You are on page 1of 37

ABSTRACT

WOMEN AND ACCESS TO REPRODUCTIVE HEALTH


By
Claudia M. Castro
May 2015
This study analyzes the effect of age, ethnicity, and citizenship status on womens
access to reproductive health care services via public assistance, private, and/or
employer-based health care coverage. The study predicted that adult women of
reproductive age have low access to reproductive health care coverage. The study also
predicted that adult Hispanic women of reproductive age are more likely to access
reproductive health care via public assistance programs such as Medicaid as opposed to
other sources of health care coverage. Lastly, the study predicted that undocumented
adult Hispanic women of reproductive age are more likely to report low access to health
care coverage, including access to reproductive health care than adult Hispanic women of
reproductive age who are permanent residents or citizens. The results of this study
showed a significant relationship between access to health care coverage and age,
ethnicity and citizenship status.

WOMEN AND ACCESS TO REPRODUCTIVE HEALTH

A PROJECT REPORT
Presented to the Department of Health Care Administration
California State University, Long Beach

In Partial Fulfillment
of the Requirements for the Degree
Master of Science in Health Care Administration

Committee Members:
Grace Reynolds, D.P.A. (Chair)
Erlyana Erlyana, M.D.
Tony Sinay, Ph.D.
College Designee:
Tony Sinay, Ph.D.

By Claudia M. Castro
B.A., 2009, University of California, Irvine
May 2015

UMI Number: 1585947

All rights reserved


INFORMATION TO ALL USERS
The quality of this reproduction is dependent upon the quality of the copy submitted.
In the unlikely event that the author did not send a complete manuscript
and there are missing pages, these will be noted. Also, if material had to be removed,
a note will indicate the deletion.

UMI 1585947
Published by ProQuest LLC (2015). Copyright in the Dissertation held by the Author.
Microform Edition ProQuest LLC.
All rights reserved. This work is protected against
unauthorized copying under Title 17, United States Code

ProQuest LLC.
789 East Eisenhower Parkway
P.O. Box 1346
Ann Arbor, MI 48106 - 1346

Copyright 2015
Claudia M. Castro
ALL RIGHTS RESERVED

ACKNOWLEDGEMENTS
I would like to say thank you to my project advisor Professor Dr. Grace Reynolds
who provided her guidance throughout this process. Your help was very much
appreciated during this journey. Thank you!
I would also like to thank my parents Carlos and Blanca Castro who have always
supported me in my pursuit of higher education. They instilled in me the importance of
hard work and perseverance in order to reach my goals. Mom and Dad, I love you and
will always be thankful for all you have done and sacrificed in order to provide me with a
life full of opportunities. I promise to never take that for granted.
Finally I would like to thank all of my classmates for sharing this experience and
providing much needed support and camaraderie. It was a pleasure getting to know all of
you. I look forward to continuing our friendship and wish everyone all the best.

iii

TABLE OF CONTENTS
Page
ACKNOWLEDGEMENTS.........................................................................................

iii

LIST OF TABLES.......................................................................................................

LIST OF FIGURES .....................................................................................................

vi

LIST OF ABBREVIATIONS .....................................................................................

vii

CHAPTER
1. INTRODUCTION ............................................................................................

Access to Reproductive Health Care Services ..........................................


Cultural/Ethnic Influence and Socioeconomic Factors .............................

3
6

2. METHODOLOGY ...........................................................................................

Overview of CHIS Database .....................................................................


Participants ................................................................................................
Present Study .............................................................................................
Analysis......................................................................................................

9
10
11
14

3. RESULTS .......................................................................................................

16

Descriptive Statistics .................................................................................


Hypothesis Testing ....................................................................................

16
19

4. DISCUSSION ...................................................................................................

22

REFERENCES ............................................................................................................

25

iv

LIST OF TABLES
TABLE

Page

1. Analysis Summary ..............................................................................................

14

2. Results

20

........................................................................................................

