Claire Brindis, DrPH Director, Philip R. Lee Institute for Health Policy Studies

1. Women and Migration Case study: The health status of Latina migrants to the US Claire Brindis, DrPH Director, Philip R. Lee Institute for Health Policy Studies Professor of Pediatrics and Health Policy Department of Pediatrics and Department of Obstetrics, Gynecology, and Reproductive Health Sciences Director, Bixby Center for Global Reproductive Health Executive Director, National Adolescent Health Information and Innovation Center Presented at the Summer Institute on Migration and Global Health, July 27th, 2012

4. Overview: • Health status of Latina migrants • Living in the US • Introduction • Migrants in the US • Health status of US Latino/as • Migrant and seasonal farmworkers • Successful approaches to improving migrant women’s health

5. Latina migrants face many of the same barriers to health care access as seen among migrants globally Tomato processing, Manteca, CA • Social isolation • Language and cultural barriers • Low levels of formal education • Frequent within-country migration – borders, states • Lack of linguistically or culturally appropriate health care services • Limited financial resources or time off work

6. Migrant women face a host of risk factors for poor health outcomes • Low rates of health insurance coverage • 86% uninsured • Changing eligibility and application standards • Wary of seeking government-linked health care or insurance due to immigration status • Lack of information about available services

7. Immigration Law Drives Flows • 1965 Added Western hemisphere quota • 1965 Added family reunification • 1980 Refugee act • 1986 IRCA – amnesty for undocumented, employer sanctions San Ysidro border crossing

8. US-Mexico migration patterns shift with the political climate • 1996 – Welfare Reform Act (PROWRA) • Immigration restrictions tacked on to 1996 welfare reform, 2005 REAL ID Act • Arizona SB 1070: harshest anti-immigrant legislation in US. • 2012+??? Dozens of U.S.-born children from across the country rally at the White House with their undocumented parents to demonstrate against recent deportations.  Photo: Getty Images/Chip Somodevilla

9. Latino/a immigrants comprise a significant proportion of the US population • In 2010, nearly 13% of the US population was foreign-born, up from 11% in 2000 • 27% of California residents are foreign-born • 47% of the US foreign-born identifies as Hispanic • Of all Mexican immigrants residing in the US, 44% are women • Asian-origin immigrants recently overtook Latinos as the largest share of immigrants (36% vs. 31%) • Nearly twice as likely to attend college as the average American; lower poverty rate Pew Hispanic Center, 2010.; Pew Research, 2012

10. State proportion of the Mexican-born population in the US

11. Changing face of Immigration in the US   Pew Research Center's (June 2012) new report highlights Asian Americans as fast growing, best-educated, highest-income race group in the US. - China, Philippines, India, Vietnam.

12. Decreases in immigration from Mexico are due to: • weakened U.S. job and housing construction markets • heightened border enforcement • a rise in deportations • growing dangers associated with illegal border crossings • the long-term decline in Mexico’s birth rates • broader economic conditions in Mexico However, nearly a third of all current US immigrants were born in Mexico.    Pew Hispanic Center, 2010.; Pew Research, 2012

13. A Brief Socio-Economic Profile of Latinos living in the US

14. US poverty level by immigration status, 2010 Pew Research Center

15. Adult women by income group, 2007 Pew Hispanic Center

16. Educational Attainment of US Women, 2007 Pew Hispanic Center

17. Weekly earnings for adult women employed full time, 2007 Pew Hispanic Center

18. Most common occupations for adult Latina women, 2007 Pew Hispanic Center

19. Health care access of Latinos living in the US

20. Health insurance coverage is low among foreign- born Latino/as Foreign-born Latinas are most likely to lack health insurance coverage

21. Health Care Access of US Latino/as, 2007 Pew Hispanic Center

22. Primary reason cited by those with no usual health care provider, 2007 Pew Hispanic Center

23. Reasons for receiving poor quality care, among those who received poor quality care in the past 5 years Pew Hispanic Center

