Background

Undocumented immigrants face many barriers in accessing pregnancy care, including language differences, implicit and explicit bias, limited or no insurance coverage, and fear about accessing services. With the national spotlight on maternal health inequities, the current literature on undocumented immigrants during pregnancy requires synthesis.

Objective

We aimed to describe the literature on pregnancy care utilization, experiences, and outcomes of undocumented individuals in the United States.

Methods

We performed a scoping review of original research studies in the United States that described the undocumented population specifically and examined pregnancy care utilization, experiences, and outcomes. Studies underwent title, abstract, and full-text review by two investigators. Data were extracted and synthesized using descriptive statistics and content analysis.

Results

A total of 5,940 articles were retrieved and 3,949 remained after de-duplication. After two investigators screened and reviewed the articles, 29 studies met inclusion criteria. The definition of undocumented individuals varied widely across studies. Of the 29 articles, 24 showed that undocumented status and anti-immigrant policies and rhetoric are associated with decreased care utilization and worse pregnancy outcomes, while inclusive health care and immigration policies are associated with increased prenatal and postnatal care utilization as well as improved pregnancy outcomes.

Conclusions

The small, heterogeneous literature on undocumented immigrants and pregnancy care is fraught with inconsistent definitions, precluding comparisons across studies. Despite areas in need of further research, the signal among published studies is that undocumented individuals experience variable access to pregnancy care, heightened fear and stress regarding their status during pregnancy, and worse outcomes compared with other groups, including documented immigrants.

Objective

To assess trends in childbirth at a hospital-birth center among women living in Compañeros En Salud (CES)-affiliated communities in Chiapas, Mexico and explore barriers to childbirth care. Our hypothesis was that despite interventions to support and incentivize childbirth at the hospital-birth center, the proportion of births at the hospital-birth center among women from Compañeros En Salud-affiliated communities has not significantly changed after two years. We suspected that this may be due to structural factors impacting access to care and/or perceptions of care impacting desire to deliver at the birth center.

Design

This explanatory mixed-methods study included a retrospective Compañeros En Salud maternal health census review followed by quantitative surveys and semi-structured qualitative interviews.

Participants and Setting

Participants were women living in municipalities in the mountainous Sierra Madre region of Chiapas, Mexico who received prenatal care in one of 10 community clinics served by Compañeros En Salud. Participants were recruited if they gave birth anywhere other than the primary-level rural hospital and adjacent birth center supported by Compañeros En Salud, either at home or at other facilities.

Measurements

We compared rates of birth at the hospital-birth center, other health facilities, and at home from 2017-2018. We conducted surveys and interviews with women who gave birth between January 2017-July 2018 at home or at facilities other than the hospital-birth center to understand perceptions of care and decision-making surrounding childbirth location.

Findings

We found no significant difference in rates of overall number of women birthing at the hospital-birth center from Compañeros En Salud-affiliated communities between 2017 and 2018 (p=0.36). Analysis of 158 surveys revealed distance (30.4%), time (27.8%), and costs (25.9%) as reasons for not birthing at the hospital-birth center. From 27 interviews, negative perceptions and experiences of the hospital included low-quality and disrespectful care, low threshold for medical interventions, and harm and suffering. Partners or family members influenced most decisions about childbirth location.

Key Conclusions

Interventions to minimize logistical barriers may not be sufficient to overcome distance and perceptions of low-quality, disrespectful care.

Implications for Practice

Better understanding of complex decision-making around childbirth will guide Compañeros En Salud in developing interventions to further meet the needs and preferences of birthing women in rural Chiapas.

Background: Immigrants who experience homelessness in the United States are a unique and under-studied population. The determinants of homelessness and immigration increase exposure to health risks. However, there is scant information on the intersection of both groups and little evidence to guide health care practice in this area. Because community health centers serve patients regardless of insurance status, ability to pay, language spoken, or immigration/citizenship status, they are tasked with providing comprehensive care to this unique population. Methods: The Oasis Clinic at Boston Health Care for the Homeless was piloted for 12 months prior to the COVID-19 pandemic and explored innovative ways to deliver services to this unique population. Staff and volunteer orientations were provided before each clinic and debriefing sessions were held at the conclusion. Oasis centered the experiences, strengths, and needs unique to immigrants experiencing homelessness. Results: The pilot clinic served 330 diverse individuals during 43 weekly clinic sessions for a total attendance of 841. Organizational lessons were learned about distribution of key components of healthcare delivery, improving patient engagement, preventing parallel clinic structures, and creating spaces of belonging for highly marginalized populations. Conclusion: Investment in organizational approaches to improve health services to immigrant individuals experiencing homelessness may also improve the quality of care delivered to others experiencing homelessness. Critically reflective quality improvement and patient feedback can help guide interventions to address gaps in healthcare disparities for underrepresented groups. The COVID-19 pandemic continues to increase the risk of eviction, unemployment, poverty, and homelessness especially among racial and ethnic minorities. Policies are not adequately addressing the growing problems of affordable housing and access to health care for disenfranchised populations

Homelessness remains a pervasive, long-standing problem in the United States and is poised to increase as a result of the COVID-19 pandemic. Individuals experiencing homelessness bear a higher burden of complex medical and mental health illnesses and often struggle to obtain quality and timely health care. The United States desperately needs to train a workforce to confront this large and growing crisis, but few health professional schools currently devote curricula to the clinical needs of people experiencing homelessness. This article discusses educational and curricular strategies for health professional students. Understanding the health needs of—and the social influences on the lives of—people experiencing homelessness is crucial for addressing this health equity challenge.

