The effect of immigration and welfare reform legislation on immigrants' access to health care, Cuyahoga, and Lorain Counties

This study examined the effect of the passage of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 and the Illegal Immigration Reform and Immigrant Responsibility Act of 1996 on immigrants' ability to access health care in two counties in Northeastern Ohio. Semistructured interviews were conducted with 251 individuals of varying immigration status and ethnicity. Data collected included type of recent illness, type and location of care received, type of health insurance, if any, and problems encountered. Significant associations were found between birth in a former Soviet-controlled area and use of public insurance. We did not detect an adverse effect of the welfare and immigration reform laws on ability to access care, most likely because a large proportion of respondents were permanent residents or asylees and were eligible for publicly funded medical care under the reform laws. The most common problems in obtaining medical care included lack of insurance and/or money, transportation, language, dissatisfaction with the doctor's care, and long waits. Individuals born in former Soviet-controlled areas as well as those who spoke Spanish or Slavic languages at home or work reported more difficulties in accessing care. Many undocumented individuals indicated that they would delay or refrain from seeking care due to fear of immigration consequences.     

The Impact of Local Immigration Enforcement Policies on the Health of Immigrant Hispanics/Latinos in the United States

Objectives. We sought to understand how local immigration enforcement policies affect the utilization of health services among immigrant Hispanics/Latinos in North Carolina.Methods. In 2012, we analyzed vital records data to determine whether local implementation of section 287(g) of the Immigration and Nationality Act and the Secure Communities program, which authorizes local law enforcement agencies to enforce federal immigration laws, affected the prenatal care utilization of Hispanics/Latinas. We also conducted 6 focus groups and 17 interviews with Hispanic/Latino persons across North Carolina to explore the impact of immigration policies on their utilization of health services.Results. We found no significant differences in utilization of prenatal care before and after implementation of section 287(g), but we did find that, in individual-level analysis, Hispanic/Latina mothers sought prenatal care later and had inadequate care when compared with non-Hispanic/Latina mothers. Participants reported profound mistrust of health services, avoiding health services, and sacrificing their health and the health of their family members.Conclusions. Fear of immigration enforcement policies is generalized across counties. Interventions are needed to increase immigrant Hispanics/Latinos’ understanding of their rights and eligibility to utilize health services. Policy-level initiatives are also needed (e.g., driver’s licenses) to help undocumented persons access and utilize these services.Federal immigration enforcement policies have been increasingly delegated to state and local jurisdictions, leading to increased enforcement activities by local police. This shift has resulted largely from the implementation of 2 federal initiatives: section 287(g) of the Immigration and Nationality Act and the Secure Communities program. Section 287(g) authorizes Immigration and Custom Enforcement to enter into agreements with state and local law enforcement agencies to enforce federal immigration law during their regular, daily law enforcement activities. The original intention was to “target and remove undocumented immigrants convicted of violent crimes, human smuggling, gang/organized crime activity, sexual-related offenses, narcotics smuggling and money laundering.”1 Added to the Immigration and Nationality Act in 1996, section 287(g) was not widely used in its first decade, but its use accelerated in the mid- to late 2000s.2,3The Secure Communities program differs from section 287(g) in that it does not authorize local enforcement bodies to arrest individuals for federal immigration violations. Instead, when individuals are arrested for nonimmigration matters, the Secure Communities program facilitates the sharing of local arrestees’ fingerprints and information with Immigration and Custom Enforcement and the Federal Bureau of Investigation, which checks them against immigration databases. If these checks reveal that an individual is unlawfully present in the United States or otherwise removable because of a criminal conviction, Immigration and Custom Enforcement takes enforcement action.4Some evidence suggests that both section 287(g) and the Secure Communities program contribute to Hispanic/Latino immigrants’ general mistrust of local law enforcement and fear of utilizing a variety of public services, such as police protection and emergency services.2,5–7 Although many immigrant Hispanics/Latinos in the United States experience barriers to care because of a lack of bilingual and bicultural services, low health literacy, insufficient public transportation, and limited knowledge of available health services,8–12 studies have suggested that individuals lacking legal status may have more difficulty obtaining health services and may experience worse health outcomes than do individuals with legal status.13–18 Among immigrant Hispanics/Latinos, the fear of deportation, a lack of required forms of documentation, interaction with law enforcement personnel, and racial profiling are factors also associated with reduced utilization of health services and worse health.6,19–22 Such fears lead to incomplete sequences of care,19,20,23,24 promote the use of nonstandard and unsafe contingencies for care,16,25–27 and contribute to public health hazards, as immigrants delay preventive care or treatment.13,22,28 These fears further affect long-term health outcomes as immigrant Hispanics/Latinos alter their physical activity, food purchasing behaviors, and food consumption because of concerns about being in public.29 They may withhold information from health care providers19 and experience high levels of stress, leading to compromised mental health.20,30,31The Patient Protection and Affordable Care Act bars undocumented or recent legal immigrants from receiving financial assistance for health insurance32; thus, many will continue to remain uninsured and dependent on public health services and free clinics for a significant portion of their care. Because these services are associated with government authority, there is the potential that increasing immigration enforcement policies will deter noncitizens from seeking needed care, not only to their detriment but also to the detriment of public health.Currently there is little research examining the impact of recent immigration enforcement policies on the access to and utilization of health care, and there has been a call to better understand the public health impact of current immigration policies and their enforcement.29 Through mixed methods, we explored the effect of local immigration enforcement policies on access to and utilization of health services among immigrant Hispanics/Latinos in North Carolina. We analyzed vital records data to determine whether there were differences in utilization of prenatal services by Hispanic/Latina mothers pre- and postimplementation of section 287(g), and we conducted focus groups and in-depth interviews with Hispanics/Latinos living in counties that had implemented section 287(g) and in “sanctuary” counties, counties in which leaders, including politicians and clergy, have spoken out against the program.     

