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. With 700 new neural connections created every second in the first three years and strong effects from nurturing relationships on lifelong health and development, the foundation for health and well-being starts here1. 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 fourth highest infant mortality rate in the country. According to the most recent State Child Death Review (CDR) report, 42% of infant deaths are due to conditions originating in the perinatal period. These conditions are closely related to maternal health before conception. Maternal health is also closely linked to low birth weight and premature birth2, 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 baby3.

Since improving maternal health before and after conception is an integral part 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. 

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

During the 2015-2020 Title V cycle, Perinatal/Infant Health Domain efforts and investments targeted the priority need to ensure high performing essential MCH screening and surveillance systems through Fetal Infant Mortality Review (FIMR) and the Centers for Disease Control and Prevention’s (CDC) Sudden Unexpected Infant Death (SUID) Case Registry.

Mortality surveillance: Louisiana conducts statewide fetal and infant mortality surveillance through Fetal Infant Mortality Review (FIMR) and the Centers for Disease Control and Prevention’s (CDC) Sudden Unexpected Infant Death (SUID) Case Registry. BFH oversees both systems through the statewide team of regional MCH Coordinators.

FIMR consists of two parallel strategies: case review and community action teams. FIMR reviews all cases of stillbirth over 28 weeks gestation and expected medical deaths 24-36 6/7 weeks gestation. Perinatal periods of risk (PPOR) analyses reflect that the majority of those deaths are related to maternal health before and between pregnancies. In FFY 2020, the mortality surveillance team began evaluating FIMR surveillance to identify high opportunity focus areas and to strengthen the maternal health aspect of FIMR case review.

Over the past several years, BFH revitalized the regional community action teams, originally part of the FIMR model, and now known as Community Action and Advisory Teams (CAATs). The redesigned teams connect BFH programs and services with families and stakeholders to foster a community-driven process designed to improve health outcomes, prevent injuries, and reduce inequities across the state. The new CAATs are intended to anchor BFH programs and services in communities and ensure family supports are responsive and tailored to the needs of each community. BFH aims to accomplish this through a shared decision-making process, meaningful engagement of local families and agencies, cultivation of community advocates, and filling gaps in services.

SUID Surveillance: The SUID Case Registry is a CDC-funded surveillance strategy that allows BFH to explore the context of sleep related deaths – the leading cause of injury-related deaths among Louisiana’s infants – to identify opportunities for prevention. Louisiana’s regional Child Death Review (CDR) panels review case materials and craft recommendations. The regional CAATs then translate recommendations from case review into action at the local level, or notify the state panel, if appropriate.

Accurate assignment of the cause and manner of death in SUID cases is critical for accurate vital statistics data to direct limited resources to appropriate targets, and to implement optimal and safe risk reduction strategies. ICD-10 (International Classification of Diseases) codes arise from the cause of death recorded on the death certificate. These codes are helpful for monitoring mortality rates, and incorrect coding of SUIDs can lead to difficulty in monitoring trends and directing resources. MCH Coordinators notify the Mortality Epidemiologist of cases that may have been assigned an incorrect cause of death per case review team. The Mortality Epidemiologist then provides a list of those cases to Vital Records on an annual basis, and Vital Records requests coroners review these cases and amend the death record if appropriate. After consultation with CDC partners, BFH determined that this activity does not appropriately measure progress. SUID rates are unchanged by any feedback loop with the coroners, as all cases under question are ultimately included as potential SUID cases as part of the CDC algorithm for SUID case identification. In FFY 2019, 13 cases were identified as incorrectly coded; however due to changes in this process, none of the respective coroners were notified.

BFH also provided ongoing support to coroner’s offices through regular training opportunities, investigation tools, and reimbursements for case information. In FFY 2019, the mortality surveillance team offered trainings through the Coroner Portal, hosted on BFH’s learning management system, where coroner investigators can learn how to investigate SUID cases, including doll reenactments. Doll reenactments assist mortality review teams in understanding the environmental circumstances contributing to the death. Supplies for these reenactments are purchased at regular intervals to ensure coroners and law enforcement have adequate tools to investigate SUIDs. Coroners also receive training on completing tailored SUID Investigation Reporting Forms (SUIDIRF). The SUIDIRFs provide information specific to infant death scenes and, coupled with a full abstraction, help mortality surveillance teams create a narrative of the circumstances that lead to the death. To encourage quality and completeness, Title V allocated funds to reimburse coroners for submitting autopsies and SUIDIRFs.

Translation of SUID data: Maintenance of quality data is key to produce BFH’s annual CDR Report. In FFY 2018, the CDR report was reformatted to reflect BFH’s commitment to ensure accessible, accurate data. Each page of the report can serve as a fact sheet, including cause and prevention information in addition to traditional incidence data. Based on recommendations from the CDR panelists and stakeholders, the latest report incorporated a new section highlighting injury prevention considerations for children and youth with special health care needs (CYSHCN), as well as individual regional mortality surveillance profiles for the 9 LDH regions.

