2020 Annual Report

NPM 1 - Percent of women, ages 18 through 44, with a preventive medical visit in the past year

Objectives:

• Increase prenatal care utilization by 10% among women in the targeted impact area(s) (Border Region of the State) by October 2020
• Prevent the onset of the Type II diabetes for women with a history of Gestational Diabetes Mellitus (GDM).

Strategies

• Complete a curriculum on perinatal health for community health workers
• Work in a collaborative partnership to address the prevention of Type II diabetes by addressing barriers to postpartum visit completion for women with Gestational Diabetes

Objective 1. Increase prenatal care utilization by 10% among women in the targeted impact area(s) (Border Region of the State) by October 2020

The objective to improve prenatal care utilization in US/Mexico border counties has changed in scope and focus starting in 2019 with efforts shifting from a marketing campaign/web application promoting first trimester prenatal care to developing, piloting and delivering CEU- approved Community Health Worker (CHW) training modules focusing on preconception and prenatal care. The new scope of work, supported by Project Concern International, also employed human centered design principles with community discussion and opportunities to shape and modify project​. 

During the reporting period, our team reviewed qualitative community data, surveillance data in Vital Records and PRAMS, data collected by community coalitions and academic partners on the US/Mexico border and qualitative information analyzed at Project Concern International (PCI). With technical assistance and input from Dr. Milton Kotelchuck and other national experts, we developed a theory of change to guide our work around prenatal utilization promotion in NM border counties. Part of a Collaborative Improvement and Innovation Network (CoIIN) for infant mortality, we interacted with colleagues in TX, CA, and AZ to apply social determinants of health frameworks to preconception and prenatal utilization outcomes.

As described in other NMDOH reports, NM does not have a high infant mortality burden, relative to other parts of the country, and our Healthy Start programs have historically addressed poverty, barriers to care and mental health concerns with NM families. Unfortunately, the recent grant criteria for poor prenatal or birth outcomes were only applied by one Healthy Start service area, leaving over 350 families in the Las Cruces area without support. To mitigate the impact of this gap, a strong MCH coalition of public and community-based families and providers helped navigate families to other services, such as Families FIRST and home visiting or Early Head Start. Conversations continued to indicate community health workers and trusted promotoras as important facilitators of health care in rural communities and colonias. While they do not provide prenatal care, these respected individuals have supported diabetes and obesity prevention, lactation support and mental health interventions for many years. They are first-line informants and messengers, with direct knowledge of community and consumer resources and concerns.

NM PRAMS data point to two primary barriers to timely care in Dona Ana County (DAC), the first being late recognition of pregnancy and the second, having challenges securing prenatal appointments when needed. To address the need for better and more timely care, Title V staff and Project Concern International (PCI) worked together in the Fall of 2019 to assure a transition from Healthy Start- La Clinica de Familia staff involvement to leadership by the University of New Mexico Health Extension Rural Officer (UNM HERO) in Las Cruces and rural communities of Anthony, Berino, Chaparral, including trans-border and floating populations.  Women in these border communities clearly need support in their access to and utilization of timely prenatal care, including postpartum follow up. Brief statistics presented in the FY20 Plan showed that:

• 56.4% of women residing in the communities of Anthony, Berino or Chaparral (small rural colonias) had prenatal care within the first trimester (2012-2016 births). This compares to 59.8% of all women in Dona Ana County (DAC), and 63.9% in NM, overall.
• Excluding women delivering a very low birthweight baby (<1500 grams), just 48.7% of DAC residents with a low birthweight infant (<2500 grams) had prenatal care in the first trimester (NMVR, NM-IBIS).

While these small-area prenatal care statistics vary significantly from state averages, the reasons given for delayed care (PRAMS) mirrored statewide experiences, and we were confident that whatever we developed and piloted in DAC would be translatable to other community and cultural settings. Building on the shifting work with the University of New Mexico (UNM) HERO, our team re-established a team charter with revised process and outcome measures. From Oct 2019-Jan 2020 the team focused on curriculum development by the UNM HERO with input on evaluation measures for measuring the success and impact of the curriculum. The UNM HERO officer met several times over this period for technical assistance from PCI and the TA advisor provided by PCI. Long-term project measures were developed to monitor long-term project and scaling goals:

