When Amina went to a clinic for her first prenatal exam in May, she was already eight months pregnant.
“I felt unhealthy, but I didn’t go to the hospital because I was undocumented and couldn’t pay the fee,” says the Somali asylum seeker, who lives alone with her younger sister in Kuala Lumpur and lost her job early on in the pandemic.
Suffering from high blood pressure and anxiety, she collapsed in the waiting room and was taken by ambulance to a government hospital. After a month in the hospital, she gave birth by caesarean.
As for any of the tens of thousands of undocumented asylum seekers and refugees in Malaysia, showing up at the hospital exposed Amina to the possibility of arrest by immigration authorities. Fortunately for her, however, a community assistance group run by Somali refugees intervened on her behalf. They contacted the UN Refugee Agency, UNHCR, and petitioned for a letter confirming that her application for refugee status was under consideration, protecting her from arrest. The letter also allowed Amina to access a 50% discount on government medical services given to UNHCR-recognised refugees.
Still, the hospital bill was RM 10,000 (US$2,500). It was covered by a combination of UNHCR emergency funds and donations from Somali refugees.
Speaking on condition of anonymity, a representative of the Somali Refugee Community Malaysia tells New Naratif that she has seen many cases similar to Amina’s. “They don’t go to the hospital until eight or nine months … until they have an emergency case and are suffering,” she says.
New Naratif spoke with five asylum-seeking and refugee women who gave birth during the COVID-19 pandemic. Each faced medical bills amounting to several months’ wages, but with little or no savings to cover the costs, they were left to rely on donations or borrowed money. Financial desperation and fear of arrest, exacerbated by lockdowns and an immigration crackdown, deterred or prevented these women from seeking the medical services they needed for themselves or their babies.
Fear of Arrest
As of December 2020, nearly 180,000 people, predominantly from Myanmar, were registered with UNHCR in Malaysia, of whom about a third were women. Malaysia is not a signatory to the UN Refugee Convention and does not offer any formal protections to refugees, but those registered with UNHCR are usually spared immigration-related arrest.
Refugee community leaders tell New Naratif, however, that tens of thousands await registration appointments with UNHCR, often for years. Until they register with the agency, they remain vulnerable to arrest as undocumented immigrants.
The [clinic] price is higher than the government hospital, but I have no choice.
Muna*, a Rohingya woman from Myanmar who arrived in Malaysia in August 2019, is still awaiting a UNHCR registration appointment. Her husband Zubair, who is registered, knows the risks of being undocumented; he spent nearly three years in immigration detention before Muna arrived in Malaysia. The couple, who live in the state of Perak, decided to seek maternal healthcare for Muna at a private clinic due to her undocumented status.
“The [clinic] price is higher than the government hospital, but I have no choice,” says Zubair, who lost his job at a fish market in March and has since had irregular work loading and unloading vegetables at a market. “Because [Muna] doesn’t have a [UNHCR] card for her safety, I had to take her to a private clinic.”
In May 2020, as neighbourhoods were emerging from coronavirus lockdown, the government conducted sweeping immigration raids in Kuala Lumpur. More than 2,000 undocumented immigrants were arrested, many of them asylum seekers. The defence minister described the operations as “a continuous exercise to weed out undocumented foreigners”.
The Malaysian government also launched workplace raids and warned businesses not to hire or rent apartments to undocumented migrants. At the same time, xenophobic hate speech proliferated online, much of it targeting Rohingya refugees.
As their husbands were arrested in front of them, they are afraid to seek medical care.
Thuzar Maung, who runs a volunteer community assistance group called the Myanmar Muslim Refugee Community (MMRC), tells New Naratif that hundreds of Myanmar Muslims were arrested during the raids in May, including the husbands of several pregnant women.
“As their husbands were arrested in front of them, they are afraid to seek medical care,” she says.
She adds that during the pandemic, approximately 20 pregnant women contacted MMRC seeking social or financial support, though her group mainly provides education and referrals to other services, few of which are available to undocumented asylum seekers.
While MMRC has been able to petition for under-consideration letters from UNHCR for four or five women with critical medical conditions, Thuzar Maung says most have no option but to go to private clinics or, for those who cannot afford them, deliver at home.
