The Maternity Action report in 2018 What Price Safe Motherhood? documents the damaging effects on pregnant migrant women of charging for NHS maternity care. It includes stories of destitute women who were presented with huge unpayable bills (often after pregnancy loss or complications). It starkly documents how the fear of debt and of being reported to the Home Office deters migrant women from seeking care. These are women who have fled here to seek safety from war, persecution and sexual violence, only to be met by the ‘hostile environment’ policy (introduced in 2012 by Theresa May).
Their heartbreaking accounts are even more disturbing in the light of the latest Maternal Mortality Report, (MBRRACE 2018), which notes that black women in the UK are five times more likely to die, and Asian women twice as likely to die of childbirth-related causes than white women.
The government’s policy of charging for maternity care therefore has extremely serious implications for both women and midwives: Maternity Action’s latest report, Duty of Care, (September 2019),exemplifies the moral and practical difficulties it causes to midwives trying to act in accordance with their professional Code of Practice. As Gill Walton, Chief Executive of the RCM writes in her foreword to the report:
The role of the midwife has always been to be ‘with woman’. The bedrock of quality, safe care is recognition that women’s health is affected by many different forces, not just physiological processes but how she lives, how she is able to realise her ambitions and make choices that are right for her. The Code of Practice for midwives in the United Kingdom recognises this truth, that the midwife is an advocate as well as a competent, skilled clinical practitioner….Anything that prevents the midwife from being an advocate, and supporting a woman to access the care she needs, is not in the spirit of our NHS’.
‘Not in the spirit of our NHS’ is absolutely right – midwives do not pick and choose for whom they care – they care for ALL women. Inequality reduction in maternal health is a central aim of midwifery care and is spelt out in successive policy/guidance documents eg Better Births, NICE Guidance (CG110) and emphasisd again in the new NMC Future Midwife Standards. The midwives interviewed in the report considered that charging had an adverse effect on their professional relationship with the women, eroding the relationship of trust that is so important for good midwifery care and making women less likely to disclose sensitive issues. The midwives experienced a contradiction between the NMC code of practice (to ‘prioritise people’) and the charging requirements.
The wider effect of the NHS charging policy is to cement in people’s minds the idea that some are worthy of being cared for while others are not. In time, the continual pressure to be ‘with government/institution’ rather than ‘with woman’ erodes professional ethics (the duty of care), making it increasingly acceptable for midwives and other health professionals to act as ‘border guards’ policing entitlement to care. (It also accustoms people to the idea that charging for ‘our NHS’ is normal as is checking identity and means to pay – paving the way for further charges to be introduced).
The Duty of Care report illustrates that difficulties in providing an equitable level of care for migrant women can be a source of professional tension and personal distress for midwives. Charging causes overt damage to women and babies but also sets up an ongoing, insidious erosion of professional ethics. It normalises the prioritising of arbitrary bureaucratic decisions over professional judgement and ordinary human kindness. The RCM recognises this and, together with Maternity Action, the British Medical Association, The Royal College of GPs and many others, is calling for a suspension of the charges, (see here). (Editor's note: in Scotland and Wales the situation is different from that in England, charging is not encouraged and you are entitled to free NHS care if you are a refused asylum seeker.)