Needs Assessment Update- 2021
The 2019-2020 Maternal Child Health needs assessment input from several community-based and professional surveys, focused discussions, ongoing fatality review committees and statewide collaborative work, population surveillance and administrative data formed the basis of the MCH population health status summary. In 2020, COVID-19 pandemic infections, hospitalizations and restrictions brought on more concerns about new and aggravated barriers to care, especially for pregnant and birthing people.
Emerging MCH Concerns, COVID-19 pandemic
In the Spring of 2020, Title V staff and partners developed protocols rapidly to ensure that pregnant and postpartum people with COVID-19 infections received immediate follow up and monitoring, with referrals to community support services across the state. MCH Epidemiology staff, Children’s Medical Services social workers and Tribal Epidemiology Center case monitors aligned resources to provide clinical, behavioral and social support, referrals and case tracking across the state. Approximately 900 people were reached for monitoring out of 1519 estimated pregnant people contacted through case investigation from March 2020-July 2021. By the end of 2021, over 1300 families had been referred to the Family Health Bureau Title V staff by case investigators or contact tracing personnel.
A small amount of private funding helped us with staffing from a social worker and to develop surveillance and data management for tracking of pregnancy COVID cases. Using the modified PRAMS CDC-CSTE COVID supplement and the CDC COVID pregnancy supplement, MCH Epidemiology staff designed a database for retrospective data collection using linked case investigation records. MCH Epidemiology developed protocols and training with the Albuquerque Area Southwest Tribal Epidemiology Center (AASTEC) and Navajo Nation for retrospective data collection. The centers worked together to ascertain health status obtained through the CDC COVID-19 investigation pregnancy supplement and pending post-data collection IRB approvals with the Navajo Nation, the information will give New Mexico in-depth information about the birthing people of our state and their experiences with the pandemic.
During interactions with families contacted for positive case status, we heard time and again problems with access to prenatal care, misinformation about lactation, and many anecdotal conversations sparked concerns for Title V staff. We learned that some clinical practices were turning women away from prenatal care, and some people were going without care without telephonic or virtual appointment alternatives. Disparate treatment of birthing families at a major birthing Albuquerque delivery hospital corroborated ethical problems accentuated by the pandemic. Hospital staff reported to outside media sources that they had been directed to separated Native American newborns on the basis that they were more likely to be infected with COVID-19 than other populations. Outrage and confusion led to important development of guidelines and conversations to improve emergency preparedness for the perinatal population. Guidelines (October 2020) were released by Bold Futures, a New Mexico-based, reproductive justice organization in New Mexico created by women of color, for women of color. They recommended best practices of communication and consent for birthing patients with COVID-19, implementing a shared decision-making approach when discussing care, and giving an evidence-based discharge plan, including the conditions of their discharge from the healthcare facility (Bold Futures, 2020).
In the Spring of 2021, NMDOH was approached by the NM Doula Association with concerns about doulas not allowed in labor and delivery suites to support their clients with in-hospital births. As COVID infections decreased, some facilities had relaxed restrictions, but a few had not, leaving some families without evidence-based labor support. And as we approach a ravaged healthcare provider workforce for support, we are facing the probability of increasing cases, despite a 75% statewide vaccination rate. While balancing the concerns of overwhelmed birthing facilities with evidence supporting birth workers as essential staff (not visitors), NM Title V program staff have been seeking support from DOH leadership and the NM Perinatal Collaborative to address this concern persisting with rising cases in 2022.
Vaccination for pregnant and lactating people
Beyond ethical concerns about differential treatment and denial of care, we are now confronted with multiple, contradictory messages about vaccination against COVID-19 during pregnancy and for breastfeeding persons. Strengthening our communications and referral avenues with lactation specialists, we will continue to correct and redirect people in their questions about vaccination and breastfeeding. In coordination with maternal fetal medicine specialists and pediatricians, Title V staff led a media campaign to promote the safety of vaccination during pregnancy. This is a key equity and access component to assure that the most vulnerable members of NM are provided with the best care and safety.
