Reproductive Healthcare Success Guide

Bold Futures NM and Forward Together are non-profit Reproductive Justice organizations that have worked alongside intergenerational communities of color to protect and expand reproductive healthcare access in our state for decades. The University of New Mexico (UNM) Health Sciences Center has been an important ally as a provider of reproductive healthcare services, education, and advocacy.

In New Mexico, women and people of color, Indigenous leaders, intergenerational community leaders, healthcare providers, and LGBTQI people have worked for decades to protect and expand reproductive healthcare access, including safe and legal abortion care. During the 2021 New Mexico Legislative Session, Bold Futures NM and Forward Together Action, alongside many committed organizational partners, community leaders, and decision makers, all worked collaboratively to support the passage of the Respect NM Women and Families Act.

This new act repealed a pre-Roe abortion ban that had remained on the books in New Mexico. Passage of this critical legislation means that even with threats to abortion care at the federal level, legal abortion care in New Mexico is protected. Despite favorable policy conditions, real access to abortion care remains limited across the state.

While we applaud expanding access to the care that people need and deserve, we know a deliberate community-based approach is necessary to truly meet our communities’ full-spectrum reproductive healthcare needs. In addition to the need for expanded abortion access, many rural areas of the state have lacked a range of basic reproductive healthcare services for years.

Providing limited care options focused only on abortion will not fully meet the reproductive healthcare needs of our communities. Providers seeking to offer this limited scope of care in light of bans in neighboring states can be received as opportunistic, which could lead to additional scrutiny and negative responses from New Mexican communities. This guide for practitioners is the direct result of a community centered, collaborative project aimed at thoughtfully and strategically expanding long-term, affirming reproductive healthcare access in our state.

Bold Futures NM and Forward Together are proud to be in collaboration with the University of New Mexico (UNM) Health and Sciences Center in developing the Reproductive Healthcare Success Project. This project set out to accomplish two outcomes:

1. Develop a community-based care model that advances the quality and accessibility standards of reproductive healthcare that all people deserve.
2. Determine one of three counties that is best suited for the placement of a full-spectrum reproductive healthcare clinic to be established by local healthcare entities with the potential for partnerships.

Thousands of individuals living in more rural parts of New Mexico lack access to basic reproductive healthcare. Cost, distance, lack of transportation, lack of insurance coverage, a lack of specialists in a given area, limited knowledge about where to access care, and shame and stigma surrounding specific reproductive healthcare options are just some of the barriers keeping people from accessing the care they may need. Focusing on those who have the least access to quality care, and in turn aiming to serve all people with equitable care, is key to a system that actually benefits everyone. Queer, trans, intersex, and gender non-conforming people, those with disabilities, those who speak languages other than English, immigrants and people with various documentation statuses, system-impacted people, those with low-income opportunities, young people seeking confidential care, people in various family structures, Black people, Indigenous people, Latine people, and people of color must all be centered in order to provide high-quality reproductive healthcare in New Mexico. Our community values demand it.

All people deserve real access to culturally congruent, trauma-informed care that is patient-driven and that addresses and roots out power dynamics and imbalances. New Mexico is a unique ecosystem whose complex history and traditions cannot be ignored, even in the context of reproductive healthcare. Providing culturally congruent care in New Mexico requires healthcare providers to acknowledge the long and short-term effects of poverty, oppression, and trauma and understand how these social forces and systemic injustices can affect physiological and mental health needs.

Culturally congruent care also requires that providers acknowledge traditional healing practices and understand varying family and community dynamics. Treatment approaches should be identity-inclusive and patient-driven, in order to support providers to treat the whole person. Providers must learn to take into consideration that while someone’s condition may be common, their personal experience is not. When it comes to identity-aware, patient-driven care, providers should always ask and not assume.

