Priority Need: Prevent Maternal Mortality

 

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, including 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 the report.

 

NPM 1: Well-Woman Visits

 

Preventive Medical Visit

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 2020 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.

 

In the reporting year, the Women’s Health program collaborated with the Breast and Cervical Cancer Program (BCCP) contractors to improve preventative care for women by meeting or exceeding the CDC Guidelines for breast and cervical cancer screening 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 (e.g., 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 Guidelines for the percent of initial cervical screening tests that are conducted among women who have never been screened or have not been screened within the last 10 years.

 

Maternal Mortality Review Committee (MMRC)

The support of the Governor and the Georgia Legislature with the passage of Senate Bill 273 in 2014 laid the foundation for the ability for the MMRC to identify pregnancy-associated deaths, review those caused by pregnancy complications, 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 2018 cases and continued working towards reviewing cases within two years of the date of death to align with CDC guidelines. Data entry was completed for 2017 cases. The MMRC continued to improve processes and the quality of the recommendations that were made and implemented to meet this goal.

 

Key Informant Interviews continued as part of the review process. The Key Informant Interviewer interviewed family members or other key informants and developed a summary that was included in the case narrative provided to the committee. Qualitative data provided contextual information on the woman’s life, pregnancy, and events surrounding her death which helped the committee better identify contributing factors and recommendations for prevention.

 

As of June 30, 2021, all abstraction responsibilities were transitioned to DPH staff. Efforts were made to continue enhancement of case identification and abstraction while DPH worked 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.

 

In 2021, the Women’s Health program, in partnership with the DPH Office of Telemedicine, developed and launched the Maternal Health Extension for Community Health Outcomes (ECHO). Project ECHO was developed to help improve access to care, especially in rural areas, and provider expertise in taking care of patients with complex health conditions. In Georgia, the goal was to enhance knowledge and interprofessional collaboration and disseminate resources and recommendations from the MMRC to impact Georgia’s maternal mortality and severe maternal morbidity rate. Each ECHO session was composed of a brief content presentation by a local subject matter expert followed by a case study and  discussion of resources and guidelines available to guide care. The Maternal Health ECHO launched on September 14, 2021 with a perinatal mental health session. Sessions occur on the third Wednesday of each month.

 

Center for Black Women’s Wellness Health Equity Lab

In the reporting year, 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 on 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 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 DCH. 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. 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 the Maternal and Neonatal Levels of Care 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 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.

 

Georgia is divided into six perinatal regions covering 159 counties with a RPC associated with each region in Albany, Atlanta, Augusta, Columbus, Macon, and Savannah. In the reporting year, efforts to strengthen the system of regionalization and communication with RPC stakeholders continued. RPC site visits were conducted virtually, and conference calls were held with RPC medical directors, outreach educators, finance staff and data coordinators.

 

Alliance for Innovation on Maternal Health (AIM) Bundles

Georgia was accepted as an AIM state in October 2017 to lead the GaPQC initiative to implement the use of AIM hemorrhage and hypertension patient safety bundles in the state’s birthing hospitals. The AIM HMG and the AIM HTN were chosen for implementation. In the reporting year, 44 hospitals participated in the HMG initiative and 42 hospitals participated in HTN. To support perinatal quality improvement (QI) efforts in rural hospitals, seven rural hospitals received an additional year of state funding.

 

In the reporting year, a partnership was formed with the AIM Community Care Initiative (AIM CCI) to build on the existing quality improvement efforts underway at hospitals by focusing on using maternal safety bundles in non-clinical settings. This effort enhanced existing maternal quality improvement initiatives and maximized impact within the state.

 

The MMRC identified the leading causes of pregnancy-related maternal deaths between 2015-2017 to be cardiovascular and coronary conditions, cardiomyopathy with a large Black-White disparity gap. GaPQC prepared to launch the CCOC AIM bundle in 2022. Extensive planning has gone into preparing for the launch of the CCOC bundle during this reporting period which includes the formation of a multidisciplinary working group and subgroups focusing on creating products that address key bundle elements.

 

Thirty of the 56 (54%) AIM hospitals submitted Quarter (Q) 3 2021 data for structure and process measures, representing a seven percent increase in the submission rate from Q2 2021. A decrease in 2021 reporting was noted due to the pandemic’s impact on hospital teams so the increase in data submission for Q3 2021 may indicate a positive turnaround. During the reporting 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 HTN QI Initiative began reporting on two process measures by race and ethnicity; time to treatment and treatment with Magnesium Sulfate.

