TITLE 7 HEALTH

CHAPTER 4 DISEASE CONTROL (EPIDEMIOLOGY)

PART 8 MATERNAL MORTALITY AND SEVERE MATERNAL MORBIDITY REVIEW

7.4.8.1 ISSUING AGENCY: Department of Health, Public Health Division, Family Health Bureau.

[7.4.8.1 - N, NMAC, 11/08/2022]

7.4.8.2 SCOPE: These regulations shall apply to the New Mexico maternal mortality review committee; any department staff or contractors engaged in supporting committee activities; and any public or private entity from whom information may be requested to conduct maternal mortality and morbidity reviews. These regulations supersede any other regulations previously promulgated by the department related to the operations of the New Mexico maternal mortality review committee.

[7.4.8.2 - N, NMAC, 11/08/2022]

7.4.8.3 STATUTORY AUTHORITY: The regulations set forth herein are promulgated by the secretary of the department of health by the authority of Subsection F of Section 9-7-6 NMSA 1978 and implement the Public Health Act, Section 24-1-3 NMSA 1978, as amended, and the Maternal Mortality and Morbidly Prevention Act Section 24-32-1 to 24-32-5, NMSA 1978.

[7.4.8.3 - N, NMAC, 11/08/2022]

7.4.8.4 DURATION: Permanent.

[7.4.8.4 - N, NMAC, 11/08/2022]

7.4.8.5 EFFECTIVE DATE: November 8, 2022, unless a later date is cited at the end of a section.

[7.4.8.5- N, NMAC, 11/08/2022]

7.4.8.6 OBJECTIVE: These regulations are promulgated pursuant to statute to define and support the maternal mortality review committee, the purpose of which is to comprehensively review and analyze deaths that occur during pregnancy, childbirth and the year postpartum; to identify remediable problems contributing to maternal mortality; to develop recommended interventions to prevent these deaths; and disseminate findings. The committee shall also review aggregate data related to severe maternal morbidity to look for opportunities for improvement in care that could lead to improved maternal outcomes and fewer deaths. Given the persistent and significant disparities in maternal morbidity and mortality experienced by people of color in New Mexico and the United States overall, the committee will apply lenses of racial justice, diverse representation and health equity across its functions including staffing, committee membership and leadership, case review and analysis.

[7.4.8.6 - N, NMAC, 11/08/2022]

7.4.8.7 DEFINITIONS: As used in these regulations:

A. Definitions beginning with “A”:

(1) “Abstractor" means an individual who is trained to comprehensively gather pertinent information from a variety of available sources in order to accurately capture the events of a person’s life leading up to and including their death in the form of a case summary for committee review. All abstractors will possess a professional background in maternal health and the requisite training, provided or endorsed by the department, to approach cases with a health equity lens. Given the critical role of the abstractor in identifying the defining details leading to a death, including factors such as racism, bias and discrimination, the department shall undertake deliberate, demonstrable efforts to engage abstractors who possess lived experience as members of communities of color disproportionately impacted by maternal mortality who are able to apply an anti-racist lens to the abstracting process.

(2) “Act” means the Maternal Mortality and Morbidity Prevention Act.

(3) “Administrative co-chair” means the chief medical officer, or another representative of the department and who is appointed by the secretary to serve as co-chair of the committee for administrative matters. The administrative co-chair shall be equipped with the measurable skills, training or lived experience to incorporate the racial, ethnic and linguistic diversity of New Mexico into this leadership role.

(4) "Aggregate data" means health care data that exclude any individually identifiable health information, including patient and health care provider identification.

B. Definitions beginning with “B”: “BVRHS” means the department of health bureau of vital records and health statistics.

C. Definitions beginning with “C”:

(1) “Case-related material” means any de-identified information that relates to or summarizes an incident of maternal mortality or severe maternal morbidity.

(2) “Case summary” means a de-identified summary of an incident of maternal mortality.