LIST OF FIGURES
FIGURE

Page

1. Health insurance coverage distribution ...............................................................

17

2. Race and ethnicity distribution ............................................................................

18

3. Citizenship status of Latino participants..............................................................

19

vi

LIST OF ABBREVIATIONS
ABR

American Birth Rate

CHIS

California Health Interview Survey

PACT

Planning, Access, Care and Treatment

PPACA

Patient Protection & Affordable Care Act

SPSS

Statistical Package for Social Services

vii

CHAPTER 1
INTRODUCTION
Womens access to reproductive health care services has traditionally centered on
pregnancy related services. Since 1965, the United States government has sought to
reduce the number of unplanned pregnancies through the implementation of a family
planning policy, which subsidizes contraceptive and related preventive services (Wherry,
2013). However, the scope of reproductive health cannot be constrained to only include
pregnancy related services. Preventive services such as screening for breast and cervical
cancer, as well as testing for sexually transmitted diseases, can also be categorized under
the scope of reproductive health. Access to these services is vital to providing
comprehensive health care services to women.
Programs such as Medicaid and Californias Family PACT (Planning, Access,
Care and Treatment), a statewide family planning and reproductive health services
program, give women, primarily those of limited economic means, access to health care
services that may otherwise be out of their reach. It must also be noted that particular
populations, such as minorities and undocumented immigrants, also benefit from these
government subsidized programs in that they allow those groups to access care through
means other than private insurance. The type of provider can also have a great impact on
patterns and trends in the use of sexual and reproductive health care services by women
in the United States. According to Dr. Jennifer J. Frost (2008), U.S. women do not limit
1

themselves to specific resources when it comes to seeking sexual and reproductive health
care services. Rather, women use a mix of public and private providers (Frost, 2008).
After analyzing data from the National Survey of Family Growth, Dr. Frost found that
approximately two-thirds of the respondents reported receiving reproductive health care
service from a private doctor; 1 in 4 received their primary care from a publicly funded
clinic, hospital or other provider. An interesting result to note is that those clients relying
on publicly funded clinics received a broader scope of reproductive health care services
(Frost, 2008). Yet, there are women who are limited in accessing even publicly funded
health services. It is these populations that are in danger of falling victim to health
disparities due to not having access to various health care services.
Culture, ethnicity and socioeconomic factors can also cause barriers in access to
reproductive health care (Espinoza et al., 2014). The Hispanic population, specifically,
encounters many of those barriers, preventing their access to reproductive health care
services. An estimated 10.2 million members of the Hispanic population are women
between the ages of 15 and 44 (Wingo et al., 2009). These women have the highest
fertility rate of all ethnic/racial groups (Sanchez-Birkhead, Kennedy, Callister &
Miyamoto, 2011). Immigration status plays a major role in determining what kind of
access Hispanic women have to quality reproductive health. It is the Hispanic population
of women, regardless of immigration status, that can benefit from the expansion of
reproductive health services through various different avenues. This study will discuss
the relationship between Hispanic women of reproductive age and their access to health
care, focusing on the factors that affect Hispanic womens access to reproductive health
care
2

Access to Reproductive Health Care Services


One example of a public assistance program that can serve as an option for
women who are seeking reproductive health care services is Californias Family PACT
program. This program provides health services and family planning program and was
implemented to reduce the number of unintended pregnancies among low-income people
(Watts et al., 2012). However, similar to Medicaid, it grants beneficiaries access to
additional reproductive health services such as sexually transmitted infections screenings.
It is a program that is open to public and private sector providers.
Medicaid is another program that was established in order to grant health care
access to low-income individuals who would otherwise be forced to pay out of pocket for
access to health care insurance. Medicaid was primarily geared toward children and
pregnant women. This subsidized government health care coverage sought to reduce the
number of unplanned pregnancies (Wherry, 2013) by making contraceptive and relate
preventive services to women, along with maternity and postpartum services to those
who were already pregnant. From 1985 to 1996, Medicaid eligibility expansions on the
health insurance coverage on women giving birth has reduced the proportion of pregnant
women who were uninsured by approximately 10% (Dave, Decker, Kaestner & Simon,
2011). Medicaid has expanded so dramatically that it now covers approximately 40% of
all births (Dave et al., 2011).
With the implementation of the Patient Protection & Affordable Health Care Act
(PPACA), Medicaid is now even more readily available to those who qualify and the
scope of coverage in regard to reproductive health care services is set to expand along
with the greater access. Women of reproductive age experience a variety of health issues
3

that would not be otherwise addressed if Medicaid did not facilitate access to
reproductive health care services. The PPACAs impact on reproductive health has
received less scrutiny except when discussed in terms of ideological issues (Sonfield &
Pollack, 2013). However, the implementation of the PPACA has the potential to improve
reproductive health by increasing the number of women with coverage, improving the
quality of that coverage, and increasing access to reproductive health services and
knowledge. (Sonfield & Pollack, 2013). With this expansion of Medicaid, reproductive
health services will be more readily available to women, specifically low-income women,
who are in need of the health care services as well as the knowledge that comes with
receiving medical attention from a professional source. The PPACA is expected to
improve health outcomes and reduce health disparities for women. However, there is
widespread confusion and varied awareness and attitudes regarding womens perception
of PPACA (Hall, Fendrick, Zochowski & Dalton 2014). This is compounded by
sociodemographic characteristics including age, race/ethnicity, income level and
insurance status (Hall et al., 2014). According to Bustreo, de Zoysa, and de Carvalho
(2013), health care systems are not responsive to womens needs and perspectives even
though they are the greatest users of health care services.
The private market has allowed for more variable reproductive health services
(Sonfield & Pollack, 2013). A study analyzing the relationship between insurance and
delivery type, a reproductive health service, found a higher rate of elective cesarean
deliveries among women with insurance than uninsured women (Huesch, 2011). This is
an example of how a womans access to health care can shape her choices, or limit those
choices, in regard to her reproductive health. There are those who are unable to seek
4

