Women/Maternal Health Priorities and Performance Measures

Improving birth outcomes and improving women’s mental health were ranked as the most pressing issues for the Women/Maternal Health domain in the 2020 Needs Assessment. To address these issues, Title V strategies in the 2021-2025 State Action Plan align with the “Improving birth outcomes for birthing persons and infants” Population Priority.

To strengthen the systems and upstream factors that impact the above priority, Title V will also implement strategies that align with the following Systems Priorities:

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

In alignment with the above Priority Needs, 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 cesareans10. 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

Facilitate alignment and meaningful collaboration: As described throughout the report narrative, BFH has invested in many programs and initiatives that aim to improve birth outcomes for birthing persons and infants. Although the programs and initiatives overlap and collaborate in many ways, BFH does not have a coordinated strategy to improve birth outcomes.

A foundational strategy for the 2021-2025 cycle will be to facilitate alignment and meaningful collaboration among all Title V-supported programs and initiatives working to improve birth outcomes. During the state action planning sessions, members of the ‘birth outcomes’ workgroup expressed a desire to maintain a forum to ensure a high level of coordination among the related efforts. In FFY 2021, Title V will establish a birth outcomes working group or other forum that can effectively support cross-program collaboration. Title V will also work with the group to identify and support monitoring for shared population outcome and performance measures.

Defining Title V’s role in women’s mental health: The issue of women’s mental health also ranked high in the priority setting process during the Needs Assessment. During the state action planning sessions, program representatives shared that they have received an increasing number of requests and opportunities related to this topic, but it was often unclear how or even if BFH should respond. Outside of providing direct and enabling mental health support through home visiting and mental health consultation, BFH has not traditionally led population-level efforts focused on women’s mental health. The workgroup determined that programs would be better able to evaluate the appropriateness of and respond to these requests and opportunities if they had a common understanding of the role BFH has in improving women’s mental health at a population level.

In FFY 2021, Title V will convene a workgroup to assess and define the role of BFH related to women’s mental health. The group will inventory and map the various BFH programmatic interactions and intersections related to women’s mental health, and they will also conduct an environmental scan of existing resources and initiatives, including those within LDH and community partners. The results from these activities will help determine next steps in defining BFH’s role in supporting and expanding efforts to improve women’s mental health in Louisiana.

Improve access to and quality of clinical and support services, including care coordination

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 care and to ensure that the care that is available and accessible is provided with the skill, integrity, and accountability necessary for optimal outcomes.

Louisiana Perinatal Quality Collaborative (LaPQC): As described in the annual report, in FFY 2017 the Title V program launched the LaPQC with an initial focus on implementing the hemorrhage and hypertension-focused improvement strategies that are being promoted nationally through American College of Obstetricians and Gynecologists (ACOG) Alliance for Innovation on Maternal Health (AIM). These two areas of focus were selected because they are among the leading factors contributing to severe maternal morbidity and mortality and there was an opportunity to build on hospital-focused improvement. While complex, this area of focus is often recommended as a starting point for teams to learn the evidence-based improvement tools and concepts, and for hospitals to learn how to support the development of collaborative learning and improvement science. This foundational work has been essential to advance complex changes (i.e. around practices related to cesarean deliveries).

The work of NPM 2 in FFY 2021 will center on Louisiana’s Title V program capturing final learnings on how to execute the evidence-based Model for Improvement and the IHI Breakthrough Collaborative Series (BTS) model. The first campaign applying this implementation strategy was the LaPQC Reducing Severe Maternal Morbidity Initiative, launched in August 2018. This initiative will end in late FFY 2020 and, with findings and learnings captured, the LaPQC intends to launch their next initiative - the Safe Births Initiative - by early FFY2021. The Safe Births initiative will not only continue improvement work related to hemorrhage and hypertension, but also serve as a vehicle for a new focus on reducing Louisiana’s NTSV cesarean section rate. With this constellation of improvements, the goal of Safe Births is the implementation of practices that promote a safe, equitable, and dignified birth for all birthing persons in Louisiana where:

• A safe birth is one where evidence-based best practices are employed by health care providers at all levels in an effort to increase readiness, decrease response time, and ensure high quality communication across a care team;
• An equitable birth is one where best practices are not only employed with every patient, every time, but that women of color – particularly Black and African American women – are given access to the life-saving and sustaining resources they need throughout the birthing process;
• A dignified birth is one where, throughout the birth process, birthing persons experience timely and accurate communication with their health care providers, are acknowledged as informed health care consumers, and are included in decision-making about their health care.

