Overview and context of population domain
The perinatal and infant period is a time of transition for women and families and an unparalleled period of development for the child. Through the child’s first three years, 700 new neural connections are created every second1. Strong, stable, and nurturing relationships in this period can have lifelong impacts on health and development. The foundation for health and well-being starts here. Louisiana Title V invests in a variety of programs and initiatives to support infants and their families during this sensitive developmental period.
Louisiana has the fifth highest infant mortality rate in the country2. According to the 2019-2021 State Child Death Review (CDR) report, 41% of infant deaths are due to conditions originating in the perinatal period3. These conditions are closely related to maternal health before conception. Maternal health is also closely linked to low birth weight and premature birth4, both of which are risk factors for the second most common category of infant death in Louisiana, Sudden Unexpected Infant Death (SUID). Many of these deaths are sleep-related. While behaviors like co-sleeping expose infants to a heightened risk of SUID, social factors may influence a caregiver’s decision to co-sleep with their baby5.
Perinatal / infant health priority needs and performance measures
The 2020 Needs Assessment priority ranking process underscored the importance of improving birth outcomes, supporting secure infant-caregiver attachments, and reducing injury for Louisiana’s babies. The 2021-2025 State Action Plan strategies for this population domain are aligned with the following population priorities:
To strengthen the systems and supports that shape these factors, Louisiana Title V continues to execute strategies that align with the following systems priorities:
Throughout the FFY 2021-2025 strategic period, Title V investments in the perinatal / infant health population domain in Louisiana will contribute to improvement of the following outcomes at both state and national levels:
- Reducing the infant mortality rate per 1,000 live births
- Reducing the post neonatal mortality rate per 1,000 live births
- Reducing the Sudden Unexpected Infant Death (SUID) rate per 100,000 live births
Recognizing the evidence of the strong linkages between the desired outcomes and interventions promoting breastfeeding and safe sleep practices, Title V supported programs in Louisiana delivered strategies to improve the following performance measure(s):
- Percent of infants who are ever breastfed
- Percent of infants breastfed exclusively through 6 months
- Percent of infants placed to sleep on their backs
- Percent of infants placed to sleep on a separate approved sleep surface
- Percent of infants placed to sleep without soft objects or loose bedding
Summary of perinatal / infant health interventions supported by Title V in FFY2023
Population Priority: Improve birth outcomes for individuals who give birth and infants
Since improving maternal health before and after conception is a critical component of preventing infant mortality, many of Louisiana’s Title V initiatives that aim to improve perinatal and infant health outcomes are closely linked to maternal health efforts described in the previous section.
Similar to the NPM 2 strategies outlined in the Maternal / Women health domain, the core strategies related to NPM 4 also align with the Addressing Disparities in Maternal and Child Health Outcomes for African Americans: Summit Recommendations Report recommendation 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.”
Align hospital-based quality improvement initiatives to foster culture of improvement among Louisiana’s birthing facilities
The Louisiana Perinatal Quality Collaborative (LaPQC) implements a variety of initiatives promoting maternal and child health across the state. In partnership with hospitals and birthing centers, the specific initiatives implemented by the LaPQC include:
In FFY2023, the LaPQC team sought to create a culture of learning and continuous quality improvement through provision of a variety of training, coaching and technical assistance supports including:
- Conducting combined 1:1 hospital improvement planning meetings for the Safe Births Initiative (SBI) and the Gift including monthly Coaching Calls and quarterly Charter Chats.
- Providing coaching to hospitals to establish and maintain a joint SBI-Gift multidisciplinary quality improvement task force that coordinates both Gift and SBI-related work to increase efficiency and strengthen a facility’s capacity to implement change based on quality improvement science.
- Establishing a unified look across the LaPQC’s designation programs by transitioning the Gift Designation levels and related icons to “Gift” and “Gift+”.
- The development of the LaPQC website to create a visual hub unifying LaPQC initiatives for the general public, as well as a password protected section for participating facilities that houses initiative-specific, as well as cross-cutting tools, resources and information.
- Continued utilization of LifeQI, a shared quality improvement platform designed to facilitate the management and reporting of multi-site QI projects, across LaPQC initiatives.
- Planning the Perinatal-Neonatal Quality Improvement Conference (PNQIC) to be held in April 2024.
- Conducting a two-day, virtual Gift-SBI joint Learning Session for birthing hospital teams.
Population Priority: Reduce child injury and violence
Ensure high-quality fetal, infant, and child mortality review processes
Title V supports one mortality epidemiologist and a statewide network of nine regional maternal and child health (MCH) coordinators who work within their communities on critical maternal and child mortality surveillance activities. To complete the Child Death Review (CDR), MCH coordinators abstract comprehensive information from vital records, coroner, law enforcement, and medical reports, and summarize information on deaths among children under the age of 15 years.
