Maternity care for undocumented migrant women: The impact of charging for care

Addressing inequalities in the maternal health of vulnerable migrant women

Ethnic inequalities in maternal mortality were highlighted in Why Mothers Die, the 2004 Confidential Enquiry into Maternal and Child Health (CEMACH) report (Lewis, 2004). CEMACH's next report addressed the disproportionate numbers of maternal deaths among migrant women more specifically (Lewis, 2007). In the UK, recent migrants, refugees and asylum seekers, and women who have difficulty reading or speaking English, have been identified as being at especially high risk of pregnancy-related deaths (Lewis, 2007; Cantwell et al, 2011). The CEMACH report covering 2003–05 found that Black African women had a maternal mortality rate nearly six times that of White women (Lewis, 2004). Despite a downward trend in overall maternal mortality in the subsequent triennium, the risk is still almost three times higher for African women than for White women (Knight et al, 2014).

These reports highlighted the association between maternal death and lack of antenatal care. Many of the migrant women who died had underlying health conditions that were not identified because they had not accessed routine antenatal care. Successive Confidential Enquiries have shown that women who died received disproportionately insufficient or no antenatal care, and that migrant women were particularly likely to receive less than the level of care recommended by the National Institute for Health and Care Excellence (NICE) (Lewis, 2007; Cantwell et al, 2011; Knight et al, 2014).

Investigating the causes of maternal mortality is part of a more general interest in health inequalities in the UK since the 1990s (Marmot, 2010). The goal of reducing inequalities in health has been repeatedly restated in recent NHS policy from the start of the millennium (Department of Health (DH), 2000), as well as in the coalition government's Health and Social Care Act 2012. The DH's National Service Framework for Children, Young People and Maternity Services and Maternity Matters proposed specific improvements to maternity services as a means of reducing social inequalities in pregnancy outcomes (DH, 2004; 2007). Lewis (2012) has suggested that such policies have been developed in response to the evidence from the Confidential Enquiries, and have led to improvements in maternal mortality rates, including among the most socially excluded groups.

Maternal health has also become an international concern. Improving maternal health was one of the eight Millennium Development Goals and also features in the post-2015 Sustainable Development Goals as part of Goal 3, to ensure healthy lives and promote wellbeing for all at all ages (United Nations, 2014; 2015).

NICE guidance on antenatal care for women with ‘complex social factors’—‘women whose social situation may impact adversely on the outcomes of pregnancy for them and their baby’—is also part of this approach (National Collaborating Centre for Women's and Children's Health, 2010: 25). This terminology identifies social problems or disadvantage in distinction to additional health problems which could complicate a pregnancy (National Collaborating Centre for Women's and Children's Health, 2010; Scottish Government, 2011). It singles out recent migrants, refugees, asylum seekers and women with little or no English as a distinctive risk group.

NICE guidance and other policies have been developed to meet the needs of disadvantaged and vulnerable pregnant women in order to reduce maternal and infant mortality rates. They consistently emphasise the need for special efforts and/or service provision to identify and reach disadvantaged women in order to facilitate early booking, continuity of midwifery care throughout pregnancy, birth and postnatally, interprofessional and inter-agency collaboration, and provision of language and translation services, including extra time at antenatal appointments.

In spite of these efforts, more women with underlying medical conditions or complex social needs are giving birth, and funding cuts and staff shortages are placing greater demands on maternity services (Smith and Dixon, 2008). Migrant women are especially vulnerable in these respects, but face additional barriers to accessing appropriate maternity care.

Migrant health policy in the UK

For over 50 years after the establishment of the NHS, the question of entitlement to NHS care barely arose as almost anyone could obtain an NHS number as a permanent or temporary patient. Regulations for charging overseas visitors were introduced in 1982 but not rigorously or consistently enforced (Department of Health and Social Security, 1982). In 2004, however, entitlement to free NHS care was, for the first time in Britain, legally linked to immigration status, thus enabling the health service—like the benefit system—to become a mechanism for immigration control. Since then, hospital Trusts have had a statutory duty to determine the eligibility to health care of an ‘overseas visitor’ (NHS, 2004). This responsibility was extended in 2011 when government acquired the right to refuse further immigration applications from overseas visitors who have debts to the NHS of over £1000, and NHS bodies were ‘strongly encouraged to… improve the recovery of their debts by providing relevant information to the Home Office’ (DH, 2014a: 3).

Since 2004, only people ordinarily resident or who belong to an exempted group have been entitled to free secondary care. Until April 2015 ‘ordinarily resident’ meant living in the UK on a lawful, voluntary and properly settled basis for the time being (DH, 2015a). However, the Immigration Act 2014 redefined ordinary residence in relation to non-EEA nationals (people from outside the European Union or European Economic Area), restricting it to people with indefinite leave to remain (ILR) in the UK. This is far fewer people than formerly. All other visitors with stays of 6 months or more must now pay a visa surcharge on top of their visa application fee, after which they are entitled to free use of all NHS services.

