System of Care for Mothers, Children, and Families

The Maternal Child Health (MCH) system in New Mexico includes numerous public health organizations, healthcare providers, tribal and community organizations, advocates, and families who collaborate to promote statewide health for mothers, children, and adolescents, and their families. The New Mexico Title V program plays a central role in directing this system toward identifying new requirements, prioritizing data, and facilitating cross-sector partnerships to improve outcomes for the state's most vulnerable populations.

Public Health Infrastructure and System Strengths

Through its partnership with the Title V Program, the New Mexico Department of Health (NMDOH) offers statewide support for the MCH population. This support includes newborn screening and referrals to partnering early intervention and home visiting programs, school-based health services, children’s medical services (CMS), and preventive care services for women, children, and adolescents. Public health and community-based organizations in New Mexico have provide programs and expertise in areas including safety net services for prenatal clients, breastfeeding and nutritional support, midwifery-led care, substance use recovery, perinatal mental health, behavioral health services, and culturally responsive care.

The Title V program partners with the Healthy Start programs, with lactation specialists and clinicians in the New Mexico Breastfeeding Task Force, the New Mexico Doula Association and Tribal doula programs, Project ECHO at the University of New Mexico, Office of Community Health Workers, the Community Health Representative Association, professional medical associations, and academic partners like the University of New Mexico and New Mexico State University, and public health authorities, including Medicaid at the Health Care Authority and the Navajo Department of Health, as well as the Albuquerque Area Indian Health Board (AAIHB). Through their involvement with the New Mexico Statewide Maternal Health Task Force, Family Voices, Family Leaders and other initiatives, these organizations have raised community voices and built the system's capacity to address disparities entrenched by geography and socioeconomic status.

Needs Assessment and Community Engagement

Between September 2024 and June 2025, the Title V program conducted an extensive needs assessment to evaluate the current system of care and determine key priorities for the upcoming five years. The needs assessment process utilized extensive community involvement through statewide events organized by the Maternal Health Task Force, combined with CMS Summit annual meetings and meetings of the ECECD Advisory Council, also in collaboration with focused tribal health councils and culturally specific organizations. These activities presented initial results alongside structured discussions and qualitative data collection from families, providers, and advocates. The MCH Community Health Survey, which was distributed throughout the state, revealed information about community experiences and service gaps affecting vulnerable populations.

Identified Strengths and Gaps in the System

The New Mexico care system shows several positive aspects through its dedication to cultural sensitivity, its rural and tribal alliances, and its innovative programs, such as Project ECHO's Midwifery and family-to-family care coordination models. Community-based doulas, home visitors, and midwives provide essential support to areas that lack other forms of healthcare access.

However, gaps persist. According to data from the MMRC and community input, disparities in maternal mortality and morbidity persist, particularly affecting American Indian, Black/African-American women, as well as Medicaid recipients, older women, and residents of rural areas. The review committee identified discrimination, including racism as a key barrier to maternal wellness. The state recorded most pregnancy-related fatalities as preventable, and mental health problems and substance use disorders composed risk factors for many of these preventable deaths. Primary and secondary data revealed three primary gaps in services, including postpartum care extension before 2022, perinatal mental health assistance, and the coordinated provision of services and assistance to families affected by substance use disorder as an integral component of comprehensive support networks. 

Children and youth face multiple challenges, including insufficient behavioral health services, particularly for adolescents, as well as difficulties accessing preventive oral health and immunizations and inadequate care coordination for children with special health care needs (CYSHCN). Behavioral health and specialty care provider shortages make systems of care very difficult for families of children, and especially for those who are medically fragile or have complex medical needs. Delays in care are mitigated by more utilization and expansion of telehealth models, but some parents express hesitation to use virtual visits. Others do not have consistent access to internet or devices which make telehealth comfortable or private.

