Executive Summary 2004 I Full Report 2004 www.health.state.ga.us DPH04.233.HW II B.J. Walker, Commissioner Georgia Department of Human Resources Division of Public Health Kathleen E. Toomey, M.D., M.P.H., Director 2 Peachtree Street NW Suite 15.470 Atlanta, Georgia 30303-3142 404-657-2700 FAX: 404-657-2715 August 2004 Dear Georgians, Welcome to Maternal & Child Health in Georgia: Birth Through Age 5. This Maternal & Child Health (MCH) report on CD-ROM describes the progress we have made during the 1990s and provides data and information to help us plan for the future. It also includes key strategic recommendations, tools for advocates, Web links, video clips, and a variety of other features. The heart of the report is a "Maternal and Child Health Topics" section with information related to pre-pregnancy health, prenatal and maternal health, infant health, and early childhood health and development. This interactive CD is a resource for anyone interested in learning more about the health of Georgia's mothers and children, including those who are working on these important issues throughout the state. Community planners, state and local leaders, advocates, legislators, and students as well as families and clinicians will find a wealth of information and resources. Whether the goal is to strengthen one family or many families throughout Georgia, we believe this CD is a great tool for educating the public and policymakers alike. As this interactive report illustrates, innovative programs and hardworking people are improving the health of mothers and children across Georgia. Although we still have many challenges, by working together we can make great progress on the issues addressed in the report, such as prenatal care, low birth weight, infant mortality, and child abuse and neglect. To get started, simply put the disk in your CD-ROM drive. It will begin for you! Many of the resources on the CD including text, graphics, and video clips are downloadable so that you may incorporate these into your own presentations and reports. For more information on how to use the CD, see the "How To Use the CD-ROM" section of this Executive Summary. If you have questions or comments about the MCH report, you can e-mail the Division of Public Health at gdphinfo@dhr.state.ga.us. We believe this Maternal & Child Health in Georgia report will be useful to those working on these issues, and we hope that you will find it helpful. Together, we will create a healthier Georgia. Sincerely, Kathleen E. Toomey, M.D., M.P.H. Director Division of Public Health Rosalyn K. Bacon, M.P.H. Director Family Health Branch III About This Report In 1997, the Georgia Division of Public Health (DPH) and the March of Dimes Georgia Chapter published The Challenge of Change: A MidDecade Look at Maternal and Child Health in Georgia. The report served as a starting point to assess needs and create effective intervention strategies to improve the health of mothers and infants throughout the state. Today, with new and expanded ways of accessing and presenting information, the latest report, Maternal & Child Health in Georgia: Birth Through Age 5, disseminates data and analysis in even more engaging, thought-provoking, and user-friendly ways. Through a collaborative and multidisciplinary effort, we have developed a dynamic, interactive report that provides information about important issues relating to the health and wellbeing of Georgia's mothers and young children. KEY PARTNERS The Georgia Division of Public Health (DPH) - Family Health Branch - Maternal and Child Health Epidemiology Section, Epidemiology Branch - Office of Health Information and Policy The Georgia Healthy Start Initiative - Atlanta Healthy Start Initiative - Augusta-Richmond County Partnership for Children and Families - Enterprise Community Healthy Start Initiative - Heart of Georgia Healthy Start March of Dimes Georgia Chapter Governor's Council on Maternal and Infant Health Healthy Mothers, Healthy Babies Coalition of Georgia Georgia Public Health Association ORC Macro Because the CD is interactive and multimedia-based, it keeps data current and brings it "to life" more than ever before. For instance, video clips included with the CD put a face on maternal and child health issues. The CD provides links to the latest reports and data from the DPH and to hundreds of Georgia and national Web sites. Additionally, charts, maps, images, and data are easily downloadable from the CD to your computer, making it simple to add information and materials into your own presentations or reports. This material includes: Background information on maternal and child health topics Local, state, and national data on maternal and child health A description of the social context of health in Georgia Key strategic recommendations for improving maternal and child health Highlights of community programs that have successfully improved maternal and child health Contextual Issues in Georgia Introducing a range of topics in maternal and child health, the report provides an overview of key demographic, social, and policy trends influencing the health of Georgia's population. Such trends, which create a number of challenges and opportunities for Georgia's health service delivery system, include: Increasing growth and diversity of the state's population--Georgia's population increased 26.4 percent since the 1990 census. Georgia has the 5th largest African-American population of any state and also has rapidly growing Asian and Latino populations. 