Overview and Context of Population Domain

Title V historically focused on the “maternal” aspect of this population, but the scope of this domain has expanded throughout the years to include women who have not given birth or are not yet planning a family. The factors affecting maternal health are complex, and many are associated with a woman’s health before she becomes pregnant. A woman’s physical, emotional, and economic well-being are all significant to her own long-term health. The Louisiana Pregnancy Associated Mortality Review (PAMR) suggests that maternal health outcomes can improve by increasing access to family planning services and coordinated care before and between pregnancies1. Factors beyond reproductive health can also have long-lasting implications for mother and child.

In addition to quality health care and insurance coverage, social and behavioral factors play a role in a woman’s health and the well-being of her entire family. Through the Needs Assessment, violence was identified as a growing issue for Louisiana’s women. In 2019, Louisiana had some of the highest national rates of homicide committed by men against females2. In 2018, homicide was the leading cause of death for pregnant women in Louisiana. In the same year, one quarter of pregnancy-associated deaths were due to homicide1. In response to the prevalence of domestic violence against women, the Louisiana state legislature passed legislation in 2021 that mandated a domestic violence fatality review within LDH. In addition to causing injury, hospitalizations, and mental health/substance abuse disorders for the woman, violence against mothers also negatively impacts children, in-utero and beyond.

Rates of substance use disorders have risen for several years3. According to the 2018 PAMR, substance use is a leading contributor to pregnancy-associated mortality, and in almost one fifth (17%) of deaths, the birthing person or someone in their immediate family had a Substance Use Disorder (SUD) that influenced the death. High rates of substance use are correlated with high rates of mental health issues. According to the 2020 PRAMS Report, roughly 14% of women surveyed reported experiencing depression prior to and during pregnancy. Nearly 17% (16.8%) reported frequent symptoms of postpartum depression. Even if violence, drug abuse, or mental health issues are only present prior to conception, traumatic experiences can still have negative implications for a woman and her future children. Research shows that child behavioral health problems are linked to higher Adverse Childhood Experiences (ACEs) scores by their parents, particularly their mothers4. Improved health outcomes for all women will, by proxy, improve health outcomes for mothers and children.

Overview of Priority Needs

The 2020 Needs Assessment priority ranking process underscored the importance of improving birth outcomes and mental health for Louisiana women. To elevate and address these issues, the 2021-2025 State Action Plan strategies for this population domain are aligned with the “Improving birth outcomes for birthing persons and infants” Population Priority.

This priority is impacted and facilitated by several upstream factors. To strengthen the systems and supports that shape these factors, Louisiana Title V continues to execute strategies that align with the following Systems Priorities:

• Ensure equitable access to quality, coordinated care and supportive services
• Ensure Title V strategies are outcomes-focused and rooted in essential public health services
• Partner with families, youth, and communities at all levels of systems change
• Boldly work to undo systemic drivers of disparities and institutionalize equitable policies and practices

In alignment with these Priority Needs, Louisiana Title V selected NPM 2: Low-risk Cesarean Delivery as the Women’s/Maternal National Performance Measure for the FFY 2021-2025 cycle.

Summary and Reflection of Domain-specific Title V Efforts to Date

Population Priority Need: Improve birth outcomes for birthing person and infants

Many of the FFY 2021-2025 State Action Plan strategies for the Maternal/Women and Perinatal/Infant domains were informed by recommendations from two special legislatively-mandated studies regarding racial disparities in maternal and infant birth outcomes: 1) Healthy Moms, Healthy Babies Advisory Council Report, which was written in response to Act 497 of the 2018 Regular Session of the Louisiana Legislature, and 2) Addressing Disparities in Maternal and Child Health Outcomes for African Americans: Summit Recommendations Report, which was written response to House Resolution 294 and Senate Resolution 240 of the 2019 Regular Session of the Louisiana Legislature.

The core strategies related to NPM 2 align with the specific recommendation from the HR294/SR240 report that birthing facilities in Louisiana should be well-supported, equipped, and motivated to supply sustainable, high-quality, equitable, dignified, and patient-centered maternal and infant care.

