Memorandum by the Reaching Out Project,
Medact (HI 27)
1. ABOUT THE
The Reaching Out Project, Medact aims to improve
access to maternity care for marginalised women from Black and
minority ethnic communities.
Medact is a membership organisation of health
professionals. Medact speaks out for countless people across the
globe whose health, wellbeing and access to proper health care
are severely compromised by the effects of war, poverty and environmental
This submission focuses on maternal health of
marginalised women from Black and minority ethnic communities.
Maternal health outcomes for this group are
significantly worse than for the White population. The recent
report of the Confidential Enquiry into Maternal and Child Health
found that Black African women have maternal mortality rates 5.6
times higher than White women; Black Caribbean 3.7 times higher;
Middle Eastern 2.9 times higher; "Other" 2.5 times higher;
Bangladeshi 2.1 times higher; Indian 1.9 times higher; and Chinese
and other Asian 1.3 times higher (Lewis 2007a:30).
Maternal mortality rates for refugees and asylum
seekers are extremely high. In the period 2003-2005, 36 of the
295 maternal deaths in the UK were of refugees and asylum seekers
(Lewis 2007a). The total number of refugee and asylum seekers
births was not known, so a mortality rate could not be calculated.
As a rough indication, 12% of maternal deaths in 2003-2005 were
to refugee and asylum seeking women while the UN High Commission
for Refugees estimates that refugees make up about 0.3% of the
Infant mortality data does not yet permit a
comprehensive analysis by ethnic background. The limited data
which is available indicates significantly worse health outcomes
to children born to Black and minority ethnic mothers. The infant
mortality rate for children of mothers born in Pakistan was 10.2
per thousand live births in 2002-2004 and 8.3 per thousand live
births where the mother was born in the Caribbean (Department
of Health 2007). These are, respectively, 108% and 63% higher
than the national average.
Many births to marginalised women from Black
and minority ethnic backgrounds will fall within the "NS-SEC
Other" category. This group has an infant mortality rate
of 9.3 per thousand live births which is 90% higher than the population
as a whole (Department of Health 2007).
3. TERM OF
1: The extent to which the NHS can contribute
to reducing health inequalities, given that many of the causes
of inequalities relate to other policy areas eg. taxation, employment,
housing, education and local government
3.1 Eligibility for free NHS maternity care
Free NHS maternity care is available to women
who are considered to be "ordinarily resident" in the
UK or who fit within certain defined categories. Women who are
not entitled to free NHS care will be charged for their care but
care cannot be refused on grounds that a woman is unable to pay.
Department of Health guidance states that this is because of the
severe health risks associated with conditions such as eclampsia
and pre-eclampsia (National Health Service 2004)
One objective of the current regulations is
to address "health tourism". A "health tourist"
is a person who comes to the UK with the express purpose of making
use of free NHS services. While there have been various statistics
produced on the costs of overseas visitors to the NHS, these have
not been disaggregated. In addition to any "health tourists"
who obtain free NHS care, these figures include people who have
travelled to the UK in order to receive care as private patients
and have paid for this care, and those who are living in the UK
but are liable to pay for care because of their immigration status.
Amongst the women who are not entitled to free
NHS maternity care are many vulnerable migrants, including asylum
seekers whose appeals have been exhausted ("refused asylum
seekers"), trafficked women and undocumented migrants. These
women have not come to the UK in order to obtain health care and
may have lived in the UK for some years before seeking treatment.
Project London provides health services to undocumented migrants.
In its first year of operation the average service user had been
in the country for three years ((Project London 2007), indicating
that service users had not come to the UK in order to seek health
The financial circumstances of these women are
often extremely difficult. They are not permitted to work or to
obtain state benefits. A small number of women receive subsistence
support from NASS. Many destitute women rely on support from church,
community groups and friends. They do not have the funds to pay
the charges for maternity care, which range from £1500 to
in excess of £3000 for a normal vaginal delivery. Neither
are these women in a position to negotiate repayment plans as
their future may be very uncertain.
The policy of charging for maternity care has
the effect of deterring women from obtaining care. Many women
are intimidated by the prospect of incurring a debt of several
thousand pounds when they know it will be impossible to repay
it. They therefore choose not to receive care they cannot afford,
and disappear from maternity services (Joint Committee on Human
Rights 2007, Kelley & Stevenson 2006). Some women are able
to raise part of the sum but feel that they have no option but
to discontinue the care when the money runs out. Some women are
fearful that their irregular immigration status will be reported
to the Home Office.
