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

(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

 

Background: State analyses and community-led policy work 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.

 

The New Mexico Doula Association (NMDA) has convened independent and organization-based doulas and developed their resources to support a variety of home-grown doula trainings and a new series for community doula trainings. Community-based organizations with long-standing doula programs such as Tewa Women United continue to lead much of the work in New Mexico, and newer programs aiming to train up doulas and Community Health Workers in MCH or perinatal competencies include NMDOH and the UNM MCH CHW ECHO program.

 

Since 2020, NMDOH Title V and the NMDA promoted discussions with state leadership on the importance of an executive order or legislation which would require NM birthing hospitals to admit doulas as providers, not as personal guests at delivery, however formal policies applied to all birthing centers are not codified. Doula advocates drafted legislation during the reporting period and later introduced a bill in the 2025 legislative session. This led to the passage of a law giving doulas some protection in hospitals, but to date there is no universal mandate. With closing or struggling labor and delivery units across NM, growing maternity care ‘deserts’ and low maternity care access in much of the state, doulas and community-based health workers continue to be important and potential in more demand for Medicaid and privately-insured consumers in the perinatal period.

 

The Medicaid reimbursement package, which was included in a state plan amendment (SPA) for New Mexico, went live July 1, 2024. 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 the sustainability of their profession. NMDOH set us a doula registry, and by the end of 2024, the state had its first doulas voluntarily certified to become Medicaid providers.

 

Strategy- Expand and improve Medicaid reimbursement for doulas, midwives, and community health workers

 

ESM- Number or percent of Licensed Midwives (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 serious barriers to expanding access to perinatal care. Efforts to improve billing procedures and support for midwives providing out of hospital delivery services is chronically problematic, creating barriers to care and a struggling workforce.

 

NM Medicaid covers the third highest percentage of births (55% of 2023 deliveries) in the nation[1]. NM PRAMS data indicate that self-reported coverage in the prenatal period hovers around 62%, and including those eligible for Indian Health Services, we estimate that at least 65% of the NM birth population enrolls in Medicaid through fee-for-service or managed care organization (MCO) services.

 

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). 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 continued the work with the NM HCA Medicaid Program- Medical Assistance Division to assure that licensed midwives-LMs receive equitable reimbursement for their comprehensive community and home-based services. Title V works with Medicaid directors on updates to the billing and coding guidance that governs the BOP, and while rates for midwives increased in the 2023 legislative session, they now lag behind NM doula reimbursement rates. 

 

As reported in the maternal health updates, NM achieved pay parity for midwives attending deliveries who now charge the same rate as physicians for births attended in hospitals or stand-alone birth centers.

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.

Midwives navigate participation in the BOP through an array of managed care organizations (MCO) contracted to provide Medicaid services under New Mexico’s Turquoise 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.

 

Strategy - Scale curriculum for perinatal training for Community Health Worker (CHW) and health promoters (promotoras 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, community organizations or colleges

 

The NMDOH Office of Community Health Workers (OCHW) partnered with the University of New Mexico MCH-CHW ECHO program to deliver continuing education for Spanish speaking and Indigenous-serving perinatal CHWs in 2024. In collaboration with Tewa Women United, they began planning an expanded curriculum to keep up with demand for more training and continuing education planned for 2025.

 

While local and national organizations provide certification for health workers and doulas, NM has grandfathered CHR (community health representatives working in tribal nations) and other CHW or promotoras in without requiring additional certification requirements while doula workforce advocates have not resolved that concern.

 

Title V coordinates with the DOH Office of Community Health Workers in their support and training offered for certified perinatal community health workers, and both offices collaborate with the Community Health Representatives CHR Association, which supports the professional development of CHRs serving tribal nations.

 

Objective 2. Improve the 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 birth center integration.

The Improving Perinatal Health (IPH) 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 a former 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.

New Mexico is challenged by Labor and Delivery closures, and it is now more than ever challenged to integrate midwifery equitably or even at all in some facilities. This is limiting our ability to serve New Mexicans in a very basic way, and Title V staff are deeply engaged in opportunities to change this trend through policy and innovative payment strategies.

 

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

 

Background: 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) which was signed into law in April 2019. The law required hospitals to create Plans of Care (POC) 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 were fashioned with a non-punitive approach to plan of care notifications, and the plans of care were meant to provide treatment and support for families who struggle with addiction. A team composed from the Children Youth and Families Department (CYFD), Department of Health Title V and University of New Mexico Pediatrics Department designed initial CARA process and protocols.