2 3 Disparities in health--Significant racial and ethnic differences exist in rates of infant mortality and percentages of low birth weight babies born, both important indicators of community well-being. An economic downturn--Just at the time when more families require additional governmental services to obtain needed health care, public agencies have found themselves with substantially fewer resources to meet these needs. Lingering child poverty--Poverty is an unfortunate fact of life for 19.3 percent of Georgia's children. Changes in Federal policy designed to increase insurance coverage for children--Georgia's PeachCare for Kids, providing comprehensive health care for children who do not qualify for Medicaid, has increased its enrollment over 65 percent since 1999, with more than 161,000 children enrolled at the end of FY 2002. Ongoing need to close the gap in the number of uninsured in Georgia--Despite PeachCare's effectiveness in increasing the enrollment of uninsured children, 312,000 children younger than age 19 (13.1 percent of this age group in Georgia) remained uninsured in 2002. Moreover, at the end of 2001, 19 percent or 943,500 adults in Georgia aged 19 to 64 were uninsured. Downstream effects of welfare reform, including decreased Medicaid enrollment--Georgia has had a substantial number of children losing Medicaid coverage as their families leave the Temporary Assistance to Needy Families program. Some of these children have enrolled in PeachCare for Kids. Accomplishments Since the last report, The Challenge of Change: A Mid-Decade Look at Maternal and Child Health in Georgia, many important changes have positively affected the health of the state's mothers and children. Below we highlight some of the most significant changes. The good news is: The infant mortality rate decreased 10 percent from 9.4 to 8.5 infant deaths per 1,000 live births between 1995 and 2001. The perinatal mortality rate decreased 50 percent from 16.0 to 8.0 fetal and neonatal deaths per 1,000 live births between 1995 and 2001. The pregnancy rate among teens 15 to 17 years old decreased 33 percent from 66.2 per 1,000 in 1995 to 44.4 in 2001. For teens 18 to 19 years old, the pregnancy rate decreased 13 percent from 146.7 per 1,000 in 1995 to 127.3 in 2001. The percent of unintended pregnancies decreased from 47.5 percent in 1995 to 41.5 percent in 2000. Such progress has been possible, in part, due to innovative public health programs and interventions across Georgia, supported by multisector, cross-disciplinary partnerships involving state and local agencies, private providers, and many others. Examples of such programs and partnerships include: DPH has developed a system to streamline access to services for Georgia's newborns and young children. Children 1st is designed to be a single point of entry for public health programs to make it easier for families and health care providers to reach needed services such as Babies Can't Wait, Children's Medical Services, WIC, and many others. DPH is working with the Healthy Mothers, Healthy Babies Coalition of Georgia and DPH's HIV Section to implement the social marketing component of the state's Perinatal HIV Transmission Project, funded by the Centers for Disease Control and Prevention (CDC). The DPH, Department of Community Health (DCH), CDC, March of Dimes Georgia Chapter, and Emory have established a partnership to expand Georgia's Newborn Metabolic Screening program. 4 5 Implementation of Universal Newborn Hearing Screening and Intervention in 2000 resulted in dramatic improvements in newborn hearing screening in Georgia. Newborn hearing screening went from less than 30 percent to 98 percent of all newborns being screened as of April 2003. This is a partnership with DPH, DCH, and Georgia hospitals. DPH expanded its neural tube defects work with the March of Dimes Georgia Chapter to develop a seamless system of data collection, analysis, and research to provide early identification of children for referral to health and early intervention programs. An Early Childhood Comprehensive Systems strategic planning grant from the Health Resources and Services Administration (HRSA) will support the development in Georgia of a comprehensive early childhood service system that integrates access to health insurance and a medical home, mental health and socioeconomic development of children, early childcare and education, parenting education, and family support. The Oral Health Prevention Program, a $2.1 million a year initiative, has supplemented dental prevention and treatment services for lowincome, high-risk children with support to all 19 health districts in Georgia. DPH and DCH have worked together and with other stakeholder partners to explore opportunities to expand dental