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 percent of female victims (39 out of 40) were murdered by someone they knew. Of the victims who knew their offenders, 56 percent (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, 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. High rates of substance use are correlated with high rates of mental health issues. According to the 2020 Pregnancy Risk Assessment Monitoring System (PRAMS) Report, roughly 14% of persons surveyed reported experiencing depression prior to and during pregnancy. 16.8% 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 5.

 

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

 

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 (NOM) 2)
• reducing the rate of maternal mortality per 100,000 live births (NOM 3)

 

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 (National Performance Measure (NPM) 2)

 

The strategies implemented to reduce cesarean deliveries among low-risk first births are evidence-based, and adapted to the unique context of the state of Louisiana. In FFY2022, LA Title V aimed to achieve the following objectives in relation to the women / maternal health population domain:

• By December 2022, reduce the number of low-risk, first-time cesarean births from 28% to <25% through the second year of the Louisiana Perinatal Quality Collaborative (LaPQC) Safe Births Initiative (SBI)
• Annually award Louisiana Birth Ready Designation to birthing hospitals meeting designation criteria

 

Summary of women / maternal health interventions supported by Title V in FFY2022

 

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”.

 

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 Perinatal Commission is authorized to review statistical and provider-level data in order to carry out this charge. The state’s PAMR and 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 FFY2022, Title V continued to fund key staff roles to support an engaged and forward-moving membership.

 

Louisiana Perinatal Quality Collaborative (LaPQC):  During FFY2022, BFH continued to invest Title V funding to sustain and support the growth of the LaPQC. The LaPQC is a network of perinatal care providers, public health professionals, and advocates who work to improve outcomes for individuals who give birth, families, and newborns in Louisiana. The LaPQC partners with hospitals, policy makers, governmental entities, and advocates to support the implementation of evidence-based practices to improve outcomes for all individuals who give birth in birthing facilities.

 

Operating under the authority and data privacy protections of the Perinatal Commission, the LaPQC supports birthing facilities across the state by using improvement science to implement evidence-based best practices that promote safe, equitable, and dignified birth for all individuals and neonates. Since its inception, the LaPQC has focused on ensuring quality improvement occurs through a lens of equity. The LaPQC serves as the vehicle for implementing the Alliance for Innovation on Maternal Health (AIM) patient safety bundles. The overarching vision for the LaPQC; however, is much broader than implementation of evidence-based practice in service of improving outcomes for all individuals who give birth and neonates. 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 beyond birthing hospital settings. For Louisiana’s Title V program, LaPQC was envisioned as part of the systems change continuum that originates with public health surveillance of maternal and child health (MCH) outcomes. Since its inception in 2018, the LaPQC has launched a total of 6 initiatives, in addition to two designation systems (Birth Ready and Gift). 

 

Provide technical assistance and data support to birthing facilities pursuing the LaPQC Louisiana Birth Ready Designation: In January 2021, the LaPQC launched the SBI as a vehicle for continued work related to hemorrhage and hypertension, as well as new efforts, such as reducing Louisiana’s first time, low-risk cesarean delivery rate. SBI now serves as a “home” for AIM patient safety bundle implementation as guided by recommendations generated by the PAMR Committee and published in the annual PAMR Report. The goal of SBI, and the LaPQC overall, is the implementation of practices that promote safe, equitable, and dignified birth for all individuals giving birth in Louisiana. A safe, equitable, dignified birth is defined as:

• 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 patients of color – particularly Black and African American patients – 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, patients 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.

 

In FY2022, 40 of the state’s 48 birthing facilities participated in SBI. Each participating birthing facility attended structured monthly coaching calls with the LaPQC leadership. While the coaching calls catered to the individual needs and priorities of each hospital team, they also included a shared learning component that allowed peer facility-based improvement teams to highlight how they applied improvement science methods to change practices in their facilities and achieved results on their teams and with their patients.

 

The LaPQC leadership also facilitated a monthly topic call for participating hospitals, which gave facility-based teams access to topic specific experts in order to ask questions and share resources. The topic calls were didactic, while the coaching calls allowed for more collaborative learning. Individualized hospital improvement coaching was also provided to participating teams through quarterly “Charter Chats”. During Charter Chats, LaPQC improvement coaches worked with each team to develop a 30-60-90 plan for the hospital’s improvement work, inclusive of an overall aim and an equity related aim.

 

Through SBI in participating facilities, the low-risk, first time cesarean birth rate as defined by the Joint Commission (TJC) PC-02 has been reduced by almost 5% in the last 18 months. At the beginning of the launch of the initiative, the Louisiana TJC PC-02 was 33%. By December 2021, the rate had been reduced to 28.6% and was 27.7% by the end of September 2022.

