David Holcombe, medical director for Region 6 of the Louisiana Office of Public Health, recalls the day he received the 2015 statistics from the Bureau of Family Health. “I went beserk and immediately wrote an article for the local publication claiming all the credit,” he says with a laugh. All joking aside, Holcombe had legitimate reasons to be excited. The region’s infant mortality rates were down 50 percent from the previous year. He viewed it as proof that he and his team’s concerted effort to tackle the root causes of the problem had borne fruit.
Infant mortality is an important indicator of a society’s overall health. Despite being the wealthiest country on earth, the United States lags behind other wealthy nations in many health outcomes, including infant mortality.
Compared to 19 similar Organisation for Economic Co-Operation and Development (OECD) countries, babies born in the United States are three times more likely to die from extreme immaturity and 2.3 times more likely to experience sudden infant death syndrome. Because infant deaths in Louisiana exceed the national average, the picture there is even more bleak. In 2014, Louisiana’s rate was 7.5 compared to 5.8 nationally. By 2017, the state’s rate had declined to 7.1, while the national rate held steady.
“Louisiana has long been 48th, 49th and 50th in health outcomes for low birth weight, infant mortality and maternal mortality,” says Holcombe. “After a while, you don’t want to be 48th, 49th or 50th. So, we did a lot of soul-searching and shifted to focusing on the importance of social determinants in health outcomes and evidence-based activity about how you can make things better.”
Made up of forests, swamplands and prairies, Region 6 is bordered by the Mississippi River on the east and the Sabine River on the west. And, like most places along the Mississippi, its health outcomes are abysmal. “The counties in eastern Arkansas, Western Mississippi and the river counties in Louisiana are characterized by these atrocious levels of poverty, low educational levels and low socioeconomic status,” says Holcombe. “All of these social determinants contribute to these perennial problems, including poor health outcomes.”
The annual per capita income in Central Louisiana is just $24,000. The high school graduation rate is 77 percent versus 85 percent nationally and only 15 percent of residents have college degrees, compared to 35 percent nationally. Those statistics go a long way toward explaining why the region’s 2013 infant mortality rate was the highest in the state at around nine deaths per 1,000 live births. “Social determinants are 50% of what determines health outcome,” says Holcombe. “Because we’re so poor, uneducated and unhealthy, we really should have the highest rates.”
In 2015, the infant mortality rate in Region 6 dropped to 4.7, the lowest of the state’s nine public health region. Here’s what they did to make that happen.
PROVIDING MORE AND BETTER CARE
On the down side, central Louisiana has only six federally qualified health centers, community-based health care providers that receive federal funds to provide primary care services in underserved areas. However, thanks to a federal grant, Region 6 was able to hire a public health nurse to educate its patients about contraceptive options, STD testing and other reproductive health needs. The team also increased participation with the Nurse Family Partnership program which assigns Medicaid-eligible pregnant women with a nurse who will assist them through pregnancy and the baby’s first year of life.
Because Region 6 does more direct care services than any other region of the state, including providing contraceptives directly to the patients, they enacted policies to make their clinic more efficient and proactive. The population they serve is plagued by problems that make it difficult to keep an appointment, such as a lack of reliable transportation, childcare, and an inability to take off work, resulting in a 50% no-show rate.
“We can be more effective if we’re seeing more people, so we started double- and triple-booking to use our resources more efficiently. We start earlier, go later and eliminated a lunch time to keep the flow and see more patients,” explained Holcombe.
The best ways to ensure healthier pregnancies and babies is avoiding unintended pregnancies and appropriately spacing between children. Encouraging more women to use long-acting reversible contraception (LARC), such as IUDs and arm implants, was only half the battle. “The problem was they had to be ordered and women had to come back later for the procedure. However, 30% of the people will never come back, so we chose to implement this very aggressive procedure.”
While many doctors’ offices require a separate appointment to insert LARCs, Region 6 made same-day insertion available. They made sure to keep these contraceptives in stock and that all Advanced Procedure Registered Nurses (APRNs) and medical directors were trained to perform the procedure. “It horrifies some people because we can give contraceptives to 13 year-olds. But in a state like Louisiana where we have this very high rate of teenage pregnancy and rural health illiteracy, you’re going to remain at the bottom if you don’t do something.”
REDUCING THE NUMBER OF EARLY INDUCTIONS
Labor induction is stimulating contractions before labor begins on its own to achieve a vaginal birth. In many cases, doctors recommend it when there is concern for a mother’s health or the health of the baby. Women who are induced often have babies born a little early and early babies might have a higher risk of long-term developmental problems. Complications during delivery may also occur, particularly for women who have had a previous C-section.
Holcombe describes Louisiana’s selective induction rate as being “off the charts” when compared to the national averages because it was done for convenience. “Prior to 39 weeks, there was a huge increase in complications and an economic problem because it costs more.”
In 2014, the state implemented the 39-week initiative to reduce the number of early cesareans and induced childbirth. Unless there was a medical reason to induce before 39 weeks, doctors would not receive Medicaid reimbursement. At the time, Secretary of the Louisiana Department of Health Dr. Rebekah Gee said she had seen women use various excuses for seeking early deliveries, but she said it most often boils down to convenience.
“Things I’ve heard for convenience were, ‘I needed to be able to fit into that bridesmaid’s dress,’ ‘I wanted to get on to my vacation scheduled three weeks from now,’ ‘My Aunt Sandy is in town and we wanted to have the baby then,’” Gee said. “Those are not good reasons to have a baby early.”
While many doctors perceived Gee’s move as heavy-handed, Holcombe says it has been wildly successful at producing better birth outcomes. “It brought inducements to a screeching halt,” says Holcombe. “That had a very dramatic effect in reducing the problems. The physicians didn’t like it because it made their lives more complicated and they risked not getting paid.”
The number of infant deaths to live births in the region inched up slightly in 2016, which is typical when evaluating small data sets. However, there are signs that things are moving in the right direction in Central Louisiana, in large part due to the Medicaid expansion.
A review by Georgetown University Center for Children and Families found that Medicaid expansion states saw infant mortality rates fall 50 percent more than states that did not expand Medicaid and saw maternal mortality rate declines of 1.6 deaths per 100,000 women.
Louisiana expanded Medicaid after the election of Democratic governor John Bel Edwards. By November 2018, an additional 481,500 Louisiana residents were covered under the Healthy Louisiana guidelines. “Our rates of uninsured fell suddenly from 14 percent to less than 9 percent,” says Holcombe. “That didn’t mean they always had providers, but it meant that they at least had a card that gave them access to care, especially via the federally qualified health center.”