Support Louisiana Commission on Perinatal Care and Prevention of Infant Mortality: The Louisiana Commission on Perinatal Care and Prevention of Infant Mortality (referred to as the Perinatal Commission) is the legislatively authorized governor-appointed body responsible for making recommendations to strengthen the community and clinical care systems to improve maternal and perinatal outcomes. The Perinatal Commission has two primary responsibilities: 1) to research and review all state regulations, guidelines, policies, and procedures that impact perinatal care and, when appropriate, make recommendations to the secretary of the Louisiana Department of Health and/or the legislature, and 2) to conduct special studies in order to inform state efforts to address maternal and infant mortality. The Commission is authorized to review statistical and provider-level data in order to carry out this charge. The state’s Pregnancy Associated Mortality Review (PAMR) and Louisiana Perinatal Quality Collaborative (LaPQC) all function as special studies under the authorization of the Perinatal Commission, all of which are supported by Title V.

For many years, supporting the Perinatal Commission has been an integral part of Louisiana Title V strategies to improve maternal and infant health through system-level changes. While the Perinatal Commission is one of many legislatively-appointed bodies that the Title V program supports, it has been one of the most engaged with formulating and influencing policy and systems change around maternal and perinatal health. In FFY 2021, Title V continued to fund key staff roles to support an engaged and forward-moving membership.

Louisiana Perinatal Quality Collaborative (LaPQC):  During FFY 2021, BFH continued to invest Title V funding to sustain and support the growth of the LaPQC. This voluntary partnership of perinatal clinicians, hospitals, policy makers, governmental entities, and advocates provides a core workgroup to sustain initiatives to promote evidence-based practices and the use of improvement science to improve birth outcomes throughout the state.

Operating under the authority of the Perinatal Commission, the LaPQC supports birthing facilities across the state by using improvement science techniques to implement evidence-based best practices that promote safe, equitable, and dignified birth for all birthing persons and neonates. The overarching vision for the LaPQC, however, is much broader than implementation of evidence-based practice in service of improving maternal and neonatal outcomes. The LaPQC was designed to not only serve as a long-term quality improvement (QI) hub, but as a platform to coordinate multiple campaigns, pilots, and other improvement efforts. For Louisiana’s Title V program, LaPQC was envisioned as part of the systems change continuum that originates with public health surveillance of MCH outcomes.

LaPQC Reducing Maternal Morbidity Initiative (RMMI): In August 2018, the LaPQC launched its first initiative, the Reducing Maternal Morbidity Initiative (RMMI), which sought to address preventable maternal mortality and morbidity related to hemorrhage and hypertension, while also focusing on reducing racial disparities in these maternal outcomes. Specifically, the RMMI sought to 1) reduce Severe Maternal Morbidity (SMM) by 20% among those persons who experience hemorrhage and/or severe hypertension by May 2020; and 2) decrease the Black-white disparity in SMM among hemorrhage and hypertension in the same time period. Originally, 31 of the state’s 52 birthing facilities signed on to the LaPQC RMMI Initiative, designed as an Institute for Healthcare Improvement (IHI) collaborative model for “achieving breakthrough improvement.”

Hemorrhage and/or severe hypertension were selected as the first areas of focus because they are among the leading factors contributing to severe maternal morbidity and mortality. Furthermore, there was an opportunity to build on hospital-focused improvement. While complex, this area of focus is often recommended as a starting point for teams to learn the evidence-based improvement tools and concepts, and for PQCs to learn how to support the development of collaborative learning and improvement science. This foundational work has been essential to advance complex changes, such as those related to cesarean deliveries.

LaPQC Safe Births Initiative: In January 2021, the LaPQC launched the Safe Births Initiative (SBI) which continues past improvement work related to hemorrhage and hypertension, and serves as a vehicle for a new focus on reducing Louisiana’s NTSV cesarean section rate. With this constellation of improvements, the goal of Safe Births is the implementation of practices that promote safe, equitable, and dignified birth for all birthing persons in Louisiana where:

• A safe birth is one where evidence-based best practices are employed by health care providers at all levels in an effort to increase readiness, decrease response time, and ensure high-quality communication across a care team;
• An equitable birth is one where best practices are not only employed with every patient, every time, but that women of color – particularly Black and African American women – are given access to the life-saving and sustaining resources they need throughout the birthing process;
• A dignified birth is one where, throughout the birth process, birthing persons experience timely and accurate communication with their health care providers, are acknowledged as informed health care consumers, and are included in decision-making about their health care.

