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The sexual and reproductive health of foreign-born women in the United States

Open AccessPublished:February 15, 2018DOI:https://doi.org/10.1016/j.contraception.2018.02.003

      Abstract

      Objective

      To explore the sexual and reproductive health (SRH) behaviors, health insurance coverage and use of SRH services of women in the United States (U.S.) by nativity, disaggregated by race and ethnicity.

      Study design

      We analyzed publicly available and restricted data from the National Survey of Family Growth to assess differences and similarities between foreign-born and U.S.-born women, both overall and within Hispanic, non-Hispanic (NH) white, NH black and NH Asian groups.

      Results

      A larger proportion of foreign-born women than U.S.-born women lacked health insurance coverage. Foreign-born women utilized SRH services at lower rates than U.S.-born women; this effect diminished at the multivariate level, although race and ethnicity differences remained. Overall, foreign-born women were less likely to pay for SRH services with private insurance than U.S.-born women. Foreign-born women were less likely to use the most effective contraceptive methods than U.S.-born women, with some variation across race and ethnicity: NH white and NH black foreign-born women were less likely to use highly effective contraceptive methods than their U.S.-born counterparts, but among Hispanic women, the reverse was true.

      Conclusion

      Our findings demonstrate that the SRH behaviors, needs and outcomes of foreign-born women differ from those of U.S-born women within the same race/ethnic group.

      Implications

      This paper contributes to the emergent literature on immigrants in the U.S. by laying the foundation for further research on the SRH of the foreign-born population in the country, which is critical for developing public health policies and programs to understand better and serve this growing and diverse population.

