2022 Annual Report- Maternal Health

Priority: Promote high-quality maternal care with a focus on patient-centered and trauma-informed models

Objectives:

1. Increase access to perinatal care for women with the highest social, economic, or medical need by 2024.

2. Increase Maternal Depression and Anxiety screening and referrals, during and after pregnancy or inter-conception through formalized partnerships and assessments by 2024.

3. Improve Patient-Centered Care knowledge and practice with measurable, patient-reported results by 2023.

Objective 1. Increase access to perinatal care for women with the highest social, economic, or medical need by 2024.

Strategy - Leverage the prenatal High-Risk Fund to address gaps in geographic distribution and service provider type.

ESMs:

• Number of NM counties where HRF services are available: 6 counties
• Number of HRF sites where midwifery is a key service offered: 2 sites

During the report year, the High-Risk Fund continued to serve as a critical resource supporting access to perinatal clinical services for uninsured New Mexico residents. As outlined in our Maternal Health Plan for FY23, Title V staff began an evaluation of the current portfolio of contracts to assess the geographic distribution and array of services and provider types currently in place. The following specific activities were planned in support of the proposed evaluation:

1. Conduct site visits, confirm numbers and geographic area served, and evaluate services provided for each of the eleven currently contracted sites.
2. Conduct outreach to potential contractors with the potential to increase access in ways not currently addressed due to geographic location, ability to deliver mobile or community-based services, ability to deliver needed services that are not currently available, and cultural congruency with underserved New Mexico communities.
3. Confirm the network of contractors to be in place by Fiscal Year 2024 and establish an ongoing monitoring plan for these contracts.

Our progress to date:

1. Site Visits: Staffing limitations and ongoing COVID-19 mitigation policies in place for most of the contracted clinical sites prevented the scheduling of site visits. Instead, Title V Staff conducted virtual meetings with clinical and administrative staff at four sites: one federally qualified health center (FQHC), an academic medical center-based maternal-fetal medicine service, an academic medical-center affiliated clinic, and an ultrasound imaging provider. In addition, in February 2023, Title V staff hosted a webinar that was attended by representatives of most sites. The webinar provided a refresher on the purpose of the High-Risk Fund and scope of funded services, and it provided the opportunity for sites to engage with Title V staff and ask questions regarding current and future contract provisions.
2. Outreach: Title V staff began discussions with two separate midwifery practices that offer community birth services covering large geographic territories in the northern and southern parts of the state. One group prioritizes care for Indigenous families from the northern Pueblos and the Navajo Nation, including culturally supportive wraparound services not currently covered by Medicaid or other health insurance benefits. The other group is based in the south and is interested in leveraging Public Health Office locations to provide services in communities that are maternity care deserts. At the time of the writing of this report, draft scopes of work are under review.
3. Confirmation of network for Fiscal Year 2024: Three FQHCs serving Santa Fe, Rio Arriba, and Doña Ana counties have one remaining year on their current provider agreements. The University of New Mexico Hospital, Maternal Fetal Medicine service and Maternity & Family Planning Clinic are critical to serving the largest concentration of individuals eligible for HRF services, and they will continue within the network. Title V staff are just beginning to confirm the remaining sites.

Our work to oversee the HRF over the past year, including the process of communicating with current and future providers, has confirmed an array of ongoing and evolving challenges related to serving birthing people without access to insurance coverage. These are the primary themes that have emerged:

• Demand for services is rising, while funding remains flat.
• Programs are fragmented in the face of comprehensive needs.
• Costs (labor, equipment, supplies) have risen in the wake of the COVID-19 pandemic, and skilled providers and technicians are less available for hire.
• The standard of care for certain high-risk conditions is out of reach for uninsured birthing people who must bear a significant out-of-pocket cost for medications and supplies not currently covered by the HRF.

The Maternal Health Plan for FY24 will address Title V staff’s plans to account for these themes in our ongoing efforts to increase access to perinatal care for people with the highest social, economic, or medical need by 2024.

Strategy- Enhance uptake of, and increase access to, prenatal and postpartum care navigation.

Given the complexity and disconnection within the healthcare system, the geographic expanse of New Mexico, and the persistent siloes separating the array of services available to birthing people and families, care navigation services have the potential to benefit all, yet they remain significantly underdeveloped and underutilized.

