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 percent of female victims (39 out of 40) were murdered by someone they knew. Of the victims who knew their offenders, 56 percent (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 the 2017-2019 Pregnancy-Associated Mortality Review (PAMR) Report, substance use is a leading contributor to pregnancy-associated mortality.  In one-fourth (25%) of deaths, the individual giving birth had a Substance Use Disorder (SUD) that contributed to their death.1 High rates of substance use are correlated with high rates of mental health issues. According to the 2020 Pregnancy Risk Assessment Monitoring System (PRAMS) Report, roughly 14% of individuals surveyed reported experiencing depression prior to and during pregnancy. 16.8% 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.

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 (National Outcome Measure (NOM) 2)
• Reducing the rate of maternal mortality per 100,000 live births (NOM 3)

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 (National Performance Measure (NPM) 2)

The strategies implemented to reduce cesarean deliveries among low-risk first births are evidence-based, and adapted to the unique context of the state of Louisiana. In FFY2024, LA Title V will implement strategies to achieve the following objective(s) in relation to the women/maternal health population domain:

• By December 2024, reduce the number of low-risk, first-time Cesarean births from 27.6% (end of year 2022) to 24.7% through the third year of the Louisiana Perinatal Quality Collaborative (LaPQC) Safe Births Initiative.
• Annually award Louisiana Birth Ready Designation to birthing hospitals meeting designation criteria
• By September 2024, register the first cohort of doulas in the Doula Registry making them eligible for insurance under Act 182.
• By September 2024, enroll 10 additional pediatric practices in the Caregiver Perinatal Depression Screening Initiative.
• By September 2024, following an initial period of integration of the perinatal consultation program into the Provider to Provider Consultation Line (PPCL), conduct an internal review to identify challenges and define strategies for improvement.
• The PAMR process is strengthened as a result of collection of complimentary informant interview data.
• Timely access to domestic violence services and health services is improved as a result of the implementation of a bi-directional referral system.
• LA PRAMS data collection is strengthened following the introduction of additional online survey data collection methods.
• Publish at least two LA PRAMS data reports annually

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.

Implement the LaPQC Safe Births Initiative with a focus on reducing Louisiana’s nulliparous, term, singleton, vertex (NTSV) cesarean section rate: In FFY2024, Title V will continue to provide support and leadership oversight for the ongoing implementation of the LaPQC Safe Births Initiative. As part of the Safe Births Initiative, participating hospitals will continue to submit data related to priority improvement areas related to obstetric sepsis and sustaining gains for NTSV. Using a secure data portal, participating hospital teams will track their implementation progress and use their own data to identify new areas of improvements.

Provide technical assistance and data support to birthing facilities pursuing the LaPQC Louisiana Birth Ready Designation: In FFY2024, 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. In FFY2024, birthing hospitals will apply for designation for requirements met in 2023. The 2023 Birth Ready requirements were expanded to include additional measures around health equity and patient partnership; policy and procedures around obstetric sepsis; annual staff and provider education around obstetric sepsis; the spread of obstetric drills to multidisciplinary teams and emergency departments; structured debriefs with patients and families after severe obstetric events; and patient education on sign and symptoms of perinatal mood and anxiety disorders (related to Act 188). As substance use disorder is now the leading cause of pregnancy-associated deaths according to the 2017-2019 Louisiana PAMR Report, birthing facilities applying for designation are required to implement a validated screening tool for substance use. 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.

Through the Safe Birth Initiative, over FFY2023, participating hospitals completed several structural measures to prepare for a deeper dive into process measures. In FFY2024, birthing facilities will evaluate their process measures to ensure compliance with evidence-based recommendations to ensure compliance with the Society for Maternal Fetal Medicine for labor dystocia. Additionally, participating facilities will now submit their low-risk, first time cesarean birth rate as defined by the Joint Commission (TJC) PC-02 disaggregated by race and ethnicity to ensure equitable care. Because we are still focusing on improving Severe Maternal Morbidity for hemorrhage and hypertension, birthing facilities will continue to submit process measures - risk assessment on admission to Labor and Delivery, quantification of blood loss during delivery, postpartum risk assessment, timely treatment of hypertension and postpartum follow-up in three days for patients with severe hypertension. As with TJC PC-02, facilities are required to submit timely treatment of hypertension and postpartum follow-up data, disaggregated by race and ethnicity. While other reporting agencies are now starting to require disaggregated data, most facilities are not optimized to do so. Title V funding will be utilized to provide the technical assistance needed to guide the birthing facilities in both submitting and analyzing their disaggregated data to ensure equity in these process and outcome measures.

