Question:
You are given the full text of a scientific research paper.

    Identify and summarize the **policy problem** that this research addresses. Your response should:
    - Clearly state the societal, environmental, or strategic issue motivating the study
    - Be written in accessible, policy-brief style sentences
    - Focus on the core challenge the research aims to solve
    - Avoid excessive detail or technical jargon unless necessary for clarity

    Write a short paragraph suitable for inclusion under the “Policy Problem” section of a policy brief.

    Scientific Research Paper:
    https://doi.org/10.1177/00221465241230839
Journal of Health and Social Behavior
2024, Vol. 65(3) 324–339
© American Sociological Association 2024
DOI: 10.1177/00221465241230839
journals.sagepub.com/home/hsb
Original Article
In the past two decades, states have emerged as
important players in the immigration policy arena,
passing immigration legislation at a scale not seen in
over a century (Chacon 2019; Gulasekaram and
Ramakrishnan 2015). State legislatures have passed
more than 4,000 immigration-related laws and reso-
lutions since 2005, spanning domains including pub-
lic benefits, immigration enforcement, driver’s
licenses and identification systems, education, and
employment (Johnston and Morse 2013; Morse
2019). While some of these policies aim to drive out
immigrants by enacting new immigration enforce-
ment schemes and restricting immigrants’ access to
services and benefits, others seek to support immi-
grant integration by expanding protections from
deportation and facilitating access to health care,
social services, higher education, and other resources.
These policies have important health implica-
tions for the well-being of immigrants and their
children. For one, the expansion of public health
insurance to immigrants is associated with greater
health insurance enrollment and preventive care
utilization and in some cases, improved health out-
comes (Drewry et al. 2015; Rosenberg et al. 2022;
Schut and Boen 2022; Swartz et al. 2017, 2019;
Wherry et al. 2017). Furthermore, a growing body
of research shows that non-health-related state
immigration laws can also impact the health and
psychological well-being of immigrants and their
families (Crookes et al. 2021; Perreira and Pedroza
2019; Philbin et al. 2018).
Despite growing attention to the links between
state immigration policies and health, we have a
1230839 HSBXXX10.1177/00221465241230839Journal of Health and Social BehaviorMoinester and Stanhope
research-article2024
1Washington University in St. Louis, St. Louis, MO, USA
2Emory University, Atlanta, GA, USA
Corresponding Author:
Margot Moinester, Washington University in St. Louis,
Box 1112, St. Louis, MO 63130, USA.
Email: mmoinester@wustl.edu
Extending Driver’s Licenses to
Undocumented Immigrants:
Comparing Perinatal Outcomes
Following This Policy Shift
Margot Moinester1
 and Kaitlyn K. Stanhope2
Abstract
Research shows that restrictive immigration policies and practices are associated with poor health, but
far less is known about the relationship between inclusive immigration policies and health. Using data
from the United States natality files, we estimate associations between state laws granting undocumented
immigrants access to driver’s licenses and perinatal outcomes among 4,047,067 singleton births to
Mexican and Central American immigrant birthing people (2008–2021). Fitting multivariable log binomial
and linear models, we find that the implementation of a license law is associated with improvements in
low birthweight and mean birthweight. Replicating these analyses among U.S.-born non-Hispanic White
birthing people, we find no association between the implementation of a license law and birthweight.
These findings support the hypothesis that states’ extension of legal rights to immigrants improves the
health of the next generation.
Keywords
driver’s licenses, Hispanic or Latino, immigration policy, perinatal health, United States

Moinester and Stanhope
325
limited understanding of whether and to what
extent the enactment of inclusive immigration poli-
cies at the state level can improve health. Extant
scholarship largely focuses on the deleterious
health effects of restrictive state-level immigration
policies (Hardy et al. 2012; Torche and Sirois 2019;
Wang and Kaushal 2019; Young, Crookes, and
Torres 2022) or on the health effects of states’
immigration policy climate, a measure that captures
a range of immigration-related policies enacted in a
given
state
(Dondero
and
Altman
2020;
Hatzenbuehler et al. 2017; Schut and Boen 2022;
Stanhope et al. 2019; Sudhinaraset et al. 2021;
Young et al. 2019). Among the studies that examine
how specific state-level inclusive immigration poli-
cies impact health, the focus has primarily been on
policies that extend access to public health insur-
ance to immigrants (for notable exceptions, see
Koball, Kirby, and Hartig 2022; Potochnick, May,
and Flores 2019; Schut and Boen 2022). How non-
health-related inclusive immigration policies shape
the health and well-being of immigrants and their
children remains far less clear. Additionally, to what
extent individual inclusive policies can positively
affect health independent of states’ broader policy
climate is also not well understood.
The present study expands understanding of the
links between state immigration policies and health
by leveraging 14 years of data from the U.S. natal-
ity files to assess how state laws that authorize
undocumented immigrants to obtain driver’s
licenses are associated over time with key indica-
tors of perinatal health—early entry into prenatal
care, gestational age at delivery, and birthweight—
among Mexican and Central American immigrants.
Identification (ID) laws represent a prominent
domain of immigration policymaking with impor-
tant health implications. Government-issued IDs
are required to access a range of economic and
material resources critical for health, including
bank accounts, utilities, prescription medications,
housing, and safety net programs (de Graauw 2014;
LeBrón et al. 2018). A driver’s license is a form of
government-issued ID that has particularly strong
health-promoting potential for immigrants. For one,
given the spatially decentralized character of much
of the United States and limited public transit sys-
tems (Jones 2008), a driver’s license provides an
undocumented immigrant with not only the identi-
fication needed to obtain the aforementioned
resources but also the mobilty often required to
access these resources and occupational opportuni-
ties. Furthermore, given the recent devolution of
immigration enforcement to local law enforcement,
traffic stops now constitute a key pathway into the
U.S. immigration enforcement system (Moinester
2019; Waslin 2013). Access to a driver’s license
substantially reduces the chances that a routine traf-
fic stop leads to arrest and deportation, thereby
addressing a considerable source of stress for
undocumented immigrants and their families (Kline
2017; Rhodes et al. 2015).
At the population level, Mexican and Central
American immigrants are especially likely to expe-
rience the health benefits of this policy change.
Through its immigration policies and enforcement
actions over the past several decades, the U.S. fed-
eral government “irregularized” long-established
patterns of migration from Latin America (Menjívar
and Kanstroom 2013) and, in turn, actively con-
structed “illegality” as a racialized social condition
that is essentially synonymous with “Mexicanness”
and Latino-ness (Armenta and Vega 2017; De
Genova 2002).1 As a result of these policy changes,
Latine immigrants now comprise over 70% of the
U.S. undocumented population, with 67% of this
population hailing from Mexico and Central
America (Migration Policy Institute 2019).2
Additionally, Latine immigrants are disproportion-
ately stopped by the police and turned over to immi-
gration authorities when a driver’s license cannot be
furnished (Armenta and Vega 2017; Gardner and
Kohli 2009; Moinester 2019). Risk of deportation
following driving without a valid license is thus
especially pronounced for this population.
Findings from this study highlight the potential
of an individual state policy to positively shape the
lives of Mexican and Central American immigrants
and their children amid a highly conflictual federal
and state immigration policy climate. Over the past
two decades, deportations from the United States
have reached record levels, and anti-immigrant
rhetoric has intensified (Callaghan et al. 2019;
Golash-Boza 2015). Many states have simultane-
ously passed laws that intensify surveillance and
immigration enforcement (Young and Wallace
2019). Within this context, we find that states’
move to extend access to a driver’s license to
undocumented immigrants is associated with
improvements in low birthweight and mean birth-
weight for Mexican and Central American immi-
grants. We further find no association between
these laws and birthweight among U.S.-born non-
Hispanic White birthing people—a group for whom
no effect from the law was expected. Given that
birthweight is a critical measures of early develop-
ment (Torche and Conley 2015), this study’s find-
ings underscore how states’ extension of legal
rights to immigrants can improve the health of the
next generation.