      Keywords

      1. Introduction

      Since the passing of the Immigration and Nationality Act of 1965, the foreign-born have grown from 5% to 14% of the United States (U.S.) population in 2015, and this proportion is expected to reach 18% by 2065 [
      • Pew Research Center
      Modern immigration wave brings 59 million to U.S., driving population growth and change through 2065: views of immigration's impact on U.S. society mixed.
      ]. Foreign-born women and their families now live in every state in the country, with over half living in California, New York, Texas and Florida [
      • Greico E.M.
      • Acosta Y.D.
      • de la Cruz G.P.
      • Gambino C.
      • Gryn T.
      • Larsen L.J.
      • et al.
      The foreign-born population in the United States: 2010.
      ,
      • U.S. Census Bureau
      American community survey, 2012–2016 American community survey 5-year estimates, table B05002; generated by Hannah Whitehead; using American FactFinder.
      ]. With the rapid growth of the immigrant population
      Nativity is defined as whether someone is born in the country or outside, as it is used in this paper. Nativity is sometimes, though not typically, collected with citizenship status (e.g., Census Bureau surveys, American Community Surveys and in the Current Population Surveys). Nativity is also sometimes derived from a question about place of birth alone. The National Survey of Family Growth (NSFG), the dataset we examine in this paper, lacks information on citizenship at birth. U.S. citizens born abroad to U.S. citizen parents are thus potentially included in the NSFG's foreign-born population. However, the vast majority of the foreign-born population (upwards of 95%) are immigrants [
      • U.S. Census Bureau
      American community survey, 2012–2016 American community survey 5-year estimates, table B05002; generated by Hannah Whitehead; using American FactFinder.
      ]. Thus, in this paper, we use “foreign-born” and “immigrant” interchangeably.
      and the country's changing political climate, researchers and advocates alike have called for more research on the health behaviors, needs and outcomes of immigrants [
      • Johnson P.J.
      • Blewett L.A.
      • Davern M.
      Disparities in public use data availability for race, ethnic, and immigrant groups: national surveys for healthcare disparities research.
      ,
      • Islam N.S.
      • Khan S.
      • Kwon S.
      • Jang D.
      • Ro M.
      • Trinh-Shevrin C.
      Methodological issues in the collection, analysis, and reporting of granular data in Asian American populations: historical challenges and potential solutions.
      ,
      • Lau D.T.
      Advancing the field of public health surveillance and survey methods.
      ,
      • Ro M.J.
      • Yee A.K.
      Out of the shadows: Asian Americans, Native Hawaiians, and Pacific Islanders.
      ]. Literature suggests that immigrants, broadly, have a health advantage when compared to the U.S.-born population, with generally better birth and maternal health outcomes and lower mortality rates [
      • Waters M.C.
      • Pineau M.G.
      The integration of immigrants into American society.
      ,
      • Derose K.P.
      • Bahney B.W.
      • Lurie N.
      • Escarce J.J.
      Review: immigrants and health care access, quality, and cost.
      ]. At the same time, their access to health care is often challenged due to myriad factors, such as lower rates of insurance coverage, legal restrictions that prevent eligibility for government-funded services, lack of familiarity with the health care system and language barriers [
      • Waters M.C.
      • Pineau M.G.
      The integration of immigrants into American society.
      ,
      • Derose K.P.
      • Bahney B.W.
      • Lurie N.
      • Escarce J.J.
      Review: immigrants and health care access, quality, and cost.
      ]. To date, the impact of these factors on the sexual and reproductive health (SRH) behaviors, service utilization and outcomes of many immigrant groups has not been well documented.
      Past research has documented disparities by nativity in specific SRH services and outcomes among women of different race and ethnicity groups. For example, foreign-born non-Hispanic (NH) white, NH black and NH Asian women are less likely to receive SRH-related cancer screenings than their U.S.-born counterparts, but findings are mixed when considering foreign- and U.S.-born Hispanic women [
      • Clough J.
      • Lee S.
      • Chae D.H.
      Barriers to health care among Asian immigrants in the United States: a traditional review.
      ,
      • Singh G.K.
      • Hiatt R.A.
      Trends and disparities in socioeconomic and behavioural characteristics, life expectancy, and cause-specific mortality of native-born and foreign-born populations in the United States, 1979–2003.
      ,
      • Goel M.S.
      • Wee C.C.
      • McCarthy E.P.
      • Davis R.B.
      • Ngo-Metzger Q.
      • Phillips R.S.
      Racial and ethnic disparities in cancer screening.
      ,
      • Kagawa-Singer M.
      • Pourat N.
      • Breen N.
      • Coughlin S.
      • Abend McLean T.
      • McNeel T.S.
      • et al.
      Breast and cervical cancer screening rates of subgroups of Asian American women in California.
      ,
      • Tsui J.
      • Saraiya M.
      • Thompson T.
      • Dey A.
      • Richardson L.
      Cervical cancer screening among foreign-born women by birthplace and duration in the United States.
      ]. Additionally, there are differences in where immigrant and U.S.-born women obtain SRH services [
      • Frost J.J.
      US women's use of sexual and reproductive health services: trends, sources of care and factors associated with use, 1995–2010.
      ]. Nativity differences in sexual activity and contraceptive use have also been documented. Overall, U.S.-born women are more likely than foreign-born women to initiate sexual activity and give birth before age 20 [
      • Singh S.
      • Darroch J.E.
      • Frost J.J.
      Socioeconomic disadvantage and adolescent women's sexual and reproductive behavior: the case of five developed countries.
      ,
      • Singh G.K.
      • Rodriguez-Lainz A.
      • Kogan M.D.
      Immigrant health inequalities in the United States: use of eight major national data systems.
      ]. While immigrant and U.S.-born women have similar probabilities of receiving contraceptive services overall, nativity differences are seen in contraceptive use within racial and ethnic groups [
      • Frost J.J.
      US women's use of sexual and reproductive health services: trends, sources of care and factors associated with use, 1995–2010.
      ,
      • Farid H.
      • Siddique S.M.
      • Bachmann G.
      • Janevic T.
      • Pichika A.
      Practice of and attitudes towards family planning among South Asian American immigrants.
      ,
      • Shih G.
      • Vittinghoff E.
      • Steinauer J.
      • Dehlendorf C.
      Racial and ethnic disparities in contraceptive method choice in California.
      ]. As the immigrant population grows and policy debates over immigration and health care remain at the forefront of the national agenda, there is a heightened need to understand better how the intersection of these two policy arenas impacts the SRH of immigrant women in the U.S.
      Although the existing body of evidence points to some important differences in SRH by nativity, this literature is fragmented, sparse and incomplete. Much of the prior research consists of small, nonrepresentative studies that focus on a single racial or ethnic group or on only a few dimensions of SRH. Studies using nationally representative data typically focus on a particular race, ethnicity or country of origin (most often Latinas, specifically Mexicans), and often compare immigrants to U.S.-born NH whites rather than to their U.S.-born counterparts of the same race or ethnicity [
      • Derose K.P.
      • Bahney B.W.
      • Lurie N.
      • Escarce J.J.
      Review: immigrants and health care access, quality, and cost.
      ,
      • Shih G.
      • Vittinghoff E.
      • Steinauer J.
      • Dehlendorf C.
      Racial and ethnic disparities in contraceptive method choice in California.
      ]. Furthermore, certain racial groups, such as Asians, are underrepresented in the literature, in part because national studies often do not sample enough members of these groups to represent them accurately in their datasets [
      • Islam N.S.
      • Khan S.
      • Kwon S.
      • Jang D.
      • Ro M.
      • Trinh-Shevrin C.
      Methodological issues in the collection, analysis, and reporting of granular data in Asian American populations: historical challenges and potential solutions.
      ,
      • Ro M.J.
      • Yee A.K.
      Out of the shadows: Asian Americans, Native Hawaiians, and Pacific Islanders.
      ]. Our study aims to bridge these research gaps and contribute to the literature on immigrant SRH in the U.S. by providing a more comprehensive overview through comparisons between foreign-born and U.S.-born women of the same race and ethnicity.

