Women/Maternal Health Priorities and Performance Measures

In FFY 2023, Title V will continue to implement strategies to improve birth outcomes and mental health for Louisiana women. Improving systems and upstream factors will be crucial in executing the State Action Plan strategies associated with these priorities. To that end, Louisiana Title V will also implement strategies that align with the following Systems Priorities:

• Ensure equitable access to quality, coordinated care and supportive services
• Ensure Title V strategies are outcomes-focused and rooted in essential public health services

Louisiana Title V selected the following Women’s/Maternal National Performance Measure for the FFY 2021-2025 cycle:

• NPM 2: Low-risk Cesarean Delivery: While cesarean delivery can be life-saving under some circumstances, for most low-risk pregnancies, cesarean delivery poses preventable risks such as hemorrhage, infection, and blood clots. Data show that cesarean deliveries increased 60% between 1996 and 2011. Today, 60% of cesarean births are primary cesareans5. Reductions in rates of low-risk cesareans, also known as nulliparous term singleton vertex (NTSV) cesareans may help reduce adverse maternal birthing outcomes. Title V will build upon the progress from the previous cycle to scale hospital quality improvement initiatives through the Louisiana Perinatal Quality Collaborative (LaPQC) and support implementation of evidence-based practices to reduce rates of low-risk cesarean deliveries.

Summary of Title V Efforts and Alignment with Priorities

Population Priority Need: Improve birth outcomes for birthing person and infants

One of the key factors related to birth outcomes is access to quality preventive and specialty care, including family planning services and pregnancy-related care and support through one year postpartum. Title V-supported strategies focus on system improvement efforts complemented by reinforcing policy change to improve access to and care and to ensure that the care that is available and accessible is provided with the skill, integrity, and accountability necessary for optimal outcomes.

Implement the Louisiana Perinatal Quality Collaborative Safe Births Initiative: In FFY 2023, Title V will support the ongoing implementation of the Louisiana Perinatal Quality Collaborative (LaPQC) Safe Births Initiative. As part of the Safe Births Initiative, participating hospitals will continue to submit data related to priority improvement areas. Using a secure data portal, participating hospital teams will track their implementation progress and use their own data to identify new areas of improvements. To measure the impact of this evidence-based strategy, Title V will continue utilizing ESM 2.1: Percent of birthing hospitals actively participating in Louisiana Perinatal Quality Collaborative quality improvement initiatives related to NTSV.

Louisiana Birth Ready Designation: In February 2022, a second round of Birth Ready Designations were awarded to 11 additional hospitals, bringing the number of hospitals with Birth Ready and Birth Ready+ Designations to 27 as of August 2022. In FFY 2023, the LaPQC will continue to provide support to all facilities seeking Birth Ready designation and re-designation. All previously designated facilities will be required to apply for redesignation each year. Moving forward, the Louisiana Birth Ready Designation period will be from January to December, and the LaPQC team will review applications for designations and re-designations annually.

Birth Ready Designation reflects the next level of the LaPQC tools and approaches to encourage hospitals to implement best practices to improve readiness for addressing the leading causes of maternal deaths. Title V will continue to measure the impact of this evidence-based strategy with ESM 2.2: Percent of birthing hospitals achieving Louisiana Birth Ready Designation.

Through the Safe Births Initiative, participating hospitals submit several “structure measures” related to priority improvement areas. Many of these structure measures are being utilized as criteria for the Birth Ready Designation. Since the Birth Ready Designation encompasses care components beyond those related to improving NTSV rates, in FFY 2023, Title V plans to seek TA from the MCH Evidence Center in the development of an ESM that more clearly captures the LaPQC progress in supporting the evidence-based hospital policy and practice changes related to NTSV reduction.

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

Support implementation of new regulations for Louisiana’s birthing facilities: In December 2021, the notice of intent (NOI) was published in the Louisiana Register to notify the public that hospital licensing regulations for birthing facilities will be updated to align with national guidelines. Public comment was received in response to that NOI, prompting some changes to be incorporated into the proposed new regulations. A revised NOI was published in the July 2022 Louisiana Register. In FFY 2023, BFH will work with the Louisiana Hospital Association to support facilities with implementing the new requirements.

Support launch and operation of Louisiana Doula Registry Board: In FFY 2023, BFH will continue to provide support to the Louisiana Doula Registry Board and facilitate the development and implementation of the state Doula Registry. Since facilitating the inaugural Louisiana Doula Registry Board meeting in January 2022, BFH has been working with doulas, community advocates, healthcare providers, and insurers to draft the doula registry application and the administrative rules that define the duties of the doula board and the process of registration. BFH is working to align the Doula Registry requirements in a way that facilitates potential coverage by Medicaid and other insurers. In FFY 2023, BFH will develop and test an online application for the Doula registry and begin accepting applications from doulas to join the Louisiana Doula Registry. Additionally, BFH will develop and release a report that outlines the steps timeline that would be necessary to initiate coverage and reimbursement for Doula services by Louisiana Medicaid.