(3) “CDC” means the U.S. centers for disease control and prevention.

(4) “Chief medical officer” means the chief medical officer of the department.

(5) “Clinical co-chair" means a committee member with maternal child health clinical or paraprofessional training nominated and approved by a two-thirds vote of the committee and approved by the department to serve in this position for a term that aligns with the overall duration of their membership on the committee unless the member chooses to step down from the co-chair role prior to the end of their membership term. The clinical co-chair shall be equipped with the measurable skills, training or lived experience to incorporate the racial, ethnic and linguistic diversity of New Mexico into this leadership role.

(6) “Committee” means the maternal mortality review committee.

(7) "Committee member" means a person who has been appointed to sit as a member of the committee and who participates in committee business and votes on committee matters.

(8) “Community co-chair” means a committee member nominated and approved by a two-thirds vote of the committee to a term that aligns with the overall duration of their membership on the committee unless the member chooses to step down from the co-chair role prior to the end of their membership term. The community co-chair shall possess lived experience as a community member able to represent the regional, racial, linguistic, and ethnic diversity of New Mexico’s communities disproportionately impacted by maternal mortality in this leadership role.

(9) “Contributing factors” are the circumstances, events, exposures, procedures, or products identified by the committee as having contributed to an incident or group of incidents resulting in maternal mortality or severe maternal morbidity which may include systemic racism or inequities.

(10) “Coordinator” means the operational staff member designated by the department to manage the day-to-day operations of the committee.

(11) "Critical income" means income lost as a result of uncompensated work time used to attend a committee meeting.

D. Definitions beginning with “D”:

(1) “Data set” means a collection of de-identified information collected or created by or under the direction of DOH epidemiologists.

(2) “De-identified data” means information that has been purged of all personally identifying information including, but not limited to, names; any geographic subdivision smaller than a state including street address, city, county, precinct, zip code, and their equivalent geocodes; all elements of dates except the year of an incident, including birth date, admission dates, discharge dates, and dates of death; telephone numbers, fax numbers electronic mail addresses; social security numbers; health plan beneficiary numbers; certificate and license numbers; vehicle identifiers and serial numbers, including license plate numbers; device identifiers and serial numbers; web universal resource locators (URLs); internet protocol address numbers; biometric identifiers, including finger and voice prints; full face photographic images and any comparable images; and any other unique identifying number characteristic, or code.

(3) “Department” or “DOH” means the New Mexico department of health.

(4) “DOH epidemiologist” means the operational staff responsible for creating, interpreting, and analyzing data sets and for supporting committee efforts to develop and disseminate data-driven recommendations.

E. Definitions beginning with “E”:

(1) “Executive committee” means a subcommittee of the committee consisting of the co-chairs and additional committee members that provides leadership and guidance to the committee and operational staff to effectuate the objective of the committee.

(2) “Expertise” means special skill, knowledge, or judgement that results from training, practice or lived experience.

F. Definitions beginning with “F”: [RESERVED]

G. Definitions beginning with “G”: [RESERVED]

H. Definitions beginning with “H”:

(1) "Health care provider" means an individual licensed, certified or otherwise authorized to provide health care services in the ordinary course of business in the state; or a health facility that the department licenses.

(2) “Health equity” means the attainment of the highest level of health for all people through focused and ongoing efforts to address avoidable inequalities, historic and contemporary injustices, and the elimination of health and healthcare disparities.

(3) “HIDD database” means the hospital inpatient discharge database or state inpatient database.

I. Definitions beginning with “I”:

(1) “IAD” means: Indian affairs department of the state.

(2) “Identifiable information” means any information that may be used to determine the identity of an individual directly or indirectly involved in an incident of maternal mortality or severe maternal morbidity.

J. Definitions beginning with “J”: [RESERVED]

K. Definitions beginning with “K”: [RESERVED]

L. Definitions beginning with “L”:

(1) "Law enforcement agency" means a law enforcement agency of the state, an Indian nation, tribe or pueblo or a political subdivision of the state.

