AMCHP 2005 ANNUAL CONFERENCE
DELIVERING RESULTS, IMPROVING PREGNANCY & BIRTH
February 19-23, 2005
RODNEY WISE: Thank you, Ellen, and thank you AMCHP for this opportunity to kind of present what's going on in Louisiana.
I would like to begin this workshop with a presentation of the Louisiana fetal and infant mortality reduction initiative. This initiative is a comprehensive effort to coordinate all parties in the State dealing with MCH outcomes. The initiative is lead by MCH program within the Office of Public Health, but it's scope is not limited to public health. The initiative's goal is to address all aspects in the entire spectrum of MCH care, whether you're looking at the MCH pyramid, or the essential services our goal is to touch and contact everything involved with MCH outcomes.
Several states have pretty comprehensive infant mortality initiatives, we are not unique in that respect. I think one of the things that makes us a little unique for this workshop is that our initiative began with FIMRs .
So, just kind of briefly review what we are going to cover here, what is the FIMR process needed and we'll look at some of the statistics in our states. The development of FIMR in Louisiana. Several states have pretty comprehensive infant mortality initiatives and we are not unique in that respect. I think one of the things that makes us a little unique for this workshop is that our initiatives began from FIMRs and a regionalization of FIMRs.
So to briefly review what we will cover here, why is the FIMR process needed in Louisiana and we'll briefly look at some of the statistics in our states, the development of FIMR in Louisiana and how FIMR has helped mold the activities at the central level, what we are doing statewide that began at the FIMR level, and then some regional examples of FIMR at work and where we are going next is development of formal regional MCH coalitions.
And as I go around Louisiana, I think one of the things that I always like to show is our comparisons, because generally being an OB/GYN and working with OBs, I think we all do our best every day to do what we do. And we think that our outcomes are good. And while our individual outcomes may be good, we are not aware of our regional outcomes, our state outcomes or US outcomes. I think you saw some of this data yesterday, it was a little more updated. Singapore, I think has the top right now with Hong Kong and Japan following. But look at United States down there was 28th in 1999 to and Louisiana with an infant mortality rate of 10.2 in 2002 ranked right below Chili. Now I know a lot of you think Louisiana is a third world country, but if you look at infant mortality rates, we are a third world country or we rank in third world countries. And this is always an eye opener to individuals within the State, that one of the most industrialized, best medical care system in the world has horrible infant mortality rates.
The other point I make here is as I'm traveling around the State I often hear infant mortality is a process of poverty. And it's the regions of poverty that have high infant mortality. I would tell you that Chili probably has much more poverty, Singapore probably has much more poverty than Louisiana, so infant mortality is not an issue of poverty, it's an issue of systems. Now, poverty may be a point of that, but it's your healthcare system. Cuba certainly is an impoverished nation, but they are -- you know, the infant mortality is better than ours.
And in comparison to other states, Louisiana, they are in the middle of the south central area, is in the highest of infant mortality rates pretty consistently. Louisiana is pretty much always in the top or bottom five, I should say.
So kind of an overview, in 2001 we were 48th in infant mortality with Mississippi and Delaware being worse. Most of our infant mortality is related to a very high preterm, low birth weight rate. We were 49th in 2001 with a rate of 10.4 percent.
The population in Louisiana is largely African American and white. We don't have a large Hispanic population or Asian population. Like most states, there's a large disparity in African American and white populations. In 2002 the white rate was 6.9, the African American was 15. Here's increasing tend and it's very worrisome over the last three to five years for both the state and in New Orleans and for both the black and white populations. And you might think that the urban New Orleans area, the inner city area, would have the highest rates. That's not necessarily true. There's other regions of the state with higher rates than inner city New Orleans.
Louisiana is divided into nine administrative regions and we work pretty much through the regional basis. New Orleans is down in the southeast corner of the state in blue, Baton Rouge, the State capital in region two, and Shreveport the other largest city is in the far northwest corner of the state. And I'm mentioning this just because regionally we try to do comparisons, we try to give our data back to the regions by the regions so we can help motivate them and to try to take ownership into their infant mortality problems.
From '91 to '98 this is what our trend in infant mortality looked like for the State and we break it down by regions so we can talk to the regions and try to address them. We'll flip through some of the regions. In Region 9 there is on the north shore and they historically have had one of the better infant mortality rates in the state.
From 2000 to 2002, though, we've seen a reversal of that trend. Both the State and most of the regions have had upward trending in infant mortality rates.