Starting July 1, 2019, the cross-agency CARA team began training for labor and delivery and pediatrics staff working among 30 birthing facilities and for navigators in 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. Refresher trainings were at annual provider conferences for the NM Pediatric Society and the NM Family Practice Association, and clinical providers participating in the UNM Perinatal ECHO series.

Barriers and changes: With 2020 COVID-19 pandemic emergencies, plans of care were created and reported to the CARA portal managed by CYFD, however staffing and resources in each department were insufficient to develop a responsive and accountable program. Without dedicated positions or funding at NMDOH, Title V provided the safety net just to keep basic operations and evaluation afloat. In 2022, CYFD announced that it would transfer the entire CARA program to DOH, however, a bill in the legislature was stripped of appropriations, and it was no longer clear who would take the lead without resources. In 2023, DOH staff were told by agency leadership to stop working on the program, and they were given instructions to transfer materials and data management to CYFD.

Again, in 2024, NMDOH was instructed to work with the NM Health Care Authority on staffing the CARA program with navigators, and those positions were transferred to the Family Health Bureau at NMDOH following the 2025 state legislative session.

 

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

ESM- Number of hospitals participating in DOH-coordinated conversations

During the reporting period, NMDOH staff were not in communication with hospitals or managing plans of care for CARA. Therefore, staff were only communicating with CYFD navigators if a plan of care was issued for a family who had no health insurance so they could be informed about free community services or care coordination offered without insurance.

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

Currently, there is limited understanding of how birthing facilities interact with families and Medicaid managed care coordinators. The trainings provided to hospitals beginning in 2019 were not effectively evaluated, and the inter-agency CARA evaluation team established measures to evaluate the concordance of ICD-10 codes in Medicaid claims linked to the plans of care for 2020-2021 births as a starting point. These analyses demonstrated that there was significant under-reporting for plans of care and that the facilities were probably missing many opportunities to help families struggling with substance use disorder. Without funding or staff in 2023 to 2025, the NMDOH evaluations stalled, and it is unclear if CYFD evaluated the work of CARA.

Plans of Care in New Mexico

In 2020, there were 1623 Plans of Care in New Mexico, 1385 in 2021, 2066 in 2022, 1775 in 2023, and 1596 in 2024. Among plans (n=7641) created for all families in 2020-2024, exposures most frequent were marijuana, followed by methamphetamines, and opioids.

Annual counts for plans of care by exposure and year, NM 2020-2024	2020	2021	2022	2023	2024	Total
Alcohol	23	59	78	72	61	293
Benzodiazepines	14	40	38	35	23	150
Buprenorphine	37	108	113	102	67	427
Cocaine	17	48	75	78	80	298
Marijuana	192	568	785	691	672	2908
Methadone	52	128	129	112	124	545
Methamphetamine/Amphetamines	132	335	414	328	287	1496
Nicotine	35	114	141	119	83	492
Opioids	79	223	293	238	199	1032
	581	1623	2066	1775	1596	7641

 

Data obtained from the CARA portal and provided by the Early Child Education and Care Department (2025)

NMDOH did not track plans for part of 2023 forward, however the plans were reported annually from the Early Child Education and Care Department.

 

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

Initial evaluation data and tracking indicated that all birthing facilities are trained, and all non-federal hospitals reporting plans of care, however screening tools for perinatal substance exposure were and are still not universal, and screening protocols are not consistent for all families or facilities.  A key strategy for improving CARA implementation included evaluating family’s knowledge of their Plan of Care, experiences engaging with health care providers and care coordinators, as well as assessing the efficacy of services families were receiving.

Sharing results and discussing implications with the coalition of CARA workgroup members led to some notable areas for improvement; family survey results through 2021 (n=146) showed that:

-54% of families knew 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

Survey questions assessing bias experienced by families demonstrated that 32.3% agreed or strongly agreed that their healthcare team made them feel judged for having used substances during pregnancy, and a much lower proportion (3.2%) agreed or strongly agreed that their Medicaid care coordinator made them feel judged. These were improvements from the first evaluation, and third evaluation to include family perspectives is in process.

 

Data linkages and Evaluation:

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. It is not known if the rate increased after CYFD became the lead agency, and NMDOH did not resume evaluation plans until they were directed to do so in 2025.

 

Safe Sleep for infants

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

A re-emerging concern in NM has been the persistence of SUID, including sleep- related deaths. Efforts to address growing disparities and strengthen prevention among all New Mexican 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 available 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 with participation from CYFD, NMDOH, and ECECD with a collaborative to include external partners from UNM, the NM Breastfeeding Task force, and Las Cumbres Community Services.

