The figure of the undocumented pregnant woman and the healthcare system

While the overseas department of Mayotte rarely features in national and international news, when it does it is mostly portrayed as a peripheral piece of French territory overwhelmed by irregular migration from the neighbouring islands. This portrayal relies on the assumption that migrants, and in particular women, come to Mayotte in the hope of bearing French children. These are typical depictions of undocumented pregnant women in Mayotte and of their intentions:

Yet in contrast to such recurrent media depictions, there exists no automatic birth right citizenship in France; rather, children born in France become French nationals as teenagers, at age thirteen at the earliest, on condition of continuous residency since the age of eight. Many journalists give in to simplistic depictions of women’s mobility within the Comorian archipelago. These portrayals obscure, on the one hand, the importance of traditional local mobilities across the islands, mostly owing to family ties (Geisser, Reference Geisser2016), and reproduce, on the other hand, the idea that undocumented women have necessarily arrived recently. In contrast, previous research (Math and Duflo, Reference Duflo2019), as well as results from this study, suggest otherwise. The high number of foreign women who give birth on the island is due more to barriers to regularisation than to the number of recent arrivals (Sahraoui, Reference Sahraoui2020a). Yet the representation of Mayotte as constantly facing new arrivals does produce performative categories that are mobilised by local actors and engender political and material implications in terms of healthcare delivery to pregnant women. This discourse, carried out by Mahoran politicians, was equally adopted by politicians at the national level, so that in 2018 France passed a restriction on future access to French nationality of children born in Mayotte by making it conditional on the legal status of one of the parents at the time of the birth (Duflo, Reference Duflo2019).

Caught in the migration debate, the perinatal and maternal healthcare services of Mayotte represent the bulk of healthcare services on the island, as neonatal and maternity care accounts for 61 per cent of all hospital activities (Chambre Régionale des Comptes Mayotte, 2019). The sector is composed of a network of twenty-one ‘mother and child’ care centres (Protection Maternelle et Infantile, PMI) as well as five maternity wards related to the hospital. The main ward is situated in the Mamoudzou hospital, with four annexes located across Mayotte. The financing of the hospital stems from global envelopes of State subsidies and the PMI network is funded by the departmental council. The State Medical Aid (AME) that gives undocumented migrants the possibility of having some of their healthcare expenses covered by social security after three months of residency does not apply in Mayotte. Pregnant women, however, have access to perinatal and maternal healthcare even if undocumented. Yet, the following section explores how the political instrumentalisation of the figure of the undeserving undocumented Comorian woman seeking to give birth in Mayotte led to the underfunding of the whole sector of perinatal care on the island.

Perinatal care centres stigmatised for attending undocumented patients

The PMI centres were financed by the State before Mayotte became a formal department. The process of ‘departmentalization’ led to the transfer of the PMI governance to the departmental council, composed of the local Mahoran elite, and thus to its budget. Healthcare services to pregnant women, crystallising tensions concerning undocumented migration, witnessed political manoeuvres around its financing. The metropolitan doctor at the head of the network of PMI centres, in his position for a year and a half at the time of the interview, analysed the situation in terms of political calculation and financial reciprocity aimed at securing votes:

The social security services I interviewed ^{Footnote 2} in 2017 indicated that between 25 and 30 per cent of the patients attending the PMI health centres possessed a social security number, meaning that the remaining 70 to 75 per cent of patients were not registered within the national healthcare coverage scheme; anyone who is French or a regular resident can register in Mayotte. Healthcare professionals were caught in the midst of this political battle over who should pay for the healthcare of those labelled ‘foreigners’. Although these categories do not entirely overlap – a Comorian with a residency card can register with the national healthcare coverage scheme while a Mahoran might not be registered if s/he has not completed the necessary administrative procedures – they are widely mobilised and have become performative. Mariele, a metropolitan midwife at one of the PMI centres, deplored the crisis that resulted from the intentional underfunding of perinatal healthcare services:

While undocumented women in metropolitan France might experience difficulties in accessing specific PMI centres (GISTI, 2004), by law these health centres attend all pregnant women and children under six without administrative discrimination (Davoudian, Reference Davoudian2018). In Mayotte, the significant share of non-registered patients, but above all the detrimental political context, has led to the stigmatisation of the PMI health centres, associated with servicing allegedly undeserving pregnant women. At the political level, their undeservingness is framed in terms of lack of financial reciprocity, leading in practice to the underfunding of the health services that these women attend. For most of 2017, the network of PMI centres remained understaffed, with worries growing at the approach of the usual ‘summer departures’ caused by the high turnover of metropolitan healthcare personnel on the island. Laure, one of the very few working on the island for over ten years, shared her anxiety:

