'Women Are Dying': The Severe Effects of Clinic Closures on Undocumented Women

The Rio Grande Valley sits at the southernmost tip of Texas, nestled right above Mexico. One of the poorest places in America, it is also home to nine percent of the state's undocumented immigrants. Almost half of its population has less than a ninth-grade education. There are a high number of colonias here—unincorporated communities that don't have basic services like plumbing, clean water, sewage, electricity, and paved roads.

For many women living in the region, accessing affordable reproductive healthcare is yet another problem to add to the list. Nine out of 32 family planning clinics in the area shuttered between 2011 and 2012, while 82 clinics have closed in the state as a whole. That means that women seeking contraception, a routine pap smear, or a mammogram are left without options.

The Rio Grande Valley is far from an anomaly: Finding adequate health and abortion care proves difficult in other parts of the country as well. Prohibitive federal and state laws surrounding health insurance, combined with decreased funding to clinics, unsteady income, and a lack of transportation, leave very few options for undocumented immigrants. These factors come together in a pernicious way, leading to dire health consequences and perpetuating cycles of poverty.

One woman I spoke to, Gabriela Hernandez, says that as a child, she only went to the doctor for emergencies. Originally from Ciudad Juarez in Mexico, Hernandez has lived in the United States for 16 years. She was approved for a work permit in October of 2013, but some of her family remains undocumented. When she was younger, health care was hard to find. "Growing up, my mom was also afraid that we could be deported or not be able to afford to go to the doctor, so we hardly went," she told me over email. Most "undocumented people don't have health care, so going to the doctor is expensive and finding a clinic that could help low income [people] was hard because of the language, location, or time."

These challenges can prove deadly. Cervical cancer, for example, is highly preventable disease, but the rate is almost twice as high for Hispanic women along the border than non-Hispanic women. "It's not because they're less healthy or there's something inherently wrong with their bodies," Jessica González-Rojas, the executive director at the National Latina Institute for Reproductive Health, says. "It's literally because they do not have access to regular, affordable, quality health care." Eveline Shen, the executive director at Forward Together, similarly says that that "undocumented women are less likely to use prenatal services and have higher rates of low birth weight than documented immigrants."

As Katrina Anderson, the interim director for US Human Rights and Foreign Policy at the Center for Reproductive Rights, explains, there are some women in the Rio Grande Valley who know that they have symptoms of cancer but can't get treatment. "They have large cysts in their ovaries or in their uterus and they're unable to access any kind of screening." That means they're living in a state of anxiety and pain. She says that some women hadn't received any kind of test even after two years of living with symptoms. "There are people who get totally preventable forms of cancer, like cervical cancer, and die from it prematurely."

According to Anderson, this dangerously restricted access comes from two sources: policy-based barriers and structural barriers. Coverage (and lack thereof) "depends on your status, and it depends on where you live," she says.

In most cases, under federal law, undocumented immigrants can't sign up for health insurance under Medicaid and the Children's Health Insurance Program despite being low income. They're also not able to purchase health care. That means women are often denied easy access to preventive reproductive health care, such as wellness exams or contraception. González-Rojas told me that undocumented immigrants can meet many of their needs through federally-qualified community health centers or Title X clinics, which provide contraception, sexuality education, and other forms of family planning health care. But understanding which clinics to go to is yet another challenge.

Max Hadler, a health advocacy specialist at the New York Immigration Coalition, explains that accessing quality reproductive health care is difficult precisely because "it's very complex—even for people who study this all the time—to understand what the options are." Laws differ by state, so deciphering their nuances is even more complicated. While some states, like New York, provide insurance for undocumented immigrants and also offer services for children and pregnant women, not all do.

Texas is the poster child for reduced health care access and its effects. A report from the Center for Reproductive Health and the National Latina Institute for Reproductive Health entitled Nuestro Voz, Nuestro Salud, Nuestro Texas surveyed the severity of the problem in the Rio Grande Valley. Seventy-eight percent of the women interviewed (including lawfully present immigrants) didn't have health insurance at all. The report states that "most US lawful permanent residents and citizens interviewed are low-income but do not meet the extremely low threshold for Medicaid in Texas. Others do not qualify for Medicaid because they lack US residency or citizenship." Out of the 19 undocumented women interviewed for the report, 11 said that their immigration status posed as an impediment to accessing reproductive health care.

Barriers here also tend to be more restrictive than other parts of the country. For example, while, nationally, lawfully presenting immigrants must wait five years to become eligible for Medicaid, Anderson explains how there you can be a lawfully present immigrant, living in Texas for years, and still not be eligible for Medicaid.

