Everyday Violence: Immigration Enforcement, COVID-19, and Depression among Undocumented Young Adults in California.

Background: The immigration enforcement system has significant effects on the health of immigrants, their families, and society. Exposure to the immigration enforcement system is linked to adverse mental health outcomes, which may have been exacerbated by sustained immigration enforcement activities during the COVID-19 pandemic. Objectives: This study was conducted to investigate the association between exposure to immigration enforcement and the mental health of undocumented young adults in California during the COVID-19 pandemic. Methods: Data are from the COVID-19 BRAVE (Building Community Raising All Immigrant Voices for Health Equity) Study, a community-engaged cross-sectional survey of the impacts of the COVID-19 pandemic on undocumented immigrants in California. A total of 366 undocumented immigrants between 18 and 39 years of age completed the online survey, which was conducted between September 2020 and February 2021. Multivariable logistic regression models were fit to examine the association between immigration enforcement exposure and depression. Results: Almost all participants (91.4%) disclosed exposure to the immigration enforcement system, with most reporting an average of 3.52 (SD=2.06) experiences. Multivariate analyses revealed that an increase in the immigration enforcement exposure score was significantly associated with higher odds of depression (adjusted odds ratio [aOR]=1.24; 95% confidence interval [CI]: 1.10, 1.40), and women were 92% more likely to report depression than were men (aOR=1.92; 95% CI: 1.12, 3.31). Those who reported deportation fears were significantly more likely to be depressed (aOR=1.24; 95% CI: 1.10, 1.40). Conclusions: Researchers should consider the mental health implications of a punitive immigration enforcement system, and policymakers should examine the impacts of immigration policies on local communities.

Integrating support persons into maternity care and associations with quality of care: a postpartum survey of mothers and support persons in Kenya.

BACKGROUND: Despite research that has shown that the presence of support persons during maternity care is associated with more respectful care, support persons are frequently excluded due to facility practices or negative attitudes of providers. Little quantitative research has examined how integrating support persons in maternity care has implications for the quality of care received by women, a potential pathway for improving maternal and neonatal health outcomes. This study aimed to investigate how integrating support persons in maternity care is associated with multiple dimensions of the quality of maternity care. METHODS: We used facility-based cross-sectional survey data from women (n = 1,138) who gave birth at six high-volume facilities in Nairobi and Kiambu counties in Kenya and their support persons (n = 606) present during the immediate postpartum period. Integration was measured by the Person-Centered Integration of Support Persons (PC-ISP) items. We investigated quality of care outcomes including person-centered care outcomes (i.e., Person-Centered Maternity Care (PCMC) and Satisfaction with care) and clinical outcomes (i.e., Implementation of WHO-recommended clinical practices). We used fractional regression with robust standard errors to estimate associations between PC-ISP and care outcomes. RESULTS: Compared to low integration, high integration (≥four woman-reported PC-ISP experiences vs. <4) was associated with multiple dimensions of quality care: 3.71%-point (95% CI: 2.95%, 4.46%) higher PCMC scores, 2.76%-point higher (95% CI: 1.86%, 3.65%) satisfaction with care scores, and 4.43%-point (95% CI: 3.52%, 5.34%) higher key clinical practices, controlling for covariates. PC-ISP indicators related to communication with providers showed stronger associations with quality of care compared to other PC-ISP sub-constructs. Some support person-reported PC-ISP experiences were positively associated with women's satisfaction and key practices. CONCLUSIONS: Integrating support persons, as key advocates for women, is important for respectful maternity care. Practices to better integrate support persons, especially improving communication between support persons with providers, can potentially improve the person-centered and clinical quality of maternity care in Kenya and other low-resource settings.

The "disproportionate costs" of immigrant policy on the health of Latinx and Asian immigrants.