Grossly understaffed, the PMI centres also suffered shortages of equipment and basic resources. In light of the material consequences of the department’s policies, midwives were left helpless. Aurélie, a metropolitan midwife employed in one of the island’s busiest health centres, lamented:

The ‘humanitarian situation’ Aurélie mentioned was particularly worrying during the early summer of 2017, when healthcare professionals of the PMI network jointly published an open letter asking for the State to step in to ensure continuity of care ^{Footnote 3} . Meanwhile, they also recounted episodes that had occurred during even more desperate weeks earlier that year. The centres’ needs ranged from ultrasound scanners to items of basic hygiene such as soap. During water shortages that affected the Southern half of the island over two months in 2017, hygiene became impossible to maintain, as Claude, a metropolitan midwife, remarked in an exasperated tone:

The situation escalated to the point where some PMI centres had to close, given that, despite the extent of needs in terms of vaccination and pregnancy monitoring, healthcare professionals had no means of ensuring patients’ and their own safety due to a lack of resources. Aurélie explained how she and some of her colleagues had to discontinue their work in the face of such unacceptable conditions:

Such extreme lack of resources, though to a large extent resulting from the political struggle described here, reinforced the image of the PMI services as being overwhelmed by demand, and thus fed into this representation of uncontrolled immigration of pregnant women, highly stigmatised and cast as undeserving. Hence the network of PMI centres became caught in a symbolic political battle. The construction over the years of symbolic boundaries (Lamont and Molnar, Reference Lamont and Molnar2002) between Mahorans and Comorians resulted in deeply entrenched social boundaries. On the surface a competition between different levels of governance (that of the State and that of the department), the conflict revealed an underlying battle over whose presence is legitimate and who is deemed deserving of healthcare. The following section unpacks how Mahoran healthcare professionals framed this undeservingness.

Shortcomings of the healthcare system and Mahorans’ perceptions

The intentional undermining of the PMI services due to their association with support for the undeserving neighbours exacerbated the healthcare system’s malfunctioning, notably through ongoing staff shortages. The deterioration of working conditions in the public sector affected the quality of healthcare and fuelled Mahorans’ frustration and resentment, directed towards Comorians. All of which created a vicious circle: the more the PMI and the hospital were overwhelmed, the more patients who had registered with social security, many of whom were Mahorans, were encouraged to consult medical practices of midwives and doctors outside the hospital or the PMI centres to avoid long waiting lists. Given that not every treatment could be fully reimbursed when consulting doctors in private practice, Mahorans resented the fact that possession of a social security card might paradoxically result in lesser coverage of one’s medical costs. This situation pitted Mahorans and Comorians against each other, whereas in the past Mahorans seem to have focused more on denouncing the lack of investment by the French State than on blaming Comorians for the saturation of public services (Sakoyan, Reference Sakoyan2012). The words of Fati, a Mahoran healthcare assistant employed in the main hospital, illustrate how this resentment grew:

The PMI health centres, understaffed and under-resourced, faced similar if not greater challenges than the public hospital; thus midwives often advised patients with social security to consult a midwife in the private sector, as the delay for an appointment was shorter and chances of adequate continuity of care were higher. For Mahorans used to the healthcare system in metropolitan France, this came as a surprise. Mariama, a Mahoran social worker who worked as healthcare assistant for several years in metropolitan France before moving back to Mayotte, recounted the following anecdote:

It thus appears that, while Comorians were blamed for what was perceived as substandard conditions within the public healthcare system, Mahorans’ practices of healthcare access followed a logic of social distancing from Comorians. Najma’s reference to the unwelcome cousins in the introductory quote entails in this regard an apparent paradox for deservingness theory that considers social proximity (Willen and Cook, Reference Willen, Cook and Thomas2016) or identity (Laenen et al., Reference Laenen, Rossetti and van Oorschot2019) as a factor that facilitates the construction of judgements of deservingness. In contrast, discourses by Mahoran social agents tended to combine a fully-fledged acknowledgement of Comorians’ social proximity with a discourse as to their undeservingness to access the department’s healthcare services. Yet the less Mahoran women use the PMI services, the more it is associated with a service ‘dedicated’ to undocumented migrants and thus stigmatised. Zainaba and Mariama, both Mahorans, believed that the reception conditions in the public sector caused many Mahorans to avoid the facilities altogether:

This resentment towards Comorians translated into daily tensions in the maternity wards and perinatal consultation services. The following section examines how metropolitan midwives and Mahoran healthcare assistants navigated these tensions and, in the process, produced specific understandings of undeservingness.

