Disruptions in Sexual and Reproductive Health Care Service Delivery for Immigrants During COVID-19

Purpose: To provide perspectives from heterogenous cisgender immigrant women and service providers for immigrants in New York City (NYC) on how restrictive sexual and reproductive health (SRH) care delivery environments during COVID-19 shape immigrant's access to health care and health outcomes to generate insights for clinical practices and policies for immigrant women's health care needs. Methods: A qualitative study was conducted in 2020 and 2021, including in-depth interviews with 44 immigrant women from different national origins and 19 direct service providers for immigrant communities in NYC to explore how immigrants adapted to and were impacted by pandemic-related SRH care service delivery barriers. Interviews were coded and analyzed using a constant comparative approach. Results: Pandemic-related delays and interrupted health care, restrictive accompaniment policies, and the transition from in-person to virtual care compounded barriers to care for immigrant communities. Care delays and interruptions forced some participants to live with untreated health conditions, resulting in physical pain and emotional distress. Participants also experienced challenges within the health care system because of changes to visitor policies that restricted the accompaniment of family members or support persons. Some participants experienced difficulties accessing telehealth and technology, while others welcomed the flexibility given the demands of frontline work and childcare. Conclusions: To mitigate the health and social implications of increasingly restrictive immigration, reproductive, and social policies, clinical practices like expanding access to care for all immigrants, engaging immigrant communities in health care institutions policies and practices, and integrating immigrant's support networks into care play an important role.


Introduction
More than 44 million immigrants and 8 million citizens with at least one undocumented family member live in the United States. 1,2 Immigrants account for 17% of cisgender women of reproductive age and there is considerable heterogeneity by national origin. Before the COVID-19 pandemic, women in immigrant and minoritized communities had greater barriers accessing sexual and reproductive health (SRH) care, 3,4 reported poorer quality of care, 5,6 and experienced poorer SRH outcomes than the US-born population. 4 The limited existing literature 7 on immigrants' SRH primarily focuses on prenatal care and gynecological cancer screening practices, with less of a focus on SRH experiences and fertility, contraception, and abortion. 8 Furthermore, while immigrant populations face well-known social, economic, and political barriers to obtaining SRH care, these barriers stem from intersecting consequences of structural inequalities, xenophobic immigration policy, and racism, [9][10][11][12] which are rarely the focus of immigration SRH research. 3 COVID-19 offers a glimpse into the consequences of structural barriers for immigrant access to SRH care. SRH care is an important emphasis of study, given the pervasive impact of oppressive structures and restrictive policy making that leave SRH care uniquely inaccessible and stigmatized relative to other aspects of health and health care. 13,14 During COVID-19, SRH services, which are essential primary care, were negatively impacted by shifting priorities within health care systems. 13,15 Studies with service providers demonstrated the scope of tremendous interruptions to SRH services through shifts from in-person to virtual visits, supply chain disruptions, and reduced staffing. 15 Access to SRH care was further reduced by loss of health insurance and wages due to pandemic-related job losses and fears of exposure to the virus. 3,16 There were also lower rates of sexually transmitted infection screening, reduced access to contraception and abortion care, and reduced access to services for intimate partner violence (IPV). 17,18 Yet little is known about how these changes in SRH service delivery during COVID-19 were experienced among immigrant communities. 19 To fill this gap in knowledge among a large, underserved population in the United States, we conducted a qualitative study among a unique sample that includes both cisgender immigrant women from diverse national origins and direct service providers for immigrant communities in New York City (NYC). We use the perspec-tives of immigrant women and direct service providers to describe immigrant women's experiences of disruptions in SRH care delivery during COVID-19 and discuss clinical and policy implications.

Methods
A qualitative study, including semistructured, in-depth interviews, was conducted with cisgender immigrant women in NYC from several regions and countries of origin and direct service providers who serve immigrant communities from all five boroughs (Bronx, Brooklyn, Manhattan, Staten Island, and Queens). Interviews explored experiences of SRH care services among women and providers during the first and second years of the COVID-19 pandemic (September 2020-May 2021). Institutional Review Board (IRB) approval was received for the study (AAT2404). Table 1 includes eligibility criteria for both samples.
