Overview and context of the population domain

 

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 incidents.1  For homicides in which the victim-to-offender relationship could be identified, 98% of female victims (39 out of 40) were murdered by someone they knew. Of the victims who knew their offenders, 56% (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 both the 2017-2019 and 2020 Pregnancy-Associated Mortality Review (PAMR) Report, substance use is a leading contributor to pregnancy-associated mortality.  In 2020, Substance Use Disorder (SUD) contributed to almost half (44%) of maternal mortality cases.1 High rates of substance use are correlated with high rates of mental health issues. According to the 2021 Pregnancy Risk Assessment Monitoring System (PRAMS) Report, over 14% of individuals surveyed reported experiencing depression during pregnancy. 12.1% 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 a woman and her future children. Research shows that child behavioral health problems are linked to higher Adverse Childhood Experiences (ACEs) scores by their parents4. Unaddressed ACEs result in the single largest predictor of future problems for adult health and wellbeing.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 for 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
• Ensure Title V strategies are outcomes-focused and rooted in essential public health services

 

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
• Reducing the rate of maternal mortality per 100,000 live births

 

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 will deliver actions aiming to effect the following performance measure(s):

• Reducing the percent of cesarean deliveries among low-risk first births
• Increasing the percent of women who attended a postpartum checkup within 12 weeks after giving birth
• Increasing the percent of women who attended a postpartum checkup and received recommended care components

 

 

Planned Title V efforts and alignment with women / maternal health priorities

 

Population Priority: Improve birth outcomes for individuals giving birth and their 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 available and accessible care is provided with the skill, integrity, and accountability necessary for optimal outcomes.

 

Support implementation of the Louisiana Perinatal Quality Collaborative (LaPQC) Safe Births Initiative and Louisiana Birth Ready Designation

As part of the LaPQC’s Safe Births Initiative, participating birthing hospitals will continue to submit data related to priority improvement areas related to obstetric sepsis and sustaining gains for Nulliparous Term Singleton Vertex (NTSV), hemorrhage and hypertension. Using a secure data portal, participating hospital teams will track their implementation progress and use their own data to identify new areas of improvements. During the first quarter of FFY2025, the LaPQC will focus on supporting birthing hospitals with strengthening coordination between hospital birthing units and their emergency department, laying the groundwork for the Obstetric Readiness in Emergency Department (ORED) initiative starting in January 2025. In January 2025, the LaPQC will also begin new change work around postpartum access and continuity of care, with an initial focus on recognition and response to perinatal substance use disorder and mental health conditions. The LaPQC will continue building its capacity to support improvement work across various healthcare settings by expanding its staff.

 

The LaPQC’s Birth Ready and Gift Designation programs are central to the LaPQC’s overall strategy of building equitable and sustainable changes for maternal and newborn care in birthing hospitals. In FFY2025, the LaPQC will release Birth Ready Designation requirements for the upcoming year. Additionally, in the second quarter of FFY2025, the LaPQC will award Birth Ready designations to hospitals that met requirements in the 2024 calendar year. Technical assistance is provided throughout the year during office hours, one-to-one meetings with hospitals (Charter Chats), and collaborative monthly coaching calls.

 

The LaPQC will continue to provide ongoing support to participating teams in using disaggregated data for improvement through narrative reporting, coaching and data visualization.

 

 

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

 

Support implementation of new regulations and assessment of levels of maternal care in Louisiana against national recommendation for Louisiana’s birthing facilities

In FFY2025, the LaPQC will support the implementation of new regulations for Louisiana birthing hospitals and free-standing birth centers, related to LaPQC participation, through the following strategies:

• ensuring all birthing hospitals and free-standing birth centers are informed of LaPQC participation requirements through regular communications and coaching activities
• establishing internal monitoring processes
• communicating in a timely manner to facilities at risk for not meeting requirements

 

In FFY2025, the LaPQC will also support the administration of the Centers for Disease Control and Prevention (CDC) Levels of Care Assessment Tool (CDC LOCATe).  The Louisiana Department of Health’s Louisiana Health Standards Section updated Louisiana levels of maternal care to be more closely aligned with the American College of Obstetrics and Gynecology (ACOG) and Society of Maternal Fetal Medicine (SMFM) guidance for levels of maternal care. While some updates were made, the current regulation does differ from the national recommendation. The Louisiana Department of Health will assess birthing facilities to determine what capabilities exist and what resources are needed for Louisiana’s birthing facilities to demonstrate the same classification as recommended by ACOG/SMFM. Because of established relationships with birthing facilities, the LaPQC will facilitate the administration of the CDC LOCATe Tool.