There are 9 local level Child Death Review (CDR) panels. Each panel includes approximately 10-15 people who represent local public health offices, local child and family services offices, local community based organizations, local faith-based organizations, local coroners offices, local sheriff / police offices, and other local officials and concerned persons. Local CDR panels meet on a six-monthly basis. Recommendations defined by local CDR panels are disseminated to local state agency offices and to local community based organizations to promote evidence based actions for childhood injury and mortality prevention.
At the state level, the Louisiana Child Death review panel is a multidisciplinary panel of 28 members of Louisiana state and non-governmental agencies and organizations. The state CDR panel serves as a platform to elevate local-level issues or to support CDR partners in statewide systems change efforts. The LA Child Death Review panel is also responsible for the publication of annual Child Death Review reports that highlight specific prevention recommendations by audience and topic area.
In FFY2023, Louisiana’s State CDR Panel created a Safe Sleep Workgroup. This workgroup collaborated with Woman’s Hospital in Region 2 (Baton Rouge area) to highlight and disseminate strategies of their Safe Sleep Initiative. Their initiative includes a local task force, staff education, patient education, peer counseling, and hospital policies and has resulted in a decrease of Sudden Unexpected Infant Deaths (SUIDs) in the region. The workgroup also reviewed and updated safe sleep presentation materials with updated graphics, messaging, and data with input from healthcare providers, safe sleep experts, and community partners. The Safe Sleep Workgroup also worked on revising their SUID notification process. The process going forward will not only provide healthcare providers with information on whether a patient from their practice died due to unsafe sleep environments but also with resources to help empower their patients and reduce infant deaths.
Train professionals on evidence-based safe sleep practices
Every year in Louisiana, an average of 57,808 infants are born alive. Of these infants approximately 450 die before their first birthday. Child Death Review (CDR) investigations carried out by local and state CDR panels show that the top causes of infant mortality are conditions originating in the perinatal period and causes associated with Sudden Unexpected Infant Death (SUID). In Louisiana, most SUID deaths occur when the infant is 1 to 3 months old. The most common SUID risk factors present among these deaths are: infants sleeping in something other than a crib or bassinet (83%); infants sleeping with other people (85%); and infants sleeping with loose bedding or toys (70%). Other evidence-based risk factors for SUID include: stomach- or side-sleeping position; preterm birth or low birth weight, cigarette smoke in the home; and alcohol, drug, or tobacco use during pregnancy. The infant mortality rate due to SUID in Louisiana has remained consistently above the rate for the United States.
LaPRAMS 2021 infant sleep environment data coupled with data collected via the Louisiana Child Death Review Reporting System (2019-2021) elevated the need for providers to target caregivers with safe sleep education during the prenatal period. In July 2022, the American Academy of Pediatrics released an updated policy statement and corresponding technical report on evidence-based infant safe sleep recommendations. The updated recommendations emphasized the need for physicians, non-physician clinicians, hospital staff, and childcare providers to endorse and model safe infant sleep guidelines from the beginning of pregnancy.
The Bureau of Family Health Communications Specialists created the Safe Sleep Toolkit to support this recommendation. The toolkit includes provider talking points, social media assets, and the following outreach materials: ABCs of Safe Sleep; Clear the Crib; Flat Surfaces; Share the Room not the Bed. The Safe Sleep Toolkit release coincided with national SUID Safe Sleep Awareness Month in October 2023. Both the Louisiana Department of Health and Bureau of Family Health conducted coordinated social media campaigns targeting providers, caregivers, and the public. In addition, Maternal Child Health Coordinators shared the toolkit within networks of stakeholders and providers among hospital staff, providers, regional CDR teams, CAATs, and at community events encouraging all to incorporate into their practices.
In FFY2023, MCH Coordinators trained 2,546 professionals on evidence-based safe sleep practices. The nine MCH Coordinators provide training through in person and virtual platforms. Training included, safe sleep demonstrations, presentation and distribution of printed safe sleep materials. The CAAT and CDR teams were instrumental in providing education to professionals throughout the state. Two of the nine regions have active safe sleep task forces that train professionals and caregivers. They collaborate with Cribs for Kids and local coroners office to provide safe sleep resources including sleep sacks.
Support a statewide network of qualified Louisiana Child Care Health Consultants (CCHC) to provide training on safe infant sleep to licensed childcare facilities
In FFY2023, childcare consultants continued to provide safe infant sleep training to licensed childcare facilities. Approximately 1270 childcare centers participated in safe infant sleep training in FFY2023.