Hispanic lesbians and bisexual women at heightened risk for [corrected] health disparities

Objectives. We investigated whether elevated risks of health disparities exist in Hispanic lesbians and bisexual women aged 18 years and older compared with non-Hispanic White lesbians and bisexual women and Hispanic heterosexual women.Methods. We analyzed population-based data from the Washington State Behavioral Risk Factor Surveillance System (2003–2009) using adjusted logistic regressions.Results. Hispanic lesbians and bisexual women, compared with Hispanic heterosexual women, were at elevated risk for disparities in smoking, asthma, and disability. Hispanic bisexual women also showed higher odds of arthritis, acute drinking, poor general health, and frequent mental distress compared with Hispanic heterosexual women. In addition, Hispanic bisexual women were more likely to report frequent mental distress than were non-Hispanic White bisexual women. Hispanic lesbians were more likely to report asthma than were non-Hispanic White lesbians.Conclusions. The elevated risk of health disparities in Hispanic lesbians and bisexual women are primarily associated with sexual orientation. Yet, the elevated prevalence of mental distress for Hispanic bisexual women and asthma for Hispanic lesbians appears to result from the cumulative risk of doubly disadvantaged statuses. Efforts are needed to address unique health concerns of diverse lesbians and bisexual women.Equity in health and health care is of critical societal importance given its ethical and social justice implications. Despite tremendous advancements in medicine and improved health for many Americans, historically disadvantaged and underserved communities continue to bear higher levels of illness, disability, and premature death. The National Institutes of Health affirms a commitment to reducing and eliminating health disparities affecting disadvantaged populations across the country.1 In addition, Healthy People 2020 has specifically recognized racial/ethnic minorities and sexual minorities as primary targets of health disparity reduction.2A growing body of literature endorses such federal initiatives’ recognition of health disparities by race/ethnicity and sexual orientation. Health disparities among the Hispanic population, for example, have been well documented. Higher death rates from stroke, chronic liver disease, diabetes, and HIV/AIDS have been observed among Hispanics compared with non-Hispanic Whites, and Hispanics are more likely to be obese and less likely to participate in regular physical activities.3,4 Furthermore, the Hispanic population is at increased risk for limited health care access.5–7 The likelihood of Hispanics not having health insurance is almost twice as high as that of the general population.8The evidence of health disparities affecting sexual minority women is also growing. According to previous studies based on probability samples, sexual minority women, compared with heterosexual women, report experiencing higher levels of poor physical and general health,9–11 mental distress,9,11–13 and higher prevalence rates of asthma10,11,13 and disability.10,11 In terms of health risk behaviors, lesbians and bisexual women are more likely to smoke9–11,13,14 and to consume higher quantities of alcohol.9,11,13,14 Sexual minority women are also at increased risk for poor health care access.10,14,15 Emerging research has also found within-group differences among sexual minority women; for example, lesbians, but not bisexual women, are more likely to be obese10,16 and have arthritis12 than are heterosexual women, whereas bisexual women are more likely to report poor general health and mental distress than are lesbians.17Yet, the evidence of health disparities by race/ethnicity and sexual orientation might not be generalized to sexual minorities of color,18 and knowledge regarding health among Hispanic sexual minorities is still limited. Without better understanding the potential interplay between these marginalized statuses, it remains difficult, if not impossible, to develop culturally sensitive health services that are responsive to the needs of the Hispanic sexual minority population.19The possibility of cumulative risks resulting from multiple disadvantaged statuses affecting health among Hispanic sexual minorities has been raised in the literature. It has been suggested that Hispanic sexual minorities experience heightened risks of poor physical and mental health compared with non-Hispanic White sexual minorities and Hispanic heterosexuals. According to a comprehensive