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Improving Birthing Outcomes through Midwifery Care: New Mexico

Midwives play a critical role in improving birth outcomes and advancing maternal health equity. To support robust access to certified nurse-midwives and licensed midwives in home and community birth settings, New Mexico has successfully implemented a Medicaid midwifery benefit under its Birthing Options Program (BOP) for over 15 years, building on a historical key partnership between the curandera-parteras (traditional Latina midwives) and the New Mexico Department of Health. In part through these efforts, midwives practicing in New Mexico are more than twice as likely to attend births compared to the national average, which may contribute to New Mexico’s improved birth outcomes. This case study highlights New Mexico’s Medicaid midwifery benefit under its BOP which has strengthened access to high-quality midwifery care among pregnant people, providing ideas and experience for other states seeking to reimagine maternity care by better integrating midwifery into their health care systems.

Background

Over the past decade, rates of adverse birth outcomes (e.g., preterm births and low birthweight) have been relatively stagnant both nationally and within New Mexico.[1] Conversely, the maternal mortality rate has been steadily rising over the years. According to the Centers for Disease Control and Prevention (CDC), the 2018 US maternal mortality rate was 17.4 maternal deaths per 100,000 live births.[2],[3]  New Mexico’s maternal mortality rate is higher than the national average, averaging 23.7 maternal deaths per 100,000 live births between 2015-2018.[4],[5] Significant racial, ethnic, and socio-economic disparities persist with non-Hispanic Black women having the highest rates of poor birth outcomes in the US, substantially higher than rates for non-Hispanic White or Hispanic women.[6],[7] Within New Mexico, Black or American Indian women are 1.5 times more likely than their non-Hispanic White peers to experience a low birthweight delivery.[8] These disparities are largely due to barriers to high-quality, culturally competent medical care compounded by the effects of social determinants of health, such as structural racism or poverty.[9]

Many states are investing in robust, culturally responsive supports for pregnant people to address the growing maternal mortality crisis as well as prevent adverse birth outcomes, with some focusing on high-quality midwifery care. The benefits of receiving midwifery care include higher rates of spontaneous vaginal birth and lower rates of induction, preterm birth, and infant mortality.[10],[11] States with a strong connection between their health care systems and midwives tend to have better birth outcomes than states that do not.[12] As states explore opportunities to improve birth outcomes, there is growing interest in strengthening access to midwifery care. Despite midwives having deep historical ties to maternity care, particularly in communities of color,[13],[14] fewer than 10 percent of US births are attended by midwives.[15]

Summary of Midwifery

Midwifery includes a full range of primary health care services for women, including gynecologic and family planning services, preconception care, care during pregnancy, childbirth and the postpartum period, and care of the newborn.[16] A midwife’s scope of practice depends on their certification and licensure credentials, which may vary by state. The most common types of midwives include certified nurse-midwives, certified midwives, and certified professional midwives (see Types of Midwives Licensed to Practice in New Mexico).[17] Depending on the type of midwife, services may include conducting physical examinations, prescribing medications (e.g., contraception), ordering and interpreting laboratory results, among many other functions delivered across a wide range of settings (e.g., clinical settings, birth centers, or in private homes).[18]

History of Midwifery in New Mexico

Maternity care has deep historical roots and cultural importance within many New Mexico communities. New Mexico shares territory with 21 Tribes, Pueblos and Nations, each of which holds traditional birthing knowledge and practices.[19] Curandera-parteras (or traditional Latina midwives) have been present in New Mexico since before its statehood and were once the primary maternity caregivers, providing critically important services to the pregnant women and babies in largely rural and Latino villages in northern New Mexico.[20] New Mexico’s Department of Health began a partnership with the curandera-parteras under the Midwife Consultation Program in the 1930s in recognition of the important work being done by curandera-parteras in tandem with the need to improve maternal health outcomes within the state.[21] This partnership bridges modern medicine and traditional health systems, in part, by offering instruction by nurse-midwives to the curandera-parteras on certain public health functions (e.g., effective hygiene practices and completion of birth certificates).[22] Building on these efforts, New Mexico has continued to make significant investments to strengthen access to midwifery care across the state, such as through its Medicaid Birthing Options Program.

Types of Midwives Licensed to Practice in New Mexico

There are several pathways to becoming a midwife. The two types of midwives licensed to practice in New Mexico and eligible to enroll as BOP providers include certified nurse-midwives and licensed midwives.

  • Certified nurse-midwives (CNMs) are independent practitioners educated in both midwifery and nursing. CNMs must be certified by the American Midwifery Certification Board and maintain licensure as a Registered Nurse through the New Mexico Board of Nursing or another nursing compact state. CNMs may practice in all settings, including hospitals, clinics, and community settings.[30]
  • Licensed midwives (LMs) are independent practitioners educated in midwifery either through an accredited education program or a traditional apprenticeship model. Many LMs in New Mexico are certified as Certified Professional Midwives (CPMs) through the North American Registry of Midwives. Unlike CNMs, LMs practice in community settings, including homes and birth centers.[31]

Licensure for both CNMs and LMs is overseen by the New Mexico Department of Health, Division of Public Health’s Maternal Health Program.

