The 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA, “welfare reform”) was a broad federal measure in the United States that ended the guarantee of welfare (cash assistance) to eligible families.1 Under the PRWORA, states were given block grants to provide time-limited support to low-income families who complied with work requirements. Although the PRWORA did not change low-income citizens' eligibility for Medicaid, it imposed new restrictions on the use of federal Medicaid funds for some groups of documented (legal) immigrants and retained prohibitions on the use of federal Medicaid funds for undocumented (illegal) immigrants, except for emergency services.1
Prenatal eligibility for Medicaid was expanded in the late 1980s,2 resulting in a doubling of the proportion of births financed by Medicaid, from 15% in 1986 to 31% in 1991.3 It is likely that immigrant women, including undocumented women, benefited greatly from these expansions in Medicaid eligibility. In California, where state funds were used for undocumented women, one third of Medicaid-financed deliveries in 1995 were to undocumented women.3
Hispanic women represent a unique subset of childbearing women in the United States, with high fertility rates and late entry to prenatal care.4 Twenty percent of all childbearing women in the United States are Hispanic and nearly two thirds are foreign-born.4 Although the exact number of undocumented childbearing Hispanic women is not known,5 the policy changes associated with the PRWORA were expected to have an impact on immigrant Hispanic women.3,6
Under the PRWORA, states were given the option of providing benefits to federally ineligible groups using nonfederal sources of funding. Some states, including Florida and Texas, adopted the federal eligibility criteria, resulting in restricted access to prenatal care through Medicaid.7 Other states, such as California and New York, opted to continue providing services to ineligible groups using state sources of funding (California and New York) or as a result of legal measures (New York).6,7 It is not clear whether state-based differences in the implementation of the PRWORA influenced access to or use of prenatal care. We undertook a multistate study to assess the effect of the PRWORA on use of prenatal care among Hispanic women.
MATERIALS AND METHODS
From March 1999 through February 2001, we recruited childbearing Hispanic women who delivered at 1 of 7 hospitals in 1 of 3 states (3 hospitals in New York City, 3 hospitals in the San Francisco/Bay Area, and 1 hospital in Miami, Florida).8 In the 3 cities, which had a large population of Latinos, we selected those hospitals that had the largest number of deliveries to Hispanic women in the year before initiation of the study. We recruited women who were at least 17 years old, self-identified as being Latina/Hispanic, had at least 1 parent or grandparent born in a Latin American or Latin Caribbean country (excluding Puerto Rico and Brazil), intended to care for their children, planned to remain in the area for at least 6 months, were able to communicate in Spanish or English, and gave informed consent. A total of 4,724 women met the study criteria, and 3,957 (84%) were available for the interview and agreed to participate. For this analysis, we restricted the study sample to the 3,831 women who delivered a liveborn singleton infant and were not in the PRUCOL immigration category, a small group of immigrants who are “permanently residing under color of law” (PRUCOL) but who are distinct from other groups of documented immigrants.7 The project was reviewed and approved by the institutional review boards at all study sites.
A structured interview that lasted 45 minutes was administered in English or Spanish during the delivery hospitalization. The interview assessed immigration status and demographic and other maternal characteristics. Information about use of prenatal care was abstracted from the maternal medical record.
The dependent variable was use of prenatal care, defined by the onset of care and the number of prenatal visits. First, we calculated the median month of onset of prenatal care and the mean number of prenatal visits. Second, we dichotomized use of prenatal care as adequate (onset during the first trimester and ≥ 6 prenatal visits) or inadequate (onset during the first trimester and < 6 prenatal visits or onset after the first trimester). Both the U.S. Public Health Service and The American College of Obstetricians and Gynecologists (ACOG) recommend that prenatal care begin in the first trimester, although the recommended minimum number of visits for a full-term pregnancy ranges from 8 (U.S. Public Health Service) to 14 (ACOG).9 Thus, our definition of at least 6 prenatal visits was a conservative definition of adequate prenatal care.
