In Their Own Voices: Low-income Women and Their Health Providers in Three Communities Talk about Access to Care, Reproductive Health, and Immigration

These focus groups with low-income, reproductive age women and their providers were conducted in three very different cities at a time of increasing restrictions on reproductive health in some states as well as heightened discrimination toward and fears among immigrant groups across the country. San Francisco, known to be one of the most progressive cities in the country, has few policy restrictions on reproductive health care and immigration, whereas Tucson and Atlanta are both in states with more limits on abortion access and immigration enforcement policies.

Despite the different climates in San Francisco, Tucson, and Atlanta, there were many commonalities in the discussions. Most women, including both non-immigrant and immigrant women, were able to obtain the contraceptive method of their choice, despite the different mix of providers that serve the three cities. However, some women in each city reported negative experiences, particularly with unexpected side effects that have made them reticent to try other methods. Desire for deeper relationships with providers was a common theme between the three sites.

We heard clearly that the social determinants of health – including poverty, stable housing, food, and transportation, underlie access to care for low-income women in all three of these communities. While most were obtaining contraceptive services, women and their providers did speak about putting off other preventive and specialty care because they must prioritize addressing an array of other daily challenges. Some immigrant women put off care until they could return to their native countries where they obtained services at a lower cost.

One of the widest gaps that women spoke of was in mental health care. This was the case in the English and Spanish groups, with many women saying they could not afford services because they were uninsured or their coverage was limited and some not being able to find a provider. Furthermore, many women talked about surviving domestic violence, and limited resources for assistance in the health care, justice, and social services sectors.

Low-income, immigrant women reported experiencing many of the same gaps as those born in the U.S. However, in all the cities, some of the immigrant participants said they were curtailing use of health care and related services, such as non-urgent appointments and enrolling in public benefits such as Medicaid and food stamps, due to anti-immigrant sentiment and policies designed to curb immigration. In some communities, particularly Tucson, immigrants say have been accustomed to these attitudes and restrictions for decades, but even there, both women and providers said that fears have increased and providers were expending more resources to ensure that their clinics remain as safe spaces.

Among providers, there was a striking similarity in their priorities between the three cities, with most expressing a strong desire to build their capacity to address the myriad of challenges that their low-income patients face. Providers articulated their observations of the impact that larger social determinants of health play in women’s reproductive health care. Many providers say they are strapped financially and face difficulty with provider recruitment and being able to expand services beyond what they already offer, particularly to address complex issues such as mental health and domestic violence. There was also a lot of agreement among women across the cities on reproductive health priorities, particularly that care should be affordable, available, and high quality for all, regardless of socioeconomic status.

One of the areas of greatest difference between the three cities was abortion access and knowledge. San Francisco has the fewest limits on access to abortion services, and women in the city were most likely to know where they could obtain services and were most comfortable discussing the topic. Women in Tucson and Atlanta were less supportive of abortion access and less likely to know where to go for services. Since the groups were conducted, the state of Georgia passed a law that would ban abortion after approximately six weeks of gestation, before many women know that they are pregnant. While this law is not in effect, it has generated widespread attention and could exacerbate knowledge gaps. The law also has repercussions for the entire Southeast region of the country because providers in the Atlanta focus group said that currently they see many patients from neighboring states, where there are fewer abortion providers.

Since the focus groups were conducted, there have also been more policy restrictions on reproductive health put forward at the federal level. Most notably, the Trump Administration has implemented new rules for the Title X program, which funds the provision of family planning services at safety-net clinics, including ones that many of the women and providers in the focus groups use and represent. Litigation over the new rules is ongoing, but if they remain in effect, the network of participating providers across the country will shrink, the scope of family planning services offered to low-income people will be reduced, and safety-net providers such as the ones represented in these focus groups will have fewer resources, when they already report being financially strapped.

Additionally, the nation is in the midst of a very contentious and emotional debate about immigration. The rise in deportations, periodic raids by ICE and threats of more are likely to exacerbate fears in immigrant communities that we heard in these focus groups. While the current crises related to separating families and turning away refugees are distinct, we heard that they also contribute to the stress and fears that keep many immigrant families from seeking care.

Policy changes across a range of issues — immigration, access to abortion and contraception services, Medicaid and Title X funding for safety-net providers—affect the range and quality of services that low-income women can obtain. This is on top of the many health and financial challenges that low-income women face on a continuing basis, no matter where they live.