Written evidence from Maternity Action [EAP0015]
About Maternity Action
- Maternity Action is the UK’s maternity rights charity dedicated to promoting, protecting and enhancing the rights of all pregnant women, new mothers and their families to employment, social security and health care.
- Maternity Action has two advice services serving migrant and asylum seeking women. The Maternity Care Access Advice Service delivers advice and casework on charging for NHS care to migrant and asylum seeking women, midwives and advisers, and advises approximately 400 women each year. The Migrant Women’s Rights Service provides advice and training to midwives and voluntary sector workers on housing, income and healthcare for migrant, refugee and asylum seeking women. In the past 18 months, the Migrant Women’s Rights Service has delivered 15 training sessions reaching 174 midwives and voluntary sector workers and has provided ‘second tier’ advice to 129 midwives and voluntary sector workers.
- In this submission, Maternity Action will focus on the treatment of pregnant women and new parents and the asylum support system. The submission will address the following questions in relation to dispersal (relocation) of pregnant women and new mothers; financial support for pregnant women and new mothers; and the impact of charging for NHS maternity care on asylum seeking women:
- Is the UK asylum process safe and fair for those with protected characteristics?
- Are individuals with certain protected characteristics more at risk of harm or unfair treatment when going through the UK asylum process?
- How is the Government addressing any discrimination or specific dangers for those with protected characteristics in the asylum process, and what more could be done?
- What challenges do those with protected characteristics face on the basis of those characteristics if they are granted asylum in the UK?
About pregnant women and new mothers in the asylum support system
- Pregnant asylum seeking women are at high risk of poor physical and mental health. Successive Confidential Enquiries into maternal deaths have found migrant and asylum seeking women to be at higher risk of maternal deaths. The National Institute for Health & Care Excellence has issued guidance which identifies asylum seekers as having complex social needs and recommends additional measures to improve access to care and support (NICE CG110).
Dispersal (relocation) of pregnant women and new mothers in receipt of asylum support
- In 2013, Maternity Action and the Refugee Council jointly released a research report exploring the practice of ‘dispersing’ pregnant women and new mothers seeking asylum in the UK, When maternity doesn’t matter: Dispersing pregnant women seeking asylum. Dispersal involves relocation of individuals in receipt of asylum support on a ‘no-choice’ basis, often to accommodation some distance away, necessitating a change of maternity service and likely loss of social support networks. The research, which was based on interviews with 20 women who had experienced dispersal while pregnant and 17 midwives who had supported asylum seeking women, found significant problems with the practice of dispersal.
- Fourteen of the asylum seeking women interviewed were in their final trimester of pregnancy and eight were in their last month when they were dispersed. Two women were dispersed one day before they gave birth and another woman gave birth two days after dispersal. Women reported being moved despite their treating clinicians advising against travel.
- The journeys were often very distressing. Women were often moved at very short notice, without being informed of their destination or the distance to be travelled until the last minute, or when they would be picked up. Several women reported not being able to eat during the journey, inadequate toilet breaks, and lack of assistance with luggage.
- Some women received little help to register with a GP in their new location. Women with other children faced problems enrolling their existing children into school or nursery. Accommodation for pregnant women or those who had recently given birth was often inappropriate. There was rudimentary equipment for the baby but little effort was made to ensure adequate hygiene and sanitary facilities for newborns. Women often had to climb several flights of stairs to their rooms.
- Over half the women spent time in Initial Accommodation before being moved on. Women’s feelings about Initial Accommodation were generally very adverse. They complained about dirty bathrooms and toilets, bad or inedible food, being forced to sterilise bottles in the toilets, safety issues, rooms on upper floors without lifts, and being assigned top bunks.
