Priority Need: Prevent Infant Mortality
Perinatal services are focused on the health of women and babies before, during and after birth. The Georgia Perinatal-Infant Health program aims to assure pregnant women in Georgia every opportunity to access comprehensive perinatal health care services appropriate to meet their individual needs. DPH is committed to providing access to high-quality perinatal care to Georgians and recognize that there is a direct relationship between perinatal birth outcomes and the quality of health care services.
The number one cause of infant mortality in Georgia are disorders related to preterm birth and low birth weight. In 2019, the Infant Mortality Rate for Georgia was 7.0 per 1,000 live births, with the infant mortality rate among Black, non-Hispanic infants two times higher than White, non-Hispanic or Hispanic infants. Research indicates that maternal and infant morbidity and mortality can be reduced if high-risk pregnant women and newborns receive risk-appropriate care, health equity is ensured, and social determinants of health are addressed.
NPM 3: Risk-appropriate Perinatal Care
Perinatal Regionalization
Perinatal Regionalization is a collaborative system of hospitals & providers striving to assure that deliveries happen in the hospital with the appropriate level of care for the mother and infant. The purpose of the Regional Perinatal Centers (RPCs) is to coordinate access to optimal and appropriate maternal and infant health care. Regionalized systems assign hospitals risk-appropriate levels and ensure high-risk infants are born in facilities with appropriate technology and specialized health providers. The impact of appropriate level of care on maternal and perinatal health outcomes is great as low birth weight or premature infants born in risk-appropriate facilities are more likely to survive.
Basic perinatal services include comprehensive obstetric care through neonatal newborn services. There are six RPCs, specially qualified hospitals, which are designated to specific geographic regions that provide the most advanced care for high-risk mothers and infants. Meetings with RPC medical directors and outreach educators and having conference calls with finance staff and data coordinators continued to strengthen the system of regionalization. RPCs in the six birthing regions actively responded to the COVID-19 pandemic in addition to continued transport and high-risk care to mothers and babies across the state. Two perinatal regions, Albany in the rural southwest, and Atlanta, were significantly impacted by the pandemic. Maternal and Neonatal Outreach educators from these two RPCs supported clinical needs within their facilities in addition to providing support for their regions’ birthing centers.
A joint quarterly RPC Outreach Educator and Women’s Health meeting was held in January 2020 to plan regional trainings for the state’s birthing hospitals. A survey completed by all birthing hospitals identified a need for training for hospital staff to implement clinical simulation drills in their individual facilities. Clinical simulation drill implementation is required to implement maternal quality improvements for hemorrhage and hypertension emergencies. The curriculum was developed, and meeting invitations were sent to obstetrical unit staff in all birthing facilities to attend one of five regional trainings scheduled in March through May 2020. However, the trainings were canceled due to the COVID-19 pandemic and will be rescheduled when operations return to normal.
SPM 4: Breastfeeding
Breastfeeding
Georgia's 5-STAR Hospital Initiative was developed to recognize hospitals that have taken steps to promote, protect, and support breastfeeding in their hospital. A five-star system was developed to encourage maternity centers to promote and support breastfeeding one step at a time. Georgia 5-STAR awards one star for every two steps implemented of the Ten Steps to Successful Breastfeeding, as defined by the World Health Organization (WHO) and Baby-Friendly® USA. In the reporting year, the Georgia 5-STAR program worked to review the current Georgia 5-STAR program offerings and provided support to hospitals. Women’s Health developed additional support materials to assist hospitals in evaluating their progress on the Ten Steps to Successful Breastfeeding-Georgia 5-STAR journey and revised the training programs as suggested by the review.
In the reporting year, skills fairs were completed at the following hospitals: Archbold Hospital, Augusta University, Colquitt Regional Medical Center, Northeast Georgia Health System- Gainesville and Braselton, and Upson Regional Medical Center. Hospital managers reported 75–90 percent of the staff attended. The successful training of large numbers of staff proved invaluable to the hospitals in helping them to accomplish clinical competency.
SPM 3: Rate of Congenital Syphilis (2016-2020)
Congenital Syphilis
The Sexually Transmitted Diseases (STD) Office’s mission is to prevent STDs by providing quality intervention strategies, programmatic support and education to all throughout the state of Georgia. With a focus on Congenital Syphilis, the STD team works to promote first and third trimester testing for HIV and Syphilis, as well as improve the data quality of Congenital Syphilis. The STD Office works to improve the identification of pregnant females with syphilis to ensure timely and appropriate treatment. In the reporting year, Syphilis During Pregnancy was added to the Notifiable Disease List. The promotion of first and third trimester testing for HIV and syphilis continued and efforts to provide education through trainings, community outreach, provider outreach, and district STD staff continued to be a priority. A total of 1,764 cases of primary and secondary Syphilis were reported in Georgia which was a 7.3 percent increase in cases from the previous year. When compared to other states in the U.S., Georgia ranked eighth in reported primary and secondary syphilis and twelfth in reported Congenital Syphilis cases. In 2019, there were 52 Congenital Syphilis cases out of 126,250 Georgia resident births. In comparison, there were 31 Congenital Syphilis cases out of 126,051 Georgia resident births in 2018, showing a 67percent increase in Congenital Syphilis cases.
SPM 4: Neonatal Substance Abuse (2016-2020)
Neonatal Abstinence Syndrome
Neonatal Abstinence Syndrome (NAS) is a Notifiable Condition in Georgia as of January 1, 2016. DPH requires notice and reporting of incidents of NAS by a health care provider, coroner, medical examiner, or any other person who has knowledge of diagnosis or health outcomes related, directly or indirectly, to NAS.
In the reporting year, the Neonatal Subcommittee of the GaPQC continued to implement the NAS initiative with 45 (62 percent) birthing hospitals in the state participating in the initiative. The number of participating hospitals decreased by one due to a rural birthing hospital closure. GaPQC supported the neonatal teams by hosting the monthly webinar series to facilitate education and collaboration. The didactic presentations were designed to guide hospitals through implementing interventions listed in the key driver diagram. A quality improvement focus was included as part of each webinar following the stages of the Model for Improvement from the Institute for Healthcare Improvement.
