Removing Barriers to Maternity Care
“I am not here to enforce immigration rules”: New research finds NHS charging undermines midwives’ ability to care for vulnerable migrant women
New research from Maternity Action has exposed the impact that the government’s hostile environment is having on NHS midwives who are caught between their duty of care to pregnant women and Department of Health and Social Care requirements that some patients should be charged for their care. While the possibility of charging for NHS services is not new, it wasn’t until 2015 that it became a legal requirement to charge certain groups of patients. The political rhetoric around NHS charges and the pressure on NHS Trusts to recover costs has been ramped up in recent years.
This report follows an earlier Maternity Action report, What Price Safe Motherhood?, published in 2018, which found that vulnerable and destitute women were being deterred from accessing maternity care due to NHS charges which start at £7,000. NHS Trusts are required to inform the Home Office when debt of £500 or more is unpaid for 2 months and this can result in refusal of future immigration applications.
This latest research, Duty of Care? The impact on midwives of NHS charging for maternity care, based on interviews with NHS midwives, explores what the charging regime means in practice for frontline NHS staff. The launch of the report coincides with a Royal College of Midwives motion to TUC Congress on the issue of charging for maternity services.
The midwives we spoke to felt that charging regime had undermined their relationship of trust with the women they care for. Even though the midwives themselves are not responsible for issuing the charges, they are often expected to gather data on nationality and immigration status, to report this to hospital administrators who are responsible for implementing charging, and it is often the midwife who has to break the bad news to a pregnant woman that she is likely to be charged thousands of pounds for her care.
The midwives involved in the study were clear that the charges target the most vulnerable, often destitute women with no means of buying clothes and nappies for their newborn baby, let alone repaying debts of thousands of pounds.
Describing the types of women who are being charged, one midwife explained:
“They haven’t got a lot of money for food, they’re having to resort to food banks. They can’t afford the vitamins. There’s domestic abuse sometimes and they’re dependent on this spouse for money, when they haven’t got any access to anything themselves. So they’re vulnerable women.”
Another community midwife described the type of accommodation one of her patients was living in:
“This one family where mum, dad, two children, and she was 36 weeks pregnant, were in one room. And it was a really difficult situation. They had all their belongings in one room, the five of them, and they were piled up everywhere and the toddler was bouncing between bunkbeds.”
A common theme in the midwives’ interviews was the chilling effect of the charging regime on women’s contact with health services. Some described women not presenting for their initial appointment until very late in the pregnancy for fear of being charged. Others knew of women who, once they were told that they would be charged, never returned for subsequent appointments. While it’s not the responsibility of the midwife to inform her patient about charging, many of the midwives we spoke to felt there was an ethical dilemma: Does she tell her patient that she may be charged in the hope that she can reassure her and persuade her to continue to attend appointments? Or does she keep the question of charging out of her relationship with her patient and leave it to hospital administrators?
Another issue raised by midwives was women trying to opt out of elements of their maternity care in order to minimise the costs. One midwife explained how risky this strategy is:
“We’ve got a care plan for our clients and each part of it is evidence based. There’s a reason for each appointment and each test. But if clients are thinking, that one is really expensive, say maybe a blood test is more expensive than another appointment, then they’ll miss it. And that’s quite frustrating because you can’t make good clinical decisions with only half the information.”
Even those midwives who weren’t politically opposed to charging in principle, were concerned about the implementation of the policy in practice and the impact of the policy on the women they cared for, as well as on their own professional practice.
The report identifies ways in which the implementation of the policy could be improved in order to minimise the damaging impact on midwives and the women they care for. But ultimately the only way to remove the barriers to maternity care created by the NHS charging regime, is to suspend NHS charges for maternity care.
Find out more about this issue and how you can get involved in campaigning here.
Scarlet Harris is Head of Policy and Campaigns at Maternity Action