 

Increase the readiness and response of statewide healthcare facilities to address and improve perinatal and neonatal outcomes:

National best practice recommendations, state surveillance data, and feedback from participating teams, subject matter experts, as well as patient and community partners, indicate the need and opportunity to expand quality improvement approaches to care settings beyond hospital birthing units. As such, the LaPQC will continue to not only serve as a long-term quality improvement hub, but also as a platform to coordinate multiple campaigns, pilots, and other improvement efforts beyond birthing facility settings, while increasing its visibility and building its team. During FFY2025, the LaPQC will partner with emergency departments across the state to implement the components of the AIM Patient Safety Bundles for Hemorrhage and Severe Hypertension as well as relevant breastfeeding/infant feeding best practices.

 

In September 2024, the LaPQC, in partnership with the Provider to Provider Consultation Line and Pediatric Development Screening program, will conclude its 2024 Caregiver Perinatal Depression Screening in Pediatric Clinics Learning Collaborative and prepare for recruitment and launch for the 2025 cohort. The team will test new strategies related to recruitment, engagement and ensuring readiness to conduct improvement work.

 

The LaPQC will continue to implement new work as part of its Community Birth Initiative (CBI). The CBI will include partnering with the state's Free-standing Birth Centers (FSBCs) to build quality improvement capacity and provide support related to the implementation of best practices. The CBI will also encompass coordinated efforts to improve the transfer of community births to hospitals. This work will involve establishing a Perinatal Transfer Committee who will review sentinel events, make recommendations for improvement and inform the development of transfer protocols to be adopted in regions across the state. The LaPQC will lay the groundwork for transfer improvement in local areas by facilitating collaboration among hospitals, emergency medical services and community birth providers.

 

Foundational to all LaPQC initiatives is its faculty, inclusive of clinical subject matter experts as well as community and patient partners with lived experience. Faculty help to inform the planning and implementation of LaPQC initiatives and also serve as a direct resource to participating teams.

 

The LaPQC will also continue to maintain an advisory group inclusive of health systems, public health officials, representatives from the state Maternal Mortality Review Committee (MMRC), community partners, managed care organizations and representatives from policy and advocacy organizations.

 

Support the Louisiana Doula Registry Board with developing and implementing the Louisiana Doula Registry, aligning requirements to facilitate potential coverage by Medicaid and other insurers:

Births where doulas are involved in care have been shown to have a lower birth complication rate, decreased Cesarean delivery rate, increase in breastfeeding initiation, and decreased low-birth weight infants.6,7 Community-based doulas are important to provide linkages of care for mothers after delivery and throughout the postpartum period, the time period when mothers have the highest rate of pregnancy-related deaths.8,9 While there is proven success of doula involvement in birth, lack of coverage from insurance payors prevent doulas from being accessible to all individuals.

 

In alignment with Act 182 of the 2021 Louisiana Regular Legislative Session, BFH has created the Louisiana Doula Registry Board within the Louisiana Department of Health for the purpose of reviewing and approving doula registration to allow for health insurance reimbursement of doula services. This creates equitable access to doulas as a resource for all patients.

 

The registry will begin accepting applications in 2025 with a goal of having 50 doulas registered by FFY2025. As part of the infrastructure, BFH has contracted with Tyler Technologies, a technology company that works with the public sector to ensure data is secure and easy to manage, to establish the platform where doulas will apply for and be listed in the registry.

