ACCESS DENIED: PRENATAL CARE FOR
Michelle Maria Piccininni
B.A., Metropolitan State College of Denver, 2004
A thesis submitted to the
University of Colorado Denver
in partial fulfillment
of the requirements for the degree of
Master of Arts
This thesis for the Master of Arts
Michelle Maria Piccininni
has been approved
Piccininni, Michelle Maria (M.A., Anthropology)
Access Denied: Prenatal Care For Undocumented Immigrants In
Thesis directed by Assistant Professor Sarah Horton
Prenatal care is widely promoted in national and international
arenas as essential care that improves birth outcomes, reduces
maternal and infant mortality and morbidity, and reduces healthcare
costs. Yet, states such as Colorado choose to deny public benefits for
prenatal care to undocumented women due to immigration status.
With US welfare reform devolving authority to states to decide
which services will be publicly covered for different types of
immigrants, eligibility requirements for prenatal care public benefits
vary widely across states. For example, California, New York and
Illinois employ various policies to provide prenatal care coverage to
women regardless of immigration status, while Florida and Colorado
deny any coverage for prenatal care to undocumented immigrants. In
several studies health insurance coverage and ability to pay for
services were cited as the primary factors in receiving adequate
healthcare in the United States. Latina women receive the lowest rates
of adequate prenatal care in the US and in Colorado, and several
studies demonstrate that Latina immigrants experience even
greater health and healthcare access disparities.
This research aims to describe the ways that denying public
coverage for prenatal care to undocumented immigrants contributes to
low utilization rates by Latina women, exposing mothers and their
infants to higher risks of morbidity and mortality. It also aims to
describe the ways it devolves responsibility for essential public health
services to local safety net institutions. It finds that access to prenatal
care for undocumented immigrants is highly dependent on localities
within Colorado and a critical gap in access to services exists for
complicating conditions in pregnancy such as diabetes, exposing
pregnant, undocumented women and their infants to increased risk of
illness, disability and death.
This abstract accurately represents the content of the candidates
thesis. I recommend its publication.
Thank you to my thesis advisor, Dr. Sarah Horton, for guiding me
through the literature on immigrant health for this project, helping to
narrow my focus, reading and editing the many versions, and kind
patience and encouragement. Thank you to Dr. John Brett for inspiring
me to continue in anthropology and years of sound advice as my
graduate advisor, and to Dr. Jean Scandlyn for sparking my interest in
global and maternal health. Also, thank you to all in the Department of
Anthropology for being supportive over the past six years as I balanced
graduate school and motherhood. Finally, I would like to express my
gratitude to all the participants in this research for generously
contributing their time and knowledge.
TABLE OF CONTENTS
1. INTRODUCTION........................................... 1
The Prenatal Care Imperative......................... 1
Prenatal Care Access Disparities..................... 3
Welfare Reform and the Devolution of
Authority for Public Health.......................... 6
Colorado Policy Following PRWORA..................... 9
2. THEORETICAL FRAMEWORK................................. 16
Biopower: Race, Sex and Immigration
In the United States.............................. 16
Governmentality and the Third Sector............ 18
Devolution of Responsibility and
Variability of the Safety Net......................20
3. METHODS............................................... 23
Research Design................................... 23
Research Validity................................. 25
Data Analysis...................................... 32
4. FINDINGS............................................. 34
The Importance of Localities........................35
Variability in Access to Services.................. 40
The Role of Ethic of Care........................ 43
The Double-Edged Sword........................... 46
High-Risk Pregnancy: The Critical Gap in
Prenatal Care Access for Uninsured
Negative Health Effects of Restrictive
Welfare Policy: Diabetes........................... 52
5. CONCLUSION........................................... 59
6. BIBLIOGRAPHY......................................... 63
The Prenatal Care Imperative
Prenatal care is widely considered an essential, preventive care
strategy to reduce maternal and infant mortality and morbidity. A
number of organizations endorse expanded access to prenatal care.
The World Health Organization (2007) recommends integrated care
strategies for womens reproductive health to include pre-conception
health, prenatal care, labor and delivery, and postpartum care. The
United Nations Millennium Development Goal 5 (2008) aims to
improve maternal health, with universal and equitable access to
reproductive health services. The Healthy People 2010 campaign
identifies equitable healthcare access as a primary goal and promotes
prenatal care to improve the health of women, infants, and children
The purpose of prenatal care is to provide risk assessment,
treatment for medical conditions or risk reduction, and education as
well as an opportunity for appropriate nutritional supplementation
(USDHHS 2009). Often considered essential not only for improving the
health of the mother but also the health of the infants, prenatal care
seeks to prevent low birth weight, premature birth and fetal growth
retardation; reduce prevalence of sexually transmitted diseases and
other infections; manage gestational diabetes, pregnancy-induced
hypertension and pre-existing chronic diseases; and change high-risk
behaviors of pregnant women such as smoking and drug use (CDC
2005). Both the American College of Obstetrics and Gynecology and
the US Department of Public Health recommend early initiation of
prenatal care in addition to a minimum number of visits for normal, low-
risk pregnancies (Loue, et al 2005).
Prenatal care is also frequently cited as a cost-effective strategy
to reduce immediate and long-term healthcare costs. One such study
in California by Lu et al (1999) found that among 970 undocumented
women, those without prenatal care were more likely to deliver low-
birthweight or premature infants than those with prenatal care. For
each dollar cut from prenatal care coverage for undocumented women,
costs increased by $3.33 for postnatal care and $4.63 for long-term
Prenatal Care Access Disparities
Despite the importance of prenatal care for positive health
outcomes and cost savings, utilization and access disparities persist.
Latina women in particular have low rates of prenatal care use in the
United States (Gavin et al 2004, USDHHS 2000) and in Colorado
utilization is lower than the national average with only 64.9% of Latina
women receiving adequate prenatal care, compared with 72.7% of
African-American women, 81.8% of Asian women, and 84% of non-
Latina White women (CDPHE 2008a). The Institute of Medicine (2003)
and the Kaiser Family Foundation (2000, 2004) report that Latina
women in the U.S. experience greater health disparities than either
non-Latina White or African American women. They delay care more
often due to costs, greater reporting of fair or poor health, more often
lacking a primary care provider, being less likely to receive preventive
diagnostics, having greater difficulty communicating with physicians,
and having less access to health insurance. In Colorado 36% of the
Latino population is uninsured, compared to 20% of African-American
and 11% of non-Hispanic White populations.
Among Latina women, immigrants experience additional health
disparities and more limited access to prenatal care. Financial barriers
and lack of health insurance are the primary factors in abetting access
to prenatal care (Fuentes-Afflick et al 2006) as immigrants are more
likely to have lower incomes yet have more limited access to insurance
or public medical assistance (MPI 2005). In the U.S. 16.2% of
immigrants live below the poverty line compared with 12.9% of U.S.
born citizens. In Colorado 20.8% of the immigrants lived below the
poverty line, compared with 10.9% of U.S. born citizens. Research also
demonstrates that low English proficiency is associated with increased
poverty (Capps et al 2002) and more difficulty in navigating the health
system (Ellwood 1999, Holcomb et al 2003). Of individuals who speak
Spanish at home in Colorado, 20.7% lived below the poverty line,
compared with 11.4% of those who spoke Asian or Pacific Islander and
10.1% of Indo-European languages at home.