1. % of certified CHWs who have gone through any formal training (with CEUs) in prenatal care
2. % of certified CHWs who have gone through any formal training (with CEUs) in preconception care
3. % increase in test scores from pre-/post-test on preconception care curriculum 
4. % increase in test scores from pre-/post-test on prenatal care curriculum

 The planning work and curriculum development was contextualized by 2 years of community input and of our collective knowledge about health systems in New Mexico, especially in DAC. Our theory of change was rooted in the understanding that people living in their own communities will best serve the needs of people working those communities, and that community health workers, including CHRs and promotores de salud are trusted health advocates. We further recognized that social determinants such as lack of transportation, underinsurance and poverty level were driving some of the barriers to care we hoped to impact. These concerns were iterated several times in community meetings, and we also strived to reflect the traditional of promotores de salud and their important historical role in diabetes and other chronic disease prevention. Knowing that delayed entry to prenatal care includes trust with healthcare systems, we did not want our model to rely solely on clinical or population-based media communications. Rather, we saw CHW/promotoras as a key vehicle and navigation corps prepared for change.

Graphic source: NM technical brief: Supporting Community Health Workers to Increase Early Entry to Prenatal Care in Southern New Mexico (Nixon, Coronado, Avery, 2020)

On a broader level we aimed to track the following process outcomes to monitor progress and sustain work of the five-year block grant cycle. The following process and balancing measures were defined:

• Process: # CHWs trained in new curriculum
• Process: Diversity (geographic, ethnicity, differently abled) of CHWs trained in new curriculum
• Balancing: Funding for CHW workforce does not increase thereby leaving skilled workers without employment or under employed
• Balancing: Increased demand by CHW students for women’s health focused CEU approved training modules are not developed/available and/or lack cultural sensitivity/awareness of the NM border region

The perinatal curriculum was introduced in the CHW programming available to this workforce via Dona Ana County Community College (DACC). The first class was held in February 2020 over a two-day period with twelve participants. Data from this recent class was evaluated and revealed optimal post-test improvements in key competencies. The team completed a technical brief in September 2020 and has plans to continue scaling curriculum and credentialing in 2021. Although the COVID-19 pandemic delayed our efforts to expand in-person and college-based learning, online modules were developed and tested among health promotions staff (n=10) in NE New Mexico as part of the HRSA ROAMS grant objectives. Going forward, online and in-person modules will include the role of doulas, postpartum care concerns, and collaboration with the NM Doula Association and the Navajo MCH Work Group will be centered to include more curriculum content and certification avenues.

During the pandemic we could not pursue the scaling of curriculum and certification more health workers, however we are laying the groundwork with the NMDOH Office of Health Workers and the Early Childhood Education and Care Department to expand offerings and incentives for future certification.

Objective 2. Prevent the onset of the Type II diabetes for women with a history of Gestational Diabetes Mellitus (GDM).

ESM. The percentage of women in UNM hospital’s Maternal and Family Planning (MFP) clinics completing a postpartum visit and appropriate testing to 80% by June 2019

Members of the “GDM Project”: the NMDOH Diabetes Control and Prevention Program, the UNM Maternity and Family Planning Clinic(s) (UNM M&FP) and Title V Maternal Health and MCH Epi staff have worked together on the improvement of services for clients at risk of gestational diabetes mellitus (GDM) at a UNM-run urban clinic located in Albuquerque. The work started in March 2018 with members of the DOH team and the UNM M&FP staff team attending and participating in an MCH Workforce Center Learning Collaborative. Project members are full-time employees in their respective professional settings and devote in-kind hours to this project. An evaluation component facilitated planning and technical assistance, but staffing has been challenging even pre-Pandemic. In 2020, things slowed down more and have not advanced as planned, however a team still meets to test and monitor changes in service delivery for people at risk for or diagnosed with gestational diabetes.

The project had 4 phases at its inception:

Phase I: Improve the scheduling, completion and appropriate testing for women with GDM history at their postpartum visit

Phase II: Introduce an evidence-based, tailored counseling and education approach for managing diabetes risk for women with history of gestational diabetes that starts at their postpartum visit

Phase III and: Disseminate the education and methods to a wider-net of providers Phase IV:  Attempt to create incentive-based initiatives to assure sustainability as well as reach this population in clinics and other settings across the state.

