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.

Establishing healthy habits and accessing quality health services promotes optimal health outcomes for women at all stages of life. Conditions like hypertension, obesity, and diabetes can cause complications during pregnancy. These conditions are largely preventable and their management is dependent on high-quality, accessible, and affordable care. Most women in Louisiana are insured following the 2016 Medicaid expansion, and Louisiana has high rates of annual well-woman visits2. However, statewide provider shortages remain a barrier to care for all Louisianans.

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. More than 33% of Louisiana women experience intimate partner physical violence, intimate partner sexual violence, and/or stalking in their lifetime3. Homicide was the leading cause of maternal mortality in Louisiana in 2017, and the state ranked 2nd in the country for females being murdered by males in single victim/single offender incidents in 20194,5. Violence against women negatively impacts children, in-utero and beyond.

Rates of substance use disorders have risen for several years6. In Louisiana, overdoses are the second leading cause of death in women of reproductive age and a leading cause of pregnancy-associated death7. Drug overdoses are also the leading cause of injury-related hospitalizations for women of reproductive age8. Even if violence or drug abuse happens 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 mothers9. Improved health outcomes for all women will, by proxy, improve health outcomes for mothers and children.

Women who start families face several challenges in Louisiana, where rates of maternal mortality, preterm birth, and other negative birth outcomes remain high. The 2015 Title V Needs Assessment highlighted the role of routine, preventative preconception care in improving these outcomes. At the time of the initial performance measure selection for the 2015-2020 Title V Block Grant plan, insurance options were very limited for women. With the state’s expansion of Medicaid in 2016, the options for coverage for general preventive care increased.

In Louisiana, rates of maternal mortality and severe maternal morbidity remain high, with significant disparities by race and ethnicity. Through continued epidemiological surveillance and partnerships with community and national birth equity advocates, and the establishment of the Louisiana Perinatal Quality Collaborative (LaPQC), BFH began to shift more resources towards understanding and addressing this complex issue. Beginning with the FFY 2019 Application, Louisiana Title V shifted the Women’s/Maternal Health Domain focus from NPM 1: Well Woman Visit to NPM 2: Reduction of Cesarean among First Time Low Risk Births. These shifts along with the growing local and national attention on maternal mortality, made this shift a timely and relevant change in the context of the state’s needs and capacity.

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

Invested in high performing essential MCH screening and surveillance systems

During the 2015-2020 Title V cycle, a core priority need was to ensure high performing essential MCH screening and surveillance systems. Regarding the Maternal/Women’s Health Domain, efforts and investments related to this priority focused on Louisiana Pregnancy Risk Assessment and Monitoring System (LaPRAMS) and Pregnancy Associated Mortality Review (PAMR).

Louisiana Pregnancy Risk Assessment and Monitoring System (LaPRAMS): One of the core MCH surveillance systems is LaPRAMS. The Centers 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 2019, 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 2015-2019 that exceeded the CDC required threshold. For the first time in over 12 years, Louisiana’s data were included in the national datasets beginning 2015. These process improvements and robust response rates have earned LaPRAMS recognition as a national leader with Louisiana providing technical assistance to peer states. This technical assistance work, which began in 2018, is ongoing.

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 programs, as well as research, both locally and nationally. Increasingly, Louisiana has integrated 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.

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. Despite these challenges, Title V funding has been committed over the past several years to build the core infrastructure for rigorous, timely, ongoing surveillance of maternal deaths. At the center of this effort is a dedicated mortality epidemiologist and a statewide network of 9 Regional MCH Coordinators who work within their communities on critical maternal and child mortality surveillance activities, including Fetal-Infant Mortality Review (FIMR), Child Death Review (CDR) and data collection for PAMR. For maternal deaths, the MCH Coordinators abstract comprehensive information from vital records, as well as from coroner, law enforcement, and medical reports, and summarize case information for state-level review and systems action.

In August 2018, Louisiana’s Title V Program 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. 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 from causes directly related to the pregnancy or its management (pregnancy-related deaths) and 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 is now poised to fully integrate ongoing surveillance and action processes as a core public health activity.

In FFY 2019, BFH was awarded a competitive CDC Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) grant. The ERASE MM grant has enabled PAMR to expand and enhance its capacity through additional full-time staff and access to CDC resources.