326
Journal of Health and Social Behavior 65(3)
Background
Theorizing Driver’s License Laws
Relationship to Perinatal Health
As Young and Wallace’s (2019) health and policy
context framework elucidates, state-level immigra-
tion policies can affect health by heightening the
criminalization of immigrants or by increasing
immigrants’ integration into U.S. society. Criminal
ization policies can deleteriously affect health by
increasing stress and experiences of discrimina-
tion. Alternately, integration policies can improve
health by facilitating access to health-promoting
resources.
Access to driver’s licenses for undocumented
immigrants is a dynamic area of immigration poli-
cymaking that shapes both the criminalization of
immigrants and their integration into U.S. society.
Since 2013, 16 states and the District of Columbia
have enacted legislation that expands access to driv-
er’s licenses to undocumented immigrants. In total,
19 states and the District of Columbia currently
extend driving privileges to undocumented immi-
grants (National Conference of State Legislatures
2023). As illustrated in our conceptual model in
Figure 1, prior scholarship and Young and Wallace’s
(2019) framework suggest two key mechanisms
through which these license laws may improve peri-
natal health: (1) reduced stress and (2) increased
access to financial and health care resources. We
detail each of these mechanisms in the following.
Driver’s Licenses and Stress
The expansion of the legal right to a driver’s license
may improve Mexican and Central American immi-
grants’ perinatal health by lessening deportation
fears and subsequent stress. Exposure to stress prior
to and during pregnancy can increase risk of adverse
birth outcomes, including low birthweight and pre-
term birth. Chronic stress leads to wear and tear on
physiologic systems, altering the body’s neuroendo-
crine and immune systems, and possibly resulting in
subcellular weathering or accelerated aging (Hobel,
Goldstein, and Barrett 2008; Kramer and Hogue
2009; Traylor et al. 2020). Research links restrictive
immigration policies and enforcement actions to
elevated risk of preterm birth and lower birthweight
among Latine birthing people, with stress operating
as the presumed mechanism (Novak, Geronimus,
and Martinez-Cardoso 2016; Ro, Bruckner, and
Duquette-Rury 2020; Stanhope et al. 2019; Torche
and Sirois 2019).
Driving without a license is a source of stress for
many undocumented immigrants and their families.
In large swaths of the country, a car is needed to
access jobs, schools, health care services, places of
worship, and basic necessities such as grocery
stores (Sanchez, Stolz, and Ma 2003). Yet for immi-
grants unable to obtain a driver’s license, driving
produces risk of police discovery, arrest, and even-
tual deportation and, in turn, chronic worry and
stress (Armenta 2017; Kline 2017; Stuesse and
Coleman 2014).
Figure 1.  Conceptual Model of the Relationship between Driver’s License Laws and Perinatal Health.

Moinester and Stanhope
327
Risk of arrest and deportation following a traffic
stop has intensified for immigrants over the past 15
years—a period marked by enhanced immigration
enforcement in the U.S. interior and increased coop-
eration between local law enforcement and federal
immigration authorities (Coleman 2012; Moinester
2019). Because of these dual dynamics, routine traffic
stops now function as a key funnel into the immigra-
tion enforcement system (Armenta 2017). Racialized
policing practices and the common elision of race and
immigration status have led Latine drivers, specifi-
cally, to disproportionately be stopped by the police
and arrested when found driving without a U.S.
license (Armenta and Vega 2017; Moinester 2019).
Altogether, evidence suggests that living in a
state without legal access to driving may act as a
chronic stressor for undocumented Mexican and
Central American immigrants and their families,
with implications for perinatal health. Pregnant per-
sons may experience stress prior to pregnancy, fear-
ing for themselves or family members that a traffic
stop will result in arrest and deportation. By reduc-
ing the criminalization of immigrants, driver’s
license laws may lessen deportation fears and subse-
quent stress, potentially improving birth outcomes.
Driver’s Licenses and Access to
Resources
Extending driver’s licenses to undocumented immi-
grants may also improve immigrants’ perinatal
health by facilitating access to a diverse set of health-
promoting resources, including financial resources
and health care. Economic disadvantage is associ-
ated with adverse birth outcomes (Auger et al. 2012;
de Graaf, Steegers, and Bonsel 2013; Forde et al.
2019), and research shows that acute improvements
in financial well-being may improve birth outcomes
(Glassman et al. 2013; Hoynes, Miller, and Simon
2015). A government-issued ID, such as a driver’s
license, provides immigrants with the required docu-
mentation needed to access various financial
resources, including setting up bank accounts, cash-
ing checks, and applying for loans (de Graauw 2014;
LeBrón et al. 2018). A driver’s license also facilitates
the mobility often required to obtain these resources.
Furthermore, by making it easier for undocu-
mented immigrants to commute to work, driver’s
license laws may also lead to improved access to
jobs and potentially, increased earnings. The one
study to date that assesses this possibility finds that
the availability of driver’s licenses leads men who
are likely to be undocumented to increase their
weekly work hours and therefore their take-home
pay. This study further finds that availability of driv-
er’s licenses broadened the set of job opportunities
for undocumented immigrants (Amuedo-Dorantes,
Arenas-Arroyo, and Sevilla 2020). Given the strong
association between financial hardship and stress
(O’Neill et al. 2005), the improved financial well-
being resulting from access to a driver’s license may
also impact perinatal health by reducing stress.
Access to driver’s licenses may also improve
immigrant’s perinatal health by increasing access to
timely prenatal care. Prenatal care functions as a
mechanism for identifying and managing risk fac-
tors that may contribute to poor pregnancy out-
comes (Conway and Kutinova 2006). Early entry
into prenatal care is particularly important for birth-
ing people without regular access to preventive care
outside of pregnancy to identify and manage under-
diagnosed chronic conditions.
Disparities by nativity and ethnicity in prenatal
care utilization exist (Fuentes-Afflick, Hessol, and
Pérez-Stable 1998; Goldfarb et al. 2017; Korinek
and Smith 2011). Although limited access to insur-
ance is likely a primary driver of these disparities
(Fuentes-Afflick et al. 2006; Korinek and Smith
2011; Reed et al. 2005), limited access to reliable
transportation options, including restrictive driver’s
license policies, is an important contributor, too
(Koball et al. 2022; Korinek and Smith 2011;
Rhodes et al. 2015). Altogether, this body of work
suggests that extending driving privileges to undoc-
umented individuals may faciliate immigrants’
incorporation into society, increasing financial
resources and timely entry into prenatal care, with
positive implications for Mexican and Central
American immigrants’ birth outcomes.
Study Overview and Hypotheses
We examine the effect of enacting a state law that
extends driver’s license access to undocumented
immigrants on key indicators of perinatal health—
preterm birth, birthweight, and timing of entry into
prenatal care. Based on our conceptual model
(Figure 1), we hypothesize that the implementation
of this law would improve perinatal outcomes for
foreign-born Mexican and Central American birth-
ing people exposed to this legislation prior to gesta-
tion both by reducing deportation worry and
subsequent stress and increasing access to financial
and health care resources. We further hypothesize
that the effects may be strongest for those exposed
to the law for longer periods prior to conception,
allowing potential decreases in chronic stress and
increases in resources to take full effect.

