Abstract
Introduction:
Pregnant immigrant and migrant patients experience restricted access to prenatal care. Even when publicly insured or low-cost prenatal care is available, late entry into prenatal care is common. To understand barriers to prenatal care, we interviewed patients from a federally qualified health center with a high volume of immigrant and migrant patients to explore their pregnancy care experiences and access to postpartum support in southeast Minnesota.
Methods:
Pregnant and recently postpartum patients completed semi-structured phone interviews in English or Spanish. Transcripts were qualitatively analyzed for iterative themes related to experiences with and barriers to prenatal and postpartum care.
Results:
Of the 20 participants, most identified as Hispanic/Latina and were multigravida. Participants described several barriers to medical care including limited Spanish proficiency among health care team members and support services offered primarily in English, which impacted their ability to be understood or use recommended services. The medium rurality of the area, clinic distance, and difficult winter travel impacted access to care, especially when transportation was limited. Participants also described varying social support influenced by their relationship status and proximity to immediate and extended family.
Conclusions:
These findings suggest that immigrant and migrant patients experience barriers to prenatal care irrespective of legal status and even when they have access to publicly insured prenatal care. Targeted interventions to mitigate these barriers, such as community-based care coordination, and the identification and promotion of Spanish-language services, may facilitate improved perinatal care and support.
Introduction
The population of immigrant and migrant women is increasing in the Midwest. 1 Immigration status is a known barrier to prenatal and reproductive care leading to lower levels of uptake and late entry or no prenatal care. This, in part, is the result of a heterogenous policy landscape that frequently restricts Medicaid eligibility to noncitizens even after legal residency is obtained. 2 At present, 22 states provide pregnancy-related coverage to patients regardless of immigration status. 3 Even when Medicaid coverage is available, uncertainty about insurance eligibility, lack of familiarity with the U.S. health care system, language barriers, and negative health care interactions discourage access to reproductive care.2,4 Individual and en masse migration and fluctuating employment opportunities also pose challenges to consistent access to prenatal care.2,5 Relative advantages in some health outcomes for non-U.S. compared with U.S. born women are reported, along with increases in certain comorbidities and adverse outcomes. Pregnant immigrant and migrant women are at increased risk of social vulnerabilities including social isolation, anti-immigration bias, poor or insecure housing, interpersonal violence, and mental health disorders, and other life course stressors associated with poor health outcomes.6–8
Prior to June 2022, pregnant individuals in Minnesota were eligible for Medicaid insurance during pregnancy and 60 days postpartum. Nearly three-fourths of foreign-born reproductive-aged women rely on a publicly insured clinic as their usual source of care, 9 including in southeast Minnesota. Experiences at a local federally qualified health center (FQHC) suggest many patients continue to experience difficulty in accessing health care and pregnancy-related services and support, despite proximity to a large tertiary academic hospital and a nonprofit community hospital.
To understand these barriers, we interviewed pregnant and recently postpartum patients on their experiences accessing pregnancy care to better understand how to improve perinatal support for immigrant and migrant patients within our hospital’s catchment area.
Methods
Study development
This study was determined to be minimal risk by Mayo Clinic’s Institutional Review Board (#21–004266). Members of the research team with expertise in obstetrics, health disparities, community health needs assessments, and qualitative research methods developed an interview guide designed to explore experiences with prenatal care, including access barriers and desired support during pregnancy. The interview guide was professionally translated into Spanish and reviewed by native speakers for accuracy.
Data collection
Individuals aged 18 years or older who were currently pregnant or pregnant within the preceding 18 months and received care at a Community Health Services, Inc. (CHSI) clinic in southeast Minnesota were invited to participate. CHSI is a federally qualified health center with a patient population that is over 80% uninsured, Hispanic, and with a primary language other than English. Additional recruitment occurred at a local Head Start that primarily serves migrant farmworkers and their families. Two bilingual interviewers conducted the interviews over the phone between August 2021 and November 2022 in the participants’ preferred language of English (EN) or Spanish (SP). Participants were compensated with a $45 gift card. All interviews were audio recorded and transcribed by a HIPAA-compliant vendor with English and Spanish transcription capability. Interviews conducted in Spanish were translated to English by one researcher and subsequently translated back to Spanish to ensure appropriate translation. All interview transcripts were deidentified prior to analysis.
