More than 22 million non-citizens live in the United States — about 7% of the total U.S. population. Many do not have access to healthcare, including reproductive services.1
Immigrants — including refugees, those with permanent residency, and those who are undocumented — face additional challenges and barriers to reproductive care.2,3
Not all immigrants experience the same barriers to care, but most — from a Ukrainian refugee to a Guatemalan woman without documentation, to a Turkish woman with legal residency — have language obstacles that healthcare providers need to help them overcome. Many also face financial issues, such as a lack of public or private health insurance.
“Typically, immigrants are excluded from public health programs,” says Goleen Samari, PhD, MPH, MA, an assistant professor of population and family health at Columbia University Mailman School of Public Health in New York. “Even without a pandemic, immigrants are non-citizens, and their families are unable to obtain affordable sexual reproductive healthcare. This is due to limited access to public health insurance programs and rules around legal status and residency.” Uninsurance rates for immigrants and non-citizens is three times higher than for U.S. citizens, she adds.
Refugees undergo specific health screenings when they come into the United States. Their care and follow-up needs look different than those of someone who is undocumented. “We need to make sure when we talk about immigrants as a homogenous group that we’re aware there are differences between countries of origin and how they arrived — whether they are asylum-seeking or an undocumented immigrant or a refugee,” Samari says.
There also is a need for inclusive state policies and more research into immigrant communities’ needs in the area of sexual and reproductive health. “There are some state-level exceptions, but undocumented immigrants have no access to public health programming that would give them additional access to sexual healthcare,” Samari adds.
For example, while emergency Medicaid can be used for childbirth services, many states do not provide prenatal care or contraceptive care. Immigrants who are undocumented also are not eligible for insurance coverage under the Affordable Care Act.1
Policies Threaten Access to Care
In a recent literature review of publicly funded reproductive health services to immigrant women in the United States, researchers found most articles focused on prenatal care.2 The research discusses some of the specific barriers for undocumented women, including their geographic location, notes Samantha Garbers, PhD, study co-author and associate professor in the department of population and family health at Columbia University..
“We quantified a lot of gaps and access [issues] for immigrant women and talked specifically about some of the barriers of care, including waiting periods for Medicaid and undocumented people not having access — being ineligible,” Garbers explains. “There are laws that discourage people from seeking care.” In general, the Medicaid expansion is improving prenatal care, but its effect on improving the reproductive healthcare of immigrant populations is not well studied, she notes.
Anti-immigrant policies threaten the sexual and reproductive health of immigrant communities. The Health Equity and Access under the Law (HEAL) for Immigrant Women and Families Act would expand immigrants’ insurance eligibility and access to reproductive health services, according to a 2020 paper Samari co-authored.4 The bill was introduced in the U.S. House of Representatives in 2019 but did not receive a vote.5
The COVID-19 pandemic exacerbated discrimination and exclusions in the social and healthcare systems. For instance, many non-citizens cannot access essential reproductive care, including family planning services, pregnancy-related care, and screening for sexually transmitted infections (STIs) and reproductive cancer.4
“Think about Medicaid coverage, for example,” Samari says. “Does a state provide public health insurance to undocumented women?”
There is no single answer. Every state follows different policies, including many that are xenophobic and racist, Samari and co-authors noted. Within state and local environments, there is a combination of both criminalization and integration policies.6
When Samari and co-investigators studied the Immigration Policy Climate across all states from 2009-2019, they found that two-thirds of state-level immigration policies are based on excluding immigrants. Their data showed that Georgia and Alabama were the most exclusionary environments for immigrants, and California and Washington had the most inclusive policies.6
“The majority of states have no insurance option for legal permanent residents or undocumented women,” Samari says. “They can go into the emergency room and seek care in an emergency situation, but they don’t get prenatal care, which is integral to reproductive healthcare.”
When a state does not offer coverage for pregnant people in communities of immigrants, then other sexual and reproductive healthcare — like birth control — becomes more difficult. Often, the only affordable option for reproductive health services to low-income people and uninsured immigrants is a family planning center, Samari notes.
When the Trump administration enacted the Title X gag rule, which resulted in hundreds of family planning centers leaving the Title X program, the capacity for Title X clinics to meet uninsured immigrants’ contraceptive needs was cut in half. Although the Biden administration reversed the gag rule, lack of funding has prevented programs from expanding.
In addition to the barriers of low income, lack of insurance, and state policies, there also is an important barrier related to fear and distrust. Immigrant communities may hold rational fears about accessing any public services because of the risk of arrest, detention, deportation, and even worse outcomes. For example, in 2020, a whistleblower in Georgia told a shocking story of how immigrants underwent invasive gynecological procedures, including hysterectomies, without their consent, Samari says.