24. Chronic illness among Latinas

25. Latinas fare worse on obesity-linked chronic illnesses; better on others Latino/as report lower rates of hypertension, asthma, chronic bronchitis, and cancer than Black and white Americans 78% of Mexican-American women are overweight or obese, compared to 60% of non-Hispanic white women 31% of Latina adolescents; 19% of white; and 36% of Black adolescent girls are obese or overweight National Health Interview 2006 Survey Data; DHHS Office of Minority Health 2010

26. Latinas fare worse on obesity-linked chronic illnesses; better on others • Due to obesity, Latinas at higher risk for: • diabetes (including gestational), • heart disease, and • stroke • Latinas are 1.5 times as likely as white women to die from diabetes, although Blacks are 2.2 times as likely as non-Hispanic whites to die from diabetes • In 2008, 139,251 Hispanics (62,380 women) died from diabetes (Source: http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_10.pdf) National Health Interview 2006 Survey Data; DHHS Office of Minority Health 2010

27. Latina women are at risk for other poor health outcomes Kaiser Foundation 2003; Abriado-Lanza et al. 2004; http://www.minorityhealth.hhs.gov/templates/content.aspx?lvl=3&lvlID=7&ID=3327 • Many of these can be linked to lack of access to preventive care • Latina women have five times the HIV/AIDS rate compared to white women; Black women have 20x the HIV rate of white women • Hispanic females have an HIV rate of 9.2 per 100,000, compared to 2.1 for white women; for Black women: 41.7 per 100,000 (2010) • Latina immigrant women are half as likely as US-born women to have a Pap test • Latina women have the highest rates of invasive cervical cancer among California women

28. Cervical cancer incidence and mortality rates per 100,000 women by race, 2006 National Cancer Institute, SEER data

29. What about the “migrant paradox”? Refers to Mexican-born women’s lower incidence of certain chronic diseases (i.e., cancer, cardiovascular disease) compared to US-born women Advantages disappear with time spent in US. For example, 4% recently arrive immigrants are diabetic; over time, increases to 9%.

30. What about the “migrant paradox”? • Mexican-born women are less likely to experience hypertension during pregnancy (2%% compared to about 4.5% among US born-Non-Hispanic Whites and 4.6% for Blacks) • Less likely to have low birth weight babies • 5.9% of Mexican-born, 7.5% of other immigrants, 7.3% of US born NHW, 14.4% of Black • However, this does not hold true for the migrant and seasonal farmworker population National Population Council of the Government of Mexico, University of California. 2010.

31. Birth, fertility and reproductive health outcomes among Latina women in the US Domestic workers rallied at the Women's Building in San Francisco's Mission District

32. The vast majority of Latina women have used contraceptives Contrary to the stereotype that Latinas don’t use contraceptives because of religious beliefs or the desire for a large family, 97%of US Latinas who have ever had sex have used contraception 90% of married Catholic Latinas have used modern contraception The disproportionate number of Latinas who are very low income may account for inconsistent contraceptive use in this population Mexico’s state family planning program, MEXFAM, provides rural and urban family planning services, HIV/AIDS prevention, cancer screening, and adolescent sexual health education National Latina Institute for Reproductive Health, 2012

33. US fertility rates by race/ethnicity, 2010 Latina women have the highest fertility rate of any race or ethnicity Pew Research Center

34. Birth outcomes maternal race/ethnicity, 2007 US DHHS, HRSA, Health USA 2010

35. Maternal and infant mortality and births to unmarried women US DHHS, HRSA, Health USA 2010

36. Migration to the US may alter Mexican women’s reproductive behaviors The process of adapting to US culture affects relationships, contraceptive use, attitudes towards reproduction and gender roles • Move towards more equitable attitudes on gender roles among both men and women • Increased family planning: delaying, spacing and limiting births • Increased contraceptive use Maternowska et al. 2010

37. One migrant woman speaks about changing gender roles: Maternowska et al. 2010 “I have changed my way of thinking, my way of being. Before, I believed I had to do whatever my husband said and be in the house with the kids, but here [in the USA], one has rights to everything and one doesn’t have to endure these things from your husband. Before he was macho, he wanted me to do whatever he wanted, told me who I could go with, where I could go . . . but not here and [not] now.” -- Sonia, 28