Lack of compliance with the policy has also
resulted in women being denied or deterred from obtaining care.
The Joint Committee on Human Rights inquiry into the treatment
of asylum seekers 2006-7 specifically considered the misapplication
of the rules by hospitals and the deterrent effect of the rules.
The Committee concluded:
It is clear to us that there is considerable
confusion. Pregnant women are denied, or fail to access, essential
care as a result. The evidence shows that additional [Department
of Health] guidance has not removed the confusion.
The Reaching Out Project has found numerous
instances of the policy not being applied.
Women have been refused care when
they have arrived at the hospital in labour.
Women have been refused care unless
they can pay. In some cases the refusal has been communicated
Voluntary organisations advocating
for individual women have found it extremely difficult to resolve
disputes about entitlement to care. Advocates state that they
have quoted the regulations and guidance without effect and the
response from the Overseas Visitor Managers has often been extremely
unhelpful and, in some cases, very rude.
The process of negotiating access
to care can take weeks or months, creating significant delays
in accessing antenatal care.
Women have experienced aggressive
treatment from the Overseas Visitor Manager. Some have experienced
Women have been contacted by debt
collectors prior to the birth.
Women who are entitled to free care
have been wrongly denied free care because trust staff did not
understand Home Office information.
Overseas Visitor Managers have met
with women who speak little or no English to discuss their entitlement
without use of an interpreter, resulting in confusion.
As a result of this policy, many vulnerable
women commence antenatal care late, receive intermittent care,
or receive no antenatal care and attend only for the birth. There
is also evidence of women giving birth alone and unattended (Kelley
& Stevenson 2006). Suboptimal antenatal care is a major risk
factor for maternal deaths and was present in 19% of maternal
deaths investigated in the Confidential Enquiry into Maternal
and Child Health report, Saving Mothers' Lives (Lewis 2007a).
Antenatal care provides opportunities to identify and treat conditions
including pre-eclampsia, eclampsia, gestational diabetes, and
cardiac disease. The risk of a child being born with HIV is reduced
from 30% to 1-2% if a HIV positive mother receives appropriate
The CEMACH report recommended improvements in
service accessibility to promote early commencement of antenatal
care (Lewis 2007a). The importance of this issue is reflected
in the selection of indicators for the 2007 Public Service Agreements.
Delivery Agreement 19, Indicator 4 is "the percentage of
women who have seen a midwife or a maternity professional for
health and social care assessment of needs, risks and choices
by 12 completed weeks of pregnancy". It is not possible to
reconcile the current focus on promoting improved access to antenatal
care with the policy of charging for maternity care.
At present, there is a strong financial disincentive
for trusts to provide care to women who are not entitled to free
NHS care. The trust is obliged to provide care to women who cannot
pay for care, but there is no source of funds to cover this obligation.
The introduction of Payment By Results means that the costs cannot
be absorbed into block contracts. As a result, there is a financial
penalty for trusts which provide maternity care to this group
of vulnerable women.
3.2 Proposals to deny eligibility to free
NHS primary care to vulnerable migrants
At the time of writing, a joint Department of
Health and Home Office review was considering proposals to extend
the current charging regime to primary medical services. This
would have the effect of denying eligibility to free NHS GP services
to vulnerable migrants, including refused asylum seekers, trafficked
women and undocumented migrants.
The review was announced in a Home Office document,
Enforcing the Rules (Home Office 2006) which described
one of its aims as:
to ensure that living illegally becomes ever
more uncomfortable and constrained until they leave or are removed.
This sits in contrast with the rationale for
the 2004 regulations on charging for secondary care, which was
to combat perceived abuses of the NHS by "health tourists".
While government policy supports direct access
to midwives, 83% of women first seek pregnancy care from their
GP (Redshaw et al 2006). This rises to 86% for women having their
first child. Charging for GP services may result in vulnerable
migrants delaying the commencement of maternity care or not seeking
it at all. Given evidence that vulnerable women are already being
deterred from obtaining maternity care by requests for payment
by maternity services, charging for GP appointments is likely
to increase the proportion of women who do not obtain satisfactory
antenatal care. Another deterrent factor is the increase in data
sharing which is anticipated to accompany this policy, as this
will add to women's fears that attending for care will bring them
to the attention of immigration authorities.