Recruitment of the immigrant sample began in August 2020 and interviews were completed by March 2021. Community-based organizations (CBOs) that work with and provide services (health, education, social work, gender-based violence, legal, and financial) for immigrant communities facilitated recruitment by identifying participants, posting flyers, and distributing emails to their clients. Recruitment for direct service providers began in March of 2021 and concluded in May of 2021. The CBOs that facilitated recruitment for immigrant women also facilitated initial outreach for service provider interviews, and additional service provider participants were recruited through snowball sampling.
The interview guides were developed by the study team based on the literature on immigrants' SRH and access to health care and revised and finalized after Recordings in English were transcribed using transcription software and transcripts were manually compared with the audio recording for accuracy. A certified transcriber and certified translator transcribed and translated the Spanish interviews to English. We utilized separate coding and analytic processes for each sample. Codebooks were developed with a subset of each sample's transcripts using a line-by-line approach to identify prominent themes and patterns. Thematic codes based on existing literature were also integrated into the codebooks. Several rounds of codebook revisions were conducted until there was a high level of agreement among the study team about the meaning and application of codes.
Transcripts were deidentified, uploaded, and coded using Dedoose. Data for both samples were analyzed using a constant comparative method, 20 which is an iterative process of continuously reviewing data alongside emergent themes and patterns until core categories and relationships between categories are identified. The study investigators developed an initial codebook that was revised, finalized, and applied with a four-member study team through an iterative coding and meeting process to review and resolve codes, questions, and discrepancies. This helped ensure validity and consistency of coding across team members and identification of all possible themes. Once all transcripts were coded, we identified and described themes and narratives that emerged around immigrant women's and direct service providers' experiences with SRH care service delivery during COVID-19. Common themes across the two samples were combined using detailed memos and study team meetings to generate cross-sample thematic results.

Results
The sample includes 44 immigrant women and 19 direct service providers. Sample characteristics are provided in Tables 2 and 3. Immigrant participants had a mean age of 33 years; 49% were from Latin America and 71% were undocumented. About 42% of immigrant women were married or cohabiting and 54% were single or separated. The 19 direct service providers represented leadership and clinicians at CBOs (63%), family planning clinics (16%), and family practices or community health clinics (22%) across all five boroughs.

SRH needs and vulnerabilities
Participants explained how they contended with a range of SRH concerns over the course of the pandemic. When asked if they experienced any change in their SRH during the COVID-19, 12 (27%) women reported changes in their menstruation, including early and late onset of periods, missed periods, irregular bleeding, and increased menstrual pain. Eight women (18%) reported other ailments, including vaginal yeast infections, pain during intercourse, and obstetric complications. And others were receiving care for problems diagnosed before the pandemic, including thyroid cancer, breast cysts, uterine fibroids, and an abnormal cervical cancer screening.
Fifteen participants reported managing current chronic illnesses (e.g., asthma, metabolic disorders) and eight reported a history of IPV. Most participants reported experiencing mental health distress, such as sadness or anxiety, and some described mental health illnesses, including depression, substance use disorders, and eating disorders. Below, we describe the main SRH service delivery barriers that emerged for immigrants and providers, including the consequences of delayed and interrupted health care, harm from restrictive accompaniment policies, and mixed experiences with transition to telehealth. Table 4 includes illustrative quotes from the participants for each theme.

Consequences of delayed and interrupted health care
Respondents discussed the negative impact of cancelled and delayed health care appointments on women's SRH during the pandemic, including decreased access to family planning services and delayed chronic illness management. Respondents noted challenges for immigrant women in need of services, which required inperson clinic visits, such as the insertion or removal of long-acting forms of contraception (e.g., intrauterine devices) and abortion care. Some providers described how abortion was still accessible, but often delayed to later in pregnancy.
Cancelled and delayed appointments took a toll on immigrant women with complicated SRH conditions that required ongoing management. Barriers that are specific to immigrant communities like lack of health insurance, not having a regular source of primary care, low knowledge about and distrust in the health care system, reduced care continuity, fewer opportunities for culturally concordant care, and limited assistance in languages besides English were exacerbated during COVID-19, prolonging what had already been extensive waiting periods for women to receive treatment and care.
