Needs Assessment Update- FFY 2023

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 outpatient restrictions brought on more concerns about new and aggravated barriers to care, especially for pregnant and birthing people (Bold Futures, 2020). Title V staff developed protocols to support all families with COVD-19 infection and worked with community and clinical partners to help meet their needs during the public health emergency. These protocols and referral systems are now adaptable to other public health concerns, and for perinatal and special health care populations, these supports are just as important now as they were during the pandemic.

Emerging MCH Concerns and Opportunities

Congenital Syphilis- Rapidly increasing and impacting all NM birthing communities, congenital syphilis is a national and state crisis, disproportionately experienced among Native American tribes. In NM 2021-2022, the rate of congenital syphilis among America Indian women was five per 1,000 live births while among all others it ranged from .7 to 1 per 1,000 live births.

Table of congenital syphilis counts by year, NM 2018-2023

Table of congenital syphilis rates per 1,000 live  births by ethnicity, NM 2021-2022

Title V staff engage with families at risk for syphilis and other infectious diseases, and they promote health advisory network communications and education for health providers practicing in hospital and out-patient care.

Youth mental health, suicide and violence- The 2020 needs assessment clearly identified mental and behavioral health for adolescents a priority area, and the post-pandemic mental health for youth in New Mexico continues to be a pressing concern. The NM YRRS reported that 32.1% of NM youth reported frequent mental distress, and 18.6% of youth had seriously considered suicide. Twenty percent were in a physical fight in the previous seven days, and 7.6% reported binge drinking, a 3.5-fold reduction from 2011 (2021 NMYRRS).

Perinatal mood disorders, behavioral and socioeconomic health- Also identified as a priority in the 5-year needs assessment, perinatal mood disorders are experienced by 12.4% of women in the postpartum period, and there has been no observed change in this prevalence since 2016 (NM PRAMS, 2022 births). This is a key indicator for Medicaid and behavioral health interventions, especially as we seek to understand the impact of the 12-month postpartum Medicaid benefit in NM.

These areas are described in the narrative plans and objectives by population domain in the annual submission which further outline the following concerns:

• Medicaid reimbursement challenges for licensed midwives and doulas
• Limited, dedicated funding for perinatal substance treatment and in-patient care
• Maternity low access areas and deserts
• Postpartum Medicaid benefit awareness and redetermination for children

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 health outcomes in NM. New Mexico infant mortality rates (IMR), while average for the US (5.4 per 1,000 live births, 2021), are three times as high among non-Hispanic Black women compared to non-Hispanic white women (12.7 v. 4.1 deaths per 1,000 live births). The IMR for the same period was 5.8 deaths per 1,000 for Hispanic women and 5.5 per 1,000 among Asian American women (NM Vital Records and Health Statistics, 2018-2021, NM-IBIS).

Causes of pregnancy-associated deaths (all deaths occurring during pregnancy or within 365 days of pregnancy) and recommendations from the 2015-2020 maternal mortality review committee (MMRC) findings indicate that substance use disorder and mental health are the areas requiring the most attention and effort for prevention.  The MMRC determined that mental health was a contributing factor in 47% of pregnancy-associated deaths while substance use was a contributing factor in 54% of pregnancy-associated deaths.  Starting with the review 2018 deaths, discrimination was formally considered as a possible contributing factor in pregnancy-associated deaths.  The committee determined that discrimination contributed to 37% of deaths occurring between 2018-2020.  The committee also found that over 83% of maternal deaths occurred in the postpartum period, and at least 83% of all deaths reviewed had some degree of preventability. The MMRC concluded that 40% of deaths were pregnancy related, which means the cause of death was directly attributed to pregnancy or a chain of events beginning in pregnancy which led to the death.

Recommendations and opportunities to improve maternal outcomes

A key MMRC recommendation, postpartum Medicaid extension, was achieved in 2022, and the impact on maternal deaths and related morbidity will be monitored by Title V epidemiologists. However, despite data sharing and consultation with state agencies, community partners and clinicians, NM struggles to address gaps in mental health care access, disjointed care coordination and many factors related to distance to care; fear in seeking needed care or inter-personal violence and social determinants of health impeding support for pregnant and postpartum individuals.

While the CDC Preventing Maternal Deaths or ERASE-MM grant does not fund prevention activities, it does support the foundational work of case review and recommendation making which will inform efforts for change. Just at the end of the Title V reporting period, NM received its first Maternal Health Innovations grant, a 5-year cooperative agreement with the Health Resources and Services Administration (HRSA). This provides a significant opportunity to convene subject matter experts of all backgrounds to strategize and prioritize actions based on the findings of the MMRC among many other data sources.

Birthing Options Assets 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 2016 CDC survey to assess maternity and neonatal levels of care, NM Title V Maternal Health MCH 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” and an inaugural report of findings https://www.nmhealth.org/data/view/report/2156/ to inform facilities and consumers of the established levels of maternal and neonatal care. With the closing of three birthing facilities in the last three years, closer assessment of risk-appropriate care is required.