review on racial/ethnic disparities in health, racial discrimination and related stressors have an inverse relationship to physical and mental health and health care access.20 Previous studies also have emphasized that health disparities among sexual minorities likely result from exposure to life stressors, including stigmatization, victimization, and discrimination.21–23 The consequences of multiple stressors, such as racial/ethnic discrimination within sexual minority communities and antigay values within Hispanic communities, may lead to an increased risk of poor physical and mental health.18,24,25 Furthermore, Hispanic sexual minority women may experience additional stressors if they are perceived to violate conventional feminine norms in Hispanic communities.26A few studies have assessed health-related concerns among Hispanic sexual minority women. One study found that Hispanic sexual minority women had increased psychiatric morbidity risk compared with Hispanic heterosexual women.27 Another study found that among sexual minority women, Hispanic women were more likely than were non-Hispanic White women to report depressive symptoms.28 In terms of physical health status and behaviors, Hispanic lesbians and bisexual women have shown elevated risks and higher prevalences of obesity, smoking, and drinking than have Hispanic heterosexual women.29Yet, to identify the potentially cumulative impact of multiple disadvantaged statuses on health disparities, the prevalence of health indicators for Hispanic sexual minority women must be compared with Hispanic heterosexual women as well as non-Hispanic White lesbians and bisexual women within the same sample. Furthermore, because the patterns and extents of health disparities may be dissimilar between lesbians and bisexual women, the cumulative effects should be tested separately among lesbians and bisexual women. Disaggregating groups of sexual minorities is an important stage in developing tailored interventions to respond to the unique health-related needs of these subgroups.17The Washington State Behavioral Risk Factor Surveillance System (BRFSS) provides population-based data that allow us to examine indicators of health disparities. In this study, we compared the unadjusted and adjusted prevalence of health disparities including health status, health risk behaviors, health care access, and health outcomes by Hispanic lesbians (the reference group), non-Hispanic White lesbians, and Hispanic heterosexual women as well as by Hispanic bisexual women (the reference group), non-Hispanic White bisexual women, and Hispanic heterosexual women. We hypothesized that Hispanic lesbians and bisexual women would experience higher risks of health disparities than would non-Hispanic White lesbians and bisexual women as well as Hispanic heterosexual women.     

Improved Outcomes for Hispanic Women with Gestational Diabetes Using the Centering Pregnancy<Superscript>©</Superscript> Group Prenatal Care Model

Objective To determine the impact of Centering Pregnancy^©-based group prenatal care for Hispanic gravid diabetics on pregnancy outcomes and postpartum follow-up care compared to those receiving traditional prenatal care. Methods A cohort study was performed including 460 women diagnosed with gestational diabetes mellitus (GDM) who received traditional or Centering Pregnancy^© prenatal care. The primary outcome measured was completion of postpartum glucose tolerance testing. Secondary outcomes included postpartum visit attendance, birth outcomes, breastfeeding, and initiation of a family planning method. Results 203 women received Centering Pregnancy^© group prenatal care and 257 received traditional individual prenatal care. Women receiving Centering Pregnancy^© prenatal care were more likely to complete postpartum glucose tolerance testing than those receiving traditional prenatal care, (83.6 vs. 60.7 %, respectively; p < 0.001), had a higher rate of breastfeeding initiation (91.0 vs. 69.4 %; p < 0.001), had higher rates of strictly breastfeeding at their postpartum visit (63.1 vs. 46.3 %; p = 0.04), were less likely to need medical drug therapy compared to traditional prenatal care (30.2 vs. 42.1 %; p = 0.009), and were less likely to undergo inductions of labor (34.5 vs. 46.2 %; p = 0.014). When only Hispanic women were compared, women in the Centering group continued to have higher rates of breastfeeding and completion of postpartum diabetes screening. Conclusion for Practice Hispanic women with GDM who participate in Centering Pregnancy^© group prenatal care may have improved outcomes.     

