When it comes to health outcomes for babies, the United States has some catching up to do: For every 1,000 live births, around six infants die before their first birthday, putting the U.S. behind poorer countries such as Cuba and Poland.
Central Louisiana had some particularly troubling statistics. In 2013, the region’s infant mortality rate was hovering around nine per 1,000 live births. Infant mortality usually correlates with poverty -- the rural region has an average per-capita income of just $25,000 -- and such associated contributing factors as low birth weight, premature birth and exposure to secondhand smoke. “Unfortunately, Louisiana is full of them,” says David Holcombe, medical director for Region 6 of the Louisiana Office of Public Health, which encompasses the central portion of the state.
That’s why the Region 6 team decided to focus on infant mortality. Their solution was straightforward: Offer more care.
In a time when rural clinics and hospitals are scaling back women’s health services or closing altogether -- 86 rural hospitals have shuttered across the country since 2010 -- central Louisiana was able to take advantage of a federal grant to staff up. Now every parish in the region has a public health nurse who can counsel women on contraceptive options, STD testing and other reproductive health needs. The Region 6 team also ramped up 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.
As part of the effort’s more holistic approach, the region started promoting long-acting reversible contraception (LARC), such as IUDs and arm implants. The idea is to help prevent teenage pregnancies or help women space their pregnancies out. While many doctors’ offices require a separate appointment to insert LARCs, Region 6 made same-day insertion available. “We know that 30 percent of women who say they want one, but have to come back to get it, won’t come back,” Holcombe says.
There is a delicate balance between encouraging long-acting reversible contraception in low-income populations and the impression of coercion, which harkens back to a history of involuntary sterilization in the early and mid-20th century. But the Region 6 effort is not about forcing women to get an IUD or implant. “It’s not that we want everyone to have them, but that we want to make sure everyone who wants one can have one,” says Amy Zapata, director of Louisiana’s Bureau of Family Health.
The demand is certainly there. One of the Region 6 health clinics is the state’s busiest by patient volume. “If we had satisfied the need, we should have seen a decrease in the number of patients wanting LARCs, but we haven’t,” says Holcombe. “We’ve seen mothers bring in their 13-year-olds to make sure they don’t get pregnant.”
These efforts have paid off -- and quickly. In just two years, the infant mortality rate in Region 6 was halved, down to 4.7 deaths per 1,000 live births in 2015, the lowest of the state’s nine public health regions. The number bumped up slightly in 2016, but a minor uptick isn’t unusual when looking at small data sets. “We’re looking to see if that rate is generally going up or down,” says Zapata.
Health officials know that focusing on the needs of women and babies is just part of the picture. “We can put in a lot of LARCs and provide a lot of contraception,” says Holcombe, “but ultimately what drives your health is three things: education, income and social status.”