Data analysis
The software program Delve (New York, New York) was used to qualitatively analyze interview transcripts for iterative themes. 10 The initial codebook was developed using inductively and deductively derived codes. 11 The codebook was revised and validated by initial consensus coding on 10% of the transcripts by two researchers. The finalized codebook was applied to all transcripts. The remainder of transcripts were equally divided and independently coded by the two researchers with an additional 20% of transcripts intermittently coded to consensus to ensure uniformity in coding. Quotes are presented with minimal editing in accordance with published standards in reporting qualitative research. 12
Results
Out of 32 individuals invited to participate, 20 completed an interview (62.5% completion rate). Demographics are presented in Table 1. Participants had a mean age of 30, with most identifying as Hispanic or Latina and received a high school diploma or equivalent. Most were multigravida, with three currently pregnant.
Participant Demographics
Three respondents were born in the United States (U.S.). Other respondents were born in Mexico, Guatemala, Colombia, Nicaragua, and the Philippines. Most respondents born outside the U.S. immigrated in adulthood and had spent an average of 8 years in the U.S. at the time of the interview. Participants described a wide range of journeys to the U.S., with some immigrating directly to their current place of residence in Minnesota, while others migrated from California, Nebraska, or New York. Nearly all participants relocated to be with family prior to the onset of the COVID-19 pandemic.
Barriers with English language proficiency
Although several women in the cohort spoke some English, they reported that language and being understood by providers was a frequent concern.
Because the truth is that sometimes it was quite difficult for me to go there to make my appointments and everything. And thankfully the clinic has translators, because when one is Latino it costs a lot [meaning it is difficult] to translate, or sometimes they talk to you and you do not even know what they are saying.
-Participant 14, SP, Age 27
Participants also spoke about the challenges of living in a region in which there were limited support services targeted to their demographic. Even when support groups and parenting classes were available, there remained cultural barriers to full participation resulting in an under-utilization of community-based resources.
I would like to see more support… for the Hispanic people and like the classes that you are talking about; parent meetings and that, there are many, but there is never in Spanish. They are always in English and many people also do not attend…The ones we are going to, there are two people there who speak Spanish; so, they give the classes in Spanish, but the others are in English.
-Participant 06, SP, Age 31
Some participants reported success with language accommodations, including remote interpretation services via phone or through video calls via tablet. However, they frequently mentioned others in their community who had differing experiences.
When I call the interpreter line, they return my calls right away. Everything has been good. I’ve heard from other people that sometimes they don’t give them good service, or this, or that they take too long to see you.
-Participant 12, SP, Age 40
Financial barriers to care
Even participants who were fluent in English experienced significant barriers to care, including challenges to afford health care costs on a fixed income. As one participant, who was born in the U.S. recounted:
How would you pay for [health care]?
Interviewee: I get a disability check. I would pay my bills with what they sent me, and then I would also get food stamps at the moment, at that time. I would be able to get food with the food stamps.
-Participant 17, EN, Age 28
Nearly all participants described difficulty accessing health care services prior to pregnancy due to ineligibility for state health insurance. Participants also noted difficulty once their eligibility ended postpartum.
It [health care] was more for my pregnancy because I didn’t qualify for MA [Minnesota Medical Assistance]. The part of the immigration law was that they can only help people in my status if you’re pregnant [for a] few months. Everything was taken away from me, all the health care benefits, but it was given, still, to my son and my husband. Right now, I just go to the clinic, actually, that I work at. It’s very affordable.
-Participant 02, EN, Age 24
This had impacts on the management of acute and chronic comorbidities. One woman described her lack of access to care for an infection and depression before the pregnancy:
I didn’t go to the doctor (…) Because normally here, we who come from another country, because we do not have insurance or anything and everything is very expensive for us.
-Participant 15, SP, Age 30
Intermittent employment also posed accessibility challenges and created additional financial burdens on participants.
I feel like it was a challenge from the beginning just because I was not working and I was not getting paid at all for the two months that I was out of work. It ended up adding up and sending me to the collection department.
-Participant 19, SP, 27
Participants described knowledge barriers to knowing how to receive public insurance or find free or low-cost clinics.
In fact, when we first arrived here, well we didn’t have insurance, we didn’t know where to go see the doctor or anything and that was the first time they started taking us when we felt bad. They helped us apply for insurance themselves and told us that we could go to hospitals or other clinics.
-Participant 16, SP, Age 24
Some wished there was additional support available to help them navigate complicated processes to apply for insurance:
[I wish] there would be more support for low-income women and easier for them to help them get their insurance, and all that because that is what one gets occupied with in those moments. You’re not going to be able to do that. Even though here, they help on that side, but those people don’t know how to do it. Many people say, “No, you need to apply. Send an email. Send this, send the other, but not all people have the ability to learn fast, easily. I’ve met people who are very stressed about those things. I have also had to help as I have been learning.