Progress related to these strategies will be measured by tracking two evidence-based strategy measures (ESM): ESM 2.1: Percent of birthing hospitals actively participating in Louisiana Perinatal Quality Collaborative Initiatives; and ESM 2.2: Percent of birthing hospitals achieving Louisiana Birth Ready Designation.

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

Support implementation of new regulations for Louisiana’s birthing facilities: In FFY2024, Title V will continue to provide subject matter expertise to the department and to the state’s birthing hospitals and free-standing birth centers as they implement the new licensing requirements. In the new requirements, hospitals and free-standing birth centers are now required to participate in the state Perinatal Quality Collaborative. While participation requirements may be more or less intensive depending on the level of care, all facilities are allowed to participate in any of the initiatives or quality designation systems that are applicable to the types of services provided. In FFY2024, the LaPQC will begin to enroll free-standing birth centers who apply for licensure. The LaPQC will work with enrolled freestanding birth centers to co-create implementation strategies aligning with Alliance for Innovation on Maternal Health (AIM) bundles and infant feeding best practices. In addition, the LaPQC will build quality improvement capacity in enrolled freestanding birth centers through collaborative learning and technical assistance from LaPQC improvement coaches, improvement advisor and faculty.

Increase the readiness and response of statewide healthcare facilities to address and improve perinatal and neonatal outcomes: In FFY2024, the LaPQC will continue to lead the expansion of several initiatives to improve readiness and response of birthing facilities statewide through The Gift, a breastfeeding and infant feeding initiative; Improving Care for the Substance Exposed Dyad, an initiative that addresses the mother and infant dyad impacted by substance use disorder; and the Safe Births Initiative, which is focused on implementation of the AIM patient safety bundles for obstetric hemorrhage, severe hypertension in pregnancy, safe reduction of primary cesarean birth, and sepsis in obstetric care.

In FFY2024, the LaPQC will expand quality improvement efforts to emergency departments. In review of the 2017-2019 PAMR Report, improving readiness, recognition and response among healthcare providers and birthing facilities is an area of opportunity to prevent maternal deaths. Throughout FFY2024, the LaPQC will partner with emergency departments across the state to implement the components of the newly released AIM Obstetric Emergency patient safety bundle.

The LaPQC will publish its inaugural report and improve stakeholders’ timely access to data and information through regular reporting to key partner groups including patients, communities, legislators, and health care systems. In addition, the LaPQC will launch its new website to increase visibility of the LaPQC’s work and support improvement teams through a tool and resource hub accessed through the website.

Decrease racial/ethnic disparities in outcome measures across all LaPQC initiatives: In FFY2024, the LaPQC will continue to work collaboratively with participating facilities to address racial and ethnic disparities across outcome and key process measures. The LaPQC will continue to work with data equity experts to implement a data equity framework, inclusive of data equity tools and scripting, develop a system for quick capture, dissemination, analysis and sharing of stratified data and support the transition of participating facilities to allow for exclusive submission of data stratified by race/ethnicity. In addition, the LaPQC will develop and implement consistent, right-sized stratification across all of its initiatives and programs. A health equity plan to support hospitals in taking the “what now” steps to address disparities identified from their data. will be finalized and piloted. The LaPQC will also create a roadmap to help participating facilities use and communicate data for equity at the facility level and to community partners.

Progress related to the above strategies will be measured by tracking two evidence-based strategy measures (ESM): ESM 2.1: Percent of birthing hospitals actively participating in Louisiana Perinatal Quality Collaborative Initiatives; and ESM 2.2: Percent of birthing hospitals achieving Louisiana Birth Ready Designation.