New Mexico’s Medicaid Birthing Options Program

In 2006, New Mexico’s Medicaid program implemented the Birthing Options Program (BOP) under a state plan amendment[23] to offer an out-of-hospital birthing option (i.e., home birth) for pregnant women enrolled in Medicaid who are at low-risk for adverse birth outcomes.[24],[25] BOP services are provided by an eligible midwife enrolled in Medicaid as a BOP provider with the Human Services Department/Medical Assistance Division (the state’s Medicaid program). Eligible midwives include certified nurse-midwives (CNMs) and licensed midwives (LMs) (see Types of Midwives Licensed to Practice in New Mexico).

While midwives existed in the state long before BOP, many community midwives faced difficulties securing malpractice insurance, which precluded them from receiving Medicaid reimbursement for out-of-hospital births. BOP addresses this barrier to reimbursement through agreements with the midwives, MCOs, and pregnant women, increasing access to midwifery services under Medicaid.[26] Additional guidance was subsequently released allowing LMs to bypass the Medicaid managed care entity’s credentialing requirement to carry malpractice liability insurance. [27],[28] As of 2022, approximately half of New Mexico’s LMs participate in BOP.[29]

BOP services are limited to basic obstetric care (e.g., prenatal care and labor and delivery) for uncomplicated pregnancies and childbirth. The program does not cover the full scope of midwifery services nor replace pediatric care that is expected to occur in a primary care setting (e.g., well child visits). BOP services may be reimbursed through managed care or as fee-for-service (FFS) based on the plan held by the beneficiary.[32],[33],[34] CNMs are reimbursed for midwife maternity services under BOP at the same rate paid to physicians as part of the global payment, which includes prenatal care, delivery, and postnatal care.[35] LMs participating in BOP are also reimbursed for maternity services based on the global payment at 77 percent of the rate paid to physicians.[36] LMs may also be reimbursed on a FFS basis for specific procedure codes related to services provided under BOP, which are outside of the global payment.

Approximately 26 percent of all births in New Mexico are attended by midwives compared to the national average of 10 percent.[37] New Mexico’s high utilization of midwives may contribute to the state’s above average birth outcomes. Approximately 53 percent of New Mexico births are spontaneous vaginal deliveries and fewer than 24 percent of births result in caesarean deliveries compared to the national average (49 percent and 32 percent, respectively). Other positive birth outcomes include increased rates of breastfeeding at birth and reduced rates of premature deliveries and low birth weights.[38]

Conclusion

New Mexico has successfully leveraged its Medicaid Birthing Options program to strengthen access to community midwives among Medicaid-enrolled pregnant people, resulting in use of midwifery services far above the national average. With at least some Medicaid midwifery benefits available in all 50 states and DC,[39] New Mexico’s unique approach may inform other states’ efforts to reimagine maternity care by better integrating midwifery within their health care systems.

For more information on state Medicaid midwifery policies to support maternal health, explore NASHP’s 50-state scan, Midwife Medicaid Reimbursement Policies by State.

 

Acknowledgements: This case study is a publication of the National Academy for State Health Policy (NASHP). This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services HHS under the Supporting Maternal and Child Health Innovation in States Grant No. U1XMC31658; $398,953. This information, content, and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. government.

NASHP wishes to thank Christina Kupferschmidt, Annabelle Martinez, Rosemary Medrano, April Neri, Lori Peña, and Abigail Reese from New Mexico for their time and insights.

[1] New Mexico Selected Health Statistics Annual Report 2018, Bureau of Vital Records and Health Statistics, Epidemiology and Response Division, New Mexico Department of Health. https://www.nmhealth.org/data/view/vital/2352/

[2] Hovert, Donna, and Arialdi Miniño. Maternal Mortality in the United States: Changes in Coding, Publication, and Data Release, 2018, National Vital Statistics Report, January 2020. https://www.cdc.gov/nchs/data/nvsr/nvsr69/nvsr69-02-508.pdf

[3] More recent data on national maternal mortality rates in 2020 is available here.

[4] New Mexico Selected Health Statistics Annual Report 2018, New Mexico Department of Health

[5] This represents the most recently available data on New Mexico’s maternal mortality rates at the time of publication.

[6] Picture of Reproductive Outcomes, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. https://www.cdc.gov/pictureofamerica/pdfs/picture_of_america_reproductive_outcomes.pdf

[7] Hovert, Donna, Maternal Mortality Rates in the United States, 2020, US Department of Health and Human Services, Centers for Disease Control and Prevention, February 2022. https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2020/maternal-mortality-rates-2020.htm#:~:text=The%20maternal%20mortality%20rate%20for,(Figure%201%20and%20Table)

[8] New Mexico Selected Health Statistics Annual Report 2018, New Mexico Department of Health

[9] Maternal Mortality in the United States: Changes in Coding, Publication, and Data Release, 2018, National Vital Statistics Report, 2020.