Medicaid finances almost half of the NM population, and for the birth population, between 55% and 62% are covered by Medicaid. This presents both structural challenges and opportunities to streamline solutions. Over 80% of pregnancy-associated deaths were among people covered by Medicaid, and a key recommendation was to extend pregnancy-related Medicaid to 12 months, postpartum. Evaluation efforts are underway to measure the impact of this crucial expansion. Quality improvement initiatives have been slow to fund in NM, but with the support of private foundations, Medicaid and NMDOH, there is a new accountability and renewed effort to support this work, starting in the maternal and perinatal populations, and expanding across child and youth populations.

Several studies indicate that New Mexico’s maternal healthcare landscape will be more desperate and unable to meet the needs of women as resources shrink and hospitals or birthing centers are more challenged to retain skilled professionals. The March of Dimes estimates that:

• In New Mexico, there were 693 babies born in maternity care ‘deserts’, 3.2%of all births.

• 24.9% of babies were born to women who live in rural counties, while 12.9%  maternity care providers practice in rural counties in New Mexico.

• In New Mexico, women travel 14.3 miles and 19.0 minutes, on average, to their nearest birthing hospital.

• Women living in counties with the highest travel times (top 20 percent) could travel up to 97.1 miles and 109.1 minutes, on average, to reach their nearest birthing hospital.

The March of Dimes (Maternity Care Report, 2023) findings are important, and they are partly responsive to solutions for health systems, however, the MOD definitions which now include CNM and family providers, not just OB providers, do not account for licensed/direct entry midwives which are increasing capacity and reach across the state. Furthermore, while the distance traveled to deliver a baby is important, it does not measure the distance to available prenatal and postpartum care. Title V addresses this information gap through the needs assessment community health survey and is working to incorporate these measures and others in population surveillance over the next five years.

Addressing the Needs of Medically Vulnerable Populations

Through its focus on health equity, the Title V program conducts program and population assessments and plans with the voices of underserved populations as its foundation. Spanish-speaking organizations, rural families, tribal communities, and youth maintain continuous engagement throughout the assessment process. Title V focuses its efforts on populations facing the highest risk of poor health outcomes, including those living in poverty, facing unstable housing, or experiencing systemic discrimination. Through Title V funding programs and home visiting initiatives, the system delivers essential care while addressing the social determinants of health.

Medically fragile children in New Mexico can face many difficulties and sometimes tragic situations when families are under-insured or have arrived in the state without extended family or social support systems. In several areas of the state, industry promotes migration across county lines, and some families move to find housing or temporary shelter where it exists. Families without a medical home, those without consistent access to utilities, food or employment need advocacy and care coordination which exceeds that required for those with stable household incomes and medical coverage.

Children’s Medical Services (CMS) is the principal source of support for medically complex children, and they work in every county of the state to coordinate clinical and social services for families across the spectrum, from infancy to adult transition. Family Voices and Navajo Family Voices provide local, community-based support to families with special needs children, and they center equity in their service and family leadership models.

Title V provides clinical enabling services throughout the state for under-insured women for prenatal care, preventive testing and screening, and postpartum follow up through seven to ten provider agreements each year. These sites have incorporated midwifery practice and are piloting midwifery perinatal services through one NMDOH public health office in an under-served area. 

The Role of Title V in Driving Systems Change

The MCH system benefits from Title V leadership as a convening force that integrates different sectors and addresses many levels of care. The program achieves its goals by supporting interagency partnerships and developing evidence-based strategies and local and national data analyses to address key MCH issues, including maternal morbidity and mortality, stillbirth and infant mortality, prenatal and postpartum care, newborn screening, preventive care for children and adolescents, behavioral and mental health, injury prevention, and substance use. The program also supports innovative workforce development strategies, care coordination, and family engagement initiatives.

Title V sponsors family leaders, convenes policy advisory councils and promotes cross-sector collective impact work in all population domains. Youth leaders and family councils guide policy making and program implementation for adolescent programs. Their participation through Title V ensures that decisions and investments reflect their priorities and center their solutions.

This integrated care system, which includes the Title V program and an extensive network of dedicated partners, enables New Mexico to create a future that provides high-quality, equitable, culturally-responsive care for mothers, children, and their families.