private insurance directly or through an employer must seek health care coverage via
programs such as Medicaid. It is important to understand how reproductive health care
services can be expanded to address issues other than pregnancy and make this coverage
available to those with low recourses.
Women who are a part of more disadvantaged population are even less likely to
receive comprehensive reproductive health care coverage. Among the disadvantaged
population, age is a factor in regard to access to health care services. There has been a
decline in use of reproductive health services among young women between 2002 and
2008 (Hall, Moreau & Trussell, 2012). This coincides with overall worsening
reproductive health outcomes. This association between negative health outcomes and
inadequate use of health services can be attributed to disparities among women in the
United States. According to Hall et al. (2012), there exists a lower rate of service use
between 2002 and 2008 among young women who are undereducated, underinsured, and
immigrants. The adolescent birth rate (ABR) has declined substantially in the United
States (Chabot, Navarro, Swann, Darney & Bocanegra, 2014). Early childbearing has
been a concern in the United State due to the consequences for adolescent mothers, their
children, and society as a whole (Chabot et al., 2014). Programs such as Medicaid and
the Family PACT program, in California, are available to adolescents, yet even this
access is limited. A study found that access to Medicaid was highly correlated with
characteristics of a disadvantaged population (Chabot et al., 2014). Those adolescents
with access to family planning services are more likely to experience low ABR due to
reproductive health services.

Not only must access to reproductive health be aimed at the population of lowincome women but the entire scope of women who are considered of reproductive age.
The services provided to these women should include reproductive services that are not
solely related to pregnancy. Previous state expansions in Medicaid family planning
services has seen a positive effect on the frequency of breast and cervical cancer among
low-income women (Wherry, 2013). This result is an example of the important role
Medicaid family planning programs in giving access to preventive services in addition to
pregnancy and contraception related services.
Cultural/Ethnic Influence and Socioeconomic Factors
The growing need for reproductive health services among the rapidly increasing
Hispanic population (Wingo et al., 2009) is an issue that can be linked to the ability to
access reproductive health care services. Access to these services is vital to reducing
health care disparities among Hispanic women of reproductive age. Cultural and ethnic
factors influence this access along with other socioeconomic factors. Findings have
shown that inequalities in reproductive health care for women exist in the United States,
and they mostly affect young, minority and socioeconomically disadvantaged women
(Hall et al., 2012). Health care behavior is driven by knowledge of the benefits of
receiving services in the context of various barriers (Betancourt, Colarossi & Perez,
2013). Data for 2006 shows that birth rates for Hispanic women aged 15-44 are on the
rise (Wingo et al., 2009). Women of reproductive age are a growing population with
greater need of access to comprehensive reproductive health care services. According to
Wingo et al. (2009), Hispanic women of reproductive age are less likely to use
contraception than are non-Hispanic White women. Women have reported challenges to
6

obtaining consistent reproductive clinical care as well as access to care barriers (Espinoza
et al., 2014).
Immigrant Hispanic women have conflicting experiences when it comes to
seeking access to reproductive health care. While the United States provides access to
higher quality medical services than their home country, many reports state that time in
the United States negatively affects the health of Hispanic immigrants (Sanchez-Birkhead
et al., 2011). Melissa F. Natavio, MD, MPH, stated that the patients seen at a local
university-affiliated county hospital, both the uninsured and publically insured, face
barriers related to difficulty in accessing care through the public health care system
(2013). The factors contributing to this decline in health conditions can be attributed to
cultural health beliefs, past experiences with health care systems, citizenship status and
other socioeconomic conditions (Sanchez-Birkhead et al., 2011). Past experiences
include perceived discrimination from health care professionals, which discouraged them
from continuing to seek reproductive health services (Sanchez-Birkhead et al., 2011).
These factors can affect the perception immigrant Hispanic women have of health care
systems where they may seek out reproductive health care services. A study performed
by Quelopana and Alcalde (2014) found immigrant women believed that U.S. health care
services allowed them to develop autonomy over their own body. However, they
commented on the necessity of having access to health care providers with cultural and
linguistic competence.
A study found that the participants who reported enrollment in a health care
maintenance organization had the coverage through a spouses employment (Espinoza et
al., 2014). This particular access point to reproductive services falls under gender
7