328
Journal of Health and Social Behavior 65(3)
Data And Methods
Data and Sample
We used data from the U.S. restricted use natality files,
2008 to 2021 (National Vital Statistics System 2021)
and linked these data to county- and state-level charac-
teristics using the resident county and year. We started
the analysis in 2008 because this is the year when
Secure Communities was launched and funding for
287(g) dramatically expanded—two programs that
involve local law enforcement in immigration enforce-
ment and have been critical to the rise in deportations
following a traffic stop (Moinester 2019). These pro-
grams contribute to immigrants’ fears of driving with-
out a license and, in turn, may be consequential for
perinatal health (Rhodes et al. 2015).
The target population for this study was
Mexican and Central American birthing people
who were likely to be impacted by the passage of a
license law. We believe that undocumented birthing
people would be most strongly impacted because
they would personally receive an additional privi-
lege and reduction in deportation risk because of
the implementation of this law. The impact of these
laws may also spill over to birthing people who are
not themselves undocumented but whose partner or
other loved ones are. These persons may experience
a reduction in stress because of the passage of the
laws or increase in financial resources due to
changes for others in their household. Legal status
is not included in birth certificate data. However, to
make the study population more likely to be undoc-
umented or have undocumented partners or loved
ones, we restricted the analysis to birthing people
born in Central America or Mexico. These regions
account for 67% of the U.S. undocumented popula-
tion (Migration Policy Institute 2019). As a sensi-
tivity analysis, we stratified by maternal education
to determine whether associations are stronger
among individuals without a high school education,
who are more likely to be undocumented (Passel
and Cohn 2019).
Natality data from 2008 to 2021 included infor-
mation from both the standard and revised birth
certificates. The revised birth certificate was intro-
duced in 2003 but not adopted by all states until
2016. The standard birth certificate contains limited
information, and for some variables, such as entry
into prenatal care, the information is of lower qual-
ity (Gregory et al. 2019). For this reason, we used
information from the standard and revised birth cer-
tificates for birthweight and preterm birth analyses
but only information from the revised birth certifi-
cate for entry into prenatal care analyses.
Of all singleton births conceived between 2008
and 2020 (49,262,494), we excluded births with
missing or implausible (<20 or >43 weeks) gesta-
tional age (excluded 2,404,419), missing or implau-
sible (<500 or >5000 grams) birthweight (excluded
119,191), missing or invalid resident state or county
(excluded 49,939), or missing nativity (excluded
125,925). We then restricted to foreign-born birth-
ing people born in Mexico or Central America
(excluded 35,903,130). We further excluded other-
wise eligible births in Washington, Utah, and New
Mexico, which had a law in place prior to our study
period (excluded 170,648), and in Massachusetts,
Rhode Island, Virginia, and Minnesota, which
implemented a law following our study period
(excluded 138,519) for an analytic data set of
4,047,067 births. For entry into prenatal care analy-
ses, we further excluded births in states prior to the
adoption of the revised birth certificate or with
missing data on entry into prenatal care (excluded
251,001). Overall, no included variable was miss-
ing for greater than 7% of observations; the highest
proportion of observations had missing or implau-
sible data on gestational age (4.9%). The study
received institutional review board approval.
Independent Variable
We defined a license law as a law allowing individuals
to apply for a state driver’s license regardless of immi-
gration status. We used data from the National
Conference of State Legislatures (2023) to identify
which states have passed a license law, the enactment
date, and the date the law went into effect (i.e., imple-
mentation date). To date, 19 states and the District of
Columbia have enacted a license law. Thirteen of
these laws were implemented during our study period.
We excluded Washington, New Mexico, Utah,
Massachusetts, Rhode Island, Virginia, and Minnesota
from the analysis because license laws in these states
were implemented either before or after our study
period and there was no within-state variation in
exposure to the law. For a full list of these laws, see
Table S1 in the online version of the article.
We classified the exposure status of each birth
based on the resident state at delivery and the esti-
mated date of conception. To calculate estimated
date of conception, we used gestational age at deliv-
ery, month, and year of delivery. We assumed 15 as
the day of the month for all births because birthday
is not available in natality data. We considered births
for which the law was fully implemented at concep-
tion as exposed because these individuals would
have experienced all benefits of the law (the