Surveillance Systems in Action:  An essential part of any high performing surveillance system is that the data are used to drive change. For maternal and women’s health, the main body charged with systems-level action is the Louisiana Commission on Perinatal Care and Prevention of Infant Mortality (referred to as the Perinatal Commission). The Perinatal Commission is a legislatively authorized governor-appointed body responsible for making recommendations to strengthen the community and clinical care systems in order to improve maternal and perinatal outcomes. The Perinatal Commission is composed of 16 members, including 14 healthcare and public health providers appointed by the governor, and two members appointed by the Louisiana Legislature. 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 FIMR, PAMR, and Perinatal Quality Collaborative (LaPQC) all function as special studies under the authorization of the Perinatal Commission and are supported primarily through Title V funding. For Louisiana’s Title V Program, the Perinatal Commission also serves as a platform to elevate local level issues identified by the Regional MCH Coordinators that require state-level action or the support of the members to generate change.

The Perinatal Commission is one of many legislatively-appointed bodies that the Title V program supports, and it is one of the most engaged with formulating and influencing policy and systems change around maternal and perinatal health. In FFY 2019, Title V funded key staff roles to support an engaged and forward-moving membership.

One of the explicit functions of the Perinatal Commission is to review state perinatal care regulations. In 2018, the Commission reviewed the policies and guidelines for free-standing birthing centers and found that the absence of formal requirements codified in regulation was a gap in the state’s maternity care system. In 2019, Representative Hilferty, the Commission’s appointed member from the Louisiana House of Representatives, introduced legislation requiring birthing centers to attain accreditation from a nationally-recognized body and to require licensure through LDH. The LDH Health Standards Section is working with the Commission to draft regulations in accordance with the new law (see also Act 332 of the 2019 Regular Session of the Louisiana legislature). These new regulations will also be informed by recommendations emerging from an overall review of the Louisiana maternal levels of care regulations.

In August 2019, the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal Fetal Medicine published an update of the Obstetric Care Consensus: Levels of Maternal Care. In response, a workgroup was formed to perform a comprehensive review and revision of Louisiana’s maternal levels of care to ensure these levels are consistent with national guidelines. This effort has been led by the Medical Director for the LaPQC and PAMR with support from the Title V Director, LaPQC staff and the Senior MCH Epidemiologist CDC-assignee.

Expanded Louisiana Perinatal Quality Collaborative (LaPQC)

Beginning with the FFY 2019 Application, Louisiana Title V shifted the Women’s/Maternal Health Domain focus from NPM 1: Well Woman Visit to NPM 2: Reduction of Cesarean among First Time Low Risk Births. At the time of the initial selection of performance measures for the 2015-2020 Title V Block Grant plan, insurance options were very limited for women. With the state’s expansion of Medicaid in 2016, the options for coverage for general preventive care also increased. Concurrent with this change, Louisiana Title V began work to establish the Louisiana Perinatal Quality Collaborative (LaPQC), which addresses complex system changes such as efforts to reduce severe maternal morbidity, low-risk cesarean sections. These changes, along with the growing local and national attention on maternal mortality, made this shift a timely and relevant change in the context of the state’s needs and capacity.

Louisiana Perinatal Quality Collaborative (LaPQC):  During FFY 2019, 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 community members 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. Louisiana’s Title V program has been the catalyst to establish and the constant to move forward the development of this statewide Perinatal Quality Collaborative, which capitalizes on Louisiana’s experience, established partnerships, and capacity. 

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 serve 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.

In FFY2019, the true vision of the LaPQC began to come to fruition with a series of activities that sought to not only build QI capacity in hospitals, but also position the LaPQC as a vehicle for substantive systems change. In particular, the LaPQC redeveloped the Coaching Calls to strengthen shared learning from peer facility-based improvement teams, highlighting how teams were applying improvement science methods to change practices in their facilities and the results on their teams and with their patients. To ground the work in a core purpose, each call now starts with a patient story. The LaPQC also added a monthly Topic Call, which gave 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 true collaborative learning. Topic calls have focused on severe hypertension; maternal hemorrhage; postpartum mental health; Nulliparous, Term, Singleton, Vertex (NTSV) cesarean section; and more. On average, 75% of facility teams participate in monthly Coaching and Topic Calls.

