Maternal Health Plan for FY22

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

NPM 1 - Percent of women, ages 18 through 44, with a preventive medical visit in the past year

Objective 1. Increase access to perinatal care for women with the highest social, economic and/or medical need.

A critical resource for improving maternal health and establishing access to ongoing primary care is equitable access to healthcare in the perinatal period. Title V 2020 community survey input (n=262) highlighted several barriers to care for prenatal, postpartum and behavioral/mental health services, including challenges paying for and having to travel long distances for care. NM PRAMS (Pregnancy Risk Assessment Monitoring System) findings also demonstrate that women of color and low-income women disproportionately experience problems obtaining perinatal and mental health care. Statistical details are integrated into the narrative below.

We have identified two strategy areas to address these gaps during the current 5-year cycle:

1. Medicaid expansion in the postpartum period
2. Consumer navigation for perinatal care and services

Strategy 1. Extend Medicaid coverage to 12 months postpartum by 2024.

ESM: Number of analyses, technical briefs or media products developed in support of Medicaid Expansion by 2022

Medicaid finances approximately 71% of NM deliveries (2019, Medicaid*) which covers prenatal services, birth, and the early postpartum period, but ~12% of postpartum individuals report not having any form of insurance coverage as early as 10 weeks after their baby is born. The NM maternal mortality review from 2015-2017 (n=58) revealed that 59% of deaths occur between 43 days and up to one year, postpartum.  Among all pregnancy-associated cases, substance use contributed to just under half of all deaths, and mental health conditions (suicide, depression) related to the highest number of deaths (20%) after motor vehicle crashes (30%). About 76% of NM maternal deaths occurred in the postpartum period, and many were after 100 days. With 2018 deaths, we do not expect this pattern to change, and in 2021 we will complete the 2019 death reviews. Our recommendation trajectory to expand Medicaid postpartum is not likely to change.

Many women have no or limited access to mental health services or primary healthcare between the time their Medicaid coverage ends at 60 days postpartum and the time many of these deaths occur. Therefore, we are missing important opportunities to extend reimbursable services to screen and treat families struggling with depression, violence, drug misuse, or other underlying chronic conditions.

With extended pregnancy coverage, we estimate that an additional 2,600 otherwise uninsured women per year will retain insurance coverage after 60 days postpartum, when standard pregnancy-related coverage ends (NM PRAMS).  Another ~6,500 could benefit from wrap-around coverage, beyond family planning or limited coverage for certain conditions.

Activities: In year 2 of our 5-year activity plan we will continue to engage with the NM Breastfeeding Task Force, the NM Perinatal Collaborative, the NM Doula Association, the Early Childhood Education and Care Department, NM Medicaid, and other key stakeholders representing impacted communities to promote the evidence and recommendations presented in our technical brief on the economic impact and feasibility of Medicaid expansion (an activity completed according to our plan for year 1).

In next year’s FY21 report, we will share the activities that took place between October 2020 and September 2021, but we did meet our goal to complete a technical brief, which was shared with internal and work group members in October 2020 but published online in December 2021. A copy is included in the supporting document attachments.

Strategy 2. Enhance uptake of, and increase access to, prenatal and postpartum care navigation

For women with chronic conditions, late or inadequate prenatal care can have serious adverse impacts on pregnancy and long-term health status. It is difficult to overstate the impact of the COVID-19 pandemic on access to care, but New Mexicans also experience pervasive barriers to care. The rurality of New Mexico, along with persistent healthcare provider shortages, lead to challenges in accessing care for pregnant people regardless of insurance status. However, disparities are observed by payer source and ethnicity. Among all NM women with births occurring in 2017-2019, 23% of Black and Native American women did not receive prenatal care as early as they wanted, compared to 13% of non-Hispanic white and Hispanic women. The reasons for late prenatal care vary across subpopulations, but for Native American women, 15% said their care was delayed because they did not have transportation, and 13% said they could not get enough time off from work.