To measure the impact of this evidence-based strategy, Title V is introducing ESM 2.1: Percent of birthing hospitals actively participating in Louisiana Perinatal Quality Collaborative quality improvement initiatives related to NTSV. Additional ESMs may be introduced in later years as aggregate hospital performance and impact data are available.

Launch and implement the Safe Births Hospital Designation: In addition to facilitating the Safe Births Initiative, the LaPQC will also launch a designation scheme that will award hospitals who achieve and maintain certain Quality Improvement (QI) milestones a Safe Births Designation. The LaPQC will also increase efforts to support regional collaboration and physician engagement - anticipated approaches include statewide physician-focused grand rounds presentations and regional meetings of facility-based improvement teams to encourage local system-of-care collaboration.

Develop and implement a LaPQC Advisory Committee System: All of the LaPQC efforts will require a shift in how BFH collaborates with systems leaders; in FFY2021, the LaPQC will transition to a new Advisory Committee system that will bring together leaders across key areas like community advocacy, payors, and health care systems, to help align improvement efforts across key sectors related to maternal and neonatal outcomes. While this is primarily a systems-improvement strategy, the intentional inclusion of community members and advocates in the advisory structures also aligns with the Title V System Priority: Partner with families, youth, and communities at all levels of systems change. Title V will monitor this strategy from both quality improvement and community partnership lenses.

Support update to Louisiana’s Maternal Levels of Care regulations for birthing facilities: Over the past year, the LaPQC and the Pregnancy Associated Mortality Review (PAMR) Medical Director have led a stakeholder-engaged process to review the current licensing requirements for birthing facilities and the designation process for determining the maternal level of care. Participants have included clinical providers, administrators, health system leaders, the hospital licensing authority, professional associations, advocates and patients. This activity emerged as a priority out of the 2019 LDH Maternal Mortality Summit and the recommendations from various legislative study resolutions that BFH carried out in 2019. The review has also been a timely complement to the state’s Title V MCH Block Grant Needs Assessment Process. The development of proposed new regulations has had three major steps: comparison of Louisiana’s current regulations against the new national guidelines; voluntary facility-level assessment of current practices against the new national guidelines using the Centers for Disease Control and Prevention (CDC) Levels of Care Assessment Tool (LOCATEe) with support from the LaPQC; and ongoing engagement with the workgroup, the Perinatal Commission, and other stakeholders to reconcile the recommended standards in Louisiana’s system of care. In the upcoming grant year, the Medical Director, Title V Director, and LaPQC team will work to support rulemaking and implementation of the new regulations.

Support access to high-quality family planning and reproductive health care: Ensuring universal access to high quality family planning and reproductive health care is essential to improving Louisiana’s birth outcomes. In FFY 2021, Title V will continue to provide supplemental funding and infrastructure support to all BFH reproductive health efforts. Due to the competitive and politically-sensitive nature of the federal Title X program and grantmaking process, Title V infrastructure and strategy support is essential for the long-term sustainability of Title X-funded BFH reproductive health programs. BFH reproductive health priorities for FFY 2021 include:

• Deliver high-quality, evidence-based reproductive health services
• Expand and sustain access to high-quality, evidence-based reproductive health services
• Involve communities as part of overall health

The Title V Health Systems Strategy Manager will also work with the Reproductive Health Integration Initiative Coordinator and Medicaid partners to support implementation and evaluation of the Medicaid long-acting Reversible Contraception (LARC) reimbursement policy. Due to department-level budget changes, the team will explore alternative funding and provider support options to support policy implementation in Community Health Clinics.

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

Develop and implement a LaPQC Advisory Committee System: All of these efforts will require a shift in how BFH collaborates with systems leaders; in FFY2021, the LaPQC will complete their transition to a new Advisory Committee system that will bring together leaders across key areas like community advocacy, payors, and health care systems, to help align improvement efforts across key sectors related to maternal and neonatal outcomes.

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 Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (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. PAMR will also geocode maternal deaths across the state, examining contributing maternal mortality factors related to health equity, racial and ethnic disparities, and community-level contributing factors.

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 sustain the network of Regional MCH Coordinators responsible for the abstractions, mortality surveillance epidemiologists, and staff support for the PAMR meetings and follow-up actions. In addition, Title V-funded positions such as the BFH Health Systems Strategy Manager, communications staff, and other policy and strategy support will be integral to advancing the work of the review committee and its recommendations.