In March 2020, the neonatal subcommittee developed a survey for hospitals participating in the NAS initiative. The purpose was to assess interventions implemented and identify where additional support was needed. Preliminary survey results determined the area of need to be on information technology tools and using the Plan, Do, Check, Act (PDCA) cycle for rapid quality improvement. Based on the survey, training focused on increasing the frequency of quality improvement technical calls, led by the neonatal physician champion. In December 2020, GaPQC created and disseminated an environmental scan survey in partnership with the GA OB/GYN Society. This assessment targeted maternal and neonatal hospital teams to identify improvement opportunities for all initiatives and future direction. The results will be analyzed and presented in the first quarter 2021 to guide future directions.
Hospitals continued to receive the monthly Vermont Oxford Network’s (VON) Microlesson Completion Reports and received their first quarterly length of stay report containing data calculated from hospital discharge data. The reports outlined the average length of stay compared to other GaPQC hospitals. Revisions were made to the SMART Aim to decrease length of stay among newborns diagnosed with NAS in participating GaPQC hospitals from 16.3 days to 14.7 days by September 9, 2020, to reflect national recommendations with a 10 percent decrease. GaPQC received approval for Part Four Maintenance of Certification Credit from the American Board of Pediatrics for all pediatricians participating in the collaborative to further encourage physician participation.
GaPQC, along with all hospital teams and partners, actively responded to the current COVID-19 pandemic and prepared for ways that GaPQC can support hospital systems to continue to improve maternal and neonatal outcomes without further taxing the system. The Women’s Health program used staff and resources to support communities and continued to offer technical assistance as requested.
The Microsoft Teams platform was utilized to maximize data sharing and created a webinar platform that was user-friendly and robust enough for recording and posting webinars for on-demand viewing. GaPQC supported the maternal and neonatal teams by hosting a monthly webinar series to facilitate education, collaboration, and support for the process and structure measures for both AIM bundles and interventions for the NAS initiative. Webinars featured subject matter experts and hospital teams from Georgia and other states to share experience implementing the interventions. A one-hour webinar was presented and led by a panel of experts in obstetrics and neonatal care, including DPH physician champions for NAS and the AIM bundles, to support hospital teams who are on the front lines caring for pregnant and birthing women and their infants during the COVID-19 pandemic.
GaPQC virtually hosted the Health Equity and Implicit Bias learning series, for the maternal and neonatal teams in the summer of 2020. This series featured two national speakers, Dr. Joia Crear-Perry and Dr. Uche Blackstock, and offered the SPEAK UP Against Racism training through the Institute for Perinatal Quality Improvement.
The 2020 GaPQC Annual Conference was cancelled due to COVID-19 and has been rescheduled for October 14-15, 2021.
Other Perinatal/Infant Health Programs
Newborn Screening
Newborn Screening (NBS) is a life-saving public health service offered universally to infants born in Georgia. At the federal level, the Advisory Committee on Heritable Disorders in Newborns and Children (ACHDNC) conducts thorough evidence reviews to determine if a condition should be added to the Federally Recommended Uniform Screening Panel (RUSP). Georgia’s condition review process is similar to that at the federal level and Georgia typically adheres to RUSP. Recently, Georgia added and successfully implemented four new conditions to the NBS panel (Pompe Disease, Mucopolysaccharidosis Type I, X-linked Adrenoleukodystrophy and Spinal Muscular Atrophy). The implementation process included targeted communication to families via the NBS brochure, targeted information sent directly to hospitals and physicians who routinely submit NBS specimen, and general updates on the process shared during stakeholder meetings and Board of Health meetings. The Georgia Public Health Laboratory successfully purchased and calibrated new equipment, validated new testing methods, and completed updates to the IT systems that support efficient screening and follow-up.
In the reporting year, DPH completed a Newborn Screening Advisory Committee (NBSAC) recruitment cycle and engaged more family representatives as well as increased representation from areas outside the metro-Atlanta area. In February 2020, the NBSAC held a regularly scheduled semi-annual meeting during which a nomination to add Krabbe disease to the state NBS panel was presented. The NBSAC established a work group to review the condition and implications of adding Krabbe to the state panel. Work group members included the co-chair of the NBSAC, a physician skilled in pediatric transplantation and gene therapy, a family member of a child with Krabbe, a genetic counselor and board member of KrabbeConnect, a clinical, biochemical, and molecular geneticist, the Director of the NBS short-term follow-up program, a pediatric neurologist, and the parent of a child with a condition identified through newborn screening. The work group met monthly for a six-month period, conducting independent research and discussing the evidence based on standard criteria. A summary of findings and recommendations will be presented during the next semi-annual NBSAC meeting.
The NBS program designed and implemented a quality improvement (QI) project to improve the quality of specimen collection and to decrease the number of days the specimens are in transit to the DPH Laboratory. The project was designed for small cohorts of hospitals to be engaged over a six-month period. In December 2019, the NBS Team successfully conducted the project’s initial training, which welcomed 23 nursing staff from ten birthing facilities in metro-Atlanta. All ten hospitals identified two NBS Champions per facility and agreed to participate in the six-month QI project. During the training, participants learned about NBS specimen collection, data collection, and the principles of quality improvement and small acts of change. At the close of the kickoff training, the ten QI hospitals staff received posters and “badge buddies” that display instructions for specimen collection and illustrations on acceptable versus unacceptable specimens to share amongst fellow staff who routinely collect NBS specimen. Following the initial in-person meeting, the NBS team held monthly cohort calls with NBS champions to discuss strategies that they implemented during the month and the impact of the strategies on specimen quality or transit time. The NBS Program plans to recruit a second cohort of hospitals to be engaged for another cohort to improve newborn screening. For the second year of the QI project, the NBS Program plans to hold a series of virtual educational trainings with hospital staff and continue to develop and disseminate educational materials that can be used to improve specimen collection and transit.