1. Provide a Full Spectrum of Quality Reproductive Healthcare Options
   • New Mexican communities across the state need and deserve access to a full spectrum of reproductive healthcare options. While abortion access is critical, there are other unmet but integral reproductive healthcare needs that communities have lacked for decades.
   • Abortion is healthcare. Reproductive healthcare, including abortion care, must be integrated into the greater healthcare system for the health and wellness of people and families, not as a for-profit service or commodity.
   • Providing limited care options focused only on abortion does not meet the community need. Providers seeking to offer this limited scope of care, in light of bans in neighboring states, can be received as opportunistic which could lead to additional scrutiny and negative response from New Mexican communities.
2. Increase Provider Collaboration
   • New Mexico is home to skilled doulas, birth workers, midwives, promotoras, community health workers, peer support workers, nurse practitioners, physician assistants, family practice providers, and OB-GYNs. This robust network of providers must be utilized to its fullest potential. Providers, healthcare centers, and funders alike are encouraged to create systems of healthcare that incorporate various provider types in order to reduce the burden on any one set of practitioners and to simultaneously enhance the patient experience.
   • Healthcare providers such as doulas, promotoras, midwives, traditional healers, and community health workers are often left out of provider spaces such as hospitals and clinics. These providers are often deeply rooted in community traditions and can hold key solutions to systemic barriers to healthcare access and quality of care issues and injustices. Healthcare providers and centers should fully include these practitioners as part of the patient-centered, patient-driven, collaborative healthcare team.
   • A strong referral network that provides continuity of care and wrap-around services, including lactation support, mental health services, social work services, options for prenatal, perinatal, postnatal care, labor classes, new parent groups, family and peer support, community integration and social support, support for substance use disorders, and more, has great benefits to patient care.
   • Providers should work towards active collaboration between various reproductive healthcare providers enabling patients/clients to access the services that best fit their needs and address patient barriers to care.

3. Provide Access and Increase Autonomy for Underserved and Historically Excluded Populations* *This section does not serve as a comprehensive list of all underserved and excluded communities. Rather, this list is a glimpse into some of the practices that were named and discussed during the course of this project.
   • Patients have many intersecting identities—their age, race, gender, nationality, sexual orientation and sexuality, immigration status, and more. While providers cannot be expected to understand in detail each of these layers and how they interact, they can aim to provide personalized care. When in doubt, it is best to ask questions rather than rely on assumptions, stereotypes, or on something learned through classes or training that may not apply to an individual case.
   • Patient treatment, designed in collaboration with the patient, should be offered on a case-by-case basis. Considerations should be made for all of the client’s intersecting identities, desires, needs, self-understanding and self-determination and how each of these components interact with their mental and physical health. Providers should seek training and educational opportunities to learn more about the underserved and historically excluded populations and rural areas where they provide care. There are many local groups and organizations rooted deeply in community who are able to provide this type of information and engage in fruitful conversation aimed at better healthcare outcomes for all.

I spent five months looking for a healthcare practitioner when I moved to Las Cruces, NM. I was in need of services that affirmed my identity. Navigating the healthcare system is hard enough, but feels impossible as a non-binary transgender person. Calling office after office and having to explain what transgender means was difficult. It felt defeating and discouraging that our community’s providers were not aware of the needs of the transgender people in their community. I needed a provider that was aware of transgender bodies, relevant reproductive healthcare, and could provide affirming care. I was fortunate to find care, but not without sacrificing a lot. My hope is that New Mexico can lead and shift to more inclusive, updated, and relevant care. Inclusive reproductive healthcare should be accessible to all New Mexicans.

• Each patient should be recognized as an individual. Each person deserves true bodily autonomy, respect, and healthcare with dignity. Individuals with disabilities, people with varying language needs, varying socioeconomic statuses, and unique cultural needs, those with differing documentation statuses, and those of all ages deserve to be treated as people, with their social identities seen and validated, and not as “problems.” While it can be tempting to fall into the hustle and bustle of the healthcare industry, providing culturally congruent care means moving much closer to the client’s pace, listening fully, asking consent, and providing treatment options without judgment that meet the unique needs of the person.