Undocumented Latina immigrants have lower healthcare
utilization rates than other immigrants and face more barriers to
prenatal care access (Geltman and Meyers 1999). They earn less and
have fewer opportunities to obtain insurance through employment or
public programs. When access to public insurance programs or
healthcare services is available they may experience language and
cultural barriers, or fear deportation for using services which seem
official or require paperwork. Research on the statewide effect of
California welfare reform legislation on immigrants' utilization of
prenatal care found that even when undocumented immigrants are
eligible for prenatal care benefits restrictive public policies create a
chilling effect that discourages utilization (Park et al 2000). In
particular, undocumented immigrants may fear that using services
could preclude their eventual naturalization or result in deportation.
Fuentes-Afflick et al (2006) found that compared to U.S. born citizens,
documented immigrants in New York were twice as likely to receive
inadequate prenatal care, and in Florida where restrictive eligibility
policies deny prenatal care public coverage to most immigrants, they
were two to four times more likely to receive inadequate prenatal care
than native citizens. A study by Bengiamin et al (2009) demonstrates
that immigration status affects disparities in prenatal care utilization,
but notes that few studies have focused on this social factor.
Welfare Reform and the Devolution of Authority
for Public Health
Since 1965 Medicaid has provided healthcare coverage to low-
income individuals and families in the U.S. (CDC 2002). In response to
increasing infant mortality rates, Medicaid prenatal care coverage
expanded in the 1980s and now provides coverage for 41% of births
nationally (Kaiser 2000). Coverage includes services such as prenatal
care, birth and delivery, postpartum care, and automatic coverage of
infants for the first 30 days of life.
However, the Personal Responsibility and Work Opportunity
Reconciliation Act (PRWORA) in 1996 enacted major changes to both
social welfare and immigration policy, and for the first time the federal
government defined and sanctioned differential treatment of the foreign
born living in the United States (Zimmerman and Tumlin 1999). For
example, prior to PRWORA, while undocumented immigrants were
mostly ineligible for public benefits, legal documented immigrants were
entitled to the same benefits as citizens (Zimmerman and Tumlin
1999). PRWORA ended the federal governments obligation to provide
matching funds to states to cover services to newly defined classes of
immigrants, but allowed states to extend benefits to these immigrants
at their own cost and required them to pass laws defining and affirming
such coverage. This allowed states to essentially create and
implement immigration policy, historically a power strictly reserved for
federal authorities to prevent the abuse of immigrants by individual
states (Neuman 1995:1436).
The New York Medicaid agency challenged PRWORAs denial
of federal matching funds for prenatal care for undocumented
immigrants, claiming it violated the rights of unborn U.S. citizens to
equal protection. In Lewis v. Grinker, the U.S. District Court ruled in
New Yorks favor, but the Second Circuit U.S. Court of Appeals
overturned the decision the following year, finding neither a
constitutional basis to provide prenatal care to women nor a violation of
right to equal protection for the fetus since it has no constitutional
rights based on Rose vs. Wade (National Immigration Law Center
2000). Yet, the new ruling adjusted PRWORA to allow states the
option to provide public coverage for prenatal care to undocumented
immigrants through the partially federally-funded State Childrens
Health Insurance Program (SCHIP) reasoning the fetus would qualify
to enroll in the program when born. In order to provide prenatal care
through SCHIP, states are required to pass affirmative legislation.
PRWORA marked the beginning of a new era in the promotion
of self-sufficiency through social and welfare policy. Research by
Zimmerman and Tumlin (1999) demonstrates that this devolution of
authority for public health resulted in variable eligibility requirements to
enroll in programs and a patchwork safety net system. The ability of
individual states to determine eligibility requirements for Medicaid, and
the subsequent ruling on SCHIP, led to widely varied eligibility rules
throughout the United States. Prenatal care is such a service with
widely varied rules for different classes of immigrants. For example,
New York's fully state-funded program provides prenatal care coverage
to low-income women regardless of immigration status; California,
Illinois, and Texas provide prenatal care coverage through SCHIP
regardless of immigration status; Florida provides coverage only to
legal immigrants who have lived in the U.S. for more than five years;
and Colorado recently extended Medicaid coverage to all legal
immigrants but excludes undocumented women from prenatal care
coverage(National Immigration Law Center 2008).
Colorado Policy Following PRWORA
In the wake of PRWORA, with newly vested powers to decide
which immigrants are eligible for various publicly funded services,
Colorado elected a restrictive policy denying legal immigrants in the
US less than five years access to Medicaid, with no exceptions for
prenatal care. Colorado has never provided public coverage for
prenatal care to undocumented immigrants despite periodic efforts
A 1999 study conducted by the Colorado Department of Public
Health and Environment associated low rates of prenatal care
utilization with high rates of negative birth outcomes among
undocumented immigrants (CDC 2009). This study prompted a bill
which would have allowed eligibility for prenatal care public coverage
regardless of immigration status, which was then redesigned as
Colorado House Bill 99-1018 (1999), instead authorizing a study to
design a prenatal program to serve undocumented immigrants. The
following year Colorado implemented a pilot program that allowed
undocumented women to enroll in Medicaid during pregnancy
although, ultimately, the state did not allocate funds to the program
(CDC 2009). In 2000 House Bill 00-1076 extended coverage for
prenatal care to undocumented women qualifying for Emergency
Medicaid. The program would have reimbursed clinics through
managed care organizations, but was never implemented. The bill's
supporters claimed that prenatal care saved costs by avoiding costly,
negative health outcomes. Rather than allocating increased funding for
the program the legislature required a shifting of funding. In other
words, the program for prenatal care coverage would theoretically fund
itself since the costs for delivery would be assumed to be lower and
Medicaid reimbursement that would be paid to hospitals would shift to
clinics for prenatal care (Stoever 2000), a requirement opposed by
Colorado Health and Hospital Association. The bill also required
providers to submit proposals to cost-shift but none were received
In 2004 a prenatal care study by the Colorado Department of
Health Care Financing (CDHCF) claimed that the Colorado Medicaid
program rejected 30% of Presumptive Eligibility (PE) applications due
to illegal immigration status, estimating the state to have paid $9
million in prenatal care it was not required to fund and claiming such
coverage to be a magnet for influx of undocumented immigrants
(Jordan 2004). PE allows providers reimbursement for prenatal care
during the waiting application period for Medicaid, a policy
implemented to reduce disparities and negative health outcomes for
low-income women who could not initiate care early in pregnancy due
to cost. The CDHCF accused clinics of pushing through applications of
women they knew were undocumented through in order to receive
compensation for care that would otherwise not be covered.
Legislators confirmed that PE had not been a legally sanctioned
program in Colorado since 1991 and explicitly prohibited the practice.
Studies immediately demonstrated the decision's negative health
effects on women and the threat to the viability of the safety net which
was already absorbing the outcome of PRWORA, and in 2005 the
legislature legally created the PE program, with specific exclusion of
undocumented immigrants (Nguyen 2005).
In 2006 the Colorado legislature passed House Bill 1023, one of
the strictest policies of immigrant exclusion from public benefits in the
nation, and what former Colorado Governor Bill Owens promoted as
the strongest immigration law yet. A chilling effect rippled through the
state with immigrants fearful of accessing services and provider
organizations required to document proof of citizenship to provide
services for which they receive state funding. Prenatal care services
were originally included in House Bill 1023 but in order for proponents
to pass it successfully it was specifically excluded, demonstrating the
widely accepted belief that such care is a public health necessity.
Biopower: Race, Sex, and Immigration
in the United States
Jonathan Xavier Inda (2002) argues that since medical
authorities consider prenatal care essential to increase the chances of
a healthy life for both child and mother, exclusion from it defines the
lives of undocumented women and their children as expendable.