To highlight the benefits of NBS, the NBS program supported comprehensive strategies to enable the development of infants identified with a condition via NBS. For example, the sickle cell short-term follow-up and hematology program through Augusta University added a social worker to the team to strengthen care coordination for infants and children with sickle cell, or other significant hemoglobinopathy. The program served children in Augusta and conducted outreach clinics in South Georgia. Children and families who attended the clinics had access to medical care and to case management services coordinated by the social worker. The social worker most often helped families address needs for transportation, social security appeals, school 504 plans, family leave request, and community resources. The social worker also conducted developmental screens on children who had not been screened by their primary care physician or for who the hematologist had concerns. Any child that showed signs of developmental delay was referred to their primary care provider for further follow up.
The Medical Nutrition Therapy for Prevention (MNT4P) Program provided ongoing services to individuals with conditions identified through NBS. Medical nutrition therapy is the primary and lifelong treatment for most of the inherited metabolic disorders (IMD) diagnosed through NBS. The MNT4P worked to improve health outcomes and the quality of life for individuals with IMDs by increasing access to medical nutrition therapies necessary for treatment and maintenance of metabolic disorders.
NBS and NBS follow-up was sustained during the COVID-19 pandemic. Adjustments were made to protocols to maintain the urgency of follow-up while minimizing risk of exposure to the virus. NBS follow-up teams conducted conference calls with subspecialists to whom they typically refer infants that require further testing or are diagnosed with an NBS condition. During the calls, the teams discussed safety processes in place to keep children safe during appointments and under what circumstances a child’s follow-up appointment may be postponed to avoid unnecessary exposure to COVID-19. The follow-up teams included this new information in letters faxed to primary care providers when an infant screened positive for a NBS condition. Specialists maintained 24/7 call lines to support pediatricians providing services to infants and children with an NBS condition. The sickle cell follow-up teams provided supplementary guidance to pediatricians around initiating penicillin prophylaxis in cases where families were delayed in accessing follow-up or chose not to schedule an appointment with a hematologist during the pandemic. To maintain continuity of care, telephone visits were conducted for non-urgent patients.
Emerging Threat Response-Epidemiology
During the reporting year, several activities have been performed to maintain and enhance the surveillance of Zika-related health impacts through the development of the Congenital Infections Registry (CIR) and expansion of the Epidemic Response Team. Other congenital exposures have been included in the initial proposal of the CIR, including syphilis and hepatitis C. Most recently, with the ongoing COVID-19 pandemic, exposure to SARS-COV-2 began integration into the CIR as well.
MCH EPI was awarded Component W of the Epidemiology and Laboratory Capacity grant in August 2019. To accomplish longitudinal surveillance of emerging congenital infections, the Congenital Infections Registry (CIR), a SendSS module, began construction. Several staff have been hired to carry out the effort, including an Epidemiologist to serve as the Congenital Infections Registry Coordinator (CIRC2), a Medical Records Epidemiologist Liaison (MREL), and a CDC Contractual Field Staff (CFS). The CIRC2, MREL, and CFS joined the Newborn Surveillance Team to work closely with the Infant Outcomes Surveillance Manager (IOSM) on the CIR. Syphilis was the first congenital exposure selected for the CIR. The Newborn Surveillance Team have worked closely with the Technical Developer, STD EPI, and STD Program staff to (1) select with CDC key variables for surveillance; (2) map variables common among the STD Case Management module in SendSS, Vital Records (VRs), and variables requested by CDC for SET-NET; (3) create a workflow that triggers a case to be shared between the STD Case Management and CIR modules in SendSS; (4) develop a data export mechanism for validation and reporting to CDC on a quarterly basis; and (5) with the help of district Disease Investigation Specialists (DIS), collect, review, and abstract medical records for submission to CDC. To date, the CIRC2 and CFS have begun working on the 2018 syphilis cohort (N=207) by abstracting the birthing hospital records and initiating follow-up of 52 dyads composed of pregnant women with confirmed syphilis disease and infants with congenital syphilis exposure. The CIRC2 has successfully reported the initial forms (i.e., maternal health history and pregnancy outcome and birth forms) of these 52 dyads to CDC.
Safe Sleep
The Safe Infant Sleep program plans and promotes the Georgia Safe to Sleep Campaign. The campaign provides tools and resources that strengthen policy, provide consistent education and change infant sleep environments to prevent infant sleep-related deaths, empower professionals to educate parents, empower families to make informed decisions about infant sleep, and increase access to resources that support behaviors that protect infants from sleep-related deaths.
The Georgia Safe to Sleep Hospital Initiative, as part of the Georgia Safe to Sleep Campaign, is a statewide initiative designed to raise awareness about sleep-related infant deaths and evidence-based sleep practices to prevent infant mortality. The hospital initiative was launched in May 2016 to prevent infant sleep-related deaths in Georgia, empower professionals in multiple disciplines to educate parents about safe sleep environments and ensure they see proper sleeping practices modeled in hospitals. MCH continued to work with participating birthing hospitals to meet the goals of the program.
In the reporting year, efforts focused on ensuring that accurate and consistent education was provided to both professionals and caregivers, researching ways to address health inequities, and providing tools for families to practice safe infant sleep. Most of the 75 Georgia birthing hospitals participated in the hospital-based initiative. The following activities supported hospitals in their efforts to educate families about safe sleep practices:
- “This side up” infant gowns were distributed to birthing hospitals. This portion of the hospital-based program, as well as the travel bassinet distribution, ended in the reporting year.
- The “Sleep Baby Safe & Snug” board books were distributed to 67 facilities.
- A guide to assist Children’s Hospitals and Pediatric Units with implementing a safe infant sleep program was developed.
- The Children’s Healthcare of Atlanta quality improvement project was developed and initiated to all three campuses to improve modeling of safe infant sleep. A policy was approved and put into place for safe sleep and a second article on the effort was accepted for publication in the Journal of Injury Epidemiology.
- Hospital representatives were provided with a virtual safe sleep training accessible to families and caregivers eliminating the need to traveling to an in-person class during COVID19.
- A guided rapid cycle continuous quality improvement initiative for safe sleep practices in the hospital was introduced. Thirteen hospitals applied and the first cohort will begin November 2020.
The Safe Infant Sleep program distributed educational materials throughout the state, including safe infant sleep educational flipcharts for educators, one-page handouts on safe sleep environments, safe sleep brochures, crib cards, Spanish language materials and safe sleep books.
