The ‘What Price Safe Motherhood’ report, was put together by Maternity Action in September 2018. It explores ‘the impact on migrant women who faced charges for NHS maternity care during and after their pregnancies. It was carried out in response to growing concerns that women at risk of being charged for maternity care are delaying or avoiding care. It is based on in-depth interviews with sixteen women from eleven countries'.
Mothers affected by NHS charging due to being undocumented will have no recourse to public funds. This means that people who are not entitled to work, and who are unable to access almost all state support, are being put in huge amounts of debt, at a time when they have no way of paying it off.
All the experiences and information shared below are quoted from this report.
Most of the women (interviewed for report) had no entitlement to any kind of benefit or financial support during their pregnancies because of their irregular immigration status, and so were often very poor, and even destitute.
Refusal of care
In spite of clear guidelines that all maternity care must be treated as immediately necessary and not be withheld if a woman is unable to pay, one woman was informed in writing half way through her pregnancy that her future appointments would be cancelled if she failed to pay the bill. Maternity Action’s advice service has reported several similar cases where both hospitals and GP practices have incorrectly refused treatment or GP registration because of a woman’s lack of immigration status.
The impact of charging on women
All the women interviewed described their initial reactions to receiving bills for their maternity care in terms of shock and bewilderment, especially as most of them had been unaware they had to pay, and none were in a position to do so.
Three women said that had they known earlier that they would be charged they would have had an abortion though in the event, did not do so. However, for most women, the invoices, accompanied by letters and phone calls requesting money and threatening to report them to the Home Office, or even telling them that they would never be able to regularise their stay, induced very high levels of anxiety and fear, affecting their physical as well as mental health. Some women spoke constantly of their fears of what might happen because they could not pay the bills they had received. Whether or not women were billed during or after their pregnancy, the demands for payment affected their willingness to see a midwife or doctor when they were not well, or even for routine appointments after they had given birth.
The following experiences were the ones taken from the report where the mothers were most likely to have had NRPF.
Ayesha
Ayesha came to the UK in 2011 from West Africa to an arranged marriage. She had not met her future husband but he was ‘nice and caring’ when she spoke to him on the phone. They stayed together for about 4 months but she fled from him because he turned out to be violent and abusive. At that time she could not speak English and knew nothing about the UK. She survived by helping out different women she met in her mosque who offered her shelter in return for help with housework and childcare. When she became pregnant a family took her in for a longer period but made it clear she would not be able to continue to stay once she had her child. She was afraid to go back to her country because she had run away from her husband, and she was also worried that her family would force her daughter to have FGM. She applied for asylum just before she was due to give birth.
Helena
When Helena became pregnant she discovered that her partner was already married with a family and they separated. She was not eligible for any maternity pay or benefits and had to leave her rented room in shared accommodation as she was not allowed to have a baby there. She would have become homeless had not a friend in another city offered her a place to stay.
“I am afraid that if I go to the hospital they will charge me and I’m so afraid what’s gonna happen to me if I say that I don’t have money to pay for that. If they will detain me, or if … after I have delivered the baby if I’m gonna stay at the hospital or in a detention centre or something like that.”
Beatrice
Beatrice had overstayed her student visa. When she became pregnant she was living with a man who refused to accept paternity of her child and threw her out. She then moved in with another man who turned out to be violent and abusive but she did not leave him because she had no other income and nowhere to go. Her father had been supporting her from her home country but disowned her because of the pregnancy. She was afraid to approach any authorities because “I was scared of being deported.” She told her story to some “church people” who eventually paid a deposit for a room and she managed to leave her violent partner three weeks before her due date.
Mariam
Mariam was a refused asylum seeker from West Africa who came to London after leaving asylum accommodation when her claim was refused. She came from a conservative background and had herself experienced FGM. The relationship in which she became pregnant was her first sexual relationship but her partner abandoned her as soon as she told him she was pregnant and she later discovered that he was in another relationship and already had two children. When Mariam became 29 pregnant she was living with a friend who was working but who then left the country, leaving Mariam unable to pay rent for the room and dependant on the kindness of other tenants. She later moved from place to place during much of the rest of her pregnancy.
She was also desperately unhappy, unable to eat and crying all the time, and had thought of killing herself during her pregnancy. At the time of her interview her child was almost two but she had still not told her mother that she had a child because of the stigma that would attach to her. Hospital charges of nearly £3000 were yet another blow, as Mariam believed that this debt would prevent her from making any successful immigration claim.
‘I lost 13kg (while I was pregnant) because I was sick. I couldn’t eat, and I have no one... I am on my own. It’s very hard… I was one week in hospital, on my own, no one visited me, no one helped me. Even the social (worker) was saying, this girl has been here one week today, but no one has come. Can you imagine? …. I was sharing (a room) with one lady, she’s the one who knows how I cried, all those nights, crying. ‘Stop crying’ she said. I cried night and day, night and day. She always told me, “Listen, if you don’t stop it, they will take your child away.” If you cry here, they say you don’t want the baby, or that you may hurt the baby. The midwife used to come in and say, “Do you think to hurt your baby, or something?” I say, “No. It’s not about that. What’s happened already has happened, there’s nothing I can do about that. It’s just sad. It’s still sad when you have a child that none of your family can know about.”’