 

While the infrastructure has been established, work is needed to create awareness of the registry as well as the process for applying for admission into the registry. To create awareness, BFH will conduct at least 3 statewide outreach events. Through its programs, BFH has great relationships with Community-Based Organizations throughout the state. Leveraging those relationships, BFH will hold two virtual events informing doulas and other stakeholders, including payors, about the existence of the registry and the process for applying for entry into the registry. Currently, the Louisiana Perinatal Quality Collaborative (LaPQC) has planned to hold a symposium as part of their Community Birth Initiative, an initiative designed to improve readiness and coordination between community births and hospitals. The symposium will be targeted towards midwives and doulas providing and supporting community births. During this symposium, BFH will provide an educational session on the registry and the process for applying for entry into the registry. To provide an even broader reach, in collaboration with the Bureau of Media and Communications, BFH will create a social media toolkit informing the public about the existence of the doula registry with specific information for those who are doulas on how to apply. 

 

Provide supplemental funding and infrastructure support to all BFH reproductive health efforts to 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, The Bureau of Family Health’s (BFH) Reproductive Health Program is recognized as an important resource in the state with expertise around national clinical guidelines, including the Quality Family Planning (QFP) Guidelines. The Bureau has significant expertise in direct provision of comprehensive reproductive health services to high-need populations; geographic analysis of need and provider access; and adequate coverage policies.

BFH provided reproductive health services through 57 Parish Health Units (PHU), which are under the management of the Office of Public Health. 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 FFY2025, the BFH Reproductive Health Program (RHP) will continue to develop and implement systems strengthening strategies utilizing good practices and lessons learned from other Title V funded programs within the BFH. Inspired by the developmental screening toolkit (discussed in the Child Health domain), the RHP will continue to 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 is expected to be based on the Quality Family Planning (QFP) and other recommendations, guidelines, and best practices in the reproductive health field. Incorporating good practices from the Title V funded LaPQC Gift and Birth Ready hospital designation programs, the Title X program is also designing a quality designation system to recognize primary care practices that have demonstrated successful implementation of sexual and reproductive health services into their daily practice.

 

The RHP will also continue to provide financial and technical support to a network of primary care providers including one adolescent and young adult-focused health center and two sub-recipient Federally Qualified Health Centers (FQHCs).  The sub-recipients integrated reproductive health services in six sites.  These providers serve as critical access points in many communities and provide care to many low-income and/or uninsured individuals. The providers are meeting service needs as it applies to administrative, fiscal, and program activities, for example, there were only two sites who needed minor improvements and, subsequently, provided reasonable responses to adjust services to meet compliance requirements.

 

Increase awareness statewide amongst perinatal health care professionals of the mental health consultation, training, and resource and referral services and supports available to them through the Provider-to-Provider Consultation Line:

The Bureau of Family Health (BFH) continues to provide technical assistance and training to maternal health care providers, including perinatal providers and pediatricians, through the implementation of the Provider to Provider Consultation Line (PPCL) program.  The program delivers training to build perinatal and pediatric providers’ capacities to recognize and respond to the mental health needs of their maternal and pediatric patients. In addition to provider training, the program establishes a consultation line, which perinatal and pediatric health providers can call to consult with mental health specialists when they are uncertain about how to respond to the mental health needs of their patients.  A partnership with Tulane University supports provision of psychiatric consultation as needed as well as general data management support for the program. 

 

Since 2018, BFH has managed a mental health consultation line for perinatal providers.  The service was initially launched in partnership with Tulane University School of Medicine’s Department of Psychiatry, but with the acquisition of funding to launch a pediatric provider mental health consultation line, BFH integrated both the pediatric and perinatal programs under PPCL. All aspects of the two programs including call line, staff, data systems, and program management have been fully integrated.

 

While not required to access program services, PPCL strongly encourages providers to register with the program, which not only collects provider contact information for program communications, but also collects data for program monitoring, improvement efforts, and funder data requests. Program registration also reduces consultation call time because provider contact information is already in the data system.