services. In 2002, DPH's Chronic Disease Branch created Georgia Addressing Asthma from a State Perspective (GAASP) with support from CDC. Through this initiative, public and private agencies collaborated to improve the quality of life of Georgians with asthma and to reduce the burden of disease of asthma in the state. The DPH Nutrition Section led a collaborative effort in 2003 involving the WIC Branch, the Chronic Disease Prevention and Health Promotion Branch, and the Epidemiology Branch to obtain CDC funds to support the prevention and control of obesity. A 1-year planning process involving key stakeholders will result in a state plan to prevent and control obesity, especially in children and youth, followed by implementation and evaluation in years 2 to 5. DPH is facilitating work to support children and youth with mental health needs. Collaborative partners include physicians, the Department of Juvenile Justice, the Division of Family and Children Services (DFCS), the Department of Education, and the Division of Mental Health, Developmental Disabilities, and Addictive Diseases. DPH is providing leadership in the development of an inventory of mental health tools to enhance mental health screening activities. State and local representatives from DPH, DFCS, DCH, and the American Academy of Pediatrics are addressing health problems of children in foster care. A workshop provided information on how local partners can work together to improve the mental and physical health outcomes for this vulnerable group of children. Family Connection Partnership, a nonprofit, public/private initiative supported by state agencies and private funders, has continued to build relationships between state agencies and local communities to improve service delivery to families. Since 1995, the program has expanded its reach to dozens of new counties and plans additional growth from its current 148 counties to all 159 Georgia counties. Key Recommendations In the last decade, particularly in the last five years, Georgia has made enormous strides to improve the health of mothers and children. Successes have included reductions in the incidence of infant mortality, perinatal mortality, teenage pregnancy, and unintended pregnancies. At the same time, PeachCare for Kids continues to increase enrollment of uninsured children. In addition, more women in Georgia are finding access to prenatal care and learning to adopt healthy practices after pregnancy that promote the well-being of themselves and their children. 6 7 As the state continues to move into the 21st century, the challenge will be to enhance and protect the health of families while adapting to economic and policy trends affecting health and social welfare systems, insurance practices, and the availability of public and private resources devoted to strengthening maternal and child health. As Georgia's population becomes more diverse, the state also will face challenges in reducing ongoing racial and regional disparities in health and ensuring that innovative, culturally appropriate programs and best practices are disseminated to all populations, including those that are underserved, at-risk, marginalized, non-English speaking, or have special health care needs. To meet these challenges and achieve new federal and state goals in maternal and child health, recommendations for progress include the following: Pre-pregnancy Health and Health Promotion Develop and sustain efforts to inform women and their health care providers about the importance of pre-conceptional health, including issues related to nutrition, mental and emotional health, the potential impact of oral and reproductive tract infections on birth outcomes, and the dangers of alcohol, tobacco, and drug use. Encourage pre-conceptional evaluation and counseling for women with pre-existing health conditions, such as diabetes or high blood pressure, and ensure that counseling addresses methods for controlling the condition and avoiding complications, including those that may arise during pregnancy. Integrate pre-pregnancy health promotion messages across all maternal and child health programs to reduce unintended pregnancies and improve comprehensive services for all women. Continue to support programs using multifaceted and coordinated approaches to provide youth with: a) clear, accurate, age-appropriate, and culturally appropriate health information; b) accessible and affordable teen-friendly comprehensive health services; and, c) ample opportunity to learn and practice effective communication, negotiation, and refusal skills. Continue to promote smoking cessation among adults and young people 8 by identifying and eliminating tobacco-related health disparities among specific populations, eliminating exposure to secondhand smoke, and preventing youth initiation of cigarette smoking and use of smokeless tobacco. Continue to support efforts that encourage all women to engage in at least 30 minutes or more of moderate-intensity physical activity on most, preferably all, days of the week. Encourage coordination between the public and private sectors to ensure that all women, including