The most public-facing element of Louisiana’s SUID data dissemination efforts is GiveYourBabySpace.org, a part of BFH’s larger SUID and Safe Sleep communication plan. The PartnersForFamilyHealth.org website (which unifies all BFH websites under one user-friendly interface for parents and families, women and men, and partners and providers) features a searchable Data Center. The Data Center assures that fact sheets and state and local data reports are easy to find, access, and download. The website and Data Center were rigorously maintained and updated throughout the year.

The mandated CDR, as well as several regional CAATs, continued to keep Safe Infant Sleep Subcommittees active and use SUID data to assure continuous focus and action related to the issue.

Community Safe Sleep Training: Louisiana Child Care Health Consultants (CCHC) continued to provide training on safe infant sleep to day care facilities statewide with compliance of new Department of Education regulations on safe infant sleep. In 2019, the regional MCH coordinators used the Awesome Safe Sleep presentation to train 646 professionals from a variety of settings, including nursing schools, provider networks, and other agencies. Regional MCH coordinators received safe sleep demonstration “kits” to be shared with community partners for presentations and teaching opportunities about safe infant sleep. The demonstration kits consist of a flipbook, Pack-N’-Play and a baby doll. The flipbook was designed with front and back messaging, where one side displays consumer/parent-friendly visuals and education, and the reverse side includes guidance and talking points for presenters. Following COVID-19, CCHC trainings have moved online.

Coordinated Breastfeeding and Safe Sleep Messaging and Activities: Developed in FFY 2016 and used extensively in FFY 2017, the Agency Position on Safe Infant Sleep continues to guide the work of BFH in shaping messaging and policy around infant sleep. The statement requires that safe infant sleep health education material, media and client interactions reflect a family centered, risk reduction approach that does not conflict with breastfeeding messaging. Accordingly, the GiveYourBabySpace campaign materials, including a website quiz game, were redesigned to reflect this stance. To further reinforce the messaging, all related talking points developed for media interviews and public relations opportunities within BFH manifested this position.

A workgroup, composed of program leaders, continued to meet regularly to identify opportunities to coordinate messaging, update content on the Give Your Baby Space website to align breastfeeding messaging and include a risk reduction approach. BFH has continued to collaborate with a local university safe sleep researcher to identify opportunities for funding to support the spread of the evidence-based safe sleep simulation training model. Once funding is secure, hospitals in Region 5 of the state have expressed an interest in adopting the approach. 

Father Engagement: Over the past several years, Title V has been working to deepen understanding of how  BFH can engage fathers to support the health and wellness of their families, particularly their female partners and children. Father involvement in caring for their children has been shown to affect the well-being of the family unit and is linked to positive health outcomes in infants. In FFY 2018, BFH contracted with the social marketing firm, MEE Productions, to conduct four focus groups with African American fathers in 2 areas of the state. Questions and discussions focused on testing messaging and materials to inform strategies for the ongoing safe infant sleep campaign and breastfeeding work, among other topics. Following this qualitative research and a review of existing BFH approaches and goals related to father engagement, a cross-program workgroup formed to explore, identify, and implement approaches to ensure fathers and their experiences are included in BFH’s maternal and child health strategies. In January 2020, the workgroup released a Data Brief focused on Louisiana fathers. The brief compiles and displays data pertaining to fathers from Louisiana's Vital Records and Statistics and is intended to prompt further research and collaborations.

Hospital Quality Improvement Efforts

Birthing Hospital Designation: To increase the percent of infants ever breastfed, BFH continued implementing its hospital breastfeeding quality initiative and designation program, The Gift. The Gift continued its evolution from a simple designation program to a comprehensive initiative addressing both in-hospital and community breastfeeding support focusing on three main goals:

• Improving maternity care practices
• Establishing consistent breastfeeding messaging
• Ensuring that pregnant women and new mothers are aware of available breastfeeding resources and other important services, like WIC (Women, Infant, and Children nutrition services) and home visiting

BFH is particularly proud of The Gift’s successful hospital participation; 50 out of 52 Louisiana birthing hospitals, representing 99.85% of births in the state, are engaged. One of those 50 participating birthing hospitals achieved designation during FFY 2019. The Gift continued to provide participating hospitals with high quality online training for nursing staff and providers (physicians), as well as a comprehensive system of tools to facilitate consistent breastfeeding messaging and referral to community breastfeeding resources. Hospitals were successfully engaged in collaborative learning activities, like Regional Collaborative Meetings and a yearly statewide hospital summit, to facilitate hospital-to-hospital learning. One-on-one improvement coaching was also provided to hospitals to support hospitals’ continuous quality improvement efforts.

