Georgia PEACE for Moms

• Around the globe, as many as 1 in 5 new mothers experience perinatal mood and anxiety disorders (PMADs). PMADs frequently go unnoticed and untreated, often with tragic and long-term consequences to both mother and child. PSI-GA is committed to ensuring that every woman and family throughout the state has access to information, social support, and quality care to deal with PMADs, regardless of income or other social determinants of health.
• There is emerging evidence for the effectiveness of interventions that can be delivered by non-specialists for addressing PMADs. We are proposing to launch online mental health peer support groups for pregnant and postpartum women living in Georgia.
• Mental health remains conspicuous by its absence in global maternal and child health programs. Our solution has the potential to be a low-cost, flexible, and adaptable model for others that want to use technology to address maternal mental health.

Globally, depression and other perinatal mood disorders account for the most substantial proportion of the burden associated with mental or neurological disorders. In addition to the economic and human costs of maternal depression and anxiety disorders, children of mothers who are depressed are at risk for poor health, developmental, and behavioral problems, thereby contributing to the inter-generational disadvantage that accumulates throughout the life span.

The US-state Georgia ranks 50 out of 50 states for maternal mortality, with a rate of over 20 maternal deaths per 100,000 live births, with a disproportionate number of minority women dying of preventable causes. Mental health is one of the leading contributors to theses deaths, with higher rates of mental health issues in racial/ethnic minority women. The state ranks 47 out of 50 for access to mental health care, resources, and insurance. About half of the African-American population lives in rural counties, which have dramatic shortages in mental health providers and social supports for women with perinatal maternal mental health issues with no state funding to address the issue. Thus, what is needed is a technologically-based, flexible, and scalable solution to provide access to information and social support for women who need it. 

The Georgia chapter of Postpartum Support International and the Georgia chapter of Healthy Mothers, Healthy Babies will partner with at least ten faith-based and  other community partners to establish virtual mental health peer support groups for pregnant or postpartum women. The focus will be on counties that do not already have any mental health peer support groups. A trained peer specialist will use an online platform to educate community partners in  perinatal mood and anxiety disorders (PMADs), how to support women, and train them in the logistics of running virtual online support groups. Technical assistance will include training on how to set up secure Google Meet groups, how to advertise and recruit participants and peer leaders, and on best practices of conducting online support group sessions. In turn, the peer will be participating in monthly online training to stay current on best Telehealth practices and exchange information with other peer support persons in other states.

The African-American population in Georgia is higher than in the United States (30 percent versus 12.8 percent, respectively). About half of the African-American community lives in rural counties, which have approximately half as many physicians and dramatic shortages of nurses, therapists, and nutritionists (per capita) as the metro counties. According to the non-profit Mental Health America of Georgia, the state ranks 47 out of 50 for access to mental health care, resources, and insurance. Also, Georgia has an uninsured rate of 20 percent or higher for Black women, leaving too many women without insurance coverage and threatening their and their children's health and economic security.

In addition, Georgia ranks 50 out of 50 states for maternal mortality, with a rate of over 20 maternal deaths per 100,000 live births, with a disproportionate number of minority women dying of preventable causes.  We know that mental health contributed significantly too many of these deaths with higher rates of mental health issues in racial/ethnic minority women. PSI-GA has been an invaluable organization in fighting the mental health disparities that exist for black women in the state. It is committed to strengthening efforts to address the access and treatment quality gap in this population. 

Our solution directly aligns with the dimension "Support the mental and emotional health of women throughout pregnancy and after childbirth." PSI-GA's vision is to ensure that every woman and family throughout the state will have access to information, social support, and informed professional care to deal with mental health issues related to childbearing, regardless of income or other social determinants of health. It now has the capacity, community connections, and funding to focus on areas in GA which are low in resources and mental health providers, including Georgia's rural communities and other underserved populations.

Our solution merges two approaches that are considered new in mental health: 1. Online maternal health support groups and 2. Peer mentor-led support groups for maternal health

1. The treatment of mental health disorders has long been the sole purview of psychiatrists and other high-level providers. However, social and professional support for mental health are lacking in many rural and underserved areas - highlighting the need for innovative ways to improve access to services. While Telehealth has been becoming more accepted throughout medicine and for individual mental health interventions, it is still an underutilized technology for group supports, including maternal mental health.   