- Participant 08, SP, Age 31
Safe and accessible transportation to clinics
Several participants expressed that transportation and the ability to physically travel to clinics to seek care was an ongoing concern. The midwestern region in which the sample was recruited is moderately to highly rural and participants described frequent concerns over how to manage transportation.
Sometimes I would look for someone to take me or I started looking for the transportation that the insurance pays for, [Medicaid].
-Participant 08, SP, Age 31
These concerns frequently dictated where and when participants sought or accessed care. Several participants reported choosing care less by the level of care required and more by accessibility.
Because [hospital] for the pediatric is two minutes’ drive away from us, so that’s why I chose [FQHC], because it’s much nearer. If my mother is—just came home from work, we can schedule the afternoon visit at the hospital. It’s much nearer.
-Participant 05, EN, Age 31
Living in a midwestern area with severe winter weather posed additional challenges to participants, especially the impact of seasonal weather on transportation and the safety of driving or accessing public transportation.
[My partner] would drive me, ‘cause at the time I had a car, and it was snowing very hard, and I didn’t have the tires needed for the snow.
-Participant 17, EN, Age 28
Transportation concerns were exacerbated by the timing of clinic appointments and other services available for pregnant and postpartum individuals. Participants frequently expressed a desire for services catered to parents and individuals employed outside the home.
I would just find it hard to attend the classes just because I came back to work right after two months and the classes were in the morning, I believe, or around noon, so I wouldn’t be able to make it. (…) When I had my first appointment with them [WIC], they did mention that they were able to help me if I needed help (…) It was a lot to deal with and juggle [breastfeeding and working], and then adding more appointments on top of that.
- Participant 19, EN, Age 21
Social support and isolation
Participants received varying levels of support from their partners and families both during and after pregnancy. While several had supportive partners that were actively involved in their prenatal care and parenting, others described challenges due to absent partners.
Almost no one helped me…just me…I didn’t have his [my husband’s] support, just that we lived together.
– Participant 20, SP, 21
Many participants lived with their immediate family and had built-in support for postpartum care. Support from extended family and friends was often unavailable for those who had moved away from their country of origin.
Well, the thing is, like I have almost no friends here. Most of the time I’m here, at home with my husband and brother-in-law; just them here. More than anything they help me; that I don’t walk around lifting heavy things. Things like that, they take care of me.
-Participant 10, SP, Age 22
Due to the lack of support and sense of vulnerability from their pregnancy or postpartum state, participants described feeling isolated.
If you’re alone and you don’t have someone to help you…it complicates everything.
–Participant 8, SP, Age 31
This sense of isolation was magnified for participants experiencing postpartum depression and mood changes.
Being a mom of just taking care of so many kids alone, because their dad is around, but we’re not completely together (…) I felt very depressed, I would say. I wanted to probably just like harm myself at some point. I would tell my mom, ‘cause my mom lives all the way down in Texas, I would tell her, “Can you come get the kids? I just wanna be by myself.” Then I didn’t have any—I don’t have family over here.
-Participant 17, EN, Age 28
Discussion
Immigrant and migrant patients continue to face barriers to accessing medical care and support despite legal access to publicly insured prenatal care in Minnesota. Participants reported insufficient access to bilingual staff and materials in local clinics and hospitals who could communicate with them in their native language (primarily Spanish); many reported remote interpretive services were available, although experiences varied. Language concordant care is associated with improved patient experiences and outcomes,13,14 suggesting that it should be prioritized at all levels of care (e.g., primary to tertiary care), although its impact on pregnancy care is underreported. 15 Although patients with English-language fluency may not experience similar barriers to provider–patient communication, there may still be challenges with navigating the complexities of public insurance and a fragmented U.S. health system, especially when care coordination is not available, as well as the ability to afford associated health care costs. Participants expressed interest in prenatal classes and other resources available within the community that were conducted in languages other than English, noting that not all Latina/Hispanic patients spoke the same dialect. Participants also described reliance on informal word-of-mouth communication on how to navigate complexities receiving medical care and services such as Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); many were unaware of the extent of community resources available. Leveraging these existing social structures and increasing awareness and cultural relevance may be useful in improving utilization of health insurance, payment support, and peripartum care.
