Health Care for Immigrants: ACOG Committee Statement No. 4 : Obstetrics & Gynecology

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Health Care for Immigrants

ACOG Committee Statement No. 4

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Obstetrics & Gynecology 141(2):p e427-e433, February 2023. | DOI: 10.1097/AOG.0000000000005061
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Abstract

SUMMARY OF RECOMMENDATIONS AND CONCLUSIONS

Based on the evidence outlined in this Committee Statement, the American College of Obstetricians and Gynecologists (ACOG) makes the following recommendations and conclusions:

People detained in immigration custody settings should be protected from abuse and coercion and should receive obstetric and gynecologic care that complies with accepted clinical guidelines and evidence-based protocols.

Policies and immigration-enforcement practices that are detrimental to health and well-being should be opposed, including:

  •   • Separation of children from parents or caregivers;
  •   • The targeting of people who are pregnant and parenting at points of entry for immigration-enforcement activities; and
  •   • Detention of individuals who are pregnant, nursing, or postpartum.

The right to seek asylum in the United States as a result of gender-based violence should be supported.

Obstetric and gynecologic care settings should be culturally inclusive by offering interpreters and materials available in languages appropriate for the patient population and demonstrating respect for cultural health beliefs and traditions.

Quality health coverage should be available for all, regardless of immigration status and ability to pay.

BACKGROUND

In 2020, the United States was home to 43.5 million people born in foreign countries, or 13.2% of the total U.S. population (1). About half of the foreign-born population is made up of naturalized U.S. citizens (Table 1) (1). Among noncitizens, 14.5 million people are lawfully present (2). The exact number of people in the United States who are undocumented is not known. The U.S. Department of Homeland Security (DHS) reports an estimate of 11.4 million undocumented individuals (3); however, a simulation study estimates that there may be as many as 22.1 million (4).

T1
Table 1.:
Definitions

Nearly 46% of immigrant women are of reproductive age (15–44 years) (5). Among children born in the United States, 23% are born to immigrant women (6) and 6% are born to undocumented immigrants (7). Despite being more likely to have at least one full-time worker in the family, undocumented immigrants are less likely than other residents of the United States to have health insurance (8). Lack of health insurance results in individuals receiving fewer preventive health care services, including prenatal care, and reporting poorer reproductive and general health outcomes (9–11).

In addition to the barriers to accessing sexual and reproductive health care services that immigrants face while living in the United States, immigration policies can infringe on the health and rights of immigrants. A Reproductive Justice framework can be useful in evaluating the effect of immigration policies on human rights, health, and well-being. The Reproductive Justice framework was coined in 1994 by Black women and is grounded in a human rights framework and enumerates that all people have a fundamental right to bodily autonomy, to have children, to not have children, and to parent the children they have in safe and sustainable communities (12, 13). Immigration policies that limit access to obstetric and gynecologic care while in custody, target pregnant people at points of entry for immigrant-enforcement actions, separate parents and children, and restrict access to asylum for victims of gender-based violence are in direct conflict with the rights outlined by the Reproductive Justice framework. These polices are part of a long history rooted in stratified reproduction, where the pregnancy, reproduction, and parenting of some individuals is differentially valued as compared with others. As a result, there are centuries of discriminatory immigration laws and enforcement of sanctions that normalize dehumanizing and cruel treatment of immigrants, most of whom are people of color. The American College of Obstetricians and Gynecologists opposes immigration policies that undermine human rights, health, and well-being (14).

Immigrants, including those who are undocumented, benefit the economy in a number of ways, including filling essential workforce needs, starting new businesses at twice the rate of native-born individuals, and contributing billions of dollars to the tax base (15, 16). Despite these facts, anti-immigrant sentiment has become more visible in recent years. Increases in anti-immigrant rhetoric and fear of immigration-enforcement activities have detrimental effects on health, with documented increases in preterm birth; low birth weight; self-report of sadness, anxiety, and nervousness; and decreases in health care utilization in affected communities (17–19). Advocacy against systems and policies that perpetuate racism, anti-immigrant sentiment, and barriers to care is necessary to improve health outcomes (20).

RECOMMENDATIONS AND CONCLUSIONS

People detained in immigration custody settings should be protected from abuse and coercion and should receive obstetric and gynecologic care that complies with accepted clinical guidelines and evidence-based protocols.