Employing Foucaults notion of biopower, he argues that their
exclusion [fortifies] the health of the population through the elimination
of those influences that are deemed harmful to the well-being of the
nation (Inda 2002:109). Since prenatal care reduces risks of maternal
and infant morbidity and mortality, with national and international
agendas aiming to expand coverage, the restriction of access to such
care by undocumented immigrants is, in essence, letting die.
Foucault (1997) proposes that the rise of industrialization shifted
the absolute authority of the state from taking life to a population level
project of biopower, of making live in order to strengthen the
workforce. Rather than forcing death upon its subjects, or making die,
the state began the project of making live through various strategies
of self-regulation. The opposite of making live, he argues, is no
longer making die, but letting die through exclusion.
When I say killing, I obviously do not mean simply murder as
such, but also every form of indirect murder: the fact of exposing
someone to death, increasing the risk of death for some people,
or, quite simply, political death, expulsion, rejection, and so on.
Fie proposes that racism is inherent in a states exercise of biopower
and has two functions. Firstly, it attempts to create a simple biological
division between whom to let die and whom to make live. Secondly,
racism creates a distinction which perpetuates the belief that the death
of the excluded will make the population healthier. Fie emphasized that
this racial division need not be biologically based. I propose that the
undocumented immigrant is such a racialized category in the United
In addition, Foucault argues that the specificity of modern
racism...is not bound up with mentalities, ideologies, or the lies of
power. It is bound up with the technique of power, with the technology
of power. Policy is one such technique of power. As Shore and Wright
Policies are most obviously political phenomena, yet it is a
feature of policies that their political nature is disguised by the
objective, neutral, legal-rational idioms in which they are
portrayed. In this guise, policies appear to be mere instruments
for promoting efficiency and effectiveness. This masking of the
political under the cloak of neutrality is a key feature of modern
Arguments for controlling immigrationwhile racial in motivation
often take a more objective economic form. Mae Ngai (2005) argues
that racism underlies the history of US immigration policy, which
serves as a tool to control the racial demographics of the national
population. Nora Demleitner (1998) also argues that policy aimed at
restricting undocumented immigrants access to public services serves
as this cloak of neutrality. Proponents of California's 1990s anti-
immigrant legislation, Proposition 187, promoted the notion that
undocumented immigrants arrive in the U.S. to take advantage of the
generous public benefits, and to exclude them from these services
would result in their return to their native country, thus fortifying the
nations economic health. She observes that with the focus on welfare
benefits, anti-immigrant forces moved the battleground from race and
ethnicity to economic analysis, which appears more neutral and
objective (Demletiner 1998:14).
The controversy surrounding the ius soli system which grants
citizenship to all persons born on U.S. soil, a right guaranteed by the
fourteenth amendment, illuminates this economically rationalized
racism. Undocumented women are often portrayed as invaders with
profound fecundity, giving birth to their children in the United States so
they can take advantage of public benefits entitled to citizens. In The
Latino Threat: Constructing immigrants, citizens, and the nation (2008),
Leo R. Chavez shows the ways in which the media repeatedly
represent and assume that Latina women are overly promiscuous,
resulting in a fecundity that poses challenges to population control both
nationally and globally. More specifically, according to Chavez, fear of
the Latino threat has increased along with the recent browning" of
the United States, as the rate of growth of the Latino population
outpaces that of the white population. The widely used and
dehumanizing term anchor babies to describe children of immigrants
born in the United States reflects this perception, suggesting that
women arrive to the United States in order to take advantage of the
public programs not only for pregnancy and birth, but to enroll their
U.S. born citizen children in available public programs (Ramirez 2006).
It is this perceived threat that underlies the justification for U.S.
prenatal care policies that, in effect, let die."
Natalia Molina (2006) proposes in Fit To Be Citizens?: public
health and race in Los Angeles 1879-1939 that race has been used
historically in the United States as a way of demarcating social
membership; public health interventions targeted women of color
because their combined attributes of color and fecundity constituted a
dual threat." Molina primarily discusses intrusive health interventions
targeted towards the Mexican-origin population living in the United
States at the turn of the 19th century as a form of social control. Yet
Inda (2002) argues that the denial of prenatal care assistance to
undocumented immigrantsa withholding of care-- also serves as a
form of social control, as it intends to limit Latina womens capacity to
Contrasted with U.S. state-level policies restricting access to
prenatal care for undocumented immigrants, human rights
organizations have given increased attention to the right to maternal
health. The UN Council on Human Rights explicitly aims to protect the
sexual and reproductive rights of women, those living in poverty, and
migrants. Amnesty International (2010) published a study in 2010
entitled Deadly Delivery: The Maternal Health Care Crisis in the United
States, which describes increasing and understated maternal mortality
rates, health disparities, and barriers to care which more frequently
affect poor, minority women, including immigrants.
Governmentality and the Third Sector
Foucault (Burchell et al, 1991) envisions the modern nation-
state as one that provides controlled freedom to its subjects, through
governmentality, in which the state devolves control to localized
institutions to promote the self-regulation of its subjects. In Powers of
Freedom, Nikolas Rose (1999) extends Foucaults concept to our
contemporary neoliberal era. He argues that neoliberalism relies upon
a third sectorin addition to the individual and the welfare state- to
promote the self-regulation of subjects. This third way of governing,
which Rose describes as the community, devolves power to localized
organizations which are responsible for regulating its spaces and
people. As Rose argues, This third space must, thus, become the
object and target for the exercise of political power whilst remaining,
somehow, external to politics and a counterweight to it (Powers of
Freedom, p. 168). Safety net healthcare institutions could be
considered a part of this third sector, as they serve the healthcare
needs of local, low-income groups yet rely on and may be constrained
by reimbursement from public insurance programs such as Medicaid,
federal funding, and state and locally funded programs.
The Colorado Health Institute (2009) reports that safety net
clinics in Colorado compete for pregnant Medicaid clients as they
depend on these revenues for cost-shifting in order to serve uninsured
clients. As the state denies public assistance for healthcare to
pregnant undocumented immigrants, responsibility for public health
further devolves to safety net organizations, especially those with
missions of care to serve the uninsured. As a counterweight to the
exercise of political power, safety net healthcare organizations may
play a role in buffering the effect of restrictive reforms on underserved
populations such as undocumented immigrants. A number of studies
have demonstrated that safety net providers may follow an ethic of
care that prompts them to assume greater burdens in order to
compensate for restricted care for disadvantaged groups (Lamphere
2005). Deborah Boehms (2005) research demonstrates the
willingness of safety net providers to go the extra mile to serve their
clinic base even as changes in New Mexicos Medicaid managed care
system restricted funding to those institutions.
Devolution of Responsibility and Variability
of the Safety Net
Research suggests that access to services across the safety net
is variable and that inclusion of undocumented immigrants may be
locally-based. Zimmerman and Tumlin (1999) found in their research
that systems that were strong prior to PRWORA more often maintained
coverage to immigrants, and weaker systems tended to follow the acts
exclusionary guidelines. Sarah Hortons (2001, n.d.) ethnographic
research in safety net institutions demonstrates that policies and
provision of care to uninsured immigrants vary at the institutional level,
with some following their mission of care to serve the underserved, and
others withholding services if uninsured patients cannot pay up front.
