This post is part of “Inequities in Maternal Mortality in the U.S.,” a blog series hosted by the MHTF.
Does documentation status matter for maternal mortality in the United States? Aggregate data in middle and high-income countries often mask the vast underlying disparities that contribute to disproportionate poor health outcomes among marginalized groups. Inequitable societies create fundamentally different environments through which to understand and address complex health problems, such as maternal mortality.
Documentation status is a difficult variable to identify and count in large data analyses of maternal mortality. Despite the advances in medical research and increase in health sector spending, maternal mortality is increasing in the United States. Some experts argue this trend can be explained by a combination of inter-related factors: better reporting mechanisms, increasing rates of chronic disease coupled with access to assisted reproductive technologies, increasing Cesarean delivery rates and the complex social determinants of health and disease.
With the increasing obesity and cardiovascular disease rates among women of reproductive age, integrated care between primary care physicians and obstetricians is paramount to reducing pregnancy-related morbidity and mortality. The Affordable Care Act (ACA) provided expanded access to health insurance and basic health needs, such as contraception.
Notably, excluded from the ACA are more than 11 million undocumented immigrants who live and work in this country. While race and socioeconomic status are compelling lenses through which to examine inequities in health care, I propose a human rights approach to understanding the inequities undocumented women experience as they navigate childbirth and its complications in this country. Imagine a world in which people are denied health care based on where they are born – a chance occurrence over which no one has control. Why have the poor effects of documentation status not reached the human rights agenda for health care?
Undocumented immigrants represent a diverse group of individuals, families and communities. The American College of Obstetricians and Gynecologists published a Committee Opinion “Health Care for Unauthorized Immigrants” in March 2015, highlighting what is known about undocumented women and their limited interactions with the health system, particularly during childbirth. Undocumented immigrants may receive emergency services, including childbirth, through the Emergency Medical Treatment and Active Labor Act. However, prenatal and postpartum care are not covered by this federal policy, but it is up to state legislatures to decide if they will provide it. Currently, California and New York are developing health coverage options for undocumented immigrants.
One JAMA study reported that 82% of spending and 91% of hospitalizations covered under Emergency Medicaid—a financial structure that covers emergency services for low-income patients without regard to legal status—were for childbirth and pregnancy-related complications in 2004. This demonstrates the great need yet poor access for low-income women, many of whom may be undocumented. One study reported that undocumented pregnant women are the group least likely to obtain adequate prenatal care compared with women born in the United States. In addition to their exclusion from public health insurance and often limited resources, undocumented women choose not to seek health care in safety net health facilities out of fear of deportation, judgment and communication barriers.
Furthermore, undocumented women may be at high risk of sexual assault and sexually transmitted infections from their dangerous journeys. Yet, they have little to no access to basic primary care and reproductive health services once they arrive in the United States. These women experience myriad social determinants of poor health and disease: poverty, language barriers, food and job insecurity, fragmented social networks, environmental and occupational health hazards and stress related to discrimination and fear of deportation. We can assume that these women have poor access to health care and higher maternal mortality due to the measured effect these determinants have on other outcomes, but in order to best serve this population, we need better data.
Despite the complex legal and political environment surrounding undocumented immigrants, advocates have opportunities to engage undocumented immigrants and connect them with health care.
- First, undocumented immigrants must be counted in health outcomes research. While documentation status remains fragile and protected information, it is critical to 1) collect the demographics of this population, 2) identify their health problems and 3) understand their access to health care. The paucity of data regarding this population hinders meaningful advocacy projects and health policy changes.
- Second, civil society should petition legislators to expand subsidized health insurance options for undocumented immigrants to purchase. The majority of undocumented immigrants are employed, as work is the top reason immigrants come to the United States. They are the backbone of this country, often working in inhumane conditions in farms and factories that others would not tolerate. If given the option to purchase subsidized health insurance, undocumented immigrants could gain access to necessary primary health care. Since Massachusetts was the harbinger of “universal” health insurance, lawmakers can truly make it universal by making health insurance truly accessible to all the people, acting as an example to other states in the Union.
- Third, we should bring the human rights framework about undocumented immigrants to the local, state and national political arena in the upcoming elections. Examples include hosting citizenship drives, disseminating information about candidate’s proposals for immigration reform and encouraging citizens to vote for candidates who address the immigration issue with a rights-based approach.
- Lastly, health care providers should consider delivering care that supports the social needs of the undocumented community. One example is Centering Pregnancy, group prenatal care sessions that focus on building social networks and improving pregnancy outcomes for pregnant women.
Grounded in the belief that health care is a universal human right for all people regardless of place of birth, researchers, advocates, politicians and clinicians must join together to understand this hidden population and strengthen their access to healthcare. Documentation status does matter for maternal mortality in the United States.