Editor’s note: This story first appeared on palabra, the digital news site by the National Association of Hispanic Journalists.

By Yesica Balderrama

When Olivia Campos Jiménez was pregnant with her first child, she was “very afraid” the hospital would refuse to provide maternal care treatment due to her immigration status. She did receive care, but it wasn’t of the quality she’d hoped, and it wasn’t culturally competent.

In addition, the care was a financial burden for her.

“I couldn’t pay for the prenatal visits with my first child. It was a lot of money at the time, because I was earning less,” said Campos whose three children are now 17, 14 and 3.

Campos paid about $1,000 out-of-pocket for those prenatal care appointments at John C. Lincoln Hospital in Phoenix, Arizona. A friend had suggested she seek care at the private hospital. Paying for the expenses was difficult, but she prioritized her child’s well-being.

Campos, a 43-year-old Mexican immigrant, is a professional cleaner. Her undocumented status made her ineligible for state-covered maternal care.

It wasn’t just the cost that was a challenge for Campos, though. It was the interaction with staff. “I understood the baby was well, that the heart was good, and that was all they told me,” said Campos. “They gave me a birthing book in Spanish and nothing else. The doctor asked me if I was in pain or if I was nauseous, and that’s all I was able to understand.”

In over 20 states, noncitizen immigrant persons do not have access to prenatal and postpartum care. Maternal care legislation for undocumented and lawfully present immigrant persons, such as green card and visa holders, depends on state laws. Some states, like Colorado, are expanding their healthcare coverage by trying to fill gaps in the Affordable Care Act that do not provide maternal care for immigrant persons. Each state that passes maternal care legislation to cover immigrants who do not currently qualify expands the number of pregnant persons who will have healthy deliveries and recoveries.

Almost half of the noncitizen immigrant population in the U.S. is underinsured. In comparison, the insurance rate among U.S. citizens is 92%.

A lack of quality maternal care endangers the well-being and livelihood of immigrant and undocumented mothers and their children. Prenatal care helps detect birthing complications while there is still an opportunity to take preventive measures. State level legislation usually focuses on prenatal care, yet postpartum care is just as important. Mothers need guidance on healing after giving birth, and the baby’s healthy development needs to be monitored.

No language access

Campos didn’t have anyone to accompany her or translate for her at monthly doctor appointments. The language barrier made it difficult to get thorough answers to her questions. She had to use a hospital pain chart with illustrated faces to communicate her feelings. The only service she did not have to pay for was the birthing. Arizona state healthcare covers deliveries.

“After my daughter was born, they gave me care for one more day. Once they saw the baby was alright, they released me from the hospital,” said Campos.

Prenatal support proved vital during the third pregnancy. Campos had a fluent Spanish-speaking doctor recommended to her by a friend, which meant she was also able to communicate her concerns clearly and had a better understanding about her maternal health.

Campos’ third child, a daughter, was diagnosed with fetal congenital hydrocephalus, a condition that causes cerebrospinal fluid to build up in the brain’s ventricles. The pressure from the buildup can lead to Down Syndrome, a genetic disorder that causes developmental delays. Fortunately, hydrocephalus was detected early using ultrasounds and then treated with medication to prevent complications.

Campos says her maternal care experience was much better the third time; the Spanish-speaking doctor was more willing and patient to explain crucial information to her. But the challenges she faced with her earlier pregnancies are not unique. Undocumented persons throughout the country experience similar challenges in attaining quality maternal care, and without access to prenatal and postnatal care, run the same common pregnancy health risks, such as gestational diabetes, preeclampsia, and high blood pressure.

Expanding maternal care

In June 2022, Colorado passed House Bill 22-1289 “Cover All Coloradans.” In the process, Colorado became another state to offer maternal care for undocumented women, a crucial step that advanced healthcare legislation for immigrant persons. The program will go into effect in 2025.

Reyna Hetlage is senior policy manager at Center for Health Progress, an organization that advocates for health equity in Colorado and one of the seven organizations that worked to advance the Cover All Coloradans legislation. The coalition of organizations focused on healthcare legislation for children, as well as prenatal and postpartum care for undocumented immigrants.

“There’s a coverage gap that was created by the Affordable Care Act when it passed. And it left out people who are undocumented, who have DACA, and some other groups of immigrants. This bill helps to start to close that gap,” said Hetlage.

The new law will include coverage for undocumented pregnant persons and children under 18 who were not included in Medicaid or the 1997 federal Children’s Health Insurance Program (CHIP). CHIP currently covers green card and visa holders, refugees and asylees, and some qualified non-citizens.

A patchwork of laws

One formidable challenge in accessing vital healthcare, is that since 1996 federal law has kept people who are not U.S. citizens from being eligible for Medicaid, unless they’ve been in the U.S. for at least five years. How that law is implemented varies from state to state.

People can receive emergency Medicaid, but that’s for life threatening conditions. It doesn’t cover birth control, prenatal, or postpartum care.

Only 18 states, including California and New York, had expanded Medicaid via CHIP before 2022. Last year Maryland, Connecticut, and Maine also passed similar legislation alongside Colorado. The 2009 Children’s Health Insurance Program Reauthorization Act (CHIPRA) gave states the option to dismiss the five-year waiting period for noncitizen persons to receive comprehensive coverage.

Some states, including New York, California, New Jersey, as well as Washington DC, have government-funded healthcare programs for immigrants that fully cover maternal care for the undocumented.

Such coverage is greatly needed. Donauta Watson, a New York mother of three who was undocumented and uninsured at the time of her first pregnancy, was initially worried she would not qualify for maternal healthcare. Later, she was relieved to find out she was eligible for fully funded Medicaid at her local Mount Sinai Hospital. “I didn’t have any issues in my being undocumented and getting care. None of that came up,” said Watson.