Additionally, in FFY 2019, the LaPQC hosted an in-person collaborative learning session focused entirely on health equity. With reduction of the black/white disparity in complications attributable to hemorrhage and hypertension (an explicit aim of the LaPQC initiative), a common understanding of the antecedents and consequences of health disparities was needed, and the learning session gave the facility teams focused time and support from LaPQC faculty to strategize new ways to incorporate health equity into their improvement work. The LaPQC also hosted an additional Learning Session on teamwork, which focused on breaking down traditional work silos in healthcare, and elevating the patient and family as a member of the care team.

This year, the LaPQC also began conducting annual in-person “Listening Tour” site visits. The goal of the Listening Tour is to provide technical assistance and build trust through unstructured, in-person visits with hospital teams. Unlike traditional site visits, the agendas for Listening Tour visits are set entirely by the facility the LaPQC is visiting; thereby allowing the facility to set the pace and tone of the conversation. In this first year of the Listening Tour, the LaPQC visited 28 of 31 facilities. 

When Title V introduced NPM 2: Reduction of Cesarean among First Time Low Risk Births in the FFY2019 application, the corresponding evidence-based strategy was a process evaluation of the implementation of the IHI Breakthrough Collaborative Series (BTS) implementation model for the LaPQC Reducing Severe Maternal Morbidity Initiative. While LaPQC did not complete a full evaluation of the Breakthrough Series model, several areas where the BTS model required adaptation were identified. For example, traditional BTS collaboratives rely on participants leading their own PDSA cycles during Action Periods. Many participating facilities, however, found it difficult to plan, execute, and track their own PDSAs, leading to stagnated work and little progress. The LaPQC overcame this stagnation by adopting a higher-touch approach to managing a Perinatal Quality Collaborative, including altering collaborative-wide calls, engaging in increased planning and oversight, and conducting in-person visits to facilities in order to move the work forward. All efforts were designed to not only build QI capacity and increase opportunities for collaborative learning, but also to build trust between facilities and the LaPQC (and, by extension, the Louisiana Department of Health). In addition to building trust, these refinements to the Breakthrough Series model also served as a means of testing the structure and flow of future quality improvement initiatives. All of these adaptations to the BTS model have been in service of positioning the LaPQC for the launch of their NTSV initiative in FFY 2020/2021, which was the ultimate intention of the ESM.

LaPQC efforts in FFY2019 also sought to elevate the state and national visibility of the LaPQC, with members of the LaPQC presenting at community and national meetings, as well as working with the Louisiana Department of Health to host and execute the state’s first Maternal Mortality Summit (described further in section below). The Summit brought in participants and speakers from across Louisiana, the nation, and the world to learn, discuss, and generate recommendations to improve maternal mortality in Louisiana.

While these activities only represent a small portion of the work done by the LaPQC in FFY 2019, perhaps one of the most profound results of the work of the LaPQC was how their relationship changed with participating facilities. The LaPQC transformed from just a source of information on hemorrhage and hypertension, to being a collection of trusted experts on all aspects of maternal care, including health equity. Elevating the visibility of the work of the LaPQC thereby elevated the visibility of broader issues related to maternal-child health, which further concretized the work of Title V work in Louisiana.

Strengthening the Reproductive Health Service System

Improving access to and the quality of reproductive health services has been integral to Louisiana’s strategy of improving maternal and perinatal outcomes. As Louisiana’s 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 2019, 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.

Maximizing Access to Quality Care through the Reproductive Health Clinic Network: As the sole Title X grantee for Louisiana during the reporting year, BFH provided reproductive health services through 57 OPH Parish Health Units (PHU), plus an additional 6 sub-recipient sites with 3 more clinics in pre-implementation phase. These affordable and quality services include women’s preventive medical visits with Advanced Practice Registered Nurse (APRN) providers. A major focus during FFY 2019 was to maximize utilization of services currently available through Louisiana’s Title X reproductive health clinics. A key strategy to serve more women was to increase efficiency in clinical services and investigate alternate staffing models of nursing and clinical staff. A major challenge to service delivery was integration of a new Electronic Health Record (EHR) on a compressed timeline.