The program conducted focus group testing of newly created room sharing educational materials at six sites in the state. The materials were revised based on feedback and developed to specifically address the high number of sleep-related infant deaths that occur within the adult bed each year (>50 percent of all deaths). Perinatal Case Managers distributed 39,500 room sharing educational brochures through the 191 member locations of the Georgia Obstetrical and Gynecological Society. The brochures were included in the new patient packets for expecting families.
The program also launched the “Safe Infant Sleep Collaborative Network”. The network is a tool meant to provide updated resources, peer support, and education on safe infant sleep to anyone working with families. The program also continues to promote and teach the “train the trainer” sessions to help build local capacity to provide safe infant sleep education within their communities. The first sessions were conducted with Clayton County Child Fatality Review team, Children 1st and Early Head Start in Athens, and Safe Kids Georgia. Regular trainings were also provided on a routine basis and a recorded webinar was made available for those needing an on-demand option. The program expanded the previously designed, developed, and implemented, “Just Me on my Back” decal (aka floor talker) educational opportunity in collaboration with the Child Fatality Review Panel. Decals were sent to 244 additional sites throughout Georgia, including MCH home visiting sites, with specific focus to the areas with the highest rates of sudden unexpected infant death (SUID).
The program designed, developed, and began implementation of a “Safe Infant Sleep Education and Crib Distribution” program specifically designed for areas where the birthing hospital has a Medicaid-enrolled birth census of 75 percent or greater. The program was designed to address health inequity for families enrolled in Medicaid as Medicaid-enrolled families have a four times greater risk of sleep-related death than families with any other insurance payer.
The Safe Sleep program and the Title V Analyst participated in the Children’s Safety Network (CSN) Child Safety Learning Collaborative (CSLC) cohort to reduce fatal and serious injuries among infants, children and adolescents. The team chose to focus on Sudden Unexpected Infant Death prevention (SUIDP) to customize messaging and outreach approaches for greater impact. The CSLC cohort team collaborated with the Family and Community Support Services team and contracted the production of a safe infant sleep educational training video, specifically for home visitors. The home visiting program provided the education for the video which included instructions on how to involve fathers/partners into safe sleep practices as well as provided advice on helping parents/caregivers find assistance with car seats. The effort was highlighted at the Safe States annual conference in their “Addressing and Advancing Equity for Children” session.
The Safe Infant Sleep program launched a pilot with Partners Against Domestic Violence and My Sister’s House to help ensure safe sleep is being supported in shelters and to provide safe sleep education and portable cribs to parents with infants less than six months of age.
Research involved discussions with Georgia State University around geographic information system (GIS) mapping of SUID and overlaying risk and protective factors to the geocoded deaths. IRB approval was received in June 2020 and analysis will begin after data from Child Fatality Review is received. A team assembled by the program also reviewed news media reports on childhood injury deaths and compared the reports compared to the actual injury deaths. Data has been compiled and data analysis will be finalized for possible publication.
Additionally, the Safe Sleep program worked with the National Center on Shaken Baby Syndrome’s national representative to address areas with the highest reported numbers of abusive head trauma. Abusive head trauma prevention has many shared risk and protective factors associated with SUID prevention. The program participated in the 4th trimester meetings led by DeKalb public health and Emory Decatur Hospital as well as participated in the Georgia Injury Prevention Advisory Committee, DPH/Healthy Mothers Healthy Babies (HMHB)/ Georgia Bureau of Investigations (GBI) Infant Mortality Working Group, Columbus Safe Sleep Committee, Maternal Substance Abuse working group, Breastfeeding Strategy Meeting, State Health Improvement Plan committee, and the Children’s Safety Learning Network SUID Prevention National Cohort.
In the reporting year, the Safe Sleep program had two poster presentations, one oral presentation, and one accepted publication:
- Wisconsin Association for Perinatal Care Annual Conference: Salm Ward, T. C., Miller, T. J., & Naim, I. A. (2020). Evaluation of a multi-site safe infant sleep education and crib distribution program in Georgia. Poster.
- University of Georgia State of Public Health Conference: Salm Ward, T. C., Miller, T. J., & Naim, I. A. (2020). Evaluation of a multi-site safe infant sleep education and crib distribution program in Georgia. Poster
- American Academy of Pediatrics Annual Conference (2019) Lazarus, SG., Miller, T.J. Expansion of a multi-pronged safe sleep quality improvement initiative to three children’s hospital campuses. Oral Presentation
- Leong T, Roome K, Miller T, et al. Expansion of a multi-pronged safe sleep quality improvement initiative to three children's hospital campuses. Inj Epidemiol. 2020;7(Suppl 1):32. Published 2020 Jun 12. doi:10.1186/s40621-020-00256-z
Safety measures associated with COVID-19 resulted in several conference presentations being transitioned to virtual conferences and meetings. Sites providing safe sleep education with or without crib distribution discontinued education due to in-person restrictions. Several larger sites were able to adapt to an online learning session format and drive thru portable crib pick up.
Family and Community Support Services
The Georgia Home Visiting Program (GHVP) was established to strengthen Georgia’s capacity for addressing the overall health, safety and wellbeing of families and children through the implementation of Evidence-Based Home Visiting (EBHV) services and the enhanced coordination of services for at-risk families. The program is guided by a state-level infrastructure designed to support project implementation and evaluation via the provision of technical assistance and trainings as well as the collection of data to allow performance monitoring and continuous quality improvement. The federal Maternal, Infant, Early Childhood Home Visiting (MIECHV) program is the primary funding stream for home visiting. Other funding streams include Title V, Child Abuse and Neglect Prevention (CANP), and other state dollars. GHVP is dedicated to providing EBHV program models as they are proven to improve outcomes in several domains including (1) maternal and child health, (2) positive parenting practices, (3) child development and school readiness, (4) reductions in child maltreatment, (5) family economic self-sufficiency, and (6) linkages and referrals to community resources and supports.
GHVP provides appropriate home visiting services to eligible families who reside in at-risk communities and represent priority populations in 18 counties in Georgia. Within the 18 counties served, DPH has contracts with 17 Local Implementing Agencies (LIAs) and utilized the following EBHV models: Early Head Start-Home Visiting (EHS-HV), Healthy Families Georgia (HFG), Parents as Teachers (PAT), and Nurse Family Partnership (NFP). In addition, GHVP helps to coordinate necessary services within and outside of home visiting programs to provide support and technical assistance to address needs of participates, which may include mental health, primary care, dental health, children with special needs, substance use, childhood injury prevention, child abuse/neglect/maltreatment, school readiness, employment training, and adult education programs.
