Georgia’s 2021 MCH Title V Application presented a comprehensive five-year needs assessment summary describing the state’s MCH needs, strengths, capacity, and partnerships. The FY 2023 application year is the third year of the FY 2021 to 2025 grant cycle. The primary focus of this year’s needs assessment update is to provide a summary of DPH’s efforts to monitor and assess the needs of the MCH population, as well as the capacity of the system to meet those needs during the interim years. MCH Title V program staff engage stakeholders and develop strategies to address necessary changes as Evidence-based or –informed Strategy Measures (ESMs) and SPMs are developed and implemented.

 

Ongoing Needs Assessment Activities

 

Alliance for Innovation on Maternal Health (AIM) Bundles

The Georgia Perinatal Quality Collaborative (GaPQC) is focused on making meaningful, data-driven, equitable improvements in maternal and infant health outcomes through partnerships and continuous assessment and quality improvement. In Georgia, significant racial disparities exist related to maternal and infant mortality for Black women and women living in under-resourced rural areas. The MMRC assesses the leading causes of maternal death and found that non-Hispanic Black women are 2.3 times more likely to die from pregnancy-related causes than non-Hispanic White woman. To strategically address these disparities, Georgia will be the first state in the country to implement the CCOC AIM bundle prioritizing outcomes for non-Hispanic Black women and rural Georgians. On the neonatal side, GaPQC is currently enrolling hospitals in a new initiative, Optimizing Nutrition for Georgia Newborns to address Georgia’s increasing infant mortality rate that of 6.1 per 1,000, which far excesses the Healthy People 2030 goal of 5.0 per 1,000.

 

Oral Health

The Oral Health Program originally planned to carry out a Third Grade Oral Health Basic Screening Survey (BSS) throughout the state in the 2021-2022 school year. This is consistent with the recommendation from the CDC and the Association of State and Territorial Dental Directors (ASTDD) to carry one out every five years. The previous survey dissemination was conducted in the 2016-2017 school year. Preparations and planning were made early in 2021 to prepare for a fall collection. This included working with epidemiologists to design a sampling framework and generating a list of schools that would create a representative sample of children across several demographics. A survey methodological design and data collection plan was developed in collaboration with DPH epidemiologists and ASTDD subject matter experts. The Oral Health program waited for summer break to end before contacting the schools to plan for data collection implementation and scheduling in the hopes that schools would be reacclimated in a more predictable and routine classroom schedule. However, the rise of COVID-19 cases in August 2021 corresponded with the very start of the school year for many Georgia school systems. This quickly led to many systems switching back to virtual settings or having large percentages of students stay home, following quarantine protocols for extended periods of time. The nature of the Third Grade BSS requires in-person face-to-face visual observation for data collection and thus would have significantly disrupted due to this unforeseen impact. The Oral Health program decided to delay the Third Grade BSS back to the 2022-2023 school year. Planning has begun and a new sample list of schools has been generated.

 

Safe Sleep

To address the disconnect between prenatal intentions and actual safe infant sleep practices, the Safe Infant Sleep program developed and tested a “booster session,” to be delivered three to five weeks after the infant is born, to: (1) reinforce knowledge of safe sleep recommendations, and (2) help address challenges to following safe sleep recommendations. The timeframe of three to five weeks is based on evidence that the risk of sleep-related infant deaths peak between one and four months of age, and with the aim of addressing sleep practices before habits have been established. A safe sleep intervention that included coaching parents after the infant was born demonstrated feasibility and acceptability in helping to address challenges. The engagement of parents of newborns is a priority to assess information needs and determine what is most useful in helping parents and caregivers practice safe infant sleep.

 

Children’s Medical Services (CMS)

The CMS program developed and distributed a brief survey assessing the overall experience with services provided by the CMS program to families and young adults. The program’s aim was to understand the overall experience with services provided by the CMS program and to help determine what improvements in services and service delivery should be made and assist the CMS program with identifying opportunities to expand the list of comprehensive services that the program may reimburse for.

 

Survey responses were collected from parents/caregivers and young adults, 18 years of age and older, who have been enrolled in the CMS program for at least six months and who have engaged with their care coordinator for care coordination and/or specialty clinic services within the last six months.