Julia
Julia was charged for her third pregnancy and then billed for the earlier ones as well. When asked about how charging affected her, she said:
‘When they told me (about charging) I was so panicked. I was so afraid they were going to stop attending to my children, especially P (with asthma) because she needs the help. And G. (the last child with kidney disease). I was so afraid because I didn’t know anything about it….If I can’t afford the money and they won’t attend to my children what was I going to do? I was afraid to lose my children.’
Julia’s anxiety about her children also affected her own health, raising her blood pressure, until her solicitor assured her that her children would not be removed from her care, and she then calmed down. So far she has not been charged for her children’s medical care.
Isabella
Isabella and her partner were able to pay their bill over the period of year but nevertheless she felt that the bills she received affected her whole family.
‘I don’t think my whole family needs to be treated like that. It is not just a bill to me, or not even the bill, the harassment I had to endure all those months because I couldn’t pay. So I was very stressed, and that affected the way I look after my children, it affected how confident I was to be able to have a different role in society, like work or study and other things, I basically stopped for a year or so, so I could pay this debt. I felt like I was in debt with the whole country! Maybe it was a big deal for me, and it won’t be for other people but I was there, pretty much 10 hours a day with two small children while my husband was working extra hours a day to be able to pay this bill. Because we didn’t prepare for that.’
“I don’t go to the GP at all, I never go to the GP. And at the moment I have been diagnosed with a degenerative illness and I struggle to make my appointments. It really left me completely, not angry, but I can’t trust a place like that. Sometimes I think I prefer to be sick… I don’t want to go there. My husband thinks I am crazy, but you never know. Maybe in two months’ time they are going to send me another bill for something that I didn’t even have any idea about.”
Mei
Mei was a refused asylum seeker who moved to Home Office accommodation on section 4 support during her first pregnancy. A year after she gave birth she received bills for her maternity care. She went to the Red Cross for help and they asked the hospital to waive the charge and referred her to a debt advice service. The hospital agreed a small reduction in the bill from the date that the application for section 4 support was submitted. It also offered a six month suspension of ‘recovery action’ for payment. When we interviewed her Mei was still in section 4 accommodation and had had another child and had not been charged for maternity care for the maternity care for her second child. The debt recovery suspension for the first pregnancy was still operative at the time of the interview but the debt had not been cancelled.
Mariam
Mariam (see Chapter 2) applied for section 4 support to which she should have been entitled.
An applicant for s4 support must show that they are destitute or are likely to become destitute within 14 days. A person is “destitute” if they do not have adequate accommodation or do not have enough money to meet essential living expenses for themselves and any dependants.(2) Section 4 recipients receive accommodation and a prepayment card useable in certain shops.
However, due to an error by the adviser making the application, it was submitted as a section 95 4 application for which Mariam was not eligible.
Only people still awaiting the outcome of an asylum claim or appeal are eligible for Section 95 support.
So her application was refused, with the result that she was denied accommodation and financial support from the Home Office in the last weeks of her pregnancy. But, without being a recipient of section 4 support, Mariam was also not exempt from charges for that part of her maternity care that it could have covered. After she gave birth, she received further advice from a migrant support charity and was granted the section 4 support to which she should have been entitled earlier. At the time of her interview her maternity care charges had not been cancelled.
Advice case A - The role of advocacy in clarifying patients’ immigration status
A, a non-EEA national who had overstayed her visa, contacted the Maternity Action advice service when she was 37 weeks pregnant. She was at risk of violence from her husband and his family if she returned to her home country and had not sought maternity care as she was afraid she would be deported. Following intervention from Maternity Action’s solicitor she was accepted by a GP and a hospital. She was also referred to an immigration adviser who helped her to claim asylum and she was granted refugee status a year later.
Julia
Julia has had three children in the UK since 2008 and was never billed. After her last child was born in 2017 she separated from the children’s father and became homeless. She sought accommodation and financial support (section 17 support) from her local social services when her baby was about five months old. An official from the Home Office was present at her social services assessment. She was contacted the following day by the hospital where she had given birth and told that the Home Office had contacted them and told them that she owed money for her maternity care, and soon after she received a bill for about £6000. The following week she received a bill for about £13000 that included her two previous births. Julia had not been billed for any of her three periods of maternity care.
Mary
Mary was homeless and sleeping in a church for a year before she and her son, then aged 5, obtained accommodation from social services. She received a standing order mandate from a debt agency to make repayments for her maternity care bill of nearly £6000. She also received a 14 page form to set up a personal budget plan to repay her debt.
Beatrice
Beatrice found herself pregnant and giving birth with no immigration status, and no family member or close friend to support her.