- Campaigning by Maternity Action and the Refugee Council led to a redraft of the guidance on dispersal of asylum seeking women in 2016: The Healthcare Needs and Pregnancy Dispersal Guidance v3.0. However, Maternity Action is continuing to encounter serious and ongoing problems with dispersal of asylum seeking women during pregnancy. Pregnant women are dispersed during pregnancy, at short notice and without seeking input from the woman’s clinicians. Clinicians who would like to strongly advise against dispersal of an individual woman report difficulties in finding anyone to speak to in order to communicate their concerns. Dispersals are negatively impacting on women’s clinical care and her ability to develop networks of social support.
- The tragic case of Baby T, born to an asylum seeking woman, demonstrates the impact of current dispersal policies. The Serious Case Review, commissioned by Redbridge Local Safeguarding Children’s Board, found that over a four-month period, which included the baby’s birth, Baby T’s mother was accommodated in five different locations. The first was emergency overnight accommodation, followed by another location in London. She was then dispersed to Cardiff, and to a second location in Cardiff before being dispersed back to London.
- It is unsurprising that these frequent moves impacted on the care and support received by Baby T’s mother. The Serious Case Review stated:
6.8 It is not possible to reach any conclusion other than the dispersal of mother and Baby T to Cardiff exposed them to risk. Although mother was able to access services in Cardiff, she was moved again during her short stay in the city which was completely inappropriate. ‘Dispersal’ to Cardiff terminated the post-natal support network on which mother and Baby T had come to rely in Croydon and increased her vulnerability. It was unrealistic to expect her Croydon support network to be quickly recreated in Cardiff, particularly as effective support is founded on clarity in respect of needs and positive human relationships, both of which take time to develop. Mother said that she felt lonely and unsupported during her stay in Cardiff. Additionally, the dispersal to Cardiff took place just prior to the Christmas/New Year holiday period during which many services operate at diminished levels including public transport. Given that the plan was for the dispersal to Cardiff to be a temporary move prior to a return to accommodation nearer London, it is unclear why consideration was not given to leaving mother and Baby T in their initial accommodation in Croydon until the move to longer term asylum support in, or near, London could be achieved, particularly as the accommodation in Cardiff was also initial accommodation.
- Despite the serious impact of dispersals on pregnant women and new mothers, the Home Office does not collect and collate data which would enable it to assess compliance with the dispersal policy or the impacts on pregnant women and new mothers in asylum support. Maternity Action understands that the Home Office cannot provide data on:
- The number of pregnant women in receipt of asylum support;
- The expected date of delivery for each of the pregnant women in receipt of asylum support;
- The number of times pregnant women have been dispersed during pregnancy and post-natally;
- Whether or not clinicians were consulted prior to dispersal of a pregnant woman and whether or not they agreed with the dispersal; or
- Whether or not the housing provided to pregnant women and new mothers was appropriate for these women, for example, whether or not the accommodation required women to walk up stairs.
- There is work underway within Government following the safeguarding concerns raised in Baby T Serious Case Review. The Home Office and NHS England and Improvement have convened a Maternal Health sub-group which reports to the National Asylum Seeker Health Steering Group and National Safeguarding Steering Group, amongst other boards. Maternity Action is the third sector organisation sitting on this group. The group held a preliminary meeting in July 2021.
- There is an urgent need for the Home Office to address the serious and substantial failings of the Home Office in dispersal of pregnant women and new mothers in the asylum support system. Maternity Action recommends that the Home Office:
- revise its policy to ensure that pregnant women are moved from initial or emergency accommodation directly to housing which is suitable for a pregnant women and a new mother, and not dispersed again unless they make a request to do so;
- that women moved from initial or emergency accommodation are moved to locations which enable the woman to continue to receive care from the same maternity service;
- that the Home Office revise its policies and procedures to ensure that dispersals are subject to consultation with the woman’s clinicians and do not proceed if the clinician recommends against it; and
- that the Home Office rectify limitations in its data collection and track compliance.