Born at Home
Van Van*, a Chin refugee from Myanmar, works as a part-time welder in Kuala Lumpur. Outside of work, he has spent the last 10 years voluntarily helping asylum seekers and refugees, including by accompanying them to medical appointments and negotiating with police when they are arrested.
“I help those who have nowhere to go and nobody to help them,” he says.
He says he has accompanied more than 100 migrant women while they delivered their babies at hospitals and clinics, where authorities have solicited bribes from them.
“Sometimes, when I accompany undocumented pregnant women to the hospital, authorities have threatened to arrest them,” Van Van says. “Sometimes, they ask for some tea money, and then they let us go.”
Although he has no medical background, he says that over the last two years, he has also helped two undocumented women deliver babies at home.
The first case was in May 2019, when he accompanied a woman in labour to the government-run Sungai Buloh Hospital, and she was turned away due to her lack of documentation, so Van Van helped her deliver at home, by his account. He did not anticipate having to repeat the experience, but in June 2020, he accompanied another undocumented woman in labour who was turned away from the same hospital. The woman’s husband was in immigration detention, and she only had RM 500 (US$123), which was not enough to cover delivery costs at the hospital or a private clinic. Van Van made a last-ditch decision.
“I don’t have any medical equipment. The only thing I have is my two hands,” Van Van tells New Naratif. “It took six hours. …She delivered standing after trying many positions. I really prayed to God, and God helped. It was very dangerous.”
Van Van says he knows he could have been held liable if the mothers or babies had experienced complications during these home deliveries, but he felt he had no choice. “For me, it’s very dangerous and challenging to help,” he says. “However, if I didn’t help, they may have been in more trouble. Therefore, I took the risk.”
Sungai Buloh Hospital declined to answer questions posed by New Naratif over the phone.
Van Van and others interviewed by New Naratif say there is no way of knowing how many women have delivered at home during the pandemic, but they are concerned that more women are unable to access necessary healthcare due to a combination of poverty, language barriers and fear of arrest.
“The pandemic has badly affected the well-being of refugee and migrant mothers, and especially undocumented pregnant women,” Van Van says.
“I’m Afraid the Doctor Will Ask for More Money”
Even in cases when undocumented refugee women are able to access medical services, these services are often delayed or leave them incurring heavy debts to cover the costs.
Refugees are denied the legal right to work in Malaysia, forcing them, along with asylum seekers and undocumented migrants, to work in the informal sector. Exploitation and immigration raids are frequent. All five households interviewed by New Naratif had lost their primary sources of income or seen their work hours significantly reduced during the pandemic.
To give birth in Malaysia is a kind of loss because our child doesn’t have a future here.
Although Muna, the Rohingya woman who gave birth in January, has asthma, she and her husband Zubair avoided mentioning it during prenatal visits.
“Most of the time, I don’t tell the doctor about her sickness because I’m afraid the doctor will ask for more money,” Zubair told New Naratif three weeks before Muna gave birth.
Muna was also initially denied admission to the clinic while in labour because she and her husband could not afford a deposit.
“When I brought her to the clinic, the doctor asked me to pay RM 3,000 [US$740] for the deposit, but I only had 2,000 [US$495]. The doctor said they couldn’t admit her. …They kept her waiting,” Zubair says. He eventually negotiated the price down to RM 2,500 and borrowed the balance.
The World Health Organization advises women to stay at a health facility for at least 24 hours after giving birth, but Muna was discharged within 12 hours.
“They asked me to pay RM 1,500 [US$370] for one night only. I told them it was very expensive and I couldn’t afford it, so they better discharge my wife,” Zubair says. Even without the overnight charges, the bill came to RM 3,387 (US$840). Zubair borrowed around half the sum from friends.
He tells New Naratif that his excitement about being a father is tinged with grief. Zubair wishes his baby could have the chance to go to school that he and his wife did not have, but he knows this will not be possible in Malaysia.
“To give birth in Malaysia is a kind of loss because our child doesn’t have a future here,” he says.