In the inaugural report covering 2015 – 2018, the NM Maternal Mortality Review Committee (MMRC) identified inadequate care coordination and service gaps as major themes for many of the deaths reviewed. Increased funding and support for universal home visiting emerged as a specific recommendation to address the need for navigation and support across the stages of pregnancy and postpartum.

In the Maternal Health Plan for 2023, Title V staff proposed the following activities:

1. Provide or support prenatal navigation and postpartum follow up for women in key geographic areas, diagnosed or at risk for COVID-19 or chronic health conditions including substance use disorder.
2. Promote enrollment in home visiting programs statewide, especially for individuals served by providers who are contracted to provide services through the High-Risk Fund.
3. Continue to monitor modified PRAMS COVID supplement and CDC pregnancy supplement data to assess the impact of COVID-19 on birthing families.

Our progress to date:

1. Title V staff have continued to provide direct support to families impacted by the COVID-19 pandemic and those referred for a plan of care under the Comprehensive Addiction Recovery Act (CARA). Services include direct navigation and referrals to families in emergency and non-emergency situations.
2. Title V staff have also deepened collaboration with home visiting programs through participation in the New Mexico Home Visiting Collaborative and the Early Childhood Education and Care Department Advisory Council (ECECD). ECECD houses a variety of state-sponsored home visiting programs, and the Advisory Council prioritizes collaboration to connect all birthing people and families to a home visiting program that matches their interest, location, and needs for support.

Title V staff have presented the MMRC findings published during the report year to home visiting programs with an emphasis on the home visiting and care coordination recommendations. These conversations have provided an important opportunity to link home visiting to maternal mortality prevention.

HRF webinar participants were advised that identification of local options and referral to home visiting programs will be added to the scope of work for FY24 provider agreements for the sites that serve as the perinatal care homes for individuals covered by the HRF.

Objective 2. Increase Maternal Depression and Anxiety screening and referrals, during and after pregnancy or inter-conception

Strategy -. Collaborate with community-based partners to provide training and technical assistance to clinical providers and hospital teams addressing substance use disorders

ESM

• Number of high-risk prenatal funded clinics that have policy and procedure in place to ensure universal screening for perinatal mood disorders with a validated instrument

Perinatal mood disorders, especially depression and anxiety, are common conditions that have long affected NM communities in profoundly tragic ways. Data from the MMRC indicate that mental health conditions were a contributing factor in 36% of all pregnancy-related deaths 2015 - 2018, and 20% of pregnancy-related deaths were suicide. The impact of depression and anxiety have been greatly exacerbated by the ongoing COVID-19 pandemic and all the ways that the pandemic disrupted healthcare services and networks of support, both formal and informal, while promoting social and physical isolation. In order to further develop our state resources for linking people to treatment, Title V staff proposed the following activities:

1. With NM-PSI and through the PN-3 Pritzker Foundation coalition, we will continue to partner with mental health professionals, home visiting programs and early childhood advocates to monitor progress towards universal screening and referral for perinatal mood disorders.
2. We will continue to implement and verify the requirement that providers contracted to provide services through the High-Risk Fund have policies and procedures in place to guide universal perinatal depression screening in the primary language of individuals served, including steps to address referral and warm hand-off for positive screens. To support this effort, we will facilitate training and resource and referral sharing led by NM-PSI and other community partners.

Our progress to date:

1. As noted in last year’s report, the expansion of Medicaid eligibility for a full year postpartum, which went into effect on April 1, 2022, is foundational step in building a system of care that is responsive to the need for perinatal depression screening and treatment. As the public health emergency winds down this spring, and Medicaid begins the process of terminating benefits for those no longer eligible, the significance of this policy change allowing postpartum eligibility to remain in place will come into focus. Title V staff have continued to collaborate and strategize with our partners to make sure that people and systems of care understand that the full Medicaid benefits package remains in place, and to assess the impact of this policy on the development of coordinated, continuous opportunities for patient-level support in New Mexico.
2. The MMRC’s stark findings related to perinatal mental health have been shared with the HRF provider sites, and provider agreements that were due for renewal during the report year included an updated scope of work incorporating universal screening for perinatal mood disorders and substance use disorders. Much work remains to be done to assist clinical sites with implementation, including policy and procedures for referral, hand-off, and follow-up.