The malleability of the CARIN criteria within the tensed context of maternity care

Against the background of Comorian migrations being portrayed not only as a social burden but as an existential threat to Mayotte’s healthcare system, it appears that the CARIN criteria were invested with shifting meanings and different weights. The following anecdote recounted by Mahoran healthcare assistants shows that, since both Mahorans and Comorians can equally access the hospital to give birth, how they are treated becomes a contentious issue. Daily interactions in the maternity ward crystallised these tensions so that it was not the general lack of resources that was seen as the cause of unsatisfactory care, but Comorians, who were blamed for specific shortages. Mahoran healthcare personnel risked being perceived as participants in the allegedly favourable treatment that Comorian patients received. Favourable treatment merely meant the same treatment as everyone else, since the Mahoran patients described here believed they deserved ‘more’ care than Comorian patients on the basis of financial reciprocity.

If Mahoran healthcare professionals found themselves in a peculiar position and could be taken to task by Mahoran patients, metropolitan midwives, overwhelmingly white, female and young, also played a significant role in the production of the local moral economy of healthcare (Willen, Reference Willen2015; Sahraoui, Reference Sahraoui2020b). A few months after these interviews were conducted, the hospital personnel called a strike to raise the government’s awareness of the critical situation of health services in Mayotte. This time around, the medical personnel appeared to be divided along metropolitan vs. Mahoran lines. Mahoran strikers were reported to have displayed a willingness to bar Comorians from entering the hospital, having called upon the ‘Women Leaders’ [Femmes Leaders, a group of militant women who had advocated for Mayotte’s departmentalisation] to ensure a selection at the hospital’s entrance (Journal de Mayotte, Reference Journal2017). The direction of the hospital, composed of metropolitan administrators and doctors, emphasised that it was not the role of the hospital to implement such distinctions. In line with this inclusive approach, Claude, employed in a PMI centre in the South of the island, disclosed how she attempted to reduce existing tensions by emphasising her universalist commitments:

Interestingly, Claude resorted to the notion of necessity to disarm the potential opposition to her inclusive stance in that she emphasised that Mahorans needed to make sure all children were vaccinated to protect public health on the island. Yet by no means did all metropolitan midwives adopt a public health-oriented stance that opposed the dominant undeservingness frame. In contrast, Véronique, a young midwife working in one of the dispensaries, shared her opinion as to Comorians’ lack of deservingness on the basis of her assessment of patients’ needs. Her reflections on the relative privilege of Comorian women led her to dismiss their alleged ‘need’, an opinion fuelled by judgements related to their attitude:

Véronique stigmatised undocumented Comorian patients by resorting to the discursive repertoire of the ‘welfare scrounger’, using perceptions around attitude to construct representations of the undeserving migrant. The midwife’s peculiar use of the notion of need – stating a lack of need while mentioning that the Comoros are among the poorest countries in the world – also demonstrates how easily these CARIN criteria are filled with shifting meanings to sustain frames of undeservingness. At the same time, her discourse confirms the importance of the need criterion, as she senses the obligation to justify her views by dismissing any potential allegation as to Comorian women’s needs. It equally hints at a decisive hierarchy among the CARIN criteria: as long as ‘control’ is assumed, with Véronique in this case considering that this migration was chosen, hardly any situation can qualify as presenting a ‘need’. This is in line with results from quantitative studies that conclude by identifying a criterion of ‘control over neediness’ (Van Oorschot, Reference Van Oorschot2006). However, the observed situation also differs from previous comparative research into undocumented migrants’ access to various social services, which argued that in sectors of high professionalisation, such as healthcare and education, restrictive policies were most resisted by actors on the ground (Van der Leun, Reference Van der Leun2003: 123). The Mayotte-based case-study illustrates that a widespread anti-immigration political and media discourse can trump the resistance of professionals.

For migrants, as compared to other social groups, the ‘control’ criterion takes precedence and facilitates casting them as undeserving, since their very status as migrants is equated with having chosen their fate. In similar vein, Sophie, a colleague of Véronique, perceived an existing ‘need’, yet dismissed Comorians’ rights to access free healthcare on the basis of the ‘control’ they were perceived to exert over their trajectories (see Slingenberg, Reference Slingenberg2021, for a similar finding in the analysis of the legal reasoning of the Supreme Court in the Netherlands). In the following quote Sophie explained her refusal to give a pregnancy test to a woman who came to the dispensary because her period was late:

In the tense context of perinatal and maternity care in Mayotte the criteria of need and control were mobilised to sustain views as to Comorian women’s undeservingness, following lines of thought that have elsewhere served to construct groups as deserving of social welfare (Jensen and Petersen, Reference Jensen and Petersen2017; Laenen et al., Reference Laenen, Rossetti and van Oorschot2019). These healthcare professionals engaged in an active neutralisation of criteria that they assumed others – colleagues or potentially the interviewer – might consider as justifying certain forms of care. The need to make their differing interpretations explicit stemmed from an expectation that their views might contradict dominant moral sentiments within their profession.