As a part of seeking asylum protections or for administrative reasons related to immigration status, many immigrants will have contact with or be detained in jails, U.S. Immigration and Customs Enforcement (ICE) detention centers, or U.S. Customs and Border Protection facilities. This use of detention and incarceration is not only an unnecessary feature of the U.S. immigration system, but it is also harmful to the people detained.

The American College of Obstetricians and Gynecologists supports the use of community-based alternatives to detention and, for those who are detained, believes reproductive health care should be provided in accordance with the same guidelines and recommendations as for those who are not detained, with attention to the increased risk of infectious diseases and mental health conditions commonly seen as a result of forced detention (21). This care should include all recommended prenatal care (including fetal testing and ready access to triage visits), abortion, postpartum care (including initiation of reversible contraceptive methods, if desired), and breastfeeding and breastmilk-expression support, as well as timely assessment of pregnancy-related or coronavirus disease 2019 (COVID-19) symptoms, in accordance with ACOG guidance (21).

It is well documented that there is inadequate access to reproductive health care in immigration detention, including care for pregnant individuals (22). Substandard care may range from lack of responsiveness to requests for care, lack of translation or use of interpreters, provision of care by unqualified medical staff, lack of adequate mental health care, and delays in providing offsite medical care to outright refusal to provide medical care, including contraception and abortion (22, 23). Individuals have experienced miscarriage and unsafe birth in custody, but the true incidence of these occurrences is unknown because various agencies refuse to collect or release this information (24, 25, 27).

Reliable information is difficult to obtain because there is a lack of transparency across detention systems, a fact made worse by the use of private, for-profit prisons and detention centers (23). Investigations of detention facilities managed by for-profit contractors have concluded that they are ill-equipped to meet ICE’s standards of care and experience no penalties when repeatedly failing to correct deficiencies (26). The U.S. Government Accountability Office has also found fault with ICE failing to provide the standard of care in facilities it operates and oversees (27).

The detention system as it currently exists does not just fail to care for people, but also causes trauma by denying bodily autonomy, neglecting medical and mental health needs, and exposing people to potential abuse. Human Rights Watch has documented instances of physical assault, use of dehumanizing language, withholding of food as a tool of coercion, and sexual abuse (28). Immigrant women and those who identify as transgender are more likely to experience sexual assault in detention (22). Between January 2010 and September 2017, the Office of the Inspector General received 1,224 complaints of sexual abuse in DHS custody, with a detention officer or private contractor identified as the perpetrator in more than half of the complaints (22). These complaints are likely a tremendous undercount because they do not include anyone who did not file a complaint due to language barriers or fear of retaliation (22). There are also reports of abuse by medical professionals, with procedures performed that result in a loss of fertility without clear medical indication, necessity, or informed consent (29).

Many immigrants experience trauma associated with their reason for migrating from their country of origin, during the often-dangerous journey, in refugee camps, or after arriving in the United States. Immigrants often disclose sexual violence or rape and, occasionally, torture. People with a past history of trauma are particularly negatively affected by detention, experiencing greater severity of anxiety and depression symptoms after a period of detention (30). Additionally, the lack of mental health services in detention compounds this trauma (22). Facilities should provide trauma-informed, language-concordant mental health care specifically tailored to the needs of women, girls, and transgender individuals who may have experienced gender-based violence and now face forced separation from family and community.

Policies and immigration-enforcement practices that are detrimental to health and well-being should be opposed, including:

  • Separation of children from parents or caregivers;
  • The targeting of people who are pregnant and parenting at points of entry for immigration-enforcement activities; and
  • Detention of individuals who are pregnant, nursing, or postpartum.

The American College of Obstetricians and Gynecologists strongly opposes immigration practices that are detrimental to health, including separating children from their parents or caregivers (14). This practice gained national visibility because there was increased focus in real time at the southern border in 2018, but it occurs across the country out of the public eye when parents or caregivers are detained through immigration raids and when families make the difficult decision to send their children unaccompanied to seek safety in the United States. Regardless of the manner in which it arises, family separation can cause life-long trauma to both the child and the caregiver.

Studies have shown that children separated from caregivers have increased rates of behavioral problems, anxiety, depression, posttraumatic stress, (31) growth problems, lower educational attainment, and physical disease (32). The ill effects can persist even after reunification of the family, including insecure attachment to the parent (32). Similar detrimental effects, as well as the added stress of new economic hardship, were found in family separation resulting from worksite or home raids occurring within the United States (33). Parents experience similarly negative psychological effects as children (34, 35). Separation from family compounds the trauma that many parents and children have experienced in their home country or in traveling to the United States and should be avoided except in cases in which the caregiver is a danger to the child.