If you look at the actual numbers, the State rate is at the bottom there and the regions, the nine administrative regions. From '99 to 2002 we've increased to 10.2. Now, the 2000 number of 8.9 is actually not accurate. In 2000, we had some very severe budget cuts and looking at it, we've had reanalyzation of the data, and what happened was there was very significant under reporting of deaths in region 1 which is Orleans Parish in New Orleans and that significantly skewed our state data.
The infants born under 750 grams in Orleans Parish that year had a survival rate of like 90 some odd percent which is unheard of. And what happened due to budget cuts, the death certificates had never been filed and no one followed up on the death certificates. We don't think we got better in 2000. We probably continued on the upward trend. Here is infant mortality rates for the white population in Louisiana. As I said, 6.9 in 2002 and for our African American population with the rate of 15 for 2002 and trending upward over the years.
So what about FIMR and fetal mortality reviews in Louisiana? Well, the history began fairly early in two different mechanisms or two different outlets. One was New Orleans was one of the original Healthy Start grantees, it was called the Great Expectations program and they had a very strong fetal and infant death review process in that city in that Great Expectations, and that was credited from bringing Region 1, the New Orleans area, with the highest infant mortality rates in the state to one of the lowest. This occurred over a six or eight year time period. Then after cuts in the Great Expectation program occurred, the FIMR process in that city did end a few years ago.
The other mechanism of reviews was in the north eastern part of the state and that was called Improving Pregnancy Outcome committees or IPO committees. The northeast corner of the state, this is an active ongoing process. It's more of aQA process between public health and the state hospitals, because it's not a D identified, it's an open chart type review. So it's only by the providers of public health and the state hospitals that are providing the care.
15 years ago, most of the Medicaid population was getting their care through the public health units and then delivering in one of our nine state hospitals, so that system worked pretty well. That has change somewhat now to most of the Medicaid population is in the private sector. Louisiana has a strong MCH EPI division and we have a CDC assignee, Juana Kuna, who has been very, very supportive with us in the state in getting data. And back in probably 2000, the development, it was prior to my time with MCH, the development of a statewide FIMR process was developed by Dr. Kuna and Joni Wyken, our program administrator, and the wheels were put into place to start our current FIMR process.
Our data for our state and for our regions was analyzed by perinatal periods of risk, so it would help the regions and help the individuals within the regions understand the data, and GIS mapping was done and we found that to be very beneficial in motivating communities.
The state MCH Title V program funds regional FIMR coordinators in each of the regions. So we have funding, have individuals hired either half time or full time, it depends on the region, to head up this effort. And the FIMR coordinators are not put, very purposely not put within the health departments. There are two housed within the LSU health science center hospitals, there's one in a contract with a AHECK agency, a private social agency, three are in Healthy Starts or combined with Healthy Starts, one within a nursing school and one within a Health Department. So the individuals come from a broad spectrum and trying to bring that collaboration in different view points into our FIMRs.
We call this the Louisiana FIMR or LA FIMR and currently the process is going on in all regions, but currently focused in the major parish or the major county of each region. The objective of the LA FIMR network is pretty straight forward for FIMR, it's to review all fetal and infant deaths in that parish or that region, looking at assessing the care provided to the mothers, identifying social and other areas for improvements within the healthcare system, recommend to the community for services and system and really getting that community action team, that component of FIMR, very involved in working to mobilize the community.
Our LA FIMR network, this is what our state looked like in the early part of 2001. We had no active FIMR programs. The firs FIMR program began in Region 6, the center part of the state in Alexandria in '02, and then in 03, we had others common board. And then in 2004, three more regions and currently the last areas are in some stage of getting the FIMR reviews going. And our goal is to eventually have every death in the state reviewed by the FIMR process.
So how has this FIMR progressed? Well, working within the communities, the FIMR process, especially involving the community action team has helped give community ownership to MCH issues. So these communities and regions are coming back to us wanting more information wanting more formal structure and warning the state level to help organize better at the community level. So they are looking at us to help formalize regional MCH association. And we are looking to the regions for feedback also. The regions have been doing the needs assessment, they are holding community meetings and now in the process of finalizing strategic planning within the regions with guidance from the state office. So our fetal and infant mortality reduction initiative that I started out mentioning has evolved from the regional FIMRs. It involves our Louisiana FIMR network which is our evaluation part of our initiative, we also have PRAMS in our state, so that's beneficial to us.