Due to significant overlap in hospital improvement teams participating in both The Gift and the LaPQC’s Reducing Maternal Morbidity Initiative (RMMI), The Gift and the LaPQC teams identified opportunities for coordination and alignment during a series of strategic planning meetings. During these meetings, The Coffective team lead exercises to assist Gift and PQC teams in identifying overlapping activities and hospital touchpoints from the lens of the mother to the frontline worker and hospital leaders. After identifying areas of duplicity, the teams agreed on several activities for alignment: conducting joint topic calls that include cross-cutting topics, improving internal processes regarding hospital communication, working with one hospital to pilot a joint task force that works collaboratively across both initiatives. In addition, two Gift and two LaPQC team members participated in the Institute for Healthcare Improvement's Breakthrough Series Collaborative training. This helped to build upon team knowledge to implement quality improvement science in a consistent way across initiatives. 

To build the capacity of BFH’s perinatal and neonatal quality improvement work, The Gift adjusted its coaching model from three part-time to two full-time improvement coaches. Although the coaches worked predominantly within The Gift/neonatal space during FFY 2019, they also began to expand their knowledge of the LaPQC and its RMMI enabling them to provide support to hospital teams across initiatives.   

A continued success of The Gift program has been creating a culture of interest in the Ten Steps to Successful Breastfeeding and the Baby-Friendly Hospital Initiative (BFHI).

During FFY 2019, two Gift participating birthing hospitals achieved Baby-Friendly designation. The Gift worked closely with the state’s sixteen previously Baby-Friendly designated facilities to support their designation maintenance and continuous quality improvement requirements. The Gift continues to play a key role in supporting hospitals in achieving and maintaining their BFHI designation. The Gift encouraged Louisiana hospital participation in national breastfeeding quality initiatives such as the EMPower Breastfeeding and EMPower Training initiatives, in which seven Louisiana hospitals participated. The Gift also actively promoted hospital completion of the CDC’s Maternity Care Practices in Infant Nutrition and Care (mPINC) survey, resulting in a high completion rate.

In addition, The Gift continued to work closely with the Coffective Clinical Team to build The Gift’s capacity for quality improvement and BFHI alignment. During FFY 2019, The Gift transitioned to full implementation of its updated criteria for participation, designation, re-designation and maintenance. During this time, The Gift team continued to test and scale changes to improve its alignment with the BFHI and to better support quality improvement expectations.   

Support policies that make quality breastfeeding services accessible: BFH continued to provide subject matter expertise regarding Medicaid coverage of donor human milk and other breastfeeding support services and supplies, specifically breast pumps.  BFH continued to work with hospitals, providers, and community partners to facilitate successful implementation of the Medicaid breast pump policy that went into effect on January 1, 2019. BFH worked closely with community breastfeeding supporters and clinical champions to create a breast pump guide for providers and conduct pre-work for the development of a guide specifically for mothers.  BFH continued to participate in the Ochsner Medical Center led Mothers’ Milk Bank of Louisiana Community Advisory Group, facilitate coordination around efforts to increase utilization of donor human milk in Louisiana hospitals and work with the community to identify systems-level opportunities to support the utilization of donor human milk.

Community and Provider Breastfeeding and Safe Sleep Training: The Gift continued to provide online training to hospital nursing staff, as well as training for medical providers and residents. The Gift utilized the Coffective motivational training series, “Link and Spread”, to birthing facilities to empower influencers with tools that help them engage their community so that learners are motivated to start, willing to complete, and eager to apply their education. The Gift recruited a physician champion to deliver two in-person residency breastfeeding trainings. To expand the reach of residency training, The Gift began to offer these trainings through a hospital’s learning management system (LMS) as well as virtually through a live webinar. In partnership with the Coffective Clinical Team, The Gift released a 5-hour staff competency-based breastfeeding training curriculum, with a focus on safety and safe sleep, to assist with requirements of The Gift and the BFHI, as well as mPINC’s inclusion of measures related to these topics.

The Gift continued conducting in-person community trainings targeting birthing hospitals and local community organizations and programs that reach pregnant women and new mothers. These trainings facilitated networking and learning about local and statewide services, evidence-based breastfeeding practices, and how to prepare mothers to receive evidence-based practices in the hospital.

Community Breastfeeding Support and Coordination
As one of the key pillars of The Gift, BFH continued to facilitate linkages between hospitals and community breastfeeding support resources through the use of the Coffective system of tools. The Coffective online breastfeeding resource directory is a tool that serves to strengthen continuity of care by increasing awareness of services and resources that can assist mothers with their goals. Louisiana hospitals continued to have the ability to customize a prenatal preparation form, the “We’re Prepared!” Checklist. This tool outlines 15 evidence-based practices to help prepare each mother for her hospital stay and highlights postpartum appointments to optimize continuity of care. Also designed to assist with the postpartum period, this tool directs mothers to the Coffective app that connects to the online breastfeeding resource directory, where they can continue to build their team and get connected to resources after discharge.