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.

Expand data collection on specialty topics and priority populations: As one of the go-to resources for data within the health department and partners alike and an important source for data on social determinants of health, LaPRAMS is leveraging its robust data collection system to gather nuanced information on priority topics and sub-populations.   Building off of the Phase 8 LaPRAMS survey that included new or revised questions about substance use involving opioids and expanded details on experiences of discrimination, LaPRAMS implemented the CDC-funded maternal disability supplement in January 2019 and the opioid use supplement in April 2019. Program activities around the opioid call-back survey, which include new methodology, began in August 2019 and concluded in April 2020. Data collection for the maternal disability supplements will continue into FFY2021 and may be extended.

A non-CDC funded COVID-19 supplement will be distributed for six months starting in October 2020. The supplement consists of 12 questions that will examine experiences around the perinatal period during the COVID-19 pandemic. The questions focus on social, emotional, and economic impacts on pregnant women due to the pandemic. The supplement will include questions on resource access, the impact of service changes (ex: giving birth without partners or family present), job loss, food scarcity, and more.

Effectively communicate findings, implications, and recommendations: In FFY 2021, annual surveillance reports and summary data books will be published on the Partners for Family Health Data Center and shared with partners. In FFY 2020, the 2019 Surveillance Report included additional information on associations between variables in order to delve more deeply into focus areas related to maternal stressors, such as intimate partner violence and injury, discrimination, and the continuing effects of the 2016 Medicaid expansion. 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: BFH has cultivated a partnership 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).

Conduct Root Cause Analysis of adverse maternal and infant health outcomes. During the maternal and women strategy planning sessions, BFH staff reflected on the systems-level response to Louisiana’s maternal outcomes. Staff from various programs acknowledged that public health as a whole spends a great deal of time and resources developing responses to the “problem of the day” (ex. natural disasters, maternal mortality, etc.). Less time and resources are devoted to asking research questions that 1) Build public health knowledge base and 2) Help the public health system understand and develop programmatic interventions tailored to an issue’s specific contributing factors. There is a need for data to inform more focused and appropriate programmatic action. Specifically, data can help BFH and other state stakeholders identify the causes of poor maternal birth outcomes. A root cause analysis will help BFH and other stakeholders address the maternal morbidity and mortality rates across the state.

In FFY 2021, Title V will conduct at least one priority analysis related to adverse maternal and infant health outcomes. A workgroup will be convened to identify priority maternal and infant outcomes, determine methodology required to conduct root cause analysis, and assess BFH capacity to carry it out. Title V will explore opportunities with academic partners to support this effort. After the root cause analysis is complete, Title V will create a strategic communication plan to share with partners and stakeholders.

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

Support Healthy Moms Healthy Babies (HMHB) Advisory Council: In FFY 2021, Title V will continue to support the HMHB Advisory Council by facilitating quarterly council meetings and supporting the council’s work to ensure that state initiatives addressing maternal mortality and severe maternal morbidity include an equity focus informed by the community. Through its evaluation of the existing groups focused on maternal mortality and severe maternal morbidity, the HMHB Advisory Council identified LaPQC, PAMR, Perinatal Commission, and Medicaid as the primary statewide entities addressing these issues, so many of the recommendations and resulting strategies target these entities, which are all Title V investments or key partnerships.

Recommendations involving PAMR and LaPQC have begun to be incorporated into the program plans. For example, the LaPQC strategy to establish a community advisory network is also linked to the HMHB task to incorporate an ongoing community advisory process into existing state committees and collaboratives working to address maternal mortality and severe maternal morbidity.

In FFY 2021, Title V will also support the council in the development of a strategic messaging guide, co-designed with community stakeholders, for LDH, clinicians, and hospital administrators to use when communicating with the media, patients, families, legislators and the general public regarding maternal mortality and severe maternal morbidity. Consistent messaging across community, healthcare and public policy sectors is expected to help entities working toward common goals to reinforce each other’s efforts. Furthermore, the guidance is intended to support communications with patients and their families, the media, legislators and the general public. Consistency in messaging is anticipated to help assure the public that leaders understand the issues contributing to Louisiana’s disparate maternal health outcomes and are working together to protect and promote the health of individuals who give birth in the state. By providing a common language, the guide is also intended to foster a shared understanding of the practices, policies, and structures that need to change in order to address racial and ethnic disparities in maternal health outcomes.