2. Our approach also differs from others in that we are going to be employing a peer specialist to roll out and sustain the program. Socioeconomic differences and poor communication can loom large between health providers and patients, resulting in distrust of professionals. Recent research suggests that online peer support provides a critical, ongoing role in delivering social connection for people with a lived experience of mental ill-health and their carers, especially for those living in rural and remote areas. However,  the use of peers has primarily focused on individuals with severe mental illnesses such as Bipolar Disorder or Schizophrenia. By using a peer mentor who is a woman of color and who has experienced postpartum depression, we can roll out an intervention that considers women's unique preferences and cultural needs in a way that is not only affordable but also accessible across diverse populations.

By design, the technology we are going to be using is widely available, both via computers or smartphones. While we are using existing technology (Google Meet), we are going to be using it for a new application: Online maternal health support groups. While the mental health provider community was initially reluctant to use online support groups, the Covid-19 pandemic forced many practitioners to reconsider their position and to appreciate the advantages of the new format. Internet support groups offer a high degree of anonymity, where confiding in others occurs without any social repercussions, given the lack of in-person contact among members. Also, self-help groups generally do not cost the system very much in terms of dollars or resources, and therefore, any savings to the system are total dollar savings. Furthermore, self-help programs may reduce the utilization of the traditional mental health peer provided services proffer a mechanism for serving individuals in need of mental health services, but who are alienated from, or have difficulty accessing, the traditional mental health system. Recent data suggest that online peer support provides a critical, ongoing role in providing social connection for people with a lived experience of mental ill-health and their carers, especially for those living in rural and remote areas. Key to the success of this online forum was the availability of appropriate moderation, professional support, and advice, which will be provider by our trained peer support person, who is, in turn, supported by the clinicians and support staff at PSI-GA and HMHB-GA. 

Online support groups, including peer-led platforms, have emerged as an essential tool for improving mental health and well-being, including maternal mental health. There has been substantial research that analyzes the content of support groups, studies on how and why individuals engage with support groups, and how extensively support groups, are used. Such groups can provide 'just in time' support, overcome geographic barriers, facilitate open discussion of mental health concerns, and reduce social isolation. The benefits of participating in online support groups include: (1) anonymity; (2) freedom of expression; (3) control over when and how much support one would like to receive, (4) expanding social network, and (5) increased self-efficacy and empowerment.

Below are links to relevant academic research papers that speak to the feasibility and efficacy of our solution.

Baumel A, Tinkelman A, Mathur N, Kane JM. Digital Peer-Support Platform (7Cups) as an Adjunct Treatment for Women With Postpartum Depression: Feasibility, Acceptability, and Preliminary Efficacy Study. JMIR Mhealth Uhealth 2018;6(2):e38 DOI: 10.2196/mhealth.9482

Evans, M., Donelle, L., & Hume-Loveland, L. (2012). Social support and online postpartum depression discussion groups: A content analysis. Patient education and counseling, 87(3), 405-410. https://pubmed.ncbi.nlm.nih.gov/22019021/

O'Dea B, Campbell A. Healthy connections: online social networks and their potential for peer support. Stud Health Technol Inform. 2011;168:133-140. https://pubmed.ncbi.nlm.nih.gov/21893921/

Naslund, J. A., Aschbrenner, K. A., Marsch, L. A., & Bartels, S. J. (2016). The future of mental health care: peer-to-peer support and social media. Epidemiology and psychiatric sciences, 25(2), 113–122. https://doi.org/10.1017/S2045796015001067

Helping women with perinatal mood disorders does not only help them individually, but also their partners, children, family, and ultimately, their community. We also firmly believe that the existence and information shared in the groups will help reduce the stigma of PMADs and be a facilitator of much-needed and healthy discussions about maternal mental health. We are confident that our community partners will continue to run the groups with new members, hopefully for years to come. However, for this exercise, we will only count women that will be participating in groups.

• Current: We are planning on rolling out four maternal mental health groups by the end of summer 2020, which should include about 50-60 women (~10-15 women in each group)
• If we receive funding, then we are planning on establishing and supporting an additional 12 groups throughout the state each year for the next five years. We estimate that there will be between 120 – 180 in the new groups, and a new set of 50-60 women in the original groups, for a total of 170-240 women.
• In five years, we would like to see at least 40 groups throughout the state with a rotating enrollment of 10-15 women each.
• The online resources that will be generated by this solution will be widely available on the websites of PSI-GA and HMHB-GA and their “mother” organizations. 

