Undocumented and pregnant: Why women in the US are afraid to get prenatal care

Britani first learned there was something wrong with her pregnancy late one night in July 2019 when she started bleeding and rushed to an emergency room.

The doctor on duty said she had an infection that could cause her to miscarry. Britani agreed to find an obstetrician to treat the problem, knowing that she would not keep her word.

As an immigrant living in the country without legal permission, Britani, now 20, had no health insurance and could not afford to pay for her treatment in cash. Her only option would be to apply for public benefits, but she had heard from friends that doing so could make her a target for deportation or jeopardize her pending green card application. So she sat tight, hoping the infection would go away on its own.

A few weeks later, Britani shook her husband awake in the middle of the night and told him to get his mother in the next room. They returned to find Britani doubled over in pain, her face wet with tears.

“There’s a lot of blood,” Britani said.

When President Donald Trump unleashed his crackdown on immigration, people without legal status scrambled to erase the traces of their existence to avoid being swept up. They stayed home to hide from aggressive new street arrests. And thousands dropped out of welfare programs to steer clear of a policy that posed a less visible threat. Under an expansion of the limits on “public charge,” the administration said it would withhold legalization for immigrants living in the country without legal permission who had used certain public benefits.

Although immigrants living in the country without legal permission are ineligible for most welfare programs and have been shown to use those that are available at lower rates than US citizens, the Trump administration said the expansion was necessary to discourage people who could not support themselves financially from moving to the United States. “Give me your tired and your poor who can stand on their own two feet and who will not become a public charge,” Kenneth Cuccinelli, acting director of US Citizenship and Immigration Services, said at the time.

The policy contained exemptions for some vulnerable groups, including pregnant women. But doctors and public health officials say that many women living in the country without legal permission are convinced nonetheless that their chances of legalization will be diminished, and they worry that immigration officers, who are often seen at hospitals along the border, could target them for deportation.

The result, they say, is an escalating climate of fear that is having disastrous consequences for the health of pregnant women and their babies.

Within days of when the public charge policy became public, followed by wall-to-wall coverage on Spanish-language news outlets and dire warnings on social media, medical clinics saw no-show rates for prenatal care appointments rise sharply. Midwives say that requests for home births from women living in the country without legal permission who wanted to avoid going to a hospital soared. Doctors said they saw a spike in the number of women arriving in emergency rooms with serious complications or already in labour, without having been to a single prenatal appointment.

The problem has been particularly pronounced in Texas, which has the second-largest population of immigrants living in the country without legal permission.

“Are we going to fall off a cliff soon with the health of immigrant women?” said Dr Tony Ogburn, an obstetrician at DHR Health, a busy hospital in Edinburg, Texas, near the Mexican border, where between 8,000 and 9,000 babies are delivered every year. “I think we’re already there.”

Even before Trump took office, research from past cases had shown that women living in the country without legal permission were more likely to skip prenatal care and to experience complications during labour. And while recent immigrants from Latin America are often healthier than American-born women, babies born to women living in the country without legal permission are more likely than others to be born underweight and to be delivered prematurely — the most common cause of infant mortality — particularly after immigration raids.

The disparities were linked to the stress of living on the margins of society, as well as the fact that immigrants living in the country without legal permission are eligible for fewer public benefits than American citizens, and are often wary of using government help out of concern that they could face repercussions.

Ogburn said many of his clients in Texas skipped expensive ultrasounds — crucial to identifying potential problems — because they were paying in cash and could not afford such procedures.

President-elect Joe Biden has indicated that he would begin to reverse the changes to public charge designations during his first 100 days in office, but experts say some of the fear that has been instilled is likely to linger.

Britani, who like the other women in this article requested that her last name not be published because of her immigration status, said that when she landed in the emergency room for the second time, doctors told her she had developed another infection, this one more severe.

She was admitted to stay overnight. The next morning, a social worker asked the family how it planned to pay for the treatment. “They put you between a rock and a hard place,” Britani’s mother-in-law, Maria, who is also living in the country without legal permission, said later. “It’s your baby or your immigration status.”

Her only option, the family decided, was to apply for a limited version of public benefits available in Texas to pregnant women living in the country without legal permission, which allowed Britani to get the first ultrasound of her pregnancy, well into her second trimester. But the grainy black-and-white images of her growing daughter were hardly relieving. “I was scared because I didn’t know if we had done the right thing,” she said.

The colonias of South Texas where she lives, along with about a half-million people in ramshackle houses and rusty trailers, are where health workers have had to work hardest to persuade women to seek care.