structures that affect a womans ability to choose and make decisions regarding her own
reproductive health (Espinoza et al., 2014). This imbalance of gender power can shape
womens belief toward their reproductive health, allowing others to make decisions for
them. The limitation here is that while these women have insurance, they are entirely
dependent on their spouse and his employment.
In a separate study, many of the participants, immigrant Hispanic women,
reported never discussing sexual health until their first pregnancy (Espinoza et al., 2014).
This disconnect experienced by Hispanic women who have their perception shaped by
cultural and ethnic beliefs can affect their experience with reproductive health care
services. According to Betancourt et al., a mixed-method study involving Mexican
immigrants living in New York City, the highest barriers to sexual and reproductive
health services include cost, language differences, child care, and poor service quality
(2013). In this study, women stated they had a consistent pediatrician but did not seek
regular reproductive health services for themselves. These women listed low-income,
language, childcare, and fear of receiving poor quality services as the most common
barriers (Betancourt et al., 2013). While some of the participants did have Medicaid, they
were unaware of how the coverage worked and for how long the coverage lasted.
Immigrant women may have limited access to Medicaid and this lack of access to
comprehensive health services is one reason that immigrant women are able to access
services, such as prenatal care, at a lower rate than do citizens (Ostrach, 2013).
The primary purpose of this study is to examine the factors that affect adult
pregnant womens access to reproductive health care in regard to age, ethnicity, and
citizenship.
8

CHAPTER 2

METHODOLOGY

The primary focus of this study is to study the factors that affect adult pregnant

womens access to reproductive healthcare as it relates to age, ethnicity, and sources of


health care coverage. The following hypotheses will be discussed in this study: (1)
Adult pregnant women of have low access to the following healthcare: Medicaid,
Healthy Families and private insurance. (2) Adult pregnant Hispanic women are more
likely to access health care via Medicaid and Healthy Families than private insurance.
(3) Undocumented pregnant Hispanic women of are more likely to report low access to
Medicaid, Healthy Families and private insurance than Hispanic women who are citizens
and permanent residents. In order to test these hypotheses, a secondary data analysis will
be performed utilizing data from the California Health Interview Survey (CHIS) 20112012 Adult Questionnaire. The CHIS is a statewide health survey conducted on a
continuous basis in order to provide a detailed overview of the health and healthcare
needs of Californias large and varied population (CHIS, 2012).
Overview of CHIS Database
Secondary data analysis from the CHIS is chosen for this study in order to
examine the factors that affect women in general and Hispanic women, specifically, of
reproductive age and their access to healthcare coverage. The specific variables selected
for this study were: age, pregnancy status, ethnicity, citizenship/immigration status, and
source of health care coverage.
9

The CHIS is the largest state health survey in the nation. The survey is a
telephone survey conducted in al 58 counties, (UCLA Center for Health Policy, 2012).
The first CHIS was conducted in 2001 and collected information from more than 55,000
households. The survey followed a biennial survey model until 2012 when the CHIS
transitioned to a continuous survey model in order to enable a more frequent release of
data. The data from the most recent survey was gathered between 2011 and 2012. The
data collected includes statewide information on the overall population and county-level
information for most counties to aid with health planning, priority setting, and to compare
health outcomes, (UCLA Center for Health Policy, 2012).
The CHIS is conducted by the UCLA Center for Health Policy and Research in
collaboration with the California Department of Public Health, and the Department of
Health Care Services, (UCLA Center for Health Policy, 2012). The topics covered by the
CHIS include dozens of essential health topics ranging from asthma, diabetes and obesity
to immigrant health and health insurance coverage. There are core questions consistently
included in the survey every year in order to better measure significant shifts over time.
However, new questions are also added to the survey each year in order to address
emerging concerns that are vital to planning and policy development, (UCLA Center for
Health Policy, 2012).
Participants
The CHIS data is gathered through a random-dial survey model. Computers
randomly draw a sample of telephone numbers. These telephone numbers are gathered
from 44 geographic areas that represent 41 individual counties and 3 groupings of

10

counties. In 2007, CHIS decided to include a sample of cell-phone-only households


