“I never really understood how dire the need is until I experienced it myself,” said Robledo, who divides her time working as a receptionist, a maternal health activist and the mother of a preschooler and a toddler.

Pregnant women all across New Mexico are facing similar dilemmas. In the last decade, six hospitals around the state have closed their maternity wards, and at least three clinics have been forced to close or severely reduce operations due to financial stress, staff shortages or other causes.

The closures have left women without critical maternal care, putting untold numbers of mothers and infants at risk. Between 2015 and 2018, 77 New Mexico women died during pregnancy or within a year of giving birth. Some of these deaths were directly related to complications from the pregnancy, such as hemorrhages; others were caused by things like mental health or substance use disorder issues that weren’t properly treated during the pregnancy and after.

The New Mexico Maternal Mortality Review Committee concluded about 80% of these deaths were preventable.

In New Mexico in 2019, 132 infants died before reaching their first birthday, resulting in a mortality rate of 5.7 per 1,000 live births. Black newborns died at a rate four times higher than white newborns; Native American and Hispanic newborns died at a rate roughly 1.5 times higher, according to the New Mexico Department of Health.

The racial and income disparities within these statistics are sobering. Over a 10-year period, Black women, who represent only 3% of the state population, died at a rate four times higher than all New Mexican women during and after childbirth. In more recent years, women on Medicaid died at a rate five times higher than women on private insurance, statistics show. Native American women were two times more likely to experience severe health complications or near deaths than white women during birth, according to an analysis of recent hospital data obtained by Searchlight New Mexico.

Three hospitals — the University of New Mexico Hospital, Presbyterian Hospital and Lovelace Women’s Hospital — are equipped to take the most complex pregnancies. But only UNMH has a Level IV neonatal intensive care unit, qualified to take the most critically ill newborns, according to the Department of Health. All are in Albuquerque, which can be a three-hour drive or more from many corners of the state.

“If the closest labor and delivery hospital is three hours away from you, you are in danger. If the labor and delivery unit that is close to you is dysfunctional and underfunded, you are in trouble,” said Sunshine Muse, executive director of Black Health New Mexico, a statewide organization working to erase health disparities. “We can’t just depend on the big cities to have access to care. We have to make sure access is statewide.”

A national problem

The U.S. has the highest maternal mortality rate among high-income countries, one that’s three times higher than Canada’s — and more than 20 times higher than Norway’s. The pandemic did not help matters. An estimated 1,205 American women died in 2021 of complications arising from pregnancy or childbirth, a 40% jump from 2020, according to the Centers for Disease Control and Prevention.

In New Mexico, pandemic numbers have not been fully analyzed, but health officials acknowledge the state is following the same sobering trend.

“All signs are pointing that way,” said Eirian Coronado, program manager of the state’s Maternal and Child Health Epidemiology Program. “We’re verifying which cases are true pregnancy, which cases belong in our review and which ones don’t. And we’re not very encouraged right now.”

Advocates and experts alike contend that reducing maternal mortality in New Mexico doesn’t get the attention it deserves.

“When it comes to the state, there is a lack of connection with the communities,” said Nicole Martin, co-founder of the advocacy group Indigenous Women Rising, a reproductive rights organization that advocates for Native American women.

She and others point to a host of contributing factors. Among them: low reimbursement rates for Medicaid in a state where 65% of deliveries fall under its coverage; severe provider shortages across almost every medical specialty, resulting in “maternal health deserts”; bureaucratic barriers that make it difficult for midwives and doulas to provide services; and difficulty recruiting obstetricians and gynecologists in the state’s rural areas, where a third of the population lives.

New Mexico has attempted to address the crisis. Last year, it expanded Medicaid for women for up to a year after birth. This year, Gov. Michelle Lujan Grisham allocated $10 million for a women’s health clinic in Las Cruces.

Nevertheless, efforts have fallen short. Experts say the state has not invested enough in programs to reduce disparities in the maternal death rate and does not mandate the kinds of strict standards for hospitals that could improve maternal health outcomes.

New Mexico’s lack of progress was on display last year when the national Center for Disease Control and Prevention denied funding to help improve the state’s obstetric care. The agency believed the state lacked the infrastructure and staff necessary to make effective use of the money, according to the New Mexico Perinatal Collaborative, a nonprofit contracted by the state to improve maternal health care.

“It’s kind of abysmal in terms of how much funding is going toward maternal health in the state of New Mexico, given the crisis of maternal health and given the disparities that we see in this state,” said Dr. Gillian Burkhardt, medical director of labor and delivery for the University of New Mexico Hospital who served as New Mexico Perinatal Collaborative’s board president until last week, when the board resigned.

Pandemic arrives, maternity wards fold

State officials and providers all agree the last few years disrupted the maternal health care system. To free up needed beds for COVID-19 patients, hospitals across New Mexico reduced nonemergency services, which forced women to delay prenatal care.

Two hospitals — Rehoboth McKinley Christian Hospital in Gallup and Alta Vista Regional Hospital in Las Vegas — permanently closed their maternity wards in 2022. Other hospitals that shuttered their maternity wards over the past decade included Artesia General Hospital, Dr. Dan C. Trigg Memorial Hospital in Tucumcari, Union County General Hospital in Clayton and Lovelace Westside Hospital in Albuquerque.

Burkhardt said pregnant women are frequently transferred to UNM Hospital with untreated health problems due to limited — and often unavailable — care in local, rural communities.

