Women/Maternal Health Priorities and Performance Measures

Improving birth outcomes and 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

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 2022, Title V will support the ongoing implementation of the Louisiana Perinatal Quality Collaborative (LaPQC) Safe Births Initiative. The Safe Births initiative will continue improvement work related to hemorrhage and hypertension, and 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 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.

Louisiana Birth Ready Designation. While the LaPQC is not responsible for directly implementing the evidence-based improvement strategies within the hospitals, the LaPQC utilizes several tools and approaches to encourage hospitals to begin working to implement these interventions. In addition to the coaching and QI activities described above, the LaPQC is launching a designation plan that will award hospitals who achieve and maintain certain quality improvement milestones. Evidence suggests that hospital accreditation may be an effective way to incentivize hospitals to improve the quality of the care provided. Additionally, Louisiana Title V has experienced success with improving birthing hospital care and breastfeeding initiation outcomes with the Gift and Baby-friendly designation process. In FFY 2022, the LaPQC will fully launch its Louisiana Birth Ready Designation. Offering two tiers of recognition – Louisiana Birth Ready (labeled BR) and Louisiana Birth Ready + (labeled BR+) – the Designation will distinguish those birthing facilities committed to practices that promote safe, equitable, and dignified birth for all birthing persons in Louisiana. To measure the impact of this evidence-based strategy, Title V is introducing ESM 2.2: Percent of birthing hospitals achieving Louisiana Birth Ready Designation.

Through the Safe Births Initiative, participating hospitals submit several “structure measures” related 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 2022, 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.

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

Support implementation of new regulations for Louisiana’s birthing facilities: Over the past several years, the Title V program has supported the research and development of two substantive changes related to the requirements for birthing facilities in the state: 1) the creation of regulations for free-standing birthing centers and 2) the realignment of the maternal levels of care for hospitals to be clearer, more rigorous, and more closely aligned with national recommendations. The regulations for free-standing birthing centers emerged out of a multi-year inquiry led though the Title-V supported Perinatal Commission. There were several catalysts for the review of hospital regulations including the issuance of new national recommendations, as well as recommendations from the Title-V supported Pregnancy Associated Mortality Review (PAMR) report. The Title V-supported LaPQC/PAMR Medical Director has been instrumental in leading a comprehensive stakeholder-engaged process to review the current licensing requirements for birthing facilities and the designation process that has resulted in new regulations which are expected to be released in the Fall of 2021. Participants in the review and development of new hospital requirements have included clinical providers, administrators, health system leaders, the hospital licensing authority, professional associations, advocates and patients. 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 CDC Levels of Care Assessment Tool (LOCATe) 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 the final steps of rulemaking and implementation of the new regulations. The efforts to modernize Louisiana’s regulations are also memorialized in the section of the LDH Business Plan that was led by the Title V director and the Associate Medical Director of the LDH Bureau of Healthcare Finance (Medicaid) through the Title V/Title XIX interagency workgroup.

Support launch and operation of Louisiana Doula Registry Board. During the 2021 Louisiana Regular Legislative Session, a new law (Act 182) was passed that creates the Louisiana Doula Registry Board. This new board is charged with reviewing, approving and/or denying applications for doulas registering to receive health insurance reimbursement in the state and maintaining a statewide registry. Doula is defined in the Act as an individual who has been trained to provide physical, emotional, and educational support, but not medical or midwifery care, to pregnant and birthing women and their families before, during and after childbirth. BFH has been assigned to support the implementation of the Louisiana Doula Registry Board, which in the near-term includes supporting the member appointment process and facilitating the inaugural meeting. The LaPQC medical director is also responsible for appointing representatives from organizations providing doula services for people giving birth in each of the nine LDH administrative regions. Once the board formally convenes and begins executing the mandates as specified in Act 182, BFH will provide administrative support to ensure successful ongoing implementation.

Launch an LaPQC initiative to support perinatal depression screening by pediatric providers. 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 impact of this new policy, in FFY 2022, BFH will launch an LaPQC initiative with pediatric providers that aims to increase utilization of evidence-based screens for perinatal depression at well-child visits.