Watson also signed up for a parenting education program at the hospital. Additionally, the doula center By My Side Girls for women of color provided her with a doula, free of charge.

Watson had her first child, Nova, when she was an unemployed college student in 2014. During her pregnancy she was diagnosed with gestational diabetes, a condition that required bimonthly doctor’s visits.

“I had to be induced earlier at 37 weeks with Nova. And if I didn’t have prenatal care, there were just a lot of risk factors, not just for the baby, but for me as well. If I didn’t go to the hospital as much as I did, God forbid, I could have lost my life. For sure,” said Watson.

Without NYC healthcare legislation for undocumented persons, Watson would not have received medical care during her pregnancies. For all three of her deliveries, she had access to doulas, and paid for postpartum care out-of-pocket.

As of April 2022, 28 states do not provide CHIP coverage for noncitizen pregnant persons, according to the National Academy for State Health Policy. Among these states are Nevada, Arizona, Florida, and North Carolina.

The chilling effect

When prenatal care was included as part of emergency Medicaid services for low-income immigrant women, a high-risk group due to the lack of maternal healthcare access, they were likely to use it, according to a 2021 study published by the JAMA Network. The sample size included 26,586 births. The majority of the sample – 97.4% – were Black, Hispanic, and Native American, and 55.5% between the ages of 25 and 35. The use of prenatal care screenings increased significantly when such care was included in Medicaid.

Surprisingly, prenatal care coverage for immigrant women did not show significant improved outcomes for maternal and infant health. Short interpregnancy interval births, the time between a first and second pregnancy, did not decrease. Nor did prenatal care increase postpartum contraception, which reduces the number of unwanted pregnancies. Women who get pregnant for a second time after one to 18 months of having given birth are more likely to have delivery complications. Both family planning and birth control are essential components of maternal health, to ensure the parent’s and future children’s well-being.

Dr. Rachel Fabi, assistant professor of bioethics and humanities at SUNY Upstate Medical University in Syracuse, New York, has written extensively about maternal care legislation for immigrants. She explained that difficulties include “a lot of psychosocial stressors that can keep them from accessing care. You might be afraid of going out to a health center because you’re worried that you’re going to run into immigration enforcement, or that your status could be used against you. The chilling effect of enhanced immigration enforcement is it’s creating that environment of fear that keeps people from accessing services that they need.”

In New York City, immigrant and undocumented women (who have access to healthcare) are less likely to have had a healthcare visit 12 months before pregnancy. Reasons include fear of deportation, language barriers, and discrimination. When compared to 27% of US-born women, 43% of immigrant women did not visit a healthcare provider a year before pregnancy. The socioeconomic disparities were greatest among recent arrivals from sub-Saharan Africa, South and Central America, and South Asia, according to an analysis published in Journal of Urban Health.

Filling the void

In states without healthcare legislation for immigrant or undocumented women, grassroots and nonprofit organizations organize maternal care services. One of these organizations is Puentes de Salud (PSD) in Philadelphia, which provides educational, medical, and wellness services for immigrant and Latino communities. Puentes de Salud’s Starting Right Prenatal Education Program or Comenzando Bien was created in 2021 with funding from the National Coalition of Hispanic Health, Human Services and the March of Dimes after PDS nurses and leaders noticed a gap in healthcare for the local growing Latino and immigrant population.

Comenzando Bien offers physiological and psychological care during the prenatal stage, in addition to four to six weeks postpartum care. Pregnant persons attend checkups every four weeks, are assisted by nurses, and provided with therapists if needed.

Paulina de Jesus, patient services supervisor at Puentes de Salud, has worked with the Hispanic community since 2009. She noted that the clinic’s demographic includes persons who are new arrivals to the country—those who may be undocumented and do not meet the government’s criteria for Medicaid maternal care.

“They don’t have access to medical care. If they were to go to a county assistance office and try to obtain medical insurance, they would be denied. Many of our patients are Spanish-speaking women with few resources who seek pregnancy support,” de Jesus shared.

Pennsylvania does not provide CHIP or CHIPRA maternal care coverage. Lawfully present immigrants with green cards or visas who have been in the U.S. less than five years and undocumented immigrants are ineligible for Medicaid.

But even with legislation in place, and even if it covers all undocumented persons across the country, advocates say that policy must be complemented with practices that create welcoming environments for people, regardless of their immigration status.

“It’s not like you only find undocumented immigrants in certain parts of the country. They’re everywhere and need to be treated as members of the community,” said de Jesus. “Clinical spaces need to be established as safe and need to have policies in place — what to do if immigration enforcement comes to your clinic?. And making sure that your patients know that their information is protected, that no one’s going to report them for seeking care.”

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Yesica Balderrama is a bilingual journalist and multimedia producer based in New York City. Her work has appeared on Latino USA, Slate Podcasts, and WNYC, and in Yes! Magazine, Prism, The Washington Post, the Associated Press, Mental Floss and others. She was raised in Queens, NY, and is currently based in NYC.

Mariela Murdocco, a bilingual multimedia journalist and photographer, has been nominated for five Emmy Awards. Born in Uruguay and based in New York City, she began her two careers simultaneously in 2002. She has worked as a reporter, TV producer, anchor, photographer and videographer for Consumer Reports, Telemundo, News 12, The New York Daily News, Banda Oriental, The Jersey Journal and The Associated Press. She was a TV correspondent for Canal 7 in Uruguay and has contributed to The Guardian, The Huffington Post, Hola TV and Fox News. In 2012 she was elected national Spanish at-large officer for the National Association of Hispanic Journalists.