 

Babies Can’t Wait (BCW)

Less than 15 percent of children eligible for Early Intervention (EI) services access intervention services and minority groups disproportionately enroll in EI. A University of Georgia interdisciplinary team developed a proposal for an environmental scan of Georgia’s BCW system to better understand the patterns of usage across regions and demographics, as well as the barriers that interfere with enrollment or supportive factors that facilitate enrollment from the perspective of a range of stakeholders, including EI administrators, EI providers, and families. The Social Ecological Model will be used to examine the strengths and weaknesses of the EI program at multiple levels, such as the individual or caregiver level, interaction of service providers and caregivers, and organizational level. The data from the environmental scan will help inform the development of a health equity plan to increase access to EI services in communities with low referral rates and high need.

 

Changes in the Health Status and Needs of the MCH Population

 

Maternal/ Women’s Health

Maternal Mortality: From 2015 to 2017, the maternal mortality ratio was 68.9 deaths per 100,000 live births; the pregnancy-related mortality ratio was 25.1 deaths per 100,000 live births. Approximately 87 percent of the pregnancy-related deaths were preventable.

 

Well-Women Visits: The 2020 Behavioral Risk Factor Surveillance System (BRFSS) estimated approximately 70.6 percent of women, ages 18 to 44, reported visiting a doctor for a routine checkup in the past year. According to the 2017-2020 Pregnancy Risk Assessment Monitoring System (PRAMS), 59 percent of Georgian women of reproductive age (WRA) had seen a doctor in the past 12 months. The percentage of WRA reporting seeing a doctor in the past 12 months was greatest among Non-Hispanic (NH) Black women and women with health insurance coverage.

 

Family Planning: From 2017-2020, PRAMS data show the percentage of women with a recent live birth who reported an unintended pregnancy has remained relatively constant around 7 percent. Among women who were not trying to get pregnant when they became pregnant, a plurality of women (46 percent) reported use of low-efficacy birth control methods (condom, withdrawal, and natural family planning), followed by medium-efficacy methods (the pill, patch or injectables). Use of high-efficacy birth control methods (implant and intrauterine device (IUD)) was least commonly reported among women who were trying not to get pregnant when they conceived.

 

Early Prenatal Care: According to the 2020 National Vital Statistics System (NVSS), approximately 75.5 percent of pregnant women reported having their first prenatal care visit during the first trimester.

 

Postpartum Care: Available PRAMS data from 2017-2020 show the percentage of women who received a postpartum visit with a health care provider remained relatively constant around 90 percent. Among women who did receive a postpartum visit, the most reported topics discussed were birth control methods for use after birth (90 percent), mental health screening (86 percent), healthy habits (diet and exercise, 63 percent), and smoking cigarettes (65 percent).

 

Perinatal/ Infant Health

Infant Mortality: The NVSS estimated the rate of infant death in 2019 was 7.0 per 1,000 live births.

 

Breastfeeding: In the 2018 National Immunization Survey (NIS) approximately 80.9 percent of infants were reported by a parent to have ever been breastfed, while only 24.3 percent of infants were reported by a parent to have been breastfed exclusively through 6 months. The 2017-2020 PRAMS show that among women with a recent live birth, 82 percent ever reported breastfeeding or pumping breastmilk to feed their infant. At the time of the PRAMS survey (2-6 months after birth), approximately 43 percent of those women reported they were currently breastfeeding.

 

Safe Sleep Practices: According to the 2020 PRAMS data, 71.3 percent of mothers report they most often place their baby to sleep on their back only. A quarter of the mothers (25.5 percent) report that their baby always/often slept alone, usually in a crib, bassinet, or pack and play. Approximately 37.4 percent of women report their baby did not usually sleep with blankets, toys, cushions, pillows, or crib bumper pads. 

 

Evidence-Based Home Visiting Programs: According to PRAMS, seven percent of Georgia women with a recent live birth from 2017-2020 reported receiving a home visit from a health care worker since their infant was born to learn how to care for themselves and/or their new baby.

