Maternal Health Application for FFY25

Priority: Promote high-quality maternal care with a focus on patient-centered and trauma-informed models

NPM - Percent of women who attended a postpartum checkup within 12 weeks after giving birth 

Objective 1. Improve awareness among providers and birthing families about Medicaid postpartum benefits extending to 12 months, postpartum

Strategy- Develop messaging for diverse audiences: patients, providers, health systems to bring awareness to the postpartum Medicaid benefit;

Strategy- Utilize DOH telephonic staffing to enhance and increase access to prenatal and postpartum care or support services

Activities:

• Promote the DOH health telephone line for prenatal and postpartum consumers
• Convene a Medicaid policy advisory group to assess barriers and advise on communications strategies
• Contract social worker staff to manage brief encounters and assessments with Medicaid prenatal and postpartum recipients

Strategy- Collaborate with NM Medicaid and community-based providers to optimize services, including mental health resources for a full postpartum year

Activities:

• Support prenatal navigation and postpartum follow up for women in diagnosed or at-risk for chronic health conditions including substance use disorders (SUD and OUD)
• Facilitate or finance clinical and birth worker trainings for maternal depression and anxiety screening and referrals
• Collaborate with health providers and community-based partners to provide training and ongoing technical assistance for OUD and MAT.

Title V community survey and key professional stakeholder input obtained prior to the onset of the COVID-19 pandemic identified mental health disorders, including substance use disorder (SUD), as the highest priority areas for NM families. The NM Maternal Mortality Review Committee has since completed an analysis covering 109 deaths that occurred between 2015- 2020 and found that 54% of all pregnancy-associated deaths had substance use as a contributing factor or primary cause of death. Forty-seven percent of deaths had other mental health conditions as a contributing factor. Another important consideration is timing of death, and according to this analysis, 83.5% of deaths occurred 43-365 days postpartum, and 59% of the deaths specifically determined to be pregnancy-related occurred in this timeframe. Consistent with Objective 2, a priority recommendation that emerged from this analysis is to increase access to screening and resources for treatment of perinatal mental health and SUD.

As highlighted in the community needs assessment, trauma-informed care remains a guiding framework for perinatal programs and clinical care teams to address mental health and lived experience by incorporating trauma-informed approaches to standardized screening, listening, and conversation into practice.

Objective 2. Increase access to perinatal care for women with the highest social, economic and/or medical need.

Our Maternal Health Plan objective to extend Medicaid benefits for a full year postpartum was achieved when this coverage went into effect on April 1, 2022. However, the existence of the coverage itself is insufficient to improve access to care, including postpartum and inter-conception behavioral health services. We know that awareness of this significant policy change is limited across the board, and at least one major health system is continuing to discharge patients from perinatal behavioral health programs after six weeks postpartum. Targeted communications are needed across health systems, providers and patients to ensure that everyone is aware of the change for the purpose of developing or modifying treatment plans. AIM maternal safety bundle implementation may provide a vehicle for educating hospital teams. However, new benefits packages may need to be developed, and perinatal care providers who provide intensive postpartum care under a bundled rate for pregnancy-related services will need for that bundled rate to better account for the balance of services paid before and after the end of the pregnancy.

New Mexicans experience chronic and pervasive barriers to perinatal care access. The rurality of New Mexico, along with persistent healthcare provider shortages, lead to challenges in accessing care for pregnant people regardless of risk level and insurance status. Disparities are observed by payer source and by maternal ethnicity. Among New Mexico births occurring in 2019-2021, 24% of Native American birthing people did not receive prenatal care as early as they wanted, compared to 14% of non-Hispanic white and Hispanic and 15% of Black birthing people. The reasons for late prenatal care varied across subpopulations: Women under twenty years were more likely to delay care because they did not know they were pregnant compared to women 35 years or older (65.2% v. 42.6%), and they were less likely to have problems getting an appointment 33.7% v. 45.6%). Younger women struggled more with transportation and having their Medicaid card to start care (NM PRAMS, 2019-2021 births). Overall, not being aware of the pregnancy and not getting an appointment when needed were the biggest barriers to earlier care.

Among those with Medicaid prenatal coverage and delayed care during pregnancy, 12.3% did not have transportation to healthcare settings (three times the proportion of women with private insurance). Thirty-nine percent (39%) of Medicaid recipients reported they could not get an appointment when they needed one, and 10% were waiting for their Medicaid card or proof of eligibility to initiate care. Although NM recognizes presumptive Medicaid eligibility for prenatal care, women report a disconnect that leads to difficulty scheduling prenatal appointments in their first trimester regardless of proof of coverage. It is concerning to note that over the three-year interval, 2019-2021, the inability to get an appointment is increasing (34.2% in 2019, 48.9% in 2020, and 52.7% in 2021). Overall lack of financial resources is also increasingly becoming an obstacle (10.1%, 2019, 12.3%, 2020, and 12.9%, 2021).