This project has had many challenges, two of its greatest being access to data either to assess baseline activity such as current post-partum visit (PPV) completion rate, or consistent access to measure improvements in PPV attendance over time. A 2019 evaluation final recommendation was to direct the focus of the project on creating an educational module for pregnant clients who were awaiting the 3-hr glucose tolerance test at the M&FP Clinic. The evaluators also recommended measures to evaluate the effectiveness of the module. The work team planned to present the education via a video format and some funding was found to create the video. In 2020, the team drafted a script and gathered feedback from a vendor who will create the video in 2021. The script has also been reviewed by a health education team at UNM for its cultural appropriateness and reading level presentation. The start of video creation has been delayed by the COVID situation. The video will cover both the education on gestational diabetes, as well as orient clients (in a “warm handoff” approach) to the specialty clinic that follows these clients in the latter part of the pregnancy for their GDM care.

A quality improvement aspect of the project is to work with administrators of the UNM Hospital and Clinic electronic scheduling systems to introduce reminder steps to providers in the post-partum scheduling process. This aspect has met with many challenges as the team members do not have supervisory authority over the staff who work on system improvements. One 2020 development has been the designation of a UNM perinatologist to improve the system of care for GDM clients seen in the UNM clinics.

The plan was to fix gaps in the system of appointment scheduling, reminders and tracking completed PPV appts. This specialist worked to standardize the testing of GDM clients at the PPV so that diabetes risk and/or status is accurately and consistently assessed, and the appropriate counseling and teaching is set up for future visits on high-risk clients. The GDM project team has offered support in these endeavors but recognizes that the UNM specialist involvement may be the needed catalyst to make improvements in the system of care to GDM clients in the perinatal period.

The reporting year culminated with several staff vacancies and transitions during the COVID-19 pandemic This meant that Title V staff did not get to fulfill some of the plans to connect the objectives and strategies to the national performance measure on well woman care. Unfortunately, the national performance measures for the maternal health domain have not aligned well with our state efforts to increase access to perinatal care, however inter-conception and postpartum care expansion to assess risks for behavioral and physical health are intertwined in our FY22 to improve maternal and perinatal health in New Mexico.

Maternal Mortality Review and Maternal Morbidity

Although not stated as objectives or strategies during the last Title V cycle (2016-2020), maternal mortality is a growing concern in New Mexico and in the nation. Title V staff have formalized a mortality review process to include all pregnancy-associated deaths: those occurring during pregnancy or within 365 days of the pregnancy.

Committee review began in 2018, starting with the 2015 death cohort Having reviewed 2015-2017 deaths and struggling to develop resonating recommendations for prevention, the leadership of the committee observed that the membership to date had been predominantly white and clinical. Furthermore, too many seats were taken by staff her were administrative or operational to the work, and that was leaving only 2-3 seats for community-based people and those with non-clinical expertise, as members rolled off. Because clinicians had previously encouraged other clinicians from their institutions to replace one another on the committee, it was difficult to diversify the committee. Finally, there were problems in the Maternal Mortality and Morbidity Act (2019) contradicting the intention to reimburse committee members for their time (not just travel) in the review to facilitate broader representation. Given these concerns, a new bill with amendments was drafted in 2020. It was introduced and passed in 2021. This corrected the concerns detailed above, and it also led to much more awareness about the important work of the committee. The bill (SB 96) also articulated a need for trauma-informed trainings, including training on the trauma of racism, for all committee members, beginning in 2021. Working with a coalition of Black and Indigenous community leaders, the MMRC leads will develop and deliver a curriculum to support this objective over the next few years.

 From 2015-2017, maternal deaths in New Mexico were predominantly pregnancy associated, not related, and the leading causes were motor vehicle accidents, overdose and injury (homicide, suicide, other) (figure 1.).

Figure 1.

The New Mexico MMR team has been quite active at the national level with the American College of Obstetricians and Gynecologists (ACOG) and with the local perinatal collaborative to address pregnancy-related deaths, including hemorrhage and embolism. These activities have centered on the AIM maternal patient safety bundles for hemorrhage and hypertension, and these deaths are impacted by social determinants of health (distance to care, poverty, chronic disease history), but they are not the leading causes of deaths reviewed in NM. In 2020, the NM Perinatal Collaborative and the Title V leads of the MMRC embarked on a significant planning strategy to launch a substance use disorder patient safety bundle, including routine participation from a coalition of reproductive justice, community-based birth workers, and mental health researchers.