In response to improved performance in the Parish Health Units on specific metrics, the program updated the Quality Improvement Plan metrics and adjusted benchmarks for clinics to reflect provider best practices. Specifically, the completion rate for Pap smear measure was adjusted by the Office of Population Affairs to reflect current standards of practice that reflect the increased use of HPV testing and more sensitive testing media. Adjusted measures include the number of unduplicated patients receiving an HPV-specific test, as evidence suggests that this measure is a better indicator of the potential for cervical cancer, particularly for patients over age 30. Condom use at last intercourse has also been added as a metric to support the efforts in reduction of STD rates for Louisiana.

Improvement plans were developed, implemented, and monitored, in collaboration with OPH’s overall plans for QI in the PHUs.

Reproductive Health Integration Initiative (RHII): 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, vulnerable, and/or uninsured individuals. Through the Reproductive Health Integration Initiative (RHII), Title V supported the BFH RHP in initiating partnerships with six CHCs chosen as Title X sub-recipients. Following eight months of preparatory training and technical assistance, all clinics participating in RHII moved into the implementation phase and began providing Title X services. Throughout the first year of implementation, BFH and Louisiana Public Health Institute (LPHI), a contracted implementation support partner, provided ongoing support in the form of training and technical assistance. Topics for training included contraceptive counseling, procedures for long-acting reversible contraception (LARC), pregnancy testing and non-directive counseling, and conducting a sexual health assessment. Technical assistance focused on improving workflows, EHR optimization, staff utilization, and contraceptive supply stocking and billing.

Increase Access to Contraception through Medicaid Policy Change:  With the support of the Title V-funded Health Systems Strategy Manager, BFH has sought to engage more proactively in affecting policy change. The need for one such policy change emerged out of the BFH RHP’s work to integrate high quality reproductive health services in primary care settings through RHII. Early in the development of RHII, the Community Health Centers identified cost barriers to increasing availability of LARC methods. LARCs, which include intrauterine devices and contraceptive implants, are considered the most effective contraceptive methods currently available on today’s market. ACOG, American Academy of Pediatrics, CDC and the World Health Organization all recommend the option of LARCs for women of reproductive age, including adolescents.1 Unlike other forms of birth control, LARCs require no user intervention, work over long periods to prevent ovulation, and are reversible at any time. For these reasons, LARC methods are highly successful in the prevention of unintended pregnancies.

In 2015, BFH RHP and Health Systems Strategy staff identified a barrier within the Medicaid reimbursement system for community health clinics as it relates to a provider’s ability to be reimbursed for LARC devices. Nationally, Medicaid uses an enhanced reimbursement, or a flat fee calculated through the federal Prospective Payment System (PPS). In 2015, $158.85 was the base rate for all FQHCs. Payment is 80% of either the PPS rate of $158.85, or the total charges for services furnished, whichever is less. In Louisiana, there are approximately 260 FQHCs and 160 Rural Health Clinics (RHC). In 2015, the statewide average FQHC PPS rate was approximately $136.14 and the RHC PPS rate was $93.66. Whereas reproductive health is included in the list of primary health services for a CHC, the scope of voluntary family planning services such as appropriate counseling and available reproductive options are left up to the CHC to decide. As the cost of the procedure to insert LARCs and the cost of the purchase of the devices were quite high, surpassing the PPS reimbursement, the majority of CHCs in Louisiana did not stock or perform LARC insertions. Therefore, providers in CHCs who chose to provide LARCs for Healthy Louisiana Medicaid patients had to absorb the cost of the insertion procedure and device into the PPS wraparound encounter rate. Although qualifying CHCs could utilize the 340B Drug Discount program for the cost of the device, they could not be reimbursed separately for the acquisition under the PPS. Consequently, in 2015, BFH researched literature and policies in other states, and conducted a fiscal impact analysis in conjunction with Louisiana Medicaid. Based on those findings, BFH recommended that Medicaid submit a revised State Plan Amendment (SPA) to the Centers for Medicare and Medicaid Services (CMS) in order to reimburse providers for the cost of the LARC device within CHCs who voluntarily choose to provide LARCs for Health Louisiana Medicaid patients. This policy change was implemented on January 1, 2019.