pregnant women, are screened, referred, and treated for domestic violence. Strengthen programs designed to reduce unintended pregnancies among teens through use of community-level interventions that promote youth development such as structured service learning, mentoring, and skill development. Encourage interaction and positive relationships between youth and communities, schools, faith institutions, and businesses, particularly for youth who lack supportive families. Prenatal and Maternal Health Ensure that all pregnant women have access to early prenatal care. Encourage coordination between the public and private sectors to ensure that all women are prenatally screened for HIV, STD, and bacterial infections, including Group B strep, with appropriate follow-up and treatment for the whole family. Enhance strategies to remove cultural barriers to care that may contribute to delayed entry into prenatal care. Provide pregnant women who smoke with access to smoking cessation classes, counseling, and other aids to cessation. 9 Support efforts to encourage women who were physically active before their pregnancy to continue such activity during pregnancy. Ensure that Medicaid-eligible and WIC-eligible mothers and their children served by public health departments have access to nutrition services provided by licensed dietitians. Encourage breastfeeding by targeting populations and areas in which initiation rates are low and by promoting education, counseling, and other forms of support for new mothers. Strengthen capacity to identify and investigate all maternal deaths, to improve the accuracy of maternal mortality data, and to ensure that lessons learned for preventing deaths are reported to health care providers. Expand efforts to address special needs of pregnant women to improve birth outcomes. Develop and implement a comprehensive statewide approach to address maternal depression and substance abuse. Infant Health Implement strategies to decrease racial disparity in the incidence of infant mortality, low birth weight births (less than 5 pounds), and sudden infant death syndrome (SIDS). Continue the Georgia Infant Safe Sleep campaign to reduce SIDS and other infant deaths through the promotion of "safe sleep" messages, crib safety techniques, and smoking cessation for pregnant women and new mothers. Implement CDC's recommended standard investigation of sudden unexpected infant deaths to accurately differentiate SIDS from other unexpected infant deaths and to identify associated preventable risk factors. 10 Explore feasibility of establishing a Fetal and Infant Mortality Review (FIMR) process in every county for investigating fetal and infant deaths, including statewide epidemiologic analysis of causes and frequency of presence of specific risk factors for fetal and infant deaths. Ensure access to preventive health services and health care for all children, especially those in state custody. Continue to develop the Georgia Birth Defects Reporting and Information System (GBDRIS), in collaboration with the March of Dimes Georgia Chapter, for improved birth defects surveillance capacity. Continue to enhance Georgia's newborn screening programs, including metabolic, sickle cell, and hearing screenings. Fully implement the Georgia Registry of Immunization Transactions and Services (GRITS). Continue to support programs that increase parents' awareness of proper child safety seat usage and provide access to age-appropriate child restraint devices as recommended by the American Academy of Pediatrics (AAP) and the National Highway Traffic Safety Administration (NHTSA). Enhance knowledge among health care professionals, pediatricians, and parents about shaken baby syndrome, and increase parental awareness of effective coping skills for managing crying infants. Provide new mothers who have stopped smoking during pregnancy with continuing access to smoking cessation classes, counseling, and other aids to cessation. Early Childhood Health and Development Continue to support efforts to identify and assess the needs of infants and children at risk for poor health and development, and promote referral of such children and their families to appropriate public health and community services or health care providers when needed. Ensure that families have knowledge of available health insurance options and health care services, including developmental screenings and anticipatory guidance. 