Priority: Grow and sustain an equitable birth and family care workforce

 

NPM 3: Percent of very low birth weight infants born in Level III + NICU

 

Objectives:

1. Strengthen community health and a place-based perinatal workforce
2. Improve support system for rural and under-resourced birth settings
3. (hospitals, birth centers, home)

 

Objective 1. Strengthen community health and a place-based perinatal workforce

 

Strategy – Promote state policies to institutionalize universal doula and birth support presence at delivery in NM hospitals and birth centers

 

Earlier state analyses and community-led policy analysis in New Mexico demonstrate return on investment and health-based value of perinatal doula support to birthing people https://tewawomenunited.org/2020/04/expanding-access-to-doula-care-birth-equity-and-economic-justice-in-new-mexico. Positive birth and maternal/postpartum outcomes associated with doula care are well documented in national literature, and in New Mexico this includes indigenous and traditional Hispano expertise which may offer additional protective experiences for people of color.

 

COVID-19 pandemic restrictions continued to disrupt collaborative efforts and momentum to advance this work, although birthing hospitals relaxed restrictions previously barring doulas from inpatient units. To date, no statewide policy recognizes doulas as essential healthcare workers. Title V and community partners stayed in close communication and promoted unified messaging to families and healthcare providers about the importance of birth workers in hospital settings. Title V staff participated in a formal strategic planning process led by the NM Doula Association in 2021 with goals to articulate policy and communications priorities, and Title V staff proposed executive orders for New Mexico and provided NMDOH leadership with examples of legislation protecting the status of doulas in other states.  

 

Ongoing work to implement specialized care navigation services for people who are pregnant, postpartum, lactating or parenting a child with special healthcare needs continues to remind us how much we rely heavily on coordination between community-based health workers, birthing professionals and medical experts to get them the information and services they need. Home visiting, community-based birth workers such as doulas, and public health professionals are all actively engaged to optimize the best support for birthing families requiring different levels of care.

 

NM Doula Association (NMDA) strategic planning has developed to support indigenous doula trainings and a series of Black-led community doula trainings, and although Title V did not fund these efforts, we continue to be part of the conversation and to offer in-kind analytic products.  We also identified companion grant sources to compensate doulas and birth equity leaders in their consultation to Medicaid. Members of the NMDA provided ongoing leadership to reimbursement designs which would help doulas earn a living wage while serving their communities and advocating for their profession. As NM Medicaid began to move forward with the implementation of a doula benefit package, they were also trying to meet the needs of a CHW health worker reimbursement package, and this made the doula voices less focused. NMDA advocated for the inclusion of formal community-based doula input into the development of the state benefit design. Title V staff were able to support Medicaid in the development of a formal consultation process based on successful integration of BIPOC community expertise into the Maternal Mortality Review Committee. A compensated consultation process is underway, and Medicaid is moving forward with the plan to seek federal approval of the doula benefit for state Fiscal Year 2025.

 

Strategy- Expand and improve Medicaid reimbursement for doulas, midwives, and community health workers in settings such as home visiting programs

 

ESM- Number or percent of LMs who are enrolled as Medicaid providers and accept Medicaid reimbursement for community birth services.

Medicaid reimbursement for healthcare providers and services remains challenging and presents continuous barriers to perinatal care. Efforts to improve billing procedures and support for midwives providing out of hospital delivery services is chronically problematic, leading to barriers to care and a struggling workforce.

 

NM Medicaid covers the third highest percentage of births (54%) in the nation[1]. Analysis of NM PRAMS data indicates that self-reported coverage in the prenatal period hovers around 62%. Medicaid coverage represents an acknowledgment of the value of health-related services promoting accessibility to the broadest population. Title V staff worked to support community-led efforts to obtain Medicaid coverage for doula services and monitored the status of an ongoing pilot program to reimburse home visiting services. Without Medicaid coverage or special grant-funded programs, access to doula services remains limited to those who can afford to pay out of pocket. This perpetuates inequity in access to a service that has been highlighted as an intervention to improve access to lifesaving and empowering care for birthing people, especially for those from communities of color most directly impacted by disparities in maternal and newborn outcomes.