Some groups are exempted from NHS charges, including refugees, asylum seekers awaiting a decision, refused asylum seekers supported by the Home Office and most nationals of the EEA states and Switzerland (DH, 2015a). In England, support for refused asylum seekers is subject to stringent conditions, and pregnant women who have been refused asylum can only obtain it on health and destitution grounds at 34 weeks' gestation. In Scotland and Wales, anyone who has submitted a claim for asylum, whether or not it has been successful, is entitled to free NHS secondary care (Maternity Action, 2015a; 2015b).

Non-exempted groups include refused asylum seekers not supported by the Home Office (in England and Northern Ireland only), visa overstayers, and migrants in breach of their visa conditions. This may mean that their residence or work permit is invalidated or expired, often due to breakdown of the relationship on which it was dependent, or they are residing on a tourist visa. These groups are often referred to as ‘undocumented’ or ‘irregular’ migrants. Undocumented migrants in receipt of financial support from local authorities are also not exempted from charges, including families with children in need (No Recourse to Public Funds Network, 2015).

Charges apply to all secondary care except for some exempted conditions, notably infectious diseases such as tuberculosis and sexually transmitted diseases, including HIV. Charges for treatment for conditions related to sexual violence, torture and female genital mutilation may also be exempted. The key exemption, however, has been for emergency care provided in Accident and Emergency departments.

Why have charges been imposed?

Government justifications for charging have referred to growing financial pressures on the NHS, the generous nature of UK provision of health care to foreigners, and the ‘abuse’ of this provision by ‘health tourists’ (Bragg and Feldman, 2011). The latter claim is underpinned by a view that ‘NHS resources, both financial and clinical, are used to treat and care for people who have no long term commitment to our country and should contribute towards it’ (DH, 2013a: 5).

The government's 2013 consultation exercise on charging for NHS care was particularly concerned with ‘abuse’ of the NHS by ‘health tourists’ and made specific mention of ‘maternity health tourism’ as a category. For this reason, it refused to exempt maternity care from charging, despite strong support for this in responses to the consultation, and even though it acknowledged that ‘a small number of countries’ do exempt pregnant women from health charging (DH, 2013b: 24). However, the evidence it cited for ‘health tourism’ is slim and the authors of its own research for the 2013 consultation acknowledge that it is ‘based on judgements and little direct data’ (Prederi, 2013: 93). Doctors of the World found that the average length of time in the UK prior to delivery, of women who attended the organisation's maternity drop-in clinic was 4.6 years (Shortall et al, 2015).

Another purpose of extending charging in the 2014 Act was ‘to streamline the processes, maximise net income recovered, and form a basis for design and implementation of new processes’ (DH, 2013a: 36). As a result, charging regimes in hospitals have been more aggressively enforced. Since the passage of the Act there have been growing numbers of reports of people being charged and incurring debts for NHS hospital care (Shortall et al, 2015; Maternity Action, email enquiries (unpublished)).

The government also claims that ‘the NHS [is] more generous than most other comparable systems’ (DH, 2013a: 16), but maternity care is available for undocumented migrant women in France, Belgium, Spain, the Netherlands, Italy and Portugal. In Spain, despite a new policy excluding undocumented migrants from the universal health-care system in 2012, access to free maternity care has remained universal (Aleksic, 2013). In Sweden, access to health care that cannot be postponed became available to undocumented migrants in 2013; this includes all maternity care services (PICUM, 2013).

There was widespread opposition to the extension of NHS charging during the passage of the Immigration Act 2014, especially by health advocacy organisations. Local authorities also called for exemptions from charges for families with no recourse to public funds who are supported by local authority social service departments (No Recourse to Public Funds Network, 2014). Following pressure from the Royal College of Midwives and Maternity Action, a compromise amendment was tabled in the House of Lords to exempt all pregnant women from charges unless there was evidence that they had entered the UK specifically to obtain health care (Hansard, 2014), though it was later withdrawn owing to a lack of government support.

What charging means for maternity care

NHS charging guidance for England (DH, 2015a: 66) states that

Unlike other treatment, maternity care should, therefore, be routinely offered to any pregnant woman, whatever her immigration status and regardless of her ability to pay at the time. Nevertheless, she will ultimately be charged for all antenatal, intrapartum and postnatal care, and may thus incur a debt if she cannot pay within a given period.

The complexity of charging guidance has led to confusion among NHS staff about entitlement to NHS care. Women are known to have been refused maternity care because staff mistakenly believed they were not entitled (Kelley and Stevenson, 2006; Bragg and Feldman, 2011; Daynes, 2014). A recent enquirer to the charity Maternity Action (unpublished) wrote:

Another woman wrote:

Research commissioned by the DH suggests that as many as 30% of the people assessed by Trusts were incorrectly classified, resulting in charges being imposed on people who were actually entitled to free care (Creative Research, 2013).

