medicaid is an essential source of maternal and postpartum care for low-income Americans, covering 42% of births in the US. People who give birth receive maternity care for at least two months after giving birth, or longer depending on national or local policy.
But many immigrants don’t have access to this coverage, making them more vulnerable to maternal health problems, as highlighted by a new study. study of nearly 73,000 postpartum people in 19 states and New York City between 2012 and 2019.
The study, published in the Journal of the American Medical Association on Tuesday, quantifies the extent to which restrictive public insurance eligibility policies for immigrants may affect maternal care for low-income earners. The study is noteworthy for two reasons: it provides new data on postpartum coverage for immigrants, and shows that restrictive policies are associated with limited access to maternity care for all low-income immigrants, regardless of their documentation status, as well as non-immigrants.
General, almost half of low-income non-citizen women of childbearing age are uninsured in the U.S., compared to 16% of low-income women who are U.S. citizens between the ages of 15 and 44. Medicaid coverage for pregnancy is available to immigrants who meet certain income thresholds (the U.S. median limit is below 207% of the poverty line), but only after being documented for at least five years. Both undocumented immigrants and recent immigrants who are pregnant are excluded from traditional Medicaid coverage.
About half of U.S. states are making up for this Medicaid gap by covering postpartum care for all documented immigrants, waiving the five-year waiting period. And 20 states have some form of public insurance available to cover all means-tested pregnancies regardless of immigration status, though only a few of those states extend coverage to the postpartum period.
That means that even when the pregnancy is covered by public health insurance, low-income immigrant mothers often become ineligible once they give birth, and may not have the opportunity to get even the first follow-up visit that is typically scheduled between one and three months after delivery. But that’s exactly when new mothers face the greatest health risk, such as 65% of maternal mortality in the US between one day and one year postpartum.
The JAMA study sought to find out how much influence eligibility options have on whether low-income immigrant mothers have access to any kind of postpartum care. To do this, the study authors divided states into three groups.
The first group (“no coverage”) offered health insurance only to immigrants who had been papers for at least five years. The second group (“moderate coverage”) included all documented immigrants even before the five-year waiting period, but not those without documents. The third (“full coverage”) included all immigrants regardless of status.
The study used data from the states Pregnancy Risk Assessment Monitoring System (PRAMS)an ongoing monitoring system that collects information about maternal health, and looked at how the new mothers are taking the survey question, “After the birth of your new baby, did you have a postpartum checkup for yourself?” It then compared responses between nonimmigrant and immigrant mothers, as well as between immigrant mothers in states with different levels of coverage.
“Compared to immigrants living in states where there were no restrictions based on immigration status on who could receive public postpartum care, immigrants living in states with limited public insurance policies were less likely to receive postpartum care,” said Maria Steenland, an assistant professor at the Brown University’s Population Studies and Training Center and a lead author of the study.
In states without coverage for recently documented and undocumented immigrants, 20% of low-income postpartum immigrants received no care at all, compared to 12% of low-income postpartum nonimmigrants. But in states where access was granted to all immigrants, the situation reversed, with more low-income immigrants accessing postpartum care (89.5%) than non-immigrants (87.7%).
The study also suggests that a lack of coverage for immigrant parents is also linked to poorer maternal care coverage for nonimmigrants. In “no coverage” states, access to postpartum services was 4% lower, even among non-immigrants, compared to “full coverage” states.
“This indicates that these states have other challenges that low-income people face,” said Laura Wherry, a study co-author and assistant professor at New York University’s Wagner Graduate School of Public Service.
Lack of postpartum care can have major consequences, as Haywood Brown, a professor of obstetrics and gynecology at the University of South Florida, wrote in the journal Contemporary OB/GYN in 2019. These include “premature cessation of breastfeeding, undiagnosed postpartum depression and anxiety disorders, lack of family planning and increased risk of recurrence of preterm labor (PTB), preeclampsia and gestational diabetes.”
Insufficient postpartum care also contributes to racial and ethnic disparities in maternal health, according to the government’s data analytics group MACPAC. Since the majority of low-income immigrants in the US are Hispanic, insurance policy restrictions take the greatest toll on that demographic.
The study’s findings suggest restrictive policies are widening disparities between U.S.-born mothers and others who give birth in the country. The research also points to policy improvements that could have a significant impact on improving maternal health.
This research is especially important as states reevaluate their Medicaid requirements, said Cheasty Anderson, deputy director of the advocacy group Protecting Immigrant Families Coalition. “The JAMA study confirms what we are hearing from organizations across the country – immigrant-inclusive health policies are critical to meeting health care needs,” she said. “Restrictive policies pose a threat to the health of the country, and as postpartum care illustrates, it also affects the children of US citizens and spouses of immigrants.”