Disparities in Prenatal Care Among Undocumented Immigrants

By Winona Gbedey, Sanjana Ravi and Rozena Shirvani

Despite representing 6% of Texas’s population (1.8 million individuals), undocumented residents face substantial barriers to healthcare, both in Texas and across the nation.1-2 In addition to being ineligible for Medicaid, CHIP and the ACA Marketplace, undocumented immigrants utilize the services they are eligible for at much lower rates than their United States born counterparts. Furthermore, private insurance coverage is only accessible to those that can afford to pay full price without a subsidy. As a result, many undocumented residents depend on federally qualified health centers, charity clinics, and safety net hospitals for all aspects of their healthcare.3 These factors combined with lack of language interpretation services, unreliable transportation, limited knowledge of available resources, and cost to make the U.S. healthcare system incredibly complex and inaccessible to many immigrants. Consequently, immigrants with conditions that require constant management are left to struggle for care.

Pregnant women, in particular, are a special demographic because both them and their unborn child have unique particular/special healthcare needs. This problem is particularly pronounced in Texas, which is home to the second-largest population of undocumented residents in the country. Historically, undocumented women are more likely to miss prenatal visits and experience complications during delivery. When compared to their counterparts, babies born to these women are more likely to be premature and underweight, both of which contribute to the high rates of infant morbidity and mortality in this population.4 These poor outcomes have been linked to the aforementioned barriers to healthcare, which lead to underutilization of preventive health services.

Healthcare inaccessibility is not unique to undocumented immigrants. Of the over 14.6 million women living in the state of Texas, almost 30% are uninsured.5 To combat the innate health disparities that accompany these numbers, Texas created free and low-cost safety net programs, including Healthy Texas Women and Healthy Texas Women Plus, the Texas Family Planning Program and the Breast and Cervical Cancer Services.6-8 Unfor- tunately, even though these programs have helped so many U.S. born residents, they fail to address the complex needs of undocumented residents, allowing many to fall through the cracks.

Currently, undocumented pregnant women can qualify for the Texas CHIP Perinatal program, which covers up to 20 prenatal visits, delivery-related charges and two postpartum visits. 9-12 In 2002, the Centers for Medicare and Medicaid Services permitted state governments to set aside funds for unborn children. Some states, like Texas, have used this money to support pregnant mothers, regardless of immigration status. In order words, pregnancy qualifies undocumented women for essential prenatal and preventative medical care. However, once her child is born, these services are no longer available to her.

Undocumented residents who meet requirements for Medicaid but who cannot use it due to their immigration status may also be eligible for Emergency Medicaid, which has special provisions for labor and delivery. Ad- ditionally, if a patient’s condition is a medical emergency, emergency departments must treat them under the Emergency Medical Treatment and Labor Act (EMTALA). In fact, the EMTALA was specifically designed to serve the medical needs of the country’s uninsured and undocumented.13

Finally, undocumented women can seek services from clinics funded by Title V and Title X. Patients can locate these clinics through the Texas Health and Human Services (HHS) site and the national HHS online directory. The Title V Maternal and Child Health Fee-for-Service Program provides funding to support women, children, and families providing care to over 60 million individuals annually. With Title V funding, clinics are able to provide preventive and wellness visits, supply prenatal, delivery, postpartum care and much more.14 Likewise, the Title X Family Planning Program is the only federal program solely dedicated to providing family planning services to low-income families. Through Title X, over four million men and women receive wellness exams, cancer screenings, reproductive and education care, STI testing and treatment annually.15

In addition to gaps in services, mistrust of governmental and government-adjacent agencies (including healthcare and social welfare agencies) remains a significant barrier to care for undocumented individuals.16 Despite living in the margins of society, many immigrant families are wary of government assistance due to fear of potential repercussions, such as detainment by U.S. Immigration and Customs Enforcement (ICE) agents or deportation. Legislation such as the now-repealed Public Charge rule, which prohibited those who used public benefits for more than 12 months from becoming lawful permanent residents, has resulted in disenrollment and foregoment of public benefits despite eligibility for these services.17-18

In conjunction with advocating for increased coverage and access to social welfare programs, we must also focus on building trust among communities that have repeatedly been discriminated against by government agencies.19-22 We can start by educating ourselves and our patients on available resources, while also working upstream to create inclusive and equitable policies that defend the health of our most vulnerable communities.

To find more information and/or resources visit the following websites: National HHS Directory for Title X clinics https://opa-fpclinicdb.hhs.gov/

National Directory of State Hotlines for Title V Clinics https://mchb.tvisdata.hrsa.gov/Home/StateHotlines

Texas Medicaid & Chip FAQs https://www.hhs.texas.gov/services/health/m edicaid-chip

References

1. Immigrants in Texas. American Immigration Council. https://www.americanimmigrationcouncil.org/research/immigrants-in-texas. Published August 7, 2020.

2. Profile of the unauthorized population - TX. Migration Policy Institute. https://www.migrationpolicy.org/data/unauthorized-immigrantpopulation/ state/TX. Published May 1, 2022.

3. Dunkelberg A. Immigrants’ Access to Health Care in Texas: An Updated Landscape. Center for Public Policy Priorities. 2016. https://everytexan.org/images /HW_2016_ ImmigrantsAccess_FullReport.pdf. Accessed May 19, 2022.

