Written by Rasha A. Al-Lami
As a mother, physician and immigrant to the U.S. who has suffered the painful journey of family separation, I aim to highlight the neglected aspects of reproductive health and rights of immigrants (including legal immigrants). Having witnessed some of the below mentioned struggles, I am able to voice the forgotten suffering of immigrants during their reproductive years. As a physician, I am calling for broader health care professionals to advocate for the reproductive rights of immigrants.

More than 13% of the U.S. population are foreign-born individuals with almost half of immigrant women within their reproductive age (15-44 years).¹ Among all children born in the U.S., 23% are born to immigrant mothers and 6% born to undocumented immigrants.¹ Immigrants face a myriad of challenges that can impact their reproductive health. To date, the existing literature has mainly focused on the limited usage of, or access to, healthcare among immigrants ^2,3, and neglected some of the challenges of immigrants’ reproductive health that will be discussed here.

Immigrants may lose years of their reproductive lives given their immigration journey

The challenging immigration process and changing politics may cost immigrants years of uncertainty or temporary living circumstances before they finally settle in the U.S. Recently, the number of backlogged cases at the U.S. Citizenship and Immigration Services (USCIS) and immigration courts approached tens of millions of cases with some cases pending for over a decade.^4,5. Advanced age is one of the key factors associated with infertility. Thus, it is possible that immigrants may reach their extreme reproductive age and face infertility after being impacted by long-standing immigration uncertainty.⁶  Moreover, studies that tend to evaluate the impact of time-to-settlement on building or expanding families among immigrants are lacking and therefore, it is important to conduct further research to study the impact of the volatile immigration policies on the fertility rate of immigrants in the U.S.¹

The trauma of family separation impacts reproductive choices and trust in the U.S. healthcare system

The Trump administration implemented a “zero tolerance” policy that forcefully separated children from their families as a way to prosecute adults crossing the U.S. borders illegally.^7,8 Although this policy ended in 2018, reports are still documenting minor children who are being separated from their families at the U.S. borders.⁸ U.S.-born children of immigrant parents were reported to be forcefully taken from their parents at the detention centers.⁹ Trauma from family separation at the U.S. borders was shown to rise to the level of torture as defined by a U.N. convention according to a study conducted by the Physicians for Human Rights.¹⁰

Even for those who arrive legally in the U.S., the waiting times to finalize petitions at the USCIS for family union has led to extended family separations. This trauma was shown to have protracted effects that could last to adulthood and result in lower academic and functional achievements among children separated from their families. ¹¹

Further, such trauma may cause immigrants to lose their trust in governmental entities which could affect their trust in health care providers. For instance, immigrants may try to avoid mentioning their trauma to their health care providers for fear of retaliation or social stigma or may avoid seeking medical care altogether.¹² Whether the trauma of family separation affects immigrants’ choice to expand their families in the U.S. is still unclear. There exists a need to synthesize a body of evidence on the impact of family separation due to the immigration processes on immigrants’ reproductive choices and their trust in the U.S. healthcare system.

Immigrants’ reproductive rights are often threatened

There is a general notion that arriving immigrants can boost the fertility rate of the U.S., despite the statistical evidence that often proves otherwise. ¹³ U.S. news outlets have discussed increasing the admission of immigrants in the face of a low fertility rate. ^13,14  On the other hand, immigrants’ autonomy is questioned when it comes to their reproductive rights. This is evidenced by reports from detention centers at the U.S. borders where the immigrants have been sterilized or undergone hysterectomies without their consent.¹⁵ Forced sterilization has been globally documented as part of what is known as “stratified reproduction” where vulnerable women (e.g., poor, incarcerated, immigrants, undocumented or indigenous) are not given full autonomy and their reproduction is seen as problematic or undeserving.¹⁵ These two extreme scenarios (favoring immigrants to boost fertility rate of the country vs limiting immigrants’ fertility choices) raise questions about immigrants’ autonomy related to their reproductive health.

