2023 Annual Report- Maternal Health

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

Objective 1. Increase access to perinatal care for birthing people with the highest social, economic, or medical need.

Strategy - Leverage the state perinatal High-Risk Fund (HRF) to address gaps in geographic distribution and service provider type.

ESMs:

• Number of NM counties where HRF services are available: 8 counties (increase from 6 in previous report year)
• Number of HRF sites where midwifery is a key service offered: 3 sites (increase from 2 in previous report year)

During the report year, the HRF continued to serve as a critical resource supporting access to perinatal clinical services for uninsured New Mexico residents. The HRF was established more than 30 years ago at a time when Medicaid eligibility criteria were much narrower and there were very limited resources to cover the cost of care for uninsured people during pregnancy. The HRF directs TVBG funding to a portfolio of provider agreements that offset the costs to clinical sites of providing a full array of ambulatory perinatal services. As outlined in our Maternal Health Plan for FY24, Title V staff continued to evaluate the current portfolio of contracts to assess the geographic distribution and array of services and provider types currently in place. The following activities were planned in support of the proposed evaluation:

-Conduct site visits, confirm numbers and geographic area served, and evaluate services provided for each of the currently contracted sites.

-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.

-Evaluate the midwifery public health office pilot project for inclusion in the next round of HRF contracts.

Progress to date:

Site Visits: Despite the easing of COVID-19 mitigation policies, staffing limitations continued to preclude the scheduling of site visits for currently contracted sites. However, Title V staff conducted ad hoc meetings with sites to address questions and needs for support related to data collection, contract provisions and services covered under the HRF. We also worked to streamline data reporting and confirm numbers of individuals and counties served, and we continued to evaluate services provided for each of the currently contracted sites.

Outreach: Title V staff continued discussions with Vida Midwifery, a midwifery practice staffed by a Certified Nurse-Midwife and Licensed Midwives, and based in the southern border county of Doña Ana, that serves a five-county area and is interested in leveraging Public Health Office locations to provide services in communities that are maternity care deserts.

Midwifery public health office pilot project: Unfortunately, because earmarked funding in the department was strained by competing demands, the Vida Midwifery pilot could not proceed during the report year.  We did conduct a site visit to meet with the Vida midwives and public health office staff at the Truth or Consequences Public Health Office (PHO) in Sierra County. Sierra County is a true maternity care desert with no hospital based maternity care or OB/Gyn physicians in place[1]. Vida already serves this county by providing community birth services for those who desire home birth and meet low-risk criteria for care. PHO staff remain hopeful and enthusiastic about the pilot project. At this point, there is a firm plan in place to begin the pilot at the start of the new state fiscal year which begins July 2024.

Our work to oversee the HRF over the past year, including the process of communicating with current and future providers, continues to reinforce an array of evolving challenges related to serving birthing people without access to insurance coverage. Primary themes remain constant:

• Demand for services continues to rise, while funding remains flat.
• Programs are fragmented in the face of comprehensive needs.
• Costs (labor, equipment, supplies) rose in the wake of the COVID-19 pandemic, costs have not returned to pre-pandemic levels and skilled providers and technicians remain 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 (ex. Gestational diabetes).

The Maternal Health Plan for FFY25 address Title V strategies to address these themes, including efforts to increase access to perinatal care for people with the highest social, economic, or medical need.

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

Given the complexity and disjointed perinatal 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 analysis covering reviewed deaths between 2015-2020, the NM Maternal Mortality Review Committee (MMRC) identified inadequate care coordination and service gaps as major themes. Increased funding and support for universal home visiting remains a specific recommendation to address the need for navigation and support across the stages of pregnancy and postpartum. In the Maternal Health Plan for 2024, Title V staff proposed the following activity:

-Promote enrollment in statewide perinatal care programs for individuals served by providers contracted to provide services through the perinatal High-Risk Fund.

Progress to date:

Title V services included direct navigation and referrals to families in emergency and non-emergency situations. Title V staff deepened collaboration with Medicaid and NMDOH regional staff to support home visiting programs through participation in the New Mexico Home Visiting Collaborative and the Early Childhood Education and Care Department Advisory Council (ECECD) and NM Family Connects.

The Title V Program acknowledges community-based midwives and doulas as the original prenatal and postpartum care navigators and have supported this work during the report year through relationship brokering and development between individual midwives and doulas, their professional organizations, and NM Medicaid. Specific activities have included funding to support doulas’ time to provide consultation on the development of the doula Medicaid benefit, and convening of conversations between Medicaid, midwives and midwifery organizations to discuss the lack of compensation for postpartum care as part of the Birthing Options Program.

Staff successfully expanded the prenatal High-Risk Fund portfolio of providers to include community-based midwives who provide wrap around care and navigation services as core components of the midwifery model of care.

