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“You like my toenails?” Caring for pregnant migrant women

18 Dec 2021

Consultant obstetrician Dr Brenda Kelly speaks of her experiences caring for two vulnerable pregnant migrant women, and the brutal charging system which prevents many other women in their position accessing the maternity care they need.

I have cared for many vulnerable migrant pregnant women over my years in obstetrics. Some of them I can help, many others come too late or with barely adequate maternity care.

Fear of being charged and fear of being reported are two significant barriers to migrant women seeking access to safe maternity care. These barriers must be addressed urgently.

These women are not ‘health tourists’, they are desperate. It is morally reprehensible that at a time when the government instructs the NHS to tackle maternal health inequalities, they still continue charge those most at risk of harm.

By the time, Hope* presented to the emergency department with severe abdominal pain and vaginal bleeding, she had worryingly high blood pressure and kidney damage. A short time after her arrival, she gave birth to a stillborn little girl, whom she called Grace.

No one in the department that day from porter to doctor was left untouched by the anguished cries of this mother as she cradled her dead daughter. Hope thought she was around 7 months into her pregnancy.

Being “without papers”, Hope had not attended any routine antenatal appointments. When the pain started a few days prior to her admission, she had sought advice from an aunty rather than a midwife or doctor.

She had been afraid to come to hospital. Not only had she no money to pay for care, but she was deeply worried that the hospital would report her to the authorities, that she would be detained and deported.

“You like my toenails?”

Not a typical question I get asked in my antenatal clinic but Victoria* had caught my glance at the brightly coloured bejewelled toes peeping out of her sandals.  The fleeting smile on her face faded as she related the story behind the toenails.

At the cusp of puberty, she was taken from her home in Kenya to an elder woman in her village to have female genital mutilation (FGM). This was part of her initiation rite to womanhood and a prelude to the marriage she would be forced into with a man she had never met. 

Victoria fled before the wedding to the city where she found work as a servant in a brothel, cleaning and making food for women who worked there.

Subjected to repeated abuses, she tried several times to run away. The first time she was caught and returned to her owner, they removed her big toenail. By the time she made her final escape, she had one remaining toenail.

FGM, forced marriage, sexual violence, slavery and torture. She was just 14 years old. 

Sitting before me now, the 21 year-old Victoria is undocumented, pregnant and destitute. Her immigration status is of no relevance to me as her doctor; I am not a gatekeeper to the NHS.

While I am grateful that she can receive free treatment for enduring physical and psychological complications she suffers in relation to the violence she has experienced, I despair that she could be charged for her maternity care.

At risk of diabetes and already borderline hypertensive, I worry that if Victoria discovers she is liable for these costs which could run to thousands of pounds, she will default from antenatal care, risking harm to herself and her unborn baby, and becoming yet another tragic statistic in reports on maternal morbidity and mortality. 

Women such as Victoria and Hope are amongst the most vulnerable women we care for. Some, not all, have endured appalling horrors, have seen their homes destroyed, loved ones killed, been tortured, subject to physical and sexual violence or trafficked.

Some have taken long, terrifying journeys to reach safety, and are all seeking sanctuary in our country. They are not health tourists, they are desperate. 

Accessing care during pregnancy helps keep women and babies safer. This is a well-established fact. True commitment to maternal health equity means ending charges for maternity care. They and their children deserve better. Empty rhetoric must end. The time for action is now.  

*Names have been changed in this article.

  • Policy and governance
  • Pregnancy and birth