Undocumented Pregnant Women:
What does the literature tell us?
Kimberly Munro1, Catherine Jarvis2, Marie Munoz2,3, Vinita
D’Souza4, Lisa Graves2
1 Facultéde médicine, Universitéde Montréal, Montréal, Québec2 Department of Family Medicine, McGill University, Montréal, Québec
3 Centre de recherche et de formation, CSSS de la Montagne, Montréal, Québec4Herzl Family Practice Centre, Jewish General Hospital, Montréal, Québec
Outline
Background
Objectives
Methods
Synthesis
Conclusions
Background
There are no Canadian studies on undocumented pregnant women
Undocumented pregnant women are a particularly vulnerable group Status limits access to prenatal and delivery services
Prenatal care favours healthy maternal and infant outcomes
Issue of individual and public health
Objective
To provide a synthesis of the existing literature on the topic of undocumented pregnant women, regardless of research design
Methods
Literature review January 1967 to August 2009
PubMed, Medline, CINAHL and EMBASE databases + relevant grey literature
Keywords: pregnancy, medically uninsured, medical indigency, uncompensated care, insurance, health, refugee, undocumented, no status, clandestine, sans papiers, Canada, Canadian.
Inclusion criteria: pregnancy-related issues with respect to undocumented migrant women
Synthesis
Initial search retrieved 204 articles
95 articles following application of inclusion criteria
Each reviewed by primary reviewer
Classified into “include”, “exclude”, “unsure”
Consensus on “unsure”
Final sample of 22 articles
Synthesis (1): Documenting the issue
Very little information exists
Demographics vary by host country
Ex. US=Mexico, Switzerland=SA, France=SSA
Some consistent features between populations
Young, single, low-income domestic employment, lack of health insurance
Synthesis (2): Prenatal care
Less access (Chavez et al., 1986; Barlow et al., 1994)
Status cited as a reason for not seeking care (Blondel & Marshall, 1996; Higgins & Burton, 1996)
Delayed/Inadequate (Chavez et al., 1986; Reed et
al., 2005; Caulford & Vali, 2006; Wolff et al., 2008)
Synthesis (3): Prenatal care
Lack of prenatal care associated with less favourable birth outcomes
Low birth-weight infants (Lu et al., 2000)
More costs to system later
STI-related adverse birth outcomes (Kuiper et al., 1999;
Wolff et al. 2008b)
Costs to system
Public health
Synthesis (4): Delivery
Conflicting evidence
Study site (PNC vs. no PNC, tertiary care, etc.)
Number of participants (complications are rare)
Admitted at later stage, less epidural, shorter hospital stay (Barlow et al., 1994)
More complications (Reed et al. 2005)
Similar rates of complications (Wolff et al. 2008)
Synthesis (5): Birth outcomes
Conflicting evidence
Less favourable (Lejeune 1998; Barlow et al., 1994)
No difference (Kelaher & Jessop, 2002; Wolff et al., 2008)
More favourable (Reed et al., 2005)
Lower rates preterm delivery & LBW infants, despite higher rates of pregnancy-related risk factors
«Healthy Migrant Effect»
Synthesis (6): Programs
Few policies specific to the needs of undocumented populations (Wolff et al. 2000)
Few publications on programs targeting undocumented women
Programs developed on an ad-hoc basis
“Patchwork” programming leads to confusion/reticence in care seeking behaviours (Castañeda, 2008)
Synthesis (7): Programs
Dar a Luz (Carillo, Pust, & Borbon, 1986)
Initiated in September 1980 in Tucson, Arizona Free community clinic
274 clients registered in first three years
Prenatal care for pregnant Hispanic women
Trained patient advocates assigned to each woman
Childbirth education during weekly clinics
Informed local hospitals of program Women presented at emergency room with prenatal
records
No formal agreement
Synthesis (8): Programs
Unité mobile de soins communautaires(UMSCO) (Durieux-Paillard et al., 1999; Wolff, 2004)
Opened in January 1997 as a result of partnership between hospital and city
> 95% patients are undocumented migrants
Mobile clinic
Spanish-speaking staff
2002 agreement between UMSCO and University Hospital facilitated access to care for pregnant undocumented women
Conclusions
Information
Better documentation is needed
Programs
Stakeholders must be informed on policies and available resources
Political participation can help mobilize resources
Organization of services must take into account the unique aspects of each population
Public health
Advocacy tool
Thank you
ReferencesBarlow, P., Haumont, D., & Degueldre, M. (1994). Devenir obstérical et
périnatal des patientes sans couverture sociale. Rev Méd Brux, 15, 366-370.