• Providers are mandated by the Americans with Disabilities Act (ADA) to ensure effective and accurate communication with patients who are Deaf or hard of hearing. It is the provider’s responsibility to secure a qualified interpreter or auxiliary aid to facilitate communication. Providers may have multiple accessibility options, including ASL interpreters, video relay options, or telecommunications devices. Due to the complexity of communication needs, it is best to follow the guidance of the patient on which communication is most effective, even if the provider believes it goes beyond the basic requirement of the law.
• Transgender and non-binary individuals deserve gender-affirming care that supports their gender identification without judgement. Gender-affirming care includes but is not limited to intake forms with options beyond male and female, training for all medical staff regarding the use of correct names and pronouns, plus training and education about transgender and non-binary communities.
• Many individuals seeking reproductive healthcare face shame and stigma due to widespread misinformation, societal pressure, lack of education, and prevailing religious beliefs. It is critical to gain the full picture of a patient’s needs and meet them where they are at with regards to their healthcare concerns. A non-judgemental relationship between a patient and provider will result in better outcomes for both.
• Practicing patient-driven, collaborative care means getting to know the person beyond the traditional medical chart. While consultation times may not always allow for needed relationship building, adding optional intake forms or questions in multiple languages is beneficial. Many patients have specific cultural values and traditions that impact quality of care. Build the necessary collaborations with other care providers to meet this need. (See Increase Provider Collaboration section above.)

4. Seek Further Education as Providers and Support Education for Patients
   • Community members, organizational leaders, and providers alike expressed a lack of basic sex education and reproductive health education in their communities. Not everyone has had access to accurate information about the fundamentals of sex, pregnancy, contraception, or other reproductive healthcare topics. Providers must take this into consideration and aim to provide basic information related to the patient in a manner that is nonjudgmental, respectful, accurate, and affirming.
   • Education and increased awareness of the existing systemic racial bias in healthcare can positively impact infant outcomes and decrease rates of maternal morbidity and mortality. Fostering and advancing anti-racism training, values, and culture is critical.
   • Seek out continual opportunities to learn about the influential traditions, languages, beliefs, and values common to the communities providers serve in. This can lead to the bridging of cultural gaps and result in better patient and provider outcomes.
   • Access continual training in up-to-date trauma-informed and evidence-based care practices and adhere to them at all times. Trauma-informed care principles help to ensure that patient-driven care remains a priority. Trauma-informed training is important for staff and employees at all levels, from front reception to billing to physicians and nurses.
   • Seek out training opportunities and resources that provide information on the histories that have resulted in generational trauma for communities where care is being delivered. Providers are encouraged to learn about the various ways they can administer quality care across a variety of circumstances, including domestic violence, sexual assault, forced sterilization, medical coercion, substance use, and more. Healthcare systems themselves play a direct role in the history and ongoing issue of generational trauma in many communities.
   • While it is impossible to know the history and generational patterns of each person, there are ways to mitigate the harm and create a path toward positive patient outcomes. Ongoing, affirmative, clear consent throughout the process of care is key to supporting the patient against the backdrop of generational trauma and coercion. Saying yes once, does not mean saying yes to everything after that, even within a single interaction between staff and patient. A failure to address this could lead to disjointed relationships between a provider and their patients. Training in consent practices may be helpful.
5. Create Safe Environments for Patients and Providers
   • Regionally specific and appropriate security protocols should be implemented and updated frequently to address the changing safety needs of patients and providers. Because reproductive healthcare is often stigmatized and even met with violence, it is imperative that safety protocols that maintain the dignity and safety of your facility are in place.
   • Full informed consent is necessary for all people seeking reproductive healthcare. Throughout discussions for this project, community members and providers alike understood that consent at each step of the visit, procedure, or treatment is necessary to help mitigate undue distress and negative outcomes for all patients.
   • Providers can do their part to mitigate shame and stigma associated with reproductive healthcare by using their platforms to speak more openly about the realities of reproductive healthcare. This can be as public as a social media post or as private as a one-on-one conversation with a loved one. Both patients accessing reproductive healthcare and their providers can experience shame and stigma related to treatment.