Among women with Medicaid coverage and delayed care during pregnancy, 12% did not have transportation to healthcare settings (three times the proportion of women with private coverage). Thirty percent (30%) of Medicaid recipients reported they could not get an appointment when they needed one, and 13% 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. Anecdotal

These systemic barriers require multifaceted policy solutions. Some existing resources may be underutilized or underdeveloped, and disparities can be significantly ameliorated through access to care navigation, For Medicaid-eligible families, navigation can be facilitated by case managers and peer support workers in the Medicaid Managed Care Organizations (MCO) and the nurses in the Families FIRST program, now housed within ECECD. Home visiting programs statewide are another critical resource. 

Title V staff have developed a specialized role in providing support and care navigation for birthing families identified through the (Comprehensive Addiction and Recovery Act (CARA) plan-of-care process. That role has expanded during the COVID-19 pandemic to cover another distinct population of families requiring care navigation and advocacy, those with a positive COVID-19 diagnosis during pregnancy.

Prior to the COVID-19 pandemic, we aimed to establish a universal Medicaid-enrolled method for identifying women with gestational diabetes, pre-existing diabetes, or hypertension, and we planned to utilize pregnancy participation summaries from Medicaid and WIC, the special supplemental nutrition program for women and children, to support families in the prenatal and early postpartum periods.

Planned efforts shifted quickly in response to COVID-19 environment and the clear impact of the pandemic on birthing families. Our Title V staff and partners developed protocols rapidly to ensure that pregnant and postpartum or lactating 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. 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 a modified PRAMS COVID supplement and the CDC pregnancy supplement, MCH Epidemiology staff designed a database in REDCap for retrospective data collection using linked case investigation and birth certificate records. MCH Epidemiology developed protocols and training with the Albuquerque Area Southwest Tribal Epidemiology Center (AASTEC) and Navajo Nation for retrospective data collection.

Our plan for the coming year includes pursuing this data collection, which is expected to take at least six months before data are shared. It is also clear that we must continue to develop and refine the efforts inspired by the pandemic to provide monitoring and navigation services for families impacted by COVID-19 infections. Beyond the navigation, Title V staff have been instrumental in helping the DOH, state affiliates of the clinical professional societies, and the NM Perinatal Collaborative identify the need to reinforce guidance from the CDC and NM DOH on critical topics such as breastfeeding, vaccination, quarantine, and timelines for return to in-person care for individuals who have COVID-19 exposure or infection. Title V staff experience with impacted families has revealed inconsistent observance of CDC and NM DOH guidance on these topics in clinical settings. Insights gained from direct service are used to resolve issues at the individual and practice level, and they also inform training and updates provided to perinatal care providers via educational vehicles such as the NM Perinatal Collaborative’s Improving Perinatal Health Extension for Community Healthcare Outcomes (ECHO) program.

Postpartum support for families with CARA plans of care resulting from perinatal substance use is addressed more fully in the Perinatal Health Plan Narrative. However, it is critical to NM’s progress on access to care that we leverage the opportunity provided by CARA to prioritize advocacy for birthing parents to be connected to the substance use treatment, mental health, and primary care services that can facilitate recovery and promote health.

Activities:

• Provide or support prenatal navigation and postpartum follow up for women in key geographic areas, diagnosed or at risk for COVID-19 or chronic health conditions including substance use disorder.
• Promote enrollment in home visiting programs statewide, especially for individuals served by clinics that receive high risk funding through Title V.
• Educate hospital teams and perinatal care providers on the importance of referring patients to home visiting programs to facilitate ongoing access to care and identification of needs for care outside of clinical settings.

ESM:

• Percent of families identified through WIC, Medicaid or CARA plans of care and connected to services in key geographic areas
• Percent of birthing people enrolled in home visiting program services
• Number of birthing hospitals in NM that have policy and procedure in place to ensure home visiting referrals are offered to all patients upon postpartum discharge

Objective 2. Increase Maternal Depression and Anxiety screening and referrals, during and after pregnancy or inter-conception through formalized partnerships and assessments by 2024.