Indeed, one in every three women statewide — and about one of every two Indigenous women — went without prenatal care during their first trimester, according to a 2021 survey by the New Mexico Pregnancy Risk Assessment Monitoring System.

Research shows that lack of prenatal care and preexisting conditions leave women vulnerable to pregnancy complications and severe maternal morbidity, including heart attack, sepsis and complications that increase preterm births, stillbirths and death.

Geographic disparities have deepened as women increasingly travel hours for something as basic as an ultrasound. With only three hospitals equipped to treat the most complex pregnancies, transportation is one of the biggest barriers affecting women in remote areas.

Importance of listening

Among the more than 10 organizations and dozen providers interviewed by Searchlight, there was a consensus that outcomes will not improve until the health care system becomes more attuned to local communities. This is especially true, they said, for communities of color, which are disproportionately affected by the crisis and more likely to experience racial discrimination and poor treatment in the health care system.

“Work with them, reach out to them, engage with them,” said Monica Esparza, executive director of the New Mexico Breastfeeding Task Force. “Until we start doing that together, I don’t know that we are going to be able to see better outcomes.”

Many women of color say they feel culturally misunderstood and left out of decision-making. As an example, a doula told Searchlight about a woman who, in the early stages of labor, drove herself from a remote area in the Navajo Nation all the way to a hospital in Albuquerque just to reach a provider who made her feel cared for.

“They are literally looking for a provider [who] they can feel they can trust and feel safe with,” said Navajo Breastfeeding Coalition Director Amanda Singer, who provided doula services to the woman.

Data but limited analysis

Racial and ethnic disparities are not unique to New Mexico: They have contributed to worsening maternal health outcomes everywhere around the country. But here, the problem is complicated by the fact that the state and its contractor, the New Mexico Perinatal Collaborative, have failed to analyze data in a timely manner. As a result, there’s limited information about whether current efforts are working.

In 2018, New Mexico joined the Alliance for Innovation on Maternal Health, a nationwide initiative that helps states improve their data analysis, establish metrics to improve obstetric care and build infrastructure to reduce maternal and infant deaths and injuries.

Leading medical organizations have recognized this program, which has been introduced in every state, as an effective approach to reduce infant mortality and maternal deaths and injuries inside hospitals, where most births take place.

Using this program, California within 14 months reduced serious complications from severe bleeding from 27% to 18%, a CDC report shows. Northern New England improved care for women with opioid use disorders by 25%. Illinois effectively reduced severe pregnancy complications and deaths by 27%.

When New Mexico joined the alliance, it identified three areas for immediate attention: obstetric hemorrhages, hypertension, and care for pregnant and postpartum women with substance use disorders. The state contracted with the New Mexico Perinatal Collaborative to develop improvements.

Few have occurred. Instead, the rate of women who experienced severe maternal morbidity — any health condition attributed to and/or aggravated by pregnancy and childbirth —increased from 76.12 per 10,000 hospital deliveries in 2018 to 97.75 in 2020, a Searchlight analysis found.

As the state of maternal health worsened, advocates began to demand a reckoning. Last month, New Mexico’s Black and Indigenous Maternal Health Policy Coalition, a statewide group dedicated to improved access and health equity, along with New Mexico’s BIPOC Perinatal Equity Coalition, jointly called for the resignation of New Mexico Perinatal Collaborative’s board.

“In the spirit of equity and inclusion, the NMPC Board recognized the importance and urgency of diversifying its leadership and the limitations of a lack of Black, Indigenous, and Persons of Color in leadership roles at NMPC,” the board wrote in an April 19 statement. The NMPC is seeking new board members, and its work “will continue through this transition,” the statement continued. “The NMPC Board members recognize the need for more efforts within the communities most impacted by maternal morbidity and mortality and are therefore excited for the opportunity that this re-seating will provide.”

Burkhardt, the former New Mexico Perinatal Collaborative president, told Searchlight the pandemic has made it challenging to develop improvements. In addition, she said, there has not been enough funding to build the necessary infrastructure — including dedicated data teams, resources for hospitals and more — so that metrics can be analyzed and hospitals get timely recommendations.

It’s hard to compare New Mexico to places like California or Illinois, Burkhardt added. Their initiatives have been underway for years, get lots more funding and have the necessary systems in place.

New Mexico, meanwhile, can’t even get CDC funding, Burkhardt noted. “As evidenced by the CDC funding map, the CDC decided to fund states with robust data infrastructure already in place, while we were requesting funds to build a data and QI [quality improvement] infrastructure to conduct the work,” she wrote in an email.

Burkhardt said the New Mexico Perinatal Collaborative cannot do its work effectively unless the state makes this initiative, currently voluntary, a mandate and provides more resources to hospitals.

To Muse, this is passing the buck: The New Mexico Perinatal Collaborative promised to do a job and has failed, she said. “We cannot blame the collaborative’s failure to make an impact on lack of funding. I think that the Perinatal Collaborative’s failure to create the results that New Mexico so desperately needs is because they don’t have the disciplinary or cultural or regional diversity that’s needed to do this.”

Hoping for the best

At 36 weeks, when prenatal visits typically become more frequent in order to screen for signs of preeclampsia, gestational diabetes and infections, Victoria Robledo found she was losing her access to health care. Until then, she had received prenatal care services at the Plains Regional Medical Center; suddenly, she said, she was informed that she couldn’t be seen again until she went into labor.

Without a provider, Robledo said her only option was to hope for the best. Twice she went to the local emergency room, thinking she was in labor.