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: In FFY2024, BFH will continue to provide support to the Louisiana Doula Registry Board and facilitate the development and implementation of the state’s voluntary 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 that facilitate registration through an online application. We anticipate we will begin accepting applications from doulas to join the Louisiana Doula Registry in FFY2024. As the requirements are defined through rulemaking, the process is lengthy but should be completed by the end of FFY2023. Overall, doulas are becoming more formally recognized as a part of the state’s maternal support and care landscape with state policy actions such as the establishment of the registry, and most recently, the passage of House Bill 272 of the 2023 Regular Session of the Louisiana Legislature which will require insurers to cover doula services for doulas within the registry. BFH expects to hire a dedicated position to coordinate the Doula Registry Board and the Perinatal Commission by the end of FFY2023. This position will be supported in part through Title V funding.

Support the implementation of perinatal depression screening in pediatric settings: In January 2021, a Medicaid policy change took effect that allowed pediatric healthcare  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 of this new policy, in FFY2022, BFH launched the LaPQC Caregiver Perinatal Depression Screen (CPDS) in Pediatric Practices pilot  to determine which quality improvement strategies are needed to integrate depression screening and linkage to care in pediatric practices.  The LaPQC CPDS initiative was a purposefully small initiative that included four pediatric practices that demonstrated readiness for integrating the caregiver perinatal depression screening into their practice.The goal of the LaPQC CPDS pilot was to implement best practices that promote equitable access to caregiver perinatal depression screening and appropriate referral when risk is identified through a warm hand-off. By the end of the CPDS pilot, 99% of caregivers were screened for depression using a validated screening questionnaire; 100% of those caregivers who screened positive were referred to care; and 90% of those referrals were performed through a warm-hand off.

Findings from the pilot will be included in the LaPQC’s first annual report in September 2023. Building on the findings of the CPDS pilot, the LaPQC will work closely with the Developmental Screening(DS) initiative and the PPCL system to develop an implementation model to support the spread and scale of screening for perinatal mood and anxiety disorder in pediatric sites across the state.

Support the Louisiana PPCL in the development of a statewide mental health consultation system for pediatric and perinatal healthcare providers: The five year grant that has funded a majority of the development and pilot implementation of Louisiana Mental Health Perinatal Partnership’s (LAMHPP) consultation, training, and resource and referral support services for perinatal providers ends in FFY2023.  Although an application has been submitted for an additional five year grant to support these services, much of FFY2023 focused on transitioning the primary management of the program from Tulane to BFH to ensure long-term sustainability and growth of the program. As of July 1, 2023, LAMHPP is fully integrated under BFH’s Provider-to-Provider Consultation Line (PPCL) system.  The integration allows BFH to leverage multiple funding sources to support consultation services across the state and has resulted in increased efficiencies and capacity related to management, infrastructure, outreach and marketing, and staffing. In July 2022, BFH applied for and received supplemental grant funding to support a robust evaluation of its perinatal consultation services. The evaluation consists of a comprehensive analysis of all available program data as well as a qualitative component reflecting the provider experience with using perinatal consultation services. The evaluation is expected to be completed in September 2023, and in FFY2024, the BFH team will use the findings and recommendations to set the future direction of the program and to improve the program to better meet the needs of providers utilizing the program. 

Provide supplemental funding and infrastructure support to all BFH reproductive health efforts to support access to high-quality family planning and reproductive health care: In FFY2022, BFH applied for and was awarded a new five-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 OPH 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. This service system and work is supported in part through Title V funding.

In FFY2024, the BFH Reproductive Health Program (RHP) will begin implementing strategies that model several Title V systems-building strategies. Inspired by the DS 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 is expected to be based on the Quality Family Planning (QFP) and other recommendations, guidelines, and best practices in the reproductive health field. The Title X program is designing a quality designation system similar to the successful Title V-funded LaPQC Gift program (described in the Perinatal/Infant domain) and Birth Ready hospital designation initiatives to recognize primary care practices that have demonstrated successful implementation of sexual and reproductive health services into their daily practice.