According to the WHO, maternal mental health problems are considered as a significant public health challenge in countries of all income levels. Untreated maternal mental illness has harmful effects on the health of the woman experiencing symptoms, her family, and her community. Findings from a 2018 global literature review suggest that suicides may account for as many as 20% of postpartum deaths. However, the treatment gap for mental illness in low-resource settings is large, accounting for 76–85% patients with mental health problems not receiving any support. An essential driver of the care gap is the global shortage of human resources for mental health. 
However, we also know that low-cost interventions, with the involvement of non-specialized or community health providers such as peers, are an effective and inexpensive solution to the provider shortage. The emerging practice of Telehealth is another important strategy to improve access to mental health support. A 2016 review showed that Telehealth had been used to address the mental health needs of pregnant women and mothers living in remote locations. Thus, we believe that our solution, which is a combination of two innovative approaches to online support for maternal mental health (Peers and Online platform) has wide national and international applicability. Our model could be used to develop culturally-relevant maternal mental health programs  that could help rapidly train and enable peer providers in settings with mental health workforce shortages around the globe. 

We anticipate three significant barriers to success:

• Finances: The state of GA is in a major financial crisis, which was exacerbated by the Covid-19 crisis. This week, the governor will announce major budget cuts for all state agencies. Even though the state has the highest maternal mortality rate in the US, we anticipate a significant drop in maternal health and maternal mental health funding. While we are hopeful, unless we can secure non-state funding, we may not be able to continue the program after the first four groups are established.
• Our technology solution is not new, nor does it require a high level of digital literacy. However, we do acknowledge there may be significant disparities in access to technology or reluctance to using online platforms from our community partners. Our Peer Support Specialist began announcing our training program in May,and we have already had 17 applicants who are excited to become peer support group facilitators from around the State. While this is encouraging, we won not know if this first round of applicants is representative of the state as a whole. 
• Stigma: Mental illness and PMAD prevalence are higher in communities that face multiple prejudices and disadvantages within society, including Black and minority ethnic communities. Also, stigma and fear of discrimination are higher in the same populations, preventing them from seeking help and joining a support group. We may, therefore, have issues recruiting enough women to the groups. 

• Finances: PSI-GA has been tremendously successful in launching its chapter and doing its work,  led by dedicated and passionate volunteers, including a fully committed board and large individual donor base. With the support of this award, PSI-GA wants to strengthen its outreach effort to minority women and their providers. In fact, the Georgia Chapter now serves as a model for other PSI state chapters across the nation. Based on our fundraising history and momentum, we are confident that we can raise funds to continue and expand the Georgia PEACE for Moms program.
• Technology access: Surveys by the  Pew Research Center show that lower-income and minority people increasingly rely on smartphones for Internet access, and that, for many, it is the primary source of health information. Since we are using free and historical software, we believe that we can attenuate any technology access issues. Furthermore, we will be providing extensive training for our community partners in how to launch and maintain safe, online support groups with their existing digital access. 
•  Stigma: While online therapy is comparatively new, research shows that it enables people to seek help that would be otherwise reluctant to reach out for help in person by creating a more anonymous, "safer" space. In our initial set of online support groups, we have had no insurmountable technology problems, nor have we had issues with recruitment. We are therefore confident that we can overcome any potential stigma-related problems with the help of our extensive network of community partners.

PSI-GA is in the process of hiring its first Executive Director. For a layout of its governing board, volunteer network, and structure, please see:
About PSI-GA

Currently, there is one peer support specialist who works with staff from HMHB and PSI-GA to start and support the initial set of Peer Support Groups. 

The Georgia chapter of Postpartum Support International (PSI-GA) has been exceptionally successful in launching a powerful and effective initiative to address Postpartum Mood and Anxiety Disorders (PMADs) throughout the state of Georgia. Our state is becoming a safer and more supportive place for pregnant and postpartum women thanks to our work. PSI-GA is one of very few organizations in the state that directly links mental health providers and postpartum women via its network of state coordinators. PSI-GA also provides access to free weekly online support groups, a directory for in-person support groups in Georgia that are specific to maternal mental health, and has live-streamed thirty Facebook videos addressing mental health issues, reaching over 35,000 viewers. The PSI-GA site (www.psi.or g) also contains informational resources about PMADs and lists of trained providers in Georgia. Since the chapter’s inception in 2017, we have trained over 350 providers through PSI’s evidence-based program, focusing on underserved populations and areas in the state. For instance, in 2019, PSI-GA hosted a training in Macon where 48% of providers worked outside of metro-Atlanta, 57% offered sliding scale services and 24% accept Medicaid.  In its policy work, PSI-GA is currently advocating for universal screening for PMADs across Georgia, as well as implementing an addition to the Georgia Pregnancy Risk Assessment Monitoring System (PRAMS) survey to assess rates of PMADs beyond depression. In 2019, PSI-GA worked with key partners to secure $1 million to establish Georgia’s first maternal mental health program at the Department of Public Health.  