This objective is intimately tied to Objective 1: Access to perinatal care, and they are mutually interdependent. 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, as the highest priority areas for NM families.  Trauma-informed care was identified in the needs assessment as a guiding framework for perinatal programs and clinical care teams to address mental health and lived experience by incorporating standardized screening, listening, and conversation into practice. Applying this framework at the program level involves tracking changes in health status or social determinants of health over time. For example, while 9% of Native American women reported that they experienced depression during pregnancy, 18% reported postpartum depression (PPD) symptoms after their baby was born (NM PRAMS, 2017-2018). Sixteen percent (16%) of Black women experienced depression during pregnancy, and 22% reported PPD symptoms (NM PRAMS, 2015-2019). 

Trauma-informed care not only accounts for past experiences, such as adverse child experiences but recognizes that stress and trauma may change or be exacerbated by pregnancy or current social factors. Treating or referring based on social factors helps anticipate and prevent or treat potentially related medical risks. The impact of the pandemic on perinatal mental health has not yet been fully measured. However, it is projected to be enormous, contributing exponentially to NM’s established challenges and disparities.

NM already struggles to apply universal standardized screening to identify or treat depression and perinatal mood disorders early in pregnancy and postpartum. There are some known challenges for both families/consumers and for health and early childhood providers, but this has not been formally evaluated in the past five years. Efforts to quantify screening rely on provider survey reports, PRAMS surveillance (capturing birth denominator but limited to live birth-delivering people with depression) and clinic-specific responses. For clinical settings, Medicaid claims give an estimate of prenatal participants screened and treated, but there has been no way to include those not covered by Medicaid. Another barrier has been inconsistent access to Medicaid claims.

We have identified two strategies to increase statewide capacity to screen and address perinatal mood disorders and mental health:

1. Partner with the NM Chapter of Postpartum Support International (PSI) and community-based programs in their efforts to support families.
2. Collaborate with the NM Perinatal Collaborative and partners to provide training and on-going technical assistance to hospital teams working to implement the AIM Substance Use Disorder Bundle and future bundles that address perinatal mental health.

Strategy 1. Coordinate with community-based and clinical organizations to provide maternal postpartum and inter-conception depression screening and support.

New Mexico Title V programs do not provide perinatal case management or perinatal care, but they interface with Families FIRST perinatal case management, Healthy Start, home visiting, WIC, and high-risk pregnancy clinics.  The NM Chapter of Postpartum Support International (PSI) works directly with consumers, family advocacy programs and state agencies. In New Mexico, we have worked with primary and perinatal care providers to implement validated perinatal depression screening tools such as the Edinburgh scale and PHQ-9 questionnaires or 2-question versions. While some health systems do include these recommended screens in care, others do not because provider confidence is low or there are limited referral and treatment options. Coordinating community-based care will help increase confidence and follow up completion throughout the state. It will also help to clarify where the resources are truly lacking and in need of broader policy solutions to address.

Activities:

• With NM-PSI and through the PN-3 Pritzker Foundation coalition, we will partner with Mental Health professionals, home visiting programs and early childhood advocates to monitor progress towards universal screening and referral for perinatal mood disorders.
• We will require clinics receiving high-risk prenatal funds to ensure that policy and procedure are in place to guide universal perinatal depression screening in the primary language of individuals served, including steps to address referral and warm hand-off for positive screens. To support this effort, we will facilitate training and resource and referral sharing led by NM-PSI and other community partners.