11 Update standards and guidelines related to preschool and school-age vision, hearing, dental, and nutrition screening to reflect current standards of practice. Encourage pediatricians and other health professionals to adopt the recommendations included in the American Academy of Pediatrics' Policy Statement for Prevention of Pediatric Overweight and Obesity. Enhance skills of health care providers, including public health nutritionists and private physicians, to assess and provide appropriate health, nutritional, and developmental counseling to infants, children, and youth, including those with disabilities and chronic conditions. Ensure access to oral health education for low-income at-risk pregnant women, parents, and young children (ages 4 and above) in order to reduce the risks of low birth weight babies, early childhood caries, and other medical conditions correlated with chronic periodontal disease. Strengthen the capacity of Georgia's childcare professionals and providers to protect and promote the good health, safety, and well-being of children. Encourage the elimination of environmental sources of lead to decrease the risk of lead poisoning, and continue blood lead level testing for at-risk children. Continue to support state programs that increase parents' and health care professionals' awareness and knowledge of environmental health hazards (i.e., lead, arsenic, mercury, and indoor air quality) that particularly impact children. Continue to enhance professional knowledge of social and emotional development in young children on topics such as typical social and emotional development of children birth to age 5, brain development, relationships between childcare and parents, child mental health concerns, and post-partum depression. Enhance the capacity of parents, educators, childcare providers, health care professionals, congregational leaders, employers, librarians, community leaders, and children to promote the building of developmental assets in young children. Continue to promote inclusion of children with special needs in environments with typically developing children. Provide parents of children with special needs information and support to facilitate their children's development. Collaborate with internal and external partners to train public health nurses to recognize child abuse or neglect in children, including those with disabilities and developmental delays, and to make appropriate referrals. Build and sustain a comprehensive early childhood system that involves the collaboration of service providers, families, communities, and policymakers and strengthens comprehensive pediatric care services, creates a medical home, promotes social-emotional development of young children, builds early care and education, provides parenting education, and enhances family support. Through collaborative efforts, reduce deaths, hospitalizations, hospital emergency department visits, and activity limitations among children with asthma. Expand awareness of the "primary provider model" of early intervention service delivery for young children with disabilities. Continue to develop and disseminate public awareness materials to ensure individuals with disabilities have access to appropriate services mandated by Federal laws. Continue to conduct outreach and training activities for pediatricians and family practitioners to increase identification and referral of children with special needs to appropriate services. Maintain efforts to improve developmental outcomes for low birth weight babies and their families. 12 13 Maternal and Child Health Services Support coordinated maternal and child health planning, particularly regional systems of care. Support Medicaid eligibility for pregnant women and children. Enhance access for women with high-risk pregnancies to deliver in regional tertiary centers that have appropriately trained staff and equipment needed to manage complicated births. Continue to identify and address barriers to health care access for women and children, including language barriers, lack of insurance, transportation, and appropriate, accessible childcare. Develop a well-integrated referral system between health care providers, child protective services, and women's services to effectively serve children and mothers who are victims of or are at risk of intentional injuries (violence against women, child abuse). Support efforts that emphasize healthy eating and active lifestyles for women and children to achieve and maintain healthy body weight. WHAT YOU WILL FIND IN THE REPORT: CD CONTENTS Maternal and Child Health Topics The heart of the report is a "Maternal and Child Health Topics" section that includes information on four broad topics and 30 subtopics and can be accessed through cascading menus. Throughout this section of the CD, visual aids and interactive technology provide a colorful, data-driven overview of the status of maternal and child health in Georgia. For each of the subtopics, you will find background information about the issue and be able to navigate through four button bars providing additional information under the headings: What do we know? What do the data tell us? What is Georgia doing? Where can I find more information? Maternal and Child Health Topics 1. Pre-Pregnancy Health Diabetes Domestic Violence Family Planning and Unintended Pregnancy Folic Acid Hypertension Teen Pregnancy Tobacco, Alcohol, and Illicit Drugs 2. Prenatal & Maternal Health Maternal Depression & Mental Health Nutrition Perinatal Infections Utilization and Quality of Prenatal Care 3. Infant Health Birth Defects Breastfeeding Immunization Infant Mortality Low Birth Weight / Very Low Birth Weight Newborn Metabolic and Sickle Cell Screening Newborn Hearing Screening Preterm Infants Sudden Infant Death Syndrome (SIDS) 4. Early Childhood Health & Development Asthma Child Abuse