 

Advocating for improvements to the Birthing Options Program (BOP) for midwifery reimbursement

NM has already demonstrated leadership in promoting access to community birth by credentialing direct-entry Licensed Midwives (LM) as Medicaid providers through the NM Birthing Options Program (BOP). This state policy innovation was highlighted in a report published in April 2022: Improving Birthing Outcomes through Midwifery Care: New Mexico - The National Academy for State Health Policy (nashp.org) However, barriers related to allowable billing codes and delivery costs significantly hamper LMs and create a considerable hardship in providing services to Medicaid-insured clients. During the reporting year, we worked to amplify partnerships with the NM Medicaid Program- Medical Assistance Division to assure that licensed midwives-LMs receive equitable reimbursement for their comprehensive community and home-based services. Title V worked with Medicaid directors on significant updates to the billing and coding guidance that governs the BOP. This was an encouraging step to build on prior work, but implementation has not taken place.

Title V staff collaborate with midwifery community leaders through the Licensed Midwifery Advisory Board, a public board led by the NM DOH Maternal Health Program (MHP). The MHP is responsible for midwifery licensure and practice regulation. The advisory board provides an important public forum for discussion of Medicaid as a major factor influencing midwifery practice. In 2021, the MHP  began formally tracking Licensed Midwife participation in Medicaid to understand the barriers and facilitators of participation, along with the enrollment of newly licensed midwives in NM.

Midwives navigate participation in the BOP through an array of managed care organizations (MCO) contracted to provide Medicaid services under New Mexico’s Centennial Care waiver. Each MCO approaches the BOP differently and has different mechanisms in place to assist providers with questions about enrollment and reimbursement. During the previous reporting year, Medicaid released a Request for Proposals for MCOs to participate in the next five-year cycle of the 1115 waiver. The MHP organized a stakeholder meeting between representatives of one plan and midwives who participate in the BOP to represent the concerns of midwives in the design of the proposal and to begin the process of establishing accountable relationships with plan representatives.

 

For this report year, we worked with Medicaid leadership to improve the implementation of the BOP for MCOs already under contractual obligation to administer the program. This involved inviting the Chief Medical Officer of Medicaid to engage with the midwifery community through the public forum provided by the Licensed Midwifery Advisory Board and led to an ongoing process through which LMs report issues with credentialing and claims processing directly to the CMO, who is requesting formal deliverables in response to complaints for each instance reported. This has allowed Medicaid to get a sense of how the MCOs compare in their implementation of the BOP and track themes that emerge in barriers to appropriate reimbursement. Plans for the coming year include direct engagement between Title V staff who oversee midwifery practice regulation and MCO corporate and clinical leadership to educate MCO leadership about the qualifications of LMs, the regulation of midwifery practice, and the experience of midwives leading to limited participation in the BOP. Next steps also include formalizing midwifery consultation to Medicaid according to the model established for the doula community. We anticipate continuing to support that process with guidance and resources to support compensation.

 

Strategy - Scale curriculum for perinatal training for Community Health Worker (CHW) and health promotions (promotora de salud) certification

ESM-Number of community health workers, doulas or promotoras de salud certified in perinatal health modules through the NM Department of Health or colleges

 

Led by a New Mexico Health Extension Rural Officer (HERO), Title V piloted a curriculum for promotoras in 2020. The project involved collaboration with Dona Ana Community College (DACC) to develop a preconception and prenatal curriculum to gain either entry-level knowledge or to fulfill continuing education requirements as set down by the DOH Office of Community Health Workers. An initial cohort successfully completed this training in person, and Title V staff planned to collaborate to adapt the curriculum to an online format to increase accessibility for a diverse array of birth workers and CHWs.