For those registered with UNHCR or possessing under-consideration letters from the agency, government hospital costs after the 50% refugee discount are lower than at private clinics, but they are still out of reach for many under a dual pricing system based on citizenship.
Admission for a non-Malaysian to a third-class maternity ward at the Kuala Lumpur Hospital requires a RM 2,800 (US$700) deposit and RM 160 (US$40) per day in ward charges, according to the hospital’s website. For Malaysians, the costs are RM 15 (US$4) and RM 3 (less than US$1), respectively. Charges for baby delivery services are not published on the hospital’s website, and the hospital did not respond to New Naratif’s phone or email inquiries. According to a third-party website, delivery without complications in a third-class ward at a government hospital costs RM 2,593 (US$640) for foreigners and RM 10 (US$2) for Malaysians.
“There is a huge discrepancy in terms of the cost of delivery and access to health services,” says Tini Zainuddin, a child rights advocate and co-founder of the child welfare nonprofit Yayasan Chow Kit.
“COVID-19 highlighted the discrepancy even more,” she adds.
Rukia, a Rohingya in Kuala Lumpur who is registered with UNHCR, found that her ability to pay dictated the services she received at the government hospital where she sought postnatal care. She delivered prematurely at home in February and went to the hospital for stitches, but she says she was denied admission until her husband was able to borrow money to pay the deposit, even though she arrived at the hospital in pain and carrying her newborn.
“The doctor refused to admit my wife to the ward,” says her husband Shahidur. “He said if I couldn’t pay RM 1,600 (US$400), they wouldn’t give my wife any medication or treat her.”
For Hannah, a Kachin asylum seeker from Myanmar, a lack of funds forced her to forego prenatal care altogether. Although she had an under-consideration letter issued from UNHCR during a previous pregnancy, which is still valid and enabled her to seek government hospital care, she still had no way to pay when she delivered her third child in August. The street food stall where her husband works reduced his hours, and his earnings of RM 30 (US$7) per day left the family of four relying on donations and loans from other refugees even before Hannah gave birth in August.
Because of the debt that had piled up from Hannah’s RM 2,200 (US$550) delivery costs, the parents avoided taking their baby for follow-up medical appointments.
“My biggest concern for my baby is that, until now, we could not bring him to the clinic for vaccinations,” says Zau Du, Hannah’s husband.
Tini, the child rights activist, says she wants Malaysia to take a harm-reduction approach toward maternal healthcare for all women, regardless of immigration status. To start, this would entail offering amnesty from immigration-related arrest to women seeking maternal healthcare. She also advocates for parents to be allowed to pay in instalments for maternal healthcare; for all populations to have access to family planning information and services; and for the government to increase its efforts to promote vaccination for newborn babies.
“Especially now, during COVID-19, because of the rise in xenophobia and strict policies, many mothers are delivering at home or at private clinics, where there is less fear of being reported,” she tells New Naratif.
“There is no protection for pregnant mothers who don’t have money, don’t have connections and don’t know where to go.”
Additional reporting by Nu Nu Lusan
This article was supported by a grant from ARTICLE 19 under Voices for Inclusion, a project funded by the Netherlands Ministry of Foreign Affairs.
*Due to their undocumented immigration status in Malaysia, pseudonyms or nicknames were used for all mothers and fathers quoted in this article to protect their identities.
Call to Action: For those interested to contribute, here are the websites of some organisations supporting migrant, refugee and asylum-seeking mothers with accessing maternal healthcare or supporting migrant, refugee and asylum-seeking women’s initiatives more broadly:
Yayasan Chow Kit: 24-hour crisis and drop-in centre providing meals, activities, therapy, case management and educational programmes for at-risk children and teenagers around the Chow Kit neighbourhood of Kuala Lumpur.
Refugee Emergency Fund: Nonprofit crowdfunding initiative for emergency cases, including medical, rental, food and education, faced by refugees and some migrants in Malaysia.
Tenaganita: Protecting and promoting the rights of women, migrants and refugees, including anti-trafficking initiatives and a shelter for women in crisis.
Rohingya Women’s Development Network: Rohingya women-led community organisation working to strengthen and develop the Rohingya community through education, skills training and advocacy.