MCH Population Health Status
New Mexico Maternal and Birthing Population
As in the national birth population, disparities for NM Black and Native American women drive key maternal and infant outcomes, and we have leveraged Title V to New Mexico infant mortality rates (IMR), while average for the US (5.8 per 1,000 live births), are about twice as high among non-Hispanic Black women compared to non-Hispanic white women and Asian women (10.9 v. 4.7, 3.9 deaths per 1,000 live births). The IMR for the same period is 6.0 per 1,000 for Hispanic women and 6.4 per 1,000 among Native American women, but the Hispanic count includes Native women who are also Hispanic (NM Vital Records and Health Statistics, 2015-2019, NM-IBIS).
The prevalence of low birthweight grew gradually from 8.5% in 2015 to 9.3% in 2019; birthweight by maternal ethnicity from 2015-2019 was 14.3, 10.8, 9.4, 8.4 and 8.1 percent among Black, Asian/PI, Hispanic, White and American Indian families, respectively. Statistical significance is marginal, but among smaller populations such as Black and Asian people in NM, the aggregation of data over many years indicates significant disparities to address through safe sleep education and other strategies.
NM maternal mortality and severe maternal morbidity rates exceed national averages (MMR 23.7 v 18.0 per 100,000 live births), and the subpopulation disparities are sharp. The relative risk of severe maternal morbidity (21 conditions, including transfusion) for Black women in 2018 was 25% higher compared to non-Hispanic white women. For Native American women, the rate was 60% higher than for Black women and twice as high compared to non-Hispanic white. Causes of death for pregnancy-associated cases and recommendations from the 2015-2019 review process indicate that motor vehicle accidents, overdose or substance use disorder, and mental health are the areas requiring the most attention and effort. The committee found that over 75% of maternal deaths occur in the postpartum period, and at least 80% of all deaths reviewed had some degree of preventability. A key recommendation, postpartum Medicaid extension was achieved in 2022, and the impact on maternal deaths and related morbidity will be monitored by Title V epidemiologists.
from the NM Perinatal Collaborative, Birth Equity Collaborative, Maternal Mortality Review and those working in community doula programs, birth centers, home visiting programs, hospitals and in federally qualified health centers, emphasized that mental health, perinatal mood disorders and substance use disorder were the highest priorities for investment in the perinatal population. NM has a rich midwifery, cultural and linguistic heritage. We are busting with scientists, traditional healers and community-based experts. Community survey input highlights the need to bolster the doula and health navigation cadre, case management and perinatal home visiting workforce.
Perinatal and Infant Health
While social determinants of health are not in our favor, we have influenced and observed positive trends. For example, NM breastfeeding rates have steadily risen at the population level and among women in different economic and ethnic strata. Breastfeeding duration to at least 9 weeks rose from 59.2% to 68.7% statewide (2010-2019). Among US-born Latinas, the rate increased from 54.2% to 64.9% and from 52.7% to 63.9% among Black women (2010-2014 v. 2016-2019),(NM PRAMS).
Substance Use Disorder (SUD) prevention and support (especially for mother/infant dyads), training for health providers, and coordinated care all emerged as significant priority areas and activities for the five-year needs assessment and planning. These themes came across in surveys, qualitative text analysis and in conversations with health providers. For calendar year 2020 the CARA team received 1105 plans of care. About 68% of those families had received care coordination through a Medicaid Managed Care Organization. Working with the NM Perinatal Collaborative, Title V staff have engaged in the planning and design of a Maternal Patient Safety Bundle to focus substance use identification and treatment for maternal and infant dyads in birthing facilities and postpartum care.