During the reporting period, 23,135 home visits were completed statewide with 1,919 total families served in Bartow, Bibb, Brantley, Catoosa, Chatham, Clarke, Crist, DeKalb, Fulton, Gordon, Glynn, Houston, Liberty, Lowndes, Muscogee, Richmond, Rockdale, and Whitfield counties.
The Georgia Strong Families Program (GSFP) Healthy Start is implemented in two public health districts that are at-risk for poor birth outcomes. The two public health districts are South Health District, located in Valdosta (GSFP-Valdosta) serving Brook, Echols, and Lowndes counties, and West Central Health District located in Columbus (GSFP-Columbus) serving Muscogee County.
GSFP continued to focus on women at-risk for adverse perinatal health outcomes that utilized public health departments to access Presumptive Medicaid. Public health departments were designated as qualified providers to enroll eligible applicants in the Medicaid program through Medicaid Presumptive Eligibility. This process was initiated through the public health department’s Perinatal Case Management (PCM) Program, which aims to assure pregnant women in Georgia have an opportunity to access comprehensive perinatal health care services appropriate to meet their individual needs. The initial PCM assessments and the Healthy Start assessment provided an opportunity for early detection of high-risk pregnancies and allow GSFP staff to connect women to timely coordinated prenatal care. Program participants with screenings and assessments which indicated areas of concern were connected to vital resources and community services. GSFP supported access to health insurance, facilitated Medicaid enrollment, and promoted access to services through the infrastructure innate to public health. In addition, GSFP utilized local public health staff to provide enrollment assistance in the Planning for Healthy Babies® (P4HB®) waiver program for non-pregnant women which provides no-cost family planning services to eligible women in Georgia.
The Georgia Home Visiting Institute
The Georgia Home Visiting Institute (HVI) was held virtually on August 18, 2020, with 274 attendees present. The event was originally scheduled to take place in person at the Peachtree City Hotel and Conference Center in Peachtree City, Georgia; however, due to the COVID-19 pandemic, the event was held virtually using the Zoom video conferencing platform. The HVI was sponsored by DPH in partnership with the United Way of Greater Atlanta. In lieu of workshops, two one-hour keynote sessions were presented. Dr, Junlei Li, Saul Zaentz Senior Lecturer in Early Childhood Education at Harvard Graduate School of Education and Dr. Dana Winters, faculty director of the Fred Rogers Center for Early Learning and Children’s Media, Saint Vincent College led and facilitated the first keynote, Strengthening Communities and Maintaining Connections Across Physical Distances. The presentation focused on the importance of human connections as social distancing disrupts the lives of many families and the work routines of the professionals who serve families using examples of how children’s helpers support children across diverse contexts with limited resource. Dr. Lei and Dr. Winters affirmed the power of human relationships in both ordinary and unusual times by discussing how and why such relationships can support and strengthen children and families through simple, everyday interactions.
The second presentation, The Foundation of Regulation: Supporting Kids and Caregivers in Times of Stress was led by Dr. Heather Forkey, MD, Associate Professor of Pediatrics at the University of Massachusetts Medical School. The presentation focused on the development of self-regulation as a critical attribute of resilience. Through the introduction of simple skills to support caregivers, Dr. Forkey guided attendees to self-regulate, support attachment, address challenging behavior, and promote co-regulation of kids; showing that stressors can be transformed into opportunities for growth in resilience.
To promote health equity goals and continuous quality improvement efforts, the GHVP built on current strengths and relationships with other DPH programs including Children 1st, Babies Can’t Wait, WIC, Children’s Medical Services, and other maternal and child health programs. Focus was placed on maternal depression. The Mothers and Babies curriculum was used as a resource for mothers suffering with perinatal depression. The Mothers and Babies Curriculum training was offered to home visiting programs and 49 home visitors and supervisors attended the virtual training in August 2020.
The COVID-19 pandemic created a need for flexible and sustainable service delivery solutions to ensure that families continued to receive the benefits provided through home visiting programs. Although traditional, face-to-face home visits were discontinued, virtual visits were conducted and the responses from home visit providers and clients were positive. MCH ensured that families continued to be provided with evidence-based programs and support.
The GHVP state team responded quickly with technical assistance and training to ensure a smooth transition from in-person home visiting services to virtual phone and web-based services. Home visiting staff were trained and oriented to the Cisco WebEx platform to continue services with families in a virtual environment. The Home Visiting Technical Assistance Team provided written guidance entitled, “Home Visiting and First Steps Technical Assistance in Response to COVID-19,” for the Georgia Home Visiting Program and Healthy Start Sites that provided general guidance on providing screenings, home visits, group meetings, and supervision activities virtually.
DPH provided statewide virtual Group Connection monthly meetings for parents and caregivers to provide additional health education, information, and resources to families. The virtual sessions provided social contact for families and provided the opportunity to network and receive education and support. The virtual meeting format also gave LIAs a reprieve from coordinating their own virtual meetings and allowed time to adjust to the new virtual environment. During the meetings, guest speakers and experts in various fields addressed several topics including self-care during the pandemic, financial management, parenting support, breastfeeding, and child development. Sessions were provided in English and Spanish when possible.
Oral Health
The Oral Health Program provided Home Visitors a flipbook guide on oral health to help educate families on improving oral health behaviors. The flipbook was originally created by the Rhode Island state Oral Health Program and Oral Health Coalition with feedback from Home Visitors. The flipbook was adopted, with permission, and rebranded by Georgia DPH. Flipbooks were provided to all the Home Visitors in the state and provided to families through home visits.
Improving Birth Outcomes
In the reporting year, MCH created the Improving Birth Outcomes Initiative to amplify efforts, identify gaps, and create a collective, streamlined set of priorities to reduce infant mortality rates. The Improving Birth Outcomes Initiatives developed strategies to support improving birth outcomes and reducing premature births and infant mortality among all infants, specifically Black infants, by creating partnerships and collaborations aimed at focusing on the Social Determinants of Health (SDOH) and addressing the correlations between race, equity, infant mortality, and pre-term birth. MCH introduced a community approach that includes community-based outreach and education as an essential component that has the potential to substantially improve infant health outcomes.