 

To improve health equity education, elements of the Reducing Peripartum Disparities Bundle were implemented. Implicit bias training was added to HMG and HTN process measures and completing the training was made a requirement for hospital providers and nurses. 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 completing implicit bias training in their quarterly reports.

 

GaPQC launched a two-phased approach to build capacity in health equity and translate strategies into action and meaningful change across the state. Phase I launched in August 2020 with the Health Equity and Implicit Bias Virtual Learning Series. In partnership with the Institute for Perinatal Quality Improvement, SPEAK UP Against Racism trainings for clinical teams and leadership were purchased and offered to health care providers to build knowledge around racial bias in healthcare, build a culture of equity, and develop specific action plans.

 

HMG moved into the sustainability phase on September 30, 2021, with the final hospital data submission to align with the end of federal year 2021. The Women’s Health program and the Perinatal Epidemiology team continued to provide HMG outcome data for facilities that were enrolled in the initiative to support ongoing QI.

 

Efforts to reduce disparities in severe maternal morbidities and adverse maternal and early child health outcomes in Georgia continued to be a priority in the reporting year. The MCH Director served as a member of several advisory groups that included a diverse team of clinicians, health service researchers, health economists, medical providers, and epidemiologist committed to studying the complex array of individual, health care system, community and societal factors that culminate in disparities in access to care and maternal health outcomes.

 

The Advisory Boards included:

• Center for Black Women’s Wellness (CBWW) Health Equity Lab- The Health Equity Lab developed 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.

 

• 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 at Grady Memorial Hospital, an urban safety-net hospital. Funded by the National Institutes of Health (NIH), the MTG project convened a diverse team of clinicians, health services researchers, health economists, and epidemiologists 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.

 

Maternal Mental Health

In the reporting year, in collaboration with the Emory Brain Health Center, the Perinatal Psychiatry, Education and Community Engagement (PEACE) for Moms program was launched to support the mental health of women before and after childbirth. The program provided 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 worked 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, only eight possessed an adequate number of mental health practitioners. During the reporting year, a therapist referral database was developed, a Clinical Psychologist was hired, and 132 providers were enrolled into the program.  

 

DPH worked with HMHB to provide community resources related to mental health. Seven peer support facilitators led peer support groups for women during the perinatal period. The program offered community education on maternal mental health through the Pickles & Ice Cream Georgia (a platform for education, access to resources and advocacy) and various digital and print resources. The program also provided support for individuals experiencing Intimate Partner Violence. The Women’s Health program worked with the Georgia Chapter of Postpartum Support International to provide mental health training to obstetric providers and other maternal health workers.

 

Priority Need: Promote Oral Health Among All Populations

 

NPM 13: Preventive Dental Visit

 

Oral Health

In the reporting 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. The previously developed public service announcement oral health videos were boosted on social media platforms Instagram and Facebook and created a Facebook “REACH” of 164,708 and 194,871 “IMPRESSIONS” and an Instagram “REACH” of 19,460 and 22,473 “IMPRESSIONS”.

 

An Oral Health Epidemiologist was hired in the reporting year to support oral health surveillance and data analysis. The Oral Health program worked with DPH Epidemiology to add four state supplemental questions on oral health for pregnant or recently pregnant women to the Pregnancy Risk Assessment Monitoring System (PRAMS) survey to 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.”

 

The Oral Health Program focused on medical and dental integration with a local primary care center and partnered with Albany Primary Care (APC), a Federally Qualified Health Center (FQHC) network in Albany and built upon existing Medicaid services/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. 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 (EMR) for follow up at the APC dental clinics. All medical staff were cross trained with the online Smiles for Life program for medical providers. This HRSA funded project ended during the reporting period.

 

The Oral Health program completed participation in the national stakeholder and subject matter expert group to provide state level feedback on feasibility and implementation factors for including the quality indicators in state oral health surveillance. The Oral Health Director participated in the HMHB Oral Health and Pregnancy workgroup to: (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 Obstetrician-Gynecologists (OB/GYN) residents. The Oral Health Director presented on oral health in Georgia around pregnant patients and the impact on healthy birth outcomes to both the MCH Advisory Council and the DPH Improving Birth Outcomes Working Group.

