RCOG Position Statement: Equitable access to maternity care for refugee, asylum seeking and undocumented migrant women

Access to timely, safe and appropriate maternity care should not depend on a woman’s immigration status or ability to pay. Addressing additional barriers to a safe pregnancy experienced by migrant women is a vital part of ending the UK’s persistent inequities in maternal and perinatal outcomes.

Key recommendations

The UK Government must immediately and permanently suspend NHS charging regulations for maternity care due to the harm this system causes to the health of women and their babies during the perinatal period.
Until charging for maternity care is suspended or abolished, NHS Trusts in England must review and improve practices relating to charging pregnant women to ensure that women are not deterred from accessing perinatal and maternity care, or have care refused or delayed. The RCOG supports the recommendations set out in Maternity Action’s Breach of Trust report, including that all NHS Trusts adopt and commit to implementing the Maternity Action and Royal College of Midwives guidance Improving access to maternity care for women affected by charging.
Commissioners of interpretation services for maternity care must ensure that healthcare professionals have consistent access to high quality interpretation services for planned, unplanned and emergency care. To this end, the NHS in each nation should produce guidance for commissioners, outlining minimum standards for all interpreting services supporting NHS maternity care.
An urgent review is required into how the UK Government cares for pregnant women within the asylum system. This review should consider the creation of a centralised team responsible for safeguarding care and accommodation standards for pregnant women and co-ordinating the data collection vital to understanding how the system can better support safe pregnancy.

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Background

Existing policies and practices relating to the care of refugee, asylum seeking and undocumented migrant women – particularly in England – disrupt antenatal, intrapartum and postnatal care, prevent women from accessing services and ultimately influence maternal and perinatal outcomes. This contradicts stated UK Government ambitions to address ethnic and socioeconomic disparities in maternity care and halve rates of stillbirths, neonatal and maternal deaths by 2025.(1)

Depending on a woman’s immigration status, these harmful policies and practices may include the UK government policy of charging for NHS maternity care, the ongoing dispersal of pregnant women in asylum accommodation, and the lack of consistent provision of high quality interpretation services able to work within the specific context of maternity care.

Migrant pregnant women are a diverse group at risk of disproportionately worse maternal and perinatal outcomes. They often face multiple barriers to care and are more likely to experience poverty or destitution, a higher burden of disease or poorer healthcare in their country of origin or transit, trauma, experiences of conflict, limited English proficiency, barriers to accessing support services, and limited social support network.(2) They are more likely to access antenatal care later than the recommended first 10 weeks,(3) and the National Institute for Health and Care Excellence (NICE) identifies recent migrants, refugees and asylum seekers, and women who speak or read little or no English, as a group with ‘complex social factors’ requiring special efforts to improve access and engagement with maternity services.(4)

Reproductive justice demands that women can exercise bodily autonomy in their decisions to not have children and to have and parent their children in safe, sustainable environments.(5) The hostile environment created by UK Government policy in relation to pregnant refugee, asylum seeking, and undocumented migrant women is an example of reproductive injustice and an affront to the human rights of vulnerable pregnant women and their families.

NHS charging for maternity care

Under the NHS visitor and migrant cost recovery programme (NHS charging) in England, and sometimes in Wales, Scotland and Northern Ireland, people may be charged for hospital-based NHS care, including maternity care, if they have been refused asylum, are living in the UK without official immigration status, or have no recourse to public funds. These charges apply to some of the most vulnerable women living in the UK today, who are not able to work or claim benefits.(6) The true impact of this programme extends far beyond those eligible for charging, due to limited understanding of eligibility amongst both health services and patients, and fears of associated data sharing.

Under this system, maternity services – including all antenatal, labour and delivery, and postnatal services – are deemed ‘immediately necessary’ care and must not be denied or delayed due to charging issues.(7) However, women are charged for their care following birth, with bills commonly starting at around £7,000 and rising to tens of thousands of pounds for more complex care.(8) In addition, NHS bodies can report unpaid debts of £500 or more to the Home Office, which can threaten future immigration applications to enter or remain in the UK.(9)

Fear of receiving unaffordable bills for healthcare, and of data sharing between the NHS and immigration authorities, deters women from seeking and accessing essential and time-critical antenatal care, contributing to poorer outcomes for these women and their babies.(10) Despite the ‘immediately necessary’ classification of all maternity care, pregnant women have also had healthcare delayed or denied outright due to the current charging regulations.(11)

In the UK, late booking or fewer antenatal appointments than recommended have been independently associated with poorer pregnancy outcomes, including maternal death.(12) The 2019 MBRRACE-UK confidential enquiry into maternal deaths found that between 2015 and 2017 three women who died may have been reluctant to access care because of concerns over the costs of care and the impact of their immigration status.(13)

NHS charging also leaves women at increased vulnerability to domestic abuse and exploitative relationships(14) and increases stress and anxiety throughout the perinatal period, itself linked to poorer birth outcomes such as low birth weight.(15)

The UK Government must immediately and permanently suspend NHS charging regulations for maternity care due to the harm this system causes to the health of women and their babies during the perinatal period.