Moreover, as localities increasingly pass legislation such as the
ability for undocumented immigrants to use Mexican consulate
identifications or obtain drivers licenses, the inclusion of
undocumented immigrants in the body politic is highly locally variable
(Varsanyi 2006). Research also suggests localized differences of
inclusion through the provision of prenatal care services. Following
welfare reform in California research by Sun-Hee Park et al (2000)
found increased fear of using services, Loue et al (2005) noted
increased fear but no difference in utilization in San Diego and
Demleitner (1998) reported that San Francisco announced it would
continue to provide public prenatal care coverage to undocumented
women. Thus, research on the effect of restrictive policies on the
provision, utilization, and access to prenatal care by undocumented
immigrants requires a focus on localities. This focus on localities is
especially necessary for Colorado, where social services are highly
decentralized and implemented by counties (Fix and Zimmerman
This research employed a qualitative design to study the
negative health effects on undocumented immigrant mothers and their
infants due to denial of public benefits for prenatal care in Colorado,
and the ways in which safety net organizations may buffer such
effects. Semi-structured interviews were conducted with health and
immigrant advocates, outreach workers, and direct-care providers with
specific knowledge of the provision of prenatal care to uninsured,
Spanish-speaking immigrants on the Northern Front Range of
Colorado. Specifically, the research aimed to:
1. describe the negative health effects uninsured, undocumented
immigrant women and their infants experience due to
inadequate prenatal care;
2. describe the ways in which the safety net may buffer such
3. describe the role of localities in access to care.
This research employed a qualitative design using a semi-
structured interview instrument. Participants (n=22) were selected
through purposive and snowball sampling. The principal investigator
(PI) first interviewed five advocates in immigrant organizations, policy
analysis, and healthcare advocacy organizations. These advocates
served as key informants who helped shape the interview guide and
identify potential participants. Then 17 semi-structured interviews were
conducted with outreach workers and direct-care providers with
specific experience in the provision of prenatal care to uninsured,
Spanish-speaking immigrants on the Northern Front Range of
Colorado. Interviews were conducted with participants working in
safety net clinic systems (n=4) with at least one-quarter of their
clientele uninsured Latino immigrants.
Qualitative methods are appropriate in exploratory research
when variables are undefined (Bernard 2006). Little is known
quantitatively about the health outcomes of undocumented immigrant
women in the US. Although immigration status is a determining factor
in eligibility for public programs, status is not recorded in health
records. While this protects undocumented immigrants from visibility
and perhaps would serve as a deterrent to accessing care if care
providers asked immigration status, it may also leave them more
vulnerable as the prevalence of negative health outcomes remains
Bernard (2006:354) proposes, Presence builds trust. Trust
lowers reactivity. Lower reactivity means higher validity of data. The
provision of public benefits for healthcare services to undocumented
immigrants is a volatile issue in Colorado, evidenced by explicitly
restrictive legislation such as HB 1023 which bars access to individuals
that cannot provide evidence of legal residency. Most safety net clinics
in Colorado have an ethic of care to serve vulnerable populations and
also require the employees they hire to be committed to that mission.
To build trust, the principal investigator disclosed her bias that
immigrants should have better access to prenatal care. The invitation
to participate included the statement with the hope of improving
access for immigrants in Colorado. Disclosure of the intention to
improve prenatal care access builds trust, limits reactivity, and
improves data validity.
Bernard (2006) suggests that participant-observation is
essential to building this trust. While this method would have yielded
rich, qualitative data, scope and practicalities made this infeasible. The
PI conducted phone interviews using a semi-structured interview
instrument to accommodate the limited time availability of participants,
difficult access to healthcare organizations, and necessity of collecting
data from multiple sites to study the locally variable effects of policy. In
addition, the federal Health Insurance Portability and Accountability Act
makes accessing healthcare sites to conduct participant-observation
increasingly difficult and clinics demonstrate concern in protecting the
privacy of their clients, especially vulnerable populations such as
undocumented immigrants. Safety net health care workers also have
increasing workloads as demand or services increases while funding
decreases. The semi-structured interview instrument works well with
people who need efficient use of their time, and allows the researcher
to control the information provided in the interview without exercising
excessive control, and yields reliable, comparable, qualitative data,
The Northern Front Range was selected because the region
contains the three counties with the largest number of births to foreign
born Latina women based on data available in the Pregnancy Risk
Assessment Monitoring System Statistics (PRAMS) database
(Colorado Department of Public Health and Environment 2008b). While
no data exists regarding births specifically to undocumented women,
this research project assumes the ratios are similar for documented
and undocumented women. For these three counties a list of safety net
clinics was generated from Connecting Care and Health in Colorado: A
Guide to Services For the Uninsured (Ingargiola and Yodorf n.d.).
These clinics were then screened by phone to determine whether they
provide prenatal care services to the uninsured, and whether their
prenatal care client base is at least 25% Latina immigrants. Managers
of the clinics in this final list were contacted by phone to request
contacts to clinic workers, but as one clinic administrative assistant
noted, She [the director] is very, very busy. Something like this will not
have priority. The contact strategy was then changed to obtaining the
email of the clinic director, sending a description of the study and
requesting that an attached invitation to participate be forwarded to
clinic workers. All participants in clinics, with the exception of one
outreach worker, were recruited through this email strategy. The PI
contacted, recruited and interviewed health and immigrant advocates
Sampling included both purposive and snowball methods. The
purposive sample required that individuals possess specific knowledge
and experience of prenatal care provision to uninsured undocumented
immigrants. It included policy analysts, health and immigrant
advocates, and direct-care providers and outreach workers in safety
net clinics recognized as serving uninsured immigrants on the Northern
Front Range of Colorado. Advocates and clinic workers providing
services to immigrants have continual contact with the immigrant
population and can relate stories and general impressions of the
salient issues. Snowball sampling was employed to identify
organizations and individuals meeting criteria for the purposive sample.
Participation by clinics and individual workers was entirely
voluntary and participants were informed the interview would take 10 to
20 minutes. Participants contacted the principal investigator either by
phone or email to arrange the interview time, or in some cases (n=6),
the interview was conducted at the time the participant called.
Interviews were tape-recorded using a digital tape recorder and lasted
between 10 and 60 minutes each. Prior to the interview verbal consent
was obtained. Gift certificates to a local grocery store were provided to
participants to compensate them for their time.
The PI conducted 22 semi-structured interviews by phone.
Participants included policy analysts (n=2), advocacy workers (n=3),
outreach workers (n=4) and direct-care providers (n=13). Outreach and
direct-care providers (n=17) worked in four of the clinics meeting
criteria for the study. The direct care providers consisted of physicians
(n=5), physician assistants (n=3), nurse practitioners (n=2) and nurses
(n=3). Semi-structured interview instruments are especially amenable
to comparability and at the same time allow subjects the opportunity to
speak outside of structured responses (Bernard 2006:212, Patton
1999:349). This is useful for analysis since responses come from a
variety of sites and people related to safety net prenatal care for
immigrants. Semi-structured interviews also maximize time efficiency,
important since participants in this study have demanding work
schedules (Patton 1999:346). Constraints of the semi-structured
interview include the risk that the interview instrument will miss the
most salient aspects of the issue. To overcome this constraint
participants were given the opportunity to add comments they believed
relevant that were not asked. The semi-structured interview instrument
included five questions:
1. What are the reasons women tell you for not arriving to prenatal
care as early or frequently as recommended?
2. What health effects have you seen on uninsured, Spanish-
speaking women due to not accessing prenatal care?
3. What strategies does your clinic employ to improve access for
uninsured, Spanish-speaking women?
4. What do you feel could be done to improve prenatal care
access for undocumented women?