Moinester and Stanhope
329
privileges of driving and accessing resources that
require a government-issued ID and the reduction in
deportation-related stress) for their entire gestation.
To assess how the relationship between the
implementation of a license law and perinatal
health changes over time, we created a set of binary
indicators based on the number of months prior to
conception that the law had been implemented in
the resident state for a secondary, lagged analysis.
For example, an individual who resided in
California (law effective January 1, 2015) at deliv-
ery and conceived in July 2015 in California would
have been assigned as exposed at conception and
exposed for six months prior to conception.
However, an individual who resided in California at
delivery and conceived in January 2015 would have
been assigned the primary exposure of exposed at
conception but not the six-month lag.
Dependent Variables
We examined four dependent variables: (1) preterm
birth (binary, <37 completed weeks gestation), (2)
low birthweight (binary, <2500 grams), (3) birth-
weight (continuous, grams), and (4) entry into pre-
natal care in the first trimester (binary, entered in
first three months). We measured gestational age in
weeks using the combined last menstrual period and
physical estimated gestational age variable (Dietz
et al. 2014).
Controls
We considered several sets of potential confounders
of the relationship between implementation of a
license law and perinatal outcomes based on a priori
knowledge. First, we considered whether the com-
position of birthing people may vary across places
and bias the observed association. Second, we con-
sidered whether economic and demographic charac-
teristics of place may drive the implementation of a
license law and impact perinatal outcomes. Third,
we considered the overall state immigration climate
as a potential confounder.
Individual.  We included information on parity
(primiparous or multiparous), age (continuous), and
specific country of origin as individual covariates.
State demographic and economic climate.  To
characterize differences in demographic and eco-
nomic characteristics that may act as confounders,
we included information on county and state
characteristics. For counties, we included rurality
(urban or rural, binary), defined using classifica-
tions from the National Center for Health Statistics
(2017). For states, we included the following mea-
sures: the percentage of adults (≥25 years of age)
with a high school education, the percentage of
adults (≥16 years of age) who were unemployed, the
percentage of Latine individuals in the state who
were noncitizens, and the percentage of foreign-
born Mexican and Central American individuals
who were noncitizens. These time-varying variables
were created using data from the American Com-
munity Survey, three-year estimates for 2008 to
2009 and five-year estimates for 2010 to 2020.
Immigration policy and enforcement climate.  We
characterized differences in counties’ and states’
policy and immigration enforcement climates using
several indicators. At the county level, we assessed
the presence of a 287(g) agreement for each year.
For example, a 287(g) agreement that went into
effect in 2010 and ended in 2012 was recorded in
our data as being present in 2010, 2011, and 2012
for individuals residing in that county at delivery. At
the state level, we assessed the annual immigration
detainer rate per 100,000 noncitizens. We further
capture states’ overall immigration policy climate
annually using the Immigration Climate Index (ICI;
Pham and Van 2014, 2019). To avoid overlap with
the exposure, which is included in the ICI following
its enactment, we created a modified ICI. For births
conceived prior to the enactment of the license law,
this took the value of the cumulative ICI (2005 to
conception year), representing all relevant enacted
policies in the state. For births conceived following
the enactment of the license law, we subtracted 3
points—the value representing the license law—
from the cumulative ICI. As indicators of overall
support for perinatal health in the state, we exam-
ined whether the Children’s Health Insurance Pro-
gram (CHIP) unborn child option was active in the
state, which provides Medicaid coverage to other-
wise ineligible pregnant immigrants during their
pregnancy, and whether the state had expanded
Medicaid under the Affordable Care Act.3 Both of
these variables were year specific. Data on detainers
were provided by the Transactional Records Access
Clearinghouse (2024), and data on the noncitizen
population came from the American Community
Survey. Data on state adoption of the CHIP unborn
child option and Medicaid expansion came from the
Kaiser Family Foundation (Brooks et al. 2022; Kai-
ser Family Foundation 2023).

330
Journal of Health and Social Behavior 65(3)
Comparison Group
We considered two potential comparison groups to
represent the counterfactual comparison. First, indi-
viduals residing in states that never enacted license
laws were a potential comparison group and offer
the advantage of controlling for secular trends.
However, after descriptive analyses (Table 2), we
observed differences in enacting and nonenacting
states at baseline that widened over time, including
for the ICI, state detainer rate, and Medicaid expan-
sion status. Thus, we considered this group an inap-
propriate comparison group. Second, we considered
individuals residing in states that would eventually
enact a license law but had not yet enacted the law
to be a potential comparison group. This group
offers the advantage of a better counterfactual com-
parison for state economic and immigration climate
(Table 2). Furthermore, due to the large number of
states and wide variation in time of enactment of
license laws, it allows for a robust comparison
group. We selected this second group (not yet enact-
ers) as the comparison group.
Analytic Approach
For our primary analysis, we compared individuals
residing in a state with a license law in place (imple-
mented) at the estimated date of conception to those
residing in a state where a license law was not imple-
mented before the pregnancy but would be imple-
mented
following
the
pregnancy,
excluding
individuals partially exposed (e.g., individuals for
whom the law was implemented during their preg-
nancy). We fit multivariable log binomial models for
preterm birth, low birthweight birth, and entry into
prenatal care and linear models for birthweight to cal-
culate risk ratios (or beta estimates) and 95% confi-
dence intervals (CIs). We fit models including state
fixed effects to account for unmeasured characteris-
tics of the state that may have influenced the enact-
ment of a license law. We included covariates
sequentially and fit four models for each outcome:
(1) unadjusted (Model 0), (2) individually adjusted
(Model 1, controlling for age [linear and quadratic],
parity [binary: primiparous or multiparous], specific
country of origin [Mexico, Honduras, El Salvador,
Guatemala, or other], state fixed effects, year and
month of conception), and (3) adjusting for state
demographic and economic climate (Model 2, add-
ing state percentage of adults [≥25] with a high
school education, percentage of adults [≥16] who
were unemployed, percentage of Latine individuals
in the state who were noncitizens, percentage of for-
eign-born Mexicans and Central Americans who
were noncitizens, and county rurality), and (4) adjust-
ing for the cumulative ICI minus license laws (Model
3 + adding the adjusted ICI value). Finally, we fit a set
of models with lagged exposures (6, 12, 18, and 24
months) to assess how the relationship between
license laws and perinatal health changes over time.
For each lagged model, we excluded individuals par-
tially exposed to that lag (e.g., individuals for whom
the law was implemented between 6, 12, 18, or 24
months prior to conception and the birth date).
Sensitivity Analyses
We conducted several sensitivity analyses to inter-
rogate the impact of analytic choices on our
observed results. First, we repeated models among
non-Hispanic, U.S.-born White birthing people as a
placebo analysis. This group should not have been
considerably impacted by the policy decision to
extend access to driver’s license to undocumented
immigrants. Repeating the analysis for this group
would tell us if there were other time-varying pro-
cesses that may have occurred at the same time and
impacted perinatal health generally, although it does
not account for processes specific to immigrant
communities (e.g., stress due to changes in national
immigration climate during the Trump presidency).
Second, we fit models stratifying by individual edu-
cational attainment (less than high school or high
school graduate or higher). Education levels of
undocumented immigrants are well below those of
documented immigrants (Passel and Cohn 2019). A
stronger association among individuals with lower
education would be consistent with our hypothesis
that these laws would have the greatest impact on
undocumented persons. Finally, to determine the
impact that the COVID-19 pandemic may have had
on results, we repeated the analysis restricting to
births occurring in 2008 to 2019.
Results
Descriptive Analysis
Table 1 provides descriptive statistics of Mexican-
and Central American-born individuals delivering a
live-born infant in states that either never enacted a
license law or enacted and implemented one during
our study period. Statistics are provided for 2008
(the first year of data in this sample) and 2020 (the
last full year of data in this sample). Overall, pre-
term birth rates were lower in states that enacted
license laws compared to those that did not, although
rates in both groups declined over time. Similarly,
Mexican- and Central American-born birthing