Author Interview: “Training Clinicians to Care for Patients Where They Are” | Journal of Ethics | American Medical Association (ama-assn.org)

On February 1, 2020, Jessie Gaeta, the chief medical officer for Boston Health Care for the Homeless Program (BHCHP), received news that a student in Boston had tested positive for the novel coronavirus virus that causes COVID-19 disease. Since mid-January, Gaeta had been following reports of the mysterious virus that had been sickening people in China. Gaeta was concerned. Having worked for BHCHP for 18 years, she understood how vulnerable people experiencing homelessness were to infectious diseases. She knew that the nonprofit program, as the primary medical provider for Boston’s homeless population, would have to lead the city’s response for that marginalized community. She also knew that BHCHP, as the homeless community’s key medical advocate, not only needed to alert local government, shelters, hospitals, and other partners in the city’s homeless support network, but do so in a way that spurred action in time to prevent illness and death. 

The case study details how BHCHP’s nine-person incident command team quickly reorganized the program and built a detailed response, including drastically reducing traditional primary care services, ramping up telehealth, and redeploying and managing staff. It describes how the team worked with partners and quickly designed, staffed, and made operational three small alternative sites for homeless patients, despite numerous challenges. The case then ends with an unwelcome discovery: BHCHP’s first universal testing event at a large city shelter revealed that one-third of nearly 400 people there had contracted COVID-19, that most of the infected individuals did not report symptoms, and that other large city shelters were likely experiencing similar outbreaks. To understand how BHCHP and its partners subsequently popped up within a few days a 500-bed field hospital, which BHCHP managed and staffed for the next two months, see Boston Health Care for the Homeless (B): Disaster Medicine and the COVID-19 Pandemic.

Jessie Gaeta, the chief medical officer for Boston Health Care for the Homeless Program (BHCHP), learned on April 7, 2020 that the City of Boston needed BHCHP to design and staff in 48 hours one half of Boston Hope, a 1,000-bed field hospital for patients infected with COVID-19. The mysterious new coronavirus spreading around the world was now running rampant within BHCHP's highly vulnerable patient population: people experiencing homelessness in Boston. A nonprofit community health center, BHCHP for 35 years had been the primary care provider for Boston's homeless community. Over the preceding month, BHCHP's nine-person incident command team, spearheaded by Gaeta and CEO Barry Bock, had spent long hours reorganizing the program. (See Boston Health Care for the Homeless (A): Preparing for the COVID-19 Pandemic.) BHCHP leaders now confronted the most urgent challenge of their long medical careers. Without previous experience in large-scale disaster medicine, Gaeta and her colleagues had in short order to design and implement a disaster medicine model for COVID-19 that served the unique needs of people experiencing homelessness.

This case study recounts the decisive actions BHCHP leaders took to uncover unexpectedly widespread COVID-19 infection among Boston's homeless community in early April 2020. It details how they overcame their exhaustion to quickly design, staff, and operate the newly erected Boston Hope field hospital for the city's homeless COVID-19 patients. It then shows how they adjusted their disaster medicine model when faced with on-the-ground realities at Boston Hope regarding patients' psychological needs, limited English capabilities, substance use disorders, staff stress and burnout, and other issues.

Immigrant communities are foundational to the social and economic success of the United States. Health is an important factor in the ability to achieve and maintain success, but numerous barriers to equitable health access, quality and outcomes persist for many immigrants in Massachusetts. These longstanding barriers are compounded by restrictive immigration policies, creating new uncertainties about eligibility for health-promoting benefits, hamper individuals’ willingness to seek care, increase mental health concerns, and thwart the ability of healthcare providers to deliver care. Federally Qualified Health Centers (FQHCs) play a vital role in healthcare delivery to immigrants. With their unique mandate to serve all-comers, regardless of ability to pay, insurance, or immigration status, FQHCs disproportionately care for patients with low-income, lack insurance, and who prefer receiving healthcare in a language other than English. This DELTA (Doctoral Engagement in Leadership and Translation for Action) addresses the challenges and needs FQHCs in Massachusetts face in delivering healthcare to immigrant patients. In collaboration with the Massachusetts League of Community Health Centers, this work sought to understand the specific challenges and opportunities health centers face when caring for immigrant patients. The objective was to identify how the League can improve support of health centers experiencing challenges with delivery of services to immigrant patients. Between December 2018 and June 2019, 53 staff members across five FQHCs and the League participated in discussion groups about challenges and opportunities. Responses were analyzed thematically and formulated into recommendations and tools for the League. A second component of this DELTA was the launch of an immigrant-friendly clinic at one FQHC, Boston Health Care for the Homeless. Since March 2019, 23 clinic sessions have taken place, serving 201 unique patients from over 13 countries who speak more than six languages. The process of developing the new clinic has shed light on one health center’s existing challenges in immigrant healthcare delivery, constructive opportunities for improvement, and necessary core organizational components. Improvements at the organizational level of health centers have the potential to facilitate and promote individual staff capacity. However, new uncertainties, confusion and growing fears compound existing barriers and health centers require additional support.

Background: One international and three local organizations developed the Santa Ana Women's Health Partnership (SAWHP) to address cervical cancer in Santa Ana Huista, Huehuetenango, Guatemala. This paper describes the structure, outcomes, and lessons learned from our community partnership and program.

Methods: The community partnership developed a singlevisit approach (SVA) program that guided medically underserved women through screening and treatment of cervical cancer.

Lessons Learned: The program promoted acceptability of SVA among rural women by engaging local female leaders and improving access to screening services. The program's approach focused on maximizing access and generated interest beyond the coverage area. Distrust among the community partners and weak financial management contributed to the program's cessation after 4 years.

Conclusions: The SAWHP design may guide future implementation of cervical cancer screening programs to reach medically underserved women. Open, ongoing dialogue among leaders in each partner institution is paramount to success.