The CEMACH report emphasised the importance
of identifying any underlying health problems early in pregnancy,
and recommended that women who are new to the UK undergo a full
medical examination by a suitably trained doctor, such as the
woman's GP (Lewis 2007a). It is unclear whether this would be
considered part of maternity care and therefore "immediate
and necessary" care. If this is not the case, then vulnerable
migrants may be unable to obtain this examination unless they
can pay. This places an already vulnerable group of women at further
Charging for GP services also reduces the very
limited support available to vulnerable migrants who are experiencing
domestic violence. Women who are vulnerable migrants have particular
difficulties in leaving an abusive partner. Women who are failed
asylum seekers or undocumented migrants are not entitled to access
emergency accommodation or receive welfare benefits. They may
be left with the choice between remaining in an abusive relationship
GPs provide an important source of health care
to women experiencing domestic abuse and may assist in linking
her to sources of support. Vulnerable migrants who are experiencing
domestic abuse may not be able to obtain money from their partner
or family to pay for GP appointments and so may lose this source
For many women who are legally resident in the
UK, their right to remain in the UK is dependent upon their husband.
If they leave the relationship, they face deportation. For some
women, deportation back to their countries of origin may mean
violence and persecution for being divorced or separated. Many
new migrants have, as a condition of their visa, "no recourse
to public funds". Women with "no recourse to public
funds" are not entitled to access emergency accommodation,
including women's refuges and are not entitled to receive welfare
benefits. Leaving the relationship may leave them destitute.
Women with "no recourse to public funds"
who are escaping an abusive relationship may gain the right to
remain in the country if they can provide evidence of the abuse.
A letter from a GP is one of the few forms of evidence which is
acceptable to the Home Office. Currently, women with "no
recourse to public funds" are entitled to free GP appointments.
If these women were to be charged to attend a GP appointment,
they may not be able to prove to the Home Office that the abuse
Language support is fundamental to the provision
of high quality health services to vulnerable women with limited
or no English. Despite this, there are ongoing problems with provision
of interpreting services including inappropriate use of family
members to interpret and failure to use interpreters.
The CEMACH report documented the risks to patient
safety associated with unsatisfactory language support (Lewis
2007a). In 34 of the 295 maternal deaths investigated, the women
spoke little or no English and very few had access to interpreting
services. Five women who were murdered by their partners had the
abusive partner as their interpreter. In one case, diagnosis of
tuberculous meningitis was delayed as the husband was acting as
the interpreter. An asylum seeking woman who died from a complex
set of conditions had her young son translating for her. Disturbingly,
a GP reported that interpreting was a particular problem in his
practice as there was no agreed source of funding for interpreters.
3.4 Female Genital Mutilation or Cutting (FGM/C)
The number of women with Female Genital Mutilation
or Cutting (FGM/C) living in England and Wales is in excess of
66 000 (Dorkenoo 2007). This figure is expected to increase, largely
due to migration from countries where it remains common practice.
Despite the availability of education resources for healthworkers,
awareness of the issue and standards of maternity care for women
with FGM/C is variable.
Examples of unsatisfactory care for women with
FGM/C are documented in the CEMACH report (Lewis 2007a). For one
woman, late identification of FGM/C led to an unnecessary caesarean
section and may have directly contributed to her death.
3.6.1 Destitution for refused asylum seekers
The Government's policies and practices in relation
to support for asylum seekers and refused asylum seekers have
been widely criticised as inhumane and in breach of human rights.
The Joint Committee on Human Rights inquiry into the treatment
of asylum seekers (2007) concluded:
We consider that by refusing permission for most
asylum seekers to work and operating a system of support which
results in widespread destitution, the treatment of asylum seekers
in a number of cases reached the Article 3 ECHR [European Convention
on Human Rights] threshold of inhuman and degrading treatment
. . Many witnesses have told us that they are convinced that destitution
is a deliberate tool in the operation of immigration policy. We
have been persuaded by the evidence that the Government has indeed
been practicing a deliberate policy of destitution of this highly
The health impact of these policies is severe.
A national study involving 125 asylum seekers found that many
had experienced deteriorating health and a permanent state of
depression, distress and anxiety (Refugee Action 2006). A study
undertaken in Leeds concluded that destitution policies can have
an acute impact on the wellbeing of refused asylum seekers and
can lead to self-harm and suicidal thoughts (Lewis 2007b).