 

Congenital Syphilis: According to the National Center for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) AtlasPlus, there were 52 cases of congenital syphilis in 2019, with a rate of 41.1 per 100,000.

 

Child Health

Developmental Screening: The 2019/20 National Survey of Children’s Health (NSCH) estimated 26.4 percent of children, ages nine to 35 months, received a developmental screening using a parent-completed screening tool.

 

Medical Home: According to the 2019/20 NSCH, approximately half (46.7 percent) of CYSHCN children, ages zero to 17, received care that met the criteria for having a medical home. NH Black (42.1 percent) children were less likely to report having care that met the criteria for having a medical home than NH White (57.8 percent) children.

 

Childhood Immunization Rates: The 2017 Georgia Immunization Study (GIS) indicates that statewide, up-to-date vaccination coverage at 24 months of age was 84 percent. The National Immunization Survey (NIS) estimates 73.1 percent of adolescents, ages 13 through 17, received at least one dose of the Human Papillomavirus (HPV) vaccine, 90.8 percent received at least one dose of the Tetanus, Diphtheria, Pertussis (Tdap) vaccine, and 96.2 percent received at least one dose of the meningococcal vaccine in 2020.

 

Physical Activity: In 2019-2020, NSCH estimated 41 percent of children, ages six to 11, were physically active at least 60 minutes per day for one to three days per week, 22.9 percent were physically active at least 60 minutes per day for four to six days per week, and 30.3 percent were physically active for 60 minutes every day.

 

Non-Fatal Injury: From 2012 to 2020, “other” unintentional injury was the leading cause of emergency department visits for children, one to nine years of age. The emergency department visit rate due to unintentional injuries among children, ages one to nine, in 2020 was 4,194.1 per 100,000. The hospital discharge rate due to unintentional injuries among children, ages one to nine, in 2020 was 44.9 per 100,000 population.

 

Adolescent Health

Bullying: In the 2019/20 NSCH, 10.5 percent of adolescents, ages 12 to 17, were reported by a parent or guardian to have bullied others. The 2019/20 NSCH estimated approximately 36.6 percent of adolescents, ages 12 to 17, were reported by a parent or guardian to have been bullied, picked on, or excluded by other children. According to the 2019 Youth Risk Behavior Survey (YRBS), 14.5 percent of high school students reported having been bullied on school property in the last 12 months before taking the survey. In the same survey, about one in ten (10.6 percent) public high school students reported having been electronically bullied, including through texting, Instagram, Facebook, or other social media, during the 12 months before taking the survey.

 

Suicide: In the 2019 High School YRBS, 11.8 percent of Georgia high school students reported attempting suicide in the 12 months before taking the survey. Over one in ten high school students reported that in the 12 months before taking the survey, they (1) seriously considered attempting suicide, 18.5 percent and (2) planned about how they would attempt the suicide, 12.4 percent.

 

Transition to Adult Health Care: According to the 2019/20 NSCH, nearly 15 percent of non-CYSHCN adolescents, ages 12 to 17, received services necessary to make transition to adult health care. Parents and guardians of NH White adolescents (17.7 percent), ages 12 to 17, were more likely to report they received services necessary to make transition to adult health care than NH Black adolescents (12.2 percent).

 

Non-Fatal Injuries: From 2012 to 2020, “other” unintentional injury was the leading cause of emergency department visits for adolescents, ten to 19 years of age. The emergency department visit rate due to unintentional injuries among adolescents, ages ten to 19, in 2020 was 4,165.3 per 100,000. The hospital discharge rate due to unintentional injuries among adolescents, ages ten to 19, in 2020 was 80.9 per 100,000 population.

 

Physical Activity: In 2019-2020, NSCH estimated 39.3 percent of children, ages 12 to 17, were physically active at least 60 minutes per day for one to three days per week, 27.4 percent were physically active at least 60 minutes per day for four to six days per week, and 19.4 percent were physically active for 60 minutes every day.

 

Children and Youth with Special Health Care Needs

Medical Home: According to the 2019/20 NSCH, approximately two in five (43.3 percent) children with special health care needs, ages zero to 17, received care that met the criteria for having a medical home. NH White CYSHCN (48.5 percent) were reported to have care that met the criteria for having a medical home when compared to NH Black CYSHCN (41 percent).