Moinester and Stanhope
331
people delivering in states that enacted license laws
were more likely to enter prenatal care in the first
trimester. Birthweight was similar across groups
and over time. Other birthing person characteristics
were similar across groups (i.e., education, parity,
marital status). In both 2008 and 2020, a greater pro-
portion of birthing people lived in counties with
287(g) agreements in place in states that never
Table 1.  Characteristics of 368,305 Mexican- and Central American-Born Birthing People Delivering
Live Born, Singleton Infants in States That Have and Have Not Enacted Laws Providing Licenses to
Undocumented Immigrants, 2008 and 2020, 43 States and the District of Columbia.a
Never Enacted
Enacted

2008
2020
2008
2020

N = 52,752
N = 143,416
N = 55,443
N = 116,694
Birthing person characteristicsb
% (n)
% (n)
% (n)
% (n)
Preterm birth
14.8 (7,779)
12.5 (17,919)
13.5 (7,491)
11.1 (12,946)
Very preterm birth
2.3 (1,231)
1.5 (2,178)
2.1 (1,144)
1.3 (1,525)
Low birthweight
6.4 (3,372)
5.7 (8,098)
6.2 (3,448)
5.7 (6,597)
Very low birthweight
1.3 (683)
.8 (1,157)
1.2 (681)
.8 (939)
Mean birthweight, grams (SD)
3,283.8 (557.5)
3,284.6 (521.9)
3,293.3 (551.2)
3,298.3 (526.8)
Entered prenatal care in first
trimester
54.8 (28,922)
56.9 (81,659)
75.1 (41,647)
73.7 (85,983)
Mean age (SD)
27 (6.1)
29.2 (6.2)
27.8 (6.1)
30.2 (6.2)
Primiparous
25.6 (13,509)
21.9 (31,471)
26.3 (14,584)
21.4 (24,968)
Marriedc
50.6 (26,715)
52.2 (74,767)
49.6 (27,506)
46.1 (23,207)
Birthing person educationd
  Eighth grade or less
31.2 (16,294)
22.3 (31,643)
29.9 (16,145)
21.3 (23,707)
  Some high school
30.2 (15,802)
22.4 (31,791)
30.2 (16,304)
21.5 (23,938)
  High school graduate
26.3 (13,757)
32.7 (46,427)
26.2 (14,173)
32.3 (35,892)
  Some college/associates
8.1 (4,251)
13.6 (19,269)
9.6 (5,177)
16.2 (17,981)
  College or more
4.2 (2,177)
9.2 (13,039)
4.1 (2,221)
8.7 (9,699)
Country of origin
  Belize
.1 (56)
.1 (165)
.2 (122)
.3 (306)
  Costa Rica
.3 (137)
.4 (555)
.1 (65)
.4 (449)
  El Salvador
4 (2,114)
7.2 (10,330)
6 (3,343)
12.9 (15,010)
  Guatemala
4.2 (2,237)
13.6 (19,430)
4.2 (2,311)
11.6 (13,565)
  Honduras
3.5 (18,69)
13 (18,576)
1.7 (955)
6.5 (7,626)
  Mexico
86.2 (4,5464)
64.1 (91,956)
87 (48,226)
67.2 (78,423)
  Nicaragua
1.2 (628)
1.2 (1,779)
.6 (313)
.9 (1,017)
  Panama
.5 (247)
.4 (625)
.2 (108)
.3 (298)
County-level characteristics
13.1 (6,920)
12.1 (17,302)
2.7 (1,472)
2.3 (2,727)
  Lived in a rural countye
24.5 (1,2943)
19 (27,184)
6.8 (3,771)
2.6 (3,053)
  287(g) contract in placef
14.8 (7,779)
12.5 (17,919)
13.5 (7,491)
11.1 (12,946)
aExcluding seven states that implemented license laws outside of our study period.
bMeasured using data from the National Vital Statistics System (2021).
cMissing 344,884 observations.
dMissing 266,570 observations.
eNational Center for Health Statistics (2017).
fDefined as any police department within the county (including municipal) having an active 287(g) agreement with
Immigration Customs Enforcement any time during the year. These agreements were obtained using the Internet
Archive.

