Research questions

This review examines interventions and policies that enhance PMWMIs’ access to perinatal care and addresses two key research questions.

1. What are the interventions that facilitate access to perinatal care for PMWMI women?
2. What are the interventions impacts on PMWMI perinatal health
3. What are the strengths and weaknesses of the interventions, and what is the cost of implementation?

Methodological framework

The protocol of this review has been published [34]. This study utilized the Arksey and O’Malley framework [35]. It provides six fundamental steps for carrying out a thorough scoping review: (i) defining the research question; (ii) identifying relevant studies; (iii) selecting studies; (iv) extracting data; (v) analyzing and aggregating results; and (vi) conducting a consultation exercise (optional). As the consultation phase is optional, it was not undertaken in this review.

Data sources and research strategy

The study was registered in Research Registry (#6864 https://www.researchregistry.com/browse-the-registry/#home/?view_2_search=6864&view_2_page=1) and followed PRISMA-ScR recommendations [36] (see S1 Checklist). Eleven electronic databases for studies published between 2000 and 2024 were queried, including CINHAL, Web of Science, Medline-Ovid, Embase, Cochrane Library, Scopus, ScienceDirect, Hinari, Lilacs, Cairn and Banque de Données Santé Publique (BDSP). Additionally, we performed search in other sources including 1) reference tracking from reference lists; 2) key journals in the field of immigration (Revue Migrations Forcées; Migrations Société); and 3) Grey literature, including websites of non-governmental organizations (NGOs) such as Médecins du Monde, Médecins Sans Frontières (MSF), and the United Nations High Commissioner for Refugees (UNHCR).

A working meeting with the research team, which included an experienced librarian (CS), facilitated the development of the search strategy (presented in Table 3 published elsewhere [34]. An expanded version, including the complete search strategies for all databases consulted, is presented in Table 3 of the present review. This strategy was formulated using descriptors or thesaurus along with the logical operators “AND” and “OR” to identify relevant studies published in French or English. An updated screening was conducted in December 2024. The year 2000 was chosen as a reference point with the launch of eight Millennium Development Goals (MDGs), addressing gender equality (MDG 3), and child mortality reduction (MDG 4) [37].

Study selection

Inclusion Criteria.

Inclusion and exclusion criteria were based on the Population, Interventions, Comparators, and Design and Outcomes, or Anticipated Outcomes (PICO), as summarized in Table 1 in the published protocol [34].

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Table 1. Summary of studies included in the review (n = 14).

https://doi.org/10.1371/journal.pone.0357487.t001

Studies Screening

In collaboration with the librarian (CS) of the Université du Québec en Outaouais and co-authors (I.B. and D.S.) designed the selection of articles and their extraction strategy. To begin selection, data were exported to EndNote for electronic and manual duplicate removal, then transferred to Rayyan [43]. Article selection proceeded in four steps: first, the team adapted a screening algorithm —develop by the team and used in previous reviews [44–47] — (Fig 1 of the protocol [34]); second, 10% of articles were jointly reviewed to harmonize the process (D.S., I.B., N.J.-C.B., E.T., G.M.N.); third, three authors (D.S., I.B., N.J.-C.B.) independently screened titles and abstracts and abstracts, and an article was retained if at least two reviewers deemed it eligible. Across this stage, 2.32% of screening decisions resulted in a conflict, all of which were resolved through discussion after re‑examining the record. This corresponds to an agreement rate of 97.68%, reflecting strong consistency in the application of eligibility criteria. Over the process, disagreements were resolved through discussion after reviewing the title and the abstract; if consensus was not reached, the fourth author (E.T.) made the final decision.

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Fig 1. Prisma flow diagram illustrating the search strategy.

https://doi.org/10.1371/journal.pone.0357487.g001

At the final step, eligible articles have been read in their entirety by two independent reviewers (D.S. and I.B.). At the end of this step, all authors met and summarised the reasons for exclusion of articles to prepare the flow diagram of the study.

Data extraction

The data extraction grid [S2 Appendix of [34]] was adopted from Cameron et al. [48], to capture study details (authors, year, country, title, design, population, sample size, interventions (antenatal, obstetric/neonatal, postpartum, newborn care, and related policies), impact, strengths, weaknesses, and implementation costs. To ensure consistency, three authors (D.S., I.B., N.J.-C.B.) collaboratively extracted data from two of the 13 included articles, after which N.J.-C.B. completed the remaining extractions. All extracted data were validated by D.S. and I.B.