Strategy- Collaborate with community-based partners to provide training and technical assistance to clinical providers and hospital teams addressing substance use disorders

ESM-

Number of NM birthing hospitals with policy and procedure in place to require universal screening for perinatal mood disorders with a validated instrument through verified prenatal ascertainment, at admission or within six weeks of discharge

The NMPC, a 501c3 non-profit organization, continues to represent New Mexico within the AIM network and leads the deployment of maternal safety bundles in NM birthing hospitals. Reproductive justice partners and community thought leaders include birth workers from a range of disciplines and community identities, and they bring a holistic perspective and a deep understanding of the mental health challenges and resource needs of NM birthing people. The safety bundles represent a formal, evidence-based set of practices. Reproductive justice partners demand accountability for action within hospitals and health systems and engagement with communities to inform bundle adaptation to the unique needs and experiences of NM communities. Title V staff have worked to maintain opportunities for collaboration. For the report year, we proposed the following activities:

1. Collaborate with the NM Perinatal Collaborative, the SUD workgroup, or other community partners to continue to prioritize the development and implementation of screening and referral best practices in NM birthing hospitals.

2. Share outcomes data reported to the Department of Health in accordance with data-sharing agreements to facilitate accountability and interpret impact of the quality improvement initiatives.

Our progress to date:

1. Title V staff have remained actively engaged with the NMPC’s AIM state team and SUD workgroup, attending regular meetings and providing guidance informed by our clinical, public health, and quality improvement expertise and our work with statewide partners. We have shared the MMRC findings that validate the ongoing focus on SUD and mental health, and the importance of the AIM safety bundle work as a platform for promoting policies and procedures in hospitals to facilitate identification of mental health risk factors and postpartum follow-up.
2. The Improving Perinatal Health Extension for Community Healthcare Outcomes (ECHO) Program has continued an extended focus on perinatal mental health, specifically related to substance use disorders. Twice monthly hour-long virtual sessions offering free continuing education credit have focused on topics directly related to the AIM safety bundle- Care for Pregnant and Postpartum People with Substance Use Disorder (CPPPSUD), including screening, care navigation and support by doulas and peer support specialists, clinical updates on medication assisted treatment, relapse prevention, and others. The multidisciplinary audience for this program continues to draw heavily from the hospital teams that provide perinatal care statewide, and attendance is consistently above 75 participants per session. Title V staff have continued to serve in an advisory role for the ongoing development of the curriculum for these sessions and the engagement of perinatal care providers in the network of participants.
3. During the report year, Title V staff have been actively supporting the AIM initiative by sharing hospital outcomes data directly with the NMPC and enrolled hospital teams through the AIM data portal, a data repository and visualization tool that allows teams to track their progress on best practice implementation and assess impact on outcomes. This tool is meant to help hospitals identify priorities for action based on outcome trends, and support accountability for improving outcomes.

Title V staff also began work on an initiative to enhance transparency and data accessibility by designing a public query available through the DOH IBIS system on hospital birthing outcomes. This work is still in formative stages, but it will enhance and complement the data sharing with hospital teams through the AIM data portal by addressing the public and community partner need for information to engage actively in this work.

Objective 3. Improve Patient-Centered Care Knowledge and Practice with measurable, patient-reported results by 2023.

Strategy- Partner through the NM Birth Equity Collaborative to provide community forums, provider trainings and establish best practices in NM.

ESM 3.1 Number of provider trainings or community webinar/meetings completed

During the report year, our birth equity and reproductive justice partners continued to lead the work for improvements in patient-centered care knowledge and practice. As the pandemic moved into its current endemic phase, and hospitals began to relax COVID-19-justified restrictions against foundational supports, such as family members at birth, essential health workers, such as doulas and community midwives who transfer clients for needed hospital-based services, continued to find uneven access to settings to provide their services or engage as members of a multidisciplinary team supporting a birthing person. The significant weaknesses in the commitment to and capacity to provide patient-centered perinatal care highlighted by the pandemic have much deeper roots, but the pretense that hospitals and hospital-based providers alone could safely and respectfully meet the needs of their birthing patients is no longer possible to maintain. Title V staff worked to center the leadership of our partners and facilitate opportunities for their expertise to be shared in forums targeting healthcare providers.