Physical Violence by Partner during Pregnancy and Use of Prenatal Care in Rural India

The role of physical violence during pregnancy on receipt of prenatal care is poorly understood, particularly for South Asian countries that have high levels of both fertility and domestic violence. Data from the 1998/1999 Indian National Family Health Survey and a 2002/2003 follow-up survey that re-interviewed women in four states were analyzed, examining the association between physical violence during pregnancy and the uptake of prenatal care. Women who experienced physical violence during pregnancy were less likely to receive prenatal care, less likely to receive a home-visit from a health worker for a prenatal check-up, less likely to receive at least three prenatal care visits, and less likely to initiate prenatal care early in the pregnancy. This study highlighted the constraining effect that the experience of physical domestic violence during pregnancy had on the uptake of prenatal care for women in rural India. Maternal health services must recognize the unique needs of women experiencing violence from their intimate partners.Key words: Domestic violence, Pregnancy, Prenatal care, India     

Exploring Preconception Care: Insurance Status,Race/Ethnicity,and Health in the Pre-pregnancy Period

Objective To measure the association of preconception health insurance status with preconception health among women in New York City, and examine whether this association is modified by race/ethnicity. Methods Using data from the New York City Pregnancy Risk Assessment Monitoring System 2009–2011 (n?=?3929), we created a “Preconception Health Score” (PHS) capturing modifiable behaviors, healthcare services utilization, pregnancy intention, and timely entry into prenatal care. We then built multivariable logistic regression models to measure the association of PHS with health insurance status and race/ethnicity. Results We found PHS to be higher among women with private insurance (7.3?±?0.07) or public insurance (6.3?±?0.08) before pregnancy than no insurance (5.9?±?0.09) (p?<?.001). However, when stratified by race/ethnicity, the positive association of PHS with insurance was absent in the non-white population. Conclusions for Practice Having health insurance during the pre-pregnancy period is associated with greater health among white women, but not among black or Hispanic women in NYC.     

Language and use of cancer screening services among border and non-border Hispanic Texas women

Objectives. Compared to other groups, Mexican American women screen less frequently for cervical and breast cancer. The most significant barriers reported by previous researchers include not having a usual source of care, lacking health insurance and English-language difficulties. In this paper we document and examine the factors associated with disparities in cancer screening between border and non-border residents by language of interview (Spanish or English) among Texas Hispanic women. We hypothesize that, controlling for socioeconomic and demographic characteristics, border residents are more likely to utilize screening services than non-border residents because of the greater presence of bilingual services in border counties.

Design. We follow the framework of the Behavioral Model for Vulnerable Populations proposed by Gelberg et al. (Health Services Research, vol. 34, no. 6, pp. 1273–1302, 2000). This model conceptualizes use of health care as an outcome of the interplay of predisposing, enabling and need factors and recognizes that vulnerable groups face additional barriers to health care utilization. Data come from the 2000, 2002 and 2004 Texas Behavioral Risk Factor Surveillance surveys.

Results. Group differences in cancer screenings are explained largely by socioeconomic characteristics and structural barriers to access. The significance of language of interview and of border residence disappear after controlling for factors such as health insurance, income and a usual source of care.

Conclusion. Women who selected to be interviewed in Spanish were less likely to report age-appropriate cancer examinations, health insurance and a regular health care provider than those who selected to be interviewed in English. Disparities in cancer screenings among vulnerable Hispanic populations could be reduced by promoting the establishment of a regular health care provider.     