“It’s just me alone with my child. And they’re telling me you have to pay, when my child was four months. I almost went mad. I almost went crazy. It’s my first child. I’ve got no experience. And so the guy’s calling me, you have to pay, you have to do this, when you start working, they take £100 every month. … And I’m like, so you don’t know what I’m going through! … And I told him, stop calling me! There’s no way I’m going to get the money. It’s not just that I’m alone with a child. The Home office is on my back [Crying] I can’t deal with it. It’s just crazy actually. It’s just really crazy….because I’m still trying to get over the nightmare that this is happening and I have to deal with it all alone…
...When they were calling me and saying I have to pay, I have to do this, there was a point I felt like just dying. And my son was crying, I’m like, shut up! You know what I mean? I just screamed at him like, shut up! It’s just… It does have an impact (on the child) because I shouted at him when I wasn’t meant to. Because he was just a baby then, he was a crying baby. So the whole thing was just too much for me.”
Leah
Leah had previously heard about charging but she had no idea how much it would cost. It was not her most immediate problem as her circumstances were desperate. She was abandoned by her partner when she became pregnant and had nowhere to live and no money, so that a vague notion of having to pay for her care loomed less large than the immediate reality of destitution. The actual implications of charging seemed only to have hit her when the midwife told her to bring over £2000 to her next appointment when she was 32 weeks pregnant, at which point she said she just cried.
The midwife told her to contact social services but they said they couldn’t help her.
As a healthy pregnant woman without another child and no current immigration application, social services had no obligation to support Leah.
Leah had no idea what to do next as she would not be able to stay in the shelter after the baby was born. Leah was interviewed when she was about 34 weeks pregnant. She said:
“I feel lost right now. Right now I’m still confused I don’t have any documents. Then, with the charging (I feel) bad… If I hadn’t been 33 weeks (pregnant) I could have aborted it.”
Anna
Anna’s fears almost drove her to avoid her antenatal care altogether. She was charged in midpregnancy, and was very worried about where she would find nearly £7000. She became very afraid to see the midwife at the hospital, despite suffering from constant headaches and other symptoms. She was even afraid to collect her maternity exemption certificate.
“I just filled in the form but I’m scared to collect it I just filled it out and I’ve got it at home.” She only went to her further antenatal appointments after being persuaded by a friend that she should go for the sake of the baby.
“Whenever I’m going to the midwife I’m really scared to go. I’m not happy about going there now. I’m always scared. I don’t know what’s going to happen whenever I have an appointment with the midwife. I don’t know what I’m going to hear from them. Maybe they will stop me from getting care. In the hospital I was so scared.”
Eventually the hospital did persuade her to come and have a scan but she was never again comfortable at the hospital. She eventually had her baby by C-section.
Natasha
Natasha felt that the overseas charging office was sympathetic to her situation, but even so, as a result of the bills she faced, she did not return for follow up care. She was afraid to go back for a check-up or to find out what had caused this miscarriage and possibly a previous one.
“My baby was buried and I couldn’t even go. I was just so scared that I was going to go and they were going to come and detain me.
I went to see my GP, I was still bleeding then. And then there was something still remaining so they had to take me to the theatre to do a D&C. And from then I haven’t had any examination to see anything, to see if it is all OK. At times my period is so painful, I feel cramps when I sit down, when I get up I can hardly walk sometimes. But the clots, a lot of clots…. I am scared to go to the hospital because I don’t know how I will be able to pay on top of this bill. So I haven’t had any exams just to see if it is OK.
Even to just to hear what caused the death of my baby, that is what I would really like to know. Just tell me what happened, so I know what caused the death, instead I am just thinking ‘’was I stressed?’’, ‘’was I not eating well?’’ was it a time, that I was going on the stairs and I slipped? I don’t know what caused it. Or was it a medical problem? I don’t know.”
Olivia
Olivia refused to attend further antenatal appointments after she received her first bill. But her blood pressure increased and she couldn’t eat or sleep, and became very depressed an upset. Eventually she was admitted to hospital a day before her due date with very high blood pressure.
At the time of the interview she said she was suffering a lot of pain all over her body and was unable to sleep, but “I can’t go to the hospital to get it checked because I am scared of getting more bills. I don’t have the money. My life is at risk at the moment but I just have to keep praying to God to help me.”
Many of the individuals affected by charging are in the process of applying for leave to remain in the UK, but are subsequently left saddled with burdensome debts. The complexity of the rules about entitlement also mean that many people, particularly those from minority ethnic backgrounds, are caught up in the effects of charging even when they are fully entitled to free NHS services.
It is clear that most of the women interviewed in this study will never be able to pay the sums demanded, and it is likely that the costs incurred in attempting recovery, will outweigh the actual costs incurred. But the price of charging vulnerable migrant women for maternity care is much higher, undermining the ethos and principles of a national health service created to meet clinical need regardless of an individual’s ability to pay and inherently discriminating against women. Above all it has an immediate and long-term negative impact on the health of the women and families and is a significant further barrier to migrant women’s access to health services.