5. Is there anything else you would like to add?
The first question regarding barriers to prenatal care access
was employed as a grand tour question in order to break the ice and
get the interview flowing (Spradley 1979). The principal investigator
also employed probing, which was especially useful for the second
question to assist participants to recall negative health effects. Bernard
(2006:220) advises probing in qualitative interviewing to overcome
participants' reporting of normative behavior. Most participants (n=14)
could not recall any negative health effects on women due to not
accessing adequate prenatal care. Yet, when probed about gestational
diabetes, all but one participant said they regularly see patients unable
to access appropriate care for this complicating condition. For clinic
workers, who have an ethic of care to serve vulnerable populations
and work in a demanding environment to provide that care, adequately
serving their patients may be perceived as normative behavior. As one
participant noted, surprised she did not think of gestational diabetes
even though she often sees it in patients, I guess we tend to believe
we are doing a good job. In addition, since specialized diagnostics
and care for complicating conditions are often outside the scope of
primary care clinics, participants may consider that they provide all the
care they are able to provide.
To protect identities, the PI assigned participants a code to
reflect their organization, role, and name. The code sheet was kept in a
locked file cabinet at the home of the principal investigator, separately
from the tape recordings of the interviews. Following each interview the
principal investigator recorded impressions of the interview, listened to
the recorded interview again, and took field notes. These were
included in the data set.
The PI performed textual analysis with focused coding on
transcribed interviews and field notes manually and using an open-
source computer software program, TAMSAnalyzer. Interview notes
and field notes were transcribed to a word processing computer
software program and then the tape-recorded interview was erased.
The PI printed the transcribed interviews and kept them in a locked file
cabinet, separately from the code sheet identifying participants.
Following completion of data analysis the PI destroyed the code sheet.
Manual analysis consisted of reading through each printed
interview and manually recording possible codes, which were then
compiled to arrive at a final coding scheme. The interviews were also
electronically arranged in a table in a word processing program, and
the data sorted according to each interview question with the codes
barriers to care, negative health effects, safety net organization
strategies, This enabled the principal investigator to recognize
patterns and themes according to research aims. Additional codes
were added throughout the analysis, including 1) negative health effect
issue recognition, 2) systemic healthcare issues, 3) gestational
diabetes, 4) localities, 5) social knowledge of health system, and 6)
limited safety net resources. The interview data and coding schemes
were entered into TAMSAnalyzer. The PI used this tool to create a
summary of each theme and to organize participants responses.
Prenatal care access for undocumented women is highly
dependent on localities in Colorado as exclusion from public insurance
coverage devolves responsibility for public health to individual safety
net clinics. Access to services varies among clinics and depends on
the climate of fear due to local implementation of policy related to
immigrants, knowledge of the health system, and discounted services
offered by individual clinics to the uninsured. Clinics serving the
uninsured buffer the effects of exclusion through outreach in
communities, use of care navigators to guide patients through the
system, and variable discount programs for low-risk pregnancy care.
Yet, a critical gap exists for undocumented women with high-risk
pregnancies. Complicating conditions are beyond the scope of prenatal
care offered in safety net clinics serving the uninsured, but may not
pose immediate threat to life that would qualify them for Emergency
Medicaid coverage. Uninsured, low-income immigrant women requiring
care for high-risk conditions must pay out-of-pocket for specialists,
diagnostics and treatments, which would normally be covered by
Medicaid. Lacking the resources to pay for such care, undocumented
mothers and their infants are exposed to increased risks of morbidity
and mortality. Diabetes during pregnancy was the most common
condition identified by participants (n=16).
The Importance of Localities
Since policies regarding access to prenatal care vary by region
and among organizations, the inclusion or exclusion of undocumented
women from the body politic is highly locally variable. In the case of
Colorado, services for low-income, uninsured pregnant women are
mostly confined to the metropolitan area. In Colorado's rural areas,
where there are fewer health services, and even fewer that serve the
uninsured or have providers that speak Spanish, prenatal care access
is more limited. Most rural communities don't have a health center so
it's much tougher for low-income women to be seen and that's just
magnified if they're undocumented. In our catchment area it is not
really an issue because we'll take any pregnant woman at any time
[regardless of ability to pay and the capacity of our clinic], said one
urban area clinic physician.
Local implementation of non-healthcare policy affecting
immigrants also affects prenatal care access for undocumented
immigrants, creating uncertainty about whether accessing health
services will result in arrest or deportation. For example, Senate Bill 90
requires counties and cities to report arrestees suspected of
undocumented status to Immigration Customs Enforcement (ICE).
Some localities have been reported to interpret the policy more widely,
reporting witnesses of crimes to ICE or seeking out individuals
suspected of being undocumented, creating a pervasive fear that any
contact with services perceived to be connected to the government can
potentially result in arrest or deportation. Highly publicized workplace
raids by ICE resulting in arrests in localities such as Greeley also
create fear of visibility and reluctance to use services. A policy analyst
You know, Denver is constantly accused of being
a 'sanctuary city', which our mayor is adamant we
aren't. We don't really have any policy that can
violate any of these state things but we certainly
have a different reputation than Greeley or these
other places that are kind of, how do you say,
known as being more hostile to immigrants.
In addition, healthcare policies such as House Bill 1023
(HB1023) passed in 2006, requiring proof of identification in order to
receive public state services such as Medicaid, has caused confusion
even to those administering services. A health analyst and physician
said that initially there was a drop in utilization of services by
immigrants, but that strong relationships with communities and
outreach services to some extent countered the effect. Policies such
as HB1023 can also affect how care is administered and perceptions
at the provider level. A policy analyst recalled that in the wake of
I remember talking with a guy who actually was a
citizen but he was Spanish-speaking and his
daughter had multiple problems and was being
treated through [a Denver area hospital] and she
was a citizen, but because he was Spanish-
speaking there were certain assumptions as to his
immigration status [and ability to pay or qualify for
public insurance] and it took a while to get
Individual clinics were able to overcome the impact of HB 1023,
according to participants (n=6), because of their relationship with
immigrant communities, demonstrating the ways in which localities
play a role in inclusion of undocumented immigrants. A health
advocate said that denial of access to any state-funded resources
increased the amount of anxiety around seeking care, so even in
places where coverage was not an issue it sort of erected a new
barrier. He added,
For the most part I think this is a piece of the
safety net that has really taken this on. There are
a few community health centers like [clinic name]
who have a really very deliberate outreach to this
community and think the sort of credibility those
providers have in the Latina community has
allowed them, I think for them, there was some
anxiety when the law passed, the reality was that
things didn't change and I think word sort of crept
back out. I actually don't know that there are
formal programs that say our doors are open,
please come in but their commitment has
The desire to avoid any official system involving paperwork
which might reveal immigration status may delay initiation or use of
prenatal care. To overcome this barrier clinics do not require disclosure
of immigration status in order to receive services or enroll in discount
programs. Outreach and enrollment specialists in clinics serving
uninsured immigrants assist clients with filling out the necessary
paperwork to apply and enroll in discount programs, Emergency
Medicaid and WIC, a federal program which provides some services to
pregnant women and their children regardless of immigration status,
and any other services for which they qualify. A clinic physician
A lot of it is word of mouth in the community, but I
think once they are in our clinic, out financial
screeners do a great job of getting whatever
documentation they have related to income and
housing and things like that, so we can help them
get whatever they qualify for and help them
navigate through that system, then getting EM,
getting their kids on Medicaid after they deliver,
but I still think there is room for improvement and I
think a lot of these women are so preoccupied with
things like being deported or their husband being
deported, surviving a lot of that system paperwork
seems to worsen things like that, as much help as
we give them I feel like it's lost.
Another physician suggested that the perceived link between clinics
and the government could be overcome through outreach.