 

The Oral Health program manages the state’s water fluoridation program. The CDC has shown that community water fluoridation can reduce dental decay in communities by up to 25 percent. Currently almost 96 percent of Georgia residents on community water systems have access to optimally adjusted fluoridation through community water fluoridation programs. To ensure that Georgia remains one of the top states in the country in terms of access to optimally fluoridated water, six virtual fluoridation trainings were provided to community water plant operators across the state. The Community Water Fluoridation Program was presented to the Georgia Department of Natural Resources Environmental Protection Division staff.

 

Other Women/Maternal Health Programs

 

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 COVID-19 pandemic continued to result in clinic closures and reduced availability of face-to-face visits. The Georgia Maternal and 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. Guidance was provided to clinics concerning conducting remote interviews for the continuation of oral contraceptives and the Depo Provera visit.  

 

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 and interactive learning. During the reporting year, in-person Centering Pregnancy group sessions were not offered due to COVID-19. To improve capacity to provide virtual group care, the Augusta site gathered information and attended training sessions involving hosting virtual centering pregnancy sessions. Staff attended the Centering Healthcare Institute’s Basic Facilitators Workshop via virtual mode.

 

The Albany County Public Health Department’s Centering Pregnancy program was transitioned to the Albany Area Primary Health Care, an FQHC, as it was better equipped to continue to program. The new program accepted referrals and worked collaboratively with local public health but operated independently. Centering Program data was reported directly to the Centering Healthcare Institute. The Augusta Centering Pregnancy program began the transition back to in-person prenatal care visits, but Centering Pregnancy group sessions were provided remotely.

 

Perinatal Case Management (PCM)

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 special needs and facilitates access to medical, nutritional, social, psychosocial, educational, and other services to improve health outcomes of mother and baby. In the reporting year, 112 county health departments provided PCM services.

 

PCM trainings were conducted throughout the reporting year via telehealth. To increase program awareness in the community, PCM post cards and pamphlets were produced and distributed to public health districts. PCM collaborated with the Oral Health Program to provide dental kits to pregnant women entering the county health department for PCM enrollment. PCM Managers were educated via webinar on the importance of oral health care during pregnancy. PCM also collaborated with the Child Occupant Safety Program (COSP) to increase participation in the car seat program for all counties.

 

Planning for Healthy Babies (P4HB)

P4HB is a family planning demonstration waiver program issued by DCH to assist 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, the P4HB convened a working group to increase 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 CMOs, provider organizations, and community-based organizations that serve the MCH population eligible for P4HB in Georgia. Efforts made by DCH and CMOs are being amplified to increase the knowledge, understanding, and utilization of P4HB services toward reducing Georgia’s LBW and VLBW rates, unintended pregnancies, and lowering Medicaid costs. Quarterly working groups were held and the P4HB Waiver program marketing plan was finalized to include 30 to 90 second video vignettes to be used in social media and email marketing campaigns, digital billboards, and provider toolkits.

 

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 2021-Sept 2022

 

Priority Need: Prevent Maternal Mortality

 

NPM 1: Well-Women Visit

 

Preventive Medical Visit

In the current year, collaboration continues with 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. New CDC Guidelines were provided, and the annual objectives and measures were revised in the State Action Plan Table based on the updated guidance.

 

Maternal Mortality Review Committee

The Women’s Health program completed the review of 2019 cases and are reviewing 2020 cases. Data entry for 2018 and 2019 cases were completed. A fact sheet on data from 2015 to 2017 was published to the DPH website and disseminated to partners and stakeholders. The fact sheet also included key recommendations that supported the need to obtain more autopsies on pregnancy-associated deaths and extend Medicaid coverage up to one year postpartum, two key pieces of legislation passed by the Georgia General Assembly. A report on 2017 to 2019 data is currently being developed.

 

Among 2019 cases, 66 of the 85 (78%) pregnancy-associated cases were selected for outreach. Of the 66 cases selected, 38 (58%) cases had a completed interview and some cases included multiple interviews. A total of 41 interviews were completed by the MMRC Key Informant Interviewer.

 

A data sharing process with Medicaid was developed to determine opportunities for policy changes within Medicaid and to receive data to identify coverage and claims information on pregnancy-related deaths. Regular meetings have been scheduled with Medicaid to maintain a cadence and keep track of data sharing goals.