Of particularly concern is "section 9",
which enables the Home Office to cease providing support for an
asylum seeker with a dependent child if the family is not considered
to have taken reasonable steps to leave the UK. In these circumstances,
the local authority may take the child into care. According to
Refugee Action, four children were taken into care during a pilot
of section 9 in 2005 and a substantial number of families "disappeared"
from their accommodation(Joint Committee on Human Rights 2007).
These outcomes are manifestly not conducive to the good health
of parents or children.
3.6.2 No recourse to public funds and domestic
The policy of providing "no recourse to
public funds" to many new migrants creates significant problems
for women experiencing domestic violence. Women with "no
recourse to public funds" are not entitled to access emergency
accommodation, including women's refuges and are not entitled
to receive welfare benefits. They are forced to choose between
remaining in an abusive relationship or destitution if they leave
This has particular implications for maternal
health. It is estimated that 600 women who have insecure immigration
status are subject to domestic violence from their spouse each
year (Southall Black Sisters & Women's Resource Centre 2005).
Women who are pregnant are at particular risk of domestic abuse.
In approximately 30% of domestic violence cases, the abuse began
during pregnancy (Department of Health 2005). Of the 295 maternal
deaths examined in the CEMACH report, 19 of these deaths were
of women murdered by abusive partners (Lewis 2007a). 70 of the
295 women who died had features of domestic abuse (Lewis 2007a).
4. TERM OF
6: The effectiveness of the Department of
Health in co-ordinating policy with other government departments,
in order to meet its Public Service Agreement targets for reducing
The relevant PSA target for the current period
is the infant mortality target:
Starting with children under one year, by 2010
to reduce by at least 10% the gap in mortality between the routine
and manual group and the population as a whole
The relevant PSA for the CSR07 period of 2008-2011
PSA Delivery Agreement 19, Indicator 4: The percentage
of women who have seen a midwife or a maternity professional for
health and social care assessment of needs, risks and choices
by 12 completed weeks of pregnancy
4.1 Department of Health and Home Office policy
Proposals to deny eligibility to free NHS primary
care to vulnerable migrants, discussed at 3.2 above, are part
of a joint Home Office/Department of Health review. As discussed
above, the proposals under consideration in this review are likely
to reduce timely attendance for maternity care and, consequently,
are likely to have a negative impact on infant mortality. While
there appears to be a high level of coordination between the Department
of Health and the Home Office, this is not conducive to meeting
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Department of Health, 2007, Review of the
health inequalities infant mortality PSA target, COI: London.
E. Dorkenoo, L. Morison & A. Macfarlane,
2007., A statistical study to estimate the prevalence of Female
Genital Mutilation in England and Wales, Forward: London.
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S. Saxena, 2006, The identification and charging of Overseas
Visitors at NHS services in Newham: a Consultation, Newham
Primary Care Trust & Imperial College: London.
Home Office, 2007, Enforcing the rules: a
strategy to ensure and enforce compliance with our immigration
Joint Committee on Human Rights, House of Lords
and House of Commons, (2007), The treatment of asylum seekers:
tenth report, HMSO: London.
N. Kelley & Stevenson, 2006, First do
no harm: denying health care to people whose asylum claims have
failed, Refugee Council: London.
G. Lewis (ed), 2007a, The Confidential Enquiry
into Maternity and Child Health (CEMACH) Savings Mothers' Lives:
reviewing maternal deaths to make motherhood safer 2003-2005 The
Seventh Report on Confidential Enquiries into Maternity Deaths
in the United Kingdom, CEMACH: London.
H. Lewis, 2007b, Destitution in Leeds,
Joseph Rowntree Charitable Trust: York.
National Health Service (NHS), 2004, Implementing
the Overseas Visitors Hospital Charging Regulations: Guidance
for NHS Trust Hospitals in England, COI: London.
Project London, 2007, Project London: Report
2006, Medecins du Monde: London.
M. Redshaw, R. Rowe, C. Hockley, & P. Brocklehurst,
Recorded delivery: a national survey of women's experience
of maternity care 2006, National Perinatal Epidemiology Unit.
Refugee Action, 2006, The Destitution Trap:
Asylum's untold story.
Southall Black Sisters & Women's Resource
Centre, 2005, How can I support her? Domestic violence, immigration
and women with no recourse to public funds, Southall Black
Sisters & Women's Resource Centre: London.