To support successful implementation of the LARC reimbursement policy change, BFH consulted with leadership from Louisiana Medicaid and offered to pilot the proposed LARC policy change language with a small number of CHCs. Through RHII and amiable stakeholder relationships with the OPH Bureau of Primary Care and Rural Health (BPCRH), Louisiana Rural Health Association (LRHA) and the Louisiana Primary Care Association (LPCA), BFH staff have a direct line of communication to CHC providers that is not always as accessible for Louisiana Medicaid. The language testing with CHCs ensured that the new policy verbiage and directions on how to bill and stock for the LARC device made sense to providers. BFH RHP and Health Systems Strategy staff conducted meetings with BPCR, LRHA, and LPCA in July and August of 2018 to explain the impact of the new policy. Since the implementation of the new rule, BFH RHP has identified CHCs that will review and test the information in the summer and fall of 2019 and report back to Louisiana Medicaid with their findings. BFH will then work with Medicaid leadership to develop technical assistance documents to ensure that the implementation of the policy change is clear to the CHC provider community.

Evaluate RHII FQHC Contraceptive Use Outcomes:  An increasing focus for Title V programs is to contribute to the evidence base for Title V strategies. To that end, in the FFY 2019 application, Title V introduced State Performance Measure (SPM) 6: Most or Moderately Effective Contraceptive Methods as measured by the percent of women aged 15-44 years at risk of unintended pregnancy that adopt or continue to use a most or moderately effective method of contraception. The intention of this SPM was to evaluate the effectiveness of the RHII technical assistance and the impact of the Medicaid LARC reimbursement policy change. After reflection over the past year, the team determined that the measure itself misrepresents BFH’s goal regarding contraceptive access. BFH operates under the philosophy that the most effective method is the one that the patient chooses and fits their lifestyle, and it is not the intention of BFH to coerce patients regarding their contraceptive method. The LARC policy change and RHII support aim to reduce barriers to LARC access, but simply measuring change in LARC use does not represent the impact of those targeted strategies. Although BFH will continue to support the implementation of the policy change and monitor uptake of the most and moderately effective categories per Title X reporting requirements, Title V has decided to retire SPM 6 as a performance measure.

Support Implementation of Legislation Related to Equity

Healthy Moms Health Babies (HMHB) Advisory Council: In FFY 2018, the Title V Director assisted a legislator who sought to form a study group to examine and address racial inequities in maternal deaths and life-threatening complications. The Healthy Moms, Healthy Babies Advisory Council was authorized by Louisiana Revised Statute 40:2018.5 as a result, and has served as a call to action to ensure that state initiatives addressing maternal mortality and severe maternal morbidity include an equity focus informed by the community. In FFY 2019-2020, Title V provided support to the HMHB Advisory Council, including  facilitation of quarterly meetings, administrative follow-up, literature reviews, data analysis, and documenting findings and recommendations in the 2020 Healthy Moms, Healthy Babies Advisory Council Report.

Addressing Disparities in Maternal and Child Health Outcomes for African Americans: During the 2019 Regular Session of the Louisiana Legislature, the House Resolution 294 (HR 294) and Senate Resolution 240 (SR 240) required LDH to “take immediate action to address racial disparity in maternal and child health outcomes and the alarming rate of mortality for Black infants and mothers in Louisiana.” These resolutions asked LDH to submit a report on the immediate actions the Department is taking to address this issue, gather experts and key stakeholders for a summit in order to generate long-term recommendations to address the issue, and submit a report on recommendations from the summit. BFH was charged to carry out these legislative-mandated requests.

In FFY 2019, BFH worked with the LDH Office of the Secretary and the Louisiana March of Dimes to co-host two summits on the subjects of maternal and infant health outcomes. Summit attendees included community leaders, hospital leadership, healthcare providers, policy makers, state and local government representatives, doulas, midwives, non-profit professionals and volunteers, and public health specialists. Stakeholder input and recommendations resulting from the summits were also incorporated into the Title V Needs Assessment. Stakeholders agreed that improvement in the health of Black mothers and infants requires the coordination of community-based advocacy, political will, public health investment, community leadership, and the thoughtful and persistent elevation of the disparities that impact Black mothers and infants in Louisiana.