Other reports indicate that pregnant women themselves are afraid that they will be refused services, that they will face charges which they cannot pay, or even that they will be arrested (Taylor, 2013; Shortall et al, 2015). In this author's experience from personal communication, many midwives are unclear on what advice to give to women about being charged and what their responsibilities are with respect to charging. As a result, some migrant women do not book for maternity care, or they book very late or may avoid other necessary treatment (see case study in Box 1).

Case study

A woman had become pregnant by a British man whom she met in her country of origin, and then came to the UK on a 6-month visitor's visa; during this time, she developed complications with her pregnancy. Her baby had not moved for several weeks and no heartbeat had been detected. Clinicians told her that it was likely her baby had died, and that she would have to be induced, but the treatment would cost approximately £2500. She refused treatment because she wanted to travel back to her own country in order to apply for a 2-year spouse visa to live with her husband in the UK. A lawyer acting for her directed her to an international relief charity which ran a clinic staffed by volunteer clinicians, but did not know the outcome of her case (Aston, 2014).

Local advice agencies are receiving growing numbers of reports from women that they have been sent bills for large sums after their maternity care. One woman was charged over £4000 for maternity care for her second child, which she was unable to pay. She was only told that she would be billed after she had given birth (personal communication, Hackney Migrant Centre).

Women questioned at the Doctors of the World drop-in clinic in East London were reported to have had positive experiences of maternity care when they were not billed, but felt very anxious and pressured by charges that were beyond their means. The charge was seen as the main problem, rather than the quality of care itself (Shortall et al, 2015).

Since April 2015, charges have been set at 150% of the standard NHS tariff for the cost of the patient's care (Department of Health, 2014b). This means that standard antenatal and postnatal care plus normal delivery would incur a charge of £4190, based on 150% of the standard tariff of £1496 for delivery without complications and comorbidities, £1060 for standard antenatal care and £237 for standard postnatal care (Monitor, 2013). A caesarean section would be charged at £2244 to £3282, depending on complications and comorbidities, based on the same formula. All of these costs would exclude extra days spent as an inpatient, or intermediate or intensive antenatal care. Such charges are likely to be wholly outside the reach of almost all undocumented migrant women. NICE (2010: 16) guidelines recommend that

Moreover, migrant women who have suffered domestic abuse, or have underlying medical or psychological conditions, would also require additional appointments. In such cases the cost would be more than the average.

Health risks

The 2007 CEMACH report noted that recently arrived migrant women may have poor overall health, underlying and possibly unrecognised medical conditions, including congenital heart disease, HIV/AIDS or tuberculosis. Some may have been subject to female genital mutilation (FGM) or cutting, or are suffering psychological or physical effects of living in and fleeing from conflict zones (Lewis, 2007).

Migrant women are also significantly more likely to receive suboptimal antenatal care. The latest Confidential Enquiry into Maternal Deaths report of maternal deaths from 2009–12 found that, although 90% of all women who died did receive antenatal care, only 29% received the recommended level of care according to NICE antenatal care guidelines (booking at 10 weeks or less and no routine antenatal visits missed). The highest maternal mortality rate by country of birth was among Nigerian-born women (34.2 per 100 000 maternities, compared with 10.6/100 000 for all women, and 15.2/100 000 for all women born outside the UK). Among the 10 Nigerian women who died in this period, only one received the NICE-recommended level of care (Knight et al, 2014). By contrast, a recent general survey of maternity experiences suggests that 91% of women overall reported having attended a booking appointment by 12 weeks of pregnancy, with a median of eight antenatal check-ups (Redshaw and Henderson, 2015).

Late booking or missed antenatal appointments prevent midwives from identifying and treating health conditions early in pregnancy, in turn leading to far worse health outcomes for vulnerable migrant women. Inadequate antenatal care may prevent screening and routine scans, reversal procedures for FGM, proper planning for labour or timely implementation of multidisciplinary health or social interventions if they are needed.

Women who have had FGM are significantly more likely than others to have obstetric complications and outcomes, especially those with more extensive cutting (Banks et al, 2006). Some of these may be prevented if FGM reversal has taken place. In a study of women who had had type 3 FGM, more than 85% opted for FGM reversal after becoming pregnant. Multiparous women who had undergone FGM reversal had significantly lower rates of caesarean section than multiparous women from the general population. Multiparous women who did not opt for reversal were significantly more likely to have a caesarean section (Raouf et al, 2011).