      2. Study design

      This study pooled data from the National Survey of Family Growth (NSFG) collection years 2006–2010, 2011–2013 and 2013–2015 [
      • National Center for Health Statistics
      2006–2010 National Survey of Family Growth (NSFG).
      ,
      • National Center for Health Statistics
      2011–2013 National Survey of Family Growth (NSFG).
      ,
      • National Center for Health Statistics
      2013–2015 National Survey of Family Growth (NSFG).
      ]. These nationally representative, cross-sectional surveys collect retrospective data from men and women aged 15–44 during in-person interviews in respondents' homes. The NSFG uses a multistage probability sampling design that oversamples black and Hispanic groups and teenagers aged 15–19. More detailed information on survey methodology, sample design, response rates, fieldwork procedures and variance estimation is published elsewhere [
      • National Center for Health Statistics
      About the National Survey of Family Growth.
      ]. While the majority of data are publicly available for download on the NSFG website, we accessed restricted race and ethnicity information through a data use agreement with the National Center for Health Statistics (NCHS). Accessing this restricted data allowed us to study Asians by disaggregating this group from the “Other” race and ethnicity category. We conducted analyses of the restricted data at the NCHS Data Center in Hyattsville, MD, in June 2017.
      The analytic sample included all female respondents (n=23,573). We focused our analysis on four mutually exclusive race and ethnicity groups — Hispanics, NH whites, NH blacks and NH Asians — and did not include “Other” as a separate group. For each of the four examined groups, we stratified respondents by nativity (born inside the U.S. or outside). We examined a number of SRH behaviors, including contraceptive method use and contraceptive method effectiveness. We also analyzed SRH service utilization and form of payment for SRH services. For SRH service utilization, we examined whether respondents reported utilizing any of the following services: birth control counseling, birth control checkup, birth control method or prescription, sterilization counseling, sterilization operation, emergency contraception counseling, emergency contraception pill or prescription, pap test, pelvic exam, testing/treatment/counseling for STD, test for HIV, pregnancy test, prenatal care and postpregnancy care.
      We performed all analyses using Stata version 14.2. Due to the NSFG's multistage, probability-based complex sample design, we applied sampling weights that yield estimates representative of the U.S. civilian, noninstitutionalized, household population aged 15–44. In addition, we used design variables for the sampling stratum and cluster to obtain correct standard errors for all estimates.
      We stratified survey respondents into eight groups, by race, ethnicity and nativity. We calculated descriptive statistics on all variables used in our regression analyses; proportions and means were weighted. We then performed t tests and bivariate logistic regressions to identify differences between U.S.-born and immigrant respondents for each of the race and ethnicity groups. We employed logistic regression models to determine the likelihood of any contraceptive use, highly effective method use, utilization of SRH services and type of payment of SRH services, controlling for demographic and socioeconomic predictors (specifically age at interview, household income, relationship status, employment status, level of educational attainment, insurance status, urbanicity, age at first sex and parity). We limited these multivariable logistic regressions to women 20–44 years old to account for completed educational attainment.