There is growing evidence that Asian and Latinx immigrants' health and health care access is shaped by immigrant policies that determine their rights, protections, and access to resources and the extent to which they are targeted by policing or deportation based on citizenship/legal status and other immigration-related social categories. However, there is limited population-based evidence of how immigrants experience the direct consequences of policies, nor of the impact of such consequences on their health. Between 2018 and 2020, we conducted the Research on Immigrant Health and State Policy (RIGHTS) Study, developing a population-based survey of Asian and Latinx immigrants in California (n = 2010) that measured 23 exclusionary experiences under health care and social services, education, labor/employment, and immigration enforcement policies. Applying Ruth Wilson Gilmore's concept of "disproportionate costs," we conducted a latent class analysis (LCA) and regression models of the RIGHTS data to 1) describe patterns of immigrant policy exclusion experienced by Asian and Latinx immigrants and 2) test relationships between patterns of policy exclusion and health care access and health status. LCA analyses identified 6 classes of distinct combinations of policy exclusions. In regression analyses, respondents in the class with cumulative exclusions across all policy sectors had the worst health care access and highest level of psychological distress, but the best self-rated health; while those in the class with employment and enforcement exclusions also had poor health care access. Respondents in the other 3 classes experienced combinations of health and social services exclusions, but these alone were not associated with worse outcomes. Findings show that the consequences of immigrant policies harm health through both cumulative exposure to and intersections of exclusions across policy sectors. Labor/employment and immigration enforcement policies, specifically, likely drive health inequities within immigrant populations. The RIGHTS study highlights the need to measure the cumulative and intersecting "disproportionate costs" of immigrant policy within diverse immigrant populations.

Person-centered abortion care scale: Validation for medication abortion in the United States.

OBJECTIVE: Medication abortions now make up the majority of abortions in the US, with new service delivery models such as telehealth; however, it is unclear how this may impact patient experiences. The objective of the study is to adapt and validate a person-centered abortion care (PCAC) scale for medication abortions that was developed in a global South context (Kenya) for use in the United States. STUDY DESIGN: This study includes medication abortion patients from a hospital-based clinic who had one of two modes of service delivery: (1) telemedicine with no physical exam or ultrasound; or (2) in-person with clinic-based exams and ultrasounds. We conducted a sequential approach to scale development including: (1) defining constructs and item generation; (2) expert reviews; (3) cognitive interviews (n = 12); (4) survey development and online survey data collection (N = 182, including 45 telemedicine patients and 137 in-person patients); and (5) psychometric analyses. RESULTS: Exploratory factor analyses identified 29-items for the US-PCAC scale with three subscales: (1) Respect and Dignity (10 items), (2) Responsive and Supportive Care (nine items for the full scale, one additional mode-specific item each for in-person and telemedicine), and (3) Communication and Autonomy (10 items for the full scale, one additional item for telemedicine). The US-PCAC had high content, construct, and criterion validity. It also had high reliability, with a standardized alpha for the full 29-item US-PCAC scale of 0.95. The US-PCAC score was associated with overall satisfaction. CONCLUSION: This study found high validity and reliability of a newly-developed person-centered abortion care scale for use in the US. As medication abortion provision expands, this scale can be used in quality improvement efforts. IMPLICATIONS: This study found high validity and reliability of a newly-developed person-centered care scale for use in the United States for in-person and telemedicine medication abortion.

Navigating a climate of administrative burden: the perspectives of young adult undocumented immigrants in applying for COVID-19 disaster relief assistance for immigrants in California.

Undocumented immigrants experienced high levels of economic insecurity during the COVID-19 pandemic while being excluded from government-based relief and unemployment benefits. In April 2020, California became the first state to offer financial aid to undocumented immigrants through the innovative Disaster Relief Assistance for Immigrants (DRAI) program in collaboration with several community-based organizations (CBOs). However, the process of applying for aid was marked by many implementation challenges, such as intake and language access; however, little data exists on the direct experiences of the undocumented community. This qualitative study examines the experiences of undocumented Asian and Latinx young adults living in California in applying for DRAI through framework of administrative burden. Themes distilled from participant experiences highlight how administrative burden via learning, psychological, and compliance costs shape the ways in which undocumented immigrants navigate policies and programs, such as DRAI. These experiences highlight the need for policymakers to address structural and programmatic administrative burdens in policy development; failure to do so result in detrimental impacts that outweigh financial benefits or cause communities to forgo needed resources.

Intimate partner violence and postpartum healthcare access in Kenya: a cross-sectional study.