I think that in general education needs to be given
to immigrants in a way that they think is not
punitive so I mean, you cant give out the
information at any location that is a government
office, right, so you have to give out the
information at, like, grocery stores, something
else, something that they dont perceive as being
punitive about how important it is to get early
prenatal care and why and what could happen to
their baby if they dont, and where they can
actually go to get it. I find that they are very
resourceful and they would do it if they only
believed it would be safe for them.
Outreach workers (n=3) confirmed that relationships between
the safety net clinic and immigrant communities helps to overcome
fears of using services, demonstrating that localities are an important
role in whether undocumented immigrants are included in the polity
through provision of healthcare.
Variability in Access to Services
In addition to local climates of implementation of immigration
policy, variability among providers serving uninsured immigrants exists,
demonstrating the role of localities. Clinics offer variable sliding scale
discounts based on income with various payment policies. One clinic
offers basic prenatal care services for a lump-sum fee as low as $400,
but requires the entire amount upfront before providing those services.
Two others provide prenatal care services for as low as $100-$250,
and while they do request payment at time of service, they will not
refuse services for any pregnant woman who cannot pay. An outreach
In reality we serve many communities and in many
of these communities we are very well-known and
people know that we can serve anyone. It doesnt
matter whether they have insurance or not, and
documentation or not. We have different programs
for different people. For example, we have a
prenatal program and if a woman who comes
doesnt have any insurance at all she can have
this program, so she pays $250 for the 12 visits
that are the prenatal care and then we can help
them apply for Emergency Medicaid so they can
be served for delivery in the hospital. And that is
for everyone, it doesnt matter. So there are
essentially services for everyone. We serve
patients on a sliding fee and will require their
income, size of their family...so in a way a woman
that has a higher income would pay the full fee
and a woman with a very, very low income will pay
a discounted fee.
A physician in another clinic with a similar policy described their policy
of providing prenatal care regardless of the clients ability to pay,
Their delivery is covered by Emergency Medicaid
and what we charge them is a sliding scale global
fee for all of the prenatal care services packaged
into a lump sum. So no matter what week of entry
they come into our care at, they pay the same fee
based on their income level. And in general its a
couple of hundred dollars. We have an unofficial
policy that we never withhold care. If they cant
pay it, it will be billed to them and they can pay it in
installments, and there are people that elect to
default on the installment payments, but our policy
is never to withhold them care.
Yet another clinic offers discounted fees but requires the fee before
providing any services.
And theres also a payment, it does cost money to
get services, probably more money than it would
cost a person with private insurance, so there is
an outlay of money that is required. I mean, its a
lot of money, but its relatively do-able. Its (the
prenatal care) about $400 or so, so like I said, its
not a lot of money but its a fair amount of money.
There are legal, financial and ethical reasons that clinics offer
different payment policies. Funding streams have different
requirements and restrictions on safety net healthcare services. For
example, federal funding guidelines to clinics with Federally Qualified
Health Center status require they provide discounted services with
sliding-scale fees (Colorado Health Institute 2009). State laws such as
FIB 1023 can limit the use of state funding to provide services to
individuals without proof of legal residence. One clinic subsidized
three-quarters of costs to operate and provide care with federal, state
and private funding. The remainder of funds to operate the clinic
comes from billed services, paid to them directly or reimbursed by
insurance programs such as Medicaid. A physician explained,
The clinic has a number of funding sources an so
we get a large federal grant as what's called an
FQHC, a federally qualified health center, that
covers about half of our total operating budget and
we get some additional state money and some
additional private money that covers another
quarter. So 3/4 of the cost of running the clinic,
including the costs of all the visits of all kinds of all
the patients, are kind of subsidized by this sort of
funding and then the last 1/4 of our total operating
budget comes from what we are able to bill. In
other words, the patients that do qualify for regular
Medicaid and if we're able to bill Medicaid for their
visits, or the amounts that patients are able to pay
on the sliding scale. All of that is pooled together
with all of the federal grant funding in order to
keep our doors open and keep us able to see
patients, able to take care of patients.
The PI attempted to contact directors and financial services employees
of clinics to further understand why safety net clinics on the Front
Range have these variable payment policies but none were available
The Role of Ethic of Care
The ethic of care plays an important role in serving the
uninsured, including undocumented immigrants and is locally based. A
clinic physician explained,
For most providers documentation status doesn't
matter, the only thing that matters is whether they
have money or not. Unfortunately undocumented
women are also less likely to have money and
they don't qualify for programs other than
Emergency Medicaid and that only deals with
delivery. It doesn't cover prenatal care at all. So
it's a money issue, not a documentation issue.
An ethic of care to serve the uninsured in combination with available
funding streams contributes to the devolution of responsibility for
healthcare and variability of the safety net. One nurse practitioner said
that her clinic specifically hires those committed to serving the
underserved, while others (n=3) mentioned that the people working in
safety net clinics feel committed to serving the underserved. With
increasingly limited budgets to cover costs for uninsured populations,
the responsibility for public health devolves not only to organizations
but to individual providers. A physician suggested, its very based on
the provider culture in the community and whether you have docs who
are a little more whats the word altruistically oriented.
This ethic of care can also been seen in the increased
workloads of providers. More than half (n=8) of direct-care providers
mentioned that they are working longer hours and spending less time
with patients in order to accommodate the demand for services. One
physician assistant suggested reduced state funding due to budget
cuts has resulted in increased workloads. A clinic nurse practitioner
Services other than Emergency Medicaid aren't
going to be reimbursed to the clinic and that's
Colorado's law, and it's causing issues for all
prenatal health centers because they're not
supposed to be using any state funding for non-
documented patients so that right there limits the
money that we have in general and it just makes it
very difficult to provide care for people who are not
documented. Budgets in Colorado are getting
slashed and at least our clinic, and most prenatal
clinics in general are not looking to make a profit,
but just looking to serve underserved populations
and it's getting incredibly difficult for us and I think
it makes a compromise in the quality of care when
we have to see more patients to have to make up
the deficit that we have from the lack of funding.
We're working longer hours and people are getting
pretty burnt out.
Research also provides evidence that changes in the funding structure
and sources in the safety net result in increased workloads for
providers (Boehm (2005) and variability in the services the safety net
provides to different populations (Horton 2001).
The Double-Edged Sword
Knowledge of the Health System and Availability of Services
Outreach workers and direct-care providers (n=9) said that
women often initiated prenatal care late because they did not know
there were services available to them.
Im not saying this isnt important the public
benefits that is important for many reasons in
other ways, in the way people read those
messages like they think cannot access many
things, but the truth is that most people have
access to networks that already know where they
can go and where they cannot.
A physician also expressed that knowledge of the health system plays
a role in accessing services.
At our clinic we have a really good rate of people
coming in during the first trimester because its
word of mouth in the community, but when we
have people that do come in late its because they
didnt know about our clinic or they didnt know of
other places they could go.
Clinics providing prenatal care to uninsured immigrant women have
bilingual outreach services that work in communities to inform them of
the discounted services available and assist them with applying for
these programs and those such as Emergency Medicaid. Two clinics
rely on word-of-mouth through patients, and have mobile units to
inform members of the community about the services available. An
outreach coordinator recalled,
I remember one time we were at we have a
mobile unit and we were at the Mexican
consulate providing gestational screening and we
were there about a week and this girl came to visit
us because she had just found out she was
pregnant. She wasn't even sure she was pregnant,
and she didn't know where to go or what to do and
we just gave her information. They need to know
where to go because they could not go to a
regular clinic because they could not afford the fee
and they don't have any insurance, but there are
places for them to go [like our clinic].