Sudden Unexpected Infant Death & Safe Sleep – SUID Prevention
Background- Definitions and program activities
Sudden Unexpected Infant Death (SUID) includes deaths of infants which are either unexplained after thorough case investigation (i.e., SIDS ICD-10 R-95, Unknown ICD-10 R99) or explained by Accidental Suffocation or Strangulation in Bed (ASSB) (ICD-10, W-75). All cases are reviewed in field investigation and by autopsy to assess sleep environment related risks and prevention factors. New Mexico joined the Centers for Disease Control and Prevention Sudden Unexpected Infant Death Registry in 2009, and in 2011, the NMDOH Office of Injury Prevention and MCH Epidemiology began formally planning and implementing safe sleep prevention plans.
SUID rates have trended at an average of between .8 and .9 per 1000 births between 2011-2020. Rates are about twice as high among male infants compared to female. By ethnicity, rates are 2.9 deaths per 1000 for Black or African American infants, 1.0 per 1000 among Native American infants and .8 per 1000 among Hispanic and non-Hispanic white babies (NMVR, NM-IBIS, 2011-2020).
Safe Sleep Interventions
NMDOH Title V and the Children, Youth and Families Department have offered webinar trainings for birthing hospitals, perinatal case management, midwifery and WIC nutrition programs since 2012. These trainings informed initial strategies to work with perinatal clinicians and hospital staff responsible for policy development and regulations at clinical or facility settings. We developed trainings in collaboration with Dr. Michael Goodstein, a nationally recognized neonatologist and board member of Cribs for Kids, who we later contracted to train New Mexico hospital staff in safe sleep hospital policy and procedure development (October 2014). Title V and Office of Injury Prevention work with UNM Prevention Research Center professionals to train hospital staff in American Academy of Pediatrics (AAP) safe sleep recommendations and to assess current practices.
The panel for the NM Sudden Unexpected Infant Death Registry is managed by the NM Office of the Medical Investigator. The panel is active and includes ongoing representation from OIP and Title V. Dr. Lori Proe, OMI Pathologist, led the death review panel with participation from lead field investigator, Rebecca Tarin. The team was rounded out by the NMDOH staff to develop recommendations for the annual child fatality review. Nicholas Sharp, the Title V MCH Epidemiologist/Evaluator, participated in the SUID panel and contributed to the recommendations for policy or program applications. He evaluated SUID registry data and developed a survey of NM birthing hospitals to assess their understanding and practice of the AAP Safe Sleep guidelines.
Statewide safe sleep development strategies
To promote coordinated efforts in safe sleep education, Title V staff drafted a statewide, multisector safe sleep strategic plan in 2019. Evaluator Nicholas Sharp drafted the plan, which was developed with input from the NMDOH tribal liaison, the Child Fatality Review SUID registry staff, Title V program and UNM partners. The NM Children’s Cabinet Executive Director, Mariana Padilla, was consulted for support in the implementation of the statewide plan, and cabinet secretaries from each state agency have convened to review the current activities and plans for interagency coordination.
The SUID panel drafted their 2020 prevention recommendations based on death review findings. Title V staff and OIP staff worked together to align title 5 strategies and objectives with the findings applied to the recommendations.
In 2020, MCH Epidemiology Title V staff worked with tribal partners through MCH coalitions and with a student from the College of Population Health at the University of New Mexico to review cultural competencies and articulation in the strategic plan development. With that assessment, a new draft of the strategic plan was released, and a quarterly planning group meets to discuss and act upon the recommendations and focus areas of the plan. In 2021, the participation expanded to include vital partners from the NM Breastfeeding Taskforce, the Indian Affairs Department, and Tribal WIC programs. An invitation is pending with the DOH Office of Community Health Workers, Office of African American Affairs and with community-based programs led by people of color.
Safe Sleep Campaign
In New Mexico, 8 out of 10 sleep-related sudden unexpected infant deaths were determined by Child Fatality Review to be preventable (2015-2020). To increase knowledge of sleep related SUID and safe sleep practices, NMDOH, UNM Early Childhood Services Center, and ECECD collaboratively developed informational rack cards in English and Spanish, which described safe sleep tips, as well as information for parents and caregivers to receive a free Safe Sleep Baby Kit (https://www.newmexicokids.org/ececd-safe-sleep-baby-kit/). The New Mexico Department of Health shared a press release in November of 2021 (https://www.nmhealth.org/news/awareness/2021/11/?view=1706); this press release was accompanied by a social media post which highlighted safe sleep practices.
