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 women’s

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

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 Copyright 2015

Claudia M. Castro

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 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....................................................................................................... v

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

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

CHAPTER

1. INTRODUCTION ............................................................................................ 1

Access to Reproductive Health Care Services .......................................... 3

Cultural/Ethnic Influence and Socioeconomic Factors ............................. 6

2. METHODOLOGY ........................................................................................... 9

Overview of CHIS Database ..................................................................... 9

Participants ................................................................................................ 10
Present Study ............................................................................................. 11
Analysis...................................................................................................... 14

3. RESULTS ....................................................................................................... 16

Descriptive Statistics ................................................................................. 16

Hypothesis Testing .................................................................................... 19

4. DISCUSSION ................................................................................................... 22

REFERENCES ............................................................................................................ 25

iv  
 LIST OF TABLES

TABLE Page

1. Analysis Summary .............................................................................................. 14

2. Results ........................................................................................................ 20

v  
 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

Women’s 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 California’s 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 women’s 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 California’s 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 PPACA’s 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 women’s 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 women’s 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 woman’s 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.

5
 Not only must access to reproductive health be aimed at the population of low-

income 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 spouse’s employment (Espinoza et

al., 2014). This particular access point to reproductive services falls under gender

7
structures that affect a woman’s ability to choose and make decisions regarding her own

reproductive health (Espinoza et al., 2014). This imbalance of gender power can shape

women’s 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 women’s 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

women’s 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) 2011-

2012 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 California’s 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 study’s focus in regard to women’s 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 study’s focus in regard to

women’s 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 participant’s 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 chi-

square 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 participant’s 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 Dependent Independent Variable(s) Statistical Test

Variable
1. Adult pregnant Healthcare Age Independent
women have low Coverage: sample t test
access to Medicaid, Healthy
reproductive health Families or Private
care coverage Insurance
2. Adult pregnant Healthcare Ethnicity Chi-square test
Hispanic women Coverage:
are more likely to Medicaid, Healthy
access reproductive Families or Private
health care via Insurance
public assistance
programs such as
Medicaid than
other sources of
health care
coverage
3. Undocumented Healthcare Ethnicity, Chi-square test
adult pregnant Coverage: Citizenship/Immigration
Hispanic women Medicaid, Healthy Status
are more likely to Families or Private
report low access to Insurance
health care
coverage than
Hispanic women
who are citizens or
permanent
residents

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   Asian  

4%   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  

35  
Numer  of  Participants  
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 (χ2  (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 (χ2  (6, N = 91) = 195, p = .001).

20
TABLE 2. RESULTS

Hypothesis Dependent Independent Variable(s) Statistical Test P-value

Variable
1. Adult Healthcare Age Independent = .004
pregnant women Coverage: sample t test
have low access Medicaid,
to reproductive Healthy
health care Families or
coverage Private
Insurance
2. Adult Healthcare Ethnicity Chi-square test = .011
pregnant Coverage:
Hispanic women Medicaid,
are more likely Healthy
to access Families or
reproductive Private
health care via Insurance
public assistance
programs such as
Medicaid than
other sources of
health care
coverage
3. Healthcare Ethnicity, Chi-square test = .001
Undocumented Coverage: Citizenship/Immigration
adult pregnant Medicaid, Status
Hispanic women Healthy
are more likely Families or
to report low Private
access to health Insurance
care coverage
than Hispanic
women who are
citizens or
permanent
residents

21
 CHAPTER 4

DISCUSSION

The purpose of this study was to examine the factors affecting adult pregnant

women’s 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 women’s 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.

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25
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