The work of PSI-GA is firmly rooted in the spirit of collaboration. We strongly believe that fragmentation of care and services is one of the major barriers to good maternal health and mental health care, and that we will not be able to overcome health disparities without a unified network of organizations and institutions. The following are some examples of some of our most useful collaborations: 

In 2019, PSI-GA worked with Healthy Mothers Healthy Babies-Ga to secure $1 million to establish Georgia’s first maternal mental health program at the Department of Public Health. This will include both training for providers, conducted by PSI-GA, and a telepsychiatry link for providers.

PSI-GA is also part of the Atlanta Healthy Start Initiative - Community
Action Network that last year prioritized Black maternal mental health as a
focus and authored a study on community-based participatory research on Black maternal mental health.  

PSI-GA has also been working with the Department of Public Health to include additional questions on the Pregnancy Risk Assessment Monitoring Systems (PRAMS) survey related to PMADs.

In 2019, PSI-GA partnered with Emory University's Rollins School of Public Health to launch a faith-based community partner initiative. We strongly believe that partnerships with faith-based communities will be a key component to reducing stigma about mental illness. There are plans to continue a number of further academic partnerships. 

PSI-GA has been tremendously successful in launching our chapter led by dedicated and passionate volunteers, including a fully committed board and large individual donor base, both of which are detailed in the 2019 annual report. In fact, the Georgia Chapter now serves as a model for other PSI state chapters across the nation. Due to its success, PSI-GA has reached a point in its development that it is hiring of an Executive Director who is committed to leading the organization through its next stages of development. Based on our fundraising history and momentum, we are confident that we can continue covering this expense of the solution. Specifically, our advocacy efforts led to a contract with the Georgia Department of Public Health to train providers in underserved areas. That contract, once in effect, will contribute the partial cost of the solution. We are also confident that with a full-time Executive Director onboard, this person will be able to continue the work of growing our relationships with local and national foundations. Finally, peer services are Medicaid-reimbursable in the state. Thus, we are hoping to cover part of the peer's salary through the Medicaid funding stream. The GA senate voted today to expand Medicaid coverage for post-partum women until six months after giving birth, which open up a significant funding stream for our agency, and increases access to care for women needing services. 

Becoming part of the Solve network would an incredible opportunity for our organization. We do the best we can with the tools available to us, but we strongly feel that there are so many more options and solutions out there that we could use to better the lives of women and children. We would love to hear about innovative approaches, have creative people to brainstorm with, to be able to broaden our organizational horizons. Our wish to interact with problem-solvers around the world may seem odd coming from a US-based organization, but Georgia is, in many ways, like a low-income country. Wide-spread poverty, health and economic disparities, and deep-rooted racism and discrimination are just a few of the barriers that we encounter. When it comes to health services, most of the flagship models that we face are based on states that have very different conditions, including universal healthcare, strong social programs, and a willingness to listen to scientists and innovators. In short, they would be hard or impossible to implement in our state, which is resource-poor, science-averse, and short on leaders that believe in the social contract. What we need instead are ideas and models that we can translate to our setting, but that would also allow us to contribute back with ideas and programs. We believe that being part of this network could be rewarding and stimulating, and it would enable us to set our sights at much larger goals than we currently have. 

We believe that we are currently limited in our use of technology. While Google Meet is adequate for running this round of online support groups, we are concerned about its (lack of) security features and its inability to host any kind of discussion groups and interactions outside of the group sessions. We currently have a very active Facebook forum where people can ask questions, find information and support, and find social support. However, we would love to arrive at a solution where we can create a comprehensive, non-commercial “hub” that can hold educational information, host groups, host discussion groups, serve as a referral source, and also allow more individualized contributions, including video or written blogs. We do not have the technical expertise to create and run such a site, and it would be wonderful if we could collaborate with somebody that gets us started in the right direction. 

We believe that the Beyond Care group would be an interesting partner for us. While they work on chronic disease and not maternal mental health, it looks like they are trying to achieve similar objectives in terms of health information and health behavior change. 

In addition, we think that the work of Sexperto is fascinating as well. The interactive format seems to be close to what we are trying to achieve. In addition, they are working with a sensitive topic, and we are curious to see how they make their users feel safe and comfortable with sharing sensitive information.