[10] Sandall j, et al., Midwife-led Continuity Models Versus Other Models of Care for Childbearing Women, Cochrane Database of Systematic Reviews, 2016. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004667.pub5/epdf/full

[11] The Benefits of Midwives, American Pregnancy Association. https://americanpregnancy.org/healthy-pregnancy/labor-and-birth/midwives/

[12] Midwifery Linked to Better Birth Outcomes in State-by-State Report Card, American College of Nurse-Midwives, February 2018. https://www.midwife.org/Midwifery-linked-to-better-birth-outcomes

[13] Dominique Tobbell, Black Midwifery’s Complex History, University of Virginia School of Nursing, February 2021. https://www.nursing.virginia.edu/news/bhm-black-midwives/

[14] Felina Mychelle Ortiz, History of Midwifery in New Mexico: Partnership Between Curandera-parteras and the New Mexico Department of Health, Journal of Midwifery & Women’s Health, December 2010. https://onlinelibrary.wiley.com/doi/abs/10.1016/j.jmwh.2004.12.001

[15]March of Dimes Position Statement Midwifery Care and Birth Outcomes in the United States, March of Dimes, 2019.https://www.marchofdimes.org/materials/Final%20midwifery%20position%20statement%20August%2029%202019.pdf

[16] Definition of Midwifery and Scope of Practice of Certified Nurse-Midwifes and Certified Midwives, American College of Nurse-Midwives, February 2012. https://www.midwife.org/acnm/files/ccLibraryFiles/Filename/000000007043/Definition-of-Midwifery-and-Scope-of-Practice-of-CNMs-and-CMs-Feb-2012.pdf

[17] Types of Midwives, Midwives Alliance of North America, https://mana.org/about-midwives/types-of-midwife

[18] Definition of Midwifery and Scope of Practice of Certified Nurse-Midwifes and Certified Midwives, American College of Nurse-Midwives, 2012.

[19] Abigail Reese. (New Mexico Department of Health). Email. April 5, 2022.

[20] History of Midwifery in New Mexico: Partnership Between Curandera-parteras and the New Mexico Department of Health, Journal of Midwifery & Women’s Health, 2010.

[21] Ibid.

[22] Ibid.

[23] April Neri. (New Mexico Department of Health, Benefits and Reimbursement Bureau, Registered Nurse). Email. March 18, 2022.

[24] State of New Mexico Medical Assistance Program Manual Supplement Number 19-02, Human Services Department, June 21, 2019. https://www.hsd.state.nm.us/wp-content/uploads/Supplement-19-02-Birthing-Options-Program-Billing-Procedures-Reimbursement.pdf

[25] Human Services Department Secretary Pamela Hyde Announces the Medicaid Birthing Options Program, New Mexico Department of Human Services, 2006. https://www.hsd.state.nm.us/wp-content/uploads/PressRelease/2f473c14ee654f868b5a25b3cfd15a6d/2006 (5-10) BirthingOptionsPrgmNR.pdf

[26] Human Services Department Secretary Pamela Hyde Announces the Medicaid Birthing Options Program, New Mexico Department of Human Services, 2006

[27] State of New Mexico Medical Assistance Program Manual Supplement Number 17-10, Human Services Department, October 26, 2017. https://www.hsd.state.nm.us/wp-content/uploads/files/Providers/New%20Mexico%20Administrative%20Code%20Program%20Rules%20and%20Billing/Supplements%20for%20MAD%20NMAC%20Program%20Rules/Supplement-Licensed-Birth-Centers-17-10.pdf

[28] State of New Mexico Medical Assistance Program Manual Supplement Number 19-02, Human Services Department, June 21, 2019.

[29] Lori Pena. (New Mexico Department of Health, Women, Children and Family Medicaid Unit, Deputy Bureau Chief). Email. January 11, 2022.

[30] Certified Nurse Midwives and Licensed Midwives, New Mexico Department of Health. https://www.nmhealth.org/about/phd/fhb/mwp/

[31] Certified Nurse Midwives and Licensed Midwives, New Mexico Department of Health.

[32] State of New Mexico Medical Assistance Program Manual Supplement Number 19-02, Human Services Department, June 21, 2019.

[33] April Neri. (New Mexico Department of Health, Benefits and Reimbursement Bureau, Registered Nurse). Email. April 5, 2022.

[34] Individuals (i.e., Native Americans) who have the option to opt out of managed care are eligible to receive BOP services under FFS.

[35] Provider Policies Health Care Professional Services, New Mexico Health Services Department, Effective February 1, 1995. https://www.hsd.state.nm.us/wp-content/uploads/FileLinks/db231204433241998f49d260c6129473/MAD_718.1.pdf

[36] Provider Policies Health Care Professional Services, New Mexico Health Services Department, Effective February 1, 1995

[37] Midwifery Integration State Scoring System Report card: New Mexico, Birth Place Lab, 2019. https://www.birthplacelab.org/wp-content/uploads/2019/03/New-Mexico.pdf

[38] Midwifery Integration State Scoring System Report card: New Mexico, Birth Place Lab, 2019.

[39] Emily Creveling, Taylor Platt, Anoosha Hasan, Midwife Medicaid Reimbursement Policies by State, National Academy for State Health Policy, April 19, 2022. https://www.nashp.org/midwife-medicaid-reimbursement-policies-by-state/

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