But even if one were to qualify for insurance, structural barriers—such as a lack of transportation, poverty, and border checkpoints that make travel to distant clinics anxiety-ridden and difficult—cause even more difficulties when accessing the basic care every woman needs. Shen explained that many undocumented immigrants depend on federally-funded Title X clinics, but "border cities often exist in remote areas, far from abortion and family planning clinics, making it difficult to get to where services are offered."

Making matters worse, the cost for these services is prohibitive. In the Rio Grande Valley "nearly every woman interviewed identified cost as the primary barrier to accessing reproductive health services and supplies," according to the Nuestro Voz, Nuestro Salud, Nuestro Texas report. If a woman could pay for a preventive care visit, subsequent tests, follow-up care, medication, and contraception were often unaffordable.

Anderson says that the only option for undocumented women is often those clinics that provide free or sliding scale services regardless of insurance or immigration status. But as funding decreases and these clinics close, an undocumented woman is likely to encounter even more roadblocks on the road to decent health care.

As Daniela Ramirez, a spokesperson for Planned Parenthood, notes, "Blocking patients from receiving care at Planned Parenthood—and thus reducing the availability of quality, trusted health care providers—also strikes a huge blow to undocumented immigrants' already limited access to reproductive health care." The Nuestro Voz, Nuestro Salud, Nuestro Texas report similarly concluded that "the clinic closures and the severe reduction of services in the Valley have greatly exacerbated these systemic barriers by requiring women to wait longer for appointments, travel further away from their communities, and pay more for reproductive health goods and services."

As Anderson says "the first [clinics] to go are the ones in rural areas where undocumented people tend to reside." To make matters worse, public transportation in places like the Rio Grande Valley is limited. The Nuestro Voz, Nuestro Salud, Nuestro Texas report explains that women will often ask friends or family for help, but "arranging rides around others' availability—most commonly in the evenings after work—is often challenging due to limited appointments at clinics." On top of that, women must find babysitters or bring their children with them.

Almost every person I spoke to cited fear as another hurdle. According to Ramirez, "many immigrants stay home instead of visiting a health care provider for fear of encountering law enforcement." Hadler similarly said that there's "a huge amount of stigma and fear around approaching any sort of authority such as a health care provider." Shen explained that a huge reason that pregnant immigrants don't get prenatal care is because of "fear of ICE, police, and healthcare providers—of being reported for one's documentation status while accessing health care." These fears are not unfounded. One undocumented woman recently faced deportation after visiting an OB-GYN.

These roadblocks increase exponentially when a woman tries to access an abortion. When Grace Klein worked as a Patient Advocate at Cleveland's Preterm clinic, a woman came in asking for an abortion. Throughout their introductory session, as Klein was explaining the procedure and asking how she was doing, the woman acted uneasy and nervous. Towards the end, the woman became tense and asked, "So do you need to see my papers?" When Klein assured the woman that she was safe there, she says, she "saw her whole body just relax."

Since abortion is not covered by Medicaid in most cases, an undocumented woman who wishes to terminate an unwanted pregnancy has few options. Republican-backed restrictions on abortion clinics put even more strain on undocumented immigrants by closing providers and forcing women to travel across long distances in order to receive an abortion. Ramirez says that, "for undocumented women, this could put safe abortion completely out of reach, since these drives may require crossing border checkpoints." Zoey Lichtenheld, Communications Coordinator at NARAL Pro-Choice Texas, agreed, noting, "It's impossible for them to travel to the nearest clinic without going through border checkpoints. "

As a result, some undocumented women will choose to self-induce abortions. Ramirez says, "Research and experience have shown that where abortion is illegal or highly restricted, women may resort to self-inflicted trauma, consumption of chemicals, self-medication, and even unqualified, untrained and likely unsafe providers."

Moreover, a woman who wants an abortion but can't get one is three times as likely to drop below the poverty line in the years following. "A woman struggling to make ends meet should not have to make the decision about whether or not to end her pregnancy based on how she gets her health coverage or how much money she has—her decision should be based on what is best for her and her family's circumstances," says Ramirez.

Undocumented women are experiencing the struggles that all women in America are experiencing right now: an increasing lack of control over their health and their bodies. The difference is that undocumented immigrants are further caught in "the intersection of anti-immigration policies and restrictive reproductive health care legislation," according to Ramirez.

And the results are harrowing. As Gonzalez-Rojas puts it, "Women are dying."