(2) “Lead abstractor” means the clinical co-chair or operational staff member designated to coordinate the activities of any operational staff engaged as abstractors. This person also prepares case summaries for committee review and enters committee decisions into the MMRIA database.

M. Definitions beginning with “M”:

(1) "Maternal mortality" means the death of a pregnant person or a birthing person within one year postpartum.

(2) “Maternal mortality review” or “MMR” means the review of all reported deaths of individuals who die of any cause during pregnancy or within one year of the end of pregnancy.

(3) "Medical record" means the written or graphic documentation, sound recording or electronic record relating to medical, behavioral health and health care services that a patient receives from a health care provider or under the direction of a physician or another licensed health care provider. "Medical record" includes diagnostic documentation, including an x-ray, electrocardiogram, and electroencephalogram; other test results; data entered into a prescription drug monitoring program; and an autopsy report.

(4) “MMRIA” means the CDC maternal mortality review information application or any successor application.

N. Definitions beginning with “N”: [RESERVED]

O. Definitions beginning with “O”:

(1) “OAAA” means the office of African American affairs of the state.

(2) “OMI” means the office of the medical investigator.

(3) "Operational staff" means staff or contractors of the department assigned or contracted to support the work of the committee or its executive committee.

P. Definitions beginning with “P”:

(1) “PHD” means the public health division of the department.

(2) “Pregnancy-associated death” means a death during or within one year of pregnancy, regardless of the cause. If the definition is updated by the CDC, that definition shall be the applicable definition for these rules.

(3) “Pregnancy-related death” means a death during or within one year of pregnancy, from a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy. If the definition is updated by the CDC, that definition shall be the applicable definition for these rules.

Q. Definitions beginning with “Q”: "Qualified invited guest" means a person approved by the co-chairs and invited by the committee to attend a committee meeting to provide technical expertise to the committee, to enhance training in maternal health, to provide insight on maternal mortality or severe maternal morbidity review in other jurisdictions or to provide operational support to the committee.

R. Definitions beginning with “R”: [RESERVED]

S. Definitions beginning with “S”:

(1) “Secretary” means the secretary of the department of health or designee.

(2) “Severe maternal morbidity” means unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a person's health as identified by hospitalizations using administrative hospital discharge data and the world health organization's international classification of diseases diagnosis and procedure codes.

T. Definitions beginning with “T”: “Trauma” means individual and communal trauma, defined as the experiences inflicted upon people and communities impacting their physical, mental and emotional well-being. This unresolved impact leads to a perceived and experienced lack of safety and a recurring experience of stress that impacts the physical and mental bodies of the victim and at times their families and communities intergenerationally. Trauma is linked to acts of violence, including micro-aggressions, systemic inequity and the feeling that oneself, one’s family or community are not fully safe or capable of being safe as a result of the traumatic incident(s).

U. Definitions beginning with “U”: [RESERVED]

V. Definitions beginning with “V”: [RESERVED]

W. Definitions beginning with “W”: [RESERVED]

X. Definitions beginning with “X”: [RESERVED]

Y. Definitions beginning with “Y”: [RESERVED]

Z. Definitions beginning with “Z”: [RESERVED]

[7.4.8.7 - N, NMAC, 11/08/2022]

7.4.8.8 PROGRAM ADMINISTRATION: The committee’s activities shall be administered by the department using a health equity framework across all functions including staffing, committee membership and leadership, and case review and analysis in order to assure that the values of cultural awareness, racial justice, and equity are infused throughout these functions. The department shall designate a committee coordinator in an employed or contracted position and hire contractors and employ operational staff to support the work of the committee. The co-chairs may designate an executive committee to conduct business as outlined herein.