Data analysis

Data analysis was conducted using a narrative synthesis informed by thematic analysis. Following data extraction, study findings were systematically coded and compared across study objectives, intervention types, and settings. A thematic synthesis was then undertaken to identify recurring patterns and relationships across the included studies, with themes generated through iterative review and discussion among members of the research team.

While themes emerged inductively from the data, the organisation of the Results section was guided by key outcome domains relevant to the review objectives, including intervention impacts, strengths, weaknesses, and costs. This combined analytical approach enabled a structured comparison of interventions and facilitated the identification of effective strategies for improving access to perinatal care among PMWMI women. The synthesis also informed implications for future research, practice, and policy development.

The study was approved by the Research Ethics Committee of the Université du Québec en Outaouais (Project #2021-1490, March 11, 2021). No informed consent was required, as no individual data were collected.

Study characteristics

We identified 16,593 records and removed 3,915 duplicates (last update in April 16, 2026). After screening titles and abstracts, an additional 12, 563 records were excluded (see Flowchart). A total of 14 studies met the inclusion criteria and were included in this review (Table 1). These studies were published between 2000 and 2025. The studies were conducted in four countries: the United States (n = 8) [49–56], Canada (n = 4) [2, 21, 57, 58], Thailand (n = 1) [59], and Iran (n = 1) [14]. Study designs varied and included cohort (longitudinal) studies (n = 6) [2, 49, 52, 53, 55, 57], quasi-experimental studies (n = 2) [21, 56], qualitative studies (n = 1) [14], cross-sectional descriptive studies (n = 1) [50], grounded theory studies (n = 1) [59], Retrospective and decision-analytic models (n = 1) [51]. Sample sizes ranged from fewer than 100 participants (n = 2) [14, 59], 100–999 participants (n = 3) [2, 21, 52], 1,000–1,999 participants (n = 3) [56, 58, 60], to 2,000 or more participants (n = 6) [49–51,54,55,57]. Across publication periods, one study was published between 2000–2005 [52], two between 2006–2010 [50, 60], three between 2011–2015 [2, 21, 59], seven between 2016–2020 [14, 49, 54–58], and one in 2025 [51].

The Prisma flow diagram is presented in Fig 1.

The results are presented according to themes identified through inductive thematic synthesis of the included studies. Four overarching themes structure this section: (1) interventions facilitating access to perinatal care for PMWMIs; (2) barriers affecting PMWMIs’ access to perinatal healthcare; (3) strengths and weaknesses of identified interventions; and (4) costs associated with intervention implementation. Within these themes, subthemes address key dimensions of the evidence, including actors involved in implementing perinatal care policies for PMWMIs, types of policy and programmatic interventions, and reported strengths and limitations. This thematic organisation reflects recurring patterns across the included studies and provides a coherent framework for synthesising findings related to access, implementation, and outcomes of perinatal care interventions for PMWMIs.

In relation to the first theme, across the 14 included studies, we identified eight existing interventions and policies designed to improve access to perinatal care for PMWMIs. These included government‑led policies such as the OHIP, the CHIP, the CHIPRA, CAWEM Plus, and state‑level public health insurance expansions, as well as non‑governmental initiatives such as MdM community‑based services. These interventions covered the full perinatal continuum, including prenatal, postpartum, and newborn‑care components such as postpartum contraceptive access and neonatal care packages. Together, these eight interventions constitute the existing policy landscape documented in the included studies.

1. 1. Interventions in favor of access to perinatal care by pregnant migrant women without medical insurance (PMWMIs)
   1. 1.1. Actors involved in implementing perinatal care policies for PMWMIs

Of the studies selected, six [49,54–58] highlight two classes of policies promoting access to perinatal healthcare for PMWMIs, from which two types of actors emerge: intervention by government actors [49,51,54–57] and intervention by non-State actors [58]. The State-level interventions included, in Canada, The Ontario Health Insurance Plan (OHIP) of the Ontario government in force since 1994. As exhibited in the Table 2, in the USA, there was the Alternative policies implemented through Medicaid to address the loss of access to care following restrictive reforms, namely, the Children’s Health Insurance Program (CHIP) [54], the Health Insurance Program Reauthorization Act (CHIPRA) [49, 56] and Citizen/Alien Waived Emergent Medical Care (CAWEM Plus) or Emergency Medicaid Plus, expanded in 2008 by Oregon to include all recent and unauthorized immigrant women in the prenatal care offering [55].