During FFY 2019, efforts also continued to align breastfeeding messaging and activities through internal and external partnerships including OPH Bureau of Nutrition Services (WIC), OPH Bureau of Chronic Disease Prevention and Health Promotion, BFH’s MIECHV program, and Healthy Start New Orleans.

Support community breastfeeding organizations: Title V continued to provide staff support to the Louisiana Breastfeeding Coalition (LBC) steering committee. The LBC works across sectors on state and local levels with the mission “to make breastfeeding the norm for all babies in Louisiana.” Title V staff helped the LBC steering committee maintain current activities, projects, and grants, build coalition capacity, and facilitate the development of local coalitions and networks.

To help address racial breastfeeding disparities, BFH provided support to the New Orleans Breastfeeding Center (NOBC) to build a network of community-based breastfeeding support groups for women of color. BFH transitioned from the Black Mothers’ Breastfeeding Club model to the NOBC Louisiana Cafe au Lait model, which provides infant feeding support for families of color. Support includes overcoming barriers to breastfeeding as well as the prevention and management of breastfeeding problems during the prenatal/postpartum periods. The five Cafe au Lait groups, located throughout Louisiana, are led by persons of color who are trained breastfeeding professionals. The primary focus is to build peer relationships and learn from community knowledge as opposed to “lactation expert classes.” Peer support groups have been demonstrated to be effective in increasing the initiation, duration, and exclusivity of breastfeeding. This partnership with NOBC also aims to increase the skills, capacity and number of professional and peer lactation supporters of color and advance health equity in BFH breastfeeding programs/strategies. This is accomplished through the training of NOBC’s Cafe au Lait facilitators as well as conducting quarterly Breastfeeding Grand Rounds, which is a meeting of lactation support people to review and learn from recent lactation case studies.

Neonatal Abstinence Syndrome (NAS): BFH remained involved in state-level, interagency collaborative efforts to enhance NAS identification, treatment, and prevention in Louisiana, to identify best practices, and to make recommendations to stem the growing number of NAS cases statewide. The Office of Behavioral Health (OBH) is the designated lead agency to address the opioid crisis in Louisiana, and Regional MCH coordinators collaborated with regional OBH-funded Opioid Prevention Outreach Coordinators to integrate local opioid efforts.

During the 2018 regular legislative session, LDH was charged with creating an evidence-based pilot demonstration project that improves outcomes associated with Neonatal Opioid Withdrawal Syndrome (NOWS), and BFH was assigned to oversee the pilot. The NOWS Pilot Project is positioned under the Bureau’s Louisiana Perinatal Quality Collaborative (LaPQC). In February 2019, birth facilities and affiliated perinatal quality improvement teams interested in partnering with the LaPQC to test, implement, and evaluate care delivery approaches for mothers and infants impacted by opioids were invited to respond to a public call for proposals. The LaPQC convened a multi-disciplinary team to review responses and in May 2019, two birthing facilities were selected to participate in the LaPQC Neonatal Opioid Withdrawal Syndrome (NOWS) Pilot Project. With the support from LDH’s Office of Behavioral Health’s Substance Abuse and Mental Health Services Administration (SAMHSA) funded LaSOR 1.0 grant, the pilot project grew from two to four facilities in January 2020. 

Through this pilot, the LaPQC team works closely with the pilot facility teams to:

• Co-create a menu of evidence-based best practices that can be implemented by birthing facilities across Louisiana;
• Collaborate on the development of a comprehensive measurement strategy that captures key process and outcome measures;
• Build quality improvement capacity at the facility level by teaching the fundamentals of quality improvement, including plan-do-study-act cycles;
• Develop a core group of NOWS/Opioid Use Disorder (OUD) thought and process leaders to serve as mentors for future improvement work;
• Lay the foundation for a larger, statewide initiative related to NOWS/OUD.

The pilot project prioritizes co-location of the mother-infant dyad, optimizes maternal access to evidence-based treatment of OUD, and promotes practices that improve infant health outcomes. The pilot facility teams meet monthly with the LaPQC team, complete facility- and provider-level assessments of current practices, develop work plans that include patient partnership, test changes and submit monthly data reports capturing the learnings from the practice changes tested. Teams work to implement best practices to support and improve the care for substance exposed mothers and newborns outlined in national and state level toolkits, including the ACOG Alliance for Innovation on Maternal Health (AIM) Obstetric Care for Women with OUD bundle and the California Maternity Care Collaborative’s Mother & Baby Substance Exposure Toolkit.