The primary independent variables were state of residence and maternal immigration status. We analyzed state of residence as a measure of policies that could affect access to or use of prenatal care. Nativity was defined by country of birth and dichotomized as U.S.-born or foreign-born. Immigration status was ascertained with a series of questions; the sequence began by asking if the woman was a citizen and ended by asking if the woman was an undocumented immigrant. Whenever the woman answered affirmatively to an immigration status category, the sequence of questions ended. We created 4 mutually exclusive categories: U.S.-born citizens, foreign-born citizens, documented immigrants, and undocumented immigrants. We used U.S.-born citizens in New York as the reference group for all comparisons because we hypothesized that U.S.-born women would be the least affected by the policy changes, and the subgroup from New York was the largest group.
Additional independent variables were maternal national origin subgroup, age, education, marital status, gravidity (number of pregnancies), prenatal health insurance, and cigarette smoking during pregnancy. We assessed barriers to prenatal care by asking if any of the following factors prevented a woman from initiating prenatal care as early as she wanted: 1) no child care, 2) no transportation to clinic, 3) no doctor or nurse would accept her as a patient, 4) the inability to obtain an earlier appointment, 5) a lack of money or insurance to pay for the visit, and 6) not knowing where to go for care.
We used χ2 and exact statistics to compare the distribution of maternal characteristics by state immigration status groups. We used pairwise t tests to evaluate differences in the median month of onset of prenatal care and mean number of prenatal visits, using New York women as the reference group. Stepwise logistic regression was used to estimate the effect of all covariates on the risk of inadequate use of prenatal care. The variables retained in the stepwise regression model were included in the final multiple logistic regression model, and odds ratios (OR) were computed. To account for the potential clustering of data by recruitment hospital, we used hospital-adjusted empirical standard error estimates to calculate 95% confidence intervals (CIs). We used SAS 8.2 (SAS Institute, Cary, NC) for all statistical analyses.
Of the 3,831 Hispanic women who met the inclusion criteria, 3,242 women (84.6%) had complete data on all study variables and were included in the analyses: 913 (28.2%) from California, 886 (27.3%) from Florida, and 1,443 (44.5%) from New York. Among women who had incomplete data and were excluded, Hispanic women in California were more likely to have missing data on maternal birthplace (0.9%) and educational attainment (2.7%) than women in Florida or New York (P < .05). Women in Florida were more likely to have missing data on the number of prenatal visits (10.7%) than women from California or New York (P < .05). Women in California (1.1%) and New York (1.2%) were more likely to have missing information on prenatal health insurance than women in Florida (P < .05).
Overall, 12.8% of women were U.S.-born citizens, 7.9% were foreign-born citizens, 15.3% were documented immigrants, and nearly two thirds (64%) were undocumented immigrants. The distribution of maternal characteristics varied by state immigration status groups (Tables 1–3). The majority of U.S.-born citizens in California and New York were publicly insured, compared with 30% of comparable women in Florida. Over 8% of U.S.-born citizens in Florida were uninsured, a rate that was 8 times higher than the rate among U.S.-born citizens in California or New York. Whereas 85% of U.S.-born citizens in California and New York entered prenatal care during the first trimester, less than half of U.S.-born citizens in Florida had early entry to prenatal care. Nearly half (44%) of U.S.-born citizens in Florida received less than 6 prenatal visits, a rate that was 4 times higher than the rate among U.S.-born citizens in California or New York. In 5 of the 6 categories of barriers to prenatal care, U.S.-born citizens in Florida reported higher rates than women in California or New York.
Among foreign-born citizens, 70% of women in California were publicly insured, twice as high as the rate in Florida or New York (Tables 1–3). Thirteen percent of foreign-born citizen women in Florida were uninsured, twice as high as the rate in California. Nearly 90% of foreign-born citizen women in New York had early onset of prenatal care, a rate that was 20% higher than California and 40% higher than Florida. Almost 40% of foreign-born citizens in Florida had fewer than 6 prenatal visits, 3 times higher than foreign-born citizens in California or New York.
In the group of documented immigrants, three fourths of women in California were publicly insured, a rate that was 44% higher than Florida and twice as high as New York (Tables 1–3). Twelve percent of documented immigrants in Florida were uninsured, compared with less than 1% of documented women in California or New York. Three fourths of documented immigrants in California and New York entered prenatal care during the first trimester, compared with two thirds of women in Florida. One third of documented immigrants in Florida received fewer than 6 prenatal visits, a rate that was 60% higher than documented immigrants in New York and 4 times higher than documented women in California.