BACKGROUND: Intimate partner violence (IPV) impacts physical health, mental health, and healthcare use. IPV during pregnancy, in particular, is associated with lower rates of antenatal care, but no studies have assessed the association between IPV and postpartum healthcare. This study aims to examine the link between IPV (emotional, physical, and sexual) and two outcomes: postpartum healthcare use and access to family planning. METHODS: This study uses data from a cross-sectional survey of 859 women in Nairobi and Kiambu counties in Kenya who gave birth during the COVID-19 pandemic in 2020. RESULTS: In this sample, 36% of women reported ever experiencing IPV. Of those, 33% indicated the frequency of IPV stayed the same or increased during COVID-19. Nearly 17% of women avoided postpartum healthcare and 10% experienced issues accessing family planning. Those who experienced any form of IPV during pregnancy had approximately twice the odds of avoiding postpartum healthcare compared to those who did not experience any form of IPV. Compared to those who did not experience IPV during pregnancy, experiencing sexual IPV was associated with 2.25 times higher odds of reporting issues accessing family planning. Additionally, reporting fair or poor self-rated health was associated with both avoiding postpartum healthcare and reporting issues accessing family planning. Experiencing food insecurity was also associated with avoiding postpartum healthcare. CONCLUSIONS: To our knowledge, this is the first study to establish the link between IPV during pregnancy and postpartum healthcare access. During COVID-19 in Kenya, postpartum women who had experienced IPV were at increased risk of disengagement with healthcare services. Women should be screened for IPV during pregnancy and postpartum in order to better support their healthcare needs. In times of crisis, such as pandemics, policymakers and healthcare providers must address barriers to healthcare for postpartum women.

"It is not by choice that I gave birth at home": the social determinants of home births during COVID-19 in peri-urban and urban Kenya, a qualitative study.

BACKGROUND: The COVID-19 pandemic significantly impacted the provision of global maternal health services, with an increase in home births. However, there are little data on women's decision-making and experiences leading up to home births during the pandemic. The objective of this study is to examine the economic, social, and health system factors associated with home births in Kenya. METHODS: Community health volunteers (CHVs) and village leaders helped identify potential participants for an in-depth, one-on-one, qualitative telephone interview in Nairobi and Kiambu County in Kenya. In total, the study interviewed 28 mothers who had home births. RESULTS: This study identified a number of economic, social, neighborhood, and health system factors that were associated with birthing at home during the COVID-19 pandemic. Only one woman had planned on birthing at home, while all other participants described various reasons they had to birth at home. Themes related to home births during the pandemic included: (1) unmet preferences related to location of birth; (2) burdens and fear of contracting COVID-19 leading to delayed or missed care; (3) lack of perceived community safety and fear of encounters with law enforcement; and (4) healthcare system changes and uncertainty that led to home births. CONCLUSION: Addressing and recognizing women's social determinants of health is critical to ensuring that preferences on location of birth are met.

Access to support during childbirth?: women's preferences and experiences of support person integration in a cross-sectional facility-based survey.

BACKGROUND: Integrating support persons into maternity care, such as making them feel welcome or providing them with information, is positioned to increase support for women and improve birth outcomes. Little quantitative research has examined what support women need and how the healthcare system currently facilitates support for women. We introduce the Person-Centered Integration of Support Persons (PC-ISP) concept, based on a review of the literature and propose four PC-ISP domains-Welcoming environment, Decision-making support, Provision of information and education and Ability to ask questions and express concerns. We report on women's preferences and experiences of PC-ISP. METHODS: We developed PC-ISP measures based on the literature and applied these in a facility-based survey with 1,138 women after childbirth in six health facilities in Nairobi and Kiambu counties in Kenya from September 2019 to January 2020. RESULTS: We found an unmet need for integrating support persons during childbirth. Between 73.6 and 93.6% of women preferred integration of support persons during maternity care, but only 45.3-77.9% reported to have experienced integration. Women who reported having a male partner support person reported more PC-ISP experiences (B0.13; 95% CI 0.02, 0.23) than those without. Employed women were more likely to report having the opportunity to consult support persons on decisions (aOR1.26; 95% CI 1.07, 1.50) and report that providers asked if support persons should be informed about their condition and care (aOR1.29; 95% CI 1.07, 1.55). Women with more providers attending birth were more likely to report opportunities to consult support persons on decisions (aOR1.53; 95% CI 1.09, 2.15) and that support persons were welcome to ask questions (aOR1.84, 95% CI 1.07, 2.54). CONCLUSIONS: Greater efforts to integrate support persons for specific roles, including decision-making support, bridging communication and advocacy, are needed to meet women's needs for support in maternity care.