Although clinics are committed to and want to provide
healthcare services needed in their communities, the lack of resources
constrains the capacity of services they can provide. There are not
enough services available for low-income, uninsured people, and the
more they inform people, the more they arrive to the clinic which
cannot take any more patients. One nurse practitioner said, It's a
double-edged sword: the more we advertise, the more people come
here. An outreach specialist also said the safety net clinics need more
services because you can go out and outreach and then people go
and look for services and they are denied, not because the patient has
no insurance but because they cannot see more patients. One
physician explained that her clinic limits advertising and relies more on
word-of-mouth referrals because they would not be able to
accommodate everyone needing their services.
Clinics such as ours and other safety net clinics in
the area don't advertise in the local Spanish
media, not because we don't care, but because we
don't want to invite more volume than we can
accommodate, and so a lot of it is word-of-mouth,
figuring out how to [navigate the system]. So
hopefully, if you've just arrived here you meet a
friend or a neighbor or a co-worker who knows
their way around a little bit better, who helps you
fined the resources you need.
Once in the health system navigating it can be confusing for
immigrants, which may lead women to delay initiation or not use
prenatal care. A clinic nurse said,
People who live here can't even figure it out. It's
really hard. I mean, for those of us who have
worked in the public health system for many years
it is difficult to understand how it works. I can't
even imagine what it might be like for those who
don't speak the language or know how the system
One clinic system employs bilingual care navigators to guide people
through the health system. A physician explained how the daunting
complexity of the health system can cause delays in initiating prenatal
I think sometimes, especially for women who are
more recently here in the U.S., we don't have a
very organized, simple public health kind of a
system in this country and it can be really
overwhelming to try to figure out...so sometimes
we see people who realized they were pregnant at
4-5 weeks but just trying to figure out 'how do I find
a clinic? how do I get enrolled in a clinic? what do I
need to do in order to be able to see the doctor?'
may take them an additional 12-16 weeks to
navigate all that.
Yet, for women with pregnancy complications late initiation of prenatal
care may have serious negative health effects on her and her infant.
High Risk Pregnancy:
The Critical Gap in Prenatal Care Access
for Uninsured Immigrants
A critical gap in prenatal care access exists for uninsured,
undocumented women with high risk pregnancies. While basic prenatal
care for normal pregnancies may screen for conditions, their scope of
practice and resources limit the care available for diagnostics and
treatments. A clinic physician said,
And a lot of women, if they have blood screens
that aren't normal, they have to pay to get multiple
ultrasounds, or pay to get an amnio, and the
perinatalogists and a lot of women can't pay for
that. More advanced care is not covered, only
normal pregnancies, and we feel like we're doing a
really good job with what we can do, but then
there's just a lot of extra stuff that in our practice
we can't provide, they just don't have access to.
A maternal health director in another clinic said,
And then if there's any specialty care or high-risk
care needed for the women, it is another process
and another sometime difficult step to get care a
the referring hospital because it's a crowded place,
I mean, there is just much more demand than
supply of care out there for undocumented
Safety net clinics employ a variety of strategies to buffer the
effects of restricted access to prenatal care services, such as priority
for pregnant patients despite capacity issues, outreach and care
navigators, and discounts for low-risk pregnancy care. Undocumented
immigrant women may also qualify for Emergency Medicaid for labor
and delivery and for life-threatening conditions. However, access to
services is limited for women with high-risk pregnancies which have
not escalated to a life-threatening condition, but require additional
specialists, diagnostics and treatments. A physician said,
The problem for us is if they run into complications
that we aren't able to handle. It's hard to get
obstetrical backup for that. When they develop
complications we can't get anyone else to take
care of them, and I think we do a very good job,
but still our providers do not want to work outside
their comfort zone, and no one would suggest that
the best place for these very complicated,
obstetrical patients is in a primary care community
The availability of obstetrical backup also depends on localities
according to a clinic physician.
It depends on the communities, for example in the
[A and B] communities, we have very good
obstetrical backup. We have obstetricians who will
take our patients without any hassle at all. The
patient still has to pay more, so the patient may
not go because they have to pay more. But in
some communities, there's just no obstetrical
backup at all, they just will not see our patients
under any circumstances.
This is a critical gap in prenatal care that exposes mothers and
infants to increased risks of injury, illness, disability and death. Among
clinic workers (n=17) the most commonly mentioned (n=16)
complicating condition that goes untreated due to lack of access to
high-risk pregnancy care is diabetes.
Negative Health Effects of Restrictive
Welfare Policy: Diabetes
Diabetes is a condition in which glucose levels in the blood are
elevated and the body does not produce enough insulin to break it
down. A woman may already have preexisting diabetes or develop
gestational diabetes, which presents during pregnancy. Any type of
diabetes that remains unmanaged in pregnancy increases the risk of
short and long-term negative health effects for both mother and child.
Diabetes is a risk factor for preeclampsia, a form of hypertension that
may lead to injury or death from seizures, stroke, or blood clots
causing brain damage during labor and delivery, and may lead to
premature birth due to early induction of labor to avoid these outcomes
(CDC 2010). Women with hypoglycemia, a condition experienced by
women with diabetes, may cause seizures or difficulty breathing for
newborn infants (CDC 2010). Diabetic women are also more likely to
deliver large babies due to elevated glucose levels that pass to the
fetus, a condition called macrosomia, increasing the risk of birth
injuries to the mother and shoulder dystocia, a delivery complication in
which the infant's head delivers but the shoulders cannot fit through the
birth canal, increasing the infant's risk of permanent nerve damage
(CDC 2010). Infants born to mothers with unmanaged, preexisting
diabetes are also more likely to have birth defects, such as heart
malformations and neural tube defects, due to elevated glucose levels
that can damage organs as they develop during the first eight weeks of
pregnancy (Correa et al 2008, March of Dimes 2009). Glucose levels
return to normal for most women with gestational diabetes, but they
and their infants are more likely to develop diabetes later in life. For
women with preexisting diabetes, long-term complications affecting
vision, heart and kidneys may worsen after a pregnancy if their
condition is not properly managed. Sharon Devines (2009) research
on birth outcomes of Hispanic mothers in Colorado suggests there is a
hidden epidemic of infants born with macrosomia.