Each birthing facility in LaPQC Safe Births Initiative participates in structured monthly Coaching Calls with the BFH LaPQC team. To ground the work in a core purpose, each call starts with a patient story. While the Coaching Calls are catered to the individual needs and priorities of each hospital team, they also include a shared learning component that allows peer facility-based improvement teams to highlight how they have applied improvement science methods to change practices in their facilities and achieved results on their teams and with their patients.

The LaPQC also facilitates a monthly Topic Call for participating hospitals, which gives facility-based teams access to topic specific experts in order to ask questions and share resources. While the Coaching Calls are highly structured, the Topic Calls are largely unstructured, allowing for more collaborative learning. The collaborative nature of the LaPQC initiatives is intentionally designed to create a culture of sharing, improvement, and readiness for change.

Louisiana Birth Ready Designation: While the LaPQC is not responsible for directly implementing the evidence-based improvement strategies within the hospitals, the LaPQC utilizes several tools and approaches to encourage hospitals to begin working to implement these interventions. In FFY 2021, the LaPQC launched a designation plan that awards hospitals who achieve and maintain certain quality improvement milestones. The Louisiana Birth Ready Designation distinguishes those birthing facilities committed to practices that promote safe, equitable, and dignified birth for all birthing persons in Louisiana.

In August 2021, the initial Birth Ready Designations were awarded to 16 facilities. The press release announcing the initial designations was released October 2021 (delayed due to Hurricane Ida). To achieve designation, facilities met criteria in five dimensions: participation in collaborative learning; health disparity and patient partnership; policies and procedures; structures and education; and outcome and process measures. The designation initiative offers two tiers of recognition – Louisiana Birth Ready and Louisiana Birth Ready+. Hospitals that achieved Birth Ready+ Designation have met a higher threshold of compliance and achievement of the requirements.

Ensure equitable access to high-quality and coordinated clinical and support services

Support implementation of new regulations for Louisiana’s birthing facilities: Over the past several years, the Title V program has supported the research and development of two substantive changes related to the requirements for birthing facilities in the state: 1) the creation of regulations for free-standing birthing centers and 2) the realignment of the maternal levels of care for hospitals to be clearer, more rigorous, and more closely aligned with national recommendations. The regulations for free-standing birthing centers emerged out of a multi-year inquiry led by the Perinatal Commission.

There were several catalysts for the review of hospital regulations including the issuance of new national recommendations, as well as recommendations from the PAMR report. The Title V-supported LaPQC/PAMR Medical Director has been instrumental in leading a comprehensive stakeholder-engaged process to review the current licensing requirements for birthing facilities and the designation process. Participants in the review and development of new hospital requirements included clinical providers, administrators, health system leaders, the hospital licensing authority, professional associations, advocates and patients.

The development of proposed new regulations had three major steps: comparison of Louisiana’s current regulations against the new national guidelines; voluntary facility-level assessment of current practices against the new national guidelines using the CDC Levels of Care Assessment Tool (LOCATe) with support from the LaPQC; and ongoing engagement with the workgroup, the Perinatal Commission, and other stakeholders to reconcile the recommended standards in Louisiana’s system of care.

In late FFY 2021, a notice of intent (NOI) was submitted for publishing in the Louisiana Register to notify the public that hospital licensing regulations for birthing facilities will be updated to align with national guidelines.

Support launch and operation of Louisiana Doula Registry Board: During the 2021 Louisiana Regular Legislative Session, a new law (Act 182) was passed that creates the Louisiana Doula Registry Board. This new board is charged with reviewing, approving and/or denying applications for doulas registering to receive health insurance reimbursement in the state and maintaining a statewide registry. Doula is defined in the Act as an individual who has been trained to provide physical, emotional, and educational support, but not medical or midwifery care, to pregnant and birthing women and their families before, during and after childbirth. In late FFY 2021, BFH was assigned to facilitate the implementation of the Louisiana Doula Registry Board and began supporting the member appointment process. The LaPQC medical director was also charged with appointing representatives from organizations providing doula services for people giving birth in each of the nine LDH administrative regions.