332
Journal of Health and Social Behavior 65(3)
enacted license laws compared to those that did. The
proportion of birthing people living in counties with
287(g) agreements declined over time in both
groups. Finally, individuals living in states that
never enacted a license law were more likely to live
in a rural county than individuals residing in states
that passed a license law.
State demographic and economic characteristics
were similar across groups at each time point (Table
2). However, indicators of immigration enforcement
climate show a more positive climate for immigrants
in states that enacted license laws with increasing
inclusivity in 2020 compared to 2008. The median
ICI was −7 (interquartile range [IQR] = 11) in states
that never enacted a license law in 2008 and −15
(IQR = 47) in 2020. In states that enacted a license
law, the ICI was 2.0 (IQR = 4.0) in 2008 and 39
(IQR = 27) in 2020. Similarly, the median detainer
rate was lower in both 2008 and 2020 in states that
enacted license laws than in states that never enacted
a license law. States that enacted license laws were
also more likely to adopt the unborn child option
under CHIP and expand Medicaid than states that
never enacted a license law.
Multivariable Log Binomial and Linear
Models
After adjusting for year and month; individual,
county, and state characteristics; and state ICI,
Central American- and Mexican-born individuals
residing in states at delivery with a license law in
place since the estimated date of conception had
lower risks of preterm birth (fully adjusted relative
risk [RR] = .90; 95% CI = [.89, .92]) and low birth-
weight birth (adjusted RR = .93; 95% CI = [.91,
Table 2.  Characteristics of State Demographics, Economy, and Immigration Climate in States That
Have and Have Not Enacted Laws Providing Licenses to Undocumented Immigrants, 2008 and 2020, 43
States and the District of Columbia.a
Never Enacted,
2008
Never Enacted,
2020
Enacted, 2008
Enacted, 2020
N (States)
31 States
31 States
12 States + DC
12 States + DC
State-Level Characteristics
Median (IQR)
Median (IQR)
Median (IQR)
Median (IQR)
Median Immigration Climate
Indexb
–7 (11)
–15 (47)
2 (4)
39 (27)
Median state detainer rate (of
100,000 noncitizens)c
712.9 (1,115.4)
709.4 (403.6)
422.5 (715.5)
263.3 (265.6)
Percentage with a high school
(or more) educationd
85.7 (7.2)
90.4 (5.1)
86.9 (3)
90.2 (1.7)
Percentage of Latines who are
noncitizensd
27.2 (17.4)
20 (13.2)
28.9 (10.2)
21.9 (7)
Percentage of foreign-born
Mexican and Central
American-born who are
noncitizensd
79 (7.4)
73.6 (10.7)
79.5 (9.6)
72 (8.5)
Percentage of adults
unemployedd
8.6 (1.5)
7.2 (1.3)
8.3 (1)
7.3 (1)
Medicaid expansion under
Affordable Care Act, % (n)e
25.8 (8)
54.8 (17)
100 (13)
100 (13)
State CHIP unborn child
option in place, % (n)f
22.6 (7)
29 (9)
46.2 (6)
46.2 (6)
Note: IQR = interquartile range; CHIP = Children’s Health Insurance Program.
aExcluding seven states that implemented license laws outside of our study period.
bPham and Van (2014, 2019).
cTransactional Records Access Clearinghouse ( 2024).
dFrom American Community Survey, three-year estimates for 2008 to 2009 and five-year estimates for 2010 to 2020.
eKaiser Family Foundation (2023).
fBrooks et al. (2022).

Moinester and Stanhope
333
.96]), a slight increase in mean birthweight (adjusted
β = 5.2; 95% CI = [1.6, 8.7]), and lower probability
of first-trimester prenatal care (adjusted RR = .98;
95% CI = [.97, .98]) compared to individuals resid-
ing in a state without a license law implemented
prior to conception (Table 3). Additionally, varying
the lag in the exposure (i.e., classifying individuals
as exposed only if the law was in place 6, 12, 18, or
24 months prior to conception) did not change the
results for first-trimester prenatal care (Table 4). For
preterm birth, low birthweight, and mean birth-
weight, the estimated associations were slightly
stronger the greater the lag time, with the greatest
change occurring for birthweight.
Sensitivity Analyses
We conducted a series of additional analyses to
assess assumptions underlying our analysis and
interpretation. First, a causal interpretation of our
results assumes there were no other events occur-
ring at or around the passing of these laws in each
state that affected perinatal outcomes for Mexican/
Central American-born birthing people living in the
state. To test this possibility, we used a placebo
approach and examined the effect of passage of a
driver’s license law on U.S.-born, non-Hispanic
White birthing people (see Table S2 in the online
version of the article), a group for whom no effect
from the law was expected. In the fully adjusted
model, there was no observed association for low
birthweight, mean birthweight, or entry into prena-
tal care and a slight inverse association for preterm
birth (RR = .97; 95% CI = [.96, .98]). Second, we fit
models stratifying by birthing person’s educational
attainment (Table S3 in the online version of the
article). In fully adjusted models, we observed a
slightly stronger protective association among indi-
viduals who did not have a high school education
for preterm birth, low birthweight, and mean birth-
weight. However, the observed association with
first-trimester entry into prenatal care remained in
the opposite direction of our hypothesis (lower
probability of entry for individuals exposed to the
law since conception). Lastly, to determine whether
the COVID-19 pandemic impacted our results, we
repeated our analysis excluding births in 2020 to
2021 (Table S4 in the online version of the article).
Table 3.  Models (Log Binomial and Linear) Estimating Associations between Exposure to a Law
Since Conception Allowing Driver’s Licenses for Undocumented Immigrants and Perinatal Outcomes,
Mexican- and Central American-Born Birthing People in the 12 States and the District of Columbia That
Implemented a License Law between 2008 and 2020, N = 1,903,939.a
Preterm Birth
Low Birthweight
Birthweight
First-Trimester
Entry into Prenatal
Careb

RR [95% CI]
RR [95% CI]
β [95% CI]
RR [95% CI]
Unadjusted
1.02 [.96, 1.07]
1.09 [1.06, 1.12]
–15.9 [–25.1, –6.7]
1.01 [.97, 1.05]
Individually adjustedc
.94 [.92, .96]
.94 [.92, .97]
3.7 [.7, 6.7]
.99 [.98, .99]
Adjusted for state
economic and
demographic covariatesd
.91 [.89, .93]
.93 [.91, .96]
5.7 [2.2, 9.2]
.97 [.97, .98]
Additionally adjusted for
Immigrant Climate Index
.90 [.89, .92]
.93 [.91, .96]
5.2 [1.6, 8.7]
0.98 [.97, .98]
Note: RR = relative risk; CI = confidence interval.
aData obtained from the National Vital Statistics System (2021); American Community Survey, three-year estimates
for 2008 to 2009 and five-year estimates for 2010 to 2020; National Center for Health Statistics (2017); and Pham
and Van (2014, 2019).
bIncluding births in states following the implementation of the revised birth certificate (1,832,026).
cAdjusted for fixed effects for state, year of conception (continuous and quadratic), parity (binary), birthing person’s
age (continuous and quadratic), month of conception, and country of origin.
dAdjusted for fixed effects for state, year of conception (continuous and quadratic), month of conception, parity
(binary), birthing person’s age (continuous and quadratic), country of origin, rurality (county-level, binary),
unemployment rate (state), percentage of Latine individuals who are noncitizens (state), percentage of foreign-born
Mexican- and Central American-born individuals who are noncitizens, and percentage of adults without a high school
diploma.

