Overview and context of population domain

 

The scope of the Title V maternal health domain has expanded throughout the years to include individuals who have not given birth or are not yet planning a family. The factors affecting maternal health are complex, and many are associated with an individual’s health before they become pregnant. The 2020 Needs Assessment identified violence as a significant contributor to poor maternal health outcomes in Louisiana. According to the Violence Policy Center 2020 study, When Men Murder Women, Louisiana ranked 5th in the United States for women murdered by men, with a homicide rate of 2.18 per 100,000 females killed by males in single victim/single offender incidents1.  For homicides in which the victim-to-offender relationship could be identified, 98% of female victims (39 out of 40) were murdered by someone they knew. Of the victims who knew their offenders, 56% (22 victims) were wives, common-law wives, ex-wives, or girlfriends of the offenders.  From 2017-2019, homicide was the second leading cause of pregnancy-associated deaths in Louisiana.2

 

Rates of substance use disorders have risen for several years3. According to the 2017-2019 Pregnancy-Associated Mortality Review (PAMR) Report and 2020 PAMR Report, substance use is a leading contributor to pregnancy-associated mortality.  In one-fourth (25%) of deaths, the individual giving birth had a Substance Use Disorder (SUD) that contributed to their death4. The trend has increased as SUD contributed to nearly half (44%) of deaths5. High rates of substance use are correlated with high rates of mental health issues. According to the 2021 Pregnancy Risk Assessment Monitoring System (PRAMS) Report, 14.7% of persons surveyed reported experiencing depression during pregnancy. 12.1% reported frequent symptoms of postpartum depression. Even if violence, substance use or mental health issues are only present prior to conception, traumatic experiences can still have negative implications for the individual and for the future child or children. Research shows that child behavioral health problems are linked to higher Adverse Childhood Experiences (ACEs) scores by their parents 6.

 

Women / maternal health priority needs and performance measures

 

Priority needs:

The 2020 Needs Assessment priority ranking process underscored the importance of improving birth outcomes and mental health individuals who give birth in Louisiana. The 2021-2025 State Action Plan strategies for this population domain are aligned with the following population priority:

• Improve birth outcomes for individuals who give birth and infants

 

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 high-quality and coordinated clinical and support services
• Ensure Title V strategies are outcomes-focused and rooted in essential public health services

 

Performance measures:

Throughout the FFY 2021-2025 strategic period, Title V investments in the women / maternal health population domain in Louisiana will contribute to improvement of the following outcomes at both state and national levels:

• reducing the rate of severe maternal morbidity per 10,000 delivery hospitalizations (National Outcome Measure
• reducing the rate of maternal mortality per 100,000 live births

 

Recognizing the evidence of the strong linkages between the desired outcomes and interventions aiming to reduce the percentage of cesarean deliveries among low-risk first births, Title V supported programs in Louisiana delivered strategies to improve the following performance measure(s):

• Reducing the percent of cesarean deliveries among low-risk first births

 

 

Summary of women / maternal health interventions supported by Title V in FFY2023

 

Population Priority: Improve birth outcomes for individuals who give birth 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 the PAMR and 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”.

 

Launch and implement the Louisiana Perinatal Quality Collaborative Safe Births Initiative, with a focus on reducing Louisiana’s NTSV cesarean section rate

The Bureau of Family Health’s (BFH) Safe Births Initiative (SBI) was launched in 2021 with a goal to ensure every individual giving birth in Louisiana experiences a safe, dignified, and equitable birth. While continuing to strengthen processes to improve outcomes related to hemorrhage and hypertension, SBI also focused on reducing the first-time, low-risk cesarean section (C-section) delivery rate.

 

At the launch of SBI, 40 Louisiana birthing facilities pledged to participate. Using our traditional quality improvement approach, the LaPQC supported these facilities as they grounded their quality improvement work and prioritized equitable, patient-centered care in evidence-based practices. Over the course of involvement, process and outcome measures are defined and collected to track facilities’ progress in SBI’s third iteration of strategy measurement. Specifically, SBI sought to reduce the nulliparous, term singleton, vertex (NTSV), C-section delivery rate in participating birthing facilities from the baseline of 33% to 28% by December 2021 and to 24.7% by December 2022.