ESM:

• Number of high-risk prenatal funded clinics that have policy and procedure in place to ensure universal screening for perinatal mood disorders with a validated instrument
• Number of stakeholder meetings held with identified partners and NM Medicaid representatives that result in actionable steps toward universal screening and referral for perinatal mood disorders

Strategy 2. Collaborate with the NM Perinatal Collaborative and partners to provide training and on-going technical assistance to hospital teams working to implement the AIM Substance Use Disorder Bundle

The NM Perinatal Collaborative works statewide to implement maternal safety best-practices promoted by the Alliance for Innovation on Maternal Health (AIM). Currently, 23 out of New Mexico’s 26 non-federal birthing hospitals participate actively in this initiative, including data-sharing measures of structure, process, and outcomes related to implementation. The three Indian Health Service (IHS) birthing facilities in NM also participate, currently without data-sharing. Previous bundles have focused on clinical issues directly related to or proximal to birth. However, the NMPC will launch a new bundle in August 2021 that is focused on care for birthing people experiencing substance use disorder.

SUD is a distinct condition, although often co-occurring with other mental health disorders, that requires a distinct set of practices and resources to promote maternal and infant safety, recovery, and well-being. However, there is significant overlap in the skill set (for non-stigmatizing, compassionate diagnosis and treatment), policies and procedures (for screening and referral) and referral networks (for hand-off to services) that must be in place to serve all birthing people who may be experiencing a mental health condition. Therefore, work on this bundle implementation has the potential to impact access to quality screening and intervention across the spectrum of mental health disorders.

The NMPC’s SUD work is further strengthened by the multidisciplinary workgroup that has formed to guide its development. The workgroup includes clinical providers from medicine, nursing, and midwifery, along with mental health professionals. Reproductive justice advocates, community members with expertise through their own lived experience of SUD, home visitors, doulas, lactation providers, and peer support workers, in addition to Title V staff, also participate. The group is charged with developing curriculum for the NMPC’s dedicated forum, the Improving Perinatal Health ECHO, adapting and prioritizing bundle practices for implementation, and guiding the development of technical assistance to hospital teams. Through the NMPC initiative, hospital teams are accountable for best-practice implementation, and the data-sharing allows the Title V program to track progress and impact.

Activities:

• Collaborate with the NM Perinatal Collaborative, the SUD workgroup, and other community partners to prioritize the development and implementation of screening and referral best practices in NM birthing hospitals.
  • The following opportunities will be leveraged for the current grant year: ongoing sessions of the IPH ECHO (occurring twice monthly), the NMPC annual meeting (scheduled for October 2021), quarterly implementation meetings with hospital teams, ongoing technical assistance support.
• Share outcomes data reported to the Department of Health in accordance with data-sharing agreements to facilitate accountability and interpret impact of the initiative.

ESM

• Number of NM birthing hospitals with policy and procedure in place to require universal screening for perinatal mood disorders with a validated instrument prior to discharge

Objective 3. Improve Patient-Centered Care knowledge and practice with measurable, patient-reported results by 2023

Plans to address quality and trauma-informed content of care have been both disrupted and shaped by COVID-19. NM Title V remains committed to taking on new ways of evaluating healthcare and the wellness of NM families, and the pandemic has reinforced the urgency of this task. Centering patients and honoring lived experience in healthcare is not yet standard in institutionally based 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. Partner with the NM Birth Equity Collaborative and the NM Perinatal Collaborative to support provider trainings and community forums.
2. Consult with a broad spectrum of community leaders to define and model respectful maternity care.
3. Implement better measures of quality care that incorporate lived experience and equity.

Strategy 1. Partner through the NM Birth Equity Collaborative to provide community forums, provider trainings and establish best practices in NM.

The NMBEC is currently the only NM entity that centers women of color with an explicit priority of improving the health of Black and Indigenous women in NM, and it is the only collaborative to identify lived experience of Black and Indigenous people as a key driver and measure of quality in healthcare. The participating organizations have a commitment to patient-centered principles and people of color leadership in the collaborative, and it is important that NMDOH institutionalize these shared values to build capacity and improve care in NM.