334
Journal of Health and Social Behavior 65(3)
The direction and magnitude of the associations did
not change, but the association for birthweight was
no longer statistically significant.4
Discussion
Over the past several years, states have increasingly
enacted policies that extend access to driver’s licenses
to undocumented immigrants. We exploit state and
temporal variation in the implementation of these
policies to estimate their association with perinatal
health outcomes for birthing people from Mexico and
Central America. We proposed that access to a driv-
er’s license law may improve perinatal health by
reducing chronic stress and/or expanding access to
financial and health care resources and that the
strength of the association would increase over time.
Overall, our results provide support for these hypoth-
eses. Adjusted models showed reduced risk of pre-
term birth and low birthweight and higher mean
birthweight comparing individuals in a state with a
license law in place during gestation to those residing
in a state who would eventually implement a license
law but had not yet during that pregnancy. For pre-
term birth, low birthweight, and birthweight, we fur-
ther observed a lagged association—the estimated
associations were slightly stronger the greater the lag
time. Our sensitivity analysis with U.S.-born,
non-Hispanic White birthing people suggests that the
laws do not appear to impact birthweight among indi-
viduals who were already eligible to receive driver’s
licenses prior to the passage of the law and who are
unlikely to be perceived as undocumented. However,
we observed a slight protective association for pre-
term birth among U.S.-born, non-Hispanic White
birthing people, suggesting that other secular pro-
cesses may have driven part of the observed associa-
tion for Mexican- and Central American-born
birthing people as well. Our sensitivity analysis strat-
ifying results by education suggests that the imple-
mentation of a license law is associated with greater
improvements in preterm birth, low birthweight, and
birthweight among Mexican and Central American
birthing people with less than a high school education
compared to those with at least a high school degree.
Immigrants with lower levels of education are more
likely to be undocumented and thus directly impacted
by these laws (Passel and Cohn 2019).
Overall, our results and sensitivity analyses pro-
vide the strongest support for a protective effect of
license laws on low birthweight and birthweight.
Although we find an association between license
laws and improvements in preterm birth, our sensi-
tivity analysis with non-Hispanic White birthing
people suggests that the protective effect for pre-
term birth may have partially resulted from secular
Table 4.  Models (Log Binomial and Linear) Estimating Associations between Implementation of a Law
prior to Conception Allowing Driver’s Licenses for Undocumented Immigrants and Perinatal Outcomes,
Mexican- and Central American-Born Birthing People in the 12 States and the District of Columbia That
Implemented a License Law between 2008 and 2020, N = 1,903,939.a
Number of
Months in
Place prior to
Conceptionb
Preterm Birth
Low Birthweight
Birthweight
First-Trimester
Entry into
Prenatal carec
N
RR [95% CI]d
RR [95% CI]d
beta [95% CI]d
RR [95% CI]d
1 or more
1,903,939
.90 [.89, .92]
.93 [.91, .96]
5.2 [1.6, 8.7]
1.01 [.97, 1.05]
6 or more
1,830,680
.89 [.87, .91]
.93 [.9, .96]
7.5 [3.4, 11.5]
.98 [.97, .98]
12 or more
1,760,122
.88 [.86, .9]
.92 [.89, .96]
8.6 [3.8, 13.4]
.97 [.96, .98]
18 or more
1,698,533
.88 [.86, .91]
.91 [.87, .95]
10.8 [5.6, 16.1]
.97 [.96, .98]
24 or more
1,638,869
.87 [.84, .9]
.88 [.84, .93]
16.3 [10.4, 22.2]
.97 [.97, .98]
Note: RR = relative risk; CI = confidence interval.
aData obtained from the National Vital Statistics System (2021); American Community Survey, three-year estimates
for 2008 to 2009 and five-year estimates for 2010 to 2020; National Center for Health Statistics (2017); and Pham
and Van (2014, 2019).
bFor each lag, partially exposed individuals were excluded (e.g., individuals for whom the law was implemented in
between the specific lag cutoff and the birth date).
cIncluding births in states following the implementation of the revised birth certificate (1,832,026).
dAdjusted for fixed effects for state, year (continuous and quadratic), parity (binary), birthing person’s age (continuous
and quadratic), country of origin, rurality (county-level, binary), unemployment rate (state), percentage of Latine
individuals who are noncitizens (state), percentage of foreign-born Mexicans and Central Americans who are
noncitizens, percentage of adults without a high school diploma, Immigration Climate Index.