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Table 2. Interventions in favor of access to perinatal care, barriers, Strengths, weaknesses and costs.

https://doi.org/10.1371/journal.pone.0357487.t002

Regarding the policies of non-governmental actors, the study by MdM [58] was retained, as its initiatives address the shortcomings of both levels of government by directly providing care and services to PMWMIs.

1. 1.2. Policy Interventions for Access to Perinatal Care

Several studies have focused their purpose on Policy Interventions for prenatal care services solely. This is the case of study of Atkins et al. [49], Fuentes-Afflick et al. [50] and Darling et al. [57]. The second category of intervention included both prenatal and postpartum/newborn care. On that perspective, Swart et al. [55] for instance compared pregnancies’ package (e.g., Prenatal visits, diabetes screening, fetal ultrasounds) covered by Emergency Medicaid, Emergency Medicaid Plus, and Medicaid, while Rodriguez et al. [60] looked at women's access to contraceptive methods following delivery, specifically using postpartum intrauterine devices. Besides, Wherry et al.’s [56] study examined the impact of state public health insurance expansions on prenatal care utilization, delivery methods, and infant health among pregnant immigrant women. Finally, in addition to above mentioned portrayal as exhibited in Table 2, other studies were concentrated on newborn care and potential perinatal complications (e.g., cerebral palsy and infant mortality) [54] and neonatal resuscitation and admissions to intensive care units [2]. The Kim et al. [51] study estimated effects of immigrant policies on prenatal care use and timing comparing three policy option: Immigrant Children’s Health Improvement Act (ICHIA), From-Conception-to-the-End-of-Pregnancy (FCEP), and the State-only funds option, publicly insured immigrants. Their data (2333,526 mothers and infants: 1280,847 residents in states with the ICHIA, 1227,879 in states with the FCEP, and 341,101 in states with State-only funding) from National Center for Health Statistics for the years 2015–2019.

1. 2. Barriers to PMWMIs’ access to perinatal health care

Studies have revealed several barriers, notably those linked to the reduction of health funding that supported undocumented immigrant women in the United States. The policy changes initiated in 1996 created significant obstacles to accessing prenatal care for this population [52]. The qualitative study by Mohammadi et al. [14] shows that Afghan immigrant women (uninsured) experienced delays and disparities in maternal care provided to them compared to Iranian women in Iran. Participants emphasized serious gaps in communication, significant delays in the recognition and management of complications, and profound, enduring psychosocial repercussions. Jarvis et al. [21] noted that uninsured women in Canada initiated their first prenatal care 13.6 weeks later than their insured counterparts. Additionally, they receive fewer routine prenatal screening tests (e.g., blood tests: 93.7% vs. 100%, p = 0.045, ultrasound screenings: 82.5% vs. 98.4%, p = 0.003).

Fuentes-Afflick et al [50] compared the implementation outcomes of PRWORA, found that Florida exhibited a significantly higher rate of inadequate prenatal care utilization (OR = 3.55). In contrast, California (OR = 1.91) and New York (OR = 1.66), which opted to continue providing services to ineligible groups, demonstrated better utilization of prenatal care. Crozier et al. [59] study highlighted ineffective provision of information, internal and external barriers to accessing information, implications of migrant status, and perceptions of risk (Table 2). Finally, Kim et al. [51] laid out barriers related to: immigration-related restrictions, enrollment burden, public charge fears, lack of coverage, delays in eligibility verification, and communication barriers.

1. 3. Strengths and weaknesses of perinatal care policies and their implementation

This theme synthesizes evidence on the strengths and weaknesses of policy and programmatic interventions shaping PMWMIs’ access to perinatal care, including enabling policy mechanisms as well as structural and implementation‑related limitations.