 

Louisiana Birth Ready Designation: In FFY2021, the LaPQC launched a designation system to award hospitals that achieve and maintain certain quality improvement milestones. The Louisiana Birth Ready Designation distinguishes birthing facilities committed to practices that promote safe, equitable, and dignified births. In August 2021, Birth Ready Designations were awarded to 16 facilities and in February 2022, 11 additional hospitals were awarded, which brought the total number of hospitals with Birth Ready and Birth Ready+ Designations to 27. 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 met a higher threshold of compliance and achievement of the requirements.

 

 

Population Priority: 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 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 birth centers and 2) the realignment of the levels of maternal care for hospitals with recommendations provided by the American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine. The regulations for free-standing birth centers emerged from a multi-year inquiry of standards and best practices for birth centers, a need first identified 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 led the comprehensive, stakeholder-engaged process to review the current licensing requirements for birthing facilities and the designation process. Participants in the review and development of the new requirements included clinical providers, administrators, health system leaders, the hospital licensing authority, professional associations, advocates and patients.

 

The development of the proposed new regulations included three steps: comparison of Louisiana’s current regulations against the new national guidelines; voluntary facility-level assessment of current practices against the new national guidelines 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 FFY2022, LDH published the final rules for birthing hospitals and the first-ever draft regulations for free-standing birth centers.

 

Support launch and operation of Louisiana Doula Registry Board: During the 2021 Louisiana Regular Legislative Session, a new law (Act 182) created the Louisiana Doula Registry Board to review, approve, and/or deny applications for doulas registering to receive health insurance reimbursement in the state and to maintain a statewide registry. Act 182 defined doula as an individual who has been trained to provide physical, emotional, and educational support, but not medical or midwifery care, to clients and their families before, during, and after childbirth. BFH was assigned to facilitate the implementation of the Louisiana Doula Registry Board and supported the member appointment process. The LaPQC medical director was responsible for appointing representatives from organizations providing doula services in each of the nine LDH administrative regions. This work was supported through staff funded by Title V.

 

Launch an LaPQC initiative to support perinatal depression screening by pediatric providers: The Caregiver Perinatal Depression Screening (CPDS) in Pediatric Clinics pilot was a 12-month learning collaborative tasked with developing QI strategies to support the implementation of perinatal depression screening in pediatric settings at the 1, 2, 4, and 6-month well-child visits. The aim of this pilot was to achieve and maintain an 85% screening rate among pediatric clinics participating in the LaPQC pilot. Teams were asked to commit to QI activities including monthly calls and data submission, as well as test change ideas throughout the course of the pilot.

 

In fall of 2021, the LaPQC enlisted content experts across BFH to develop the foundational documents for the pilot including a change packet and measurement strategy. In January of 2022, LaPQC hired a team lead for the project, identified funding to support faculty and staff time, and began recruitment. Faculty included an obstetrician, pediatrician, mental health provider and a person with lived experience. The team selected four clinics using a rubric to score experience in quality improvement (QI) work, identification of champions, and diversity of clinic personnel.  The pilot launched in May 2022 and clinics began reporting data in June 2022.

 

Support improvements in the implementation of the Louisiana Mental Health Perinatal Partnership (LAMHPP): In FFY2022, BFH continued its partnership with Tulane University School of Medicine to support and provide direction to LAMHPP, a provider-to-provider consultation system to support licensed healthcare clinicians serving pregnant and postpartum individuals and their families. LAMHPP supports 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 training and online resources related to perinatal depression, anxiety, substance use disorders, interpersonal violence, and related health risks, as well as through psychiatric phone consultation and 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 FFY2022, 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. BFH also initiated the process to bring LAMHPP more directly under the day-to-day oversight of the Bureau to align it with pediatric consultation.

 

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, including 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 FFY2022, 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 57 OPH parish health units (PHU). 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 and use 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 of these efforts. These providers serve as critical access points in many communities and provide 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.

 

 

Population Priority: Partner with families, youth, and communities at all levels of systems change

Develop and implement the RHP Patient Advisory Committee: In FY2022, initial steps were taken to constitute an advisory committee for the RHP.  A question was added to RHP client satisfaction surveys to gauge client interest in participating in an advisory committee. During the first survey period, nearly 60 clients, including persons of all age ranges, expressed interest. The first meeting has been planned for August 2023. Members will review and provide feedback on all RHP reproductive health information and educational materials and will provide input on which services should be offered and what populations should be served.