(UCLA Center for Health Policy, 2012).
Participants are chosen at random and a random adult, teen and child from each
household are asked to participate. The CHIS 2011-2012 data set chosen for this study
includes data gathered from 44,559 households, including 42,935 adults, 2,799
adolescents and 7,334 children, (UCLA Center for Health Policy, 2012). Adults,
adolescents and children are categorized as follows: adults 18 years of age or older,
adolescents ages 12-17 and children ages 11 and under. The CHIS includes people from
a variety of different ethnic groups. In order to provide health-related information for
both small and large racial and ethnic populations in California, the CHIS is conducted in
English, Spanish, Chinese (Cantonese and Mandarin), Korean, Tagalog and Vietnamese.
Present Study
This study used data from the 2011-2012 CHIS. The focus of this study is women
of reproductive age who declared their age to be between 18 and 44 years of age,
therefore only the adult data set was used. While a portion of adolescent females
between the ages of 12 and 17 are biologically capable of reproduction, they were not
included in this study. Due to the studys focus in regard to womens access to
reproductive health, the final data sample used included women between the ages of 18
and 44 who declared that they were pregnant.
The 2011-2012 Adult CHIS secondary dataset was utilized to address the
following hypotheses:
Adult pregnant women of between the ages of 18 and 44 have low access to
healthcare coverage (Hypothesis 1).
11

Adult pregnant Hispanic women between the ages of 18 and 44 are more likely to
access reproductive healthcare via public assistance programs Medicaid and Healthy
Families than private insurance (Hypothesis 2).
Undocumented adult pregnant Hispanic women between the ages of 18 and 44 are
more likely to report low access to healthcare coverage than Hispanic women who are
citizens/permanent residents (Hypothesis 3).
The subset data sample used in this study included women between the ages of 18
and 44. Only women who indicated in question QA11_A4 that they were between the
ages of 18 and 44 were used in this analysis. Due to the studys focus in regard to
womens access to reproductive health, the subset data sample used also included women
who indicated in question QA11_E1 that they were pregnant.
Dependent Variables
Whether or not a pregnant woman had access to healthcare coverage was
addressed by a participants answer to the following 2011-2012 CHIS questions:
QA11_H15: Is it correct that you are/Are you covered by Medi-CAL?
QA11_H16: Is it correct, then, that you are/Are you covered by the Healthy
Families Program?
QA11_H18: Are you covered by a health insurance plan that you purchased
directly from an insurance company or HMO?
The coded responses for all three questions were Yes = 1 and No = 2. The
primary comparison will be made between women who answered Yes or No. The
dependent variable is inclusive of all three types of healthcare: Medicaid, Healthy
Families Program and private insurance.
12

Independent Variables
The outcome variables examined in this study are the age, race/ethnicity and
citizenship/immigration status of the participants. The participants answering the
following CHIS questions determined the data for these variables that address the
proposed hypotheses:
The first hypothesis (Hypothesis 1) stated that adult pregnant women have low
access to the following healthcare: Medicaid, Healthy Families or private insurance. The
first independent variable that will be used was age and will be evaluated according to the
participants answer to question QA11_A4: Are you between 18 and 29, between 30
and 39, between 40 and 44, between 45 and 49, between 50 and 64, or 65 or older?
Participants who declared they fell within the 18 to 44 year age range and were pregnant
will be included in a t test to determine if there is a correlation between age and access to
healthcare.
The second hypothesis (Hypothesis 2) predicted that adult pregnant Hispanic
women of reproductive age are more likely to access healthcare through the public
assistance programs Medicaid and Healthy Families than private insurance. This
hypothesis is comparing Hispanic women of different ages and their access to any
healthcare coverage. The first independent variable that will be used is age. The second
independent variable that will be used is ethnicity and will be evaluated according to the
participants answer to questions QA11_A6: Are you Latino or Hispanic? A chisquare test will be used to determine if there is a relationship between ethnicity and
access to Medicaid, Healthy Families and private insurance.

13

The third hypothesis (Hypothesis 3) stated that undocumented pregnant Hispanic


women of reproductive age have less access to Medicaid, Healthy Families and private
insurance than those who are citizens or permanent residents. Both independent variables
of age and ethnicity will be used. The third variable that will be incorporated is
citizenship/immigration status and will be evaluated according to the participants answer
to questions QA11_G8: Are you a citizen of the United States? and QA11_G9: Are
you a permanent resident with a green card? For this hypothesis, a chi-square test will
be used to determine if there is a significant relationship between variables.
Analysis
The Statistical Package for Social Services (SPSS), software used to manage data
and calculate many different statistics, was used for the analysis of this study. The
dependent variable in all three hypotheses was the participants access to the following
healthcare coverage: Medicaid, Healthy Families, or private insurance. For Hypothesis 1
a t test was used to determine the relationship between variables due to its continuous
nature. For Hypotheses 2 and 3, a chi-square test was used due to the categorical nature
of he variable. The following table summarizes the three hypotheses presented in this
study and the corresponding statistical test used to determine the significance of each
hypothesis.