 

The curriculum was adapted to an electronic format with the Rural Obstetric Access to Maternity Services (ROAMS) program which facilitated online deployment of perinatal community health worker training 2020-2022, and the NMDOH Office of Community Health Workers began to pursue different specialty certifications with emphases in maternal and child health, so they became interested in the curriculum implemented in the NE region of the state through ROAMS.

 

An early phase pilot with partners at the University of New Mexico evaluates the impact of CHWs on family wellness and intends to connect people to services which are health related but broadly connected to social determinants of health. The project aims to demonstrate feasibility and replicability of a social needs navigation and empowerment model adapted from Pathways navigation in Bernalillo County and integrated with innovative Health Extension Regional Offices (HERO) approaches. Community Health Worker Initiatives (CHWI) will connect with community members while HEROs engage with key stakeholders at each site. The selected sites include: Bernalillo (International District), Luna, Lea, McKinley, and San Juan Counties.

Using an electronic resource navigation platform for screening and connecting clients with resources, CHWs assist clients with a broad range of social needs: Medicaid, SNAP food benefits, WIC nutrition for women infants and children, LIHEAP/utility supports, EITC, housing assistance, and transportation.

 

Perinatal health worker curriculum supports and is informed by the pilot, and the emphasis on poverty-related services broadens the content from perinatal health to an array of determinants impacting health.

 

Objective 2. Improve support system for rural and under-resourced birth settings (hospitals, birth centers, home)

Strategy- Integrate the expertise of midwives and doulas providing care in rural settings into statewide quality improvement initiatives (hospital and community settings)

Title V staff have collaborated with community midwives, the NM Coalition of Midwives, the NM Doula Association, and the Licensed Midwife Advisory Board to identify barriers and facilitators of integration.

The Improving Perinatal Health ECHO program has also endeavored to include community birth workers, midwives and doulas in their offerings which were either excluded or not centered in previous years. The Maternal Health Program Manager is an advisor to this work, and we have supported the dissemination of resources developed by community partners to promote doula care and highlight the role of doulas in providing essential wrap-around services for birthing people even or especially during a public health emergency.

During the report year, statewide partners, including BIPOC and community-based birth workers, moved beyond calls for integration of birth workers into existing perinatal quality improvement activities and demanded accountability for hospital improvements sought through QI initiatives. Those who accompanied families in hospital settings, and those who provided home-based services following challenging hospital-based birth experiences became convinced that, as the COVID-19 pandemic progressed, hospital-based care remained organized around the needs of strained systems of care, and not around birthing families. In the context of worsening national maternal outcomes, demands were directed at the NM Perinatal Collaborative and enrolled hospitals to demonstrate the impact of resources dedicated to perinatal quality improvement programming.

In the previous Perinatal Application, Title V staff proposed to engage in the following activities:

1. Meet with midwives (CNM and LM) and doulas to review existing policies related to community provider access to hospital settings, including guidelines and resources. Identify the need for updates and create new and revised tools.
2. Collaborate with NM Perinatal Collaborative to assure ongoing community birth providers in site-based trainings for Critical Access Hospitals.
3. Continue efforts to recruit midwives to participate in the Improving Perinatal Health ECHO program and ensure that content is relevant to community-based midwifery practice.

 

Progress for reporting period:

1. Collaboration with midwives and doulas: Title V staff have remained in regular contact with community midwives, the NM Coalition of Midwives, the NM Doula Association, and the Licensed Midwife and CNM Advisory Boards to identify barriers and facilitators of integration. These conversations have not led to a systematic analysis of hospital policies, yet the need for updated tools and resources is highlighted in these conversations. Work to advance the doula services benefit through Medicaid has been a focus of energy and bandwidth and has some of the greatest potential to legitimize hospital-based doula care for the institutions that failed to classify doulas as essential healthcare workers once their care is reimbursable. The work to maintain regular forums for engagement with midwives and doulas is established and ongoing. Title V staff will continue to support community generated priorities for the development of policy and program tools.