The majority of undocumented women in California and New York were of Mexican origin (Tables 1–3). Whereas nearly all (92%) undocumented women in California were publicly insured, 52–59% of undocumented women in Florida and New York were publicly insured. One fifth of undocumented women in Florida were uninsured, compared with only 1–2% of women in California or New York. Approximately three fourths of undocumented women in California and New York entered prenatal care during the first trimester, compared with 57% of undocumented women in Florida. More than one third of undocumented women in Florida had fewer than 6 prenatal visits, a rate that was nearly 3 times higher than the rate of undocumented women in California or New York.
The median month of onset of prenatal care varied by state immigration status group (Fig. 1). United States–born citizen women in Florida entered prenatal care 1.1 months later than U.S.-born citizens in New York (P = .002). Undocumented women in California and Florida entered prenatal care approximately 2 weeks later than their New York counterparts (P = .01 and P < .001, respectively). There was no difference in median onset of prenatal care among foreign-born citizens or documented immigrants across the 3 states. The difference in mean number of prenatal visits was more striking; in each state immigration status group, women in Florida averaged 3–4 fewer visits than their counterparts in New York (P < .001, Fig. 2).
In a multiple logistic regression model for risk of inadequate use of prenatal care, the statistically significant variables were state immigration status group, maternal age, marital status, prenatal health insurance, gravidity, and lack of money or insurance for prenatal care (Table 4). United States–born citizens, foreign-born citizens, documented immigrants, and undocumented immigrants in Florida were all more likely to have inadequate use of prenatal care than U.S.-born citizens in New York (OR range 2.47–4.45). Documented women in New York were 90% more likely to have inadequate use of prenatal care than their U.S.-born citizen counterparts.
Increased risk of inadequate use of prenatal care was also observed among women who were 17 years old (OR 1.96) compared with women 18–26 years old, never-married women (OR 1.53) compared with women who were separated, divorced, or widowed (OR 1.47) compared with married women, women with no prenatal insurance (OR 1.77) compared with those with private insurance, women with at least 4 pregnancies (OR 1.45) compared with those with 2–3 pregnancies, and women who reported a lack of money or insurance (OR 2.12) compared with women who did not report this problem (Table 4).
The PRWORA represented a major change in U.S. social policy.7,10 In this large, prospective, multistate study to assess the effect of the PRWORA on access to and use of prenatal care among Hispanic women, we found that the state of residence was strongly associated with use of prenatal care. In Florida, where restrictions on immigrants' eligibility for Medicaid and other publicly funded services were implemented as of July 1, 1997,11 Hispanic women in all immigration status categories had less adequate use of prenatal care than U.S.-born citizens in New York, the reference group. The women in Florida were the furthest below the national goals for adequate use of prenatal care, as defined by the U.S. Public Health Service and The American College of Obstetrics and Gynecology,9 and use of prenatal care is a core measure used to assess the impact of policy efforts to optimize maternal and child health outcomes.
The anticipated impact of the PRWORA on perinatal health outcomes was primarily a loss of eligibility for public insurance.12 In our study, prenatal health insurance was independently associated with use of prenatal care, which may provide indirect support for this hypothesis. However, a number of other possible explanations exist.10 For example, the PRWORA may have contributed to a climate of fear and intimidation among immigrants,13 and these psychological factors may have deterred women from seeking prenatal care. In a small, community-based study of Mexican-origin Hispanic women in San Diego, undocumented women reported higher levels of fear associated with receipt of medical care than documented or citizen women,9 although specific types of fears were not individually assessed and prenatal care was not the focus of the study. In our study, documented women in New York had less adequate use of prenatal care than U.S.-born citizens in New York, despite uninterrupted eligibility for Medicaid-funded prenatal care, which offers some support for the “fear” or “chilling” hypothesis of the PRWORA. On the other hand, the pro-employment aspects of the PRWORA could increase family income or improve maternal self-esteem,12 which could contribute to improved perinatal outcomes. Although employment may be beneficial, working in physically demanding jobs may be disadvantageous for pregnancy outcomes.10 In our study, we assessed 6 potential barriers to prenatal care and found that a lack of money or insurance for prenatal visits was the only barrier that was independently associated with use of prenatal care, which demonstrates that financial barriers continue to be important among Hispanic women. However, we may have overlooked another important factor that links the PRWORA to health outcomes, and future studies should assess a broad spectrum of potential explanations or pathways.
