Prenatal Care for Undocumented Immigrants: Implications for Policy, Practice, and Ethics

Rachel Fabi 
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KEY FINDINGS

  • Policies that cover undocumented immigrants during pregnancy sometimes restrict what services can be covered.
  • Health care providers feel like they cannot always treat all of their patients the same due to policy restrictions.
  • Some providers develop workarounds in order to meet their undocumented patients’ needs.

Nearly 250,000 citizens are born each year to undocumented immigrant parents in the U.S.,1 but undocumented immigrants are ineligible for most public insurance, making it difficult for them to access prenatal care.2 Because prenatal care is vital for healthy births, 19 states have enacted policies that provide coverage for pregnant undocumented immigrants.3 Some states, like Nebraska and California, do this by treating the fetus as an unborn citizen who is eligible for Children’s Health Insurance Program (CHIP), but this may limit the care that the mother receives. Other states, like New York, provide state funding to cover the mother herself during pregnancy. Most other states, including Maryland, provide no coverage for pregnant undocumented immigrants. No states provide coverage for pre-pregnancy care to this population, and postnatal coverage only lasts two months in states that offer it.3 Policy limitations on the care that is provided before, during, and after pregnancy can cause health care providers to feel distressed at their inability to live up to their professional norms, like treating all of their patients the same.

We interviewed health care providers at eight safety net health centers in California, Nebraska, New York, and Maryland about the experience of providing care to undocumented immigrants under their state policy. Providers were asked about undocumented immigrants accessing care in their health centers, their professional practice norms, and if they felt they could live up to their professional norms when seeing undocumented patients under policy restrictions.

Policy Restrictions on Prenatal Services Can Create Moral Distress in Providers
Health care providers reported several professional norms that guide their practice, including treating every patient the same and advocating for patients. Many respondents indicated that they felt the policy restrictions on the services covered for pregnant undocumented immigrants in each state sometimes prevented them from treating patients the same, regardless of immigration status. These restraints led to moral distress among providers. Moral distress is defined as “an acute feeling of risk to one’s own personal and professional integrity that is associated with the perception of powerlessness to prevent some wrong.”4 A nurse midwife in Maryland described feelings of moral distress caused by policy restrictions saying, “I feel like my hands have been tied, there’s nothing else I can do. That’s been hard… it’s very, very hard to get specialists to agree to see them who they can afford to see.” A nurse in New York echoed this sentiment, saying: “In a perfect world everyone who comes to our office would be able to get the care that they need, not only just for their pregnancy…I feel like the whole system doesn’t really allow me and people in my role to help ensure all of that, for everyone we work with.”

Health Care Providers Use Workarounds to Fulfill Professional Norms
Given the distress that can be caused by restrictions on care for pregnant undocumented immigrants, many providers try to employ workarounds to get their patients the care they need. Workarounds, which are “navigational tools devised to get around some barrier to getting the job done,”4 include strategies to avoid compliance with law, policies, or standards that impede their ability to do their jobs as they believe they should be done. Some of these workarounds involve leveraging personal resources for patients, like when one provider said “I actually called my own cardiologist and talked to him personally. [This] is the sort of thing I would do for my daughter.” Other workarounds might involve bending the rules for patients. An Ob/Gyn in California explained that “I think everyone should [have] access to health care and to insurance. So that frustrates me that we have to kind of maneuver around the system to get people to where they need to be at times. You get to use some creativity, but … some people — they can even break the law at times.” She then clarified that she herself did not break that law, but she knew other people who did.

Recommendations for Practice and Policy
The distress experienced by these health care providers is a direct effect of a complex and patchwork health care system that systematically excludes undocumented residents of the United States, even when their children are U.S. citizens. Given this, health centers should create mechanisms that facilitate a dialogue for health care workers to critically examine their own practice norms and to discuss, in a safe environment, their concerns about the systemic constraints they encounter. It is important for providers who use workarounds to understand the ethical ambiguities of the practice and reflect on the patients for whom they choose to bend the rules, as these choices may in fact exacerbate existing injustices. Organizing regular meetings to discuss the care of pregnant undocumented patients, and the (legal) workarounds providers employ may help to reduce provider moral distress and increase access to care for undocumented patients. On a policy level, states should expand access to care for additional undocumented populations beyond just those who are pregnant, including children and adults with Deferred Action for Childhood Arrivals (DACA) status. The ideal solution to improve health outcomes among undocumented residents of the U.S. and reduce providers’ moral distress is a policy to enact universal health coverage for all U.S. residents, which would enable providers to “treat every patient the same.” However, such a policy seems unfeasible at this moment in American political discourse. Further discussion of these findings can be found in the original paper.5

Data and Methods
We interviewed 34 health care providers at one urban and one rural safety net health center in each of these four case states: California, Nebraska, New York, and Maryland. Interviews were semi-structured and were conducted by phone between 2016 and 2017. Data were analyzed using iterative emergent thematic coding in NVivo.

References

  1. Passel, J. S., Cohn, D., & Gramlich, J. (2018). U.S. births to unauthorized immigrants have fallen since 2007. Pew Research Center. Retrieved November 19, 2019, from http://www.pewresearch.org/fact-tank/2018/11/01/the-number-of-u-s-born-babies-with-unauthorized-immigrant-parents-has-fallen-since-2007/
  2. Gusmano, M. K. (2012). Undocumented Immigrants in the United States: U.S. Health Policy and Access to Care. Undocumented Patients: Undocumented Immigrants and Access to Care. Garrison, NY: The Hastings Center.
  3. The Henry J. Kaiser Family Foundation. (2019). Where Are States Today? Medicaid and CHIP Eligibility Levels for Children, Pregnant Women, and Adults. The Henry J. Kaiser Family Foundation. Retrieved November 19, 2019, from https://www.kff.org/medicaid/fact-sheet/where-are-states-today-medicaid-and-chip/
  4. Berlinger, N. (2016). Are Workarounds Ethical?: Managing Moral Problems in Health Care Systems. Oxford University Press.
  5. Fabi, R. E., & Taylor, H. A. (2019). Prenatal Care for Undocumented Immigrants: Professional Norms, Ethical Tensions, and Practical Workarounds. The Journal of Law, Medicine & Ethics, 47(3), 398–408.

Acknowledgements
The author acknowledges Dr. Holly Taylor of the NIH, the coauthor of the paper on which this research brief is based, as well as Dr. Nancy Berlinger of the Hastings Center, whose comments on the original paper and the application of the “workarounds” model were invaluable.

About the Author|
Rachel Fabi is an Assistant Professor in the Center for Bioethics and Humanities at SUNY Upstate Medical University and a Faculty Research Affiliate with the Lerner Center for Public Health Promotion at Syracuse University (fabir@upstate.edu).