Xenophobia in South Africa has spilt over into the health sector, with some foreigners afraid to visit local clinics and hospitals.  A Zimbabwean woman, Yolanda Dumpson, shared her traumatic birthing experience at a public hospital in Johannesburg last year.

Pregnant woman’s first-hand horror

“I couldn’t sit down or bend my knees. My hands were on the floor and I was in so much pain. I was fully in active labour. One of the nurses came by and started shouting at me and demanding that I wear a mask. After I explained to her that I couldn’t breathe because of the excruciating pain and that no one else is wearing a mask in the room, she insisted that I will spread “my coronavirus” if I don’t wear a mask.”

Dumpson was verbally abused, neglected, and exposed to a delay in birthing support during her 29th week of pregnancy.

After showing the officer her valid permit and passport, she was requested to make a payment of R5000 in cash. This was required because she is a “foreigner” and wanted to give birth at the facility. She was told that she wouldn’t be touched by a healthcare worker until the payment was made. It didn’t even matter that she was in premature labour. 

Following the transaction that was finalised in the presence of a doctor, she received a receipt and was told to wait on a bench.

“I begged to go to the bathroom even though the nurses wouldn’t let me. They were shouting at me in a language I don’t understand and can’t identify.  I saw that I had blood coming out of my panty. When I tried to tell the nurse, she forced me to go back to the bench,” the 35-year-old explained.

She continued: “I went back on my knees and kept trying to breathe. Then suddenly somebody grabbed me from the back and pulled me. She took me to this room and told me to take off my clothes and get on the bed. As I was taking off my clothes, the water sac burst and there was water everywhere.”

Left all alone

Dumpson screamed and begged for help.

“Please help me! Please help me! I think the baby is coming!”

While she could feel the pressure on her baby, Dumpson was left neglected and unattended.

She began to push.

“The baby came out and she was crying. Oh, Lord! It wasn’t the right time for her to be born but I knew that she could not die. So, I took the baby, held her and prayed for life over her.”

Dumpson screamed: “The baby is here! Please come! Please come!”

After more than 10 minutes of giving birth, Dumpson said that a nurse appeared and scolded her, accusing her of not calling them for help. The flustered mother explained that her efforts were in vain.

An everyday struggle

Dumpson, a preschool teacher from Zimbabwe, found out that she and her husband were expecting a baby last year.  Although this was good news, her family feared for her safety when giving birth at public healthcare facilities as an African woman of foreign origin.

Dumpson was diagnosed with a condition referred to as an “incompetent cervix.” This places her at high risk when she is pregnant and means that she has to go to the clinic as soon as possible to be referred.  This also means that her chances of having a premature birth are higher, as her condition doesn’t allow her to carry for a full term.

“Mentally, I fight. I still have difficulty sleeping because there are so many things running through my mind and I don’t know how to deal with these feelings.  I don’t trust anyone anymore at medical facilities,” she said. 

Dumpson said that she wants nothing to do with state hospitals and plans to get her family on medical aid. This could one day protect their health and save their lives against the horrific birth outcomes influenced by xenophobia.

Living with the ‘what-ifs’

“Every day I look at my baby and it crosses my mind that, what if she didn’t make it? What if she had complications as a premature baby? This could easily have been the case because she didn’t have oxygen for a long time. I’m grateful she is here, but I am still struggling.”

Dumpson has not yet reported this incident at the hospital because of her lack of faith in the system as a non-South African citizen.

"The state has tended to stand down while a neighborhood is roiled with xenophobic violence."

Read Richard Pithouse's article, produced by Globetrotter, on xenophobia in South Africa.#SouthAfrica #Xenophobiahttps://t.co/ZfjXimhhQa

— Peoples Dispatch (@peoplesdispatch) August 10, 2022

Obstetric violence in SA

Nkululeko Mbuli, Advocacy and Communication Strategist at Embrace, described obstetric violence as a form of gender-based violence that includes any kind of abuse or abuse of treatment of pregnant women within reproductive health care.

“Depending on your age, race, sexual orientation, employment status or immigration status, all of these result in a particular increased level of vulnerability to obstetric violence,” Mbuli explained.

Mbuli said that this treatment of African women of foreign origin is influenced by xenophobia and Afrophobia.

She continued: “It would be a manifestation of the kinds of attitudes that as South Africans, we often have toward Africans hailing from different parts of the continent. In this particular case, it would be around the perception of African migrants being a burden or placing a further burden on an already overburdened healthcare system.”

Mbuli explained that obstetric violence in SA also impacts women who are citizens of the country because of its systemic and structural form.

Ripple effect

“If we consider the conditions that healthcare workers work in, in this country, it’s no surprise that the entire system is under strain. This has a ripple effect on workers and patients when they don’t have support or access to mental health services and sufficient equipment,” said Mbuli.

She recalled the organisation’s experience in engaging with undocumented women and said that they have had a harder time accessing respectful maternity care. They also tend to experience high levels of discrimination, neglect, verbal abuse, and the denial of care as a result.

Although antenatal care is a significant determinant of birth outcomes, some African women of foreign origin forgo this service to avoid violence and abuse at healthcare facilities.

“We have also seen how delayed or denial of antenatal care for undocumented women who are living with HIV can lead to adverse birth outcomes and the transmission of HIV or disrupt the prevention of transmission of HIV between mother and child.

Violence swept under the carpet

Beverly Chigwanda-Kambarami said that instances like this are prevalent and most go unreported.

“This is because many of these foreign Africans are undocumented and they are afraid of victimisation, which might lead to possible deportation,” she explained.