From the lens of reproductive endocrinology and infertility, the above-mentioned aspects of immigrants’ reproductive health has been neglected and there exists a critical need to study their impact on immigrants’ reproductive choices. All of these challenges may foster a state of fear among immigrants and could hamper their utilization of the U.S. healthcare system. The Reproductive Justice framework of 1994 states that all people have a fundamental right to bodily autonomy, to have children, to not have children, and to parent the children they have in safe and sustainable communities¹⁶. Immigrants of the U.S., whether legal or undocumented, are enduring circumstances that are in violation of the Reproductive Justice framework. Health professionals, among other community leaders, are uniquely positioned to take actions to advocate for immigrants and to negotiate with policy makers to advance immigrants’ sexual and reproductive rights, especially in area of politics and challenging immigration policies in the U.S. Such actions have the potential to change the trajectory and assure reproductive rights in the U.S. that can extend for generations to come.

References:

1. Health Care for Immigrants: ACOG Committee Statement No. 4. Obstet Gynecol. Feb 1 2023;141(2):e427-e433. doi:10.1097/aog.0000000000005061
2. Tapales A, Douglas-Hall A, Whitehead H. The sexual and reproductive health of foreign-born women in the United States. Contraception. Jul 2018;98(1):47-51. doi:10.1016/j.contraception.2018.02.003
3. Hasstedt K, Desai S, Ansari-Thomas Z. Immigrant Women’s Access to Sexual and Reproductive Health Coverage and Care in the United States. Issue Brief (Commonw Fund). Nov 1 2018;2018:1-10.
4. Backlog of Pending Cases in Immigration Courts as of Jan 2023. Accessed March, 2023. https://trac.syr.edu/phptools/immigration/court_backlog/apprep_backlog.php
5. Bier D. Processing Backlogs in the U.S. Immigration System: Describing the Scale of the Problem. Accessed 2023, 2023. https://www.cato.org/briefing-paper/processing-backlogs-us-immigration-system-describing-scale-problem
6. Carson SA, Kallen AN. Diagnosis and Management of Infertility: A Review. JAMA. 2021;326(1):65-76. doi:10.1001/jama.2021.4788
7. U.S. border agents are separating migrant children from their parents to avoid overcrowding, inspector finds. 2024. https://www.cbsnews.com/news/migrant-children-separated-parents-u-s-border-agents-overcrowding/#:~:text=Under%20the%20%22zero%20tolerance%22%20policy,uproar%20and%20a%20court%20ruling.
8. Children Are Still Being Separated from Their Families at the Border. 2024. https://www.vera.org/news/children-are-still-being-separated-from-their-families-at-the-border
9. U.S.-Born Children, Too, Were Separated From Parents at the Border. 2024. https://www.nytimes.com/2023/04/11/us/migrant-family-separations-citizens.html
10. Trump’s border separations left children, parents with severe trauma, study finds. 2024. https://www.nbcnews.com/news/latino/new-study-finds-severe-trauma-children-parents-separated-border-rcna7287
11. Hampton K, Raker E, Habbach H, Camaj Deda L, Heisler M, Mishori R. The psychological effects of forced family separation on asylum-seeking children and parents at the US-Mexico border: A qualitative analysis of medico-legal documents. PLoS One. 2021;16(11):e0259576. doi:10.1371/journal.pone.0259576
12. Stutz M, Rivas-Lopez V, Lonquich B, Baig AA. Health Repercussions of a Culture of Fear Within Undocumented Immigrant Communities. J Gen Intern Med. Sep 2019;34(9):1903-1905. doi:10.1007/s11606-019-05161-w
13. Camarota S, Zeigler K. Fertility Among Immigrants and Native-Born Americans.Difference between the foreign-born and the native-born continues to narrow. Accessed March, 2023. https://cis.org/Report/Fertility-Among-Immigrants-and-NativeBorn-Americans
14. Frey W. New census estimates show a tepid rise in U.S. population growth, buoyed by immigration. Accessed March, 2023. https://www.brookings.edu/research/new-census-estimates-show-a-tepid-rise-in-u-s-population-growth-buoyed-by-immigration/
15. Sullivan MM, Matache M, Peisch S, Bhabha J. Reproductive healthcare in immigration detention: The imperative of informed consent. The Lancet Regional Health – Americas. 2022;10doi:10.1016/j.lana.2022.100211
16. ‘We Are Grabbing Our Own Microphones’: How Advocates of Reproductive Justice Stepped Into the Spotlight. 2024. https://time.com/5735432/reproductive-justice-groups/