Participants described financial barriers to care, including uncertainty as to how to sign up for Minnesota’s Medicaid program and worrying about being dropped from care because of language difficulties or administrative burden. These findings support previous research showing delayed entry to prenatal care among Hispanic/Latina and migrant women in the Midwest, 5 which is associated with worse pregnancy outcomes. 7 Several participants noted challenges in accessing needed care during periods in which they were not pregnant, impacting their ability to manage chronic conditions that may have pregnancy implications. Just under 60% of non-U.S. born, non-White residents in Minnesota were uninsured in 2021. 16 A little over half of uninsured patients choose to forgo care; Hispanic patients have the second highest rate of foregone care in the state. 17 Postpartum insurance lapse is experienced by Medicaid patients who become financially eligible during pregnancy. 18 Minnesota has recently expanded its coverage to 12 months postpartum, which enables greater continuity of care.19–21 In other states access to care is constrained due to lack of expansion of postpartum coverage, specific limitations based on immigration status, and 5-year waiting periods.3,22
In southeast Minnesota, many immigrant and migrant workers reside and work in more rural agricultural settings and obstetrics and gynecology care is limited in small town and isolated rural settings. 23 Transportation was a noted barrier due to distance from the clinic, as well as difficult winter weather conditions that are frequent in the region. This impacted participants’ choice of where to receive care, even if alternative clinics and hospitals might provide more advanced levels of care. Medicaid-provided transportation was not universally available, and participants described being reliant on partners or family members for transportation to perinatal appointments and other services. Mobile health clinics, which have been able to connect rural patients to primary and specialty care in other areas,24,25 may significantly benefit immigrant and migrant workers in southeast Minnesota by providing basic prenatal care services that would otherwise require travel and referrals to advanced care and services. Language-congruent care in these areas would also increase patient–provider communication and improve shared decision-making.
Participant responses also shed light on the limited social support immigrant and migrant women experience during pregnancy and the postpartum period. Immigrant women are at particular risk of postpartum depression, up to 2-fold greater than nonimmigrant patients.26,27 While the data here were impacted by the 2020 pandemic, which increased isolation for most people, migrant and immigrant workers were among the least likely to be able to quarantine or isolate. 28 The persistence of these concerns, therefore, argues strongly for more community-based, multilingual, social support services that can ameliorate the known increased risk of mental health complications during the postpartum period. Proactive interventions including home visits by midwives, doulas, or community health workers or opportunities to foster expansion of their social network should be considered.29–31
Strengths and limitations
We conducted qualitative interviews for in-depth exploration of experiences. The sample size of this exploratory study was small but sufficient to generate iterative themes. 32 Some participants were hesitant to disclose details about certain aspects of their experience, such as their immigration/migration history; to support their psychological safety during the interview, we did not ask about their immigration status (i.e., authorized/unauthorized). Further research is needed to better understand the experiences and needs of this community to effectively address identified disparities in southeast Minnesota.
Conclusion
Immigrant and migrant pregnant patients within Southeast Minnesota continue to experience barriers to perinatal care and support resulting from limited availability of language-congruent services, transportation challenges, and uncertainty related to eligibility and financial burdens of care. Initiatives to support perinatal health, such as care coordination to connect patients to Spanish-language community services, may facilitate increased utilization of services already available in the community and proactively mitigate social isolation. Additional public health investment in care coordination and outreach partnerships with larger health care organizations may bridge the gap between the needs of migrant patients and sources of needed care.
Footnotes
Acknowledgments
The authors would like to thank Community Health Services, Inc. in Rochester, MN and Tri-Valley Opportunity Council for their support and recruitment assistance for this study. The authors are also grateful to the participants for sharing their experiences.
Authors’ Contributions
Study Conception and Design: V.E.T., E.Y.R.C., Y.S.B.T., S.L., E.B., M.A.A., and K.A.R. Data Collection: E.B. and M.O. Data Analysis: J.R., E.B., and K.A.R. Article preparation: J.R., K.A.R., and M.A.A. All authors revised the initial draft of the article and read and approved the final version.
Ethics Approval
This study was approved by Mayo Clinic’s Institutional Review Board (#21-004266) and was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments.
Consent to Participate
All participants provided written consent to have their anonymous results used for research.
Data Availability
The data that support these findings are available from the corresponding author upon reasonable request.
Author Disclosure Statement
The authors have no conflicts of interest to disclose.
Funding Information
This project was funded by Mayo Clinic’s Department of Obstetrics and Gynecology. Further support was provided by Mayo Clinic’s Values Council.