Maternity Action Report Cover from the report: Duty of Care? | Credit: Screenshot of report cover With kind permission of Maternity Action
Maternity Action Report Cover from the report: Duty of Care? | Credit: Screenshot of report cover With kind permission of Maternity Action

The UK government policy to charge overseas visitors and those without papers in the UK for national health services (NHS) is putting vulnerable migrants at risk, say midwives in a new report from Maternity Action and the Royal College of Midwives (RCM).

“Can you imagine the stress of somebody who is already in a stressful situation? And most of these women have no source of income, so to have to think about [charges] on top of things; it is just another layer of anxiety,” commented one community midwife when asked about the situation for some of the migrant women she treats.

In fact, the words “horrific,” “trauma,” “strain,” and “pressure,” come up frequently when midwives describe the situations that many migrants and overseas visitors find themselves in when presenting themselves for care with the NHS. A doctor looks out of a window at a hospital  Photo Picture-alliance

The source of much of that stress and pressure is a UK government decision in 2015 that made charging possible. Upfront charging came into force in 2017. Since then, the NHS can and will charge overseas visitors and migrants without papers around 7,000 pounds for accessing standard medical care for a birth. If there are complications, the figures shoot up too.

The charity Maternity Action who published the report with support from the UK’s Royal College of Midwives (RCM) say they are the first to investigate the impact of the NHS charging policy on midwives and those they work with.

‘A climate of fear’

The midwives they interviewed say the policy is creating a “climate of fear and undermining trust” for women who access NHS services. Some of the women eligible for charges include “destitute women in the asylum system, women who have escaped sexual exploitation and domestic abuse.”Annie was trafficked in the UK since 2004 she filed her first asylum application in 2010 and she has been appealing rejection decisions since then  Photo Marianna KarakoulakiDW

“They haven’t got a lot of money for food; they’re resorting to food banks. They can’t afford the vitamins. There’s domestic abuse sometimes and they’re dependent on this spouse for money, when they haven’t got any access to anything themselves. So they’re vulnerable women. These are the issues really,” commented a community midwife.

Another specialist midwife seconded this description, describing the women she sees as “all poor, all destitute. They’ve all come in to the immigration service as destitute asylum seekers. Some have partners, some don’t.”

Impact on mental health

This has a serious impact on the mental health of many of the women say midwives.

“[One woman] ended up having a C-section [caesarian] because she was so traumatized by everything and unfortunately the baby wasn’t growing as it should and she wasn’t eating and she was admitted for mental health problems, for banging her head against the wall. She was just completely and utterly scared and frightened by the whole process.”

Many of the women the midwives visited were already living in precarious housing situations, several people in one room, belongings piled up on every available space, perhaps with several young children already. Many were trying to navigate their way through the asylum system with little or no English, their fear of the authorities often already compromised by earlier situations. Many women are forced into prostitution to repay the costs of coming to the UK  Photo Picture-alliancePAWireDLipinski

Presenting late

The fear of being charged or of being reported to the authorities means that many women present late to medical authorities. This presents dangers to the lives of the mother and baby or babies. One community midwife reported:

“I looked after a woman who didn’t access care until very late in her pregnancy because she was worried about charging. She had quite a lot of health problems as well. It ended up being very difficult for us to get the care plan in place before she delivered. Had she come earlier we could have got her on the right medication for her blood pressure. […] She had been avoiding health services, because of her worry about being charged. And that is the situation we don’t want for women, we always put the care first. And that is difficult when people have money on their minds.”

The report points out that it is not just non-EU migrants who are being charged. One midwife reported her meeting with a Roma woman from an EU country who stopped attending her appointments at 34 weeks. When the midwife went to visit her at the place she knew she was living, the Roma woman brought out a bill for 6,000 pounds saying “How can I afford this? What am I going to do? I can’t come anymore.”

The midwife says that she tried to mediate in this situation with the Overseas Visitor Manager at the hospital. This person said that they would cancel the bill “if the woman in question would take documentation to an office in the center of the city.” The documents included a tenancy agreement and wage slips. According to the report, the midwife knew this woman “a very marginalized Roma would not have access to these kinds of documents. Nor would it be feasible for her at 34 weeks pregnant, without any transport, to travel to the distant office location to prove her eligibility.” But the manager was “uncompromising.” The midwife said she felt “ridiculous,” when she had to go and deliver this message to the Roma woman. The Roma woman left the country at 36 weeks to seek medical care at home.

Health risks

Another case of a refused asylum seeker with HIV was described as “horrific.” The midwife in question explained that “although HIV treatment is exempt from charging, maternity care is not.” Women with HIV are liable for even higher charges than women without because of the extra care they require. This means that the woman was sent a large antenatal care bill and considered “delivering the baby at home without professional help.” The midwife noted that “without proper treatment, a woman may risk transmitting HIV to her baby during labor or afterwards.” The woman was reported as having lost trust in medical authorities and feeling afraid to talk to anyone anymore.Examples of dirty properties - UK inspection of asylum accommodation 2018 Credit ICIBI

In this case, states the report, the midwife managed to access some additional funding in order to continue the woman’s maternity care in her home. However, working overtime, worrying about funding and referring women to community support services and charities, which are themselves oversubscribed, is unsustainable and not something midwives should have to be worrying about, thinks Maternity Action and the RCM.

‘Professional duties at risk of being compromised’

In fact, NHS midwives “fear that their professional duties and the health of their patients are at risk of being compromised by [the] NHS charging policy.” One midwife expressed dismay at being made to feel like she was “working for the Home Office,” calling being forced to think about charging "an awful, awful feeling."

The Director of Maternity Action, Rosalind Bragg, condemned the charging regime wholeheartedly. She pointed out that midwives “are already overwhelmed by heavy workloads." What's more, “the NHS charging regime is failing both patients and the professionals who care for them.” Consequently, Maternity Action is calling for “the immediate suspension of NHS charging policy pending a full and independent review of its impact.”

Gill Walton, the Chief Executive and General Secretary of the Royal College of Midwives (RCM) agreed. “We believe maternity care should be exempt from NHS charging altogether to protect and promote maternal and new-born health,” she stated; adding that “the recommendations from this report, if implemented, will absolutely improve the situation for vulnerable migrant women and the midwives who care for them; [as well as] begin[ning]to right the wrongs of Cost Recovery. The RCM hopes the NHS Trusts, commissioners and most of all, the Government, listen to the voices of the midwives in this report and do the right thing.”


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