[7.4.8.8 - N, NMAC, 11/08/2022]

7.4.8.9 EXECUTIVE COMMITTEE: If called, the executive committee must include and reflect the ethnic, geographic, and disciplinary make-up of the committee, state and the communities disproportionately impacted by maternal mortality and morbidity.

A. The formation of an executive committee must be endorsed by a vote of a two-thirds majority of the current membership.

B. An executive committee shall consist of co-chairs of the committee and up to three additional committee members nominated and approved by a two-thirds majority of the current membership to effectuate the objectives of the committee. No less than one appointee from either IAD or OAAA will be offered the opportunity to serve on the executive committee. Appointment to the executive committee will be for the duration of the term of membership, or until the member elects to step down from the executive committee, whichever is sooner.

C. Operational staff and qualified invited guests may participate in executive committee deliberations in an advisory capacity as directed by the executive committee, but they are not part of the committee membership.

D. If called, the executive committee shall:

(1) meet at the call of the co-chairs;

(2) monitor and support the activities of the full committee;

(3) establish policy and procedure and provide guidance to operational staff on implementation; and

(4) make final decisions regarding data analysis, data dissemination and evaluation based on findings and recommendations from the full committee.

[7.4.8.9 - N, NMAC, 11/08/2022]

7.4.8.10 MEMBERSHIP:

A. Members will be formally appointed by the administrative co-chair. The administrative co-chair may consult with the clinical and community co-chairs, and if called, the executive committee to confirm appointments.

B. The committee shall be composed of no more than 30 members, not including the co-chairs, provided that at least, four of those members shall include:

(1) two members nominated by the secretary of Indian affairs; and

(2) two members nominated by the director of the office of African American affairs.

C. Additional members will be recruited through an open call:

(1) Operational staff will post a call for members along with an application form on the department’s website and advertise the call broadly in collaboration with OAAA, IAD, and community-based organizations whose work focuses on health equity within the communities most impacted by maternal mortality and morbidity.

(2) Operational staff will receive applications and conduct an initial analysis using a scoring matrix to evaluate applications that prioritizes applicants who are working in and representing communities that are most impacted per the state maternal mortality ratio so that the composition of the committee reflects:

(a) the racial, ethnic, and linguistic diversity of the state;

(b) the differing geographic regions within the state, including rural and urban areas;

(c) tribal areas and communities; and

(d) communities that are most impacted by pregnancy-related deaths, severe maternal morbidity, or a lack of access to relevant perinatal and intrapartum care services.

(3) Consideration will also be given to assure that core disciplines and organizations representing needed expertise in maternal health and safety, as identified by the committee, are represented.

D. Upon closure of an open call, operational staff will present a completed scoring matrix for all applicants to the co-chairs for consideration.

E. Membership is voluntary.

F. Members may be reimbursed for expenses related to meeting attendance.

(1) Members who must forsake critical income to attend meetings may, with the approval of the department, be reimbursed for loss of that income in an amount not to exceed three hundred dollars ($300.00) per meeting, whether virtual or in person.

(2) Members required to travel in excess of 50 miles for an in-person meeting may, with the approval of the department, receive per diem and mileage for attending that meeting pursuant to the Per Diem and Mileage Act.

(3) Operational staff will advise all members of the opportunity to receive these types of reimbursement, provide forms needed to complete enrollment according to departmental policy, and provide any assistance members need to complete and submit forms.

(4) Members may not initiate a request for critical income or travel reimbursement for meetings that occurred in a previous fiscal year.

G. Members are appointed for a three-year term, with no consecutive terms. Terms served by committee members may be staggered to assure continuity of effort.

H. Each member shall receive training on trauma and the impacts of trauma, including secondary trauma, trauma of racism and trauma of maternal mortality and morbidity presented by a trainer who is a member of communities that are most impacted by pregnancy-related deaths, severe maternal morbidity, or a lack of access to unbiased, affordable and culturally congruent perinatal and intrapartum care services.