Maternity Care at the Intersections of Language, Ethnicity, and Immigration Status: A Qualitative Study.

INTRODUCTION: Women of color and immigrant women are more likely than US-born White women to report mistreatment and poor quality of care during their reproductive health care. Surprisingly little research exists on how language access may impact immigrant women's experiences of maternity care, particularly by race and ethnicity. METHODS: We conducted qualitative in-depth, one-on-one semi-structured interviews from August 2018 to August 2019 with 10 Mexican and eight Chinese/Taiwanese women (n = 18) living in Los Angeles or Orange County who gave birth within the past 2 years. Interviews were transcribed and translated, and data were initially coded based on the interview guide questions. We identified patterns and themes using thematic analysis methods. RESULTS: Participants described how a lack of translators and language- and cultural-concordant health care providers and staff impeded their access to maternity care services; in particular, they described barriers to communication with receptionists, providers, and ultrasound technicians. Despite Mexican immigrants' ability to access Spanish-language health care, both Mexican and Chinese immigrant women described how lack of understanding medical concepts and terminology resulted in poor quality of care, lack of informed consent for reproductive procedures, and subsequent psychological and emotional distress. Undocumented women were less likely to report using strategies that leveraged social resources to improve language access and quality care. CONCLUSIONS: Reproductive autonomy cannot be achieved without access to culturally and linguistically appropriate health care. Health care systems should ensure that comprehensive information is given to women, in a language and manner they can understand, with particular attention toward providing in-language services across multiple ethnicities. Multilingual staff and health care providers are critical in providing care that is responsive to immigrant women.

Person-centred sexual and reproductive health: A call for standardized measurement.

Person-centred sexual and reproductive health (PCSRH) care refers to care that is respectful of and responsive to people's preferences, needs, and values, and which empowers them to take charge of their own sexual and reproductive health (SRH). It is an important indicator of SRH rights and quality of care. Despite the recognition of the importance of PCSRH, there is a gap in standardized measurement in some SRH services, as well as a lack of guidance on how similar person-centred care measures could be applied across the SRH continuum. Drawing on validated scales for measuring person-centred family planning, abortion, prenatal and intrapartum care, we propose a set of items that could be validated in future studies to measure PCSRH in a standardized way. A standardized approach to measurement will help highlight gaps across services and facilitate efforts to improve person-centred care across the SRH continuum. PATIENT OR PUBLIC CONTRIBUTION: This viewpoint is based on a review of validated scales that were developed through expert reviews and cognitive interviews with services users and providers across the different SRH services. They provided feedback on the relevance, clarity, and comprehensiveness of the items in each scale.

Can a quality improvement intervention improve person-centred maternity care in Kenya?

Few evidence-based interventions exist to improve person-centred maternity care in low-resource settings. This study aimed to understand whether a quality improvement (QI) intervention could improve person-centred maternity care (PCMC) experiences for women delivering in public health facilities in Kenya. A pre-post design was used to examine changes in PCMC scores across three intervention and matched control facilities at baseline (n = 491) and endline (n = 677). A QI intervention, using the Model for Improvement, was implemented in three public health facilities in Nairobi and Kiambu Counties in Kenya. Difference-in-difference analyses using models that included main effects of both treatment group and survey round was conducted to understand the impact of the intervention on PCMC scores. Findings suggest that intervention facilities' average total PCMC score decreased by 5.3 points post-intervention compared to baseline (95% CI: -8.8, -1.9) and relative to control facilities, holding socio-demographic and facility variables constant. Additionally, the intervention was significantly associated with a 1.8-point decrease in clinical quality index pre-post-intervention (95% CI: -2.9, -0.7), decreased odds of provider visits, and less likelihood to plan to use postpartum family planning. While improving the quality of women's experiences during childbirth is a critical component to ensure comprehensive, high-quality maternity care experiences and outcomes, further research is required to understand which intervention methods may be most appropriate to improve PCMC in resource-constrained settings.