 

2. Collaboration on site-based training:  During the report year, the NM Perinatal Collaborative paused implementation of their site-based training model, as the organization has begun an organizational leadership transformation. During the previous year, work that engaged community-based midwives in Silver City led one of the midwives to join the NMPC Board to bring the perspective of rural community-based midwives directly to leadership. There are plans to resume the outreach visits in the coming year.

 

Title V staff have also supported some initial explorations led by birth workers in northern NM to engage with Emergency Medical Services (EMS) to advocate for collaborative training opportunities focused on emergency homebirth transfer. We anticipate continuing to elaborate this work in future reports.

 

3. Recruit midwifery participation in IPH ECHO: Programs of specific interest to a midwifery audience were promoted directly with the professional organizations and midwifery licensees. Targeted messaging to practicing midwives and students have increased midwives’ participation in IPH ECHO sessions, which has the potential to enrich a multidisciplinary conversation in response to provide opportunities to provide updates and training with a focus on the needs of hospital teams to receive transfers appropriately and collaboratively.

 

Comprehensive Addiction Recovery Act (CARA) in New Mexico

 

Priority- Build statewide capacity to prevent perinatal substance use and advance equitable, culturally appropriate treatment options.

SPM- Proportion of eligible families receiving a plan of care for their substance-exposed newborn

Objective-All birthing hospitals will report safe plans of care to NMDOH and CYFD

 

After the federal child abuse protection act (CAPTA) was amended to require state notification of substance exposure at delivery, the New Mexico Legislature passed House Bill 230 (HB230) in February 2019, and it was signed into law that April. The law required hospitals to create Plans of Care for every baby born with exposure to substances and required Medicaid Managed Care Organizations to provide direct care coordination for these babies. It also clarified that substance exposure was not automatic grounds for child abuse referrals or investigations. NM rules and procedures take a non-punitive approach to plan of care notifications, and the plans of care are meant to provide treatment and support for families who struggle with addiction. A team from the Children Youth and Families Department (CYFD), Department of Health Title V and University of New Mexico Pediatrics Department have designed the CARA process and protocols, and evaluation helps measure impact and effectiveness.

Starting July 1, 2019, the team started the training with two facilities and continued with training the majority of the 31 birthing facilities and the Medicaid Managed Care Organizations (MCO) Care Coordination Units. The CARA leadership team began working on evaluation plans with Title V Epidemiology staff and charted a course to understand the impact of training and plans of care. Trainings were also presented at annual provider conferences for the NM Pediatric Society and the NM Family Practice Association, and to clinical providers participating in the UNM Perinatal ECHO series.

Strategy- Assess barriers to reporting through coordinated and focused conversations with hospital leadership

ESM- Number of hospitals responses participating in DOH-coordinated conversations

In 2020, there were 1174 Plans of Care in New Mexico, 1385 in 2021, and 1211 in 2022.

Among exposures reported for all individuals (n=3770) in 2020-2022, 44% of exposures involved ‘illicit’ drugs, 41% were marijuana only, 33% included methamphetamines, and 18% included opioids. Evaluation data and tracking show all birthing facilities are trained, and all non-federal hospitals are reporting plans of care, however screening tools for perinatal substance exposure are not universal, and screening protocols are not consistent for all families or facilities. Evaluation methods are currently assessing how these differences might be reflected in diagnosis and plans of care data.

A 2020 survey conducted of health providers (n=53) who serve birthing people found that 64.3% of providers did not think it was best practice to screen all birthing people upon admission to a hospital/labor delivery unit. In addition, data comparing Plans of Safe Care with the Birth Defect registry, a registry that tracks NAS diagnosis cases and opioid exposures, showed that in the first half of 2020 37% of NAS cases did not have a Plan of Care. While NAS is not always evident at delivery, this discordance led to additional evaluation of probably cases which never received a plan of care.  PRAMS data indicate that about 10% of NM women with live birth use marijuana just prior to pregnancy, and at least half of those continue using it during pregnancy. These findings also imply that there is an underreporting of multiple types of exposures to trigger a plan of care.