Disparities in Pregnancy Healthcare Utilization Between Hispanic and Non-Hispanic White Women in Rhode Island

Low healthcare utilization is a prime contributor to adverse health outcomes in both the general population and the Hispanic community. This study compares background characteristics and rates of prenatal and postpartum health care utilization between Hispanic and non-Hispanic white women. Using the Rhode Island Pregnancy Risk Assessment Monitoring System (PRAMS), 2002?C2008, we assess rates of prenatal and postpartum healthcare utilization relevant to maternal and neonatal care. Associations between maternal ethnicity and adequacy of health care utilization were quantified using survey weighted multivariable logistic regression. Compared with non-Hispanic white women, Hispanic women were younger (less than 24?years, 43.8% vs. 25.2%), had less education (less than 12?years of education, 38.2% vs. 10.6%), lower annual income levels (incomes less than $19,999, 72.2% vs. 21.7%), and lower insurance rates before pregnancy (47.8% uninsured vs. 12.8%). Hispanic women had higher odds of having delayed prenatal care (AOR 1.84, 95% CI 1.27?C2.65) or inadequate prenatal care (AOR 2.01, 95% CI 1.61?C2.50), and their children had higher odds of not having a 1-week check-up (AOR 1.73, 95% CI 1.21?C2.47) or any well-baby care (AOR 3.44, 95% CI 1.65?C7.10). Disparities in inadequate prenatal care and not having any well-baby care remained significant after adjusting collectively for age, marital status, education, income, and insurance status of mother and newborn. Although many previously uninsured women became insured during pregnancy, disparities in healthcare utilization remained. Interventions focusing on reducing barriers to access prior to and during pregnancy should consider potential structural, informational, and educational barriers.     

HIV Testing,Positivity, and Receipt of Services among Black,White, and Hispanic Women Participating in HIV Prevention Programs Funded by the Centers for Disease Control and Prevention, 2015

Background

Black women who are positive for human immunodeficiency virus (HIV) are more likely than other HIV-positive women to experience poor health outcomes. Given these disparities, we compared receipt of HIV testing and other preventive services among Black, White, and Hispanic women participating in HIV prevention programs funded by the Centers for Disease Control and Prevention in 2015.

Barriers to prenatal care among low-income women in New York City

Postpartum in-hospital interviews with 496 low-income women in New York City revealed that attitudinal and motivational barriers as well as financial obstacles are significant impediments to timely initiation of prenatal care. The two most common reasons cited by these women in explaining why they had obtained prenatal care late or not at all were motivational items: "feeling depressed and not up to going for care" and "needing time and energy to deal with other problems." In logistic regression analyses, receipt of late or no prenatal care was significantly associated with the latter motivational barrier, along with the cost of care, having no health insurance, being Hispanic, being a substance abuser and holding negative attitudes toward the use of prenatal care.     

Use of Home Visit and Developmental Clinic Services by High Risk Mexican-American and White Non-Hispanic Infants

Objective: To investigate whether US-born infants of mothers of Mexican descent who were enrolled in Arizonas Newborn Intensive Care Program (NICP) received follow-up services (developmental clinic and community health nurse [(CHN)] home visits) at the rates similar to White non-Hispanic (WNH) infants. Socio-economic and health status characteristics were controlled using stepped regressions in order to assess the impact of each on service use. Methods: This population-based study used retrospective data from the NICP administrative database that were linked to birth certificates for years 1994–1998. The study population was limited to Arizona-born infants; it included 7442 infants of WNH mothers, 2612 infants of US-born Mexican American (MA) mothers and 2872 infants of Mexico-born mothers. Four service use indicators were used in the analysis. Results: Both Hispanic infant subgroups were less likely to have a CHN visit by 6 months and by 1 year, and to average fewer CHN visits. A smaller percent attended the developmental clinic by age one. After controlling for language, demographics, health status, socio-economic characteristics, and mothers prenatal care use, infants of US-born MA mothers had rates of use similar to WNH. However, even after controlling for the study variables, infants of Mexico-born mothers were less likely (OR =.83) to use the developmental clinic. Hispanics continued to lag behind in the use of services compared with WNHs. The disparity is not a function of ethnicity, but appears attributable to demographic and socio-economic characteristics. Infants who had a CHN visit were significantly more likely (OR = 2.51) to use the developmental clinic than those without a nurse visit. Infants whose mothers had inadequate prenatal care were less likely to use these follow-up services even after controlling for study variables. Conclusions: Infants whose mothers had inadequate prenatal care should be targeted for more intense CHN visits. Infants of mothers born in Mexico may need additional support/assistance in using the developmental clinic.     