Care was also interrupted when providers discharged hospitalized patients earlier than the standard of care, to reduce COVID-19 exposure and free up hospital beds. One physician, for instance, noted that many of his pregnant immigrant patients during the pandemic felt ''they were like pushed out early from the hospital,'' which providers felt would shape trust and future engagement in health care for immigrant mothers and their children.
Care delays and interruptions forced some immigrant women to live with untreated health conditions, resulting in physical pain and mental health distress. One participant (38 years old, Ecuador) had experienced a recurrence of thyroid cancer; when the pandemic started, her radiation therapy came to an abrupt halt. Another woman (35 years old, Ecuador) had to postpone surgery to remove uterine fibroids, resulting in additional months of heavy bleeding, while she was juggling securing work and her childcare needs.
Immigrant women described having very limited social support to help address the physical, emotional, and logistical needs (e.g., help with childcare) associated with delayed care and untreated conditions because they did not have family in the United States. One woman (26 years old, Yemen), for example, who had recently given birth, had to wait 6 months for an operation to repair an obstetric fistula after the surgeon was diagnosed with COVID-19.
While awaiting surgery, she had to undergo biweekly hospital visits and endured tremendous physical pain, while also taking care of her newborn baby. During this time, her husband was still in Yemen because of travel and immigration restrictions implemented by the Trump administration. Her father had passed away from COVID-19, and her mother had stayed in Yemen following the funeral. She reflected on the difficulties of delayed care, given this lack of support: ''It was very hard. I had my moments where I wake up the middle of the night and I just start crying [so hard that] I can't even.And it's just like, who should I ask right now? Who [can] help me?.'' Harm from restrictive accompaniment policies Women also faced challenges within the health care system because of changes to visitor policies that restricted the accompaniment of family members or support persons. Women were deterred from seeking care because they could no longer count on the support of family members, especially their children, during clinical visits to help overcome language barriers and manage other forms of cultural brokerage.
One participant (24 years old, Bangladesh) described how her mother put off a necessary surgery to remove gynecologic cysts because of the fear of going through the procedure alone. Another participant (34 years old, Mexico) was so afraid to seek care without the people take less time off of their work, which allowed them to get health care without using those days or without feeling like this fear of like, 'oh, they could replace me or fire me if I take too much time off.' (Physician, Family Planning Clinic, Manhattan). ''Then there was this big push from national organizations and from our own hospital, our own department, about being able to safely provide obstetrical care using just video. Which one may think, ''well, you're not listening to my baby's heartbeat, you're not examining my belly. How can you guarantee that my baby is safe?'' And the evidence, quote unquote, at that point is that, ''no, if you if the baby's moving, then everything's fine,'' which I understand the leadership position and try to minimize the risk of COVID but I've heard so many women saying, ''I feel unsafe. I don't think this is optimal care'''' (Physician, Family Planning Clinic, Bronx). ''The biggest challenge was that they could not physically come in. Right. And so we switched to help, with telehealth. Almost overnight and. I mean, I think telehealth has a place, but I also think it has a lot of barriers, and especially for immigrant women who maybe don't have access to Internet, don't have the right equipment, you know, there might be using just some old crappy phone. It's hard to get on. There's a knowledge issue on how to log on. There's a there's a language barrier. There is. I mean, there was just it was really, really hard for women to access care'' (Physician, Community Health Clinic, Manhattan). ''.things that go untreated like STDs that maybe won't get diagnosed, I mean. Usually, yes, people will come in with a symptom we screen. support of a family member that she waited until her daughter's dental appointment to ask for professional assistance for what was later diagnosed as extreme anxiety. She said that she was ''embarrassed to talk to people,'' so she told her daughter, ''You speak to them in English and I'll tell you what to say.'' Some women were forced to forgo medical appointments because visitor policies prohibited them from bringing their children and they had limited or no childcare. Out of the 24 women with children in our sample, 15 (63%) were separated, divorced, or single and the primary caretaker of their children and even those in partnerships were often the primary caretaker and worked to support the family.