Louisiana Mental Health Perinatal Partnership (LAMHPP): In FFY 2021, BFH continued its partnership with Tulane University School of Medicine to support and provide direction to the Louisiana Mental Health Perinatal Partnership (LAMHPP), a provider-to-provider consultation system to support licensed healthcare clinicians serving pregnant and postpartum women and their families. LAMHPP is intended to support early recognition and response to potential mental health concerns among pregnant and postpartum patients in Louisiana. LAMHPP supports healthcare clinicians in addressing the needs of their patients through trainings and online resources related to perinatal depression, anxiety, substance use disorders, interpersonal violence, and related health risks, through psychiatric phone consultation, phone resource and referral consultation. Consultations focus on promoting screening for mental health concerns, first line management of mental health and substance use disorders, and making effective referrals to additional community resources. In FFY 2021, BFH worked with the partners at Tulane to implement new QI processes and a data dashboard to enhance the quality and reporting of the data collected during consultations.

Support access to high-quality family planning and reproductive health care: Improving access to and quality of reproductive health services has been integral to Louisiana’s strategy of improving maternal and perinatal outcomes. As Louisiana’s sole Title X Family Planning Services grantee, BFH is recognized as an important resource in the state with expertise around national clinical guidelines such as the Quality Family Planning (QFP) Guidelines, experience with direct provision of comprehensive reproductive health services to high-need populations, geographic analysis of need and provider access, and expertise in adequate coverage policies. During FFY 2021, Louisiana Title V continued to provide supplemental funding and infrastructure resources to support BFH Reproductive Health Program (RHP) efforts to increase access to high quality reproductive health services.

BFH provided reproductive health services through 56 OPH Parish Health Units (PHU). These safety-net services include women, men, and adolescent nurse and provider visits with Advanced Practice Registered Nurse (APRN) and registered nurse providers. Each Title X location provides contraceptive services using a client-centered approach offering a broad range of FDA-approved contraceptive methods, including natural family planning methods on-site, via telehealth, or by referral. Most clients receive convenient same-day access to the client's method of choice if not medically contraindicated.

In addition to increasing access to and utilization of reproductive health services in the established OPH PHU Title X network, Title V funding to the BFH RHP supported efforts to integrate high quality reproductive health services in primary care settings. Primary care providers in Community Health Clinics (CHCs), including Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), were the focus as critical access points in many communities and providing care to many low-income and/or uninsured individuals. Louisiana’s Title X subrecipient network currently includes two adolescent and young adult-focused health centers, and two subrecipient CHC. Sites were chosen based on a Solicitation of Offers application process, with priority given to areas without a PHU, and health centers that demonstrate readiness to provide reproductive health services.

System Priority: Ensure Title V strategies are outcomes-focused and rooted in essential public health services

Ensured robust, high-functioning Pregnancy Associated Mortality Review (PAMR): Over the past several years, Louisiana has been working to establish the foundation for systematic ongoing surveillance of maternal deaths and for external review and activated response. Both in Louisiana and nationally, surveillance of maternal deaths has historically been complicated by issues with the consistency and quality of data reported through death certificates and hospital inpatient discharge reporting systems, and the lack of standardized protocols or data systems to support surveillance and action. Throughout the 2016-2020 block grant cycle, Title V funding was utilized to address these challenges and build the core infrastructure for rigorous, timely, ongoing surveillance of maternal deaths. As PAMR strengthened and momentum built, BFH sought additional funding opportunities to expand and enhance the capacity of PAMR. In FFY 2019, BFH was awarded a competitive CDC Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) grant, which has enabled PAMR to onboard additional full-time staff and access CDC resources.

In FFY 2021, the core PAMR team consisted of a dedicated maternal mortality epidemiologist, a PAMR coordinator, and a statewide network of 9 Regional MCH Coordinators who work within their communities on critical maternal and child mortality surveillance activities, including the Child Death Review (CDR) and data collection for PAMR. For maternal deaths, the MCH Coordinators and PAMR Coordinator abstract comprehensive information from medical reports, as well as from vital records, coroner and law enforcement, and summarize case information for state-level review and systems action.