Clinical Characteristics and Outpatient Mental Health Service Use of Transition-Age Youth in the USA

This study examines diagnostic and service utilization patterns of transition-age youth in outpatient care derived from the 2007 nationally representative Client/Patient Sample Survey. Comparisons between 16–17, 18–21, and 22–25 year olds are highlighted. Among transition-age outpatients, the oldest youth had the highest rates of depression and bipolar disorder and co-occurring medical and substance use problems. Controlling for sociodemographic and clinical characteristics, 18–21 year olds were less likely to receive individual therapy than 16–17 year olds, but there were no age group differences in receipt of specialized therapy or psychotropic medication. Female gender and Hispanic ethnicity were positively associated with the number of services received and specialized service use, respectively; youth with private insurance were more likely than those with public insurance to receive psychotropic medication. Implications are discussed regarding access to and adequacy of services provided for young people in the critical transition to adulthood, especially with the implementation of the 2010 Affordable Care Act.     

Insurance-Based Discrimination During Prenatal Care,Labor, and Delivery: Perceptions of Oregon Mothers

The purpose of this study was to improve understanding of who experiences insurance-based discrimination during prenatal care, labor, and delivery and how their health care may differ from that of other women. We pooled data from the 1998–1999, 2000, and 2001 Oregon Pregnancy Risk Assessment Monitoring System and conducted univariate, bivariate, and multivariate analyses. The women who perceived that they had been treated differently by health care providers during prenatal care, labor, or delivery based on their insurance status were largely a lower income group. Insurance-based discrimination was significantly associated with lower annual household incomes, being unable to pay bills during pregnancy, and being without employer-sponsored insurance for their baby’s delivery, when adjusted for other factors. Insurance-based discrimination was less likely among Hispanic mothers. With respect to the relationship between insurance-based discrimination and receipt of health care, our findings were mixed. Insurance-based discrimination was not significantly associated with the number of topics covered by providers during prenatal care. In contrast, insurance-based discrimination was significantly associated with fewer breastfeeding support actions taken at the hospital and with having had a provider discuss birth control after delivery among women with employer sponsored insurance. These findings draw attention to the need to better understand women’s experiences and perceptions of insurance-based discrimination during prenatal care, labor, and delivery.     

Barriers to Prenatal Care for Mexican and Mexican American Women

Despite the presumed health benefits, Latinas are less likely than women from other ethnic groups to receive adequate prenatal care during their pregnancy. However, it is unclear whether this trend is the result of political economic conditions that limit access of many Latinos in the United States to adequate health services in general, or of sociocultural conditions that restrict the use of such services even when they are made available. Furthermore, it is unclear whether these barriers pose a risk for adverse birth outcomes in this population. To address these issues, we conducted a two-phase study of the political economic and sociocultural barriers to use of prenatal care services among Mexican and Mexican American women living in San Diego, California, and their association with adverse birth outcomes in this population. A quantitative assessment of information abstracted from the medical records of 173 Latinas who had given birth at a university medical center found that absence of Medi-Cal benefits or other forms of health insurance was the only significant predictor of inadequate prenatal care during pregnancy. However, neither lack of insurance nor adequate prenatal care was associated with any adverse birth outcomes. A qualitative analysis of information obtained from interviews of 30 Latinas receiving prenatal care services at a medical clinic for the homeless and medically underserved residents of San Diego identified three major themes underlying the lack of adequate prenatal care: lack of trust in formal versus informal institutions, wanted versus unwanted pregnancies, and the importance of the social network.     

Initiation of prenatal care by low-income Hispanic women in Houston.

OBJECTIVE: To understand why many Hispanic women begin prenatal care in the later stages of pregnancy. METHODS: The authors compared the demographic profile, insurance status, and health beliefs--including the perceived benefits of and barriers to initiating prenatal care--of low-income Hispanic women who initiated prenatal care at different times during pregnancy or received no prenatal care. RESULTS: A perception of many barriers to care was associated with later initiation of care and non-use of care. Perceiving more benefits of care for the baby was associated with earlier initiation of care, as was having an eligibility card for hospital district services. Several barriers to care were mentioned by women on open-ended questioning, including long waiting times, embarrassment the physical examination, and lack of transportation. CONCLUSIONS: Recommendations for practice included decreasing the number of visits for women at low risk for poor pregnancy outcomes while increasing the time spent with the provider at each visit, decreasing the number of vaginal examinations for low risk women, increasing the use of midwives, training lay workers to do risk assessment, emphasizing specific messages about benefits to the baby, and increasing general health motivation to seek preventive care through community interventions.     