Many participants expressed a profound fear of being isolated and separated from their children if they or their children were to require hospitalization. For some, this fear informed their decisions to forego care when they themselves or their children were ill, even if they thought it was necessary. One participant (39 years old, Mexico), for instance, described the difficult decision she was forced to grapple with when both of her children became ill in the early months of the pandemic. ''I thought that if I went [to the hospital], they would possibly isolate them from me because they would not allow any family members to be there. I panicked, I was afraid, I decided to leave them at home.'' Mixed experiences with telehealth When care was not delayed or interrupted, it was often switched to virtual or phone visits, which came with both challenges and benefits. The switch to telehealth exacerbated digital divides, including access to the internet and technological resources. Some immigrant women experienced difficulties accessing technology, including consistent, high-quality internet connectivity. For other women, their lack of familiarity with technology and different kinds of virtual platforms paired with limited English proficiency, created a substantial learning curve to engage with virtual health care services.
The availability of in-person appointments emerged as critical for allowing women to report concerns that they might feel afraid or ashamed of revealing-or that they may not even be fully aware of-and have difficultly broaching through by phone or video and with household members present, such as mental health challenges or IPV. Participants and providers frequently discussed under-reporting of IPV during COVID-19 as participants were trapped at home with their aggressors and could not safely discuss IPVrelated issues through a virtual visit.
A social worker at a Family Planning clinic in Manhattan commented, ''.even reporting is unsafe because it's like where do you find a safe place to have that conversation at home?'' Providers also shared concerns about privacy noting that women ''don't have a lot of space in their homes. Right? They night be living in one or two rooms with their children who are remotely going to school and maybe their mother-inlaw, who is in the other room within hearing distance. And so the kinds of questions that we ask in reproductive health are really personal. And I just found that was really unfair.'' Women and providers shared concerns about whether the quality of virtual care was like in-person care. One woman (38 years old, Honduras), for example, attended a virtual consultation with a physician after her menstrual cycle was delayed for over 2 months. Even though she was diagnosed with a menstrual disorder, she continued to be concerned with her cycle. When asked about her experience with the telehealth appointment, she replied: ''I was always in doubt, because the doctor only looked at my face, he didn't look at my body, how does he know that's what it was?'' Although many women found virtual appointments challenging, some women reported positive experiences, particularly when it came to counseling for mental health and other sources of psychosocial support. Many found a deep sense of relief in being able to begin or continue counseling without risking exposure to COVID-19. Some service providers relayed those virtual appointments increased access to care for women who had other constraints, such as full-time jobs with limited time flexibility. One health care provider commented that offering prenatal visits both inperson and virtually allowed women to access care without having to opt for unpaid time off or ''without feeling like this fear of like, 'oh, they could replace me or fire me if I take too much time off..''

Discussion
Although health care was delayed and interrupted for almost everyone during the COVID-19 pandemic, in this qualitative study with a large, heterogenous sample of immigrant women and service providers, we found that pandemic-related delayed and interrupted health care, restrictive accompaniment policies, and the transition from in-person to virtual care compounded barriers to care faced by immigrant women before the pandemic. Data illustrate that immigrant women experienced physical and emotional suffering during COVID-19 related to SRH service delivery because their social status as immigrants was a compounded vulnerability as an unprepared and under-resourced health care system attempted to adapt. Changes at the policy and health care system levels are needed to increase health equity for immigrant communities.
This study describes ways that immigrant women's health care suffered during the pandemic. Cancelled health care appointments were common at the pandemic's onset due to risk of exposure and reduced staffing. 21,22 Our findings align with existing literature that COVID-related cancellations compounded already substantial barriers to care and resulted in unnecessary progression of health conditions and mental distress for uninsured or underinsured immigrant women, 23,24 and further show that delays in SRH care are an added dimension of care discontinuity for immigrants during the pandemic. For under-resourced communities, finding timely and adequate care is often hampered by bureaucratic hurdles, complicated financial assistance plans, and a lack of care continuity. [25][26][27] Findings demonstrate how immigrant women's already limited access to specialty care and management of a range of health conditions, SRH related and otherwise, caused physical and mental distress as they were denied essential health care, including obstetric surgeries, cancer treatment, and other chronic illness management. Because chronic illness management requires access to care, 28,29 study findings confirm that lack of health care access for immigrants is associated with reduced confidence in the health care system and future engagement. 24,30 Clinical efforts are needed to close gaps in equitable provision of care, including supporting primary care providers to help uninsured patients access to specialty care. Health care institutions can engage community members and local governments in planning and reassessment of the definition of ''essential care,'' and create systems to ensure cancelled appointments are rescheduled quickly.