To bring awareness about sleep related SUID and safe sleep practices on a broader scale, a public campaign was designed in 2021. The Safe Sleep NM Campaign is currently in development and will be the first public campaign in New Mexico to highlight safe sleep practices through broadcast and social media. The campaign will also direct the public to a new website which will be a resource for knowledge sharing about safe sleep practices and obtaining free safe sleep spaces such as travel bassinets, portable bassinets and pack and plays.
To better understand parent and caregiver perceptions about safe sleep in New Mexico, diverse focus groups are also being convened by the Prevention Research Center at UNM. This research seeks to answer the following research question: Why are some high-risk populations in New Mexico not practicing infant safe sleep behaviors?
The NM populations of interest include mothers of infants with a CARA plan of Safe Care, Black or African American and Indigenous mothers of infants, young mothers, immigrant/refugee mother, and mothers who are experiencing housing instability, as well as staff from homeless and domestic violence shelters. The UNM PRC will develop an overall project report with data summaries for each population described, as well as recommendations for increasing safe infant sleep best practices among diverse populations.
Birthing Options and Risk-Appropriate Care
New Mexico has a highly integrated midwifery workforce, which is an asset to birthing options and contributes to trust in delivery and maternity care for many consumers. Starting with a CDC survey to assess maternity and neonatal levels of care, NM Title V Maternal Health and Epidemiology staff observed a discordance in levels of care when comparing the CDC results and the self -assessment of those facilities. Results have led to the publication of a “key” to inform facilities and consumers of the appropriate neonatal care levels. With the closing of birthing Indian Health Service facilities in the last decade and some rural facilities recently, closer assessment of risk appropriate care is required.
Title V helps provide direct entry for licensed midwives and has worked with the Midwife Association to trouble shoot Medicaid reimbursement barriers. While many birthing people would not choose a home birth or may not qualify based on medical risks, a large percentage could choose birth centers or home births if they understood the benefits and accessibility.
Child health
New Mexico child health rankings (Annie E Casey Foundation, Kids Count Data Center) are consistently 49th or 50th among US states, and because some of the national indicators are based on poverty, food security and housing, the experience of adverse child experiences, and incarceration, it would take many generations to change this relative risk, compared to the nation. Some indicators are arguably less predictive of health outcomes than might be supposed. For example, a high proportion of NM children live in single-parent households, but those households are not assessed for quality of parenting, adjusted for income level, or related to health outcomes such as low birthweight.
Home visiting, Early Head Start, perinatal case management and health navigation support do help many families already. Strategies to support more families and to make options available were identified through the Preschool Development Grant and Title V assessment in 2020. These recommended strategies center on 1) Equitable, representative workforce development; 2) Quality and trauma-informed training and support; and 3) Cost studies and expanded reimbursement options.
Trauma and Understanding Adversity
Adverse Childhood Experiences (ACEs) are potentially traumatic experiences faced by children in their household or neighborhood, including abuse and neglect, divorce, substance abuse, domestic violence, mental illness, suicide, and bullying. New Mexico children experience higher rates of ACEs than the general U.S. population. In New Mexico 23.4% of children 0 to 17 years have experienced at least one ACE (2018-2019, National Survey of Child Health), and one in four NM children experienced two or more adverse experiences compared to 18.2% of children, nationwide. The PDG grant and the Title V stakeholders identified ACE and trauma as a key area of concern.
New Mexican children with special health care needs experience ACEs at significantly higher rates than children without. Almost half of NM Children and Youth with Special Health Care Needs (CYSHCN) experienced two or more ACEs compared to 20.4% of non-CYSHCN. Seventeen percent of CYSHCN experienced four or more ACEs compared to 5% of non-CYSHCN. Nineteen percent more CYSHCN in the state lived with someone who was mentally ill, suicidal, or severely depressed than non-CYSHCN, and 12% more CYSHCN than non-CYSHCN had lived with someone who had a problem with alcohol or drugs.