Support improvements in the implementation of the Louisiana Mental Health Perinatal Partnership (LAMHPP). In partnership with Tulane University School of Medicine, BFH will continue to support and direction to the Louisiana Mental Health Perinatal Partnership (LAMHPP), a provider-to-provider consultation system to support licensed healthcare clinicians serving pregnant and postpartum women and their families. Similar to the driver diagram guiding the LaPQC efforts, LAMHPP is intended to support early recognition and response to potential mental health concerns among pregnant and postpartum patients in Louisiana. LAMHPP supports healthcare clinicians to address the needs of their patients including perinatal depression, anxiety, substance use disorders, interpersonal violence, and related health risks, through psychiatric phone consultation, phone resource and referral consultation, in-person and online training, and online resources. Consultations focus on promoting screening for mental health concerns, first line management of mental health and substance use disorders, and making effective referrals to additional community resources. In FFY 2022, BFH will implement new QI processes that will enhance the quality and reporting of the data collected during consultations. BFH will also be soliciting provider feedback on the services offered through LAMHPP to inform improvements and future direction of the program. 

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 2022, 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 2022 include:

• Deliver high-quality, evidence-based reproductive health services
• Expand and sustain access to high-quality, evidence-based reproductive health services
• Increased focus on service provision for adolescents
• Involve communities in decision-making to increase service provision and move from a health equity model to a health justice model

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.

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

Develop and implement a RHP Patient Advisory Committee: In FFY 2022, RHP plans to develop a patient advisory committee to advise RHP on population needs and services offered. In FFY 2021, RHP began building out plans for the committee with the intention to launch the committee in FFY 2022. This committee will include adolescent voices, and RHP is working with school-based health centers (SBHCs) to identify these committee members.

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 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.

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 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.

Support implementation of Louisiana Domestic Abuse Fatality Review Panel. During the 2021 Regular Session of the Louisiana State Legislature, Act 320 was signed into law that creates a domestic violence fatality review team within LDH. Due to the Bureau’s expertise in leading comprehensive mortality reviews, such as PAMR, BFH has been assigned as one of the lead agencies responsible for implementing the new panel as soon as funds are appropriated by the Legislature. According to the most recent PAMR Report, in 2017, the leading causes of pregnancy-associated deaths in Louisiana was homicide. The Louisiana Domestic Abuse Fatality Review Panel presents an opportunity to further investigate the causes, trends, and other factors related to these deaths, as well as build new action-oriented partnerships around domestic violence prevention.

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, the opioid use supplement and the Opioid Call Back Survey 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 was completed in June 2021.

In response to the COVID-19 pandemic, LaPRAMS collaborated with CDC and Council for State and Territorial Epidemiologists (CSTE) to implement the COVID-19 supplement from October 2020-June 2021. The supplement consisted of 12 questions examining 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 included questions on resource access, the impact of service changes (ex: giving birth without partners or family present), job loss, food scarcity, and more.

In preparation for Phase 9 of the LaPRAMS survey, LaPRAMS staff are working with both the CDC and the LaPRAMS Steering Committee around the development of the new survey iteration. Phase 9 is scheduled to be released in April 2023.

Effectively communicate findings, implications, and recommendations. In FFY 2022, 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 2020, the 2019 Data 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. Additionally, the 2018 PRAMS Surveillance Report was publicly available through the BFH Data Center. 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).

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

Support development and dissemination of strategic messaging guide:  As mandated through the authorizing legislation, the Healthy Moms Healthy Babies (HMHB) Advisory Council was formally disbanded on 3/31/21. During the final year, BFH began working with a workgroup formed through the council to develop a strategic messaging guide 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. The purpose of the guide is to promote consistent messaging across community, healthcare and public policy sectors and 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 aims 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. Although it is no longer legislatively mandated, BFH and members of the council workgroup are continuing to work together through FFY 2022 to finalize and disseminate the strategic messaging guide.

Actively participate in AMCHP Healthy Beginnings learning and practice cohort. In June 2021, BFH applied for and was selected to participate in the AMCHP Healthy Beginnings with Title V: Advancing Anti-Racism in Preterm Birth Prevention project. The purpose of the 18-month learning and practice cohort is to build transformational partnerships between Title V MCH agencies and community-based organizations that aim to dismantle policies and programs that perpetuate racism through inequities in funding and support the sustainment and spread of community innovations. Throughout the 18 months, BFH will be working with Sista Midwife Productions, a birth advocacy organization based in New Orleans, to identify and address racism in policy, data and funding structures at the state level that sustain inequities in perinatal health. The 2020 Needs Assessment highlighted the need for BFH to better support and partner with community-based organizations, especially those led by and supporting Black, Indigenous, Latinx, Asian, Pacific Islander, and other communities of color. This learning and practice cohort offers a timely opportunity and supportive forum to understand how BFH can uplift community-driven solutions and improve services and operations to more fully meet the needs of communities.