Late or inadequate antenatal care also impedes the development of a trusting relationship between midwives and women, which is recognised as basic to good maternity care, especially for women who have experienced trauma or abuse (National Collaborating Centre for Women‘s and Children‘s Health, 2010). It is impossible to build this kind of relationship if women avoid antenatal care because they are afraid of being charged, with the result that the midwifery role becomes one of crisis management rather than of planned and supportive care.

The impact of charging can have broader consequences for both mothers and babies, as illustrated in the case study in Box 2. In this case, in spite of attending her antenatal appointments, fear of further costs deterred the woman concerned from obtaining necessary inpatient care, leaving her with long-term health problems that could have been prevented had she received all the care that she needed earlier in her pregnancy.

Case study

A woman who had experienced problems with her first baby was found to have high blood pressure during her second pregnancy. Her doctor wanted her to be admitted to hospital but she refused this because she was fearful about being charged for her maternity care (she had been charged for the care she received when she had her first baby). She attended appointments with a midwife during her pregnancy but continued to refuse to go to hospital, despite strong recommendations from the midwife and doctor that she do so. By the end of her pregnancy she was very ill and, when she gave birth, her baby was unwell. The woman's kidneys failed and she was admitted to the hospital's intensive care unit. She now requires long-term dialysis.

Another woman, whose baby had been in special care, refused to attend follow-up checks on the baby. She had been invoiced for over £3000 in maternity costs, which she could not pay, and was afraid that she would be pursued by debt collectors and that the hospital would use the appointment as a way to deport her (Kelley and Stevenson, 2006).

Cost savings to the NHS?

Charging for maternity care is not necessarily cost-saving. Charges for services cannot be recovered from impoverished women, so charging in these cases does not save money but actually incurs significant administrative costs. It can even generate further costs, as undetected or untreated health conditions in pregnancy can require complex interventions at a later date if not identified during antenatal care. NICE calculated national benefits and savings from screening and care recommendations in routine antenatal care and concluded that implementing the guidelines on antenatal care in pregnancy would enable better identification of women for whom additional care is necessary, improve care for the women and reduce complications during pregnancy and labour. It could also lead to a possible reduction in caesarean section rates, and in unnecessary admissions to neonatal care. NICE proposed that compliance with its guidance be considered a criterion of good risk-reduction strategies, which could lead to a discount on Trust contributions to critical negligence schemes (NICE, 2008).

Complex interventions, as well as the persistence of health problems because of late treatment, can lead to significant costs for the NHS. For example, identifying and treating a urinary tract infection during standard antenatal care can prevent a woman developing kidney infection which may result in premature birth. Such a minor intervention could avoid over £50 000 in costs associated with treating a very premature baby (Mangham et al, 2009).

Similarly, routine antenatal HIV testing and prophylaxis, recommended to prevent vertical HIV transmission, is likely to save the lifetime cost of HIV treatment for an affected child, estimated at around £300 000 (Health Protection Agency, 2012). It is estimated that 2% of children born to all HIV-positive women between 2005 and 2011 became HIV-positive, but the mother-to-child transmission rate was less than 1% among women with diagnosed HIV infection (Public Health England, 2013), suggesting much higher rates among the unknown but likely small number of women with undiagnosed HIV infection.

Although HIV prevalence in Black African communities in England is approximately 40 times greater than among the White population, nearly half of Black Africans with HIV are diagnosed late (Burns et al, 2007; Health Protection Agency, 2008). Routine testing is an especially effective way of enabling the reduction of vertical HIV transmission, but charges for maternity care can mean that some women at risk may not be reached.

Even when there is no major unknown health condition, extra costs are involved in caring for women in labour who have not previously booked into maternity services, such as urgent blood tests and a greater likelihood of increased interventions. Furthermore, the effort involved in trying to obtain payments from destitute or very low-income women can itself be costly to Trusts (Creative Research, 2013).

Conclusion

Charges for NHS secondary care have now been in place for over 10 years. The Immigration Act 2014 has not only extended their reach, but also made it harder for NHS Trusts to avoid charging undocumented migrants whom they know will not be able to pay. DH guidance that maternity care must not be refused because of a woman's inability to pay is likely to be of little comfort to women who are aware that a debt to the NHS can block further immigration applications which could help them regularise their status.

This article has shown how charging for maternity care continues to deter undocumented migrant women from seeking essential antenatal care, and sometimes other services. It has also highlighted the absence of evidence or cogent argument behind the government's refusal to exempt pregnant women from charging in the face of overwhelming evidence of the health risks resulting from failure to access antenatal care.

Midwives and others providing maternity care to migrant women need to inform themselves about the rules governing access to maternity care and the health risks if care is not available. Information on charging rules is available from charities such as Maternity Action (2015a; 2015b) as well as from the DH (2015b). In Sweden, pressure from activists, advocacy organisations and health professionals has reversed very restrictive access to health care for migrants. For this to happen in the UK, there is an even more urgent need for more systematic data on migrant women's experiences of maternity care.

Key Points