The Effect of Medicaid Managed Care on Prenatal Care: The Case of Puerto Rico

Objectives From 1994 to the year 2000 the government of Puerto Rico implemented a health care reform which included the mandatory enrollment of the entire Medicaid eligible population under Medicaid managed care (MMC) plans. This study assessed the effect of MMC on the use, initiation, utilization, and adequacy of prenatal care services over the reform period. Methods Using the vital records of all infants born alive in Puerto Rico from the year 1995–2000, a series of bivariate and multivariate analyses were conducted to assess the effect of insurance status (traditional Medicaid, MMC, private insurance and uninsured) on prenatal care utilization patterns. In order to assess the potential influence of selection bias in generating the health insurance assignments, propensity scores (PS) were estimated and entered into the multivariate regressions. Results MMC had a generally positive effect on the frequency and adequacy of prenatal care when compared with the experience of women covered by traditional Medicaid. However, the PS analyses suggested that self-selection may have generated part of the observed beneficial effects. Also, MMC reduced but did not eliminate the gap in the amount and adequacy of prenatal care received by pregnant women covered by Medicaid when compared to their counterparts covered by private insurance. Conclusions The Puerto Rico Health Reform to implement MMC for pregnant women was associated with a general improvement in prenatal care utilization. However, continued progress will be necessary for women covered by Medicaid to reach prenatal care utilization levels experienced by privately insured women.     

The Association Between Health Insurance Coverage and Skilled Birth Attendance in Ghana: A National Study

Objectives Skilled birth attendance (SBA) is a key health intervention used by roughly two-thirds of women in Ghana. The National Health Insurance Scheme provided by the Government of Ghana is widely expected to improve maternal health outcomes by removing financial barriers to health services. In this paper, we examine if indeed health insurance is able to improve SBA, a key maternal outcome. Methods We use data from the 2011 Ghana Multiple Indicator Cluster Survey implemented by the Ghana Statistical Services with support from the United Nations Children’s Fund (UNICEF). We use a multivariate logistic model controlling for a number of enabling and predisposing factors and past experience with the health system to examine the effect of health insurance on skilled birth attendance. The sample is 2528 women. Results Our results show that women with health insurance are 47 % more likely to use SBA than women without health insurance. Results also underscore that women with repetitive contact with the health system (such as antenatal care) are more likely to have a skilled delivery (OR 3.00, p value 0.000). We also find that higher parity, rural and poor women are much less likely to use SBA. Conclusions Health insurance may indeed be a useful mechanism to improve coverage of SBA, though many barriers to delivery care still exist for women. Further work to understand the effect of health insurance on other maternal outcomes is also warranted.     

Racial/Ethnic Differences in the Correlates of Mental Health Services Use among Pregnant Women with Depressive Symptoms

Objectives To examine correlates of lifetime mental health services (MHS) use among pregnant women reporting prenatal depressive symptoms by race/ethnicity. Methods This cross-sectional population-based study included 81,910 pregnant women with prenatal depressive symptoms using data from the Florida Healthy Start prenatal screening program (2008–2012). Multivariable logistic regression was conducted to ascertain adjusted odds ratios and corresponding 95 % confidence intervals for racial/ethnic differences in the correlates of lifetime MHS use. Results Findings of this study revealed racial/ethnic differences in MHS use among women with prenatal depressive symptoms, the highest rates being among non-Hispanic Whites and the lowest rates among Mexicans and other Hispanics. Most need for care factors, including illness, tobacco use, and physical or emotional abuse, consistently predicted MHS use across racial/ethnic groups after adjusting for covariates. Adjusted associations between predisposing and enabling/restricting factors and MHS use were different for different racial/ethnic groups. Conclusions Racial/ethnic differences in MHS use were found, with pregnant Hispanic women reporting prenatal depressive symptoms being the least likely to use MHS. Our study findings have significant public health implications for targeted intervention for pregnant women with prenatal depressive symptoms.     

