Medical Hostages

A disturbing but common practice in many developing countries is the detainment of women who have recently given birth and who cannot afford their hospital charges. Contrary to policies aimed at encouraging women to deliver in health facilities, this practice is an abuse of their rights and has implications for wider maternal and neonatal health. Detention of women is a surprisingly common problem, with current and recent examples of this practice found in Burundi, Cameroon, the Democratic Republic of Congo, Ghana, Kenya, Nigeria, the Philippines and Zimbabwe.1 It is, however, very difficult to estimate the extent of the problem as there are no prevalence studies and in many situations these detentions are illegal with no official figures. Most of the information concerning this practice therefore comes from assessments of single hospitals or anecdotal reports. A typical example involves a woman being admitted to hospital, often with a complication of pregnancy that requires an emergency intervention. She is treated with no upfront charges but is then required to pay before being allowed to leave. If she doesn’t have the money to pay on departure, she may be detained, often with her baby, for weeks or months while her family raises the necessary funds. A Caesarean section, for example, can cost a woman more than the average annual wage in her country. In effect, she is held hostage until the debt is paid. A report from Cameroon described a case where an infant spent nearly an entire year with her mother in hospital.2 For their part, hospitals stress that women are not denied treatment and point to the need for co-payments for services to be delivered. This practice is not limited to maternal health; it also happens with patients who have had surgical or other costly procedures. Generally law enforcement agencies are not involved in detaining patients, but hospitals employ private security guards, who check and stop patients on exit. Some are “just” detained, while others are forced to work to earn money. Women who need emergency obstetric care are therefore faced with a ghastly dilemma: do they risk giving birth at home without access to medical care, or do they face an uncertain period of detention in hospital until someone pays their bill? Detention is detrimental to maternal and child health with short and long-term implications for the infant. Pregnancy and childbirth are precarious times for both mother and baby and institutional deliveries are considered best practice in global health. The threat of being detained discourages women from going to hospital in the first place, reducing antenatal care and increasing the risk of maternal and infant death around childbirth. Globally, 290,000 women die from pregnancy-related causes each year.3 Usually the causes are preventable and, in a clinical setting, relatively simple to treat. In addition to this unacceptable