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

Strategy- Facilitate or finance perinatal mood disorder trainings for screening and referrals

Perinatal mood disorders, especially depression and anxiety, are common conditions that have long affected NM communities in profoundly tragic ways. Findings from the MMRC indicate that mental health conditions were a contributing factor in 50% of all pregnancy-related deaths occurring 2015-2020. We recognize, and the data support the assertion that SUD is part of an array of mental health concerns. To strengthen the state’s capacity for linking people to treatment, Title V staff proposed the following activities:

-Collaborate with the NM Perinatal Collaborative, the SUD workgroup, and other community partners to prioritize and expand training on the development and implementation of screening and referral best practices in NM birthing hospitals and other perinatal care settings;

-Explore opportunities to develop internal perinatal quality improvement expertise;

-Share severe maternal morbidity outcomes data reported to the Department of Health in accordance with data sharing agreements to facilitate accountability and interpret impact of the initiative

Progress to date:

Title V staff continue to support ongoing trainings deployed through the Improving Perinatal Health ECHO program and by the NM Perinatal Collaborative. During the report year, planning began for a series of IPH ECHO sessions focused on perinatal mental health that was launched at the start of 2024. The NM Perinatal Collaborative maintains a focus on perinatal SUD and has collaborated with the NM Department of Health and the NM Bridge Program and the NM Opioid Hub to present regional trainings for hospital-based teams on Medication for Opioid Use Disorder (MOUD). The goal of regional trainings is to increase the capacity and confidence of perinatal care providers as prescribers of MOUD and to educate them on stigma, bias, and community-based resources for wrap-around support.

Title V staff remain committed to developing internal perinatal quality improvement expertise. During the report year, the NM Perinatal Collaborative continued to experience organizational turmoil resulting in the reseating of the board of this independent, non-profit organization. Our approach was to await a determination from the new board on the intended focus of the organization going forward. This process has taken longer than anticipated. In addition, funding streams to support internal perinatal quality improvement capacity remained uncertain. The Maternal Health Plan for FFY25 outlines the next steps informed by these challenges.

To date, our greatest opportunities for sharing findings on perinatal mental health outcomes come directly from the maternal mortality review. We have not disaggregated these data at the regional or facility level but have shared the statewide and subpopulation findings of the Maternal Mortality Review Committee in numerous forums addressing those with specific roles in screening and referral for mental health conditions, including Community Health Workers and home visitors, in addition to perinatal healthcare providers.

Strategy- Collaborate to operationalize Medicaid benefits to one year, postpartum

Following the postpartum extension of the full Medicaid benefits package in 2022, it was clear that a concerted effort would be needed to operationalize this significant policy change and ensure that it created opportunities for increased access to behavioral health services.  During the report year, Title V staff have supported relationships with NM Medicaid to monitor and evaluate the impact of postpartum Medicaid expansion in our state and across the national landscape. Title V staff accompanied NM Medicaid representatives at a National Academy for State Health Policy convening to share early adopter experiences, including NM’s initiatives related to midwifery and doula access. The timing of the unwinding of the public health emergency also intervened and required Medicaid leadership to prioritize the need for eligibility redetermination for the NM population.

A state inter-agency Medicaid evaluation group met bimonthly to establish measures of postpartum Medicaid uptake, and the Medicaid program anticipated CY2024 provision of neonatal and maternal claims to Title V epidemiology staff for analysis.

Objective 3. Improve Patient-Centered Care Knowledge and Practice with measurable, patient-reported results by 2024.

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

Seeking consultation and elevating the lead of community-based organizations and thought leaders is a deeply-embedded maternal health strategy for the NM Title V Program. Activities in support of this strategy for the report year were:

• Sustain consultation with Bold Futures NM, NM Breastfeeding Task Force, Tribal Epidemiology Centers, Tewa Women United, Black Health NM 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.
• Facilitate a research project let by Bold Futures NM to understand the barriers to and facilitators of community-based midwifery practice as an exemplary model of respectful maternity care.

Progress to date:

We engaged community partners and birth equity leaders on a variety of topics. These included a Black and Indigenous Perinatal Equity Coalition, including members of this coalition who participated on the Maternal Mortality Review Committee. Title V staff financially supported the development of a Medicaid doula reimbursement package with partners participating from a variety of community-based organizations. As described in the perinatal report narrative, this robust consultation process led to a successful but challenging Medicaid reimbursement plan in New Mexico.

At the conclusion of the report year, we were awarded HRSA’s State Maternal Health Innovations program. This led to community conversations and concrete plans to convene a statewide maternal health task force that will be charged with the creation of a maternal health strategic plan and prioritization of maternal mortality prevention recommendations.

During the report year, we finalized the terms with Bold Futures NM for the intended research project on barriers and facilitators of community midwifery practice. Unfortunately, procurement delays shifted the timeline, however we have a firm plan in place to address progress and findings in future reports.

Strategy- Increase the number and quality of patient-centered and maternity care metrics.

Opportunities to strengthen PRAMS surveillance measures were supported by the PRAMS and Tribal PRAMS Steering committee and Title V participation in the Diné College Navajo MCH Collaborative.

The phase 9 PRAMS survey revision offered some opportunities to incorporate experiences with discrimination in perinatal care, and it allowed for more information about doula support during pregnancy and in the postpartum period. Unfortunately, though, the PRAMS team did not have sufficient resources to pilot state-generated questions, and the CDC standard questionnaire options did not completely meet the goals to improve an understanding of patient experience or of respectful maternity care.

Activities to remediate the shortfalls in PRAMS metrics are addressed in the FFY2025 planning narrative.

[1] Where you live matters: Maternity care access in New Mexico | PeriStats | March of Dimes