MCH epidemiologists updated some available data to guide the next prevention efforts:

Table. Count and ratio of NM Sudden Unexpected Infant Deaths and births by subpopulation, 2019-2023

Population	Sudden Unexpected Infant Deaths n	Live Births n	Ratio of deaths per 1,000 live births (95% Confidence Intervals)
Black/ African American	5	2,495	2.0 (0.2-3.8)
American Indian/ Native (non-Hispanic)	14	12,158	1.2 (0.5-1.8)
Hispanic/Latino	58	62,538	0.9 (0.7-1.2)
Non-Hispanic white	24	28,476	0.8 (0.5-1.2)
Asian/Pacific Islander	0	.	.

NM Vital Records and Health Statistics, NM-IBIS

 

Analysis of NM PRAMS indicators ascertained that there were behavioral areas which might be modified across different populations if caregivers had more information about safe sleep.

 

 

 

Table. Prevalence of Infant Sleep-Related Factors, NM, 2017-2023 (NM PRAMS)

	Weighted % by year of birth
	2017	2018	2019	2020	2021	2022	2023
Baby most often sleeps on back	79.2	80.6	80.7	82.7	83.8	83.9	93.6
Baby usually sleeps with blankets	67.7	66.3	62.6	60.9	55.5	50.7	30.1
Baby usually sleeps in crib**	81.0	84.9	81.9	84.6	84.9	85.3	87.0
Baby usually sleeps with pillows ∞	9.6	10.5	10.9	10.0	10.5	8.6	11.8
Baby always sleeps alone	46.1	48.7	45.6	45.4	49.5	48.5	47.9
Baby sleeps in swaddled blanket	24.0	23.6	25.4	31.0	37.1	39.3	40.6
Baby sleeps in wearable blanket or sleep sack							35.8
Baby ever breastfed	89.2	88.8	89.5	88.9	90.7	91.2	89.8

Data source: NM PRAMS    **or cradle, basinet or pack n play; ∞ pillows, cushions or toys 

 

PRAMS results show key improvements which can be leveraged and shared with health promotions staff and with public health practitioners interacting with families through WIC, CMS, Healthy Start and other programs. In cooperation with Albuquerque Area Southwest Tribal Epidemiology Center (AASTEC) staff, Title V contributed to the Native Babies Safe Sleep consultation with 23 tribal nations across NM and UT, and findings informed the state needs assessment and strategic planning for safe sleep. 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 Tribal CHRs, 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.

Activities:

The NMDOH Injury and Violence Prevention Unit conducts surveillance through child fatality review (CFR) panels and promotes prevention activities based on panel findings and national evidence. The Sudden Unexpected Infant Death (SUID) panel reviews deaths investigated by the Office of the Medical Investigator with field investigations, including death scene doll reenactments and family interviews. This heartbreaking work gives staff insight into the risks associated with sleep-related deaths, and it guides practice and strategies to prevent future deaths.

During this reporting period, the NM Safe Sleep Interagency Work Group and Safe Sleep Collaborative expanded phase one of a multi-media safe infant sleep campaign, aimed to increase awareness and prevention of SUID in NM. Phase one of the campaign featured a website, digital and radio public service announcements, and billboard and transit ads. The original content features New Mexicans in their homes, following American Academy of Pediatrics (AAP) safe infant sleep recommendations.

Given subpopulation disparities in SUID, Title V supports cultural practices that may add protection for infant sleep. A cradle boarding video was produced to support Indigenous practices as cradle boarding is recognized as a culturally appropriate infant sleep surface by the American Academy of Pediatrics and the National Institute of Child Health and Human Development. The video features a Navajo (Diné) family in NM making a cradleboard and is currently posted on the Safe Sleep NM campaign website. In collaboration with the Diné College MCH Collaborative and Tribal Epidemiology Centers, Title V staff endeavor to promote safe sleep practices which also carry strong traditional perinatal knowledge. Cradle boards are recognized as safe sleep surfaces, and they are used by some NM tribes who receive knowledge from family or community programs.

Phase two of the safe infant sleep campaign included the purchase of more than 1,000 pack and plays (‘playards’) for distribution throughout NM. SUID rates by county were analyzed and used to inform distribution. Additionally, a video tutorial was developed (YouTube English & Spanish) to accompany distribution of the pack and plays

During the reporting period, the General Pediatric Group for Project ECHO served as a continuing education and resource hub for pediatricians in NM. Staff developed a partnership with this group to educate pediatricians in SUID awareness and safe sleep recommendations. This ECHO and the MCH-CHW ECHO continue to bring broad participation to provider education.

 

 

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