 

For SBI, the Total Joint Commission Perinatal Care Measure (TJC), PC-02 was utilized for measuring the NTSV, C-section delivery rate. Participating facilities reported their TJC PC-02 to the LaPQC for this initiative. Baseline data was determined by using the Q3 2020 TJC data reported by participating facilities. Q3 was used as the baseline as Q4 was not available at the time of the launch, January 2021. The baseline NTSV C-section delivery rate for the initiative was 33%. By December 2021, the NTSV rate had decreased to 28.6%, representing an almost 5% decrease over a year. By December 2022, the NTSV C-section rate was 27.5% demonstrating continued improvement over the next year of the initiative.

 

While still supporting the work to improve severe maternal morbidity (SMM) from hemorrhage and/or hypertension and reducing the low-risk C-section delivery rate, in May 2023, SBI began work to reduce SMM from obstetric sepsis. A Sepsis Policy Check-off Tool was developed and shared. Faculty for the Sepsis work conducted three Topic Calls for participating teams focused on screening, management and practical application.

 

Provide technical assistance and data support to birthing facilities pursuing the LaPQC Louisiana Birth Ready Designation

Through its Safe Births Initiative and The Gift, the LaPQC continued to provide quality improvement coaching, tools, training and collaborative learning opportunities to support hospitals in standardizing best practices. Participating hospitals continued to submit data related to priority improvement areas. Using a secure data portal, participating hospital teams track their implementation progress and use their own data to identify new areas of improvements.

 

In 2021, the LaPQC developed the Louisiana Birth Ready Designation to recognize participating facilities for their improvement work and create a system that acknowledges and rewards sustained change related to implementation of evidence-based best practice for maternal care. This designation program has two tiers of recognition: Louisiana Birth Ready and the Louisiana Birth Ready plus. The designations acknowledge those birthing facilities committed to practices that promote safe, equitable, and dignified birth for all individuals giving birth in Louisiana. Each designation level includes requirements across five dimensions:

• Participation and Collaborative Learning
• Equity and Patient Partnership
• Policies and Procedures
• Structure Measures and Education
• Outcome and Process Measures

 

Applications are open to all birthing facilities annually for Birth Ready Designation. Those that have already achieved designation must reapply each year. If a previously designated facility does not meet the qualifications when reapplying, they will have a 6-month (non-public) probationary period to regain their designation level. In FFY2023, 22 birthing facilities were designated as Birth Ready and 9 birthing facilities were designated as Birth Ready +. 98% of births occur in facilities that are actively participating in initiatives led by LaPQC.

 

 

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

 

Support implementation of new regulations for Louisiana’s birthing facilities

Under the authority of the Perinatal Commission, the LaPQC established and operationalized the definition of participation in the LaPQC for birthing hospitals and freestanding birth centers. Formal voting and adoption of the operational participation definitions will occur in FFY2024.

 

Support the Louisiana Doula Registry Board with developing and implementing the state Doula Registry, aligning requirements to facilitate potential coverage by Medicaid and other insurers

Act 182 of the 2021 Legislative Session established the Louisiana Doula Registry Board (DRB) within the Louisiana Department of Health for the purpose of reviewing and approving doula registration to allow for health insurance reimbursement of doula services. Tasks include creating the criteria for the registration application, reviewing applications for admission into the registry, approving applications for admission into the registry, notifying applicants of approval or denial, and maintaining a state registry of doulas approved for health insurance reimbursement.

 

The Board consists of 15 voting members and 16 non-voting members. In FFY2023, the Board held public meetings on a quarterly basis. BFH Staff/Coordinators facilitate communications with board members, advisors, technology companies, meetings, follow-up, agendas/meeting minutes, meeting venue procurement, and engage with LDH legal, legislative policy leaders and BFH staff and leadership. LDH legal representation attends all meetings.