 

Support is being provided to MMRC members to facilitate their participation on the committee. A self-care plan was created for MMRC staff and committee members which includes the development of a list of resources, such as meditations and breathing exercises that can be used before, during, and after MMRC meetings. Some MMRC members may qualify for financial support if they are community partners or if they are unable to participate on the committee as part of their job duties. These members must be present for at least 90 percent of the meetings to receive the support.

 

Multiple trainings were provided to members that include a self-care and vicarious trauma training, identifying contributing factors related to COVID-19 and the pandemic, and guidance for determining the completeness of records.

 

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.

 

Senate Bill 338 passed in April 2022, extending last year’s expansion of postpartum coverage under Medicaid from six months to one year following the end of the pregnancy. This bill also provides lactation care and services to pregnant and lactating women and children who are breastfeeding or receiving their mother's milk.

 

House Bill 977 passed in April 2022, which will provide $500,000 to fund a comprehensive care management pilot for high-risk pregnancy populations. This bill also provides $680,000 to fund a pilot program to perform echocardiograms of pregnant and postpartum women to address maternal mortality.

 

NPM 3: Risk-appropriate Perinatal Care

 

Maternal and Neonatal Levels of Care

In the current year, the Women’s Health program is contracting with the Joint Commission to implement the Maternal Levels of Care Verification Program that was announced in March 2022. All hospitals seeking a Level II and Level III designation in Georgia are required to use the Joint Commission program. Level I hospitals have the option of using the Joint Commission or receiving a survey through DPH. The Women’s Health program provides funding to participating hospitals to reduce the cost of the survey. The ability to recognize Level IV hospitals is also being explored. If successful, the Women’s Health program will revise the regulation and begin designating Level IV hospitals.

 

Perinatal Regionalization

The Women’s Health program continues to strengthen the system of Regionalization and communication with RPC stakeholders by 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: 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 (AIM) Bundles

GaPQC supports the AIM Patient Safety Bundles by providing support for birthing hospitals across the state to implement the HMG and HTN bundles and are preparing to implement the CCOC Initiative. Currently, 56 of the 72 birthing hospitals participate in one or both initiatives and 49 of 72 (68%) birthing hospitals are participating in the hypertension bundle initiative. An interest survey was disseminated to identify hospitals for the cardiac initiative. Approximately 30 hospitals said ‘yes’ or ‘maybe’ for initiative enrollment and the target launch is Q2 2022. A Cardiac Planning Workgroup initiated in the fall of 2021 identified four subgroups: Intentional Cardiac Screening, Clinician and Patient Education, Acute Management of the Cardiac Patient (in low resource settings- rural/community), and Consultation and Referral. Recruitment for the workgroups is ongoing to ensure multidisciplinary representation of specialties (e.g., Maternal and Fetal Medicine, Cardiology, Family Medicine, Emergency Medicine, Obstetrics and Gynecology, Midwifery, Anesthesiology, etc.). The CCOC bundle kick off webinar was held on March 1st, 2022 with national AIM physicians and leads presenting about the importance of improving cardiac outcomes, especially in black birthing patients. Recruitment and the official launch date was June 7, 2022. Georgia is excited to be the first state in the country to implement the CCOC AIM bundle and the GaPQC team will present on the National Network for Perinatal Quality Collaboratives (NNPQC) webinar on August 10, 2022 to share initial plans and learnings to support other PQCs with this bundle.

 

To support hospital teams, GaPQC hosts monthly webinars for current initiatives. The hypertension webinars focus on the process and structure measures for the AIM bundle. The hemorrhage initiative moved into sustainability in September 2021 and all webinars are archived in Microsoft Teams. The 2021 GaPQC Annual Meeting was held on October 14 and 15, 2021 to celebrate the tremendous efforts and impact hospitals have made, as well as to recommit to improving health outcomes and providing equitable care for all mothers and babies throughout Georgia. Featured speakers included: Neel Shah, MD, MPP, FACOG, Assistant Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School, and Director of the Delivery Decisions Initiative at Harvard’s Ariadne Labs; Marty McCaffrey, MD, Clinical Professor, Pediatric Neonatal-Perinatal Medicine, UNC School of Medicine, Director of Perinatal Quality Collaborative of North Carolina (PQCNC); and Tanya Lord, PhD, MPH Director, Patient Family Engagement at Foundation for Healthy Communities.