 

Transition to Adult Health Care: In the 2019/20 NSCH, it was estimated that 18.2 percent of adolescents with special health care needs, ages 12 to 17, received services necessary to make transitions to adult health care. 

 

Access to Specialty Care: The 2019/20 NSCH estimated 29.1 percent of CYSHCN and 8.2 percent of non-CYSHCN, ages zero to 17, received care from a specialist doctor (other than a mental health professional) during the past 12 months. Approximately 7.4 percent of CYSHCN needed to see a specialist doctor but did not receive care. Over a quarter of CYSHCN, ages three to 17, received any treatment or counseling from a mental health professional in the past 12 months.

 

Care Coordination Services: In 2019/20, NSCH reported more CYSHCN (48.3 percent), ages zero to 17, received needed health care coordination during the past 12 months compared to non-CYSHCN (32.8 percent). However, the reported percentage of CYSHCN (25.7 percent), ages zero to 17, who did not receive needed health care coordination was also higher compared to non-CYSHCN (12 percent).

 

Cross-Cutting

Dental Visits During Pregnancy:  PRAMS showed approximately 35 percent of women with a recent live birth from 2017-2020 had their teeth cleaned by a dentist or dental hygienist in the 12 months before pregnancy. Thirty-six percent of women reported having their teeth cleaned during their pregnancy. About nine in ten women reported they knew it was important to care for their teeth and gums during pregnancy, while 76 percent reported having insurance to cover dental care during their pregnancy. 

 

Childhood Dental Visits: According to the 2019/20 NSCH, 78.5 percent of CYSHCN and 75.5 percent of non-CYSHCN, ages one to 17, received a preventative dental visit in the past year.

 

Smoking During Pregnancy: The 2017-2020 PRAMS indicated 4 percent of women reported smoking cigarettes and over one percent reported using electronic nicotine delivery systems (ENDS) during the last three months of pregnancy. Among women who reported smoking during the three months before pregnancy, the most common reasons that made quitting difficult were cravings for a cigarette (61 percent), loss of a way to handle stress (54 percent), others smoking around them (52 percent), and worsening anxiety (39 percent). During pregnancy, women who smoked in the past two years were more likely to report allowing smoking inside their home than non-smokers.

 

Tobacco, or Nicotine, Use Among Children and Adolescents: The Youth Tobacco Survey (YTS) showed one in four Georgia high school students reported ever trying cigarette smoking. In 2017, eight percent of high school students reported current cigarette use, 13 percent reported current electronic cigarette use, eight percent reported use of smokeless tobacco products, and 14 percent reported cigar use.

 

Mental Health Evidence-Based Screenings: During the three months before pregnancy, 10 percent of women with a recent live birth from 2017-2020 reported having depression. Among women who reported having depression during the three months before pregnancy from 2017-2020, 32 percent reported having a health care visit for depression or anxiety in the 12 months before getting pregnant. From 2017-2020, the percentage of women reported feeling down, depressed, or hopeless since their new baby was born increased by 11 percent. Among women whose baby was alive and living with them, 5.7 percent reported using counseling services for depression or anxiety since their new baby was born.

 

Title V Program Capacity

 

Maternal/ Women’s Health

MCH uses Title V funds to provide services for women of reproductive age. Family planning clinics supported by Title V provide contraceptive counseling and preventive services. Cancer screenings and HPV vaccines are provided in the family planning clinics. MCH actively supports the MMRC and engages in various initiatives to promote maternal health. MCH has epidemiology staff to support programmatic efforts. Data sources used are PRAMS, Vital Records, BRFSS, and Family Planning program data. Women’s Health houses the data for the MMRC and identifies cases for review. MCH and Women’s Health have active partnerships with hospitals, private practice physicians, academic institutes, cancer and HIV screening agencies, the Chronic Disease Prevention Section, Healthy Mothers Healthy Babies (HMHB), Georgia Obstetrical and Gynecological Society (GaOBGYN), and March of Dimes (MoD) to ensure a comprehensive system of services for women of reproductive age in Georgia.