Licensure of early care and education is led by the Louisiana Department of Education (LDOE). The Department of Education’s Pathways credentialing system is responsible for providing certifications for qualified child care centers across the state. To support these centers, LDOE has developed a training platform where child care directors/staff can receive mandatory safety and health training. The child care health consultant services were successfully transitioned to the LDOE in FFY2023. BFH continued to provide content expertise on the training and input on requirements/policy related to credentialing for persons who wish to provide health and safety training for early child care centers/home personnel. The handover to LDOE is expected to be completed by June 30th 2024.
System Priority: Ensure equitable access to high-quality and coordinated clinical and support services
Promote and support implementation of evidence-based maternity care and breastfeeding practices in birthing hospitals, pediatric hospitals, and freestanding birth centers through the Gift quality improvement and hospital designation program
The LaPQC continued to support hospitals in implementing Gift 3.0 through quality improvement coaching, collaborative learning, and the provision of tools, resources and training. The updated Gift 3.0 criteria, introduced in FFY2022, requires hospitals to implement new data and other improvement processes that were not required for Gift 2.0 designation. While no new Gift designations were achieved during FFY2023, 39 birthing hospitals maintained their current designation status.
During FFY2023, the LaPQC rolled out access to the Coffective Breastfeeding Skills Competency, replacing the previous staff and provider training modules. The equity-focused, competency-based training is structured around The Ten Steps to Successful Breastfeeding and meets training standards outlined in Baby-Friendly USA’s 6th Edition Guidelines & Evaluation Criteria.
Freestanding pediatric hospitals with neonatal intensive care units (NICUs) were not prioritized due to the low number of freestanding Pediatric hospitals in the state. However, those hospitals are connected to hospital systems that are participating in the LaPQC and engaging in improvement work. Taking a regional and health system approach, the LaPQC encouraged those sites to reach out to their birthing hospital partners to collaborate around on-going QI activities. To inform future work with NICUs within birthing hospitals, a baseline survey was initiated at the end of FFY2023 to understand current implementation of best practices related to infant feeding.
In FFY2023, the LaPQC established a faculty for its Community Birth Initiative (CBI). The faculty consist of a multidisciplinary expert panel that will 1) Provide quality improvement coaching, tools and resources, as well as collaborative learning opportunities, to support Free Standing Birthing Centers (FSBCs) with consistent implementation of best practices and 2) Partner with FSBCs, hospitals, emergency departments and emergency medical service providers to improve preparedness for transition of care from community births to hospitals. The LaPQC also met with the Smooth Transitions team from Washington State to learn more about their collaborative improvement work related to transfers from community birth to hospital. The LaPQC also developed an operational definition for participation for FSBCs to be codified by the Perinatal Commission in FFY2024. Implementation of the CBI will begin in FFY2024.
Assist hospitals with identifying strategies to reduce racial disparities, including collecting and reporting on outcome measures stratified by race and providing hospital/clinical staff and provider education that addresses racial and socio-economic disparities in breastfeeding
The LaPQC worked with We All Count (WAC) to implement components of the WAC Data Equity Framework, which included updating and aligning the data disaggregation strategy across all LaPQC initiatives. In addition, WAC assisted the LaPQC in updating its collaborative level aim for The Gift.
Support alignment of activities and continuity of care between hospitals and community breastfeeding support resources
An informal assessment of WIC utilization of patient education materials to support consistent breastfeeding messages found that the materials are no longer in use due to competing participant education needs and implementation support for staff. The LaPQC and WIC will identify new approaches for consistent messaging and alignment in FFY2024. Community-based, culturally appropriate breastfeeding resources continued to be highlighted during coaching calls, Charter Chats and LaPQC email communications with birthing hospitals.
The BFH coordinated with WIC and Birthmark Doula Collective to develop and disseminate emergency preparedness and response information related to breastfeeding/infant feeding. The LaPQC worked with WIC to promote the Pacify app, a video-enabled, 24/7 app providing access to maternal and pediatric experts, including co-hosting a provider webinar about Pacify app + LA WIC partnership and how they can use the app to support patients.
Provide funding and staff support for community-based, culturally appropriate, peer-based breastfeeding support for women of color
The BFH continued its partnership with the New Orleans Breastfeeding Center (NOBC) to maintain seven breastfeeding support circles for women of color, including a Spanish-speaking circle, and build capacity to increase the number of lactation professionals and peer lactation supporters of color until June 2023. This work culminated in a survey of Spanish-speaking participants to learn about barriers to access for WIC, Medicaid and community-based resources for pregnant and postpartum mothers.