Support the implementation of perinatal depression screening in pediatric settings: Beginning January 2021, a Medicaid policy change took effect that allowed pediatric providers to be reimbursed for administering developmental screening, autism screening, and perinatal depression screening. This change provides a key incentive for providers, who can now bill additional codes for these screening services. To be eligible for reimbursement, providers must use a standardized tool, and complete robust documentation, referral, and follow-ups for each screening in accordance with recognized best practices.

To support implementation and impactfulness of this new policy, in FFY 2022, BFH launched a pilot LaPQC initiative to test quality improvement strategies to integrate depression screening and linkage to care in pediatric practices. The goal of the LaPQC Caregiver Perinatal Depression Screening Initiative is the implementation of best practices that promote equitable access to caregiver perinatal depression screening and appropriate referral when risk is identified.The LaPQC Caregiver Perinatal Depression Screening Initiative is a purposefully small initiative that includes four pediatric practices that demonstrated readiness for integrating the caregiver screening into their practices. The pilot will run through FFY 2023, and BFH will continue to support the participating practices by providing technical assistance and support on quality improvement strategies, providing subject-matter faculty experts, identifying and sharing best practices, and facilitating collaborative learning opportunities. At the conclusion of the pilot in June 2023, BFH will review data and lessons learned to identify opportunities to refine and scale the initiative across the state.

Support improvements in the implementation of the Louisiana Mental Health Perinatal Partnership (LAMHPP): In FFY 2023, Tulane University School of Medicine and BFH will enter into the 5th and final year of the HRSA grant that has funded a majority of the LAMHPP development work described in the FYY 2021 report. The main focus in the coming year will be the transitioning of primary management from Tulane to BFH to ensure long-term sustainability and growth of LAMHPP. In July 2022, BFH applied for supplemental grant funding to support a robust evaluation of LAMHPP during FFY 2023. The evaluation will consist of a comprehensive analysis of all available program data as well as a qualitative component reflecting the provider experience with using LAMHPP services. The BFH team will utilize the evaluation process and findings to define the future direction of the program to better meet the needs of the providers utilizing the services.

Support access to high-quality family planning and reproductive health care: In FFY 2022, BFH applied for and was awarded a new 5-year competitive Title X Family Planning Services grant. For many years, the role of Louisiana’s Title X program was to administer the federal award, provide technical assistance, lead education programs, develop resources, conduct outreach and develop new service providers, in addition to extensive oversight and policy responsibilities for all reproductive health services delivered in the parish health units (PHU). With a changing healthcare landscape, however, the role of BFH has been shifting to a greater focus on strategies to develop a broader Title X clinical network in community healthcare settings and support the efficiency, effectiveness, quality and equitable access to high quality reproductive health services in the state overall.

To better reflect this shift in strategic direction towards capacity building approaches and away from management of activities in the OPH Parish Health Unit clinical network, in FFY 2022, the Title V director redeveloped the Reproductive Health Program Manager position as a Reproductive Health Strategy Manager position. With a broadened focus beyond the management of the Title X award, this role is now responsible for management of the perinatal commission and the Doula Registry board, as well as the development and implementation of special studies and initiatives related to improve access to and quality of perinatal and reproductive health services in the state.

In FFY 2023, BFH RHP will begin implementing strategies that model several Title V systems-building strategies. Inspired by the Developmental Screening Toolkit (discussed in the Child Health domain), BFH will build and launch an interactive online toolkit that healthcare providers can use to build capacity to incorporate high-quality reproductive health services into their practice. Content for the website will be based on the Quality Family Planning (QFP) and other recommendations, guidelines, and best practices in the reproductive health field. Additionally, BFH will build upon its successful Gift (described in the Perinatal/Infant domain) and Birth Ready hospital designation initiatives to develop and launch a Quality Reproductive Health Provider (QRHP) voluntary designation program to recognize practices that demonstrate successful implementation of key elements of quality family planning services in primary care.

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

Ensure robust, high-functioning Pregnancy Associated Mortality Review (PAMR): With the joint funding of Title V and CDC’s Erase-MM grant, BFH will continue to support the development of PAMR as a core public health surveillance and systems change process, furthered now with a restructured and revitalized multi-disciplinary review team and the establishment of the LaPQC as one of the primary strategies for generating changes that will improve outcomes.