Medical Home
The National Survey of Children’s Health defines the medical home as having a personal doctor or nurse, usual sources for sick care, family-centered care, no problems getting needed referrals, and effective care coordination when needed. Among NM children who experienced 3 or more ACEs, 53% of children whose care meets MHM criteria hadn’t experience any ACEs, compared to 38% of those whose care didn’t meet the criteria. This is a significant concern for NM families, and we have observed in hospitalization data and outreach that many families whose children have asthma cannot access primary or specialty care enough to avoid Emergency Department visits. Evaluation of referrals to Children’s Medical Services (CMS) for these children suggests that ED visits could reduce by about half if they enroll in care coordination and connect with services close to home.
Children and Youth with Special Healthcare Needs
NM children and youth with special health care needs face greater risks for ACE, as described earlier, and they face many barriers to primary, specialty care and medical home as well. In New Mexico, 19% or nearly 94,000 children were identified as having a special health care need, about the same percentage as the nation. More CYSHCN face greater economic hardship; 21% of households with CYSHCN are considered working poor with parents who are employed but earn less than 100% of the federal poverty level compared to 14% of families with children not identified with special healthcare needs.
More CYSHCN families have health insurance and a place they usually get health care, but they also use more health care and face greater challenges getting referrals, specialist care and care coordination. The goals of the medical home model include health care that is family-centered, coordinated and gives access to a regular source of care, insurance and preventive, primary and specialty care. More NM CYSHCN have at least one health care provider and a place they usually get health care which is family centered. 97% of CYSHCN have health insurance but 61% are insured through public plans such as Medicaid and Indian Health Insurance as opposed to 47% of non-CYSHCN. However, parents of CYSHCN report encountering more barriers in key elements of the Medical Home than parents of non-CYSHCN. Over 31% reported having problems getting referrals to specialists than non-CYSHCN.
CYSCHN families also face difficulty with specialty or other healthcare including dental/oral health and mental health services. Compared to non-CYSCHN, families with children or youth with special healthcare needs were ineligible for services more than non-CYSHCN; faced greater difficulty finding health care in their geographic area; had more difficulty locating health care offices that were open when the child needed care; and faced greater difficulty getting both needed appointments and transportation.
Title V Program Partnerships, Collaboration, and Coordination
To encourage continuous data use and collaboration, Title V team members are designated to serve on working groups or participate in ongoing initiatives that address DOH priorities such as breastfeeding, family planning, teen pregnancy prevention, diabetes/obesity, and access to prenatal care and home visiting. Some of the following examples illustrate the data applications in those areas.
NM Perinatal Collaborative: Title V has been key to the development of a statewide perinatal collaborative (NMPC), which began in 2013. The first NMDOH collaborative innovation and improvement network (CoIIN) to analyze early elective deliveries (EED) occurred in the first couple years of the NMPC formation.
The perinatal collaborative leads a perinatal ECHO program to bring partnering hospitals together and provide technical assistance for the quality improvement work, such as the maternal hemorrhage safety bundle. The NMPC has been successful in getting 26 of the state’s 31 birthing hospitals to participate in this work. The ECHO was also used during the COVID response to train providers and hospital staff on recommended COVID practices and guidelines.
Prenatal Substance Use and NAS.
Substance use in pregnancy has been increasing sharply for the past decade, and NM has one of the highest rates of neonatal opioid withdrawal syndrome (NOWS) of any state in the nation. Some states have taken punitive approaches to substance use in pregnancy, which has not proven effective because it leads to more incarceration and family trauma, however NM is takings steps to ensure mothers and babies get the treatment and support they need. New Mexico has struggled with overdose and perinatal drug use for over 30 years, so while the opioid epidemic has exploded across the US, the substance and polysubstance use has only shifted in New Mexico.