DPH, in partnership with HMHB and the Georgia Bureau of Investigations, convened the Infant Mortality Working Group, which included representatives of area health and human service agencies to participate in a strategic planning process for the Georgia Improving Birth Outcomes Initiative. Strategies to improve infant mortality, specifically infant mortality in the Black population were developed.
MCH partnered with the Office of Vital Records to improve Fetal Death Certificate reporting. When reported accurately, Fetal Death Certificate data will positively impact the ability to interpret and draw conclusions on the Perinatal Periods of Risk analyses and/or other analyses involving fetal deaths, improving the ability to inform programmatic decision making and impacting conclusions on infant mortality.
MCH collaborated with the Mercer University School of Medicine’s Center for Rural Health and Health Disparities to conduct a qualitative mixed-methods analysis in rural areas of the state with high infant mortality rates to understand the landscape of the community to better assess needs. Exploring rural and urban mortality differences examines the impact of rurality on infant mortality and explores regional differences in primary and underlying causes of infant mortality. The environmental scan will explore socio-economic determinants of health including poverty, education, rural attitudes and culture, psychosocial risk factors, access to healthcare, employment, transportation, insurance status, and other risk factors such as smoking rates, obesity, and safe sleep practices. The environmental scan will guide strategic planning and decision making to lead to evidence-based responses that improve birth outcomes in rural communities.
MCH continued to support evidence-based home visiting programs in communities where infant mortality rates are disproportionately impacted by the leading causes of infant mortality and encourage participation in the Healthy Start Community Action Networks (CANs) to enact community-level change in reducing disparities.
The development of a Community Engagement Toolkit was initiated to promote infant mortality and health equity education and provide community, faith based, non-profit, professional, and other organizations with infant mortality data, education, and structured guidance to improve birth outcomes.
Current Year: Oct 2020 – Sept 2021
Priority Need: Prevent Infant Mortality
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.
The RPCs in the six birthing regions in Georgia are actively responding to the current COVID-19 pandemic in addition to continuing to provide transport and high-risk care to mothers and babies across the state. Maternal and Neonatal Outreach educators continue to support clinical needs within their facilities, as well as providing support for regional birthing centers.
NPM 4: Breastfeeding
Breastfeeding
In the current year, the Georgia 5-STAR Hospital Initiative continued to provide technical assistance by phone and emails. The Georgia Chapter of the American Academy of Pediatrics will continue to deliver the EPIC breastfeeding program and provide site visits and technical assistance to hospital providers.
NPM 5: Safe Sleep
Safe Sleep
The Safe Infant Sleep program continues to lead the Georgia Safe to Sleep Campaign and implement evidence-based interventions to reduce the number of preventable cases of Sudden Unexpected Infant Death (SUID). Efforts are focused on ensuring accurate and consistent education provided to both professionals and caregivers, researching ways to address health inequities, and providing tools for families to practice safe infant sleep. In the current year, most of the Georgia birthing hospitals participated in the hospital-based initiative. The initiative ensures that safe infant sleep education for staff and families is consistent to the American Academy of Pediatrics recommendations to prevent infant sleep-related deaths in Georgia, empower professionals in multiple disciplines to educate parents about safe sleep environments, and ensure that families see proper sleeping practices modeled in hospitals. The program continues to work with participating birthing hospitals to meet the goals of the program and ensure continuous quality improvement. Currently, 13 hospitals are participating in a separate, voluntary Quality Improvement Cohort led by DPH. This cohort means to further strengthen safe sleep practices in the Neonatal Intensive Care Unit (NICU), Well Baby and Pediatric Units, by utilizing QI processes.
The MCH Home Visiting program contracted the production of a safe infant sleep educational training video specifically for home visitors. The video includes how to involve fathers/partners into safe sleep as well as advice on helping parents/caregivers find assistance with car seats. The effort was highlighted at the Safe States annual conference in the “Addressing and Advancing Equity for Children” session. The program also presented education on Abusive Head Trauma to home visiting groups and provided information regarding how to include prevention education to families. The program provided a Frequently Asked Questions training to the statewide First Steps program, a home visiting program that initiates contact with families in the hospital following delivery.
The Safe Sleep program became a host for a Project Imhotep intern. Project Imhotep, funded by the CDC and in partnership with Morehouse University, is an 11-week summer internship program designed to increase the knowledge and skills of underrepresented minority students in biostatistics, epidemiology, and occupational safety and health. The Intern is working with the Safe Sleep program on a faith-based safe sleep initiative.
SPM 1: Percent of Congenital Syphilis Averted
Congenital Syphilis
The STD Office worked to prevent STDs by providing quality intervention strategies, programmatic support, and education to all throughout the state. With a focus on Congenital Syphilis, the STD team works to promote first and third trimester testing for HIV and Congenital Syphilis, as well as to improve the data quality of Congenital Syphilis. In the current year, district and provider education continued. The following site visits and trainings were provided:
- Monthly Virtual TA Calls in lieu of site visits due to COVID-19
- Congenital Syphilis Annual Review Board Meeting (December 15, 2020)
- District Online Meeting (December 15, 2020)
- Two-Day STI Intensive (Feb. 9-10, 2021)
Challenges/barriers: COVID-19 limited the ability to plan or implement community outreach events in the current year. Alternative opportunities for provider education via online learning platforms and webinars are being explored.
SPM 2: Reduce Infant Mortality in the Black Population
Improving Birth Outcomes
In the current year, MCH continued efforts to develop new strategies and move ideas to action to reduce infant mortality. MCH continued the partnership with HMHB and the Georgia Bureau of Investigations (GBI) to jointly lead the Infant Mortality Working Group. Two subgroups were developed to identify needs and develop specific strategies to advance the working groups’ goals to address existing disparities and to reduce infant mortality rates to the Healthy People 2030 target (5 per 1,000) or below for each Georgia county and for each racial/ethnic group. The Health Equity Subgroup developed strategies to facilitate community-based engagement opportunities, invest in promoting health equity and inclusion training programs for pediatric providers, and incorporate data on disparities to reveal the conditions affecting Black babies in the state.