To fully address the objective of increasing access to perinatal care, we must ensure that we offer the full range of practice models and provider types that are trusted in New Mexico communities. This includes Licensed Midwives (LM) who provide community-based services in areas identified as maternity care deserts, or who may provide higher levels of culturally congruent care outside of institutional healthcare settings.

Recent research published by Bold Futures NM pointed to the importance of community midwives and the option to birth in a home or other community setting: TheBenefitsOfLicensedMidwiferyAndCommunityBirth-MAY2023.pdf

We will continue advancing two primary strategies to promote access to perinatal care over the remainder of the cycle:

1. Leverage the Perinatal High-Risk Fund (HRF) to address gaps in geographic distribution and service provider type.
2. Enhance uptake of, and increase access to, prenatal and postpartum care navigation.

Strategy -Leverage the Perinatal High-Risk Fund (HRF) to address gaps in geographic distribution and service provider type.

ESMs-

• Number of NM counties where HRF services are available
• Number of HRF sites that offer midwifery as either the primary model of care, or with midwives integrated into a multi-disciplinary care model.

We will evaluate our current network of contracts with clinical service providers that care for uninsured individuals through the HRF. The ongoing objectives of our evaluation approach are to identify the impact of the current distribution of funds in terms of individuals served, the types of services provided, and the geographic distribution of services. We have used this approach to identify opportunities to increase access to care through the development of contracts in geographic areas and with perinatal care providers that have the potential to address gaps in care and provide continuity of care for underserved birthing people.

For FFY25, the Maternal Health Program will maintain nine contracts statewide while we pilot service delivery with a new provider. Of the established contracts, three are held by the University of New Mexico Hospital to provide ambulatory, maternal-fetal medicine, and hospital-based services in the Albuquerque metro area to the largest concentration of individuals served through the HRF. Two additional contracts are held by federally qualified health centers (FQHCs) located in the northern and southern regions of the state. There are also two contracted imaging providers and a hospital-based laboratory service. Direct clinical services at these sites are provided by an array of providers that include obstetrician-gynecologists (including some with specialization in maternal fetal medicine), family medicine physicians, nurse practitioners, physician assistants, certified nurse-midwives (CNM) and Licensed Midwives (LM). These providers offer care at clinical sites that offer varying levels of accessibility, cultural congruency, and ancillary services, including care navigation.

We will continue the newest HRF contract with Changing Woman Initiative, an Indigenous-led non-profit organization that provides community and home-based birthing services for people and families residing in ten northern Pueblos, the Santa Fe and Albuquerque metro areas, and the eastern Navajo Nation. CWI’s White Shell Woman Homebirth Service is staffed by LMs and CNMs who honor traditional birthing practices and use plant medicines as appropriate and desired. CWI also provides home-based wrap around support for lactation, newborn care and perinatal nutrition in addition to serving as a training site for Indigenous student midwives.

The next planned HRF pilot contract will move forward in FFY25 with Vida Midwifery, another integrated midwifery practice (CNM and LMs practicing collaboratively). This pilot will return ambulatory perinatal services to a Public Health Office (PHO) located in Truth or Consequences in Sierra County, a county in south central New Mexico designated as a maternity care desert. The nearest birthing hospital to Truth or Consequences is approximately 71 miles heading north (Socorro General Hospital, a Critical Access Hospital), or 75 miles to the south (Las Cruces). Vida midwives, who also play a direct role in training the next generation of midwives, will staff a walk-in perinatal care clinic the PHO in order to determine the sort of service needs that exist in the community; these may include interest in home birth services, referral to specialized care for those who have high-risk clinical conditions, the desire for local prenatal and postpartum care for those who do plan to travel to an out-of-county hospital for birthing services, or the need for Spanish-language services.

We remain committed to expanding and diversifying the network of HRF providers through Title V Block Grant and the State Maternal Health Innovations grant. Successful implementation of the HRF strategy will allow us to continue to maintain a strategic array of contracts to reach the largest and most diverse number of individuals and demonstrate the impact of the HRF on birthing and maternal health outcomes.