Beyond "Chilling Effects": Latinx and Asian Immigrants' Experiences With Enforcement and Barriers to Health Care.

OBJECTIVES: Immigration enforcement policies are associated with immigrants' barriers to health care. Current evidence suggests that enforcement creates a "chilling effect" in which immigrants avoid care due to fear of encountering enforcement. Yet, there has been little examination of the impact of immigrants' direct encounters with enforcement on health care access. We examined some of the first population-level data on Asian and Latinx immigrants' encounters with law and immigration enforcement and assessed associations with health care access. METHODS: We analyzed the 2018 and 2019 Research on Immigrant Health and State Policy survey in which Asian and Latinx immigrants in California (n=1681) reported on 7 enforcement experiences (eg, racial profiling and deportation). We examined the associations between measures of individual and cumulative enforcement experiences and the usual sources of care and delay in care. RESULTS: Latinx, compared with Asian respondents, reported the highest levels of enforcement experiences. Almost all individual enforcement experiences were associated with delaying care for both groups. Each additional cumulative experience was associated with a delay in care for both groups (OR=1.30, 95% CI 1.10-1.50). There were no associations with the usual source of care. CONCLUSION: Findings confirm that Latinx immigrants experience high levels of encounters with the enforcement system and highlight new data on Asian immigrants' enforcement encounters. Direct experiences with enforcement have a negative relationship with health care access. Findings have implications for health systems to address the needs of immigrants affected by enforcement and for changes to health and immigration policy to ensure immigrants' access to care.

Trust, Care Avoidance, and Care Experiences among Kenyan Women Who Delivered during the COVID-19 Pandemic.

We explore how the COVID-19 pandemic was associated with avoidance of, and challenges with, antenatal, childbirth and postpartum care among women in Kiambu and Nairobi counties, Kenya; and whether this was associated with a report of declined trust in the health system due to the pandemic. Women who delivered between March and November 2020 were invited to participate in a phone survey about their care experiences (n = 1122 respondents). We explored associations between reduced trust and care avoidance, delays and challenges with healthcare seeking, using logistic regression models adjusted for women's characteristics. Approximately half of respondents said their trust in the health care system had declined due to COVID-19 (52.7%, n = 591). Declined trust was associated with higher likelihood of reporting barriers accessing antenatal care (aOR 1.59 [95% CI 1.24, 2.05]), avoiding care for oneself (aOR 2.26 [95% CI 1.59, 3.22]) and for one's infant (aOR 1.77 [95% CI 1.11, 2.83]), and of feeling unsafe accessing care (aOR 1.52 [95% CI 1.19, 1.93]). Since March 2020, emergency services, routine care and immunizations were avoided most often. Primary reported reasons for avoiding care and challenges accessing care were financial barriers and problems accessing the facility. Declined trust in the health care system due to COVID-19 may have affected health care-seeking for women and their children in Kenya, which could have important implications for their health and well-being. Programs and policies should consider targeted special "catch-up" strategies that include trust-building messages and actions for women who deliver during emergencies like the COVID-19 pandemic.

A Qualitative Analysis on Sexual and Reproductive Health Needs and Issues During COVID-19 Using a Reproductive Justice Framework.

The COVID-19 pandemic exacerbated existing health inequities, further exposing the challenges in meeting the sexual and reproductive health (SRH) needs, particularly for Black, Indigenous and People of Color (BIPOC). We interviewed 11 key informants through three focus groups to explore barriers and pathways to SRH care for BIPOC during COVID-19 in the United States. Reimagining reproductive health practices requires holistic practices and multisector pathways, a comprehensive reproductive justice approach. This includes interventions across the sexual and reproductive health continuum. Using a deductive-dominant approach grounded in reproductive justice values, we explore themes around SRH during COVID-19. Five themes for advancing reproductive justice were identified: "supremacy of birth"; police violence as a determinant of SR mental health; addressing quality of care outside of hospital settings; digital redlining; and centering joy, liberation, and humanity.

Association between immigration enforcement encounters and COVID-19 testing and delays in care: a cross-sectional study of undocumented young adult immigrants in california.