 

 

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 worked to establish the foundation for systematic ongoing surveillance of maternal deaths, as well as 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 previous block grant cycle, Title V funding was used 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 FFY2019, BFH was awarded a competitive Centers for Disease Control and Prevention (CDC) Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) grant, which enabled PAMR to onboard additional full-time staff and access CDC resources.

 

In FFY2022, the core PAMR team consisted of a dedicated maternal mortality epidemiologist, a PAMR coordinator, and a statewide network of nine regional MCH coordinators working 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 abstracted comprehensive data from medical reports, as well as from vital records, coroner and law enforcement, and summarized case information for state-level review and systems action. The review of the cases that occurred in 2020 began in February 2022.  In total, the PAMR committee reviewed 82 maternal death cases. 

 

The team undertook important changes to improve processes and tools used to prepare cases for review and to facilitate robust deliberations and formulation of recommendations. They streamlined administrative processes that facilitate review across the state, including the development of a standardized process and tools (case summary form, Louisiana Bias or Racism and Social Determinants of Health (LABoRS) tool, and the Utah tool). The LABoRS tool includes a section for demographics using the Maternal Mortality Review Information Application (MMRIA) home record, social determinants of health (SDOH), a geospatial analysis of SDOH data, and a chart for capturing case record findings on potential bias, discrimination, or barriers to care. During the review of 2020 cases, the LABoRS tool helped to identify potential bias, discrimination, and/or barriers to care in 17 of the 82 cases. Additionally, the Utah Tool helped to identify pregnancy-relatedness in 7 of the 32 suicide/overdose cases reviewed in the 2020 cohort.

 

In September 2022, BFH published the 2017-2019 Louisiana Pregnancy-Associated Mortality Review Report. This report is reflective of the expanded case review eligibility, reporting on deaths that occurred while pregnant or within a year of pregnancy due to any cause of death.

 

Support implementation of Louisiana Domestic Abuse Fatality Review (DAFR) Panel: During the 2021 Regular Session of the Louisiana State Legislature, Act 320 was signed into law, mandating a DAFR team within LDH. Due to the Bureau’s expertise in leading comprehensive mortality reviews such as PAMR, BFH was assigned as one of the lead agencies responsible for implementing the new panel.

 

In FFY2021, BFH applied for and was awarded a grant from the Department of Health and Human Services (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. In FFY2022, BFH identified a multi-disciplinary panel of 20 members and four authorized agents with representation from law enforcement, the justice system, advocates, subject matter experts, and domestic violence shelters. The DAFR Panel meets quarterly to conduct case review and identify recommendations for prevention. Some preliminary recommendations based on the first three case review meetings include trauma-informed care, predominant aggressor, and best practices training for law enforcement when responding to calls of domestic violence; domestic violence training for judges to better advise sentencing recommendations after an offender has been convicted; batterer intervention program pre-trial interventions for offenders with a history of domestic abuse; increase victim access to legal and financial assistance to obtain a divorce when in a relationship with a history of abuse; and medical screenings for domestic violence during doctor visits.

 

Ensure robust, high-functioning Louisiana Pregnancy Risk Assessment and Monitoring System (LaPRAMS):  One of the core MCH surveillance systems is LaPRAMS. The CDC PRAMS funding supports some of the staff time and costs to administer this statewide annual survey of individuals 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 to inform decision-making, within LDH and among partners.

 

In FFY2022, Title V support allowed LaPRAMS to continue to strengthen its 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 uses LaPRAMS data to add depth to Louisiana’s annual CDR report, Safe Sleep educational initiatives, the Title V Block Grant, the Louisiana ACE Educator program, Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program, 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, have helped ensure that LaPRAMS is a high performing MCH surveillance system in Louisiana.

 

 

Systems Priority: Boldly work to undo systemic drivers of disparities and institutionalize equitable policies and practices

Actively participate in Association of Maternal and Child Health Programs (AMCHP) Healthy Beginnings learning and practice cohort: Throughout 2022, OPH-BFH participated in the AMCHP “Phase II: Healthy Beginnings with Title V: Advancing Anti-Racism in Preterm Birth Prevention” cohort in collaboration with Sista Midwife Productions. By December 2022, the group finalized an action plan for strategies that Title V programs can use to disrupt racism in practice. The overall strategy aims to use Title V funding to ensure perinatal data is disaggregated to analyze social determinants data so that solutions can be inclusive, relevant, and accessible to all stakeholders. In the short term, the initiative aims to ensure that all BFH staff are aware of the data center located on partnersforfamilyhealth.org, and have the capacity to effectively communicate to internal and external partners about available data and resources and how to efficiently access them. The long-term goal is to update BFH websites and other public interfaces to provide easy access to data request forms and increased transparency via live data with regularly scheduled updates.