Activities:

• Conduct site visits, confirm numbers and geographic area served, and evaluate services provided for each currently contracted site, including postpartum care.
• Conduct outreach to prospective contractors with the capacity to increase access in ways not currently addressed due to geographic location, ability to deliver mobile or community-based services, ability to deliver needed services that are not currently available, and cultural congruency with underserved New Mexico communities.
• Evaluate the midwifery public health office pilot project for inclusion in the next round of HRF contracts.

Strategy- Evaluate the Medicaid postpartum benefit utilization and cultivate equitable birthing options within the benefit

Activities:

• Promote opportunities to design a postpartum benefits package for community midwives under the Medicaid Birthing Options Program;                                    
• Invest in community-based maternal health services and leadership and raise public awareness about available birthing services in out of hospital birth center and home settings;
• Collaborate with the NM Medicaid program, academic partners and Tribal Epidemiology Centers to evaluate postpartum maternal and infant claims and surveillance data;

Objective 3. Improve Patient-Centered Care knowledge and practice with measurable, patient-reported results

NM Title V remains committed to taking on new ways of evaluating healthcare and the wellness of NM families. The COVID-19 pandemic reinforced the urgency of this task. Centering patients and honoring lived experience in healthcare is not yet standard in clinical interactions and may be new to many healthcare or perinatal service providers. In NM, community-based professionals such as midwives, doulas, home visitors, community health workers and community health representatives (CHRs) or promotoras de salud, demonstrate a depth of engagement with patient-centered principles, so we intentionally partner with leaders in those disciplines to optimize best practices and guidelines for centering patients in care.

Building on partnerships with experts in the field, we will continue to support the following strategies:

1. Work with community-based organizations and women with lived experience to define and support respectful maternity care in New Mexico. Consult with a broad spectrum of community leaders to define and model respectful maternity care;
2. Implement better measures of quality care in surveillance and program evaluation

Strategy- Elevate leadership from community-based organizations and women with lived experience to define and evaluate respectful maternity care in New Mexico.

On the national level, BIPOC-led organizations such as the National Birth Equity Collaborative and the Black Mamas Matter Alliance have established the case for formal guidance and accountability metrics informed by the experience of Black, Indigenous, and People of Color (BIPOC) birthing people. New Mexico based organizations such as Changing Woman Initiative and the NM perinatal policy coalition have contributed to this work and focused efforts on improving the experience and outcomes for New Mexico residents.

Activities:

• Continue consultation with Bold Futures, NM Doula Association, Changing Woman Initiative, Black Health New Mexico and other community partners with the goal of identifying and adapting guidelines on respectful maternity care for the endorsement of NM Department of Health.

• Pilot feasibility of a state maternity care hotline and advertise availability of consultation for people seeking or experiencing maternity care at delivery and in the perinatal period.
• Work with perinatal and reproductive health experts to raise awareness of birthing options offered through licensed midwifery support and out of hospital settings.
• Convene a statewide maternal taskforce to make decisions about policy and practice, communications and data dissemination.

Strategy- Increase the number and quality of patient-centered and maternity care metrics in DOH or partnering surveillance systems  

ESM- Number of questions on the NM PRAMS survey that address patient experience

A critical component of promoting accessible, quality and trauma-informed care is improving NMDOH population data collection and reporting to better represent the experience of birthing people.  One way we propose to do that is through revision of the PRAMS survey. Formal survey revision research began with some literature and national PRAMS survey review for ACE-related, stress/hardship and strength-based measures already validated or in the field in other jurisdictions. NMDOH and Title V staff have also received valuable input that can help us improve the way we measure quality of care and experience of life events that have bearing on health outcomes.

We will enhance PRAMS survey supplements or follow up surveys to address the following areas:

• who or what factors supported and sustained birthing people in their prenatal and birthing experiences
• what went well or what did not go well in healthcare before, during and after pregnancy
• how much respect and care birthing people experienced in their healthcare in the perinatal period
• whether or not maternity care providers perpetrated obstetric violence

Knowing more about the composition of the maternity care team and delivery experience will help Title V staff and partners communicate information to make improvements in health systems and policy arenas.

Activities: Using maternal health task force, PRAMS Steering Committee, Tribal PRAMS and Title V input, we will continue to address priority changes for the 2025 birth data collection. Because NM PRAMS includes all tribes and coordination with two Tribal Epidemiology Centers, we will continue collaboration with those centers to include input from tribal representation and tribe-serving organizations.

Specific activities will include:

• Partner with Black Health NM to enhance PRAMS surveillance with qualitative follow back interviews
• With Tribal PRAMS and Dine College MCH Collaborative colleagues, design and follow back survey to measure respectful care and obstetric violence prevalence
• Work with Medicaid and a maternal health taskforce to define and prioritize key indicators of birthing friendly hospitals.