The Evidence-Based Interventions subgroup established goals to identify, implement, and scale evidence-based interventions to ensure that more of Georgia’s babies see their first birthdays. The group plans to develop strategies to identify existing interventions and assess their scalability to ensure that families are being referred to resources such as care coordination. The group reviewed related data plans to assess evidence-based or -informed implement interventions to mitigate contributing factors to infant mortality such as medical and social determinants of health.
MCH is partnering with the Office of Vital Records to improve Fetal Death Certificate reporting to improve fetal death reporting. A survey to assess hospital state registrar’s areas of need is being developed to determine additional training needs and any areas that may be barriers to accurate and timely reporting.
The Improving Birth Outcomes Working Group was established in the current year to advise and work jointly with MCH through the development and implementation of innovative infant mortality prevention and community interventions. The working group helps determine impactful strategies and best practices to improve outcomes and reduce infant mortality by examines factors and research findings identified as affecting the mortality of infants, in particularly black infants. Working group membership is comprised of research, medical, community and public health professionals.
MCH is collaborating with Mercer University School of Medicine’s Center for Rural Health and Health Disparities to conduct a qualitative mixed-methods analysis in rural areas of the state with high infant mortality rates to understand the landscape of the community to better assess needs. Exploring rural and urban mortality differences examines the impact of rurality on infant mortality and explores regional differences in primary and underlying causes of infant mortality. The environmental scan will explore socio-economic determinants of health including poverty, education, rural attitudes and culture, psychosocial risk factors, access to healthcare, employment, transportation, insurance status, and other risk factors such as smoking rates, obesity, and safe sleep practices. The environmental scan will guide strategic planning and decision making to lead to evidence-based responses that improve birth outcomes in rural communities. Phase I of the environmental scan will be completed in the current year. Virtual focus groups are being conducted with individuals in Clinch, Irwin, Seminole, and Wilcox counties which have been identified to be highly impacted with infant mortality rates that are either twice the 2018 state average or have a relative risk for Black babies of ten or higher, when compared White babies. Project status updates and activities continue to be shared with stakeholders and partners.
A Community Toolkit was developed to empower community members, leaders, and organizations with the information and resources necessary to promote infant health and reduce infant mortality in their communities. The toolkit will introduce and highlight Georgia’s infant mortality rate, specifically in the Black infant population, discuss the top causes of infant mortality, best practices to prevent infant mortality, and provide a call to action concerning how community members can help reduce infant mortality. The toolkit will be provided to community groups and organizations via electronic format and will contain a pre- and post-test.
Other Perinatal/Infant Health Programs
Neonatal Abstinence Syndrome
In the current year, the Neonatal Committee of the GaPQC continued to implement the NAS initiative with 46 (64 percent) birthing hospitals in the state participating in the initiative, including one rural birthing hospital who joined the NAS initiative in April 2021. Seven rural birthing hospitals will receive a third year of funding to support hospital engagement in the AIM bundles and NAS initiative to improve maternal and neonatal outcomes.
GaPQC supported the neonatal teams by hosting the monthly webinar series to facilitate education and collaboration to include specialized webinars on COVID-19 and health equity. The didactic presentations were designed to guide hospitals through implementing interventions listed in the key driver diagram. In the summer 2020, GaPQC launched a Health Equity Learning Series to build capacity to improve health disparities in infant health. Addressing racial inequity is ongoing focus and will move from learning to action in 2021 through the development of individual hospital action plans.
In December 2020, GaPQC developed and disseminated a statewide environmental scan survey of all participating hospitals in partnership with the GA OB/GYN Society. This assessment targeted maternal and neonatal hospital teams to identify improvement opportunities for all initiatives and future direction. The survey included questions about health equity and disparity reduction efforts at respective hospitals. Survey results are currently being used to create a training and support plan for equity champions and clinical teams and to develop future initiatives.
Hospitals continue to receive the monthly VON Microlesson Completion Reports and nine hospitals achieved Center of Excellence demonstrating a high level of engagement and completion of all quality improvement microlessons.
GaPQC, along with all hospital teams and partners, actively responded to the current COVID-19 pandemic and prepared for ways that GaPQC can support hospital systems to continue to improve maternal and neonatal outcomes without further taxing the system. Women’s Health program staff continues to offer technical assistance to the hospitals as needed and requested while dedicating time and resources to support DPH mass vaccination efforts.
The Microsoft Teams platform is utilized to maximize data sharing and as a webinar platform to host webinars and store recordings in a repository for on-demand viewing. This became a valuable tool during the pandemic to bring people together to encourage and support hospitals in improving maternal and neonatal outcomes through the GaPQC initiatives. GaPQC supported the maternal and neonatal teams by hosting a monthly webinar series to facilitate education, collaboration, and support for the process and structure measures for both AIM bundles and interventions for the NAS initiative. Webinars featured subject matter experts and hospital teams from Georgia and other states to share experience implementing the interventions.
NAS is moving into sustainability in 2021 and the next neonatal initiative will focus on breastfeeding.
Challenges/barriers: GaPQC is being proactive to minimize engagement by actively strategizing to build relationships that do not involve travel or meeting in person for the foreseeable future. Options continue to be explored to provide hospitals with rapid access to data to inform their QI initiatives and plans.
Even with funding provided for some, several of the rural facilities struggle with dedicating resources to the AIM project.
Related legislation: O.C.G.A. §31-12-2 (2017) statutory reporting requirement for NAS
Newborn Screening
In the current year, the Newborn Screening (NBS) Program continued to identify and provide early treatment for 35 selected inherited disorders that otherwise would cause significant morbidity or death. NBS provided education for parents and health care providers, universal testing of all newborns, follow-up including rapid retrieval and referral of the screen-positive newborns, confirmation of a normal or abnormal screening test result by a private physician or tertiary treatment center, rapid implementation and long-term planning of therapy and validation of testing procedures.
NBS facilitated communication between practitioners, birth hospitals, the laboratory personnel, and the follow-up teams and provided ongoing education for practitioners.
