When Alejandra Pablos found out she was pregnant, she was in the middle of a legal battle to stay in this country.

Initially, she thought about continuing with the pregnancy, she told Vox. But the uncertainty of her immigration status was too great. She’d been in deportation proceedings since 2011, and now it was 2017. As Pablos put it, “this is the Trump era.”

“Even though you might be ready and you would love to start a family,” she said, “I don’t know how I can do that when the state can take away my baby.”

Pablos, an activist who lived in Virginia at the time, ultimately got an abortion. Her story shows just one of the ways that the Trump administration’s immigration policies and rhetoric are affecting the way people build families and take care of their own health.

Immigration and reproductive rights are often treated as separate issues by the media and the public. But advocates say that for people living under threat of deportation in America today, there’s no separating the two. In addition to people like Pablos who are deciding not to have children, doctors say many immigrants are forgoing necessary prenatal or other reproductive health care for fear that they or their families will be deported. That leads to real health disparities, from a decrease in cervical cancer screenings to an increase in labor complications.

With the threat of raids from Immigration and Customs Enforcement constantly looming and the president making racist comments about congresswomen of color going “back” to their countries (even if they were born in the US), advocates say discussions of reproductive rights today have to include an understanding of the barriers immigrants face when it comes to building families and leading healthy lives. “I don’t live a separate life for my parents being immigrants,” Bridgette Gomez, the national director of strategic partnerships at Planned Parenthood Federation of America, told Vox. “We can’t think of these as separate issues.”

Many immigrants are avoiding reproductive health care for fear of deportation

The threat of deportation affects people’s health in a number of ways. Doctors and advocates say that in the Trump era, people who are undocumented or have undocumented relatives are increasingly avoiding the doctor for fear of encountering or being turned over to immigration authorities.

Dr. Anjani Kolahi, a family medicine physician and fellow with the group Physicians for Reproductive Health, works with a federally qualified health center in Southern California that provides affordable care regardless of immigration status. But, she told Vox, “patients are not coming for care.”

She’s seen patients with cancer who only come to the doctor after experiencing significant weight loss. “They know that they’re very sick, but they’re so concerned about deportation that they will be scared to come into the hospital,” Kolahi said.

In an environment where people are afraid to go to the doctor even when they’re desperately ill, routine screenings for breast and cervical cancer can fall by the wayside. For Planned Parenthood, “a lot of our work is preventive health care,” Gomez said. But “people will forgo preventive care often” when they’re worried about being deported. That can mean that health problems that could have been caught early, from cancers to sexually transmitted infections, become more serious.

The same goes for prenatal care. Pregnant people who are worried about deportation often avoid going to the doctor until they’re in labor, Kolahi said. But that means missing screenings for conditions like preeclampsia, which can be dangerous if untreated.

“We’ve seen patients seizing” from preeclampsia, Kolahi said. “Any time you seize, that means the baby in the uterus has no oxygen at that point. That can be deadly.”

Fear of deportation can also influence people, like Pablos, to end an otherwise wanted pregnancy because of uncertainty about the future.

While it’s not clear exactly what impact recent threats of ICE raids and other messages from the Trump administration have had, birthrates among unauthorized immigrants have been falling since 2007, and in 2016 reached their lowest level since 2000, according to the Pew Research Center. “We would attribute some of it to these concerns of deportation,” Kolahi said.

But unauthorized immigrants can also face special challenges when it comes to abortion access. Four nonprofit organizations in Texas and Mexico told BuzzFeed News they’d seen an uptick in patients canceling or pushing back abortion appointments amid recent threats of ICE raids.

Like Pablos, Layidua Salazar had an abortion while under deportation proceedings. In California, where she lived, she was able to get one safely.

“I describe my abortion as coming up for air,” she told Vox. “It allowed me to feel a sense of control over my future.”

But, she said, “my experience is somewhat unique.” Because she was already involved in reproductive justice activism, she knew that a clinic in California would not look into her immigration status. In general, emergency rooms and community health centers are supposed to offer health care regardless of immigration status, and a government-issued photo ID should not be required to get medical treatment, according to the National Immigration Law Center.

But unauthorized immigrants, especially if they don’t speak English, may not always be aware of their rights when it comes to health care. Providers may not be aware either — Salazar says she’s heard stories of patients turned away at clinics for lacking US identification.