 

The Women’s Health program is transitioning focus to the CCOC AIM bundle and incorporating elements of the Reduction of Peripartum Racial/Ethnic Disparities into each AIM bundle. They are continuing to build capacity and create a culture of equity, including systems for reporting, response, and learning through partnerships with organizations to support improving population level outcomes for mothers and infants. The March of Dimes partners with the Women’s Health program in the health equity work and HMHB’s partnership supports policy and clinical implementation workgroups. Building on the foundational work of AIM, the Women’s Health program will participate in AIM Clinical Community Integration to address preventable maternal mortality and severe maternal morbidity among pregnant and postpartum women outside of hospital and birthing facility settings.

 

In the current year, GaPQC developed and implemented a two-phased approach for improving health equity and reducing disparities in maternal health. Phase I builds capacity among clinical teams at birthing hospitals and GaPQC partners around implicit and explicit bias through virtual trainings highlighting the impact of racism on maternal mortality and morbidity. Sixty-five percent of GaPQC hospitals attended the Train the Trainer SPEAK UP Against Racism training where participants became Speak Up Champions. Champions initiate project planning, which includes the creation of Project Charters and SMART goals to support hospital specific health equity projects (e.g., breastfeeding, culture change, etc.). Hospitals are currently moving into Phase II which will translate knowledge into action. Implicit bias virtual training was provided using the March of Dimes online curriculum for 100 members of the GaPQC leadership team, Advisory Council, and maternal and neonatal committee members. The Women’s Health program continues to work with partners and clinicians who completed implicit bias training to assess Race, Ethnicity and Language (REaL) data collection processes at their respective institutions and implement their action plans.

 

The 2022 Maternal Health ECHO curriculum is being developed around the AIM Obstetric bundle framework and each session will be geared towards facilitating discussion of equity in healthcare. To continue to support hospital teams in making meaningful improvements in health care and outcomes, plans are underway to build capacity to offer more one-on-one technical assistance through improvement advising with hospital teams. In addition, efforts to create a comprehensive data platform is a priority to facilitate using data as quickly as possible for rapid cycle improvement.  

 

In an effort to reduce disparities in severe maternal morbidities and adverse maternal and early child health outcomes, the MCH Director serves on the Minding the Gap (MTG) advisory group, which is in the second year of a five-year 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). The group focuses on the racial gap in severe maternal morbidities and provides actionable evidence to policy makers, community organizations, health systems, and health care providers to implement sustainable changes in policy and practice to improve postpartum and intrapartum care and reduce maternal health disparities throughout Georgia. In the current year, 28 in- depth interviews have been conducted with postpartum clients from Grady Hospital. The Interviews address clients’ postpartum care experiences, including reason for attendance or absence, their postpartum visit, and any facilitators or barriers to care. The findings are being used to inform decision making for reducing disparities in maternal morbidity and mortality.

 

Maternal Mental Health

PEACE for Moms, Georgia’s perinatal psychiatry access program, continues to provide consultations to prescribers on mental health treatment. The program has presented at various meetings and conferences to promote the program and increase the number of providers enrolled. PEACE for Moms began offering face-to-face consultations with patients of enrolled providers who require further assessment. The program also consults with Lifeline for Moms and participates in the Lifeline for Moms network to promote ongoing program improvement. In January 2022, PEACE for Moms launched the first Mothers and Babies group to prevent perinatal depression. A new website is under development that will include resources and toolkits for providers.

 

HMHB continues to offer peer support groups and community education around maternal mental health and PSI provided mental health trainings to providers.

 

Priority Need: Promote Oral Health to All Populations

 

NPM 13: Preventive Dental Visit

 

Oral Health

In the current year, the Oral Health program continues to promote oral health among all populations, with a special emphasis on promoting oral health care services among pregnant women. The Oral Health program staff serves on advisory boards and work groups for external partners including HMHB, DECAL, Georgia Cancer Control Consortium Human Papilloma Virus (HPV) workgroup, and the Georgia Bureau of Investigations (GBI), among other stakeholders. The GAFP and the GA-OBYGN Society Oral Health program will continue to create a more robust state oral health surveillance system by identifying gaps in data, researching data sources to fill gaps, and dedicating resources to incorporating sources.