      3. Results

      3.1 Contraceptive use

      Relative to U.S.-born women, foreign-born women were less likely to have sexual intercourse for the first time before age 20 (62% vs. 86%, p<.001, Table 1). Correspondingly, immigrant women were less likely than U.S.-born women to have given birth before the age of 20 (27% vs. 32%, p=.001). This pattern of results was similar across Hispanic, NH white, NH black and NH Asian comparisons by nativity.
      Table 1Sexual activity and contraceptive use among U.S.-born and immigrant women by race and ethnicity (NSFG 2006–2015)
      All races/ethnicities (n=23,573)Hispanic (n=5574)NH white (n=11,237)NH black (n=4696)NH Asian (n=1028)
      All womenU.S.-bornImmigrantp valueU.S.-bornImmigrantp valueU.S.-bornImmigrantp valueU.S.-bornImmigrantp valueU.S.-bornImmigrantp value
      Overall %100851556449649193169
      First sexual intercourse under age 20 years828662.008971.008472.009365.007630.00
      Age at first live birth
       Under 20 years313227.004637.002513.014919.00326.00
       20–29 years555459.004755.005867.064658.045064.11
       30–44 years141414.6678.451821.39522.001830.13
      Currently using contraceptive method, among women at risk of unintended pregnancy
      “At risk of unintended pregnancy” refers to women who are sexually active with men; not pregnant, seeking to become pregnant, or postpartum; and not noncontraceptively sterile.
      898988.108789.329185.028582.338989.97
       Highly effective
      “Highly effective” methods include sterilization, IUD and implants.
      434342.534153.004327.004531.012629.63
       Moderately effective
      “Moderately effective” methods include condoms, contraceptive injection, pill, ring and patch.
      343524.003222.003635.713131.934817.00
       Less effective
      “Less effective” methods include spermicide, sponge, gel or cream, and withdrawal.
      232134.002725.312038.002338.002654.00
      n=unweighted sample size. All percentages weighted to reflect national population estimates. p values represent significance levels from t tests of differences between U.S.-born and immigrant women by race and ethnicity.
      a “At risk of unintended pregnancy” refers to women who are sexually active with men; not pregnant, seeking to become pregnant, or postpartum; and not noncontraceptively sterile.
      b “Highly effective” methods include sterilization, IUD and implants.
      c “Moderately effective” methods include condoms, contraceptive injection, pill, ring and patch.
      d “Less effective” methods include spermicide, sponge, gel or cream, and withdrawal.
      The majority of women at risk of unintended pregnancy across all groups reported using contraception; rates ranged from 82% to 91%. Contraceptive use was not different between immigrant and U.S.-born women overall, or by most racial and ethnic subgroups (Table 1). However, among NH white women, immigrants were less likely to use contraception than their U.S.-born counterparts (85% vs. 91%, p=.02). We found no discernable difference overall between foreign- and U.S.-born women regarding their utilization of highly effective methods (including sterilization, IUDs and implants) (p=.53). Upon disaggregating method use by race and ethnicity, however, we found that foreign-born Hispanic women were more likely to use a highly effective method than U.S.-born Hispanic women (53% vs. 41%, p<.001). Conversely, foreign-born NH white and NH black women were less likely to use highly effective methods than their U.S.-born counterparts (p<.001 and p=.007, respectively). As a whole, immigrant women were less likely to be users of moderately effective methods (including condoms, contraceptive injection, pill, ring and patch) than U.S.-born women (24% vs. 35%, p<.001). We found the same trend comparing women in the Hispanic and NH Asian groups by nativity (Table 1). Lastly, foreign-born NH black, NH white and NH Asian women were more likely to use less effective methods (including spermicide, sponge, gel, cream and withdrawal) than U.S.-born women of the same group (p<.001, p=.003 and p<.001, respectively).