14

TABLE 1. Analysis Summary


Hypothesis
1. Adult pregnant
women have low
access to
reproductive health
care coverage
2. Adult pregnant
Hispanic women
are more likely to
access reproductive
health care via
public assistance
programs such as
Medicaid than
other sources of
health care
coverage
3. Undocumented
adult pregnant
Hispanic women
are more likely to
report low access to
health care
coverage than
Hispanic women
who are citizens or
permanent
residents

Dependent
Independent Variable(s)
Statistical Test
Variable
Healthcare
Age
Independent
Coverage:
sample t test
Medicaid, Healthy
Families or Private
Insurance
Healthcare
Ethnicity
Chi-square test
Coverage:
Medicaid, Healthy
Families or Private
Insurance

Healthcare
Ethnicity,
Chi-square test
Coverage:
Citizenship/Immigration
Medicaid, Healthy Status
Families or Private
Insurance

15

CHAPTER 3
RESULTS
Descriptive Statistics
The 2011-2012 CHIS survey consists of 42,935 adults out of which 25,087
(58.4%) are female participants. From the 25,087 women who participated in the survey,
7,113 (28.3 %) women of reproductive age, between 18 and 44, answered Yes or No
to the question Are you currently pregnant? The sample size consisted of the 195
women between the ages of 18 and 44 who declared they were pregnant at the time of the
survey. Because this study focuses on the availability of medical coverage, including
reproductive services related to pregnancy, the statistical tests performed used the sample
consisting of 195 pregnant women of reproductive age.
Health insurance coverage was investigated next. Of the respondents, 7.2%
reported they were uninsured. Approximately 14.4% reported they were uninsured
within the past 12 months and 78.5% reported they were insured within the last 12
months. From those that declared they did have insurance, employment-based coverage
emerged as the highest source of health insurance coverage at 51.3%. Medi-Cal
(Medicaid) came in second at 36.9% of respondents current health care coverage.
Privately purchased and CHIP/Other public program were represented as sources of
health care coverage at 4.1% and .5% respectively.

16

1%
4%

7%

Uninsured
Medi-Cal (Medicaid)
37%

Employement-Based
Privately Purchased

51%

CHIP/Other Public Program

FIGURE 1. Health insurance coverage distribution (N = 195).

The ethnicity of the 195 participants was examined next. Of the respondents,
46.7% of participants identified as Latino. The remaining participants are composed of
30.8% Non-Latino White, 14.4% Non-Latino Asian, 4.1% Non-Latino African
American, 3.1% Non-Latino More Than Two Races, .5% Non-Latino Pacific Islander,
and .5% Non-Latino American Indian/Alaskan Native.
17

Two or More
Races
3%

White
34%

Latino
52%

African American
4%

Asian
5%
American Indian/
Alaskan
1%
PaciKic Islander
1%

FIGURE 2. Race and ethnicity distribution (N = 195)

The citizenship status of the Latino participants was investigated. Of the 91


respondents who identified themselves as Latino, 42 (46.2%) declared U.S. citizenship.
Thirteen (14.3%) of the participants reported they were naturalized citizens and 36
(39.6%) declared they were non-citizens.
18

45
40

Numer of Participants

35
30
25
20
15
10
5
0
US Born Citizen

Naturalized Citizen

Non-Citizen

Citizenship Status

FIGURE 3. Citizenship status of Latino participants (N= 91)

Hypothesis Testing
Hypothesis 1 predicted that adult pregnant women have low access to
reproductive healthcare. An independent sample t test was performed utilizing age as the
independent variable and the type of healthcare coverage declared by the participant
(Medicaid, Healthy Families or private insurance) as the dependent variable. The t test of
the relationship between age and healthcare coverage produced statistically significant
results (t (195) = -2.900, p = .004). The mean age for women who reported they did not
have health insurance in the past 12 months was younger (M = 28.25, SD = 5.885) that
the participants who reported they had insurance in the past 12 months (M = 31.61, SD =
5.588).

19

Hypothesis 2 used the chi-square test to determine if adult pregnant Hispanic


women are more likely to access reproductive healthcare via the public assistance
programs Medicaid and Healthy Families than private insurance. The chi-square test
found that the association was statistically significant (2 (24, N = 91) = 195, p = .011).
Hypothesis 3 predicted that undocumented adult Latino women of reproductive
age are more likely to report low access to healthcare coverage, including access to
reproductive health care than Hispanic women who are citizens/permanent residents. The
chi-square test was used to determine if there was an association between current health
coverage status and citizenship status. The association was found to be statistically
significant (2 (6, N = 91) = 195, p = .001).