Moinester and Stanhope
335
processes that impacted both groups and are not
accounted for by our set of controls. These results
are consistent with prior research on the impact of
inclusive immigration policies at the federal level
on perinatal outcomes, which found that the
Deferred Action for Childhood Arrivals program
was associated with improvements in low birth-
weight and birthweight but not preterm birth
(Hamilton, Langer, and Patler 2021). Our findings
further align with work demonstrating associations
between state-level restrictive immigration policies
and birthweight (Torche and Sirois 2019). The
observed associations for low birthweight and
mean birthweight may have resulted from a reduc-
tion in stress and/or increased access to economic
resources following the implementation of the pol-
icy. These two mechanisms are both plausible
impacts of a driver’s license law as shown through
prior research (Amuedo-Dorantes et al. 2020;
Rhodes et al. 2015).
In contrast to our hypothesis, we did not observe
an increase in first-trimester entry into prenatal care
for individuals exposed to the law, and in adjusted
models, we observed a slightly lower probability of
first-trimester entry into care for exposed individu-
als. This finding suggests that the observed associa-
tion between license laws and perinatal outcomes is
not driven by access to prenatal care. There are
multiple potential explanations for this result. First,
in enacting states, most of the study population
entered prenatal care in the first trimester prior to
the implementation of the law (73.8%; Table 1),
and there may have been little room for improve-
ment. Second, although lack of access to driver’s
licenses has been described as a barrier to entry into
prenatal care for Latine birthing people in the past
(Rhodes et al. 2015), many significant barriers
(e.g., insurance, cost, distance to care, language
barriers) remain. Access to a driver’s license would
not have addressed these barriers, and other secular
processes may have exacerbated them.
Altogether, the findings from this study under-
score the potential for an individual state policy to
positively shape the lives of immigrants and their
families amid a shifting and largely exclusive fed-
eral immigration climate. The laws included in this
study were implemented between 2013 and
2020—a period characterized by increasingly nega-
tive discourse around immigration at the national
level, especially since 2015, and an increasingly
restrictive federal immigration enforcement climate
under President Trump (Callaghan et al. 2019;
Capps et al. 2018). Within this context, we find that
the extension of the legal right to drive to undocu-
mented immigrants is associated with health
benefits for the children of Mexican and Central
American immigrants. Our findings, in turn, sug-
gest that state policies that reduce the criminaliza-
tion of immigrants and facilitate immigrants’
integration into U.S. society may act as a buffer
against a restrictive federal immigration climate.
The results of this study should be interpreted in
light of several limitations. First, we relied on natal-
ity data to define place of birth, residence, and out-
comes, which may be subject to misclassification,
particularly for entry into prenatal care. To address
this problem, we only used data from the revised
birth certificate for entry into prenatal care, which
has shown adequate quality (57% to 70% agree-
ment between birth certificates and medical
records; Gregory et al. 2019). Second, we used data
from both the standard and revised versions of the
birth certificate, which were implemented in differ-
ent years in different states and may impact data
quality. Third, we imperfectly identified the popula-
tion possibly impacted by the law by restricting to
birthing people born in Mexico or Central America.
This identification strategy may exclude key popu-
lations (e.g., other immigrant groups less likely to
be undocumented) or include nonimpacted popula-
tions (e.g., lawful permanent residents and natural-
ized citizens without close network ties who are
undocumented). We speculate that if we were able
to identify only undocumented individuals, the pol-
icy effects would be larger. This is supported by the
fact that estimated effects were stronger among
individuals without a high school education, who
are more likely to be undocumented (see Table S3
in the online version of the article). Fourth, we
assign the exposure based on resident state at deliv-
ery and timing of conception. Some individuals
may have moved states during the pregnancy and
thus have the exposure misclassified. If individuals
were more likely to move into states following the
implementation of the law, this bias could be
toward the null. We speculate that this likely
impacts a minor proportion of individuals.
The findings from this study suggest several
directions for future research. More research is
needed on the mechanisms linking driver’s license
laws to improved perinatal health. Although our
findings suggest that the observed associations are
not driven by access to prenatal care, we are unable
to assess the role of reduced stress and increased
access to financial resources. To fully disentangle
the mechanisms linking license laws and perinatal
health requires other kinds of data and analyses.
Additional research is also needed on how driver’s
license laws intersect with other state-level policies
to shape perinatal health. In controlling for the ICI,

336
Journal of Health and Social Behavior 65(3)
this study shows that driver’s license laws are asso-
ciated with improved birthweight independent of
states’ broader policy climate. Yet given that many
states possess a combination of integrative and
criminalization policies (Young and Wallace 2019),
it may be that driver’s license laws lead to greater
improvements in birthweight in certain policy con-
texts. Future research should explore this possibil-
ity and variation in the impact of license laws on
different racial-ethnic groups. In the context of a
polarized and oscillating federal immigration cli-
mate, additional evidence on if, how, and for whom
state supportive policies can improve immigrant
well-being is urgently needed.
Acknowledgments
We thank Susan B. Long at the Transactional Records
Access Clearinghouse at Syracuse University, Pham
Hoang Van, and Huyen Pham for their help accessing the
data we use in this study. We thank Michael R. Kramer
and Michael Esposito for their feedback on the work in
progress. Any errors are our own.
Funding
The authors disclosed receipt of the following financial
support for the research, authorship, and/or publication of
this article: This work was conducted with support from the
National Science Foundation (Award No. SES-1655497);
the National Heart, Lung, and Blood Institute (Award No.
K99HL161355); and the American Bar Foundation.
ORCID iD
Margot Moinester
 https://orcid.org/0000-0002-2734-1863
SUPPLEMENTAL MATERIAL
Tables S1 to S6 are available in the online version of the
article.
Notes
  1.	 For example, the end of the Bracero Program and
passage of the Hart-Cellar Act curtailed long-
established legal migration pathways from Mexico
and Central America while not addressing the eco-
nomic demand for labor within the United States
or the root causes of migration across the southern
border (Calavita 2010; Massey and Pren 2012).
Furthermore, policies such as the Immigration
Reform and Control Act substantially increased the
cost and risk of crossing the United States-Mexico
border, leading undocumented migrants to reduce
their return trips to their home country after reach-
ing the United States (Massey and Pren 2012).
  2.	 The term Latine is used to capture multiple genders
and nonbinary individuals. Throughout this article,
we use the term Latine rather than Latina to acknowl-
edge that not all birthing people identify as female.
  3.	 We examined Medicaid expansion and CHIP in our
descriptive analyses but not in our regression analy-
ses because of the lack of variation in both variables
among states that implemented a driver’s license
law (see Table 2).
  4.	 This change in significance is likely due to the
smaller sample size. In addition to excluding two
years of data, we excluded New Jersey, New York,
and Oregon because no births prior to 2020 were
conceived following the implementation of the
license law in these states.
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Author Biographies
Margot Moinester is an assistant professor in the
Department of Sociology at Washington University in St.
Louis. Her research focuses on immigration, policing,
health, and inequality in the United States. Her research
has been supported by the National Science Foundation
and the Russell Sage Foundation.
Kaitlyn Stanhope is an assistant professor in the
Department of Epidemiology in the Emory Rollins School
of Public Health. Her research focuses on understanding
how structural and interpersonal stressors impact health
outcomes for birthing people and their infants and identi-
fying policy, community, and clinical interventions that
may mitigate those negative impacts. Her research has
been supported by the National Heart, Lung, and Blood
Institute and Health Resources and Service Administration.

    Policy Problem:

Answer: Access to a driver’s license is emerging as a public-health determinant for the U.S.-born children of undocumented immigrants. Nineteen states and the District of Columbia—including Minnesota in 2023—now allow residents to obtain a standard license regardless of immigration status, yet half the country still withholds this basic mobility credential. Without a license, expectant parents face greater fears of deportation during routine travel, higher transportation costs, and limited access to prenatal check-ups, nutritious food, and steady employment—all factors linked to low birth weight and other adverse birth outcomes. Evidence on restrictive immigration enforcement already shows measurable harm to maternal and infant health, but we still lack clear data on whether supportive measures like driver-license expansion can reverse or offset those harms. As more legislatures revisit licensing laws and a number of existing statutes come up for renewal or amendment, policymakers need robust, state-level evidence on the health equity stakes of driver-license access in order to weigh public-safety concerns against the potential to improve early-life health and reduce long-term healthcare costs.