According to the World Health Organization, the highest attainable standard of health, including maternal health, is a basic human right, where it is a legal obligation to address the causes of health inequalities. However, under the UK’s hostile environment policies, undocumented migrants are ineligible for free NHS secondary care including antenatal services, violating their right to health. Consequently, this population experiences poorer obstetric outcomes and disproportionate rates of maternal mortality. To dissect the complexities of this issue, intersectionality can be utilised.
Intersectionality was first introduced by Kimberlé Crenshaw to explain how African American women experience discrimination due to their gender but also their race. The theory describes how multiple identities such as race, gender, socioeconomic and immigration status, are not mutually exclusive and are in constant overlap, which compound oppressions or strengthen positions of power. According to Spade (2013), those who hold intersectional oppressions, experience unequal opportunities created within society and governmental structures. Resolving this does not mean dismantling these intersectional identities, but dismantling the structures that uphold the imposition of oppression on certain groups (Spade, 2013).
The UK government’s charging policy stipulates that undocumented migrants are ineligible for free NHS secondary care and must pay 150% of the cost of the treatment. Any debts £500 or over not settled within three months are reported to the Home Office, and influence future settlement applications. The report by Doctors of the World (DOTW) reveals how NHS antenatal care is estimated to cost undocumented migrants between £6500 and £9000, depending on the presence of health complications. Often individuals are failed by the NHS in setting up appropriate repayment plans, and in some cases mischarged for free services such as primary care (Asif and Kienzler, 2022). The high costs deter these women from accessing care, where the report by DOTW show that 65.9% did not approach the NHS before reaching out to charities for assistance, and 42.8% were too late to prevent complications. Complications can include premature pregnancy, maternal and child mortality, and preventable transmission of communicable disease.
The policy of charging has been influenced by and contributed to xenophobia, nationalism, and institutional racism, creating a notion that undocumented migrants are a threat to the NHS (Smith and Dexter, 2019). Considering gender, Shahvisi and Finnerty (2019) argue that charging perpetuates gender inequality, where the woman unable to choose the highest standard of care possible due to financial, structural, and societal constraints is denied bodily autonomy and faces the possibility of life-threatening complications. With the risk of pregnancy, women are burdened with unequal sexual responsibilities, particularly important considering that many undocumented migrant women have been subjected to sexual violence, sexual exploitation, and participate in transactional sex to earn a living. Focusing on income, it is a criminal offence for undocumented migrants to take up paid employment, and they are subject to the no recourse to public funds policy excluding them from benefits. Many do find employment, but it tends to be precarious in nature. Ultimately, they are disproportionately more vulnerable to destitution. In addition, due to the fear of being reported to the Home Office if debts are not settled, they are further deterred from accessing care. This population faces restricted agency in making choices regarding their care due to communication barriers, a complex legal structure, digital poverty, and difficulty accessing supportive services preventing safeguarding opportunities (Walker and Farrington, 2021). These lived experiences can intersect to compound the inequalities that these women experience and the extreme difficulties they face due to charging. The women become marginalised from society, lacking the tools and resources to maintain their right to health. Known as structural violence, this unequal distribution of power limiting the basic rights of individuals that is maintained in the immigration system, is argued by Asif and Kienzler (2022) to be evident, further enabling the perception that charging undocumented migrants for antenatal care is an abuse of human rights.
Needless to say, structural and systemic change is vital, and can be assisted using intersectionality. Firstly, maternal health as a human right for all individuals regardless of their background should be acknowledged by the UK government. Additionally, the principles of the NHS constitution of comprehensive patient-centred care based on clinical need not pay should be upheld by terminating the policy of charging. This would follow the lead of some European countries, where free antenatal services are offered to undocumented migrants. By doing so maternal morbidity, mortality and health inequalities can be reduced.
In conclusion, intersectionality can be a vital tool for understanding human rights abuses. In the case of charging undocumented migrants for antenatal care, the theory has allowed for the recognition, and analysis of how these women hold multiple identities that are subject to unequal power dynamics in UK society that exacerbate the inequalities they experience. Comprehending and acting upon this can allow for pursuance of the right to health for all.
References
Asif, Z. and Kienzler, H. (2022) ‘Structural barriers to refugee, asylum seeker and undocumented migrant healthcare access. Perceptions of Doctors of the World caseworkers in the UK’, SSM - Mental Health, 2, pp. 100088. doi: https://doi.org/10.1016/j.ssmmh.2022.100088
Shahvisi, A. and Finnerty, F. (2019) ‘Why it is unethical to charge migrant women for pregnancy care in the National Health Service’, Journal of Medical Ethics, 45(8), pp. 489–496. doi: https://doi.org/10.1136/medethics-2018-105224
Smith, J. and Dexter, E. (2019) ‘Implications of upfront charging for NHS care: A threat to health and human rights’, Journal of Public Health, 41(2), pp. 427–427. doi: https://doi.org/10.1093/pubmed/fdy050
Spade, D. (2013) ‘Intersectional Resistance and Law Reform’, Signs: Journal of Women in Culture and Society, 38(4), pp. 1031–1055. doi: https://doi.org/10.1086/669574
Walker, C. and Farrington, R. (2021) ‘Charging for NHS care and its impact on maternal health’, British Journal of General Practice, 71(705), pp. 155–156. doi: https://doi.org/10.3399/BJGP21X715337
Author: Kim Austen
Course: MPH International Development (Masters in Public Health)