BACKGROUND: Undocumented immigrants are expected to face increased risks related to COVID-19 due to marginalizing restrictive immigration policies. However, few studies have assessed the prevalence of direct encounters with the immigration enforcement system among the undocumented and its impacts on their COVID-related health behaviors and outcomes. In this study, we quantify undocumented immigrants' lifetime exposure to various immigration enforcement tactics and their association with delays in COVID-19 testing and healthcare behaviors. METHODS: This cross-sectional study included a non-random sample of 326 Asian and Latinx undocumented immigrants in California from September 2020 to February 2021. The primary exposure was immigration enforcement encounter scores ranging from 0-9, assessed through self-reports of direct experiences with the immigration system, immigration officials, and law enforcement. The main outcomes were positive test for COVID-19, had or suspected having COVID-19, and delayed or avoided testing and/or treatment for COVID-19 due to immigration status. We used multivariable logistic regression models to examine the association between the primary exposure and outcomes of interest. RESULTS: Among 326 participants, 7% had received a positive COVID-19 test result, while 43% reported having or suspected having COVID-19. Almost 13% delayed or avoided COVID-19 testing and/or treatment because of their immigration status. Overall, an increase in immigration enforcement encounters was associated with higher odds of suspecting having had COVID-19 (aOR = 1.13; 95% CI: 1.01,1.26). Reporting an additional enforcement encounter was associated with higher odds of delaying or avoiding testing and/or treatment because of immigration status (aOR = 1.53, 95% CI: 1.26,1.86). Compared to their Latino counterparts, Asian respondents were more likely to report higher odds of delaying or avoiding testing and/or treatment (aOR = 3.13, 95% CI: 1.17,8.42). There were no significant associations between the enforcement score and testing positive for COVID-19. Additionally, while Latinxs were more likely to report immigration enforcement encounters than Asians, there were no differences in the effects of race on COVID-19 testing and healthcare behaviors in models with race as an interaction term (p < 0.05). CONCLUSIONS: Immigration enforcement encounters compound barriers to COVID-19 testing and treatment for undocumented immigrants.

Improving stigma and psychosocial outcomes among post-abortion Kenyan women attending private clinics: A randomized controlled trial of a person-centered mobile phone-based intervention.

OBJECTIVES: The objective of this study was to evaluate a person-centered abortion care mobile-based intervention on perceived social stigma, social support, mental health and post-abortion care experiences among Kenyan women who received abortion services at private clinics. METHODS: This randomized controlled study enrolled women who obtained an abortion from private clinics in Nairobi county, Kenya and randomized them into one of three study arms: 1) standard of care (follow-up by service provider call center); 2) post-abortion phone follow-up by a peer counselor (a woman who has had an abortion herself and is trained in person-centered abortion care); or 3) post-abortion phone follow-up by a nurse (a nurse who is trained in person-centered abortion care). All participants were followed-up at two- and four-weeks post-abortion to evaluate intervention effects on mental health, social support, and abortion-related stigma scores. A Kruskal-Wallis one-way ANOVA test was used to assess the effect of each intervention compared to the control group. In total, 371 women participated at baseline and were each randomized to the study arms. RESULTS: Using Kruskal-Wallis tests, the nurse arm improved mental health scores from baseline to week two; however this was only marginally significant (p = 0.059). The nurse arm also lowered stigma scores from baseline to week four, and this was marginally significant (p = 0.099). No other differences were found between the study arms. This person-centered mobile phone-based intervention may improve mental health and decrease perceived stigma among Kenyan women who received abortion services in private clinics. CONCLUSIONS: Nurses trained in person-centered abortion care, in particular, may improve women's experiences post-abortion and potentially reduce feelings of shame and stigma and improve mental health in this context.

Immigration enforcement exposures and COVID-19 vaccine intentions among undocumented immigrants in California.