The Medical Nutrition Therapy for Prevention (MNT4P) Program provided ongoing services to individuals with conditions identified through NBS. The MNT4P continues working to improve health outcomes and the quality of life for individuals with IMDs by increasing access to medical nutrition therapies necessary for treatment and maintenance of these metabolic disorders.
NBS and NBS follow-up have been sustained during the COVID-19 pandemic. Adjustments have been made to protocols to maintain the urgency of follow-up while minimizing risk of exposure to the virus. NBS follow-up teams conduct conference calls with subspecialists to whom they typically refer infants that require further testing or are diagnosed with an NBS condition. During the calls, the teams discuss processes specialty clinics have put in place to keep children safe during appointments and under what circumstances a child’s follow-up appointment may be postponed, avoiding unnecessary exposure to the coronavirus. The follow up teams included this new information in letters faxed to primary care providers when an infant screen positive for an NBS condition. Specialists maintain 24/7 call lines to support pediatricians who provide services to infants and children with an NBS condition. The sickle cell follow-up teams provided supplementary guidance to pediatricians around initiating penicillin prophylaxis in cases where families are delayed in accessing follow-up or choose not to schedule an appointment with a hematologist during the pandemic. To maintain continuity of care, telephone visits are conducted for non-urgent patients.
Family and Community Support Services
In the current year, the Family and Community Supports program (FACS) continues its commitment to implement evidence-based, comprehensive, and community-based maternal and early childhood programs. Home Visiting programs currently include Healthy Families Georgia (HFG), Nurse Family Partnership (NFP), and Parents as Teachers (PAT). Family and Community Supports partners with the MMRC and participates in their action-oriented processes providing education and resources for women and infants through outreach activities in the community.
The Georgia Home Visiting Program (GHVP) facilitates the Georgia Healthy Start Collaborative which includes the six Georgia Healthy State grantees. The collaborative continues to work together to develop a strategic plan that addresses the Healthy Start benchmarks and Title V state performance measure. The focus areas are Father Involvement, Breastfeeding, Maternal Mortality, and Infant Mortality. The collaborative has been successful in developing a marketing video that depicts all the state’s Healthy Start programs and producing a promotional flier. The collaborative is working on developing a universal referral form and exploring other opportunities to make a population-based impact. Family and Community Supports conducts a quarterly call with the six Healthy Start sites in Georgia, Title V, and the Healthy Start National Project Officer to foster collaboration and team building and identify opportunities to leverage resources for successful partnerships. Quarterly calls focus on home visiting updates and protocols amid the COVID-19 pandemic, which include Home Visiting strategies to provide services to clients via phone, virtual visits, and group activities.
The GHVP continues to provide virtual and telephonic visits based on the evidence-based home visiting (EBHV) model recommendations. The Local Implementing Agencies (LIAs) have been creative in their efforts to engage families during the pandemic. From drive-by baby showers to virtual graduations, the sites continue to meet with their families and provide needed support, resources, and services.
Statewide virtual Group Connection meetings continued and have decreased client isolation by collaborating with partners and LIA’s to provide education and support to families. The group connections are coordinated by the Georgia Home Visiting State Team and is available to families and staff throughout the state.
State Group Connection Topics/Dates:
- Early Brian Development-Storytime- September 9, 2020
- Safe Sleep- October 13, 2020
- March of Dimes Program and Service Overview- November 10, 2020
- Strengthening Families Protective Factors- December 8, 2020
- Strengthening Families Protective Factors- March 9, 2021
GHVP developed a Safe Sleep Education and Training Video in collaboration with DPH’s Safe Infant Sleep Program Manager. MIECHV and Healthy Start Home Visiting staff participated in the making of the training video, which launched in January 2021.
Certified Lactation Consultant (CLC) Training is being offered in the current year to expand upon the success of existing CLCs. At this time, approximately 40 staff, including home visitors and program managers have registered, and have begun their coursework. All certifications to be earned by December 31, 2021.
GHVP offered the Racial Equity Institute’s (REI) Groundwater Approach Presentation, Building a Practical Understanding of Structural Racism, as a training on May 11, 2021. The training was provided to home visitors and MCH staff with over 130 participants in attendance. The training provided stories and data to present a perspective that racism is fundamentally structural in nature. By examining characteristics of modern-day racial inequity, the training addressed the following concepts:
- Racial inequity looks the same across systems
- The socio-economic difference does not explain the racial inequity
- Inequities are caused by systems, regardless of people’s culture or behavior
Additional professional development trainings for Healthy Start Staff included:
- Lemonade for Life-Trauma Informed Care/ACEs Training
- Time Management
- Motivational Interviewing
- Stewards of Children (child sexual abuse prevention)
- Connections Matter (child advocacy)
- Self-care
To ensure continued quality improvement, GHVP staff prepared and distributed full-color two-page infographics to each LIA highlighting their FY2020 performance. Highlights included the number of families and children served, demographic indicators, and performance measures outcomes. In October 2020, the GHVP Leadership completed virtual annual site visits for all the DPH-managed MIECHV programs. The site visits include an overview of the performance and plans for the subsequent year.
Monthly GHVP Check-in Calls with LIAs were established to check-in with site, provide support and guidance, and allow sites to share strengths, challenges, and ideas regarding the impact of COVID on service delivery, staff, and families.
Georgia assessed the impact of COVID-19 on Home Visiting in Georgia through a collaboration between Emory and GHVP, Project AICHV (Assessing the Impact of Covid-19), to examine the following:
- Determine the essential and unmet needs of home visiting programs and their clients during the COVID-19 pandemic
- Explore facilitators and barriers to the delivery of home visiting services in Georgia since the start of the COVID-19 pandemic
- Identify strategies for enhancing and adapting home visiting services during the COVID-19 pandemic
Challenges/barriers: The COVID-19 pandemic created a need for flexible and sustainable service delivery solutions to ensure that families continue to receive the benefits provided through home visiting programs. Although traditional, face-to-face home visits are currently discontinued, virtual visits are being conducted and the responses from home visit providers and clients are positive. MCH is committed to ensuring that families continue to be provided with evidence-based programs and support throughout the pandemic.
To Top
Narrative Search