Strengths

Several studies reported that specific policies enabled expanded access to perinatal care for PMWMIs by allowing flexibility at the provincial or state level. For example, studies conducted in the United States described the application of the Unborn Child Clause of the Children’s Health Insurance Program (CHIP) in Oregon, which permitted coverage for postpartum care regardless of citizenship status [54]. The retrospective cross-sectional study by Kim et al. [51], comparing three schemes, further highlighted the relative strengths of each policy option. The ICHIA: expands access to prenatal care, encourages initiation, improves adequacy, reduces immigration fears, simplifies enrollment procedures; the FCEP: Expands eligibility, improves access to prenatal services, reduces delays in care initiation; while the State-Only: Most effective option; increases first-trimester initiation and adequate care, reduces immigration-related fears via non-federal programs. Theire study [51] informed that the State-funded policy is associated with a greater odds of intermediate (OR 1.43), adequate (OR 1.72), and adequate-plus (OR 1.37) care, with lower inadequate care (OR 0.48) -compared to uninsured immigrants-, increased first-trimester initiation (+87.1 pp), and reduced delayed (−43.8 pp) and no care (−67.3 pp).

Other studies reported that the Health Insurance Program Reauthorization Act (CHIPRA) was associated with expanded eligibility and increased coverage for PMWMIs in several states [49, 56], as summarized in Table 2.

Weaknesses

Other studies documented limitations and adverse effects associated with certain policies and their implementation. Fuentes‑Afflick et al. [50] reported that the implementation of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) was associated with higher odds of inadequate prenatal care utilization among PMWMIs, with reported odds ratios ranging from approximately two‑ to four‑fold across states. In addition, a qualitative study conducted in Iran by Mohammadi et al. [14] reported that Afghan refugee women experienced persistent mistreatment and disparities in maternal care following the 2015 health reform, despite the extension of national public insurance to registered migrants. Reported issues included delayed care, communication gaps, and differential treatment in clinical settings.

1. 4. Policy/Intervention Costs

Several studies reported cost‑related outcomes associated with limited access to insurance coverage for PMWMIs. Jarvis et al. [21] documented higher costs related to delayed or incomplete prenatal care among uninsured immigrant women. The study of Kim et al. [51] informed that the State-funded programs involve substantial implementation costs and administrative coordination burdens. Lu et al. [52] reported that reductions in public funding for prenatal care for undocumented migrants in the United States were associated with increased postnatal healthcare expenditures. Specifically, the authors estimated that an initial reduction of approximately $58 million in prenatal care spending was followed by higher postnatal costs, estimated at $136 million and increasing to $211 million over time.

In addition, Rodriguez et al. [54] reported that providing prenatal care in addition to delivery coverage was associated with an average additional cost of $380 per woman. The study further estimated that for every 865 women receiving prenatal care alongside delivery coverage, one infant death could be averted, corresponding to an estimated cost of $328,700 per life saved.

Policy dynamics and system responsiveness

Findings from the included studies indicate that policy environments are dynamic and responsive to migration-related pressures. In North America, federal-level restrictions have, in some cases, shifted responsibility to state or provincial governments to adapt eligibility criteria. For example, policy changes following Bill Clinton’s 1996 declaration [61] have contributed to variability in access across jurisdictions. This decentralised flexibility can represent a strength, as some regions have expanded access to perinatal care for PMWMIs [57], potentially reducing costly emergency interventions [57].

At the same time, variability across jurisdictions may also constitute a weakness, leading to unequal access depending on geographic location. Broader contextual evidence indicates that migration flows have increased in recent years in countries such as Canada and the United States [62, 63], placing additional pressure on healthcare systems and influencing policy evolution. While this trend is not derived directly from the included studies, it provides important context for understanding the policy dynamics observed in the findings.

Some studies also describe collaborative arrangements between host countries and international organisations [64], supported by global frameworks such as the New York Declaration [55], to improve access to care for migrant populations. These examples illustrate both adaptive policy responses and ongoing inconsistencies in implementation.

Economic relevance of policies

From a cost perspective, included studies suggest that restrictive policies may create the appearance of short-term savings while generating higher long-term costs. Evidence indicates that lack of access to timely prenatal care leads to more complex and expensive interventions later, including increased postnatal care costs [52]. In addition, evidence suggests that even in high-income countries with adequate resources, the provision of services for PMWMIs remains insufficient [65], highlighting a significant gap in healthcare systems. NGOs play a critical role in addressing these gaps [66], representing an important strength of current systems; however, their limited capacity also highlights a structural weakness, as they cannot fully substitute for comprehensive public coverage.