 

Perinatal Health

Title V staff supports infant mortality prevention, newborn screening, breastfeeding initiatives, preterm birth initiatives, perinatal regionalization, and the Safe to Sleep campaign to promote perinatal health. MCH also participates in the GaPQC to implement quality improvement projects in participating hospitals. Title V supports epidemiology staff to collect and analyze data on perinatal health. The primary data source used are PRAMS and Vital Records. MCH and the Women’s Health program have active partnerships with RPCs, birthing facilities, private practice physicians, Association of State and Territorial Health Officials (ASTHO), GaOBGYN, HMHB, MOD, WIC, and Worksite Wellness.

 

Child Health

MCH supports child health through promoting developmental screenings among children, preventing injury, and promoting oral health. MCH state, district and local level staff are well-versed in developmental screening and the various tools used to assess developmental screening. The Child Occupant Safety Project (COSP) aims to prevent motor vehicle accident deaths among children. MCH utilizes the State Electronic Notifiable Disease Surveillance System (SendSS) and the Babies Information and Billing System (BIBS) to assess developmental screening data. To ensure comprehensive system of services among children, MCH has active partnerships with the Chronic Disease Prevention Section, Department of Early Care and Learning (DECAL), Department of Education (DOE), academic institutes, Georgia Chapter of the American Academy of Pediatrics (GA-AAP), Georgia Academy of Family Physicians (GAFP), Marcus Autism, and Emory Autism Centers.

 

Adolescent Health

The Adolescent Health program sits within the Chronic Disease Prevention Section and promotes adolescent health through programs targeting tobacco prevention, sexual violence prevention, teen pregnancy prevention, and positive youth development. Title V partners with the Injury Prevention Program to identify the prevalence and existing prevention programs and legislation on bullying and facilitate improvements in bullying prevention efforts to schools that serve the target population.

 

Children and Youth with Special Health Care Needs

MCH supports several programs to provide services to Georgia’s CYSHCN. Children 1st acts as the access point for children with an identified special need. BCW provides services for children from birth to three. CMS is established and continues to provide on-going, comprehensive medical care for CYSHCN that are not eligible for state funded Medicaid and SCHIP programs. CMS promotes access to specialty care, care coordination, transition to adulthood, and medical homes for CYSHCN. Epidemiologists support data collections for CMS.

 

Oral Health

Title V, CDC, state, and private-donated funds support oral health initiatives. MCH has access to oral health data through PRAMS, NSCH, CMS, and the Third Grade and Head Start Basic Screening Surveys. To ensure a comprehensive oral health system of services, MCH has active partnerships with WIC, private practices, dental hygiene programs, academic institutes, schools, the Oral Health Coalition, and CDC.

 

Partnerships and Collaborations

 

Title V continues to focus on collaborative partnerships and coordinating with stakeholders and families to address emerging and ongoing needs of MCH populations that support Title V work.

 

MCHB Investments: Title V works collaboratively with other MCHB investments, including but not limited to: State System Development Initiative (SSDI), Maternal, Infant, and Early Childhood Home Visiting (MIECHV), and Healthy Start.

 

Other Federal Investments: Title V receives other federal investments through CDC funding which includes PRAMS, Oral Health, perinatal quality improvement, and EHDI. The United States Department of Agriculture (USDA) funds WIC and works closely with Individuals with Disabilities Education Act (IDEA) Services Part C.

 

Other Health Resources and Services Administration Programs: District coordinators partner with Federally Qualified Health Centers (FQHC), Head Start, Early Head Start, and Healthy Start.

 

State and Local MCH Programs: The Title V program coordinates regularly with community organizations and local health departments to implement activities.

 

Other programs within the State Department of Health: MCH partners with the Office of Women’s Health, Adolescent Health, Chronic Disease Prevention, Immunizations, Injury Prevention, STD, Refugee Health, Environmental Health, and Vital Records.

 

Other governmental agencies: MCH has strong relationships with the Georgia Department of Community Health (DCH), the Department of Behavioral Health and Developmental Disabilities, the Division of Family and Children Services (DFCS), DOE, and DECAL.

 

Public health and health professional educational programs and universities: MCH frequently partners with Emory University, Georgia State, University of Georgia, Morehouse School of Medicine, Mercer University, Valdosta State University, and Augusta University.