20

TABLE 2. RESULTS
Hypothesis
1. Adult
pregnant women
have low access
to reproductive
health care
coverage
2. Adult
pregnant
Hispanic women
are more likely
to access
reproductive
health care via
public assistance
programs such as
Medicaid than
other sources of
health care
coverage
3.
Undocumented
adult pregnant
Hispanic women
are more likely
to report low
access to health
care coverage
than Hispanic
women who are
citizens or
permanent
residents

Dependent
Variable
Healthcare
Coverage:
Medicaid,
Healthy
Families or
Private
Insurance
Healthcare
Coverage:
Medicaid,
Healthy
Families or
Private
Insurance

Healthcare
Coverage:
Medicaid,
Healthy
Families or
Private
Insurance

Independent Variable(s)

Statistical Test

P-value

Age

Independent
sample t test

= .004

Ethnicity

Chi-square test

= .011

Ethnicity,
Chi-square test
Citizenship/Immigration
Status

= .001

21

CHAPTER 4
DISCUSSION
The purpose of this study was to examine the factors affecting adult pregnant
womens access to reproductive health care in regard to age, ethnicity, and citizenship.
The following hypotheses were proposed in this study: (1) Adult pregnant women of
have low access to the following healthcare: Medicaid, Healthy Families and private
insurance. (2) Adult pregnant Hispanic women are more likely to access health care via
Medicaid and Healthy Families than private insurance. (3) Undocumented pregnant
Hispanic women of are more likely to report low access to Medicaid, Healthy Families
and private insurance than Hispanic women who are citizens and permanent residents.
The results of the independent sample t test performed utilizing age as the
independent variable and health care coverage as the dependent variable found a
statistically significant relationship between the two variables. The mean age of women
who reported they did not have health insurance was younger than those women who
reported they had insurance. The results indicate that adult pregnant women are less
likely to have health insurance at a younger age and are therefore less likely to use
reproductive health care services. The decline in use of reproductive health services
among young women between 2002 and 2008 (Hall et al., 2012) indicates inadequate use
of health services that could potentially lead to negative health outcomes among a
disadvantaged population. While there has been a decline in the adolescent birth rate in
the United States (Chabot et al., 2014), it is vital that barriers faced by young women of
22

reproductive age to access reproductive health services are addressed in order to allow
this population to become knowledgeable and active participants in their reproductive
health management. The expansion of programs such as family planning and other
reproductive services not related to pregnancy can be a positive effect in addressing other
health disparities by increasing access to preventive care services.
The second hypothesis proposed in this study utilized a chi-square test to analyze
the relationship between ethnicity and health care coverage. The results of the chi-square
test showed a statistically significant relationship between ethnicity and access to health
care coverage through public assistance programs. The test supports the hypothesis that
adult pregnant Hispanic women are more likely to access health care through Medicaid
and Healthy Families than private of employer-based insurance. The rapidly increasing
Hispanic population is in need of increased access to reproductive health services (Wingo
et al., 2009). A study by Wingo et al. (2009) shows that Hispanic women of reproductive
age are less likely to use contraception than non-Hispanic White women. By increasing
access to reproductive health, disparities in health experienced by Hispanic women of
reproductive age can be reduced. Public assistance programs such as Medicaid play a
key role in increasing access to reproductive healthcare for disadvantaged populations,
including Hispanic women. Medicaid is now more readily available to previously
ineligible populations due to the implementation of the PPACA. This expansion not only
increases access to reproductive health services, but also increases the quality of the
coverage (Sonfield & Pollack, 2013).
This study also analyzed the relationship between ethnicity, citizenship status and
healthcare coverage. A chi-square test was performed and showed a statistically
23

significant relationship between the variables. Undocumented Hispanic women are less
likely to have health care coverage than Hispanic women who are permanent residents or
citizens. This is another example of health disparities experienced by a disadvantaged
population. Hispanic undocumented immigrants face barriers in accessing health care
through the public health care system (Natavio, 2013). These barriers include cost,
language differences, and poor service quality (Betancourt et al., 2013). Undocumented
Hispanic women have limited access to Medicaid and are sometimes unable to access
comprehensive health services, including reproductive health services, when compared to
permanent residents and U.S. citizens (Ostrach, 2013).
Although the results show statistically significant relationships between the
variables discussed in each of the hypotheses, the study is limited to the data that was
publicly available in 2012. Future studies should reevaluate these findings using current
surveys. Another limitation of this study was the sample size. The small sample size
restricts the ability to apply the findings to a larger population.
Literature suggests that pregnant womens access to health care is affected by
factors such as age, ethnicity and citizenship status. Public assistance programs such as
Medicaid and healthy Families are very important in addressing access to reproductive
health care. With no resources at their disposal, adult pregnant women are more
susceptible to suffer health disparities than can endanger the health of both mother and
child. This study shows that increasing access to quality reproductive health care is vital
in addressing health care disparities among pregnant women of a particular age, ethnicity
and citizenship.