Broader interpretations of these findings may be informed by theoretical perspectives such as the Womb Theory and Early Childhood Theory [67, 68], which emphasise the long-term benefits of early-life health investments. While these theories were not explicitly examined in the included studies, they provide a useful framework for interpreting the economic implications of restricted access to care.

Policy lag and access gaps

The included studies indicate that policy adaptation often lags behind changes in migration patterns, creating gaps in access to care. During these periods, NGOs frequently act as interim providers, addressing urgent needs among uninsured migrant populations. Broader contextual examples, such as recent migration trends -including increased arrivals in the United States [69] and events such as the Lampedusa tragedy [70–72] further illustrate how sudden population movements can place pressure on healthcare systems, although these examples extend beyond the included studies.

Evidence from the included literature also suggests that institutional practices, such as hospital billing policies for uninsured patients [73], may restrict access to necessary services. These findings highlight a key weakness in current systems: the lack of timely policy responsiveness. Given the vulnerability associated with perinatal care, some studies recommend the development of proactive and targeted systems to support high-risk groups, including asylum seekers and temporary migrants [65].

Ethical and public health implications

Findings from the included studies raise important ethical and public health concerns related to restricted access to perinatal care. For example, Emergency Medicaid in the United States provides coverage only for life-threatening conditions or childbirth, reaching a limited proportion of undocumented migrants [74]. This represents a significant limitation in continuity and equity of care.

From a public health perspective, the exclusion of PMWMIs from routine screening and preventive services may increase population-level risks, particularly for communicable diseases such as HIV/AIDS [27]. National initiatives, such as the Canadian Perinatal HIV Surveillance Program [75], highlight the importance of inclusive screening policies in mitigating these risks.

Some findings also indicate that alternative models of care delivery, such as home visits [57], may improve access among undocumented populations who fear engagement with formal institutions. Community-based approaches and partnerships with local organisations may therefore represent effective strategies for strengthening access to care. The findings of this review underscore the need for inclusive policies that guarantee access to essential perinatal services for PMWMI. Locally, expanding publicly funded prenatal care, reducing administrative barriers, and integrating community‑based organizations into formal care pathways could reduce preventable maternal and neonatal complications. Globally, these results align with international commitments promoting universal health coverage and migrant health equity. Strengthening rights‑based approaches and harmonizing national policies with global frameworks would support more consistent access to perinatal care and reduce disparities across health systems [76].

Implementation challenges

The included studies identify several barriers to the effective implementation of policies aimed at improving access to care for PMWMIs. These include the complexity of legal frameworks, variability in interpretation by providers, and administrative barriers related to reimbursement systems. Such challenges may discourage providers from offering services, even where policies formally allow access [13].

Importantly, evidence suggests that possession of insurance coverage does not always guarantee access to care. For example, Lusambili et al. [13] report that refugee women in Kenya were denied services despite holding valid insurance cards. These findings underscore the gap between policy design and practical implementation.

Strengths and limitations

This review included a limited number of studies (n = 13), primarily from four countries (Canada, the United States, Iran, and Thailand), which may limit generalisability. In addition, evolving policy contexts and eligibility criteria introduce variability across studies. The restriction to English and French publications may also have resulted in the exclusion of relevant studies. This limitation reflects resource and translation constraints within the review team and may have narrowed the evidence base by excluding studies published in other languages. Furthermore, the predominance of studies from high‑income countries (85%) requires caution in interpreting the results for low‑ and middle‑income settings, where migration patterns and health system contexts may differ.

However, the use of a scoping review methodology enabled the inclusion of diverse study designs and grey literature, providing a comprehensive overview of available evidence. The systematic approach to data extraction and synthesis strengthens the robustness of the findings. Additionally, the cost‑related findings reported in the included studies should be interpreted with caution, as the economic estimates are context‑specific and may not be generalisable across different health systems or policy environments. Variability in underlying assumptions and cost structures further limits the comparability of these cost‑benefit claims.

Novelty statement

This scoping review represents the first focused synthesis of interventions addressing access to perinatal care for PMWMIs. The findings highlight persistent gaps in access to care despite ongoing policy developments in high-income countries. While some progress has been observed, such as the reinstatement of universal health coverage in Spain in 2018 following earlier restrictions [77], access remains inconsistent, particularly in contexts where policies fluctuate in response to political priorities, as observed in the United States.

Overall, this review underscores the need for more consistent, inclusive, and evidence-informed policies to improve equitable access to perinatal care for migrant populations.