      3.2 Health insurance coverage and utilization of SRH services

      Immigrant women were more likely to be uninsured than U.S.-born women (33% vs. 16%, p<.001, Table 2); this disparity was particularly strong among Hispanic women. Moreover, immigrant women, overall, lacked both private and public coverage compared to U.S.-born women (49% vs. 63%, p<.001 and 18% vs. 21% p=.009, respectively). This pattern was particularly strong among Hispanics.
      Table 2Percent of women utilizing sexual and reproductive health care by race, ethnicity and nativity (NSFG 2006–2015)
      All races/ethnicities (n=23,573)Hispanic (n=5574)NH white (n=11,237)NH black (n=4696)NH Asian (n=1028)
      U.S.-bornImmigrantp valueU.S.-bornImmigrantp valueU.S.-bornImmigrantp valueU.S.-bornImmigrantp valueU.S.-bornImmigrantp value
      Overall %851556449649193169
      Insurance type
       Private insurance6349.004830.007168.474559.007277.57
       Public/gov't insurance21180.013122.001512.123621.001813.39
       No coverage16330.02148.001420.031820.49911.64
      Received any SRH service, including HIV7369.006770.037270.458076.336562.43
      Type of provider, if any SRH service received
       Private clinician7560.006748.008180.576464.916878.07
       Title X clinic1015.001321.0088.881411.4394.08
       Other clinic1525.002031.001112.572125.292317.28
      Type of payment used, if any SRH service received
       Private insurance6450.004832.007277.144661.007377.69
       Medicaid2021.393028.281411.283819.00812.19
       Out-of-pocket/free care1628.002141.001412.391620.281910.07
      n=unweighted sample size. All percentages weighted to reflect national population estimates. p values represent significance levels from t tests of differences between U.S.-born and immigrant women by race and ethnicity.
      A smaller proportion of immigrant women reported utilizing SRH services than U.S.-born women (69% vs. 73%, p=.001, Table 2). Among women who obtained SRH services, fewer foreign-born women, overall, than U.S.-born women received their SRH care from a private clinician (60% vs. 75%, p<.001). Foreign-born women went to both Title X and other clinics at higher rates than U.S.-born women. After disaggregating by race and ethnicity, however, this trend was found only among Hispanic women.
      Type of payment used for SRH services also varied by nativity. Overall, immigrants were less likely than U.S.-born women to pay for SRH services with private insurance (50% vs. 64%, p<.001) and were nearly twice as likely to pay for these services out-of-pocket (28% vs. 16%, p<.001). We found this overall pattern in payment type by nativity among Hispanic women but not among NH white, NH black and NH Asian women.