Staff in CYFD and DOH have worked to implement CARA, traveling around the state and training hundreds of medical professionals, hospital employees, and care coordinators so they understand the intent of the law and what is required of them. CYFD is developing an online portal for submission of the plans, and CYFD, DOH and UNM are working together to develop online training modules.
Home Visiting
About 14% of the NM birth population participates in home visiting programs during pregnancy or postpartum (NM PRAMS 2018). This leaves a large unmet need as 86% of births/families are not being served. It is unclear how many of those want or need home visiting, but it is known from other research that many of these families could benefit from either home visiting or other support, such as a short-term postpartum “screening and connecting” service (i.e., Family Connects, an evidence-based program out of Durham NC or the home-grown version Great Start that operates in Santa Fe County).
In 2019 Medicaid agreed to conduct a pilot of Medicaid-financed home visiting as part of their 1115 waiver. This started on a very small scale using the Nurse Family Partnership model out of Bernalillo County and serving approximately 150 families.
Title X Family Planning and Effect long-term contraception/access to contraception: Title V programs work with Medicaid to monitor progress for the family planning waiver and the NM Family Planning Program to support funding and operational planning, and to assure statewide clinical and educational services. These data are also used extensively by the NM Medical Society/NMDOH Clinical Prevention Initiative (CPI) on unintended pregnancy to educate clinicians and to provide scientific support for a spectrum of contraceptive options.
New Mexico has long had high rates of unintended pregnancy (ranging from 40-50% of live births) and high teen fertility rates. PRAMS findings indicated that while some of these pregnancies were well planned, others resulted from inadequate choice and adequate of contraceptive methods. In 2016, a LARC working group comprised of diverse interested stakeholders was formed with some funding from the NM legislature. Title V provides ongoing evaluation of effective forms of postpartum and inter-conception birth control methods. Data helped identify locations in the state where a greater need and impact were expected through targeted provider training and reimbursement for LARC insertion and removal. PRAMS indicates that more effective contraception options are increasing, especially among younger women and that access to contraceptive choices has resulted in fewer mistimed or unwanted births.
Paid Family Leave and SDOH CoIIN
Title V programs identified paid family leave as a high priority for the Social Determinants of Health infant mortality collaborative improvement innovation network starting in 2017. Staff worked with a Paid Leave coalition to develop legislation for pregnancy worker accommodations and to study the economic impacts of paid parental and family leave in New Mexico. The pregnancy worker accommodation act passed in the 2019 legislature, and although the paid family leave legislation has not passed, NM Governor Michelle Lujan Grisham signed an executive order granting all state employees paid parental leave. As part of the Social Determinants of Health infant mortality collaborative, Title V contributes to policy and survey analysis on the conversation to advance paid leave options for New Mexico families, and the Paid Family Leave Coalition continues to meet monthly to plan for future legislative attempts.
A quarterly collaborative meets to assess progress on provider and hospital trainings, family behaviors and barriers to safe sleep across NM. An academic UNM School of Medicine and NMDOH Title V and Injury Prevention partnership works to provide trainings and to pull complementary program and surveillance data from those trainings. The new ECECD is now joining our collaborative as many of their programs provide safe sleep trainings as well. The plan is to coordinate all these various strands of the work to ensure consistent messaging across agencies with regards to safe sleep and breastfeeding.
References:
Bold Futures. (October 2020). “Perinatal Emergency Recommendations, Considering Disparities and Outcomes: COVID-19 and Beyond.” Retrieved from https://boldfuturesnm.org/wp-content/uploads/2020/10/Emergency-Recommendations-Presentation.pdf
Jade Begay. (March 13, 2020). “Decolonizing Community Care in Response to COVID-19.” Retrieved from https://ndncollective.org/indigenizing-and-decolonizing-community-care-in-response-to-covid-19/
National Survey of Children’s Health https://www.childhealthdata.org/browse/survey?r=33
New Mexico Pregnancy Risk Assessment Monitoring System https://ibis.health.state.nm.us/query/selection/prams/_PRAMSSelection.html
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