 

PPCL will use multiple pathways to provide outreach about the program to providers across the state including:

• Attendance at provider association conferences including American Academy of Pediatrics, Louisiana Association of Family Physicians, School Based Health Alliance, Louisiana Rural Health Association, Louisiana Association of Nurse Practitioners. PPCL will have exhibit tables at all of the conferences and, if the opportunity is available, will also be presenting information on mental health related topics and PPCL services.
• Louisiana’s Chapter of AAP and the Louisiana Association of Family Physicians has received a grant from the Health Resources Services Administration to support efforts to promote PPCL services with its provider members. Promotion efforts will occur at the AAP and LAFP conferences, through training offered by both organizations, and through communications from the associations to their members.
• In FFY 2025, PPCL will focus its in person outreach efforts on Federally Qualified Health Centers (FQHC) located across the state.  PPCL staff will travel to FQHC’s and will meet in person with clinic staff to inform them about PPCL.
• PPCL’s training activities provide an opportunity to promote program services. Not only will PPCL be offering its ECHO training sessions, but PPCL is also partnering with Woman’s Foundation to launch a series of webinars in FY2025 focused on recognizing and responding to the mental health needs of pregnant and postpartum persons
• PPCL is partnering with the LaPQC to implement the Caregiver Perinatal Depression Screenings in Pediatric Practices Learning Collaborative (CPDS Initiative). PPCL staff provide subject matter expertise to clinics as they develop and implement best practices related to caregiver screenings and PPCL serves as a key resource for clinics in their follow-up to positive screens.
• PPCL sends out a twice monthly newsletter to providers and other stakeholders that provides useful information related to recognizing and responding to mental health conditions and community events and trainings
• PPCL has applied to HRSA for noncompetitive supplemental funding to support the hiring of an outreach coordinator who will increase the program’s capacity for outreach activities.

 

Use the Extension for Community Health (ECHO) Model to increase provider knowledge on effectively recognizing and responding to the behavioral health needs of  pregnant and postpartum persons:

PPCL is using the Extension for Community Health Outcomes (ECHO) Model in its provision of training to both pediatric and perinatal providers. ECHO has a continuously growing body of research that consistently demonstrates the efficacy and sustainability of the Model across disciplines, including health care and education. ECHO is a well-recognized platform for practice-based education and training for teaching community providers, especially those practicing in underserved rural areas, to deliver best-practice medical services. The model uses the telehealth modality of videoconferencing to support knowledge networks that link primary care providers from different geographic locations with each other and with a multidisciplinary team of specialists (Arora et al, 2010; Arora et al, 2017). In a survey of rural clinicians who participated in TeleECHO clinics between 2003-2011, the survey data show significant improvements in provider knowledge, self-efficacy, and professional satisfaction (Arora et al, 2010).

 

ECHO was inspired by the way clinicians learn from medical grand rounds and fosters the development of a virtual learning community in which participants are engaged in a continuous loop of learning, mentoring, and peer support. During an ECHO session, participants present real cases to an expert team of specialists who guide learners through managing patients with complex conditions. Participants learn from one another while also processing knowledge through a local lens.  PPCL has found success in using the ECHO Model to build the capacity of pediatric healthcare providers to better recognize and respond to the mental health needs of their patients. ECHO is a flexible model that allows experts in any field to share their knowledge with providers in rural and underserved communities, making it an ideal model for training providers who are enrolled in PPCL.

 

PPCL’s first Perinatal Mental Health ECHO series began in February 2024 and will continue monthly sessions through November 2024. A second series will be offered in 2025.

 

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):

Ensure high-quality data collection and analyses:

LA-PAMR will continue to implement standardized processes and tools that support broader identification of contributing factors and the development of actionable recommendations that address those factors. The Louisiana Bias or Racism and Social Determinants of Health (LABoRS) Tool will be used to help identify potential bias, discrimination and/or barriers to care and the Utah Tool will help identify pregnancy-relatedness in suicide/overdose cases. These tools allow our Committee to evaluate information relevant to each case and to engage in targeted discussions to build consensus around whether social determinants of health contributed to a death.

 

Support strategic action to improve outcomes:

LA-PAMR will move forward with informant interviews in FFY25. The team decided to pursue interviews for all identified cases, with the exception of motor vehicle collisions. Upon completion of interviews, the informant interviewer will provide a summary to the case abstractor and the PAMR Coordinator. The case abstractor will utilize the interview summary to obtain records from any additional sources identified in the interview. The PAMR Coordinator will incorporate details from the interview summary into the case narrative and include the full interview summary at the end of the case narrative. Incorporating family interviews will add significantly to the body of knowledge of the circumstances surrounding each case. This knowledge is not available in medical records and other records we currently access.

