Nearly three years after losing her child during birth, Janet Dube, 43, still struggles to deal with the trauma of that night. It is not only her horrifying experience that haunts her but also the suffering of the other women in the hospital waiting room.
“It won’t go out of my mind. Because even sometimes when I am staying alone, it comes like a video to my mind … There were 21 of us with no one helping us,” Dube says, sitting on the edge of her bed in the 2x3m room she shares with her husband and four sons.
Dube and at least one other woman were left to give birth without any help until it was too late. Her child died, and she witnessed another woman die in front of her.
Horror stories of women being left to give birth unattended on floors in state hospitals are not uncommon. While understaffing and overworked healthcare workers contribute to the neglect women experience in hospitals, migrants, refugees and asylum seekers face greater levels of stress and ill treatment during pregnancy and childbirth.
The Gauteng Department of Health issued a circular early in 2020, just as the Covid-19 pandemic hit, that reclassified non-citizens and made migrant, refugees and asylum seeker mothers pay for antenatal and maternal healthcare services. This is despite the National Health Act, which guarantees access to healthcare for pregnant and lactating women, and for children under six years.
Hospitals and clinics in the province demand money from mothers who mostly cannot afford to pay. Notices of birth, which are documents necessary to register a child with home affairs, are being withheld when migrant mothers do not settle their bills.
Dube, who is pregnant with her sixth child, says she worries about going to hospital for antenatal care and regular checkups because of her past experiences. At a recent checkup, she was told to pay R370 because she was using a passport as opposed to an identity document. When she was unable to pay, it was noted in her file.
“Until today I did not pay that R370. But I have to go again to follow up, so I don’t know what it is that they are going to do,” Dube says. “Previous times when I was pregnant I did not pay.” When giving birth to her other children, Dube was asked only whether she had a valid passport. “But they now said, whether you have a valid passport or permit, you have to pay.”
“The thing I can tell you, being pregnant in South Africa, it’s not easy. Why? Because when you go to hospital, you will not be treated equally as a foreigner,” Dube says, while her three-year-old son Mqondisi plays on the bed behind her.
Abigail Dawson, the advocacy coordinator at Jesuit Refugee Services (JRS) in South Africa, says, “Giving birth in South Africa’s public health system for refugee, asylum seeker and migrant women has become increasingly extracting.”
Migrant mothers are asked to pay between R250 and R400 for antenatal checkups. Natural births in hospitals cost between R5 000 and R8 000, and caesarean sections cost as much as R25 000.
“The clients that JRS have assisted express their fear of accessing further healthcare because of the debt they have at hospitals and worry they will be denied further access to health. Hospitals in Gauteng have been denying access to notice of birth documents for mothers who have not paid these fees,” Dawson says. “Imagine having your baby’s name, with all its meaning and presence in this world, and nowhere for their name to be legally recognised.”
Sibusisiwe Ndlela, an attorney at public interest law centre Section27, says it is not only that these women struggle to access sexual and reproductive healthcare but also that it is part of a broader issue of access to healthcare for migrants, refugees and asylum seekers.
The Constitution entrenches certain rights, especially the right to healthcare. “It includes reproductive healthcare services specifically. It is a right that applies to everyone,” Ndlela says. “There is existing legal precedent that says ‘everyone’, which literally means everyone without limitation to anyone on any grounds … irrespective of nationality and documentation status.
“So for instance, if the Constitution specifically says ‘citizens’, that would naturally exclude refugees, that would naturally exclude asylum seekers. But the specific provisions we are dealing with says ‘everyone’, so there is no such limitation. And there is no limitation in statute. So no limitation can be imposed by a provincial department or a circular.”
Despite the guarantees in different legislation, the Gauteng health department still makes women such as Dube pay for services that by law should be free and which she cannot afford. Dube says she has not even started thinking about what it might cost to give birth again.
Charged as private patients
Motalatale Modiba, head of communications for the Gauteng health department, says only documented refugees were means tested and exempted from paying for maternity services.