 

In FFY2023, the Board defined and codified the term “doula”.

 

“A doula is 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.”

 

Additionally, in FFY2023, under the guidance of LDH legal, the Board established through rulemaking the functions of the Board, the application for the registry, and the process for how doulas will apply for admission into the registry. The Board also developed a process for registration renewal and approval of doula training bodies.

 

With the establishment of the Board codified through rulemaking, the Board anticipates being able to accept applicants in FFY2024.

 

As of November 2022, only eight states and Washington, DC provide coverage for doulas under their state Medicaid plan. A key success for Louisiana is the promulgation of the rule that establishes the ability of the Louisiana Doula Registry Board to begin accepting applications that will allow doulas to be covered by insurance, including public and private insurance, which will contribute to increased access to professional doula services.

 

Support the implementation of perinatal depression screening in pediatric settings

The Bureau of Family Health (BFH) continues to provide technical assistance and training to maternal health care providers, including perinatal providers and pediatricians, through the implementation of the Provider to Provider Consultation Line (PPCL) program.  The program delivers training to build perinatal and pediatric providers’ capacities to recognize and respond to the mental health needs of their maternal and pediatric patients. In addition to provider training, the program establishes a consultation line, which perinatal and pediatric health providers can call to consult with mental health specialists when they are uncertain about how to respond to the mental health needs of their patients.  A partnership with Tulane University supports provision of psychiatric consultation as needed as well as general data management support for the program. 

 

Since 2018, BFH has managed a mental health consultation line for perinatal providers.  The service was initially launched in partnership with Tulane University School of Medicine’s Department of Psychiatry. Building on the experience and lessons learned from the management of the perinatal mental health consultation line, BFH launched a pediatric provider mental health consultation line in November 2022.  Under the direct management of the BFH, the pediatric consultation line is supported by a clinical team including licensed mental health professionals, resource specialists, and psychiatrists. By September 30, 2023, 165 pediatric providers had registered with the program and 112 consultations had been provided to registered providers. Half of the consultations provided were for repeat callers.

 

The perinatal consultation program previously managed by Tulane University School of Medicine’s Department of Psychiatry was integrated into the PPCL program. All aspects of the two programs including staff, data systems, and program management have been integrated and the call lines were merged in March 2023.

 

The program also conducted a TeleECHO session, which focused on screening for perinatal depression in pediatric practices. In a session evaluation, respondents reported an increase in knowledge from pre-session to post-session, and 100% of respondents indicated that they would definitely use what was learned in their work.

 

The program also provided support and expertise to the Louisiana Perinatal Quality Collaborative’s (LaPQC) pilot initiative for Caregiver Perinatal Depression Screening in pediatric practices. In November 2023, the program also completed a small study including qualitative interviews with pediatric health providers (N=18) to better understand their experiences related to conducting depression screenings during well-child visits. 

 

Develop and implement strategic and operational plan to ensure long-term sustainability and growth of Louisiana Mental Health Perinatal Partnership

At the end of the 2023 calendar year, the consulting firm, Trepwise, inc., conducted an evaluation of the Provider to Provider Consultation Line (PPCL) program. The evaluation provided an external, helicopter view of the overall program strengths and areas for possible further development.

 

In FFY2023, BFH engaged in several initiatives to support policy and legislation contributing to the long-term sustainability of the PPCL program. In the 2023 legislative session, Senate Resolution 136 was enacted and expresses the legislature’s support for a statewide mental health consultation program and requests that LDH identify and seek long-term, sustainable sources of funding for such a program. In response to the Senate Resolution, BFH developed a letter outlining potential financial sustainability strategies including administrative policy changes to allow claims from Medicaid and the State Children’s Health Insurance Program (CHIP) and/or legislative changes to require insurers to cover mental health consultation.