As a white person who’s not from the borderlands, I think one of the essential aspects of the provision of care is dealing with my own racism, my own history of white supremacy, my own prejudice, my own privilege. Even using the term cultural sensitivity, is to me culturally inappropriate. Sensitivity is not the issue. It’s dismantling and decolonizing the history of medicine. When we’re talking about reproductive health, we have to acknowledge the very real violence that has been done to communities here, the control of women’s bodies, eugenics, forced sterilization, control of who has access to contraception or not and how they have access. I think it’s a super complex thing in this area, especially in New Mexico, with the history of IHS bringing in people from all over the place to care for communities. Midwifery on the border has a long, long, long history of white women coming to learn on the backs of Mexican women’s bodies because of the political economic structure here.

1. Collaborate with Community in Funding Plans: Proposals to increase reproductive healthcare access must include stakeholder collaboration. Efforts cannot be siloed from the community. The goal must always be to improve the healthcare of communities so that all of us can thrive. This can be done by supplementing the strengths that are already present within the region of focus and amongst the people who will be served through funding efforts. When funders, organizations, and providers lose sight of this goal, they risk developing a savior complex. The savior complex is a symptom of white supremacy7 and does not reflect collaboration with the community. When this occurs, both communities and the project itself will suffer.
2. Fund Full-Spectrum Reproductive Healthcare: Abortion care is essential healthcare. While this is true, there are many other types of needed reproductive healthcare that are greatly lacking, especially in rural communities. People need access to a variety of reproductive healthcare services over their lifetimes. Swooping in to provide siloed care based on current social or political trends is not beneficial to or sustainable for communities.
3. Supporting the Whole Patient: Healthcare sites need patients in order to function. Patients face a multitude of barriers when seeking healthcare. Funding to cover child care assistance, trans- portation, and American Sign Language and other non-English language interpreters, as well as ad- vocating for and funding paid sick and medical leave are all ways funders can directly address issues that meet at the intersection of patient needs and reproductive healthcare access.
4. Funding a Sustainable Model of Reproductive Healthcare: Funding a sustainable model of reproductive healthcare means meeting needs beyond infrastructure and staffing. While start-up funding is critical, funding to implement long-term sustainability is even more nec- essary. Long-term general operating support for start-up facilities can help providers and facility administration to grow with their communities. Approaching reproductive healthcare in new ways means trying new methods, incorporating new values, and embracing change. These new methods can be very challenging to the usual, often siloed and opportunistic business models we have grown accustomed to. Long-term funding allows providers, facil- ity administrators, and the communities they serve to advance together, and adjust as they move towards improved healthcare outcomes for all stakeholders.
5. Fund Collaborative Networks of Providers: There is a robust network of providers who are critical to positive patient outcomes. Increasing access means forging a new path where birth workers, social workers, mental healthcare providers, and others providing integrated, wrap-around services are part of the essential patient network and funded appropriately.

Our collective vision for our communities includes opportunities for all people to access a full spectrum of high quality reproductive healthcare that is gender-affirming, trauma-informed, and culturally congruent with the New Mexican values we have worked so hard to protect.

Through the process of developing this guide, we heard loud and clear from our participants the importance of working to ensure that all types of providers are included in truly collaborative patient-driven care. We heard about the need for expanded wrap-around services that more fully meet a patient’s needs, and for continuity of care opportunities. We also heard about the inequities many patients face, and the challenges providers themselves face when attempting to serve their patients in the best ways they know how. Overcoming these challenges will require continual training and education for providers and their extended staff, including administration, if they seek to achieve excellence in providing healthcare that is truly responsive to the needs of the communities they serve. Cultivating this level of care will take the hearts, minds, experience, trust, and committed labor of many types of providers and funders alike — and doing so is necessary.

The reproductive healthcare system as we know it is not working for so many who live and work in New Mexico, including many providers. Our collective vision incorporates the business sustainability needed by clinics and healthcare institutions to recruit and maintain high-quality providers and staff. We are also planning for and know that community access to a broad array of reproductive healthcare services is needed by the diverse patients who seek care. The future of reproductive healthcare in New Mexico is community based, culturally responsive, long-term care that intentionally addresses both the needs and strengths of the people. It is time to go beyond the vision and work towards solutions. We hope you will join us in making this vision a reality.