and Neglect Child Mortality Childhood Nutrition Children with Special Needs Children's Mental Health Early Childhood Initiatives Injury Prevention Lead Exposure Oral Health 14 15 Informative and Useful Features A variety of informative resources on the CD can be used to enhance your own presentations and reports. As mentioned before, all of the charts, graphs, images, and data can be downloaded and saved for your individual use. To print or save any of these, simply click on the displayed print or save button. Maternal and child health data from the Division of Public Health as well as other Georgia and national sources can be found in the online data section. The section on promising practices provides numerous links to Georgia and national Web sites that profile evidence-based and best practices in maternal and child health. Most of these sites are continually updated to provide information regarding new programs and recent research findings. A section on advocacy provides information about Georgia-based and national organizations that conduct advocacy on maternal and child health issues. A grant writing section provides information on funding opportunities and helpful tips for grant writers. The glossary includes definitions for key indicators and terms that are found in the report. The CD includes video clips on diverse subjects that can be accessed by clicking the appropriate thumbnail image on the screen in each individual section. They also are organized into a multimedia section. Hundreds of useful links to national and state organizations, as well as publications and recommendations, are included throughout the CD. The links are organized alphabetically in a Web link section for easy reference. A Day in Georgia graphically illustrates key maternal and child health outcomes. How To Use the CD-ROM The CD-ROM includes a brief video tutorial that provides guidance and explains many of the report's features. The CD is designed around a familiar Web-style interface that makes it easy to navigate through large amounts of text. Those with experience surfing the Internet will find this CD easy to use, as it operates in many of the same ways. For those who are new to the technology, the process is intuitive and simple to learn. The content of the CD is arranged in pages one page for each topic or theme. Pages contain an array of information and data along with a collection of links to other sections of the CD and Web sites on the Internet. You may always access information contained on the CD; however, to access information on Web site links, your computer must be connected to the Internet. Everything needed to run the CD is included on the CD no additional software is required. If your computer does not already have certain necessary programs on it, such as Windows Media Player or others required for full use of the CD, you will be prompted to automatically install them from the disk or directed to locations on the Internet from which you can download the programs free of charge. Overall, the CD is ready to use and user friendly. We hope that you will find this Maternal & Child Health in Georgia report helpful. Together, we will create a healthier Georgia. Minimum System Requirements Pentium II 233 MHz Processor Microsoft Windows 98 Second Edition, 2000, or XP 64 MB RAM (128MB recommended) CD-ROM drive (32x or faster for best video playback) 800 x 600 24-bit color display 16-bit sound card; computer audio controls turned up 56 Kbps or faster modem (to access Internet features) 16 17 ACKNOWLEDGMENTS We wish to acknowledge the following individuals for their contributions to this report: Georgia Department of Human Resources B.J. Walker, Commissioner Division of Public Health Kathleen E. Toomey, M.D., M.P.H., Director Family Health Branch Rosalyn Bacon, M.P.H., Director Policy, Planning, and Evaluation Section Gala Hambrick, M.P.A., Director Lee Tanenbaum, M.A., M.P.H., MCH Report Project Manager Data Team Elana Morris, M.P.H., Team Leader Epidemiology Branch Paul A. Blake, M.D., M.P.H., Director MCH Epidemiology Section Emily Kahn, Ph.D., M.P.H., Chief Office of Health Information and Policy Gordon Freymann, M.P.H., Director Additionally, we would like to thank the Division of Public Health staff and partners who contributed information and data and reviewed numerous drafts of this report. A special thanks to ORC Macro, the contractor, for their expertise, creativity, management, and production of this Executive Summary and interactive Maternal & Child Health report. Funding for this report was provided by the Georgia Healthy Start projects, the Georgia Department of Human Resources Division of Public Health, and the March of Dimes Georgia Chapter. The report was supported in part by project No. 5 H49 MC 00122-02 from the Healthy Start Initiative, Maternal and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services. QUESTIONS? CONTACT US If you have questions about the Executive Summary or the CD, please e-mail us at gdphinfo@dhr.state.ga.us and include "MCH Report" in the title of the e-mail. It will be routed to the appropriate person to respond to your inquiry.