Impact of Alabama’s Immigration Law on Access to Health Care Among Latina Immigrants and Children: Implications for National Reform

We conducted in-depth interviews in May to July 2012 to evaluate the effect of Alabama’s 2011 omnibus immigration law on Latina immigrants and their US- and foreign-born children’s access to and use of health services.The predominant effect of the law on access was a reduction in service availability. Affordability and acceptability of care were adversely affected because of economic insecurity and women’s increased sense of discrimination. Nonpregnant women and foreign-born children experienced the greatest barriers, but pregnant women and mothers of US-born children also had concerns about accessing care.The implications of restricting access to health services and the potential impact this has on public health should be considered in local and national immigration reform discussions.IN THE ABSENCE OF RECENT national immigration reform, state legislatures have increasingly proposed measures to address local immigration issues. Since 2007, legislators have put forth more than 1300 immigration-related bills and resolutions annually.1 Most of these failed to become law; however, in the past 4 years, Alabama, Arizona, Georgia, Indiana, South Carolina, and Utah have passed omnibus legislation to enforce immigration policy and discourage settlement of unauthorized immigrants.1 These laws contain numerous provisions that authorize local law enforcement personnel, employers, and others to verify an individual’s immigration status. All of these states also require verification of lawful presence in the United States for individuals seeking public benefits, such as health care, from state and local agencies; exceptions are made for prenatal and emergency care, child and adult protective services, and other services exempt under federal law (e.g., immunizations; the Special Supplemental Nutrition Program for Women, Infants, and Children; and short-term in-kind disaster relief).2Previous research has found that laws aimed exclusively at restricting immigrants’ access to public benefits reduce immigrants’ use of health services. Following the 1994 passage of California’s Proposition 187, immigrants failed to receive or delayed medical care out of fear of deportation.3,4 As reported in one study, fear of deportation that results in delayed treatment of communicable diseases, such as tuberculosis, can pose significant health risks to the individual and the general public.3 Requirements to present proof of lawful residence to receive publicly funded health services, such as those established in the 2005 Deficit Reduction Act, can also affect eligible legal residents and US citizens,5–7 and groups that are less able to provide appropriate documentation, such as adolescents and the elderly, may be deemed ineligible for services.6,8The broader scope of recent state-level initiatives means that immigrants’ use of health care may be adversely affected not only because unauthorized immigrants are explicitly prohibited from receiving services, but also because the laws may exacerbate transportation and financial barriers, which affect other aspects of health care access. Anecdotal evidence suggests that recent state legislation has indeed hindered immigrants’ access to routine health care.9,10 However, few studies have assessed how these laws have affected immigrants’ use of health services.11,12 With growing calls for comprehensive national immigration reform, it is important to evaluate the impact of state-level laws on immigrants’ access to care to inform discussions that will shape future policies.We examined Latina immigrants’ experiences accessing health care following the June 2011 passage of the Alabama Taxpayer and Citizen Protection Act, House Bill 56 (HB 56), which was considered the toughest state immigration law in the United States.13 Specifically, we assessed the range of ways the law has affected several dimensions of access to care for Latina immigrants and their US- and foreign-born children. Latino immigrants constitute the largest immigrant group in Alabama and in the United States overall14,15; in fact, Alabama reported the second-largest percentage increase in its Latino population between 2000 and 2010, after South Carolina.16 We focused on Latinas because they have a primary role in their children’s health and health care and typically have more health needs and greater use of health services than men.17,18     

Undocumented immigrants and their use of medical services in Orange County, California

Does an undocumented immigration status predict the use of medical services? To explore this question, this paper examines medical care utilization of undocumented Latino immigrants compared to Latino legal immigrants and citizens, and non-Latino whites in Orange County, California. Data were collected through a random sample telephone survey of 805 Latinos and 396 non-Hispanic whites between January 4 and January 30, 2006. Findings show that undocumented immigrants had relatively low incomes and were less likely to have medical insurance; experience a number of stresses in their lives; and underutilize medical services when compared to legal immigrants and citizens. Predictors of use of medical services are found to include undocumented immigration status, medical insurance, education, and gender. Undocumented Latinos were found to use medical services less than legal immigrants and citizens, and to rely more on clinic-based care when they do seek medical services.