The NM Perinatal Collaborative is a separate organization with formal ties to clinical providers and healthcare institutions and the national Alliance for Innovation on Maternal Health (AIM). The forums maintained by the NMPC for the AIM maternal safety work (described under Objective 2 above) must be leveraged as desired and appropriate by the NMBEC to share NMBEC-designed and led content with clinical teams so that it may be integrated with work that is connected to data-sharing and regular bi-directional communication to compel accountability for action.

Activities:

• Continue to participate in the Birth Equity Collaborative and advance funding opportunities to sustain NMBEC priorities, such as trainings and health impact assessments.
• Provide in-kind staffing and resources, state and reaffirm commitments to honoring and elevating the leadership of the NMBEC as representing most-impacted NM communities, and advocate for opportunities for NMBEC to guide work with clinical teams.
• Facilitate communication and relationship development between the NMPC and the NMBEC as desired to advance these activities.

ESM:

• Number of NMBEC-led provider trainings or community webinar/meetings completed.

Strategy 2. Follow the lead of community-based organizations and women with lived experience to define and support respectful maternity care in New Mexico.

Respectful maternity care (RMC) is a World Health Organization set of guidelines to address the quality care and basic human rights for pregnant and birthing persons. In 2014, WHO released a statement calling for the prevention and elimination of disrespect and abuse during childbirth, calling for the mobilization of governments, programmers, researchers, advocates and communities to support RMC. In 2016, WHO published  new guidelines for improving quality of care for mothers and newborns in healthcare facilities, which included an increased focus on respect and preservation of dignity. The guidelines identify eight domains of quality of care and the following strategy areas to help build a systematic, evidence-based approach for providing quality care: clinical guidelines, standards of care, effective interventions, quality measures and relevant research. Only recently has there been a focused effort to apply or articulate similar quality of care definitions in the United States.

Using both qualitative and quantitative research approaches, Dr. Joia Crear-Perry, founder of the National Birth Equity Collaborative, has established some U.S. guidelines for consideration. Research that included researchers and study participants from NM, The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States (biomedcentral.com) identified consistent patterns of mistreatment and informed the development of patient centered measures that could be used for provider training, quality improvement, and the development of accountability mechanisms.

The ongoing COVID-19 pandemic has unfortunately reinforced the need for some targeted and deliberate consideration of respectful maternity care guidelines. Autonomy in decision-making around birth has eroded under COVID guidelines without evidence that all restrictions were necessary to protect birthing individuals, newborns, and healthcare workers. Given the disproportionate impact on BIPOC communities, it is essential to accelerate the pace of this work to address health disparities in our state.

Activities:

• Continue consultation with NMBEC and other community partners and long-standing birth equity leaders across the state with the goal of identifying and adapting guidelines on respectful maternity care for the endorsement of NM Department of Health.

ESMs:

• Number of NM BIPOC-led provider trainings or community webinar/meetings completed by 2023
• Number of guidelines created with a focus on respectful, patient-centered maternity care

Strategy 3. Evaluate metrics in existing surveillance and administrative data to better measure and report on lived experience and quality of care.

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 plan to address three main areas of concern in revisions to the PRAMS survey:

• 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 treatment before, during and after pregnancy;
• what kind of birth experience women hoped for, the experience they had, and what they thought was the ideal setting and healthcare team?

Knowing more about the composition of the maternity care team and delivery experience will help Title V staff and partners communicate information about the birth population to make improvements in health systems and policy arenas. Since these are open-ended concepts and they will take time to conform to survey formats, we will work with our PRAMS steering committee and Tribal PRAMS partners to formulate questions for field testing. The CDC has indicated that a survey revision will not be in the field until 2023, so we will have adequate time to engage with key informants and test questions.

Activities: Using PRAMS Steering Committee and Title V input, we will continue making progress on priority changes for the 2022 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. Other community partners engaged in this work include community health councils, the NM home visiting collaborative and the NM Doula Association, Office of Border Health, county and regional health offices and formal Title V stakeholders.