In past years, there were reports of pregnant people being referred at greater rates than nonpregnant people to the U.S. Department of Justice for prosecution for illegal entry (36). A 2020 rule change granted ICE agents the authority to use physical characteristics of pregnancy as a reason for increased immigration enforcement, including denying people who are visibly pregnant entry into the United States, even when they had a valid visa (38). Policies that single out pregnancy as the basis for immigration enforcement are in clear violation of human rights and reproductive justice and could endanger the health of the pregnant person.

Previously, ICE has maintained a policy of “presumption of release,” in which a pregnant person would generally not be detained except in “extraordinary circumstances.” However, between 2017 and 2021, ICE instituted a policy of detaining pregnant people (38). It has been well-documented that people, especially pregnant people, held in immigration detention facilities have poor access to medical care and may have worse health outcomes as a result (22). The American College of Obstetricians and Gynecologists supports policies that avoid arrest and encourage release of people who are pregnant, nursing, or postpartum to promote the health and well-being of families.

The right to seek asylum in the United States as a result of gender-based violence should be supported.

U.S. law allows for humanitarian protection for people who have been persecuted or fear persecution based on religion, nationality, membership in a particular social group, or political opinion (Table 1) (39). Refugees apply for protection outside of the United States, and asylees apply within the United States or at a port of entry. In 2020, the United States resettled 12,000 refugees, a significant drop from the 80,000 people resettled just a few years earlier (40). In 2019, the United States granted asylum to 46,500 people, with many more awaiting review of their applications (40). Public health measures put in place during the COVID-19 pandemic have severely limited access to asylum protections and resulted in expulsion of most would-be applicants from the United States without the opportunity to make an asylum claim (41, 42). Additionally, asylum-seekers who are able to file claims at the southern border have been forced to wait in Mexico while their cases are pending in the U.S. court system, where they are exposed to dangerous and overcrowded conditions without access to family and social supports (See the American Immigration Council at https://www.americanimmigrationcouncil.org/news/restart-mpp-betrayal-president-bidens-promises-restore-humane-asylum-system).

Many asylum seekers are fleeing gender-based violence, such as forced marriage, female genital mutilation or cutting, and violence perpetrated on women because of their sex. Transgender and homosexual immigrants may also be displaced or fleeing from their countries of origin because of persecution of their gender identity or sexual orientation (43, 44). Those who are survivors of gender-based violence should be allowed to submit their asylum claims and remain in the United States on humanitarian grounds. Moreover, alternatives to detention for those awaiting determination of their asylum claims should be supported, particularly given some facilities’ inability to provide basic standards of care (26).

Obstetric and gynecologic care settings should be culturally inclusive by offering interpreters and materials available in languages appropriate for the patient population and demonstrating respect for cultural health beliefs and traditions.

Given the barriers and challenges immigrants face, obstetrician–gynecologists and other reproductive health care professionals should be prepared to address immigrants’ specific needs. For example, if there is not language concordance between clinician and patient, the visit should occur with the aid of professional interpretation services. The benefit of an in-person interpreter is their ability to convey body language and assist the patient in filling out forms. In some settings, or for less common languages, the interpreter and patient may be acquainted or live in the same community, thus affecting the confidentiality of the visit or at least the confidence the patient has that the visit will remain confidential. For these reasons, some patients may be more comfortable with a national phone or video interpreter service (45).

It can also be helpful to orient the immigrant patient to the U.S medical system, including explanations of visits, the use of pharmacies and other ancillary services, and what action to take in case of a medical emergency. It is important to assess the patient’s general and health literacy, because this can affect a patient’s ability to understand and carry out instructions. The health care team should be sensitive to cultural differences, specifically as they relate to gender roles and familial participation in medical decision making. For example, patients may prefer that males in the family be involved in medical decision making, but attempts should always be made to verify the patient’s preferences when they are alone. Clinicians should inquire about and, when possible, incorporate traditional forms of healing that are familiar to the patient. Finally, care should be provided in a trauma-informed manner, with referral to mental health specialists as needed (46).