[7.4.8.10 - N, NMAC, 11/08/2022]

7.4.8.11 CASE IDENTIFICATION: “Maternal mortality”: The coordinator and operational staff shall work with BVRHS to identify any death constituting an incident of maternal mortality within one year from the date of death. Criteria for case identification shall be consistent with standard reporting requirements.

[7.4.8.11 - N, NMAC, 11/08/2022]

7.4.8.12 DATA COLLECTION:

A. Duty to report: A health care provider, the office of the state medical investigator, and BVRHS shall notify the operational staff of any incident of maternal mortality within three months of the incident. A report made to BVRHS made within these timelines will be sufficient to satisfy this requirement.

B. Authority to collect information: Except as otherwise restricted or prohibited by state or federal statute or regulation, designated operational staff may access medical records and other information relating to an incident of maternal mortality at any time within five years of the date of the incident.

C. Information gathering: Regarding any incident of maternal mortality involving a New Mexico resident, information including reports, records and data files shall be provided upon request to the designated operational staff from health care providers, law enforcement agencies, BVRHS, and the office of the state medical investigator. The designated operational staff may also request information from other entities with relevant information to a maternal mortality case review. Any committee member engaged in case review may request that designated operational staff initiate such a request for information from other entities.

D. Information collection process: Information and records requests will be conducted in a confidential manner.

E. Collection of information by interview: Individuals who are operational staff of the department, may, with appropriate training, conduct interviews with a deceased person’s family, care providers, and other relevant persons. These interviews shall be conducted according to an established protocol with the consent of the interviewee.

F. Case abstraction process: Information and records obtained through a formal request initiated by operational staff will be provided to an abstractor who is assigned to develop a case summary. An abstractor enters information directly into the MMRIA database. It is the responsibility of the abstractor to employ training, experience, and abstracting tools endorsed or provided by the department or CDC in order to create a comprehensive, accurate summary of the events of a person’s life leading up to and including their death. This process must include tools that have been developed to facilitate the identification of racism, discrimination, and interpersonal and structural bias in health care or life course events that may have been contributing factors to the death. An abstractor may consult the co-chairs or other operational staff as needed to confirm interpretations of data and the relevance of details for inclusion in a case summary.

G. Identification of race and ethnicity of the deceased: Race and ethnicity of the deceased, as identified in available records, are noted in otherwise de-identified case summaries in order to allow the committee to consider factors such as the role of systemic racism and inequities related to pregnancy-associated deaths.

[7.4.8.12 - N, NMAC, 11/08/2022]

7.4.8.13 COMMITTEE RESPONSIBILITIES:

A. The committee shall meet at the call of the co-chairs.

B. A majority of appointed committee members shall constitute a quorum.

C. The affirmative vote of at least a majority of a quorum present and approval by the co-chairs shall be necessary for any decisions pertaining directly to case review to be taken by the committee. A quorum shall not be achieved without at least one AID appointee and OAAA appointee in attendance. Administrative decisions not pertaining to case review may be voted on electronically outside of the course of a committee meeting to allow all members ample opportunity to cast a vote.

D. Operational staff and qualified guests may participate in committee deliberations in an advisory capacity as directed by the co-chairs of the committee.

E. Operational staff and qualified invited guest presence at a committee meeting shall not convey committee membership.

F. The committee shall be responsible for the following:

(1) review each incident of maternal mortality using a de-identified case summary prepared by operational staff;

(2) review aggregate data related to severe maternal morbidity;

(3) outline trends and patterns and provide recommendations related to maternal mortality and severe maternal morbidity in the state;

(4) serve as a link with maternal mortality and morbidity review teams nationwide and participate in national maternal mortality and morbidity review team activities; and

(5) perform any other functions as resources allow to enhance efforts to reduce and prevent maternal mortality and severe maternal morbidity in the state.

