist the 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. The program is intended to bridge health care for underinsured and uninsured women of high need. Efforts to increase enrollment into P4HB will continue with DCH and other partners.

 

Maternal and Child Health Information and Resource Center

In the current year, the Women’s Health Program works 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 IPC of P4HB, hypertension, heart disease, obesity, and diabetes.