 

LA-PAMR will continue to maintain a multidisciplinary review committee consisting of half-clinical and half-non-clinical members. Current committee membership has representation from obstetrics and gynecology, maternal fetal medicine, obstetric anesthesia, emergency medicine, cardiology, cardio-obstetrics, critical care, forensic pathology, doulas, midwives, perinatal mental health providers, nurse home visitors, payers, healthcare educators, as well as representation from several community-based organizations and a patient representative.

 

Currently, all nine LDH administrative regions are represented on the Committee. Diverse representation from across the state ensures both urban and rural context for circumstances surrounding each unique case reviewed by the committee. In addition, LA-PAMR will continue to ensure the Committee reflects those disproportionately affected by pregnancy-associated deaths.

 

Finally, the team is exploring opportunities to provide compensation for participation in committee meetings to support continued participation by individuals reflecting community-based organizations. Representation of key community-based organizations on the review committee ensures our work is informed by individuals who know and understand the context in Louisiana.

 

Maintain a statewide Domestic Abuse Fatality Review (DAFR) panel that uses standardized processes for data collection, review, and prevention recommendations to review maternal deaths due to violence

The LA-DAFR Panel was legislatively mandated in 2021. Throughout 2022, the DAFR team (staff, panel members, and agents) along with the help of the Victimization Data Subcommittee of the Domestic Violence Prevention Commission worked to establish a firm foundation for domestic abuse fatality review by acquiring staff and defining the systems and processes for it to successfully function. Since then, the LA-DAFR Panel has held quarterly in-person meetings to review domestic abuse fatalities. In FFY2025, the DAFR Team will continue to meet quarterly to review these cases, draft recommendations, and finalize an annual report that outlines the data and recommendations for specific agencies.

 

Ensure a robust, high-functioning Louisiana Pregnancy Risk Assessment Monitoring System (PRAMS):

Louisiana Pregnancy Risk Assessment Monitoring System (PRAMS) is a data surveillance project of the CDC and LDH-OPH-BFH. PRAMS collects state-specific, population-based data on maternal knowledge, attitudes and experiences before, during, and shortly after pregnancy. Each month we contact around 200 Louisiana women who recently gave birth to share their experiences before, during, and just after pregnancy.  In FFY2023, the LA-PRAMS overall response rate averaged 67.29%, exceeding the CDC minimum required response rate of 55%.

Louisiana PRAMS provides both quantitative and qualitative data on:

• Factors that influence pregnancy outcomes, including health insurance status, chronic conditions, pregnancy intention, contraceptive use, prenatal care, alcohol use, tobacco use, physical abuse, and life stress
• Mothers’ experience of pregnancy complications, including hypertension, diabetes and hospitalizations
• Maternal experiences and behaviors after the baby is born, including depression, maternity leave experiences, breastfeeding, contraceptive use, tobacco and alcohol use, and safe infant sleep practices

 

The ability to collect these data on a statewide population level is invaluable.  PRAMS data supports the design of the State’s Title V and Title X programs. PRAMS data is also widely used for public health research and for design of public health interventions at community level.  See examples of data topics and analyses that are unique in quality, rigor, and content to Louisiana PRAMS:

• Contraceptive use - barriers to use, failure rates, and type
• Unintended pregnancy rates - attitude towards pregnancy and ambivalence around pregnancy and use of contraception
• Prenatal Care - availability of care, barriers to care, quality and content of care
• Screening and diagnosis with STIs before and during pregnancy
• Maternal stressors experienced during pregnancy including experiences of discrimination
• Perinatal Substance Use - alcohol, tobacco, prescription and non-prescription drug use
• Intimate Partner Violence during pregnancy
• Breastfeeding - barriers to initiation, hospital practices, support received, exclusivity and duration
• Infant sleep environment - Sleep position, bed-sharing practices, safe sleep practices
• Occupational Information
• Maternity Leave - experiences and decisions around leave

 

Health professionals, policy makers, use information collected by Louisiana PRAMS and researchers to develop and modify programs and policies designed to improve the health of mothers and infants.