Trainings / Community Forums:

• The NMPC Annual Meeting was replaced with a fall educational series designed as a series of virtual recorded sessions, including one entitled “Come to the Table”, led by the reproductive justice and culture shift organization, Bold Futures NM. Bold Futures has provided significant technical assistance to the NMPC and Improving Perinatal Health ECHO program to support the implementation of the Care for Pregnant and Postpartum People with Substance Use Disorder Bundle curriculum with a trauma-informed and lived-experience-informed perspective. The session was led by organizers with lived experience of substance use and perinatal systems of care, and the purpose of was to center the stories and expertise of those directly impacted by systems to address bias and stigma in both care delivery and policymaking.
• The NMPC also hosted an in-person presentation by Jennie Joseph, CPM, Founder and CEO of Commonsense Childbirth Inc. and an array of associated programs that provide training to midwives and direct services to birthing people in Florida. Jennie Joseph is an internationally recognized expert in community midwifery, innovative service delivery, and anti-racism in perinatal healthcare delivery. Her presentation outlined her service and education delivery models centering the needs and experiences of Black and other birthing people of color. Ms. Joseph also shared time and space with local birth workers and thought leaders who joined her on stage and outlined significant concerns regarding outcomes and quality improvement efforts in New Mexico. These local experts lead and participate in the NM Black and Indigenous Maternal Health Policy Coalition, and they offered to engage in future dialogue with the NMPC Board to further the conversation on ways to assure that community leadership and lived experience greatly inform quality improvement efforts.
• The University of New Mexico Annual Women’s Health Conference is the primary state-based clinical conference serving a multidisciplinary audience in active clinical practice. At the recommendation of Title V staff, a plenary session was organized for the 2022 conference that featured a panel of Black and Indigenous members of the MMRC. The inaugural report findings were contextualized through the experience of MMRC members who identify as members of communities disproportionately impacted by maternal mortality in our state and nationwide. The panelists, who also represented diverse disciplinary experience, including a doula, mental health first aid worker, sociologist, certified nurse-midwife, psychiatric mental health nurse practitioner, and community advocate led a powerful conversation with perinatal care providers on the heartbreaking witness of maternal mortality review and the urgent need for all providers to take responsibility for prevention.

Strategy- NM Follow the lead of community-based organizations and women with lived experience to define and support respectful maternity care in New Mexico.

Our progress in following the lead of community-based organizations to define and support respectful maternity care is represented in part through the activities highlighted above. The expertise to lead this work within a birth equity framework is present in community-based organizations already deeply invested in the analysis of problems and inequities and are already providing direct service and advocacy to most-impacted New Mexico communities. We are aware that work to define and promote respectful maternity care should not proceed at the policy or agency level without deep consultation and collaboration with these leaders, and over the past year, there has been an increase in formal engagement. Members of the Birth Equity Collaborative and the Black and Indigenous Coalition have led training sessions for perinatal care providers, taken seats and operational roles with the MMRC, provided direct input into the crafting of state regulations to guide the MMRC, and technical assistance to the NM Medicaid program on policy to cover doula services. Title V staff have continued to work on strengthening relationships, building trust, and engaging in collaboration that is community-led. We committed to additional activities in maternal health plan for FY24 as follows:

1. Continue consultation with NMBEC and other community partners and long-standing birth equity leaders across the state with the goal of identifying and adapting guidelines on respectful maternity care for the endorsement of NM Department of Health.
2. Establish a maternity care hotline and advertise availability of consultation for people seeking or experiencing maternity care at delivery and in the perinatal period.
3. Convene a statewide maternal taskforce to make decisions about policy and practice, communications and data dissemination.

Our progress to date:

1. Our progress on this activity is represented above. Consultation is ongoing as is the process of defining priorities and guidelines. Although in our 2021 report we reported on the development of pandemic inspired perinatal emergency recommendations by reproductive justice and birth equity leaders, we have not yet succeeded in generating departmental or health system endorsement of these recommendations.

2. Title V staff worked in collaboration with our reproductive justice and birth equity partners to articulate the framework for a maternal health task force that would be charged with the creation of a maternal health strategic plan and implementation of maternal mortality prevention recommendations. We were not able to identify the funding needed to move forward with the task force during the report year, but we are exploring other opportunities and will highlight our plans for the coming year in our maternal health plan for 2024.