4. Health Care for Unauthorized Immigrants. American College of Obstetricians and Gynecologists. https://www.acog.org /clinical/clinical-guidance/committee-opinion/articles/2015 /03/health-care-for-unauthorized-immigrants. Published 2019. Accessed May 19, 2022.

5. State Summaries Texas | 2016 Health Of Women And Children Report. America's Health Rankings. https://www.americashealthrankings.org/learn/reports/2016health-of-women-and-children-report/state-su mmaries-texas. Published 2022. Accessed May 19, 2022.

6. Take charge of your health. Home | Healthy Texas Women. https://www. healthytexaswomen.org/. Published 2022. Accessed May 17, 2022.

7. Family Planning Program. Family Planning Program | Healthy Texas Women. https://www.healthytexaswomen.org/healthcare-programs/family-planning-program. Published 2022. Accessed May 17, 2022.

8. Breast & Cervical Cancer Services | Texas Health and Human Services. https://www.hhstexas.gov/providers/health-servicesproviders/ womens-health-services/breast-cervical-cancer-services. Published 2022. Accessed May 17, 2022.

9. Dunkelberg A. Immigrants’ access to health care in Texas. https://everytexan. org/images/HW_2016_ImmigrantsAccess_FullReport.pdf. Published 2016.

10. Medical assistance programs for immigrants in various states. https://www.nilc. org/wp-content/uploads/2015/11/med-services-forimms-in-states.pdf. Published July 2021.

11. Immigrant women's access to sexual and reproductive health coverage and care in the United States. Immigrant Women's Access to Sexual & Reproductive Coverage & Care. https://www. commonwealthfund.org/publications/issue-briefs/2018/nov/immigrantwomens-access-sexual-reproductive-health-cov erage. Published November 20, 2018.

12. CHIP Perinatal FAQs . https://www.hhs. texas.gov/services/health/medicaidchip/provider-information /texas-medicaidchip-chip-perinatal-coverage/chip-perinatal-fa qs. Published 2022. Accessed May 17, 2022.

13. Health Care for Unauthorized Immigrants. https://www.acog.org/clinical/ clinical-guidance/committee-opinion/articles/2015/03/ health-care-for-unauthorized-immigrants. Published 2015. Accessed January 29, 2022.

14. Title V Maternal and Child Health Services Block Grant Program. U.S Department of Health and Human Services. https://www.hhs.gov/guidance/document/titl e-v-maternal-and-child-health-services-blockgrant-states-program-guidance-and-forms-2. Published 2021. Accessed May 19, 2022.

15. What is Title X?. Every Body Texas. https://www.everybodytexas.org/everybody/what-is-title- x?gclid=Cj0KCQiA6 NOPBhCPARIsAHAy2zD5qBUS46q3L5dj2 _z3s2pb-xOiqcC0W2yJKRB Ec65H8IsUApxEEagaAsbnEALw_wcB. Published 2020. Accessed May 19, 2022.

16. Kerani RP, Kwakwa HA. Scaring Undocumented Immigrants Is Detrimental to Public Health. Am J Public Health. 2018;108(9):1165-1166. doi:10.2105/A JPH.2018.304596

17. Bernstein H, Gonzalez D, Karpman M, Zuckerman S. Adults in Immigrant Families Report Avoiding Routine Activities Because of Immigration Concerns. Urban Institute. https://www.urban.org/research/publica - tion/adults-immigrant-families-report-avoiding-routine-activities-because-immigrationconcerns. Published 2019. Accessed May 19, 2022.

18. Public Charge. U.S. Citizen and Immigration Services. https://www.uscis.gov/public-charge. Published 2022. Accessed May 19, 2022.

19. Family Separation and Detention. Americanbar.org. https://www.americanbar. org/advocacy/governmental_legislative_work/priorities _policy/immigration/familyseparation/. Published 2022. Accessed May 19, 2022.

20. Tau B, Hackman M. Federal Agencies Use Cellphone Location Data for Immigration Enforcement. The Wallstreet Journal. https://www.wsj.com/articles/federal-agencies-use-cellphone-location-data-for-immigration-enforcement-11581078600. Published 2020. Accessed May 19, 2022.

21. FOIA Request - DHS, CBP, and ICE Purchase and Use of Cell Phone Location Data. American Civil Liberties Union. https://www.aclu.org/foia-document/ foia-request-dhs-cbp-ice-cell-phone-location-data. Published 2020. Accessed May 19, 2022.

22. Wessler N. The U.S. Government Is Secretly Using Cell Phone Location Data to Track Us. We’re Suing. | News & Commentary | American Civil Liberties Union. American Civil Liberties Union. https://www.aclu.org/news/immigrantsrights/the-u-s-government-is-secretly-usingcell-phone-location-data-to-track-us-were-suin g. Published 2020. Accessed May 19, 2022.

Winona Gbedey is a fourth-year medical student at UT Health San Antonio Long School of Medicine. She is a member of the BCMS Publications Committee and the Texas Medical Association (TMA).

Sanjana is a third-year dual degree MD/MPAff student at Dell Medical School and LBJ School of Public Affairs. She is an active member of the Texas Medical Association (TMA) and the American Medical Association (AMA).

Rozena Shirvani is a second-year medical student at the UT Rio Grande Valley School of Medicine. She is a student member of the Texas Medical Association (TMA).