      3.3 Multivariate results

      To further explore whether differences in contraceptive use and SRH service utilization between immigrant and U.S.-born women were robust, we employed multivariable regression, controlling for confounders (i.e., age at interview, household income, relationship status, employment status, level of educational attainment, insurance status, urbanicity, age at first sex and parity). We found foreign-born women to be less likely than U.S.-born women to use a contraceptive method in the last month (Table 3). Upon disaggregating by race and ethnicity, however, this result was significant only among immigrant NH black women. Foreign-born women, overall, were also less likely than U.S.-born women to use highly effective methods (Table 3). We found this result among NH white, NH black and NH Asian women but not among Hispanic women. The relationship between nativity and SRH service utilization among all women disappeared in our regression models, except among foreign-born NH Asian women, who were less likely to receive SRH services than U.S.-born NH Asian women (Table 3). Immigrants were also less likely to use private insurance than U.S.-born women. After disaggregating, this result remained evident among Hispanic women but not other groups.
      Table 3Logistic regression: select outcomes of interest by race and ethnicity. Odds of immigrant women compared to U.S.-born women (NSFG 2006–2015)
      Controlling for age at the time of interview, low-income status, relationship status, educational attainment, employment status, urbanicity, age at first sex, parity, insurance status and NSFG cycle. Limited to women 20 years and older.
      All (n=17,764)Hispanic (n=4094)NH white (n=8605)NH black (n=3608)NH Asian (n=740)
      AOR (95% CI)AOR (95% CI)AOR (95% CI)AOR (95% CI)AOR (95% CI)
      Used a contraceptive method in the last month
      Compared to nonuse of contraceptives.
      0.8(0.7–0.94)0.9(9.7–1.1)0.8(0.5–1.1)0.7(0.5–0.9)0.8(0.4–1.5)
      Used a highly effective contraceptive method in the last month
      Compared to women who used moderately or low effective methods, among contraceptive users.
      0.6(0.5–0.7)1.0(0.8–1.4)0.4(0.3–0.6)0.4(0.2–0.7)0.5(0.2–1.1)
      Received a sexual/reproductive health service
      Compared to no receipt of sexual/reproductive health service.
      1.0(0.8–1.1)1.3(1.0–1.7)0.8(0.5–1.1)0.5(0.3–0.9)0.4(0.2–0.7)
      Used private health insurance to pay for sexual/reproductive health service received
      Compared to use of public health insurance or out-of-pocket payment, among women who received a sexual/reproductive health service.
      0.6(0.5–0.8)0.7(0.5–1.0)1.1(0.7–1.8)0.7(0.4–1.2)0.7(0.2–1.8)
      AOR, adjusted odd ratio; CI, confidence interval from multivariate logistic regression differences between immigrant and U.S.-born women by race and ethnicity.
      a Controlling for age at the time of interview, low-income status, relationship status, educational attainment, employment status, urbanicity, age at first sex, parity, insurance status and NSFG cycle. Limited to women 20 years and older.
      b Compared to nonuse of contraceptives.
      c Compared to women who used moderately or low effective methods, among contraceptive users.
      d Compared to no receipt of sexual/reproductive health service.
      e Compared to use of public health insurance or out-of-pocket payment, among women who received a sexual/reproductive health service.

