By Arianne Shahvisi and Fionnuala Finnerty
Precious is a 26-year-old Eritrean woman who has recently arrived in the UK. She wishes to apply for asylum but is yet to do so. Precious is destitute and is living in a church and relying on the kindness of the Eritrean community. She sees a GP at an out-of-hours surgery as she feels sure she is pregnant, given that her last period was six months ago. A pregnancy test is positive. Precious does not wish to attend maternity care as advised by the GP. She has heard from other members of the church that she will have to pay for this and she does not have the money. She is very concerned that she will be deported.
The anonymised clinical vignette outlined above is based on real cases encountered by one of the authors. A similar scenario was recently described to medical students within an ethics session led by the other author. Students were asked to advise the patient on whether she would be charged, and whether there was any deportation risk. They shook their heads; the NHS is free and confidentiality is a cherished value, right? Wrong.
All but the most basic healthcare is now chargeable for everyone except those who are “ordinarily resident” within the UK, i.e. those who have lived here for five years or more with legal documentation. Becoming pregnant is not only chargeable, it’s expensive. Those from outside the European Economic Area, like Precious, can expect to pay almost £7000 for care before, during, and after delivery, or £1300 for a termination. If a debt of £500 or more remains unpaid two months after treatment, the patient’s data must be shared with the Home Office, who can use that information in adjudicating asylum applications.
Precious has every reason to be concerned, and the clinical reality of doctors on the frontline having to put political considerations between women and essential antenatal care is harrowing and morally fraught. How do you explain to a patient that she ought to access antenatal care in the interests of her health and that of her baby, but that she may at a later date be billed for it, which could in turn scupper any claim to asylum and lead to deportation? It is especially frustrating from a medical perspective when it is known that asylum-seeking women are more likely to have poor pregnancy and birth outcomes. Black African women like Precious are four times more likely than white women to die during pregnancy, infants born to migrant women have higher risks of low birth weight and congenital abnormalities, and refugees and asylum-seeking women constitute around 12% of all maternal deaths in the UK, despite making up only 0.1% of the population. Placing additional barriers in the way of accessing care wilfully risks the health of migrant women and their infants, and is suggestive of the dwindling empathy for migrants within the hostile environment.
One of us is a hospital doctor, and must now inform some of her most vulnerable patients that they will be charged for essential care; the other, as an ethicist based in a medical school, is compelled to ruin the faith of her students in the guiding values of medicine and the NHS. Meanwhile, the government stands accused of covering up the effects of the new charging guidelines on the health of migrants. We remain especially concerned for the women whose pregnancies are now riddled with additional anxiety or driven underground, and fear for the futures of the infants born into such a callous and punitive context.
Authors: Arianne Shahvisi* and Fionnuala Finnerty^
Affiliations: *Lecturer in Ethics, Brighton and Sussex Medical School; ^Specialist Registrar in Sexual Health and HIV, Royal Sussex County Hospital
Competing interests: Fionnuala is an independent advisor to Refugee Rights Europe.