 

Provide supplemental funding and infrastructure support to all BFH reproductive health efforts to 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, The Bureau of Family Health’s (BFH) Reproductive Health Program is recognized as an important resource in the state with expertise around national clinical guidelines, including the Quality Family Planning (QFP) Guidelines. The Bureau has significant expertise in direct provision of comprehensive reproductive health services to high-need populations; geographic analysis of need and provider access; and adequate coverage policies. During FFY2023, Louisiana Title V continued to provide supplemental funding and infrastructure resources to support the Reproductive Health Program’s efforts to increase access to high quality reproductive health services.

BFH provided reproductive health services through 57 Parish Health Units (PHU), which are under the management of the Office of Public Health. These safety-net services include adult and adolescent nurse and provider visits with advanced practice registered nurse (APRN) and registered nurse (RN) providers. Each Title X location offers a broad range of U.S. Food and Drug Administration (FDA)-approved contraceptive methods, including natural family planning methods, and provides client-centered contraceptive services on-site, via telehealth, or by referral. Most clients receive convenient same-day access to their method of choice, if not medically contraindicated.

In addition to increasing access to services in Parish Health Units, Title V funding provided financial and technical support to a network of primary care providers including one adolescent and young adult-focused health center and two sub-recipient Federally Qualified Health Centers (FQHCs).  The sub-recipients integrated reproductive health services in six sites.  These providers serve as critical access points in many communities and provide care to many low-income and/or uninsured individuals.

 

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

 

Ensure robust, high-functioning Pregnancy Associated Mortality Review (PAMR) process

In FFY2023, LA-PAMR continued to work closely with The Bureau of Vital Records and Statistics, coroner’s offices, law enforcement officers and other partners to ensure continued submission of documentation needed for case review.  The LA-PAMR committee consists of community-based organizations such as Healthy Start, New Orleans Breastfeeding Center, Birthmark Doula Collective, New Orleans Family Justice Center, and the Louisiana Coalition Against Domestic Violence. The LaPQC and Medicaid managed care organizations are also represented to ensure visibility of system issues to payers. A Patient Advocate representative continued to provide input on the perspective of families and survivors of maternal morbidity. The breakdown of representation is a 50/50 split between clinical and non-clinical members. In FFY2023, 7 review meetings were organized to review 74 cases. 

Due to an increase in pregnancy-associated deaths from accidental causes, the LA-PAMR team recruited additional clinical subject matter experts. This includes a professor from Louisiana State University (LSU), who is also the director of LSU’s Anxiety and Addictive Behaviors Laboratory and Clinic, as well as one of our state opioid coordinators who serves on our suicide/overdose subcommittee.

LA-PAMR has undertaken many important changes to improve processes and tools used to prepare cases for review and to facilitate deliberations and formulation of recommendations. The team participated in CDC Maternal Mortality Review Information Application (MMRIA) training and technical assistance as available, which has increased understanding of critical review strategies. In addition, the team streamlined administrative processes that facilitate review across the state, including the development of a standardized process and tools (case summary form, LABoRS Tool and Utah Tool).

The Utah and LABoRS tools support broader identification of contributing factors and the development of actionable recommendations that address contributing factors related to social determinants of health, including those related to bias, discrimination, and/or racism. These tools have allowed the Committee to evaluate information relevant to each case and have targeted discussions to build consensus around whether social determinants of health contributed to a death. Surveys have shown that committee members find these tools useful, and LA-PAMR will continue to incorporate them into reviews. Additionally, having case narratives that are as complete and clear as possible, and available for committee members to review ahead of meetings, allowed us to have a more robust discussion around contributing factors and recommendations and decreases the amount of time spent on case review and clarifying questions during the review meeting.