She added: “Other women don’t go for their antenatal care because either they are too scared to come through because they don’t have the necessary documentation. Other women are traumatised from what they’d heard within the communities. Sometimes there is also a breakdown in communication due to the language barrier and healthcare workers not wanting to compromise.”

Chigwanda-Kambarami is a birthing and postpartum doula. She has worked in both the public and private sectors, assisting moms from antenatal care to post-partum.

She said that not knowing what to expect at a government clinic or hospital can determine whether or not a woman accesses antenatal or maternal care.

“The consensus out there is that payment is required. So, whether you are at death’s door or experiencing something minor, there needs to be a payment. This becomes problematic because the amounts vary. In Johannesburg, we know that the amount depends on which facility you go to. But in Cape Town, the conversation is that African women of a foreign origin can give birth for free. This grey area is a big problem for women who need to access the services,” she said.

Mostly prayer and faith as antenatal care

“I only went for my checkups twice during my pregnancy. And I decided to give birth at home with the support of my friends and members of my community,” said Linda Mujuru*.

Mujuru is from Zimbabwe and has been working as a hairdresser in Pretoria since she arrived in the country in 2016. The 36-year-old currently has one child who she lives with in SA and two sons who are growing up with their paternal family back home.

Mujuru is undocumented and described her experience when she attempted to go for a checkup as “humiliating.”  She explained that she avoided antenatal checkups for fear of being treated badly.

“The nurse shouted at me for speaking English with her instead of isiXhosa, even though I told her that I do not understand the language. She said to me: ‘You speak English but are pregnant with a Xhosa man’s baby! What language do you speak when you are having sex with him!’

Avoiding medical care at all costs

Mujuru continued: “People started laughing and continued to ridicule me. I promised myself that I’d never go to a clinic unless I knew a nurse who worked there. Even when I am sick, I would rather treat myself at home than go to a clinic.”

Mujuru said that foreign African women only receive decent healthcare treatment when there is someone that they know personally at the facility. This person can vouch for and protect them from being abused or humiliated.  

The upfront payment played a huge role in deciding to give birth at home.

“I was scared that something could happen to the baby and me. But because it was not my first pregnancy, I trusted God and continue to trust Him even now.” 

The right to health

Section 27 of South Africa’s Constitution states the right to access health care services is one of the basic human rights for everyone. This includes reproductive health care services.

“This means that women who are foreign African nationals should also be guaranteed this right,” said Mbuli.

Mbuli also referred to Section 4 of the National Health Act (NHA) no.61 of 2003, which states that relevant members of Executive Councils may prescribe conditions which categorise a person to be eligible for free health services at public health establishments. The following are exempted categories; Pregnant and lactating women and children below the age of six years.

“Guidelines for Maternity Care in SA” also stipulates that pregnant and birthing women have the right to quality care and outline the care level they should receive. Various legislation makes clear that the right to access care is for foreign African nationals too. But reports from women prove to us that this is often not the case,” she explained.  

Putting a number on it

According to the World Health Organisation (WHO), there are one billion migrants worldwide.

A report compiled by the organisation on the health of migrants included disease, famine, war, and climate change as reasons why people flee their home countries. The COVID-19 pandemic has also had a major contribution to how the health and livelihoods of migrants have been affected.

In SA, it remains unclear how many undocumented African people of foreign origin there are living in the country. The Gauteng Department of Health could also not provide statistics on how many undocumented foreign African nationals are accessing healthcare services in SA.

Statistician-General Risenga Maluleke, from StatsSA, explained in a press release: “If one uses the output of foreign-born persons counted in the Census 2011, and adds to it the number of international migrants for the period 2011-2016, as well as, in the period 2016-2021 from the 2021 mid-year population estimates, one would get an estimation of 3.95 million persons.”

This includes all migrants, regardless of their legal status to be in the country.

Same as South Africans

Head of Communication at the department, Motalatale Modiba, said that foreign nationals are currently accessing free or subsidised healthcare in the province, equivalent to SA citizens.

The Policy Implementation Guidelines on Patient Administration and Revenue Management of the provincial health department defines a foreigner as someone from outside the borders of SA, including foreign tourists or an employee of a foreign company who is visiting. This definition excludes migrants with valid documents.

Documents required for patient registration and classification include; proof of identification such as an identity document, passport, birth certificate, refugee permit, asylum seeker permit, or permanent residency permit; pay slip, and proof of address (residential or postal address). The policy is unclear about the procedure to be followed should a patient not have such documents to present to the relevant admitting officer.

“All citizens and foreign nationals in the country are classified economically in terms of the Uniformed Patient Fees Schedule (UPFS) and Non-SA Citizens (Foreign Patients) Guidelines and National Patient Classification and Tariff Determination Policy. There are costs associated with access to public healthcare resources in the country, and those who can afford them, need to pay for the services irrespective of geographic origin.”

The cost factor

Modiba noted that the costs required for different services might vary based on the healthcare facility.

Although Section 4 of the NHA means that exempted patients in these categories should be receiving free health care services when these conditions are confirmed and should not be required to pay prescribed fees irrespective of any additional diagnosis, their income or their normal classification

Modiba said that women who claimed to have been made to pay or exposed to obstetric violence should report it. However, the department was not able to confirm whether or not they are aware of xenophobic mental attitudes impacting the delivery of reproductive healthcare services and influencing levels of violence in public facilities upon foreign African nationals.

“We urge patients, regardless of their nationality, to report ill-treatment or violence to quality assurance managers at the facilities. If they don’t find the closure, they should report this to the hospital CEO or clinic manager,” he said. – Health-e News