 

Strategy- Evaluate hospital trainings and community-based trainings with a multidisciplinary team

One way to improve and boost participation in hospital plans of care and community referrals is to expand evaluation plans to understand the receptivity of staff trained in CARA screening and plans reported to CYFD/DOH. Currently, we have a limited understanding of how facilities interact with families and Medicaid managed care coordinators. Additionally, we are interested in evaluating equity and bias concerns in the trainings we perform, so the CARA team has been working with one contractor to build conceptual content and evaluate bias among providers interacting with staff or families. The team also intends to make trainings available online via webinar modules, and those will be launched over the next year. The webinar trainings will then be evaluated as well.

Many clinical and non-clinical stakeholders contribute to the CARA plans and implementation of best practices, so Title V is an important convener of interested experts and navigation of complex support to families. The CARA Team, with the help of the Director of Share NM, launched a web page for families and for providers. This web page is a tool, and contains forms, along with tools to have a conversation with patients in the hospital setting when discussing the plan of care. The web page also has a tool about language, and approach in a non- discriminatory, non-judgmental manner. The team is using this web page to retrain hospital staff who are creating plans of care, and has been very well received

 

Strategy- Evaluate family experiences, receptivity to services and impact of plans of care on family well-being

A key strategy to improving CARA implementation is evaluating family’s knowledge of the Plan of Care, experiences engaging with health care providers and care coordinators, as well as assessing the efficacy of services families are receiving.

Early findings showed that 71% of families either had no one to explain the Plan of Care or did not know what it was. In addition, 49.2% either were not contacted by a care coordinator or refused care coordination, showing that the program is not fully implemented for a proportion of the families. Sharing results and discussing implications with the coalition of CARA workgroup members has led to some notable changes: family survey results through 2021 (n=146) now show that:

-54% of families new what their plan of care and had discussed it with someone

-13% did not know what a plan of care was

-65% received a copy of their plan of care

-26% were involved in making their own plan of care

These changing perspectives bring encouragement to the CARA team and further highlight where additional change is needed.

Survey questions assessing bias experienced by families showed 32.3% agreed or strongly agreed that their healthcare team made them feel judged for having used substances during pregnancy, a much lower proportion (3.2%) agreed or strongly agreed that their care coordinator made them feel judged. These data from the implementation evaluation demonstrate opportunities for improvement, however they represent a small portion of needed changes. Staff working on family navigation and evaluation staff from MCH Epidemiology worked together to request state funds through a lengthy process with department leadership. Unfortunately, no funds were allocated, and the team working across DOH, Children Youth and Families Dept., Human Services/ Medicaid did not receive funding or positions which would facilitate a better process for the program.

Data linkages and Evaluation:

One component of the impact evaluation is a comparison of the number, and duration of CYFD investigations related to infant substance exposure prior to Plan of Care implementation and after implementation, as well as the differences in CYFD involvement in cases that received services and in cases that declined. Currently these data are not available, but increased collaboration has been planned to include a workgroup to increase stakeholder buy-in.

Using Medicaid claims to evaluate completeness of case identification for CARA

Medicaid claims records were linked to CARA POC data to assess the proportion of infants with ICD10 diagnoses within six months of delivery who should have been offered a plan of care. There were 28,604 NM resident infants with a New Mexico Medicaid birth claim born in 2020 and 2021. Of those, 2,299 were born in a New Mexico hospital with a diagnosis coded from the birth hospitalization that would qualify them for CARA services, and 1,372 (59.7%) had a POC reported to the state. Families not covered by Medicaid were excluded from the analysis. The proportion of exposed infants with a POC varied widely by hospital (between 0% and 76.7%) and by month and year of birth (39.2% to 73.0%), with the lowest proportion occurring the first month of required reporting (January 2020). In 2020, 57.9% and in 2021, 61.4% of eligible families were reported to the CARA program. Future analysis includes linkage of the CARA database to all hospitalization records to assess patterns of case identification  by facility, region, and by patient demographics.