 

The Oral Health program continues to collaborate with both internal and external partners to provide oral health resources to pregnant women and caregivers of young children. District program staff are continuously provided updates and resources that help empower them to provide care, services, and education for MCH populations, including but not limited to, free continuing education opportunities, toolkits, guidelines, best practices, and recommendations from national oral health and MCH organizations.

 

Approximately 600 oral health resources bags were distributed throughout the state. The resource bags contain an adult toothbrush, two types of infant toothbrushes, floss, toothpaste, intraoral wipes for cleaning after nursing or bottle feeding, a brochure on health oral habits/behaviors, and a baby book on oral health. Public health district oral health program staff, district public health nurses, perinatal coordinators, home visitation workers, and external partners such as HMHB distributed the resource bags.

 

The Oral Health program funded the addition of four state supplemental oral health questions to the Georgia PRAMS survey, in addition to the two standard core oral health questions. With a combination of six questions related to oral health in PRAMS, future data will give a more complete picture of burden of disease, specific challenges and barriers, and strategize on best solutions. Data from the additional questions is expected to be available in the upcoming year. The PRAMS oral health fact sheet continues to be shared with external partners. The Oral Health Epidemiology role transitioned to the MCH Epidemiology Section.    

 

The Oral Health program disseminated the message of the importance of drinking fluoridated water at all ages to pregnant and parenting women through HMHB and the Home Visiting program. Eleven virtual fluoride training presentations were provided to community water plant operators across the state to ensure Georgia remains one of the top states in the country in terms of access to fluoridated water. Currently, approximately 96 percent of Georgia residents on community water have access to fluoridated water through the Community Water Fluoridation Program. The Fluoridation Administrator attended numerous meetings with fluoridation persons across the country and other CDC grantee states.

 

Other Women/Maternal Health Programs

 

Family Planning

The Women’s Health program continues to promote and increase access to family planning services. The Family Planning Program launched Phase III of the marketing campaign to increase awareness of family planning services in the health departments. Site visits with public health districts began in November 2021 to garner insight on district level implementation of family planning and to date seven visits have been completed and two are scheduled before the end of 2022. These visits are a hybrid model of both virtual and in-person visits. Information gathered from the site visits inform the content for the quarterly Women’s Health program District Coordinators meetings. DPH will partner with Bixby to provide the Long-Acting Reversable Contraception (LARC) Continuing Medical Education (CME) course and in-depth special courses to train family planning staff on best practice in increasing access to family planning services. In early 2022, a comprehensive family planning preceptor program started in three public health districts with sites located in Valdosta, Augusta, and Macon. An eight-week series of women’s health courses for new nurses is also being provided.

 

Centering Pregnancy

Due to the concerns for client safety in relation to the COVID-19 pandemic, in-person Centering Pregnancy group sessions are not currently offered. The Women’s Health program will support public health districts in their goal to provide Centering Pregnancy services to women in the future. 

 

Perinatal Case Management

Plans are underway to increase the number of county health departments providing PCM services from 112 to 115 by the end of 2022. Marketing materials such as post cards and brochures used to promote PCM benefits have been distributed to all public health districts for use by the PCM Case Managers and the pregnant women enrolling in PCM. The PCM program is collaborating with COSP to increase participation in the car seat program in all counties and providing education to pregnant mothers on safely transporting their child. DPH will continue providing technical assistance on the PCM module, education, training, and updates of the PCM program to all district PCM Case Managers on the health outcomes for at risk women. PCM will continue collaborating with the Oral Health program to distribute dental kits to pregnant women in the public health districts that enroll in the PCM program to promote good oral health during pregnancy.

 

Planning for Healthy Babies (P4HB)

The P4HB Working Group continues with the purpose of increasing utilization and participation in P4HB. The following marketing combinations were developed to bring awareness to P4HB programming and will be provided in the priority areas of Albany, Atlanta, and Columbus. The mediums utilized and timeframes are:

• Design/Creative- March/April 2022
• Social Media- May 2022
• Social Media Ads- July 2022
• Digital Rotary Networks (Billboards)- May 2022
• Radio Advertisement- June 2022
• Email Marketing- July 2022
• Direct Mail Campaign- May 2022

 

Maternal and Child Health Information and Resource Center

In the current year, the Women’s Health Program continues to 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.