But we found to get the communities motivated we need that carrot of intervention and that carrot of intervention we've been using is a nurse family partnership program, the home visitation program. That is where the RN goes in and follows the pregnant mom and to the second year of life on the child. We now have nurse family partnership programs in about half of our parishes in our state. All nine regions have it, so we linked the MHP program with the FIMRs and having these people work in coordination. And as the medical director and the maternity nurse that works with me, we are able to coordinate and support all the efforts that I mentioned earlier that are dealing with MCH. And as we go into the regions we are working with the medical directors and the regional FIMR coordinators.
Just a couple of slides about the nurse family partnership. They have a booth here and this has been updated for the number of states and number of sites, so you can get more information from them, but Louisiana is not unique in MHP, but we are one of the states that has a broader coverage.
Tulane University, our first MHP program opened up in 1999, and in 2002, Tulane University did a study of the MHP in Louisiana, and this was an early study, we have many, many more families now. And they showed that there was a 52 percent reduction in premature births in MHP families, a 50 percent reduction in emergency room utilization and a 43 percent reduction in prenatal depression. There was also a reduction in low birth weight, partner violence, alcohol use, and (inaudible) pregnancies, but they were not significant partly due to the size of population at that time.
So we feel MHP does offer something very valuable in our state, while it's scope is relatively small because we certainly can't cover every pregnant women or at risk pregnant woman in the program we feel it's important part of our initiative.
Other statewide interventions that have occurred in the last few years, our Medicaid is at the 200 percent of poverty level. This has been very beneficial in helping Medicaid patients move into the private sector. Also Medicaid reimbursement for OB has been relatively good so a lot of the Medicaid patients have moved into the private sector. Smoking cessation campaigns are going on with tobacco control programs and private partners. And through PRAMS, we found the weight gain too little or too much was a contributing factor in Louisiana, so we've done weight gain campaigns along with our Partners for Healthy Babies which is a population base size.
Oral health coverage for pregnant women is available in Louisiana. It was covered under Medicaid in November of 2003, so this is something we've been very actively working on and through our regional coordinators.
As you open one door, you find other doors close obviously as those of you in public health know. And as we open the door to get coverage for pregnant women in public health, only to find there was a very big myth in the state, also by some dentist, you shouldn't treat pregnant women because it increased their risk of preterm labor or it may cause them to have a miscarriage. So we had to address the myth both with the dental groups and the patients. Then we found reimbursement rates for dental services was low by Medicaid, so that has been upped. So we are still having the challenge of getting enough dentists to do Medicaid coverage and treat pregnant women. So we worked with the state dental association and regional dental groups, and the president of the state dental association has asked every dentist in the state to treat pregnant women a half a day a month each. And we are getting some response to that, but it's another example of how we are trying to collaborate and improve this.
We are getting data back to the regional level. The Partners for Healthy Babies is our population services program, and the initiative is working much stronger with the partner now. We are trying to start a professional web site for the MHP program and for FIMR.
Our collaboration efforts include HIV, I work with a couple of hospitals recently in getting rapid testing going, tobacco control, family planning, STD. Louisiana is in the top five for rates of gonorrhea, Chlamydia and syphilis so we have a lot of opportunity to collaborate there because obviously that impacts pregnancies.
And as I mentioned earlier, Medicaid. We've also been working very closely with the office of addictive disorders. They are now the recipient of a fairly significant grant and are going to start getting vouchers out for treatment programs for women, well for individuals with addictive disorders. The program will be focused on women, pregnant women and adolescents, but will be open to all individuals of the state.
And our newest thing is trying to work closer with the office of mental health. We found that is really one of the biggest needs within our state.
We work closely with the state perinatal commission we have regionalization of care and there's a new plan that is coming out this summer the state perinatal commission. We have a non-profit private MCH coalition, the universities in the state and our Children's Cabinet.
Our newest partnership with the Louisiana Health Institute, this is a non-profit health entity in the city of New Orleans that is a recipient of a fair amount or good amount of the tobacco settlement funds. They will be doing media campaigns and we've gotten assurances from them to include perinatal aspects of smoking cessation. There are also housing and contracting programs, makers of fresh start family that are perinatal smoking cessation. We are one of the states in the state infant mortality collaborative with the CDC and AMCHP, we are also one of the states in the tobacco cessation learning lab. We also have a major plenary coming up at the annual MCH meeting in a couple of months.