Pre-conception health contributes directly to pregnancy outcomes for both mother and baby, and so it is very likely that this wider NHS charging system has a detrimental impact on pregnancy outcomes, as well as on women’s health more widely. We support the Academy of Medical Royal Colleges position that all NHS charging regulations should be suspended pending a full and independent review of the impact on both individual and public health.(16)

To enforce NHS charging ethnicity, name, country of origin and accent may be used as markers to differentiate between and discriminate against patients.(17) As it is not routine to enquire about the immigration status of all women who present to NHS maternity care, the existence of NHS charging encourages NHS staff to actively stereotype women and their families. In effect, this system promotes routine discrimination and racial profiling of patients to identify who may be chargeable.(18)

Historical and ongoing implicit bias, discrimination, and racism have a negative impact on the health and wellbeing of women and their babies.(19) When medicine and healthcare are used as tools of surveillance, they contribute to the persistence of mistrust between vulnerable and marginalised communities and health care workers. Such mistrust acts as a further barrier to accessing care for recent migrants, refugees, and asylum seekers.

The UK Government must more clearly separate the roles of the healthcare sector and immigration authorities, including ending the referral of patients who have incurred a debt of £500 or more to the Home Office.

It is impossible to understand the full impact of NHS charging policies on maternal and perinatal outcomes without the routine collection of quantitative data relating to the care and outcomes of those affected.

The Department of Health and Social Care must collect consistent data on the impact of NHS charging for maternity care, including the number of women who have been charged, when fear of charging may have delayed presentation (regardless of actual NHS entitlements), maternal and perinatal outcomes, and when NHS charging has influenced decisions to access abortion care rather than continue with pregnancy. This data should be regularly published, and accompanied by a plan for action on how to address any inequities found in the care of these women and their babies.

Charging practices of NHS Trusts in England

Some NHS Trusts in England have been found to be implementing NHS charging regulations in a way that is harmful to pregnant or postpartum women, including aggressively pursuing payments while women are still pregnant, and incorrectly charging exempt women who are victims of trafficking or are seeking asylum.(20) Trusts may also refuse to write off debt for women who are manifestly destitute, despite government guidance supporting this.(21)

This can contribute to high levels of stress and anxiety for the women affected, as well as again deterring women from seeking care.(22)

Until charging for maternity care is suspended or abolished, NHS Trusts in England must review and improve practices relating to charging pregnant women to ensure that women are not deterred from accessing perinatal and maternity care, or have care refused or delayed. The RCOG supports the recommendations set out in Maternity Action’s Breach of Trust report, including that all NHS Trusts adopt and commit to implementing the Maternity Action and Royal College of Midwives guidance Improving access to maternity care for women affected by charging.

Maternity commissioners should ensure Maternity Voices Partnerships and similar local and regional NHS maternity care service user and working groups ensure representation from women with experience of NHS charging for maternity care, and receive sufficient funding to do so.

Addressing other barriers to care within the healthcare system

Language barriers and interpretation services

Access to a high quality interpretation service is a vital part of the provision of safe, consensual and personalised care for all women who have difficulty reading or speaking English. Healthcare professionals rely on the provision of these services to ensure women are able to make informed choices about their care, and can give informed consent to treatment and procedures.(23)

MBRRACE-UK confidential enquiries into maternal deaths have found inadequate translation provision to have delayed care and hindered women’s ability to follow treatment plans, and frequently highlight the need for appropriate interpreting services.(24) The quality and availability of interpretation services may vary between NHS Trusts and Health Boards. For example, a small qualitative study in London reported language support provision varying widely from those almost always able to access good quality support for women, to those with only very partial access.(25)

Commissioners of interpretation services for maternity care must ensure that healthcare professionals have consistent access to high quality interpretation services for planned, unplanned and emergency care. To this end, the NHS in each nation should produce guidance for commissioners, outlining minimum standards for all interpreting services supporting NHS maternity care.

Interpreters supporting maternity care must be trained to provide high quality interpretation in the specific context of maternity care. This requirement should be set out in guidance for commissioners, and funding made available by UK governments to develop and deliver this programme of training, either within interpreting services or the NHS.

NHS Trusts and Health Boards must ensure healthcare professionals receive training on the roles of different types of interpreters working in maternity care, how to work with them effectively, how to recognise poor interpretation and how to work with people with different levels of health literacy.

Commissioners and health leaders must ensure that antenatal services can offer flexibility in the number and length of antenatal appointments to allow for the use of interpreting services, over and above the appointments outlined in national guidance, as recommended by NICE. This includes ensuring services are safely staffed so as to be in a position to do this.

Improving English language skills can help women use health services independently. The RCOG supports greater funding and support for English to Speakers of Other Languages (ESOL) classes which are free and accessible to pregnant and postpartum women. This includes flexibility in attendance, provision of childcare, and combination with pregnancy-related curricula or antenatal classes.