Many people who are victims of human trafficking are immigrants (47). For more information on how to identify victims of human trafficking in the health care setting and how to help, see ACOG Committee Opinion 787, Human Trafficking (48).

Quality health coverage should be available for all, regardless of immigration status and ability to pay.

In 2019, an estimated 46% of undocumented immigrants were uninsured, compared with 25% of documented immigrants and only 9% of citizens (8). This difference is due to immigrants’ reduced access to employer-sponsored coverage and eligibility restrictions that prohibit or delay participation in Medicaid, the Children’s Health Insurance Program (CHIP), and the health insurance Marketplaces created by the Affordable Care Act (ACA) (8). Employer-sponsored coverage may be even less available for undocumented immigrants, who are more likely to work in low-paying jobs without benefits. Despite being more likely to have at least one full-time worker in the family (8), only 50% of noncitizen full-time workers had employer-sponsored coverage, compared with 81% of nonimmigrant full-time workers (49). For those eligible to apply for insurance, many have difficulty enrolling due to language barriers, high cost, or confusion about the process; others choose not to enroll out of fear that utilizing benefits may jeopardize future immigration status.

In general, undocumented immigrants are eligible only for emergency health care services that are paid by emergency Medicaid. Since 2002, the Centers for Medicare & Medicaid Services has allowed states to use CHIP funds to cover undocumented pregnant women by conferring insurance eligibility on the fetus (8). With eligibility being for the fetus rather than for the pregnant individual, postpartum care is often not covered and patients often receive only pregnancy-related care (8). Some cities and states provide coverage for immigrants utilizing local and state funds (50).

Documented immigrants with a qualified status, such as legal permanent residents or “green card” holders, must wait 5 years before they are eligible to utilize public programs (8). States can decide to waive this waiting period for children and pregnant people (8). This 5-year waiting period is often waived for some immigrants with qualified status, such as refugees and asylees, but only after they have been granted employment authorization (8). Immigrants with Temporary Protected Status, people from a select group of counties designated by DHS that have experienced humanitarian disasters, do not have qualified status and are unable to enroll in Medicaid or CHIP for the duration of their time in the United States (8). Recipients of Deferred Action for Childhood Arrivals are barred from all public health coverage and ACA Marketplace plans, meaning many who are hourly-wage workers, students, or self-employed, among others, are unable to obtain health insurance (8).

To expand insurance coverage, providers can advocate for Congress to lift the 5-year waiting period for lawfully present immigrants to obtain Medicaid or CHIP and allow recipients of Deferred Action for Childhood Arrivals to participate in Medicaid, CHIP, and ACA marketplaces. Furthermore, the United States’ system of employer-sponsored coverage disproportionally affects low-wage workers and people who may have to work “off the books” due to their immigration status. Moving toward a system of universal health coverage would increase access to care and improve health outcomes for this disproportionately affected group of people.

CONCLUSION

The American College of Obstetricians and Gynecologists supports the health and well-being of all individuals seeking obstetric and gynecologic care, regardless of immigration status. Access to adequate, timely, and evidence-based health care should be provided for those held in immigration detention facilities, and individuals who are pregnant, nursing, or postpartum should not be held in such facilities. Obstetrician–gynecologists and other reproductive health professionals and advocates should center the unique needs of patients who are immigrants to promote reproductive justice and health equity.

NUMBER 4

FEBRUARY 2023

(REPLACES COMMITTEE OPINION NUMBER 627, MARCH 2015)

Committee on Health Care for Underserved Women. This Committee Statement was developed by the ACOG Committee on Health Care for Underserved Women in collaboration with Emma Cermak, MD; Jamila Perritt, MD, MPH; and Jennifer Villavicencio, MD, MPP, FACOG.

The American College of Obstetricians and Gynecologists (ACOG) reviews its publications regularly; however, its publications may not reflect the most recent evidence. A reaffirmation date is included in the online version of a document to indicate when it was last reviewed. The current status and any updates of this document can be found on ACOG Clinical at acog.org/lot.

This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology.

While ACOG makes every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. ACOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither ACOG nor its officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.

Published online on January 19, 2023.

Copyright 2023 by the American College of Obstetricians and Gynecologists. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.

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Health care for immigrants. Committee Statement No. 4. American College of Obstetricians and Gynecologists. Obstet Gynecol 2023;141:427–33.

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CONFLICT OF INTEREST STATEMENT

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