Blondel, B., & Marshall, B. (1996). Les femmes peu ou pas suivies pendant la grossesse: Résultats d'une étude dans 20 départements. J Gynécol Obstet Biol Reprod, 25, 729-736.
Carrillo, J. M., Pust, R. E., & Borbon, J. (1986). Dar a Luz: A Perinatal Care Program for Hispanic Women on the US-Mexico Border. American Journal of Preventive Medicine, 2(1), 26-29.
Castañeda, H. (2008). Paternity for Sale: Anxieties over "Demographic Theft" and Undocumented Reproduction in Germany. Medical Anthropology Quarterly, 22(4), 340-359.
Caulford, P., & Vali, Y. (2006). Providing healthcare to medically uninsured immigrants and refugees. CMAJ, 174(9), 1253-1254.
Chavez, L. R., Cornelius, W. A., & Williams Jones, O. (1986). Utilization of Health Services by Mexican Immigrant Women in San Diego. Women and Health, 11(2), 3-20.
Durieux-Paillard, S., Figueras, G., Tuosto-Aeschliman, R., Rollier, V., Maso, P., & Stalder, H. (1999). Précarité et accès aux soins: À Genève, l'hôpital sort de ses murs. Med Hyg, 57(2270), 1825-1829.
References (1)Higgins, P. G., & Burton, M. (1996). New Mexico Women With No Prenatal
Care: Reasons, Outcomes and Nursing Implications. Health Care for Women International, 17, 255-269.
Kelaher, M., & Jessop, D. J. (2002). Differences in low-birthweight among documented and undocumented foreign-born and US-born Latinas. Social Science and Medicine, 55, 2171-2175.
Kuiper, H., Richwald, G. A., Rotblatt, H., & Asch, S. (1999). The communicable disease impact of eliminating publicly funded prenatal care for undocumented migrants. Maternal and Child Health Journal, 3(1), 39-51.
Lejeune, C., Fontaine, A., Crenn-Hebert, C., Paolotti, V., Foureau, V., & Lebert, A. (1998). Recherche-action sur la prise en charge médico-sociale des femmes enceintes sans couverture sociale. J Gynécol Obstet Biol Reprod, 27, 772-781.
Lu, M. C., Lin, Y. G., Prietto, N. M., & Garite, T. J. (2000). Elimination of public funding of prenatal care for undocumented immigrants in California: A cost-benefit analysis. American Journal of Obstetrics and Gynecology, 182(1), 233-239.
References (2)
Reed, M. M., Westfall, J. M., Bublitz, C., Battaglia, C., & Fickenscher, A. (2005). Birth outcomes in Colorado's undocumented immigrant population. BMC Public Health, 5(100).
Wolff, H., Durieux-Paillard, S., Meynard, A., & Stalder, H. (2000). Précarité et accès aux soins: “Mieux vaut être riche et en bonne santé que pauvre et malade…”. Med Hyg, 58, 1927-1930.
Wolff, H., Epiney, M., Lourenço, A. P., Costanza, M. C., Delieutraz-Marchand, J., Andreoli, N., et al. (2008). Undocumented migrants lack access to pregnancy care and prevention. BMC Public Health, 8(93).
Wolff, H., Laurenço, A., Bodenmann, P., Epiney, M., Uny, M., Andreoli, N., et al. (2008b). Chlamydia trachomatis prevalence in undocumented migrants undergoing voluntary termination of pregnancy: a prospective cohort study. BMC Public Health, 8(391)