24

REFERENCES

25

REFERENCES
Betancourt, G. S., Colarossi, L., & Perez, A. (2013). Factors associated with sexual and
reproductive health care by Mexican immigrant women in New York City: A
mixed method study. Journal of Immigrant and Minority Health, 15(2), 326-333.
Bustreo, F., de Zoysa, I., & de Carvalho, I. A. (2013). Policy directions to improve
women's health beyond reproduction. World Health Organization: Bulletin of the
World Health Organization, 91(9), 712-4.
Chabot, M. J., Navarro, S., Swann, D., Darney, P., & de Bocanegra, H. T. (2014).
Association of access to publicly funded family planning services with adolescent
birthrates in California counties. American Journal of Public Health, 104(1), E1E6.
Dave, D. M., Decker, S. L., Kaestner, R., & Simon, K. I. (2011). The effect of medicaid
expansions on the health insurance coverage of pregnant women: An analysis
using deliveries. Inquiry - Excellus Health Plan, 47(4), 315-30.
Espinoza, R., Martnez, I., Levin, M., Rodriguez, A., Chan, T., Goldenberg, S., & Ziga,
M. L. (2014). Cultural perceptions and negotiations surrounding sexual and
reproductive health among migrant and non-migrant indigenous Mexican women
from Yucatn, Mexico. Journal of Immigrant and Minority Health, 16(3), 356-64.
Frost, J. J. (2008). Trends in US women's use of sexual and reproductive health
care services, 1995-2002. American Journal of Public Health, 98(10), 1814-7.
Hall, K. S., Fendrick, A. M., Zochowski, M., & Dalton, V. K. (2014). Women's health
and the Affordable Care Act: High hopes versus harsh realities? American
Journal of Public Health, 104(8), e10-3.
Hall, K. S., Moreau, C., & Trussell, J. (2012). Determinants of and disparities in
reproductive health service use among adolescent and young adult women in the
United States, 2002-2008. American Journal of Public Health, 102(2), 359-67.
Huesch, M. (2011). Association between type of health insurance and elective cesarean
deliveries: New Jersey, 2004-2007. American Journal of Public Health, 101(11),
e1-7.
Natavio, M. (2013). The provision of comprehensive reproductive health services in Los
Angeles: A physician's perspective. American Journal of Public Health, 103(4),
596-598.
26

Ostrach, B. (2013). "Yo no saba..."--Immigrant women's use of national health systems


for reproductive and abortion care. Journal of Immigrant and Minority
Health, 15(2), 262-272.
Quelopana, A. M., & Alcalde, C. (2014). Exploring knowledge, belief and experiences in
sexual and reproductive health in immigrant hispanic women. Journal of
Immigrant and Minority Health, 16(5), 1001-6.
Sanchez-Birkhead, A., Kennedy, H. P., Callister, L. C., & Miyamoto, T. P. (2011).
Navigating a new health culture: Experiences of immigrant Hispanic
women. Journal of Immigrant and Minority Health, 13(6), 1168-74.
Sonfield, A., & Pollack, H. A. (2013). The Affordable Care Act and reproductive health:
Potential gains and serious challenges. Journal of Health Politics, Policy and
Law, 38(2), 373-391.
UCLA Center for Health Policy (2012). California Health Interview Survey.
Watts, L. A., de Bocanegra, H. T., Darney, P. D., Hulett, D., Howell, M., Mikanda, J., . . .
Policar, M. S. (2012). In a California program, quality and utilization reports on
reproductive health services spurred providers to change. Health Affairs, 31(4),
852-62.
Wherry, L. R. (2013). Medicaid family planning expansions and related preventive
care. American Journal of Public Health, 103(9), 1577-1578.
Wingo, P. A., Kulkarni, A., Borrud, L. G., McDonald, J. A., Villalobos, S. A., & Green,
D. C. (2009). Health disparities among Mexican American women aged 15-44
years: National Health and Nutrition Examination Survey, 1999-2004. American
Journal of Public Health, 99(7), 1300-7.

27