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

Ensure robust, high-functioning PAMR: With the joint funding of Title V and the Centers for Disease Control and Prevention (CDC) 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. The core PAMR team, consisting of the PAMR medical director, PAMR coordinator and maternal morbidity and mortality epidemiologist, is working on efforts to ensure that the PAMR committee is able to continue high quality, robust case reviews. In FFY2024, a new process for recruitment will begin with the implementation of an application process to fill committee positions. The application and subsequent approval process will ensure that the committee remains diverse in gender, race/ethnicity, age, geographic location and subject matter expertise/lived experience. New members will receive orientation prior to attending their first meeting.

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. The successful implementation of the LABoRS tool and the Utah tool, shows the necessity of having non-clinical information available for case narratives and committee discussions. With this information, in FFY2024, the PAMR team will pilot an informant interview program, beginning with the review of 2022 cases, in order to obtain information that may not be readily available in medical records. Informant interviews will provide additional qualitative and subjective information about the decedent, including her perceptions and experiences throughout her pregnancy and a more in depth social and emotional history.

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.The release of the annual PAMR Report will include data and recommendations from the 2022 review of 2020 cases. The 2020 PAMR Report will outline recommendations for action directed toward specific entities, including healthcare professionals, healthcare systems, policy makers, government and public health agencies, payers and insurance carriers, and social and local community organizations. There is a robust dissemination plan for the 2020 report for optimal visibility and reach.  In FFY2024, the LaPQC will partner with the regional maternal and child health (MCH) coordinators to leverage the Community Advisory and Actions teams (CAATs) to increase visibility of the PAMR Report and the initiatives of the LaPQC in response to that data, as well as bolster community-hospital linkages. Progress related to the above strategies will be measured by tracking two evidence-based strategy measures (ESM): ESM 2.1: Percent of birthing hospitals actively participating in Louisiana Perinatal Quality Collaborative Initiatives; and ESM 2.2: Percent of birthing hospitals achieving Louisiana Birth Ready Designation.

Establish 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: In FFY2022, 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 FFY2023, 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 PRAMS: LaPRAMS data are representative of Louisiana maternal experiences and are actionable for informing state programming and policy related to the health and experiences of individuals who give birth in the state. In FFY2024, Title V will continue to supplement infrastructure support for LaPRAMS as one of the core public health surveillance systems for MCH. In July 2023, CDC implemented Phase 9 of the PRAMS survey and protocol for the 2023 birth sample. Supplemental questions related to Social Determinants of Health (SDOH, e.g., living and food environments, transportation, health literacy, mental health and discrimination) were added to the core survey and now, there is an option to complete the survey online. Over the past year, the Bureau has been preparing to implement Phase 9 by seeking approval of the Institutional Review Board, testing user acceptance testing for the PRAMS Integrated Data Collection System, developing content for the web-based survey and processes for an infant death match for the data pull each month and updating print materials and phone scripts. The first year of data (2023 births) following the Phase 9 protocol will occur during FFY2024.

Effectively communicate findings, implications, and recommendations: In late FFY2023 and FFY2024, BFH will publish and share two LaPRAMS reports: 1) the 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) the 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 webpage and shared with partners.   In July 2023, the 2019 PRAMS Surveillance Report and Social Media Toolkit were made publically available in July 2023 and the 2020 PRAMS Data Report will be released in late FFY2023. The survey data collected in FFY2023, which includes responses to the supplemental SDOH questions will be reported in FFY2024, along with the 2021 PRAMS Data Report. Additionally, BFH communications staff will update the report features to highlight relevant findings and recommendations and provide additional context to the data.

Support strategic action to improve outcomes: A limitation of PRAMS data is that it can only be reported at the whole state or stratum-specific level (race for Louisiana).  To develop a robust methodology for analyzing data at the parish level, CDC PRAMS proposed that a team of internal CDC statisticians and epidemiologists work with PRAMS data from multiple sites. In FFY2024, LaPRAMS and Louisiana Vital Records will participate in this small area estimation project and provide two additional variables from the 2016-2020 birth file: maternal parish of residence and maternal age (years). PRAMS will continue to provide data to contextualize, support, and inform the work of programs across BFH, including injury prevention, mortality surveillance, and ACEs.