      4. Discussion

      We found that the SRH behaviors and outcomes of immigrant women differ from those of their U.S.-born counterparts of the same race and ethnicity. Variation in immigrant women's SRH reflects the heterogeneity of immigrant women, who differ from one another in country of origin, language skills, emigration experiences, legal immigration status, residential location, educational attainment, employment opportunities, and experience of stigma, discrimination and marginalization [
      • Greico E.M.
      • Acosta Y.D.
      • de la Cruz G.P.
      • Gambino C.
      • Gryn T.
      • Larsen L.J.
      • et al.
      The foreign-born population in the United States: 2010.
      ,
      • Waters M.C.
      • Pineau M.G.
      The integration of immigrants into American society.
      ,
      • Gambino C.P.
      • Acosta Y.D.
      • Greico E.M.
      English-speaking ability of the foreign-born population in the United States: 2012.
      ,
      • Viruell-Fuentes E.A.
      • Miranda P.Y.
      • Abdulrahim S.
      More than culture: structural racism, intersectionality theory, and immigrant health.
      ,
      • Glick J.E.
      • White M.J.
      Post-secondary school participation of immigrant and native youth: the role of familial resources and educational expectations.
      ].
      Structural, cultural, economic and social factors contribute to the observed differences presented here by immigrant status. For example, the myriad of federal and state laws and policies barring immigrants from affordable health insurance coverage likely contributes to disparities in health coverage and outcomes between immigrants and nonimmigrants [
      • Hasstedt K.
      The case for advancing access to health coverage and care for immigrant women and families.
      ,
      Guttmacher Institute uninsured rate among women of reproductive age has fallen more than one-third under the Affordable Care Act.
      ]. Accessing contraceptive services and providers may also be more difficult for some immigrants due to language barriers, unfamiliarity with the health system, and a lack of multilingual services and providers who can provide contraceptive counseling and education [
      • Clough J.
      • Lee S.
      • Chae D.H.
      Barriers to health care among Asian immigrants in the United States: a traditional review.
      ,
      • Mengesha Z.B.
      • Perz J.
      • Dune T.
      • Ussher J.
      Challenges in the provision of sexual and reproductive health care to refugee and migrant women: a Q methodological study of health professional perspectives.
      ].
      While we selected the NSFG because it provided the best set of SRH measures collected at the national level and also included nativity, race and ethnicity information, there were important limitations with this dataset. The NSFG does not ask about legal status, country of origin or nativity of respondents' parents (which determines generational cohort); thus, we were unable to include comparisons among immigrants by these more refined dimensions, which have been documented as factors influencing immigrant health [
      • Tsui J.
      • Saraiya M.
      • Thompson T.
      • Dey A.
      • Richardson L.
      Cervical cancer screening among foreign-born women by birthplace and duration in the United States.
      ,
      • McDonald J.A.
      • Manlove J.
      • Ikramullah E.N.
      Immigration measures and reproductive health among Hispanic youth: findings from the national longitudinal survey of youth, 1997-2003.
      ,
      • Singh G.K.
      • Kogan M.D.
      • Yu S.M.
      Disparities in obesity and overweight prevalence among US immigrant children and adolescents by generational status.
      ]. Legal status can affect access to and use of health care services and, consequently, can result in differences in health status over time [
      • Kelaher M.
      • Jessop D.J.
      Differences in low-birthweight among documented and undocumented foreign-born and US-born Latinas.
      ,
      • Korinek K.
      • Smith K.R.
      Prenatal care among immigrant and racial–ethnic minority women in a new immigrant destination: exploring the impact of immigrant legal status.
      ]. Furthermore, a growing body of literature suggests that age of arrival and length of stay in the country may also affect immigrant SRH behaviors and outcomes [
      • Lee H.Y.
      • Ju E.
      • Vang P.D.
      • Lundquist M.
      Breast and cervical cancer screening disparity among Asian American women: does race/ethnicity matter?.
      ]. The nativity of respondent's parents is also important since some evidence suggests differential access to health care services by generational cohort [
      • Huang Z.J.
      • Yu S.M.
      • Ledsky R.
      Health status and health service access and use among children in U.S. immigrant families.
      ]. In addition, state of residence and English language proficiency could affect immigrants' experience with the U.S. health care system [
      • Waters M.C.
      • Pineau M.G.
      The integration of immigrants into American society.
      ,
      • Derose K.P.
      • Bahney B.W.
      • Lurie N.
      • Escarce J.J.
      Review: immigrants and health care access, quality, and cost.
      ]. However, these factors are similarly not measured in the NSFG. These data are also not representative at the state level. Consequently, we were not able to assess the effects of state policies on the use of and access to SRH services. Although many immigrants are barred from Medicaid coverage and from subsidized private coverage under the Affordable Care Act, some states provide alternative pathways to health care coverage and services; California, for example, provides free access to family planning services to all California residents living at or below 200% of the poverty line, regardless of legal status state residence [
      • Hasstedt K.
      The case for advancing access to health coverage and care for immigrant women and families.
      ,
      • California Department of Health Care Services, Office of Family Planning
      Family PACT program overview.
      ]. A final constraint of our study was the inability to conduct more granular comparisons, such as examining specific nationalities (e.g., comparisons among Chinese and Indian women) instead of the broader groups defined here, because of the small number of respondents in such disaggregated groups.
      This study lays the groundwork for future research that explores the underlying motivations, contexts and determinants of disparities in immigrant SRH. Further research is critical to address the specific needs of these diverse and growing communities. In particular, there has been almost no prior work investigating how social, cultural and structural factors shape the relative SRH disparities or advantages of different immigrant groups.

      References

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