[7.4.8.13 - N, NMAC, 11/08/2022]

7.4.8.14 CASE REVIEW PROCESS:

A. The committee reviews prepared case summaries based on the information obtained from reports, records, and data files related to an incident of maternal mortality and entered into the MMRIA database by an abstractor. The committee is responsible for reviewing the summary, identifying contributing factors, making a determination on preventability and pregnancy-relatedness, and articulating recommendations. The lead abstractor shall be responsible for documenting committee decisions regarding case summaries in MMRIA within 30 days of committee review.

B. Any committee member who is concerned that any essential information is being missed by the decisions the abstractor makes in creating summaries may initiate a request to the clinical co-chair or operational staff with the authority to collect information that:

(1) an abstractor’s work be reviewed by the clinical co-chair and designated operational staff; or

(2) an alternative abstractor be assigned.

[7.4.8.14 - N, NMAC, 11/08/2022]

7.4.8.15 CONFIDENTIALITY OF RECORDS, PROCEEDINGS, AND FINDINGS:

A. Any material obtained pursuant to these rules, any committee proceedings, and findings, including any materials created to facilitate committee proceedings shall be maintained and disposed of in a confidential manner and in any manner as required by law.

B. The following shall be confidential and shall not be subject to the open meetings act or the inspection of public records act or subject to any subpoena, discovery request or introduction into evidence in a civil or criminal proceeding:

(1) any meeting, part of a meeting or activity of the committee or executive committee where data or other information is to be discussed and that may result in disclosure to the public of information protected by law; and

(2) except as may be necessary in furtherance of the duties of the committee or in response to an alleged violation of a confidentiality agreement entered, any information, record, report, notes, memoranda, or other data that the department or committee obtains pursuant to the Maternal Mortality and Morbidity Prevention Act.

C. Only the clinical co-chair and operational staff will have access to medical records, law enforcement reports and vital records data to support the work of the full committee.

(1) The coordinator or DOH epidemiologist may share de-identified, aggregate datasets with the CDC and with state, regional, or tribal entities engaged in reducing incidents of maternal mortality or severe maternal morbidity.

(2) Identifiable information entered into MMRIA shall only be accessible to the clinical co-chair, coordinator, DOH epidemiologists and abstractors.

D. Before participating in their first committee meeting, each member, operational staff, and any qualified invited guest shall be required to review and sign a confidentiality agreement covering the duration of their membership or service to the committee. Signed confidentiality agreements will be collected and retained by the coordinator.

E. A brief reminder of the confidentiality clause and any other relevant process directives will be presented at the beginning of each case review session.

F. For in-person meetings, case-related materials may not be removed from meetings by any member. At the conclusion of any meeting at which case-related material has been distributed, the coordinator shall collect that material and destroy it.

G. For virtual meetings, case summaries and decision forms shall be distributed electronically via a secure encrypted program, and members shall be instructed to delete the summaries from their inbox, hard-drive or cloud-based storage at the conclusion of the meeting.

[7.4.8.15 - N, NMAC, 11/08/2022]

7.4.8.16 DISSEMINATION OF INFORMATION; DEVELOPMENT OF RECOMMENDATIONS; ADVANCEMENT OF RECOMMENDATIONS:

A. Data dissemination: The committee shall compile reports using aggregate data and de-identified information on an annual basis in an effort to further study the causes and problems associated with maternal mortality and severe maternal morbidity. These reports shall be distributed to:

(1) the New Mexico legislature;

(2) the Indian affairs department;

(3) office on African American affairs;

(4) health care providers;

(5) community-based organizations working in the interest of maternal and child health;

(6) other government agencies as necessary; and

(7) other entities as necessary to reduce maternal mortality rate in the state.

B. Committee members and operational staff may also deliver presentations using aggregated, de-identified information to support and promote the study of causes and problems associated with maternal mortality and severe maternal morbidity.

[7.4.8.16 - N, NMAC, 11/08/2022]

HISTORY OF 7.4.8 NMAC: [RESERVED]