Financial support for pregnant women and new mothers
- Financial support for pregnant women and new mothers in the asylum support system is insufficient to enable women to maintain a healthy lifestyle during pregnancy. The low rates of support limit women’s access to fresh food, which is of critical importance in protecting the health of mother and baby. Rates of cash support during pregnancy are: £42.63, compared to £74.96 for the standard rate of Universal Credit payments.
- Pregnant women face significant difficulties in ensuring timely payment of the maternity grant. The equivalent mainstream grant, the Sure Start Maternity Grant, has an application period of 11 weeks before the baby is due up to six months after the birth. The asylum support maternity grant has a much shorter period for application: eight weeks before the baby is due until six weeks after the birth. Applications submitted prior to these dates are returned, unprocessed. It is standard practice for applications received after these dates to be refused. Errors in applications, such as incorrect description of the form of asylum support, also result in claims being refused. Maternity Action is aware of women who missed out on the maternity grant due to the short time frames and bureaucratic complexity.
- The maternity grant is intended to enable women to purchase the equipment they need prior to the baby’s birth, however delays in processing and difficulties with the application process leave many women without these funds until after their baby is born. In the case of Baby T’s mother, the grant was received on the day she was discharged from hospital.
- There is an urgent need to increase the level of cash support for pregnant women and to extend the timeframes for application for maternity grant to ensure that women receive this payment prior to the birth.
The impact of charging for NHS maternity care on asylum seeking women
- Pregnant women who are not classed as ‘ordinarily resident’ in the UK are subject to charging for their NHS maternity care under the NHS Migrant and Visitor Cost Recovery Programme. Women with a current asylum claim are exempt from charging. Women whose asylum claim has been refused are exempt from charges in England if they are in receipt of Home Office support. In Wales and Scotland, women whose asylum claim are refused are exempt from charges whether or not they are in receipt of Home Office support. Charges for antenatal care, birth and postnatal care vary according to the care provided, and start at around £7,000. Maternity care is classed as immediately necessary treatment and should not be refused or delayed due to inability to pay in advance.
- If the rules are correctly followed, NHS charging should affect pregnant asylum seekers only if their claims has been refused, they are not in receipt of Home Office support and they are living in England. Maternity Action research into charging for NHS maternity care in England found that errors in application of the rules are widespread in England, resulting in asylum seeking women who are entitled to free care being asked to pay for their care, Breach of Trust: A review of implementation of the NHS charging programme in maternity services in England (2021).
- A case study from the 2021 ‘Breach of Trust’ research:
Mary, an asylum seeker, was pursued for payment for her NHS care while living on a very low income as a single mother with two children. The Trust rejected her proposal to pay £10/week and she was very worried about how she was going to repay the debt. When she sought advice from Maternity Action, we found that the NHS Trust had made a legal error and she was exempt from charges. The Trust took three months to respond to Maternity Action’s correspondence, leaving Mary in an extending period of uncertainty and distress.
- Research by Maternity Action and others has shown that charging for NHS maternity care deters women from attending for maternity care appointments, increases stress amongst women already at high risk of poor maternal mental health, and impacts on the ability of midwives to deliver high quality care: What Price Safe Motherhood (Maternity Action 2018), Duty of Care? The impact on midwives of NHS charging for maternity care (Maternity Action 2019), Access to healthcare for people seeking and refused asylum in Great Britain: a review of evidence (EHRC 2018).
- Given the significant risk to the physical and mental health of pregnant women and their babies, Maternity Action recommends the immediate suspension of charging for NHS maternity care pending a full independent review of the public health impacts. This recommendation is supported by the Academy of Royal Colleges, Royal College of Midwives, and Royal College of Obstetricians and Gynaecologists and others.
- Maternity Action and Royal College of Midwives have jointly prepared guidance, ‘Improving access to maternity care for women affected by charging’. In the absence of a Government decision to suspend charging for NHS maternity care, Maternity Action recommends that NHS Trusts adopt the guidance and commit to its implementation.