COVID-19 vaccines are effective in preventing COVID-19 infection, disease, and death. However, there is no data about vaccine intentions among the 10.7 million undocumented immigrants in the US. This study examined the associations between immigration enforcement exposure and vaccine intentions among undocumented immigrants in California. This community-engaged study partnered with immigrant organizations across California during the COVID-19 pandemic to recruit 366 study participants to an online survey regarding their attitudes about the COVID-19 vaccine and past exposure with the immigration enforcement system. Data collection occurred from September 2020 - February 2021 before the vaccine became available. Overall, 65% of study participants indicated that they would definitely get the vaccine were it to become available. In multivariable logistic regressions, an increase in immigration enforcement scores were associated with a 12% decrease in vaccine acceptance (aOR = 0.88, CI: 0.78-0.99). Additionally, undocumented women were 3.09 times more likely to report vaccine acceptance compared to undocumented men (CI: 1.79-5.35) and undocumented Asians were 57% less likely to report vaccine acceptance compared to undocumented Latinx immigrants (aOR = 0.43, CI: 0.21-0.88). Exposure to the immigration enforcement system may undermine public health efforts to prevent further transmission of COVID-19 by reducing acceptability of vaccines among immigrant populations.

Contraceptive use and consistency and the role of deferred action for childhood arrivals: A cross-sectional survey of undocumented young adults.

OBJECTIVE: The Deferred Action for Childhood Arrivals (DACA) program grants young, undocumented immigrants work authorization and protections from deportation, with about 1.3 million eligible for the program. This exploratory study examines the association between DACA status and contraceptive use among undocumented young adults. STUDY DESIGN: We conducted an internet-based survey between June 2017 and August 2017 among Asian and Latinx undocumented immigrants (N = 204) aged 18-31 years in California. Bivariate and multivariate logistic regressions were conducted to examine the associations between DACA status and contraceptive use and consistency. RESULTS: Among undocumented participants who were sexually active, about 60% reported having unprotected sex (52% DACA vs. 63% non-DACA) and about 80% reported that documentation status affects how they access care for sexual/reproductive health at least a little. Overall, Asians were 81% less likely to have unprotected sex compared to Latinx individuals (aOR = 0.19, 95%CI: 0.06, 0.56). DACA recipients were more likely to report using contraception every time compared to non-recipients (42.9% vs. 30.5%, p = 0.04). DACA recipients were 63% less likely to report having unprotected sex in the past 12 months compared to those without DACA (aOR = 0.37, 95%CI: 0.14, 0.99). DACA recipients were more than three times as likely to use contraception during sex every time compared to those without DACA (aOR = 3.19, 95%CI: 1.19, 8.54). CONCLUSIONS: This study demonstrates that undocumented young adults have low rates of contraceptive use; however, DACA is associated with improved reproductive health for certain undocumented immigrants. IMPLICATIONS AND CONTRIBUTION: State and federal policies that extend protections and promote immigrant integration are needed to fully achieve reproductive justice for all.

Effects of the COVID-19 pandemic on antenatal care utilisation in Kenya: a cross-sectional study.

OBJECTIVE: The aim of this study was to assess the effects of COVID-19 on antenatal care (ANC) utilisation in Kenya, including women's reports of COVID-related barriers to ANC and correlates at the individual and household levels. DESIGN: Cross-sectional study. SETTING: Six public and private health facilities and associated catchment areas in Nairobi and Kiambu Counties in Kenya. PARTICIPANTS: Data were collected from 1729 women, including 1189 women who delivered in healthcare facilities before the COVID-19 pandemic (from September 2019-January 2020) and 540 women who delivered during the pandemic (from July through November 2020). Women who delivered during COVID-19 were sampled from the same catchment areas as the original sample of women who delivered before to compare ANC utilisation. PRIMARY AND SECONDARY OUTCOME MEASURES: Timing of ANC initiation, number of ANC visits and adequate ANC utilisation were primary outcome measures. Among only women who delivered during COVID-19 only, we explored women's reports of the pandemic having affected their ability to access or attend ANC as a secondary outcome of interest. RESULTS: Women who delivered during COVID-19 had significantly higher odds of delayed ANC initiation (ie, beginning ANC during the second vs first trimester) than women who delivered before (aOR 1.72, 95% CI 1.24 to 2.37), although no significant differences were detected in the odds of attending 4-7 or ≥8 ANC visits versus <4 ANC visits, respectively (aOR 1.12, 95% CI 0.86 to 1.44 and aOR 1.46, 95% CI 0.74 to 2.86). Nearly half (n=255/540; 47%) of women who delivered during COVID-19 reported that the pandemic affected their ability to access ANC. CONCLUSIONS: Strategies are needed to mitigate disruptions to ANC among pregnant women during pandemics and other public health, environmental, or political emergencies.