Title V provides direct entry for licensed midwives and has worked with the NM 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 many might choose birth centers or home births if they were aware of the benefits and accessibility. Title V seeks to raise awareness and collaborate with reproductive health leaders to support opportunities to expand and enhance midwifery-led care.

Perinatal and Infant Health Strengths

NM has a rich midwifery, birthing-friendly culture and linguistic heritage. We are busting with scientific innovation, traditional healers and community-based experts. The 2020 community survey input highlighted the strengths and reinforced the need to sustain the doula, community health worker, perinatal health navigation, and perinatal home visiting workforce. While social determinants of health are not in our favor, we have influenced and observed positive trends under community-based and culturally knowledgeable leadership.

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 70.2% statewide from 2010 to 2021. Among Hispanic/Latinas, the rate increased from 57.3% from 65.3%, from 52.7% to 67.3% among Black/African American women, and from to 64.1% to 65.8% for Native American women (2010-2014 v. 2018-2021)(NM PRAMS). These improvements are not natural. They are the result of continuous resourced state and non-governmental partnerships which center home-grown strategies and innovations among Latinx and Indigenous birth equity leaders. Breastfeeding is one of the most yielding investments in health over the life-course, and in New Mexico, while the 2020 needs assessment did not identify breastfeeding in the prioritization process, Title V continues to recognize the indisputable evidence and value in breastfeeding promotion. With complementary funding, the program collaborates and finances breastfeeding media campaigns, peer counseling and data dissemination to improve breastfeeding across New Mexico.

Doula services and Medicaid reimbursement packages have been developing over the last two years with significant support and resourcing from Title V programs. Doulas serve an estimated 20% of the NM birth population, and among the Medicaid population where birthing options and specialized perinatal support has been less accessible, Medicaid reimbursement both expands and sustains a workforce able to support families who were left out from these benefits in the past.

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 and Violence Prevention and the MCH Epidemiology program began formulating safe sleep prevention strategies. 

SUID rates have trended at an average of .9 per 1,000 live births annually since 2012, constituting the leading cause of post-neonatal death in the U.S. and in NM. Rates are about twice as high among male infants compared to female. By ethnicity, rates were 3.8 deaths per 1,000 for Black or African American infants, 1.3 per 1,000 among Native American infants and .9 per 1000 among both Hispanic and non-Hispanic white babies (NMVR, NM-IBIS, 2015-2021).  

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.

The panel for the NM Sudden Unexpected Infant Death Registry panel is managed by the DOH Office of Injury and Violence Prevention with cooperation from Title V, MCH Epidemiology. The panel includes ongoing representation from clinical, academic and community representatives. While the CDC SUID registry no longer funds the NM death review or prevention activities, the interagency safe sleep working groups contribute to the review process policy applications and safe sleep communications strategies.

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 2017 updated in 2019 with a 2020-2024 Safe Sleep Interagency Work Group (SSIW) planning document. Evaluator Nicholas Sharp presented the 2019 plan to DOH leadership, which was then 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 convened to review the proposed activities and plans for interagency coordination.

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.

Safe Sleep Campaign 

In New Mexico, 8 out of 10 sleep-related sudden unexpected infant deaths (SUIDs) 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/). In partnership with the University of New Mexico and state Early Education and Care Department, DOH sponsors a hospital safe sleep training series for birthing hospital staff https://cpl.health.unm.edu/content/infant-safe-sleep#group-tabs-node-course-default1

To bring continued awareness about sleep related SUID and safe sleep practices on a broader scale, a public campaign was designed in 2021 with communication plans through 2026. The New Mexico Department of Health shared a press release outlining safe sleep campaign efforts in August 2023 Keeplovedonessafe.); this press release was accompanied by a social media post which highlighted safe sleep practices. 

The Safe Sleep NM Campaign is 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. A new website was launched in 2022 https://www.safesleepnm.org/ ,and a slew of media outlets are sharing safe sleep tips. Billboards and podcasts are underway and plans for 2024 build on these efforts.

Child and Adolescent 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 perinatal health outcomes or stressful experience such as delivering an infant who is preterm or low birthweight.  

Adverse Childhood Experiences (ACEs) are potentially traumatic experiences faced by children in their household or neighborhood, including abuse and neglect, divorce, parental substance abuse, domestic violence, mental illness, suicide, and bullying. New Mexico children experience higher rates of ACEs than children from the general U.S. population.  In New Mexico 21.4% of children 0 to 17 years have experienced at least one ACE (2021-2022, National Survey of Child Health), and 27.3% of NM children experienced two or more adverse experiences compared to 17.4% of children, nationwide.

New Mexico children with special health care needs experience ACEs at significantly higher rates than children without. Almost half (48%) of NM Children and Youth ages 0-17 years with Special Health Care Needs (CYSHCN) experienced two or more ACEs compared to 22% of non-CYSHCN. The rate for CYSHCN who lived with someone who was mentally ill, suicidal, or severely depressed was 3.5 times more than for non-CYSHCN, and 2.5 times more CYSHCN than non-CYSHCN 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. Just 30% of CYSHCN have a medical home compared to 42% of other children (NSCH, 2021-2022). This is a significant concern for NM families, and we have observed in hospitalization analysis 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 all children suggests that ED visits could drop by about one-half if families enrolled in care coordination and connected with primary care services.

