Immigrants make up nearly 16% of Philadelphia’s population of 1.6 million, according to a 2024 report from Pew Charitable Trusts. Pew reports this marks the largest percentage since the 1940s, and above the national percentage of 13.9%.
I am a neonatologist – a pediatrician who’s trained to care for babies in the neonatal intensive care unit – in the city. I’m also a perinatal health services researcher and study the health care and health outcomes of pregnant mothers and their infants. Because of my dual jobs, I know how important preventive health care is for decreasing the risk of disease, disability and death.
However, I also know that the political rhetoric around immigration – as well as public policies that create fear or confusion about how medical care could affect immigration status – discourage immigrants from seeking medical attention, a phenomenon described as the chilling effect.
In 2021, working with community partners Puentes de Salud and Maternity Care Coalition, my research team interviewed 24 Latina immigrant mothers in Philadelphia and the Kennett Square area. Kennett Square is about 45 miles outside Philadelphia, and its large mushroom industry draws many immigrant laborers.
All of the mothers we interviewed had been pregnant during or after the new public charge rules went into effect during the Trump administration. These new rules mandated, for the first time ever, that receiving public benefits like Medicaid and food assistance might make an immigrant ineligible for permanent residency.
Although the final rule change did not go into effect until February 2020, an executive order describing the changes was leaked in early 2017 and received significant attention from national media and researchers.
Although these expanded public charge rules were rescinded by the Biden administration in September 2022, fear and confusion persist among immigrant communities.
Our paper, published in the June 2024 edition of the peer-reviewed journal Medical Care, discusses ways to overcome this chilling effect and improve health care for Philadelphia’s large and growing immigrant community.
Evidence of the chilling effect
In June 2015, Donald Trump kicked off his run for president with a speech calling Mexican immigrants “rapists” and “criminals” on national television. Xenophobic rhetoric and platforms became a hallmark of his campaign.
Four years later, a study in Texas found that immigrant Latina women made fewer and later prenatal visits starting midway through the 2015 presidential campaign and through the first two years of the Trump administration.
In Maryland, researchers looked at how adults and children who were presumed to be undocumented accessed health care after the 2016 presidential election. They found decreases in primary care visits among both adults and children. And there was an uptick in missed preventive pediatric visits among children of immigrant mothers in Boston, Minneapolis and Little Rock, Arkansas, both after the 2016 election and after the expanded public charge rules were leaked to the press.
Consequences of less preventive care
How this chilling effect may impact overall public health is also becoming more apparent.
In the Maryland study mentioned above, researchers found that the rate of annual emergency room visits among the children in the study more than doubled. This suggests that medical issues that could have been addressed in a pediatrician’s office during preventive visits became more urgent and families ended up seeking emergency care.
In addition, one study estimated there were 2,337 more preterm births than would be expected among Latina mothers in the U.S. in the year after the 2016 presidential election.
Given what they controlled for in their analyses, the researchers concluded the increase was possibly related to added stress among this group around the election, perhaps secondary to fears around anti-immigration legislation, xenophobic rhetoric and increased deportations.
The chilling effect has also been shown to affect immigrants’ use of food and nutrition programs such as the Supplemental Nutrition Assistance Program and the School Breakfast Program. There has been a steep decline in the use of many benefits by eligible immigrant families since 2016.
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‘You feel you don’t deserve the same quality’
The moms in our study who did seek out prenatal care reported both positive and negative experiences.
Several reported feeling more comfortable when they heard their own language at a visit. For instance, one 30-year-old woman from Guatemala shared how good it felt when her health care providers “made an effort to speak Spanish even though they are American.”
Those with friends or family members who had already been pregnant in the U.S. reported little difficulty finding a trusted prenatal care provider.
However, they also reported misinformation around seeking care – such as hearing that one needed a passport to receive medical attention or to have $10,000 in hand to deliver a baby.
One woman from Honduras who had lived in the U.S. for three years shared that she has always been told to “not get help because if you get it and you want to go back home, you’re not going to be able to.”
Some also felt they were treated differently because of their immigration status. “[T]hey look at you differently because you don’t know English,” said a 32-year-old woman from Mexico. “You feel that you don’t deserve the same quality as an American in medical care.”
‘I have the right to get information’
Participants offered suggestions for health care providers and health care systems to better meet the needs of pregnant immigrant patients.
They spoke about their desire to learn about their rights as immigrants in health care settings and noted the difference it made when a doctor, nurse or entire clinic worked to correct their misconceptions.
“[My provider] made me feel more empowered to say, ‘You know what? I have the right to get information from you,’” said a mother from Mexico who had lived in the U.S. for six years.
Increased access to interpreters was also brought up often. Many of the women noted how challenging it was to communicate during the parts of a prenatal visit that occurred outside the exam room, such as phone calls to schedule appointments, or the check-in process.
Ways to improve care
Based on the 24 women’s reflections and suggestions, I believe there are several actions health care providers and systems can take to make pregnant immigrants feel safer during their medical visits.
First, medical schools and programs can include training on how to communicate with patients around their immigration status. Trauma-informed health care acknowledges patients’ adverse life experiences and how those experiences influence their medical decisions. It has been shown to improve relationships between patients and their health care providers and decrease burnout among medical providers. Yet it’s often lacking in training curricula for health professionals.
Hospitals and clinics can also provide information sheets and signs that encourage immigrant patients to understand their rights to care within that system.
And they can hire more interpreters.
Nationwide interpreter shortages are a long-standing problem. A 2016 survey of hospitals showed that only 56% offered language interpretation services. Since inadequate insurer reimbursement for language services is thought to contribute to these shortages, improving access to in-person interpretation will likely require payer reform.
Still, health care systems could better train staff in how to best use virtual interpretation resources, and include office personnel who interface with patients outside of exam rooms.
Lastly, hospitals and prenatal care clinics could do a better job of integrating patient navigators and peer support specialists into their maternal care. Patient navigators and peer support specialists are typically community health workers who are trained to support pregnant people outside of hospitals and clinics and help them navigate prenatal care. They help identify and overcome barriers to health care that a specific patient might face.
Early evidence indicates that prenatal patient navigation may be associated with healthier infant birth weights and also better recognition of postpartum maternal mental health disorders such as anxiety and depression. Yet these roles currently exist on the margins of health care, supported by philanthropy and research grants.
