PHOENIX, AZ – Most undocumented immigrants in Arizona either can’t afford private health insurance or don’t qualify for state insurance programs for low-income families. As a result, many seek alternative ways of meeting their health care needs by tapping into an underground market for medications, including birth control pills.

Maria (who declined to give her last name), buys Mexican-made birth control pills without a prescription from the local Yerberia (herbal medicine shop) where she also works. On other occasions, she gets the pills from her mother who buys them in Mexico and brings them back across the border.

Any discussion about the reproductive health needs of immigrant women has been largely absent from the public discourse surrounding both immigration and health care reform. Nationally, however, the use of birth control pills and whether or not they should be covered by health insurance has become the subject of heated debate among Republican presidential candidates.

In Arizona, some conservative lawmakers have suggested a bill to restrict health coverage for contraceptives if it goes against an employer’s religious beliefs.

For those already without insurance, like Maria, it is a moot point.

“[Insurance policies] need to cover the pills,” said Maria, who is Catholic but thinks her church stance on the pill is “old fashioned.”

In Mexico, birth control pills are sold over the counter without a prescription. For those that don’t have the means to make the trip back and forth across the border, the pills can be obtained on the underground market in Phoenix for $16 to $25.

In one Mexican market in Phoenix, the clerk said pills they carry such as Nordet and injected medications like Perlutal are originally bought in pharmacies in Puerto Peñasco, Mexico, a beach resort in the state of Sonora about 350 miles from Phoenix, and brought to the U.S. without clearing customs. Most women know by word of mouth where they can purchase the items.

“They must be very effective, because people come and buy them often,” said the clerk.

Maria, 26, said she’s a little wary of buying them without consulting a gynecologist, but it’s cheaper and she doesn’t like the type of birth control being sold in the U.S.

“I took the injection and it made me gain weight,” said Maria about her experience with the contraceptive she was provided at a local hospital, shortly after she had her last baby.

“I already have two children. I want to be sure I won’t get pregnant again.”

Choosing to buy birth control from Mexico is not unique to undocumented immigrant women.

Dan Grossman, an obstetrician/gynecologist and senior researcher with Ibis Reproductive Health, published a study in the June 2010 edition of the American Journal of Public Health that focused on women buying birth control pills along the border in El Paso.

Some U.S.-born women, according to his study, chose to cross the border into Mexico in order to have access to cheaper birth control than they would otherwise find in the U.S., much the same way that other prescription medicines are purchased at discount abroad.

“In our research, we found that most of the brands that women were getting in Mexican pharmacies in Ciudad Juarez were the same brands available in the U.S. or in Europe. These are reputable drugs,” said Grossman.

But the fact that undocumented immigrant women are buying pills brought from Mexico under the table is less than an ideal situation, he added.

“The ideal would be that they should be able to see a doctor or a nurse, get screened and be able to access the method they want free of charge,” he said. “In a context where a woman has no health insurance, where family planning services are very expensive, and this is the only option, it’s a reasonable option and a lesser evil than going without contraception.”

Grossman noted that while most pills are safe for a great majority of women, “there are some women who have contraindications or conditions that might put them at higher risk of having a problem while taking the pill.” These include a history of high blood pressure, smoking if over the age of 35 or experiencing certain types of migraines, he explained.

His research also revealed that many of the uninsured women were using the pill because they couldn’t find a more affordable option for birth control. While pills may cost anywhere from $10 to $50, using an IUD or implant can cost up to $400.

In addition, more than 60 percent of Latinas using the pill to avoid further pregnancies say they wish they had been sterilized at the time of their last delivery.

Monica Cuevas is among this group.

“I personally want to get operated on,” said Cuevas, who is saving $2,000 to have a tubal ligation, a procedure that blocks a woman’s fallopian tubes. “But I’ll take whatever [pill] I need to take because I don’t want to have any more kids”.

As an undocumented immigrant, Cuevas, 37, does not have health insurance coverage. She noted, however, that insuring sterilizations would be a more affordable option than the current practice of covering deliveries under the state’s emergency insurance plan.

For Rosie Villegas Smith, the problem is not lack of access to birth control but its wide availability combined with a lack of information.

“Immigrant women are not given information by their doctors about the side effects of birth control,” said Villegas Smith, an advocate for Voces por la Vida, a local pro-life organization.

She says she has visited Yerberias in the past to leave flyers with information for pregnant women on where to get healthcare and support in case of an unwanted pregnancy.

Another problem, she notes, is that many of these women are being pushed to use birth control by healthcare providers.

“We’ve got several reports from Catholic women that after having a baby they start receiving calls from the hospitals to make an appointment to get on birth control,” she said. “They’re pressuring them.”

Organizations like Planned Parenthood, meanwhile, are working to ensure that affordable alternatives are available to all women regardless of their immigration status.

“I think the main issue is that patients don’t have to resort to crossing the border to find birth control,” said DeShawn Taylor, director of medical affairs for Planned Parenthood Arizona. “We have affordable services for people that don’t have insurance.”