And the other thing that we are starting and really excited about is this public health MCH detailing. As I mentioned earlier, there's been a transition of the Medicaid patient from the public health unit system to the private system and to the private hospital sector, and we needed a public health response to still address the issue of these patients. So a few months back, several months back, we worked with Medicaid and identified the top Medicaid obstetrical providers and providers in our state. And now, Mary Craig who is a nurse coordinator and I, we call these providers in the regions and we go out and spend a day in the regions, just like a drug rep, and we detail them. We make an appointment, we go in, we don't bring lunch, doughnuts, we are working on that, we may have to, and we'll invite the regional FIMR coordinator to go with us to some of them, the ones that can play a role in or the regional medical director. And we give them information on the oral health program. They've gotten all this stuff, it comes in the mail and probably the physician never sees it. It's been kind of -- it's worked for a lot of reasons. One is I've been on the faculty at the medical school for 20 years, so a lot of these physicians I have trained. And the other is, half of my time is maternity program medical director, the other half I still work in a perinatal center doing prenatal diagnosis and amnios. So one half of the state refers people to me for those services. So it helps me get an in back into their offices. But the detailing is really -- and the physicians are excited about it. Because they feel they have someone they can talk to at the state level that they can air their complaints or needs or whatever, and we are providing information back to them, and it's serving as a great communication link to the providers. In summary, our FIMR has really helped motivate our community, it's help motivate us at the state level. It's built a ground sell in interest in MCH and now it's our job to lead this back and really strengthen these local coalitions.
I want to just give you a couple of examples quickly about some regional activities. The first one is the Region 6 there in the center of the state is Alexandria. That was the original FIMR cite in the state and now it's serving as our unofficial training cite. Every time we get a new FIMR individual or review or abstract or coordinator, they will go tell Alexandria and sit in on some community action teams and really learn the ropes. We are trying to formalize all of this process, but right now it's our unofficial training cite.
This region also had a Methicillin Resistance Staph Auris, and MRSA outbreak within the region and a death within an infant within this. It caused quite some community alarm. The FIMR coordinated community response, they brought in outside speakers and held a day long meeting on MRSA, so they've really been recognized in that region.
The next one is Region 7, in the northwest corner of the state, Shreveport and it's the largest of our regional FIMRs and efforts. Shreveport is where LSU Health Science Center Shreveport is based. One of the zip codes there had a three year average infant mortality of almost 29. We went into the community and they were totally unaware of it. They were clueless the infant mortality rates were that high, so we helped them and formed a northwest Louisiana coalition for the care of infant, women and children. And now they have opened up with nurse practitioners, they've partnered with a local health club and local hospitals and opened up prenatal clinics, three sites within the zip codes. Nurse practitioners are going out and delivering the care. The clinics were available at the University Medical center less than five miles away, but it was too intimidating for the patients to go, so they moved within the community. Now they are working with beauty shops for signs and symptoms of preterm labor. They are working to develop a sorority for MHP graduates for our grassroots support.
The final one I want to mention is Lake Charles which is found in the lower left corner of the state. The coordinator there does FIMR reviews and birth defect registry reviews and we are really exploring the idea of trying to get a forensic nurse in each region so they can do child death, SIDS, FIMR, birth defects they can do all the reviews. This region had a cluster of neural tube defects. It's a fairly industrial region so the community got very heightened awareness that the pollution caused the three anacephalies they had in the last six months. So FIMR worked with the television station thereto do community response.
But pretty much all regions have got something going on. Region 9, I mentioned earlier, which is in the right side of the state there, had the lowest infant mortality rate, so they were probably dragging underneath all of this.
2003 data has come out and Region 9 has had a marked increase in infant mortality. So all of a sudden my last two weeks down there I have been in Region 9 because the community is now so interested in getting FIMR going.
What is the future? We want every death reviewed. We want to strengthen and formalize these local groups, these perinatal initiative type things, target interventions based on data and other programs, MHP other targeted, and we would like to be recognized as a leader in innovative programs.
This is our 2003 data for all races, our rate appears to have gone down from 10.2 to 9.3, we still have a long way to go. For our white population of 6.4 and for African Americans 13.8. So a fairly good drop there.
If you look at Region 9, I mentioned that see they went from 7.3 to 15.8 for the African American population. So this has really motivated that region. The Shreveport region which we really focused on with the northwest Louisiana coalition which is Region 7 and their African American population appears to have a pretty significant drop and so did their Caucasian population in that region. So we've got to sustain it, but we've got these regions thinking that, hay, maybe there is some truth to all of this. Maybe we can make a difference. And basically -- so that's what I wanted to tell you about is how FIMR and how the idea of FIMR started, how it started in the regional level, it's built up to the state level, and now we are trying to take it back to motivate the regions again. Thank you.