Pregnancy has never been easy for the people who live there. Jennifer and her husband, Diego, who both came to the United States as young children, had recently lost their quasi-legal status under the Deferred Action for Childhood Arrivals program because they could not afford to renew it. Then in January of last year, Jennifer bought a test from the dollar store and discovered she was pregnant.

The couple decided to move temporarily to Indiana, where they found work in a factory that paid $13 an hour — twice as much as a worker living in the country without legal permission typically earned in South Texas. She went eight months without prenatal care. “I was worried,” she said, but she also felt resigned.

Obstetricians associated with the University of Texas Rio Grande Valley have brought mobile medical clinics into the colonias, hoping that pregnant women would be more likely to attend appointments near their homes. The clinics rely on “promotoras” — health workers with strong community ties — to help coax patients into getting treatment, which is free or heavily discounted.

Maria Aguilar, a promotora who was born in Mexico and was herself living in the country without legal permission for a time, spends her days delivering food and medicine to those too scared to go out. She brings masks to women who work the fields through their pregnancies, to protect them from exposure to pesticides. But she said women often ignore her phone calls because they were scared of seeking treatment. By the time they reach out to her in crisis, some have already miscarried.

Asked how frequently such fears are raised in her work with patients, Aguilar said, “To be honest, we haven’t seen anyone who doesn’t have this issue.”

A similar chilling effect was seen after the welfare reform that took place under President Bill Clinton limited immigrants’ access to benefits. The law was followed in Texas by an increase in maternal mortality and morbidity, said King Hillier, a vice president of the Harris County hospital district, which includes Houston.

He said a more extreme version of the phenomenon was occurring now, as social media warned women living in the country without legal permission to stay away from public assistance programs of any kind.

“What we were dealing with in the late ’90s was basically word-of-mouth. And now you have mass media 24/7,” including misinformation and rumours, he said.

Even in the liberal enclave of Austin, the state capital, practitioners say they are limited in what they can comfortably say to ease patients’ worries about the aggressive new tactics being used to track down immigrants for arrest.

“Nobody can falsely reassure them because anything is possible these days,” said Margaret Kini, an obstetrician-gynaecologist at one of the largest low-income clinics in the city.

Griselda, a woman who has lived in Austin without legal permission for more than two decades, said Trump’s election in 2016 produced an immediate impact in her community. Soon after, the father of one of her children’s classmates was deported, spooking her and the other parents. A few months later, a police officer pulled her over and wrote her a ticket, giving a warning to her son. “He said, ‘If I want, I can take your mom because she’s illegal.’”

All of it cast a shadow over the discovery in January 2019 that she was pregnant with her fourth child. Rather than going to a hospital, as she had done to deliver her first three children, Griselda found a midwife to deliver her daughter, Ava Valentina, at home. Because she hopes to legalize one day, she has continued to avoid using government services, including those to which the baby is entitled as a US citizen, for fear that it could have repercussions down the road.

“I don’t want to be a public charge,” she said, holding her week-old baby girl, worrying about the cost of her two-month checkup that was coming up, when the baby would need to be vaccinated. “If I can afford to, I’ll pay for it myself.”

Paula Rojas, who delivered Griselda’s baby, said complications have often upended her clients’ best-laid plans to avoid a hospital.

Melissa and her husband, both Christian missionaries from Mexico, had been living outside Austin for about a year when they discovered she was pregnant. Melissa planned to deliver her baby at a birthing centre — a licensed facility that accepts cash payments from low-income women.

But Rojas, who was helping her by providing naturopathic prenatal care, worried that Melissa would not make it nine months without requiring a medical intervention. She had seen it happen with other patients living in the country without legal permission, who developed stress-related ailments that can lead to premature birth and other problems. Melissa was constantly fretting, she said, and struggled to sleep at night.

About seven months into her pregnancy, Melissa was rushed to a hospital with preeclampsia, a dangerous condition that threatens the life of both the mother and the baby. Her son, Josías, was delivered via emergency C-section and weighed only 4 pounds. A nurse carried him directly to an incubator.

The next evening, in the darkness of her hospital room, Melissa asked about paying her bill in cash. A nurse explained that Josías would need to live in the hospital for at least a month and that it would likely cost hundreds of thousands of dollars to keep him alive.

After months of avoiding it, she would have to apply for public benefits.

As the nurse turned down the lights in her room, Melissa closed her eyes, trying not to think about the future, but she could not sleep all night.