Table 2.

Summary of Studies Examining Undocumented Status as a Predictor of Adverse Pregnancy and/or Birth Outcomes

First author, year	Population comparison	Outcomes measured	Undocumented outcome association	Strengths	Limitations
Birth outcomes
Dang, 2011	TX CHIP Perinatal users with unknown race/ethnicity and country of origin compared with all TX Medicaid users	LBWa	↓	• Large sample size • Inclusive of a vulnerable population	• Inadequate covariate adjustment; race/ethnicity of population using CHIP Prenatal unknown • Emergency Medicaid imperfect proxy for documentation status • Complete case analyses with known differential missingness of outcome data (31% for CHIP prenatal, 10% for Medicaid)
		PTBb	↓
Flores, 2012	UT foreign-born Latinas without SSNs compared with foreign-born Latinas with SSNs; 81% of Mexican origin	LBWa	◦	• Includes relevant covariates • Utilized a census of Utah births • Appropriate ascertainment of documentation status	• Covariate selection strategy not well justified; adjusted for factors that may be mechanisms through which documentation status affects health
		PTBb	↓
		SGAc	↑d
Geltman, 1999	MA self-reported documented and undocumented foreign-born women from a variety of countries (predominantly Haiti) compared with U.S.-born women	Birthweight (g)	U.S.-born < undocumented foreign-born < documented foreign-born	• Explicit measure of documentation status • Short time period between outcome occurrence and data collection.	• Selection bias (consecutive sampling; women not interviewed when interpreter unavailable) • Time period not disclosed • Inadequate covariate adjustment; race/ethnicity unknown • Linear examination of continuous birthweight
		Gestational age (weeks)	U.S.-born < undocumented foreign-born and documented foreign-born
Joyce, 2001	CA, TX, and NY foreign-born and U.S.-born insured and uninsured Latinas before and after PRWORA	Change in LBWa post-PRWORA	↑e	• Strong pre–post policy design • Extensive covariate adjustment • Census of all births in study locations during study periods, with the exception of those with missing data	• Weak proxy for undocumented status • Some of the covariates (e.g., smoking illicit drugs) poorly represented on vital records; may introduce more bias than they correct for
Kalofonos, 1999	CA foreign-born Latinas without SSNs compared with foreign-born and U.S.-born Latinas with SSNs; all Mexican	LBWa	◦	• Mixed methods; included medically under-served • Variables abstracted from medical records (not self-report) • Explicit measure of documentation status available for some	• Small sample size • Selection bias: LBW estimates are based on a sample in which all women with limited prenatal care were included but only a random sample of women with adequate prenatal care • Some covariates included in adjusted model may be mechanisms through which documentation status affects health
Kelaher, 2002	NY foreign-born Latinas without SSNs or residency cards compared with U.S.-born Latinas; predominantly Dominican Republic country of origin	LBWa	◦	• Proxy measure for documentation status developed/employed in prior research • Large sample size • Country of origin considered (but not in relation to documentation status)	• Previous low-birth-weight birth outcome may introduce sample selection • Possible misclassification of documentation status (by use of proxy measure) • Data come from prenatal service data source, therefore women not receiving prenatal care are not represented in research
Birth and pregnancy outcomes
Reed, 2005	CO Emergency Medicaid users of predominantly Mexican origin compared with Medicaid users of unknown race/ethnicity	LBWa	↓	• Considered wide range of pregnancy outcomes • Included behavioral mediators of pregnancy outcomes (smoking, drinking) • Statewide cohort of undocumented women	• Emergency Medicaid as imperfect proxy for documentation status • 14% of claims files that did not match a birth record or matched multiple records • Results generalizable to singletons • Complete case analyses
		PTBb	↓
		Cesarean delivery	◦
		Complications of deliveryf	↑
		Abnormal conditions of newborng	↑
Pregnancy outcomes
Chavez, 1986	CA self-reported undocumented compared with documented foreign-born women; all of Mexican origin	Cesarean delivery	↓	• Recruitment tactics optimized to achieve representative sample of undocumented people • Well-defined measure of documentation status • In-depth interviews resulted in both quantitative and qualitative data	• Potential selection bias: sample dependent on snowball sampling “seed” or initial interview • Small sample size • Unadjusted proportions and chi-square tests presented; no adjustment for potential confounding
Kuo, 2004	NY, CA, and FL self-reported undocumented compared with documented foreign-born Hispanic women; predominantly Cuban and Mexican origin	Postpartum depressionh	↑d	• Explicit measure of documentation status developed in consultation with legal professionals • Considered nonbirth pregnancy outcome • Large sample size	• Descriptive statistics suggest differences across recruitment sites; however, analyses do not account for clustering by site • Some covariates included in the adjusted model may be mechanisms through which documentation status affects health • CESD depression definition (cut points) not adjusted for factors that may be a function of having recently delivered a live birth)

◦ No association; Significant negative ↓ or positive ↑ association.

^a<2500 g with the exception of Kalofonos (<3000 g).

^b<37 Weeks.

^c<10th Percentile of birthweight for gestational age and sex.

^dSignificant before adjustment.

^eOnly significant for NYC Other Latinas.

^fIncludes meconium staining, excessive bleeding, premature rupture, precipitous labor, malpresentation, cord prolapse, and fetal distress.

^gIncludes infant anemia, birth injury, fetal alcohol syndrome, hyaline membrane disease, seizures, and requirements for assisted ventilation.

^hCES-D ≥ 16.

CHIP, Children's Health Insurance Program; CI, confidence interval; GWG, gestational weight gain; LBW, low birthweight; OR, odds ratio; PRWORA, Personal Responsibility and Work Opportunity Reconciliation Act; PTB, preterm birth; SGA, small for gestational age.