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, 20% or over 94,000 children were identified as having a special health care need, about the same percentage as in 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 (medical home), but they also use more health care services and face greater challenges getting referrals, specialist care and overall 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. Most (91%) of CYSHCN have consistent health insurance, and 60% are insured through public plans such as Medicaid and Indian Health Services as opposed as well as 53% of non-CYSHCN. Nearly 8% of non-special healthcare kids were uninsured while 6% of CYSHN were uninsured.

Parents of CYSHCN report encountering more barriers in key elements of the Medical Home than parents of 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 and IPH ECHO:  Title V was key to the development of a statewide perinatal collaborative (NMPC), which launched 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. Shaken Baby Syndrome was also identified for prevention, and with broad input, neonatal abstinence syndrome (NAS) took shape as a multi-sector prevention effort. Unfortunately, the ensuing leadership slowly prioritized and finally only engaged hospital-based clinical providers without participation from community-based birth workers or public health professionals, and the organization now struggles to exist. Critics across the state called for and supported a complete reseating of board members in 2023-2024, and while the NMPC garnered a significant grant from the Centers for Disease Control and Prevention, their staffing does not support large-scale quality improvement initiatives. It is unclear if the organization will persist as a non-profit or if its work will merge with an academic or public health entity to resume strategic planning and quality improvement.

During the reporting period, Title V participated in the leadership of the Improving perinatal Health IPH ECHO program to bring partnering hospitals together and provide expert consultation and education to advance the care of people experiencing perinatal mood disorders or anxiety, hypertension or substance use disorder. The IPH serves as a hub for hospitals and outpatient centers engaged in or planning to implement quality improvement work, such as the AIM maternal hemorrhage, hypertension or OUD maternal safety bundles. Leadership of the IPH ECHO is diverse and includes broad array of health and social work professionals working in different settings.  

Title V staff have engaged in the planning and allocation of opioid settlement funding to support trainings for health providers caring for people experiencing substance use disorder in the perinatal period. Two trainings were delivered in Gallup and Santa Fe NM, and future trainings are planned for the southern part of the state in 2024. These trainings are delivered through the collaboration of the NM Perinatal Collaborative, University of New Mexico, Indian Health Services, Department of Health and providers working in federally qualified health centers across New Mexico.

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) or neonatal abstinence syndrome (NAS) of any state in the nation.  Some states have taken punitive approaches to substance use in pregnancy; however, NM continues taking 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 U.S., the substance and polysubstance use has only shifted in New Mexico. The IPH ECHO continues to support dialogue and education for providers serving families with a variety of substance use challenges.

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 2023, there were 1039 plans of care reported to state agencies responsible for supporting families identified through CARA at delivery. While Title V staff only care for a segment of the population receiving specialized healthcare services or who are uninsured, they are deeply engaged in the policy of CARA and coordinate with other state agencies to ensure continuity of care for families experiencing addiction, have an infant who was exposed to a substance during pregnancy or who have other social or healthcare needs.

Title V staff facilitate navigation and harm reduction and safety supports for families struggling with SUD and newborns with substance exposure.  This includes assuring that parents have access to locking medication boxes and bags, along with safe sleep units such as bassinets, cribs or pack-n-plays/play-yards.

Home Visiting

An estimated 14% of the NM birth population participates in home visiting programs during pregnancy or postpartum (NM PRAMS 2021). This leaves a large unmet need as many more 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). The NM Family Connects program launched in 2022 beginning with one birthing facility in Albuquerque, NM and plans to expand in McKinley County with a community readiness assessment in process.

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.   Community Health Workers are now also covered for reimbursement of services under the 1115 waiver, and their workforce is receiving specialized perinatal and indigenous health trainings and continuing education under the CHW and MCH ECHO programs.

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 (averaging 44% of live births, 2020-2022) and high teen fertility rates. PRAMS findings indicated that while some of these pregnancies were intended when they occurred, others resulted from an inadequate choice of contraceptive methods.  In 2016, a LARC working group comprised of diverse interested stakeholders was formed with funding from the NM legislature. Title V provides ongoing evaluation of effective forms of postpartum and inter-conception birth control methods. Public health 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 contributed 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. Title V has provided surveillance and population level analysis to support the expansion of paid family leave, and the efforts will continue under the planning period in 2025.

Surveillance Enhancements and needs assessment methods

Tribal PRAMS and the toddler survey HUGS supplement to PRAMS have been running since 2016, and the Title V program coordinates community assessments with NGOs including Growing Up New Mexico, Ole, Southwest Organizing Project, University of New Mexico College of Population Health, the NM Public Health Association, the Alliance of Community Health Councils, the Dine College MCH Collaborative and many others.

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

Propublica: https://www.propublica.org/article/federal-investigation-finds-hospital-violated-patients-rights-by-profiling-separating-native-mothers-and-newborns

https://www.propublica.org/article/a-hospitals-secret-coronavirus-policy-separated-native-american-mothers-from-their-newborns

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