Since infants of women with diabetes during pregnancy are
more likely to have health issues and less likely to have access to
timely prenatal care, this gap leaves them more vulnerable to
preventable health issues that may affect quality of life, in addition to
short and long term healthcare and social services costs. A physician
I would say that undiagnosed gestational diabetes
is probably our biggest problem. We have a lot of
people presenting, who even may be our patients,
but they dont come in early enough, of course for
them they know us, they should, but you know the
reasons are not the same...they present with
horrible blood sugars, not even later in pregnancy,
as early as 11 or 12 weeks, and they can have
fetal heart malformations, so that would be the
most devastating. In general they should be
referred out to a maternal-fetal medicine OB
specialist, like even more specialized than an
obstetrician, but a lot of these females do not have
any insurance or payor status for them to be able
to see these specialists, so they dont go in
anyway. So they never see anyone, and then if the
child is born here in the United States they
automatically get Medicaid and then the child gets
whatever condition they have a small chance of
having but could have treated with Medicaid
Another physician observed,
Luckily we haven't had any women die from this in
our practice, but we certainly see more women
with this complication than in a population with
regular access to healthcare and all of the full
Access to treatments may be limited due to cost. Women
diagnosed with diabetes in pregnancy must follow diet and exercise
recommendations and may be required to monitor their glucose levels
several times per day by lancing the finger, placing a drop of blood on
a test strip and inserting the strip into a glucose meter that tells the
level in the blood. One clinic in the research provided a glucose meter
at no cost to patients with diabetes and discounted test strips, yet the
costs may still be prohibitive for low-income women, as a physician
The physiology, the normal hormones of
pregnancy, can easily take a woman who is not
previously diabetic and cause her to become what
we call gestational diabetic, temporarily diabetic
during her pregnancy, and that again, is
something that requires monitoring ideally, that
pregnant women with diabetes should be testing
their blood sugar four times a day and we're able
to give them the machine to test with for free, but
each time you test you have to use what's called
a test strip, a little special piece of paper you put
into the machine that allows it to read the blood
sugar and those are expensive at the general
market rate if you want to buy them, you don't
need a prescription, you could just walk into the
pharmacy and try to buy them, they cost about a
dollar a strip. With some of our funding programs
we're able to get that down to 50 cents a strip for
some of our patients. But if you're testing four
times a day, that's two dollars a day and that can
really add up. So we have patients who are
diabetic who should be testing their blood sugar
four times a day and based on those results
should be changing insulin doses or changing the
way they're eating to prevent complications of he
pregnancy and if they're not able to come in and
get the care, or if they're not able to afford to buy
test strips, then their blood sugars are less well-
controlled and those babies tend to have
additional problems or the mothers tend to have
medical problems during pregnancy.
In addition, some women with high-risk pregnancies require a
consultation with specialists, and ultrasounds that may cost up to
$1000 each. These services are not offered in the clinics and are not
covered by the prenatal care discount programs. A physician described
the limitation of resources for specialized services for pregnant women
It's an issue. I have a lot of gestational diabetics.
We have two OBs at our clinic so anyone who is
pretty high risk from the beginning should be
seeing an OB, they're not there all the time so
sometimes it can be tricky getting them in or one
of the regular providers will see them, and then
when OB is there they will go over the visits with
them [the non-OB providers]. One of the problems
we have is genetic screening or general anatomy
scans and if there is something concerning,
patients then have to pay if they do not have
regular Medicaid, if they have to have two
ultrasounds or if they need to be seen by the
Perinatal team, that gets to be a problem because
then patients actually have to pay for it
Another physician said,
We do a lot at our clinics, certainly far more than
what a family doctor would do in private practice,
and in private practice, a family doctor would have
probably referred women to a high-risk specialist.
We don't have that opportunity and so we do our
best to treat their diabetes, but, for example we
can give them the glucometer, the machine to
monitor their blood sugars and we can give them a
discount on the strips they need to use it, but we're
not able to provide the full in-depth range of
services that a perinatologist or an obstetrical
Lacking adequate prenatal care and management of diabetic
conditions in pregnancy, women may be more likely to deliver by
cesarean section. Rates of cesarean sections, major abdominal
surgery to deliver infants, have more than doubled in the United States
since 1996 (Menacker and Hamilton 2010), posing both increased
health risks and higher delivery costs. A physician said,
Some of the other complications we see if the
blood sugar is consistently high, we tend to see
macrosomia babies that are larger, and so there
are more birth complications with those, injuries to
the mother during childbirth, injuries to the baby
during childbirth, need for a c-section, and c-
section being surgery has a higher risk of
complications than a normal vaginal birth.
Research also suggests that infants of undocumented women
are less frequently enrolled in public insurance programs for which
they are qualified (Capps et al 2004). Medicaid automatically covers
newborns allowing time for paperwork to be processed for enrollment
in public health insurance programs and ensuring continuity of care.
Prior to the Deficit Reduction Act (DRA) of 2006, infants of
undocumented mothers were also automatically covered by Medicaid if
their delivery was covered by Emergency Medicaid (Henry J. Kaiser
2006). The DRA rules required citizenship documentation of newborns
such as hospital records or a birth certificate in order to apply, erecting
barriers to Medicaid enrollment for children (National Council for
Community Behavioral Healthcare 2010). Thus, infants of
undocumented women are less likely to have received adequate
prenatal care and more likely to lack the insurance coverage they may
need immediately at birth and through childhood. In this way letting
die policies of exclusion continue even for U.S. children of
Despite international human rights and public health policies
and programs promoting adequate prenatal care for all women and
improvement of maternal health, the trend in devolution of authority
empowers individual states in the United States to restrict such care for
pregnant women based on immigration status. Restrictive prenatal
care coverage policies that deny publicly funded prenatal care for
undocumented women increase risks of disability and death. Localities
and individual safety net organizations motivated by an ethic of care to
serve the uninsured provide a patchwork system to buffer the effects of
restrictive policy, and demonstrate the further devolution of authority
for healthcare services.
Few would argue against the importance of prenatal care to
ensure a healthy and productive life for both mothers and infants.
Women with lower incomes tend to experience lower health status
which may lead to conditions requiring specialized care, normally
covered by Medicaid. Undocumented immigrants have lower incomes
than other classes of immigrants and have less access to health
insurance. Yet, undocumented women cannot qualify for publicly
funded prenatal care coverage in Colorado that would protect their own
health and the health of their infants. Colorado justifies this letting die
policy arguing that the state cannot bear the financial burden of
prenatal care for undocumented immigrants and that providing such
care attracts undocumented immigrants to the state. Yet, research
demonstrates that medical and social services to care for mothers and
infants with preventable complications cost more than the cost of
prenatal care, and that undocumented immigrants arrive to states for
work and to reunite family, and use fewer services even if they do
qualify to receive them (Artiga and Schwartz 2007, Capps et al 2004,
Chavez et al 1992, Geltman and Meyers 1999, Goldman et al 2006,
Hagen and Rodriguez 2004, Holcomb et al 2003, Kaiser 2000, Kaiser
2004, Mohanty et al 2005, Zimmerman and Fix 1998). In terms of
Foucaults biopower, by excluding undocumented women from
prenatal care coverage Colorado deems their lives and their infants
lives as expendable and undeserving of the benefits prenatal care
offers: the best chance for a healthy and productive life.
This research identified diabetes in pregnancy as the most
common condition for which undocumented women cannot access
services to adequately manage, describing the ways in which denial of
publicly covered prenatal care is a letting die policy. In addition, it
describes the ways in which such policy results in variability of the
safety net with access to care dependent upon localities. It finds that
undocumented women have access to prenatal care for low-risk
pregnancy in some localities depending on the presence of clinics
motivated by an ethic of care to serve the underserved; and that
undocumented women, lacking access to specialized care must hope
for the best for the health of themselves and their infants. Thus,
specialized care is not accessible for women who need it most.
The cost of prenatal care compared with hospitalization and
long term medical and social services for women that could not access
adequate prenatal care in Colorado is not known. The lack of access to
such care may create more burden on society that the policy
presumable seeks to avoid.
I recommend further research to 1) describe qualitatively the
experience of women developing health complicating health conditions
and their inability to access care through participant-observation and
interviewing; 2) describe qualitatively the ethic of care and funding
streams of individual safety net institutions in Colorado through
participant-observation; and 3) a study comparing the health outcomes
and associated costs of low-income women with access to specialized
care for diabetes and without access to such care in Colorado.
As Lazarus (1997:142) proposes, restricted access to prenatal
care is one of many expressions of poor women's powerless position
in society. Current international human rights and public health
agendas aim to expand prenatal care coverage to improve the health
status of women and children. Colorado has the option to follow such
standards as other states have done by providing prenatal care
coverage regardless of immigration status, to fortify the entire
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