 

Safe Sleep for infants

SPM-Proportion of birthing families or infant caregivers receiving safe sleep education

A re-emerging concern in NM has been SUID and sleep- related deaths. Efforts to address growing disparities and prevention among all NM infants, include the following areas:

Objectives

• Expand birth worker and clinical expertise in safe sleep across the state
• Improve awareness about safe sleep recommendations and risks associated with sudden unexpected infant death (SUID) in NM

Strategies

• Include more hospitals and birth centers in safe sleep education training
• Broaden the reach of a multi-media awareness campaign

Based on baseline information for 2015-2019, the statewide interagency safe sleep work group established plans for a multi-media campaign on safe sleep information. Disparities are observed in death rates and in some behavioral and environmental factors which may help to intervene for future prevention.

A state interagency safe sleep work group continued to meet over the last four years, and after further consideration, we have reintroduced this focus back in Title V reporting to bring focus to the work we need to expand. We used some of the following analysis to guide prevention efforts:

Table 1. Count (proportion) of NM Sudden Unexpected Infant Deaths and births by subpopulation, 2015-2019

Population	Sudden Unexpected Infant Deaths n (%)	Live Births n (%)	Ratio of deaths to 1,000 live births (95% Confidence Intervals)
Black/ African American	10	2,393	4.2 (1.6-6.8)
American Indian/ Native	19	14,447	1.3 (0.7-1.9)
Hispanic/Latino	60	66,839	0.9 (0.7-1.1)
Non-Hispanic white	29	33,281	0.9 (0.6-1.2)
Asian/other	0	2,582	.

NM Vital Records and Health Statistics

 

Figure 2. SUID ratio of deaths per 1,000 live births, rolling averages, 2010-2019

               Data Source: NM Bureau of Vital Records and Health Statistics (NM-IBIS)

 

 

Analysis of PRAMS indicators ascertained that there were behavioral areas which might be modified across different populations if caregivers had more information about safe sleep. These indicators were used to plan and implement a statewide campaign. Updated analysis will guide activities during the upcoming FY24 plans.

Safe Sleep Factors by Maternal Ethnicity and Nativity, NM, 2016-2019

Proportion of SUID Risk or Protective Factors among NM Birth Population, 2015-2019

	2015	2016	2017	2018	2019
Supine (on back) sleep position	78.3	80	79.2	80.6	80.7
Baby usually sleeps with blankets*	13.3	67.8	67.7	66.2	62.6
Baby usually sleeps in crib**	80.1	79.8	81.0	84.9	82.0
Baby usually  sleeps with pillows∞	9.8	12.5	9.6	10.5	11.0
Baby always sleeps alone	.	42.8	46.1	48.8	45.6
Infant ever breastfed	91.1	88.9	89.2	88.8	89.4
Mother smoked during pregnancy	7.1	6.0	5.8	5.6	7.4

Data source: NM PRAMS    *prior to 2016, the question asked about heavy or plush blankets only.                                    **or cradle, basinet or pack n play; ∞ pillows,  cushions or toys 

New Mexico’s efforts to expand an equitable workforce can contribute to a safer sleep environment for infants, and the preservation and sustenance of traditional practitioners such as doulas and midwives is not only important to this effort, but it probably represents our best chances of instituting safer practices among New Mexico families.

Our NPM for risk-appropriate care is an opportunity to leverage and support a diverse and accessible workforce beginning with the well woman and prenatal periods with continuity throughout the postpartum and inter conception screening and Medicaid-extended services available to birthing people.

[1] https://www.kff.org/medicaid/state-indicator/births-financed-by-medicaid/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D