Very few studies have analyzed the impact of the PRWORA on perinatal health outcomes.12 Two previous studies have concluded that the PRWORA was not associated with adverse perinatal outcomes. In a study of birth certificate data from California, New York, and Texas, there was no deterioration in use of prenatal care or infant birth weight among foreign-born and U.S.-born Hispanic women in the periods before (1995) and after (1998) implementation of the PRWORA.6 The second study, which linked 1992–2000 natality data sets with data on welfare caseloads and welfare policies, reported that reductions in welfare caseloads were associated with small increases in late onset of care, fewer prenatal visits, and low birth weight infants in a multiethnic cohort of women with low educational attainment.12 Both studies concluded that the PRWORA did not have a significant adverse impact on perinatal outcomes. However, both studies analyzed vital records data and did not explicitly compare states according to implementation of the PRWORA. In our study, we found that Hispanic women in Florida in all immigration status categories had a higher risk of inadequate use of prenatal care than U.S.-born citizens in New York. Even although U.S.-born and foreign-born citizen women in Florida did not experience a change in eligibility for publicly funded services after passage of the PRWORA, our results suggest that there was confusion in Florida, which is consistent with the “chilling” hypothesis of the PRWORA. These results highlight the need to disaggregate data from multiple states, as well as the need to differentiate women by immigration status group.
In a recent analysis of data from the Current Population Survey, the PRWORA was associated with a lack of health insurance among low-educated, foreign-born, single women but had no effect on similar women who were born in the United States.13 The authors found no difference in insurance status among immigrant single women residing in states that implemented the PRWORA and states that preserved eligibility. These findings support both a direct effect of the PRWORA as well as a generalized “chilling” effect across states. In our study, on the other hand, we found that state of residence was independently associated with use of prenatal care, and the differences in findings could be related to our focus on childbearing Hispanic women, rather than the general population of women, and our detailed analysis of immigration status and prenatal care.
The Hispanic women in California and New York in our study had similar findings for the onset and use of prenatal care, which suggests that differing approaches to mitigating the impact of the PRWORA can lead to similar outcomes. For example, because of a long-standing federal court decision in New York, (Lewis v Grinker),14 Medicaid eligibility for all noncitizen pregnant women remained intact immediately after enactment of the PRWORA.3 When the federal government successfully challenged this court decision in 2001, state funds were used to continue Medicaid eligibility for noncitizen pregnant women without regard to documentation status.15 In California, programs were modified after passage of the PRWORA by replacing federally matched MediCal (Medicaid in California) with state-funded MediCal, where required.6,11,16,17 Thus, eligibility for Medicaid-funded prenatal care remained unchanged for immigrant women in New York and California after enactment of the PRWORA. Despite these programs and policies, we found that documented women in New York were nearly twice as likely to have inadequate use of prenatal care as U.S.-born citizens in New York, which suggests that there is an ongoing need for educational and outreach programs to inform immigrant women of the implications of political and legal challenges to Medicaid eligibility.
Studies of health outcomes in immigrants have focused on nativity comparisons because birthplace is available on vital records data sets, whereas information about documentation status is more difficult to obtain. The undocumented represent nearly one third (29%) of foreign-born residents in the United States, and 81% of undocumented immigrants are from Latin America.5 In our study of Hispanic women in 3 states with large immigrant populations, 64% of childbearing women reported that they were undocumented, which highlights the unique vulnerability of Hispanic women to policy changes that target immigrants. In a small, community-based study of Mexican-origin Hispanic women in San Diego, there were no differences in the length of time between recognizing the onset of pregnancy and entering prenatal care by immigration status,9 although the authors did not analyze use of prenatal care. In our larger, more comprehensive study, we found immigration status differences, and undocumented women in Florida were 350% more likely to have inadequate use of prenatal care than U.S.-born citizens in New York.
Newer studies suggest that the PRWORA is associated with instability in health insurance coverage for adults who enter the work force through work requirements. In Illinois, parents who successfully achieved the dual goals of work-force participation and reduced welfare dependence also experienced instability and loss of health insurance coverage,18 which highlights the need for longitudinal studies to assess the impact of the PRWORA on access to care for adults, parents, children, and other vulnerable populations.