Support implementation, monitoring, and evaluation of the Medicaid breast pump policy and promote awareness of Medicaid human donor milk coverage
A leadership transition in Louisiana Medicaid led to the discontinuation of regular LaPQC - Medicaid check-ins. However, prior to the transition, the LaPQC team worked with community partners, patients and hospital staff and Louisiana Medicaid to identify opportunities to amend the breast pump coverage policy to increase access to breast pumps prior to delivery. Changes to the Medicaid policy will occur in FFY2024. In addition, the LaPQC collaborated with Louisiana Medicaid, WIC and Birthmark Doula Collective on Louisiana Medicaid Outpatient Breastfeeding Focus Groups study that led to and informed the development of a new In Lieu Of Services (ILOS) Policy for Outpatient Breastfeeding support. This is currently a voluntary program that the MCOs have the option to adopt. If they do, then lactation support providers (e.g., IBCLCs and CLCs) will be able to bill participating MCOs for services they provide. Some highlights of the ILOS include:
-- services at any location (e.g., clinic, member's home, or other location)
-- services by any delivery method (e.g., face-to-face, telehealth, group)
-- services without prior authorization
-- covered until the child is 24 months old
This policy is just one feature in a larger landscape of potential services for new mothers. Adoption of this policy by the MCOs will be monitored in FFY2024.
BFH continued to serve as a liaison between patients (or people who work directly with patients) seeking support related to breast pump access and Medicaid through the breastfeeding@la.gov account.
Scale evidence-based practices related to the care and treatment of birthing persons and newborns affected by opioids through the LaPQC Improving Care for the Substance Exposed Dyad (ICSED) initiative
In FFY2023, the Bureau of Family Health (BFH) continued to take a lead role in the imminent work of the Office of Public Health (OPH) in addressing the opioid epidemic among the perinatal and neonatal populations. Through the Improving Care for the Substance-Exposed Dyad (ICSED) initiative, launched in September 2021, the LaPQC with support from Louisiana’s State Opioid Response (LaSOR) grant has worked with participating facilities to use quality improvement science and a dyadic approach to implement key hospital-based structures (policies, trainings, staff education, and procedures) related to supporting substance-exposed dyads and providing substance-use care in a respectful, informed, stigma-free, collaborative way.
By 2023, a total of ten birthing facilities, representing LDH Regions 2, 3, 5 and 9 of the state, were actively participating in the LaPQC’s ICSED initiative to improve the implementation of best practices related to recognition and response of perinatal substance use disorder and substance exposed newborns. Despite the high will and high level of urgency, this work is challenging and complex with many change ideas needed to effect change. To make the initiative more manageable, the LaPQC team, in partnership with the birthing facility teams, identified five areas of focus for the participating teams:
- Screening
- Resource mapping
- Coordinated perinatal and infant discharge, including a referral and support plan
- Non-pharmacologic care
- Breastfeeding
Using data from Q1 and Q2 of 2022 as a baseline, universal verbal screening rates increased from 70% to 92% in 2023 among participating facilities. Referral to appropriate recovery treatment services for individuals who screen positive for substance use disorder increased from a baseline of 36% to 57% in 2023. Referral to Medications for Opioid Use Disorder (MOUD) decreased from a baseline of 29% to 27%. Self-reported connection to recovery treatment services remained flat between 2022 to 2023 at 50%. In ICSED participating teams in 2023, more infants at risk for neonatal abstinence syndrome (NAS)/NOWS roomed-in with the postpartum parent or caregiver compared to 2022. The rate increased from 76% to 85%. A similar increase was seen during that same time period for substance exposed infants who were still hospitalized and allowed to room-in with the parent or caregiver after the parent or caregiver had been discharged, indicating that some facilities are beginning to overcome this logistical barrier.
In July 2023, as part of the ICSED initiative and with funding from the Louisiana State Opioid Response (LaSOR) Grant, the LaPQC worked with Stader Opioid Consultants to develop a small pilot focused on distributing naloxone to patients upon discharge from the labor and delivery unit. Five birthing facility teams are participating in the pilot that will conclude in FFY24. In addition, the LaPQC also worked with the SOC and Bedrock Productions to begin the development of a video series that brings awareness to SUD among pregnant and postpartum individuals. In doing so, the series shows how non-judgmental, compassionate, and evidence-based care for pregnant and parenting patients with SUDs is possible to achieve and improves outcomes.
The LaPQC continued to actively participate on a state team receiving in-depth technical assistance from the National Center on Substance Abuse and Child Welfare (NCSACW) to support policy and practice changes related to the needs of newborns prenatally affected by substances and their affected families. This Louisiana state team, comprised of representatives from the Louisiana Department of Children and Family Services, Louisiana Department of Health’s Office of Behavioral Health and Office of Public Health, and the Pelican Center for Children and Families/Louisiana Supreme Court, transitioned from the NCSACW’s Policy Academy to IDTA in March of 2023. In July 2023, the LaPQC helped to coordinate a cross-systems working session with the National Center to develop a shared mission, vision, and goals related to the needs of newborns prenatally affected by substances and their affected families.
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