Study findings highlight how the unique sociopolitical and health care policy environment for immigrants intensified the negative experiences related to COVID-19 restrictions on accompaniment policies. Advancing research that found accompaniment policy restrictions reduced the ability of patients' family members to help navigate health care institutions, leading to negative patient experiences and worse health outcomes 31 ; we found that restricting patients from bringing support people to health care visits was consequential for health care access for immigrants through exacerbating language barriers, lack of familiarity with the health care system, and mistrust of the health care system. Language and communication barriers exacerbate immigrants' experiences of discrimination in health care settings. 32,33 Even when formal interpreters are available, support persons are crucial to creating safe spaces for immigrant women to navigate the health care system and receive needed emotional support, cultural brokerage, and added trust. 34,35 Moreover, given the sensitive issues involved in SRH care for immigrant women, support persons may play a larger-than-anticipated role in access to care, care delivery, and quality of care, and should be integrated into care, while protecting patient privacy and autonomy. Health care institutions should welcome and integrate support persons in primary care, including SRH care, and should engage patients and communities when designing or changing accompaniment policies to ensure patients' needs are met, while addressing public health and institutional priorities.
Participants' experiences with virtual SRH services provide insight for addressing structural obstacles and refining best practices now that in-person and hybrid services are offered more consistently. Virtual care can expand or expedite access for immigrant and other underserved communities and should be offered to everyone, particularly those who express concerns with taking time-off from work, childcare, transportation, and in other resource-limited situations. Simultaneously, efforts should also be made in virtual encounters to connect patients with social services to provide patients a full scope of options. In keeping with current guidance, when determining the appropriateness of virtual care, providers should consider their existing relationship with patients, if any, as well as patients' preferences and barriers, including internet access and privacy. 36 Furthermore, virtual visits should still be consistent with standards of care, including providing mental health screening, IPV screening, and vaccine counseling. Issues of digital redlining and digital fluency, which impact marginalized populations, particularly immigrant women, 37,38 require structural interventions, such as discounts for internet and cellular services, equity-focused technology monitoring programs, and expansion of broadband connectivity. 39 In the meantime, health care staff should assess barriers to virtual care before visits and offer resources or work directly with patient's support networks as participants identified support networks as helpful in overcoming technological barriers. Finally, study findings show how primary care is both an essential source of SRH care and is an important entry point to care for immigrant women. As reproductive health care, specifically abortion and contraception, are restricted in the United States, primary care providers will become even more of an essential source of SRH care and an entry point to care.
Although women may seek out SRH care for SRH reasons (e.g., STI screening, contraception), these visits provide an opportunity for women to discuss a range of health and social concerns and for providers to assess other health and social needs, including safety, therefore serving as a principal entry point for connecting women to primary and specialty care, mental health, and other social resources. As evidenced by our results, immigrant women may use their children's health care visits to access their own care, and others described their fear of being separated from their children during health care encounters. Study data further confirm the importance of both primary care and SRH care to fully support the comprehensive needs of immigrant women and their families. 40 The study was conducted in NYC and generalizability to health care systems and populations elsewhere is limited. However, there is a critical lack of data on health care behaviors among immigrant communities, particularly those who lack documentation. We highlight important considerations for health care settings that serve immigrant populations, including expanding access to care for all immigrants, engaging immigrant communities in health care institutions policies and practices, and integrating immigrant's support networks into care. More research about how to deliver health care, whether SRH care specifically or primary care, is needed to mitigate the health and social implications of increasingly restrictive immigration, reproductive, and social policies.