Ensure high-quality data collection and analyses: The PAMR team is working closely with the CDC ERASE-MM team and Louisiana Vital Records to ensure that the Final Death files reflect the most accurate data with respect to maternal mortality. This will help ensure that the National Center for Health Statistics (NCHS) is reporting the most accurate maternal mortality data for Louisiana. The PAMR team will continue to look at the pregnancy checkbox on Louisiana death certificates to ensure accuracy around the reporting of maternal deaths in the state. In 2020, PAMR began geocoding maternal deaths across the state, examining contributing maternal mortality factors related to health equity, racial and ethnic disparities, and community-level contributing factors. This work, which is ongoing, led to the creation of the Louisiana Bias or Racism and Social Determinants of Health (LaBORS) tool which incorporates socio-spatial data, social determinants of health variables, and checkbox indicators to identify racism, bias or discrimination in case data. This innovative tool and implications to the work of PAMR was recognized by CDC. Additionally, PAMR will continue to implement the Utah Tool for Suicide and Overdose cases. The standardized tool helps Maternal Mortality Review Committes determine pregnancy relatedness for deaths due to accidental drug overdoses and suicides.

Support strategic action to improve outcomes: The Perinatal Commission and LaPQC will be leveraged as action-focused communication, policy, and systems-change platforms for the needs and opportunities illuminated through the report. Title V funding will partially sustain the network of Regional MCH Coordinators responsible for the abstractions and staff support for the PAMR meetings and follow-up actions. In addition, Title V-funded communications, policy, and strategy support will be integral to advancing the work of the review committee and its recommendations.

Support implementation of Louisiana Domestic Abuse Fatality Review Panel: In FFY 2022, BFH used Department of Health and Human Services (DHHS) grant money to help fund representatives from all mandated organizations. The first quarterly DAFR meeting was held in March 2022. Thus far, the group has developed data abstraction and review procedures, established a meeting schedule, and solicited member feedback on forms. By the end of October 2022, a DAFR chair will be selected and all forms and processes will be formalized. The first cohort of case reviews will be presented to the DAFR Panel by February 2023. In FFY 2023, BFH will support DAFR in reviewing 100% of identified “domestic violence maternal” death cases from 2020 and 30% of cases from 2021. In Summer 2023, the DAFR will produce an initial report to share preliminary information and recommendations from the initial case reviews.

Ensure a robust, high-functioning Louisiana Pregnancy Risk Assessment and Monitoring System (PRAMS): With current response rates, LaPRAMS data are representative of Louisiana maternal experiences and are actionable for informing state programming and policy related to women’s health and experiences. Title V will continue to supplement infrastructure support for LaPRAMS as one of the core public health surveillance systems for MCH. In FFY 2023, LaPRAMS will also implement a Social Determinants of Health (SDoH) supplement focuses on assessing experiences with a variety of SDoH including; living environment, food environment, transportation, health literacy, mental health, and discrimination. In preparation for Phase 9 of the LaPRAMS survey, Title V will support LaPRAMS staff and the LaPRAMS Steering Committee in their work with CDC around the development of the new Phase 9 survey iteration, which is scheduled to be released in April 2023.

Effectively communicate findings, implications, and recommendations: In FFY 2023, BFH will continue to publish and share two LaPRAMS reports: 1) an annual data report, which is published within three months of receiving the weighted data set to ensure partners have access to timely, useable data; and 2) a surveillance report, which provides a deeper analysis of the data and includes graphics, plain-language data translation, and public health implications. Both reports will be published on the Partners for Family Health Data Center and shared with partners. In FFY 2022, the 2020 PRAMS Data Report included additional survey questions regarding maternal disability and six months of data from the COVID-19 Supplement, which was part of a CDC PRAMS national evaluation of how the COVID-19 pandemic impacted pregnancy. Additionally, the 2018 PRAMS Surveillance Report was publically available through the BFH Data Center, and a 2019 PRAMS Surveillance Report will be released in late FFY 2022. BFH communications staff will continue to update the report features to highlight relevant findings and recommendations and provide additional context to the data.

Support strategic action to improve outcomes: In FFY 2023, BFH will continue to partner with a researcher from Xavier University of Louisiana, a historically Black university based in New Orleans. The Xavier research partner has received funding for a pilot grant that will use PRAMS data to examine Black maternal experiences in Louisiana. This work will allow BFH to better understand the challenges facing Black mothers and Black pregnant women in Louisiana, which will inform the Bureau’s efforts to decrease significant ethnic disparities in maternal and infant birth outcomes. PRAMS will continue to provide data to contextualize, support, and inform the work of programs across BFH, including injury prevention, mortality surveillance, and Adverse Childhood Experiences (ACEs).