Legal advocacy groups filed a whistleblower complaint by a nurse about how immigrants in a U.S. Immigration and Customs Enforcement detention center in Irwin County, GA, were given hysterectomies and other surgical procedures that rendered them infertile, or nearly infertile, without their knowledge or consent. The nurse reported that one physician performed hysterectomies on women — mostly those with limited English language proficiency — who complained of heavy menstrual cycles. The nurse called the doctor “the uterus collector.”7
According to the complaint filed by human rights legal groups, including the Government Accountability Project and Project South, one woman learned the doctor had removed the wrong ovary, another was not properly anesthetized, and a third woman received a hysterectomy when she thought she was undergoing cyst drainage. One detainee called the place an experimental concentration camp.7
Reports like these might not capture the general public’s attention for long, but they have a long-term chilling effect on immigrant communities and people who already have had troubling experiences with healthcare providers.
“I [conducted] a study of the immigrant community in New York City during the pandemic, looking at their access to sexual and reproductive healthcare,” Samari says. The New York City immigrant communities were troubled by news of the forced hysterectomies in Georgia and how the detainees’ reproductive rights were violated.8
“The news reverberated across the immigrant communities in the United States,” Samari says. “One participant talked about fear from a pregnancy loss in detention, so she would not seek any sexual reproductive healthcare out of the trauma of that experience. We had participants who experienced discrimination in waiting rooms or in the subway, and it made them hesitant to seek healthcare services.”
Public solutions include the federal government providing more Title X funding and more public health options for immigrants, including permanent residents and undocumented people. Better access to interpretation services and better cultural sensitivity among healthcare providers and staff also are important.
“A whole lot of what you hear from immigrants and citizens is they want culturally competent care and language accessibility,” Samari explains. “They say, ‘They can’t communicate with me in my language, and they make fun of me for my English.’”
Even when healthcare centers offer Spanish-language coverage, they might not offer help for immigrants who speak many other languages. “It’s easy to say, ‘We’ll have Spanish language coverage,’ but where I work, there are people from all over the world,” Samari says. “The lack of language skills and access is a much bigger barrier than I anticipated when interviewing people recently.”
Other solutions involve better training and support for virtual visits with patients who are less familiar with these. Sometimes called digital redlining, immigrants and those with low digital skills and low English proficiency may face multiple obstacles to successful telemedicine visits.
“In my study in New York, it was identified by both immigrant women and healthcare providers that there was a challenge to accessing sexual and reproductive health services when there was a shift to virtual care,” Samari explains. “Family planning centers were the access point for primary care for many of these women, but digital technology really challenged them.”
Obstacles included inconsistent or a lack of virtual platforms, difficulty with virtual English proficiency, and questioning of the quality of their virtual sexual and reproductive health providers. For example, one person was concerned about whether the physician would get a good sense of her health without seeing her in person to conduct a physical exam and draw blood.
“This was especially true of those who experienced gender-based and sexual violence, which increased in the pandemic,” Samari explains. “We need to be mindful of communities that are underserved and vulnerable because they have a lot of barriers to accessing virtual care.”
One solution is to schedule an in-person visit the first time the clinician meets the immigrant patient to provide reassurance and establish trust.
Reproductive health providers often are the first entry point for any kind of healthcare for immigrant communities in the United States. “They may not seek out healthcare social services for other reasons, but they go to family planning clinics, which are the principal entry point for connecting these women to additional resources and support,” Samari says. “That’s a huge responsibility that sexual and reproductive healthcare providers have.”
REFERENCES
- Fabi R, Banerjee M. Undocumented immigrants and health care access in the United States. The Hastings Center. Sept. 12, 2014.
- Jain T, LaHote J, Samari G, Garbers S. Publicly-funded services providing sexual, reproductive, and maternal healthcare to immigrant women in the United States: A systematic review. J Immigr Minor Health 2022;24:759-778.
- Hasstedt K, Desai S, Ansari-Thomas Z. Immigrant women’s access to sexual and reproductive health coverage and care in the United States. Issue Brief (Commonw Fund) 2018 Nov 1;2018:1-10.
- Desai S, Samari G. COVID-19 and immigrants’ access to sexual and reproductive health services in the United States. Perspect Sex Repro Health 2020;52:69-73.
- 116th Congress. H.R.4701 – HEAL for Immigrant Women and Families Act of 2019. Oct. 16, 2019.
- Samari G, Nagle A, Coleman-Minahan K. Measuring structural xenophobia: US State immigration policy climates over ten years. SSM Popul Health 2021;16:100938.
- Paul K. Ice detainees faced medical neglect and hysterectomies, whistleblower alleges. The Guardian. Sept. 14, 2020.
- Damle M, Wurtz H, Samari G. Racism and health care: Experiences of Latinx immigrant women in NYC during COVID-19. SSM Qual Res Health 2022;2:100094.
More than 22 million non-citizens live in the United States — about 7% of the total U.S. population. Many do not have access to healthcare, including reproductive services. Immigrants — including refugees, those with permanent residency, and those who are undocumented — face additional challenges and barriers to reproductive care.
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