38. Sexual and reproductive health of Latina adolescents in the US

39. Latino/a adolescents have similar rates of sexual activity to other teens, but face barriers to information Driscoll et al. (2004). Priorities, Progress and Promise: A Chartbook on Latino Adolescent Reproductive Health. San Francisco, CA: UCSF Most common reasons for not accessing reproductive health services & information reported by Latino/a youth: • unawareness of clinics (38%) • embarrassment talking about sexual issues (29%) • cost (28%) • upsetting their parents if caught with contraceptives (27%)

40. Proportion of high school students who have ever had sex, by ethnicity YRBS http://www.childtrendsdatabank.org/sites/default/files/24_tab01.pdf

41. Condom use at last sex by sexually active high school students YRBS: http://www.childtrendsdatabank.org/sites/default/files/28_tab01.pdf

42. Reported STIs among adolescents ages 15-19, by race/ethnicity, 2008 US DHHS, HRSA, Health USA 2010

43. Teen birth rate, by race/ethnicity One in four (26%) 19 year old Latinas has experienced a teen birth (compared to 22% of African American, 11% of white, and 6% of Asian 19 year olds). National Campaign to Prevent Teen Pregnancy, 2011. Ventura, Abma, & Mosher, 2009

44. Reproductive Health What contributes to higher teen pregnancy rates among young Latinas? Attitudes towards childbearing & contraception Access to family planning services, Economic & educational opportunity Relationship characteristics, Communication about sex & contraception Cultural and family norms towards childbearing

45. Migrants and seasonal farmworkers in the US* Health care access among migrants* Women migrants in the US* Reproductive health status of women migrants

46. 78% of farmworkers in the US are foreign-born, the majority from Mexico • Nationwide, migrant farmworkers tend to be young (50% under age 30), married (58%) and male (80%) • California is home to 39% of all Mexican immigrants in the US (including seasonal farmworkers) A Mexican migrant farm worker, who does not want to be identified, sits with his art piece that describes the laborers journeys from Mexico to the U.S. Emily McManamy, Free Press National Agricultural Workers Survey, 2000; Lubbock et al. 2009. ; Center for Farmworker Health, 2009.

47. Migrants from indigenous communities in Mexico and Central America are among the fastest growing migrant groups in the US. • In California, an estimated 20% of farmworkers are indigenous workers • They tend to be younger, more recently arrived, poorer, with less education and less English speaking ability than other immigrant farmworkers Strawberry picking, CA • Often discriminated against at home and continue to suffer discrimination from non-indigenous US immigrants. National Center for Farmworker Health, 2009

48. 20% of migrant workers are women and girls Harvest / La Cosecha: U.S. Child Migrant Farm Workers - A Documentary • They tend to work in fields, packing houses, and other agricultural workplaces; more likely than men to be living with their children • The reproductive health of migrant men has direct implications for the reproductive health of their female partners

49. Migrant farmworkers face multiple barriers to health care access • Five out of six farmworkers speak Spanish (84%) • Just one in ten foreign-born farmworkers speaks or reads English fluently • On average, completed six years of formal education • Median annual income for in 2000 was $6,250, compared to $42,000 for the average American worker • 85% of migrant and seasonal farmworkers were uninsured in 2000 National Agricultural Workers Survey, 1997; Rosenbaum, & Shin, 2005.

50. Migrant and Seasonal Workers have low rates of health care utilization • Paucity of data on many health issues, partly because MSFWs infrequently access health services • Often based on single-site studies • In 2000, only 20% of MSFWs had utilized any health care services in the last two years • Estimates of HIV/AIDS infection rates are based on site-specific studies and vary from 2.6% to 13% • None of these estimates are considered reliable New York State Department of Health, AIDS Institute. 2007.; Fitzgerald, Keri et. al. 2003; Painter, Thomas M. 2007