 

In May of 2023, the LA-PAMR team discussed the potential of adding informant interviews to the data collection and case review process. LA-PAMR met with an informant interviewer from Mississippi, to discuss the process for establishing interviews. In addition, the team created an informant interviewer job description. After exploring guidance documents from the CDC, the Medical Director presented this opportunity to the Louisiana Perinatal Commission, the authorizing agent of LA-PAMR, and received authorization to move forward with informant interviews in September 2023.

Historically, LA-PAMR has only reviewed cases of residents who die in-state. After discussions with CDC, the program piloted reviewing cases of residents who died out of state in order to attain data that are more complete. After completion of review of 2020 cases, LA-PAMR received positive feedback from Committee members regarding the continued review of out of state deaths. Identifying out of state deaths of Louisiana residents ensures the capture of 100% of all resident maternal death cases.

 

Establish a statewide Domestic Abuse Fatality Review (DAFR) panel that uses standardized processes for data collection, review, and prevention recommendations to review maternal deaths due to violence

The Louisiana Domestic Abuse Fatality Review (DAFR) was established in 2021 with the aim of identifying the causes of domestic abuse fatality and methods for prevention. The Louisiana DAFR Panel is made up of 20 individuals from both state and nonprofit organizations and held its first case review meeting in October 2022. The panel meets quarterly each year to review 5 - 7 domestic violence fatality cases at each meeting. The first annual DAFR Report was published in January 2023 that highlights the purpose, processes, and structure of the panel.

 

Ensure robust, high-functioning Louisiana Pregnancy Risk Assessment and Monitoring System (PRAMS)

Louisiana Pregnancy Risk Assessment Monitoring System (PRAMS) is a data surveillance project of the CDC and LDH-OPH-BFH. PRAMS collects state-specific, population-based data on maternal knowledge, attitudes and experiences before, during, and shortly after pregnancy. Each month we contact around 200 Louisiana women who recently gave birth to share their experiences before, during, and just after pregnancy.  In FFY2023, the LA-PRAMS overall response rate averaged 67.29%, exceeding the CDC minimum required response rate of 55%.

Louisiana PRAMS provides both quantitative and qualitative data on:

• Factors that influence pregnancy outcomes, including health insurance status, chronic conditions, pregnancy intention, contraceptive use, prenatal care, alcohol use, tobacco use, physical abuse, and life stress
• Mothers’ experience of pregnancy complications, including hypertension, diabetes and hospitalizations
• Maternal experiences and behaviors after the baby is born, including depression, maternity leave experiences, breastfeeding, contraceptive use, tobacco and alcohol use, and safe infant sleep practices

 

The ability to collect these data on a statewide population level is invaluable.  PRAMS data supports the design of the State’s Title V and Title X programs. PRAMS data is also widely used for public health research and for design of public health interventions at community level.  See examples of data topics and analyses that are unique in quality, rigor, and content to Louisiana PRAMS:

• Contraceptive use - barriers to use, failure rates, and type
• Unintended pregnancy rates - attitude towards pregnancy and ambivalence around pregnancy and use of contraception
• Prenatal Care - availability of care, barriers to care, quality and content of care
• Screening and diagnosis with STIs before and during pregnancy
• Maternal stressors experienced during pregnancy including experiences of discrimination
• Perinatal Substance Use - alcohol, tobacco, prescription and non-prescription drug use
• Intimate Partner Violence during pregnancy
• Breastfeeding - barriers to initiation, hospital practices, support received, exclusivity and duration
• Infant sleep environment - Sleep position, bed-sharing practices, safe sleep practices
• Occupational Information
• Maternity Leave - experiences and decisions around leave

 

Information collected by Louisiana PRAMS is used by health professionals, policy makers, and researchers to develop and modify programs and policies designed to improve the health of mothers and infants.

 

PRAMS data informed the Louisiana Department of Health’s statewide media campaign in August 2023.  The campaign focused on increasing overall breastfeeding rates and reducing disparities and included news articles, social media campaigns, and community events. The campaign was elevated to the office of Governor John Bel Edwards resulting in an official proclamation during National Breastfeeding Month and World Breastfeeding Week 2023.