 

Others: MCH has a contractual relationship with the RPCs to meet the needs of the perinatal regionalization system. GaOBGYN is contracted to administer the MMRC. Relationships with Children’s Healthcare of Atlanta and Augusta University are critical to addressing transition of CYSHCN to adult health care systems, as these sites have transition clinics that DPH has assisted in establishing and promoting. Parent to Parent and GA-AAP are contracted to support services for CYSHCN. Emory University conducts follow-ups for the Newborn Screening program and manages the medical foods program.

 

MCH Advisory Council: The MCH Advisory Council serves in an advisory capacity to the MCH Title V Program, monitors progress and addresses specific MCH population needs. The MCH Section serves as the lead for the Council. The Title V Five-Year Needs Assessment and state action plan is the guiding document as it relates to the ongoing work of the Council. The Council is comprised of a multidisciplinary team of professionals with expertise in MCH and people with lived experience.

 

Improving Birth Outcomes Working Group: A Working Group comprised of research, medical, public health, community organization professionals and people with lived experience advise MCH on the Improving Birth Outcomes Initiative’s strategic plan to prevent infant mortality in all infants, and specifically in Black infants. The Working Group includes partnerships with community organizations regarding health disparities by demographics, geographic area, or community to ensure that a health equity lens is applied to the design and selection of policies, strategies, and priorities for the initiative.

 

Operationalization of Five-Year Needs Assessment Process and Findings

 

Title V operationalized the Five-Year Needs Assessment process and findings by developing practices to better assess and monitor the status of process measures intended to advance the national and state performance measures. Quarterly ESM meetings with MCH Title V program staff provide the opportunity to regularly assess the impact of developed strategies and activities contained in the State Action Plan. The Title V team held monthly meetings with Title V programs outside of the MCH section to review program activities and provide technical assistance. The MCH fiscal representative is included in monthly meetings to ensure that the Title V budget is aligned with programming needs and activities. Through regular and continued assessment of strategies and practices, improvements in performance and improved outcomes are expected.

 

Organizational Structure and Leadership Changes                                                                                                

 

DPH is the lead agency in preventing disease, injury and disability; promoting health and wellbeing; and preparing for and responding to disasters from a public health perspective. The Division of Health Promotion Director reports to the Commissioner and State Health Officer. The DPH Commissioner and State Health Officer reports directly to the Governor. The Division of Health Promotion contains the MCH Section, WIC, Oral Health, and the Program Evaluation and Performance Improvement sections. The MCH section contains the Title V, Child Health, CYSHCN, and Family and Community Supports programs. MCH has primary responsibility for the administration of the Title V Block Grant. The MCH Director serves as the Title V Director. The Title V MCH program sets program policy and monitors compliance with state and federal laws and rules and offers technical assistance to staff in district public health departments regarding Title V programs. Other DPH programs that work toward addressing Title V priorities include the Clinical and Medical Services Division, which includes Chronic Disease, Immunization, Infectious Disease, Nursing, Public Health Pharmacy, the Public Health Laboratory, Refugee Health, and the Office of Women’s Health.

 

Emerging Public Health Issues

 

Creating health equity is a guiding priority and public health issue. DPH seeks to improve the health of all Georgians by integrating the promotion of health equity into all statewide public health programs and services and into the organizational culture of the department. Efforts to improve health equity, including those to reduce health disparities and improve minority health, is embedded across all divisions, sections, and programs.  Members of the Heath Promotion Division team partnered with the National MCH Workforce Development Center’s Advancing Equity Learning Community (AELC) to develop a Health Equity Workforce Development Plan to operationalize health equity for current and future professionals serving in the Health Promotion Division. The AELC team plans to implement organizational development strategies that build theoretical understanding of equity and impart practical skills to apply this understanding across all policies, programs, practices, and interventions.  

 

DPH continues to reduce the burden and impact of COVID-19 among vulnerable populations using the following approaches for ensuring health equity: Identify Vulnerable Populations, Community Engagement and Outreach, Utilize Data and Technology, and Identify and Engage Stakeholders.