Dr Ramya Ramaswami
Maternal mortality among black African women in the UK is up to seven times higher than it is among white women. Doctors’ surgeries are misunderstanding their obligations to migrant patients, says Dr Ramya Ramaswami
The Confidential Enquiry into Maternal and Child Health (CEMACH), ‘Why Mothers Die‘, published in 2004 by the Royal College of Obstetricians and Gynaecologists, reported that ‘women from ethnic groups other than white were, on average, three times more likely to die’ in childbirth, and that ‘black African women, especially including asylum seekers and newly arrived refugees, had a mortality rate seven times higher than white women and had major problems in accessing maternal health care’.
Seven years later, the majority of pregnant women who attend the Project:London clinic in East London, established by Doctors of the World UK in 2006 for migrants, the homeless, and female sex workers, are already in the second trimester of their pregnancy or beyond, without so far accessing antenatal care. In 2010, 40 out of the 66 pregnant women who attended the clinic for the first time were in the second or third trimester. The reason? They had been unable to register with a general practitioner, or GP. The majority of these women were migrants or asylum-seekers, from among those ‘ethnic groups other than white’ that CEMACH says are at least three times more likely to die in childbirth.
Ms P, for instance, who is awaiting a decision from the Home Office about her leave to remain, and is meanwhile living with and being supported by her sister’s family, came to the clinic 35 weeks into her pregnancy. She had been turned away by the NHS for ‘not being entitled’, and was also refused by private providers when they found out she was not able to access NHS services as a ‘backup’. She had received no antenatal care. Project:London helped Ms P register with a GP surgery, and she was referred to a hospital for her remaining antenatal care and to register to give birth. The hospital sent her an invoice for £2000 as a deposit for giving birth there. Ms P is not legally allowed to work in the UK, and has been unable to pay this sum.
Women who arrive at the Project:London clinic present themselves in fear. Not only do they face the physiological stresses and symptoms of pregnancy, they are confronted by difficulties in acquiring their basic needs, which include medical care. The backgrounds of maternity users are varied, but the common thread in those we see is their uncertain immigration status and the perception of them being ‘the outsider’. These women recount similar stories of not being ‘entitled to care’ (like Ms P), or of not possessing the ‘right documentation’, such as a visa or an ‘official’ proof of address.
The barrier to accessing healthcare is usually the reception desk of a GP surgery, as Nayanah Siva reported in The Lancet , ‘Raw deal for refused asylum seekers in the UK’. Staff may not be clear on the legislation concerning patient registration, and often turn away vulnerable individuals under the illusion that the patient may be a potential ‘illegal’ user of services. Doctors, who are insufficiently informed about these matters are often misled by their primary care trusts into believing that they will be penalised if patients without appropriate documentation are registered to their practice.
Primary care legislation gives GPs the right of discretion to exclude the registration of patients who may not live in their catchment area, or if their patient list is closed. However, Paragraph 181 of Part 12, ‘Patients’, of the National Health Service (General Medical Services Contracts) Regulations 2009, does not make any reference to a person’s immigration status being grounds for refusal. Within secondary care, those who are not ‘ordinarily resident’ in the UK are required to pay for services. But recent high court rulings have found in favour of destitute refused asylum seekers who have been unable to access healthcare due to their socio-economic or immigration status.
In the case of maternity, the Department of Health is clear that antenatal provision comes under the heading of ‘immediately necessary’ treatment. Furthermore, treatment must be provided by secondary institutions whether or not the patient has been informed of, or agreed to pay, charges. But the number of women attending the Project:London clinic without access to antenatal care in the earlier phases of their pregnancy has remained fixed, despite five years of health advocacy for maternity service users by Project:London.
The CEMACH research makes clear the value of antenatal care in reducing maternal mortality: up to 20 per cent of deaths reported in their studies are in women with delayed or absent antenatal care. In addition, lack of access to antenatal care by migrant and refugee women equates to poor population health. Early detection of preventable conditions, vaccinations, and health promotion are crucial in curbing rates of certain chronic conditions. Every HIV positive child born in the UK when the mother’s HIV status has not be tested is estimated to cost between half a million and a million pounds during its lifetime. In 2007, over 70 per cent of the pregnant women who attended our clinic did not have access to antenatal HIV screening, a service that is automatic in the normal course of antenatal care. We have a sexual health screening service weekly, but this is in partnership with a local NHS sexual health service. As maternal to child transmission of HIV is preventable, the lack of access to antenatal screening in this high-risk vulnerable group is a travesty.
Post-natal care and management of children of unregistered mothers is also often incomplete. For instance, 30-year old Ms J came to the clinic 6 months pregnant, after she hadn’t been able to register with a GP. Project:London found a GP who accepted her and referred her to a local hospital, and she eventually gave birth to a healthy baby boy. But three months after the birth, Ms J had still not been able to register with a GP, and the baby had not received his standard week 6 vaccinations. The health authority keeps removing her from the system because it ‘cannot trace her’ without her passport and date of entry into the country. Project:London aims to register children with primary care practices, but is often unable to reach doctors who will take the crucial final decision on whether they will be able to register the vulnerable children of these marginalised individuals.
The economics of health is composed of myriad complex interdependent factors. By not addressing the health of refugees, asylum seekers and undocumented migrants, we are inadvertently on a path of also excluding other socio-economic groups with the justification of cost-reduction. These issues are significant in the climate created by the NHS reforms proposed by the coalition government and contained in the Health and Social Care Bill. Vulnerable migrant patients may face greater barriers to accessing healthcare if stronger profit motives, profit-sharing or financially-based incentive schemes are incorporated into the NHS.
Maternal and child health form an integral foundation to health in our society. From a comparative review of sixteen countries in Europe, it is evident that Project:London’s experience is pertinent throughout the continent, as undocumented gravid women are often unable to access antenatal care either because of cost or discrimination. Medical doctors have an ethical responsibility to ensure that the needs of these patients are met. As the World Medical Association has frequently affirmed, ‘National Medical Associations and physicians should actively support and promote the right of all people to receive medical care on the basis of clinical need alone, and speak out against legislation and practices that are in opposition to this fundamental right.’
Project: London provides training so that healthcare professionals understand that it is within their ‘discretion’ to register migrant and undocumented patients. We advocate for an open and flexible registration system that will make our clinical services redundant. How can pregnant women be put at risk of dying, and their children at risk of llong-term ill-health, in a country like the UK?