Several limitations should be considered. We took several steps to assure the confidentiality of participants' responses, but it is possible that women may not have disclosed their true immigration status. For example, women who stated they were citizens may actually have been documented or undocumented immigrants, but citizen or documented women are unlikely to have stated they were undocumented. Our finding that foreign-born and U.S.-born citizens in Florida had an elevated risk of inadequate use of prenatal care could be partially explained by misclassification of immigration status in this subsample. Second, we interviewed women in 3 states that differed in their implementation of the PRWORA, but there may have been local factors that influenced access to and use of prenatal care, in addition to state-level factors. Third, our findings may not apply to other sites within these states or to other states, but nearly half (43%) of all Latino births in the United States in 2001 occurred in our study states.4 The descriptive characteristics of our cohort are similar to a community-based sample of Mexican-origin women in San Diego,9 which suggests that our sample was representative of childbearing Hispanic women. Finally, because of a lack of temporal data, we were unable to compare the use of prenatal care during the periods before and after the implementation of the PRWORA.
In this study of 3,242 childbearing Hispanic women in California, Florida, and New York, state of residence, a measure of PRWORA policy changes, was associated with use of prenatal care. Our findings imply that the potential adverse effects of the PRWORA on perinatal outcomes may be attenuated by state-level efforts to maintain Medicaid eligibility for pregnant women, regardless of immigration status.
1. Personal Responsibility and Work Opportunity Reconciliation Act of 1996. Pub L No. 104–193, 100 Stat 2105.
2. Braveman P, Bennett T, Lewis C, Egerter S, Showstack J. Access to prenatal care following major Medicaid eligibility expansions. JAMA 1993;269:1285–9.
3. Minkoff H, Bauer T, Joyce T. QWelfare reform and the obstetrical care of immigrants and their newborns. N Engl J Med 1997;337:705–7.
4. Hamilton B, Martin J, Sutton P. Births: preliminary data for 2003. Natl Vital Stat Rep 2004;53(9):1–20.
5. Passel J. Estimates of the size and characteristics of the undocumented population. Washington, DC: Pew Hispanic Center; 2005.
6. Joyce T, Bauer T, Minkoff H, Kaestner R. Welfare reform and the perinatal health and health care use of Latino women in California, New York City, and Texas. Am J Public Health 2001;91:1857–64.
7. Ellwood M, Ku L. Welfare and immigration reforms: unintended side effects for Medicaid. Health Aff 1998;17:137–51.
8. Kuo WH, Wilson T, Holman S, Fuentes-Afflick E, O'Sullivan M, Minkoff H. Depressive symptoms in the immediate postpartum period among Hispanic women in three U.S. cities. J Immigr Health 2004;6:145–53.
9. Loue S, Cooper M, Lloyd L. Welfare and immigration reform and use of prenatal care among women of Mexican ethnicity in San Diego, California. J Immigr Health 2005;7:37–44.
10. Wise P, Chavkin W, Romero D. Assessing the effects of welfare reform policies on reproductive and infant health. Am J Public Health 1999;89:1514–21.
11. Noncitizen policy for temporary cash assistance and Medicaid including SSI-related Medicaid. Transmittal No. Policy 97-06-00003. Linda G. Dilwoth, Assistant Secretary for Economic Self-sufficiency Services, Florida Department of Children and Families; June 17, 1997.
12. Kaestner R, Lee W. The effect of welfare reform on prenatal care and birth weight. Health Econ 2005;14:497–511.
13. Kaushal N, Kaestner R. Welfare reform and health insurance of immigrants. Health Serv Res 2005;40:697–721.
14. Lewis v Grinker, 965 F2d 1206 (2d Cir 1992).
16. Zimmerman W, Tumlin K. Patchwork policies: state assistance for immigrants under welfare reform. Washington, DC: The Urban Institute; 1999.
17. Selden T, Banthin J, Cohen J. Medicaid's problem children: eligible but not enrolled. Health Aff 1998;17:192–200.
© 2006 The American College of Obstetricians and Gynecologists
18. Holl J, Slack K, Stevens A. Welfare reform and health insurance: consequences for parents. Am J Public Health 2005;95:279–85.