“All non-South African citizens are classified as full-paying patients, excluding refugees with valid documents … The policy guideline complies with the laws of the land and was issued in consultation with legal experts,” Modiba says. “Primary healthcare services rendered at clinics and community health centres are free. Hospitals are paying facilities where all patients are expected to pay for the services rendered.”
But Modiba says the department does have a constitutional obligation to ensure the provision of services at all levels that are equitable and cost-effective. “The practice of withholding notices of birth is not supported by the policy and legislation. Hospitals should refrain from that practice. It would be better if specific cases were reported so that those can be addressed.”
Patients who are unhappy with their experiences at government hospitals and clinics in the province can lodge complaints with the department’s quality assurance unit for redress, says Modiba.
Ndlela says that because migrants and asylum seekers are not means tested, they are automatically categorised as full-paying patients. “That’s basically saying they are paying the same amount that they will have to pay accessing private services … It is largely happening in Gauteng. We don’t fully know what is happening in other provinces … [but in Gauteng] we see a distinct move to charge migrants when they try to access healthcare services,” she says.
Barriers to healthcare for migrants, refugees and asylum seekers have always existed, but Ndlela says when these policies were introduced the organisation became aware of a lot more cases of people being classified and charged as private patients.
“The circular was introduced around the time when the pandemic started, when people were most vulnerable. They just couldn’t access the funds [for] basic healthcare services,” she says.
Mbali Baduza, a researcher at Section27, describes the circular as “insidious”, saying organisations working with migrants, refugees and asylum seekers were not warned about it.
“Instead, what happened is people were going to hospital and then getting rejected. Then when there’s follow-ups, people just decide not to go. [The Gauteng health department] knows this is really bad and is a regression, and that there is going to be pushback as there should be,” Baduza says.
“All of this must be understood in the context that we are operating in a failing public health system where resources are severely limited and shrinking every year with the budget cuts. Some of these horrific instances of lack of resources aren’t just felt by foreign nationals. Even certain abusive treatment isn’t only felt by foreign nationals.
“That context is important and it can’t be ignored. I think [it shows in the way] our policies are drafted that there is an intention there to include foreign nationals specifically,” Baduza says.
‘It is just because I am a foreigner’
Josephine Kasongo*, 33, a single mother from the Democratic Republic of Congo, says her experience was mixed. “Giving birth, they were nice to me. But getting the birth certificate, that was the problem.” She cradles her nine-month-old son Kasendwe in her tiny apartment.
“They said I must pay R12 780. I did not have any work and I had no money. I said, how must I get that amount? They said I must get that amount otherwise I won’t get the birth certificate. I said I can’t afford that,” Kasongo says.
Like many women, she did not have trouble accessing her regular checkups and scans but was told she had to start paying R350 for each appointment. “I told them I can’t even afford that. Even to survive, they helped me. But I can’t pay that. When I gave birth, they said I must pay all that money to get the certificate for the baby.”
Kasongo has not paid the hospital and so has not been able to register her son’s birth. She is worried about the effect of her son growing up unregistered. The stress she feels about her child’s future was something she carried with her during the birth. “When they scanned me, they didn’t tell me they would operate on me. When I went to the hospital, they took me straight to the C-section.”
She is not sure of the details, but after the birth of her son, she fainted and was taken to a different hospital for two days for observation before she was reunited with her baby. “I still don’t know what happened to me.”
Dube still suffers from the trauma and physical consequences of the death of her child in a state hospital. “It is just because I am a foreigner,” she says. “I wish they can change the behaviour of how they treat people. Even if you go to Zimbabwe now, no one is going to ask you, ‘Where are you from? What do you want here?’ I wish they can fix these things.”
*Name changed to protect her identity
This project was undertaken in partnership with Wits University’s African Centre for Migration and Society, Sonke Gender Justice and the Consortium for Refugees and Migrants in South Africa, with funding from AmplifyChange. This story is part of The Endless Journey.