Meanwhile, living in the San Francisco Bay Area, she said, “I didn’t have to worry about dealing with law enforcement in a clinic.”

California’s sanctuary law generally prevents local law enforcement from working with immigration officials, though local officials appear to have violated the law in some cases.

In other states, “I’ve heard situations where Border Patrol is parked at Planned Parenthood,” Salazar said. “For a lot of undocumented people, places like Planned Parenthood are our primary health care providers, so what does it look like to not even be able to access basic health because border patrol agents have scare tactics?”

Detention facilities impose additional obstacles to health care

While immigrants around the country may fear seeking reproductive health care due to the threat of deportation, people in immigration detention facilities face additional barriers, said Gomez, the Planned Parenthood partnerships director. In 2017, the Office of Refugee Resettlement under director Scott Lloyd attempted to block several teenagers in immigration facilities from getting abortions. The teens were ultimately able to get the procedures, and Lloyd subsequently left the agency, but Gomez says reproductive care for people in immigration detention is still lacking.

“People who are pregnant are not getting the resources and the medical treatment that they need,” she said. She also pointed to reports of people in detention lacking access to necessary hygiene products like sanitary pads and tampons. “If they’re not getting the necessary things they need at the moment, they’re certainly not getting the preventive care that they would need,” she said.

Moreover, advocates say that the separation of children from their family members in immigration detention should be seen as a breach of reproductive justice, a term coined in 1994 that describes a focus on affordable access to a full range of reproductive health care, as well as the ability to parent children safely.

“All people deserve the right to raise children in a healthy and safe environment without being targeted by aggressive immigration tactics or being forced to live in constant fear,” Gomez said.

While abortion rights groups and reproductive justice organizations have begun to speak out against the Trump administration’s immigration policies, anti-abortion groups have been generally quiet on the separation of migrant children from parents and other issues affecting immigrant families.

“There are many policies on which we have no stand, for or against,” David O’Steen, the executive director of National Right to Life, told the Associated Press last year. “We’re not on either side of this issue.” National Right to Life has not responded to Vox’s request for comment.

An exception is the group Democrats for Life — in a New York Times op-ed last year, Charles C. Camosy, a board member of the organization, called on anti-abortion groups to speak out forcefully against the Trump administration’s treatment of children.

Fears are worsening, but advocates say there are reforms that can help

Worries about getting deported after seeking health care aren’t unique to the Trump era. The unauthorized immigrant community has “been in a state of constant fear and anxiety since 2008,” said Salazar, who had her abortion in 2013. And a 2013 study found that undocumented Mexican immigrant women were significantly less likely than documented women to get recommended cervical cancer screenings.

But fears have intensified as the Trump administration has stepped up anti-immigrant tactics and rhetoric. As Salazar puts it, “we didn’t think it was going to get worse, but boy, it did.”

In recent weeks, the president has called for ICE raids in major cities; though the raids were postponed for a time, arrests reportedly began last Sunday in some cities, and authorities said they would continue throughout the week. Even absent active ICE raids, Trump’s promises of mass deportations have made many in immigrant communities fearful anytime they leave their homes, advocates say, because they worry they could be stopped by immigration authorities.

In addition to the president’s rhetoric, advocates say policy proposals are sparking fear. Salazar pointed to a proposed rule change by the Trump administration that could allow the deportation of legal permanent residents if they use government services like Medicaid. “What does it mean for folks who need health care and can’t afford it and now are afraid to access it because of how it could impact them in the future?” she asked.

To help immigrants get the care they need without fear of deportation, advocates support legislative changes like a bill recently introduced by Sen. Richard Blumenthal (D-CT) that would prevent ICE from conducting sweeps in hospitals and other “sensitive locations.”

Salazar also recommends that clinic staff be trained to inform unauthorized immigrants of their legal rights when it comes to accessing health care, as well as to address logistical issues like what to do when a patient has an ID from another country. Staff should also understand the “genuine emotional and mental barriers” that people can face when accessing care while under threat of deportation, she said.

And advocates say such changes need to be considered as part of the push for abortion and other reproductive rights around the country. “We cannot be discussing these as separate siloed issues,” Kolahi said.

Pablos, for her part, says she thinks about her abortion story with a larger reproductive justice framework in mind. “For me, reproductive justice just means when human beings have the right to create a life or not create a life,” she said.