In August 2018, BFH published a maternal mortality surveillance report for deaths that occurred between 2011-2016, along with detailed recommendations for many different systems of care and support. The report includes maternal deaths that occurred during or within 42 days of the end of pregnancy from a cause directly related to the pregnancy or its management (pregnancy-related deaths). In FFY 2018, the Regional MCH Coordinators worked with facilities in their communities to expand their investigations of maternal deaths from 2017 that occurred during or within one year of the end of pregnancy, and investigations included pregnancy-related deaths as well as deaths causes not directly related to the pregnancy (pregnancy-associated deaths). This broader definition was selected for 2017 deaths as the program continues to develop in capacity. Vital records death certificate cause of death and pregnancy checkbox were used to identify potential cases that met these criteria. With CDC’s launch of MMRIA (the Maternal Mortality Review Information Application), the standardized data system to support case reviews in states with active maternal mortality review committees, BFH has begun to fully integrate ongoing surveillance and action processes as a core public health activity.

In September 2021, BFH published the 2018 Louisiana Pregnancy-Associated Mortality Review Report. This report is reflective of the expanded case review eligibility, reporting on deaths that occured while pregnant or within a year or pregnancy due to any cause of death.

Supported early implementation of Louisiana Domestic Abuse Fatality Review Panel: During the 2021 Regular Session of the Louisiana State Legislature, Act 320 was signed into law, mandating a domestic violence fatality review team within LDH. Due to the Bureau’s expertise in leading comprehensive mortality reviews such as PAMR, BFH has been assigned as one of the lead agencies responsible for implementing the new panel as soon as funds are appropriated by the Legislature. According to the most recent PAMR Report, in 2018, the third leading cause of pregnancy-associated deaths in Louisiana was homicide. The Louisiana Domestic Abuse Fatality Review Panel (DAFR) presents an opportunity to further investigate the causes, trends, and other factors related to these deaths, as well as build new action-oriented partnerships around domestic violence prevention. To begin implementation of Act 320, the Louisiana Commission on Prevention of Domestic Violence formed a working group which included BFH and other partners such as the Louisiana Coalition Against Domestic Violence.

In FFY 2021, BFH applied for and was awarded a grant from the DHHS Office of Women’s Health to help establish the DAFR and implement an evidence-based intervention for the prevention of maternal deaths due to violence. To support implementation of the review, BFH generated a roster of recommended members and disseminated letters of invitation to the agencies that were legislatively mandated to participate.

Louisiana Pregnancy Risk Assessment and Monitoring System (LaPRAMS):  One of the core MCH surveillance systems is LaPRAMS. The Center for Disease Control and Prevention (CDC) PRAMS funding supports some of the staff time and costs to administer this statewide annual survey of women who have recently delivered. However, Title V funding provides for over half of the true costs associated with making LaPRAMS one of the go-to resources for data to monitor health, prevention efforts and inform decision-making, both in the health department and with partners.

In FFY 2021, Title V support allowed LaPRAMS to continue to strengthen core operations. As a result of significant attention to process improvements, Louisiana was able to achieve weighted survey response rates for 2015-2020 that exceeded the CDC required threshold. These process improvements and robust response rates have earned LaPRAMS recognition as a national leader with Louisiana  providing technical assistance to peer states.

BFH now routinely draws upon LaPRAMS data to add depth to Louisiana’s annual Child Death Review (CDR) report, Safe Sleep educational initiatives, the Title V Block Grant, the Louisiana Adverse Childhood Events (ACE) Educator program, MIECHV (Maternal, Infant, and Early Childhood Home Visiting) programs, as well as research, both locally and nationally. Increasingly Louisiana has been integrating the qualitative comments from LaPRAMS into briefs, legislative reports, grants and other communications in order to contextualize issues and quantitative data. These improvements, coupled with an engaged Steering Committee of members in- and outside of the health department, have helped ensure that LaPRAMS is a high performing MCH surveillance system in Louisiana.