Navigating the maternity system

Healthcare staff, including obstetricians, midwives and administration and reception teams, play an important role in supporting migrant women to access maternity care. Migrant women may be unfamiliar with the maternity system and models of care in the UK(26) and may encounter stigma or judgement from healthcare staff.(27)

All healthcare staff must receive training on migrant women’s entitlements to care, where to find information on the charging system, and the additional barriers to care faced by migrant women.

Advocacy and support from the voluntary sector and community based organisations

Voluntary sector organisations across the UK provide vital support and community for migrant women during the perinatal period. They are able to work across traditional health and social care boundaries and may continue to support women following dispersal, enabling further continuity of care, as well as connecting women to more sustainable communities of support beyond their perinatal care.

For example, professional birth companion support, delivered by community group Happy Baby Community, has been found to significantly improve the labour and birth experiences of pregnant women housed in initial asylum accommodation.(28) Similar findings were made by independent evaluations of the ‘community link’ service and combined care models offered by the charity Birth Companions.(29)

The NHS and governments of the UK should commit to ongoing, sustainable funding for projects that support migrant women and demonstrate improvements in women’s experiences of pregnancy care. This should include the expansion of successful local projects and the extension of pilots to other areas, to ensure that support is available to everyone who needs it.

All NHS Trusts and Health Boards should have an up-to-date, easily accessible and searchable list of local voluntary sector and community-based organisations offering support to migrant women to ensure healthcare professionals can easily connect women with these important sources of support. In England, this should follow NHS England’s Equity and equality: Guidance for local maternity systems recommendation for asset mapping, with migrant women an inclusion group considered.

Dispersal policies and appropriate accommodation for pregnant women seeking asylum

The Home Office may move people seeking asylum and living in asylum accommodation to different accommodation in another part of the UK, often at short notice and sometimes several times, while their application is being processed. Dispersal of pregnant women is factor in late booking for antenatal care(30) and can disrupt continuity of care – a stated NHS England priority to improve clinical outcomes for vulnerable pregnant women.(31) Dispersal practices were found to have exposed mother and baby to risk in the case of a baby who died in 2017.(32)

UK Government guidance sets out a protected period in which pregnant women should only be moved at the request of the applicant or her treating medical practitioners.(33) This period currently runs from six weeks before the estimated date of delivery until a clinician has signed off on the postnatal checks, usually around six weeks after birth unless there have been complications. Importantly, this guidance states that the aim of dispersal during pregnancy should be to settle women into accommodation where they will be able to access services throughout their pregnancy and into new motherhood.(34)

We support the Royal College of Midwives’ recommendation that the Home Office should extend the protected period to start at 20 weeks of pregnancy, and to settle women into suitable accommodation as early as possible in pregnancy, to allow for continuity of care and to minimise disruption.(35)

In the interim, Home Office staff must follow the UK Government’s guidance on dispersal of asylum seekers in pregnancy.(36) As a minimum, women should usually not be moved during the protected period outlined, due to the adverse impact on antenatal care access and continuity of care. If pregnant women or new mothers are dispersed, caseworkers should ensure effective handover of care including referrals to maternity services, before dispersal takes place.(37)

Concerns have been repeatedly raised that asylum accommodation is frequently unsuitable for pregnant women and young children, with the Chief Inspector of Borders and Immigration finding issues including uncleanliness, lack of sterilisation equipment or facilities to boil water, inappropriate housing arrangements, lack of space, and poor information sharing inhibiting access to statutory and voluntary local services.(38) There have also been allegations of sexual harassment within initial accommodation.(39)

The Home Office must ensure all pregnant women and new mothers seeking asylum are housed in appropriate accommodation, with access to all necessary amenities and adequate privacy. To achieve this, we recommend that they set out minimum standards for asylum accommodation for pregnant woman and their babies. This may also include the provision of specialised initial accommodation hostels suitable for pregnant women and their babies.

Staff in initial accommodation may not be trained to respond to urgent health needs relating to pregnancy.(40) All Home Office staff including third-party providers must receive basic training on the needs of pregnant women, including how and when to refer them to emergency services.

The Home Office does not hold readily reportable data on the number of pregnant women in asylum accommodation,(41) which hinders the understanding and monitoring of women’s experiences, access to care and outcomes.

The Home Office must collect data on the number of pregnant women using asylum accommodation and this should be linkable to data on their pregnancy outcomes. This should include a record of how many pregnant women are being dispersed by the Home Office (including within the protected period), how many times they have been moved, and whether dispersal allows women to retain the same GP and maternity service. There should also be a record of risk assessments taken prior to dispersal, including consultation with the woman’s clinician.

An urgent review is required into how the UK Government cares for pregnant women within the asylum system. This review should consider the creation of a centralised team responsible for safeguarding care and accommodation standards for pregnant women and co-ordinating the data collection vital to understanding how the system can better support safe pregnancy.