pregconcernBehind the headline lies a worrying tale of pregnant migrants worried about accessing maternity care for fear of exorbitant costs – and they are paying a heavy price in health terms. Andrew Chilvers and Penny Hosie report:

The recent election of the Conservative government has done nothing to allay fears that the health of pregnant migrant women is at risk because of recent legislation on UK residency rights. The rising problem of pregnant immigrants and child birth has escalated since the NHS started charging people not ’ordinarily resident‘ in the UK in 2011.

The Immigration Act 2014 by compounded this by allowing the NHS to extend charging to a wider range of migrants. From April 2015, chargeable migrants have to pay 150% of their hospital costs and the government is considering charging for more services, including Accident & Emergency (A&E). Thousands of women are thought to be affected by the NHS charges for care during pregnancy and childbirth.

Many fear that the costs of care will be so high they are prepared to give birth at home – regardless of the possible complications. Many NHS staff are critical of the charges and campaigners, including Maternity Action (the UK’s leading charity committed to ending inequality and improving the health and well-being of pregnant women, partners and young children) have called for an exemption for maternity services. But what many women do not know is that they cannot be refused care if they are unable to pay.

Fear factor in avoiding care
The plight of these pregnant immigrants was recently highlighted by Doctors of the World UK. In their report Experiences of Pregnant Migrant Women receiving Ante/ Peri and Postnatal Care in the UK (2015) the organisation found that vulnerable women who are worried about debts, unable to pay or afraid of deportation are deterred from seeking maternity care. The report said that two-thirds of pregnant users of the charity’s drop-in clinic in east London – who are mostly undocumented migrants or asylum seekers – had not received antenatal care until their second trimester. Half had no care for 20 weeks or longer.

This compares with the three quarters of pregnant women in England who receive care in the first trimester. This lack of care increases the likelihood of complications, including low birth weight, pre-term delivery and higher rates of perinatal mortality. Dr Clare Shortall, the author of the report and a volunteer at the Doctors of the World family clinic in east London, said that presenting bills to people after giving birth would act as a deterrent to seeking vital healthcare.

“Many of these bills seem to have been sent out on autopilot with no thought to how they will affect those who will receive them. Just because they are able to do it does not make it the right thing to do. It’s not just inappropriate, it’s wrong,” she said. Although the NHS categorises maternity care as ‘immediately necessary’ treatment, a number of mothers-to-be reported they had tried to register with a GP and were turned away for lack of identification. The NHS doesn’t require specific documents to register with a GP, but confusion and arbitrary requirements among healthcare administrators often leads to rejection of services for the many vulnerable applicants.

“Many of these women are already vulnerable and destitute, unable to meet the cost of their own basic needs, but they are asked to pay for general medical care,” said Janet Fyle, a policy advisor at the Royal College of Midwives.

The College has urged the government “not to use midwives as ‘gatekeepers’ to determine who is, or is not eligible for NHS care”. The average time that immigrant women spent in the UK before giving birth was almost five years – debunking the myth of so-called health tourism. Furthermore, costs for NHS treatment also increase when antenatal care is received late and pregnancies become more complicated.

‘It makes no economic sense to deny women antenatal care,’ said Phil Murwill, who contributed to the Doctors of the World report. He added that untreated complications can push up costs to £50,000, 15 times higher than if complications are identified and treated early in a pregnancy.

Concern over increased mortality rates
The health issues are an added concern. Two of the 35 pregnancies featured in this report resulted in the death of the baby – a mortality rate eight times higher than the rest of the UK. Although the study’s sample size makes generalisations impossible, both women who lost their babies reported feeling neglected or mistreated by healthcare workers.

In many cases, mothers faced emergency caesarean section or inpatient hospital stays after delivery to ensure recovery or medical treatment for themselves or their babies. Screening during pregnancy dramatically minimises the risks of existing conditions and reduces the chances of communicable diseases such as HIV and hepatitis being transferred from mother to baby. Building a trusting relationship with a healthcare professional during pregnancy also allows for the identification of other issues such as domestic violence or female genital mutilation.

’Some of these women have complex health and psychosocial problems, and may be in need of urgent referral to other agencies,’ Fyle said. Cathy Warwick, chief executive of the Royal College of Midwives, concurred with the Doctors of the World UK report. She said the College had ‘real concerns [that] the aggressive pursuit of charging migrant women for medical care could deter them from accessing maternity care’.

Poor outcomes
’I fear that these women could fall through the cracks and only find their way into the health system when it is too late – if at all, ’Warwick said. ’Women from these groups are often already in poorer health, have poor pregnancy outcomes and these steps could have negative consequences for their health.

‘Our view is very clear: midwives should not act as gatekeepers to the maternity services. They owe a duty of care to all pregnant women who seek care from them and they should provide care to all pregnant women irrespective of the woman’s ability to pay.’ Maternity Action is so concerned it has set up a campaign and is lobbying Parliament, calling for all pregnant women living in the UK to have access to free NHS care, including maternity care, primary care and accident and emergency services.

In its 2014 report briefing Charging pregnant women for NHS care and the Immigration Act 2014 the organisation concludes that it is fearful of continuing risks to both individual and public health due to the policy of charging for maternity care. It views charging for primary care and accident and emergency as particularly dangerous, given that a majority of women access maternity care via a GP and such a policy would create further barriers to health care for these vulnerable migrant women.

Compassion and care approach
At the mid-May launch of a new Doctors of the World report called Access to healthcare for children and pregnant women (2015), Professor Lesley Page, president of the Royal College of Midwives, emphasised that midwives and health workers needed to fulfil their roles as service providers rather than act as barriers between vulnerable people and medical treatment. ‘What is needed is compassion and care, not red tape and obstacles,’ she said. ‘The health implications for failing to treat and care for these women and their children can be profound and, indeed, fatal.’