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Hong Kong attempts to reduce influx of pregnant Chinese
World Report
Hong Kong attempts to reduce influx of pregnant Chinese The number of mainland Chinese women choosing to give birth in Hong Kong has risen rapidly over the past 10 years, putting health services in the region under pressure. Now new laws have been introduced in a bid to quell the influx. Margaret Harris Cheng reports from Hong Kong.
www.thelancet.com Vol 369 March 24, 2007
3 day stay in hospital. Extra services, including extra visits to the antenatal clinic, attract more charges. Anyone who fails to pay the new charge and simply turns up at a hospital in labour will be punished by being charged $48 000. It is a scheme buying into the community demand for some sort of sanction against women they see as abusing Hong Kong’s health service. Ironically, Hong Kong has one of the world’s lowest fertility rates. In 2005, the fertility rate for Hong Kong residents was 0·7 children per woman, well below replacement levels (2·1), prompting the territory’s chief executive, Donald Tsang, to exhort couples to have three children. However, the vacuum has been rapidly filled, not by civic-minded Hong Kong mothers but by mainland China’s younger, and increasingly wealthier women, who are crossing the border to have their babies in Hong Kong. Since Hong Kong became part of China in 1997 the number of mainland women giving birth in Hong Kong has risen rapidly from 7810 in 2001 to 19 538 in 2005. Added to that, changes to China’s immigration rules allowing mainland citizens to visit Hong Kong on tourist visas mean many such pregnant women arrive as tourists. Indeed, so-called maternity tours to Hong Kong are now big business with travel firms offering packages that include transport, accommodation in serviced flats near hospitals with obstetric units, and assistance getting to the emergency room when in labour. The reasons mainland women wish to give birth in Hong Kong vary. Some come to evade China’s onechild policy. Others are married to a Hong Kong resident, but are not automatically entitled to live there, so
deliver in Hong Kong to ensure their children benefit from what is thought to be a better educational and social welfare system than that available in mainland China. These mainland wives have been steady contributors to Hong Kong’s population. The change now worrying the Hong Kong community has been the rapid growth in the number of children born to parents who are both mainland Chinese and do not live in Hong Kong, and thus have no rights of residence. In 2001, 601 babies were born to mainland couples. By contrast, in 2005, 9500 children—almost half of all babies born to mainland women—had mainland fathers as well. And in 2006 the number continued to climb, with over 10 000 such births in the first 9 months of the year. Although their parents have no rights of residence, children born to mainland Chinese parents in hong Kong automatically become Hong Kong permanent residents with full rights to public education, health
The printed journal includes an image merely for illustration
Empics
Mr Ng was furious. The proud prospective father had brought his wife to one of Hong Kong’s major public hospitals for her first antenatal visit only to be told that because his wife was mainland Chinese he had to come up with HK$39 000 before she could set foot in the clinic. Mr Ng, an itinerant worker, asked if he could pay in instalments. But the clerk behind the glass panel was adamant: no money, no baby. “Donald Tsang Yam-Kuen [Hong Kong’s Chief executive] tells us to have three children. But if the fees are so high how can I have more children?”, demanded Mr Ng, leaving the hospital with no booking. “If there is any accident I will ask the government to compensate us”, he threatened. Mr Ng was caught on the first day of a financial trap set at Hong Kong’s hospitals and borders to deter what the Hong Kong authorities, and much of the community, see as a social disaster in the making: a flood of mainland Chinese women choosing to give birth in Hong Kong. From Feb 1 this year, not only are any non-Hong Kong residents obliged to pay the $39 000 antenatal booking fee, no woman with a pregnancy beyond 28 weeks’ gestation can cross the Hong Kong-mainland China border unless she can prove she has made such a booking either privately or publicly. Although Hong Kong effectively has a free public hospital service, there have always been hospital fees. The differences are that the new fees are much higher than before and that mothers classified as nonentitled persons are required to pay for an obstetric package, which covers one visit to an antenatal clinic, delivery (vaginal or operative), and a
Mainland Chinese women are choosing to give birth in Hong Kong
981
World Report
Empics
The printed journal includes an image merely for illustration
Hong Kong’s high medical and nursing standards and well equipped hospitals are attractive to couples
and welfare services, all of which are cheaper than those available on the mainland. This is a result of the Chong Fungyuen case, in which the Hong Kong Court of Final Appeal ruled, in 2001, that Article 24 of the Basic Law (Hong Kong’s mini-constitution) entitled all Chinese citizens born in Hong Kong to Hong Kong permanent residency, irrespective of their parents’ residency status. Article 24, which has come back to haunt the Basic Law drafters, was put in as a bit of a titfor-tat because before July, 1997, in then British Hong Kong, Chinese did not have an automatic right of abode in Hong Kong, but any British citizen did. Although much has been made of mainlanders abusing Hong Kong’s welfare system, there is another subgroup in the mainland mother population with the potential to cause even more resentment. These are the mothers of the new China: seriously wealthy young women who can, and do, choose to have their babies wherever they wish to. Hong Kong, with its high medical, nursing, and technological standards, well equipped hospitals is attracting more and more such high-end mothers. As the distraught Mr and Mrs Ng left the Queen Elizabeth Hospital, an elegantly dressed, beautiful young woman attended by her equally 982
elegant husband, explained to the clinic nurse that she had come all the way from Guizhou (a landlocked province in south-eastern China—a journey akin to leaving Germany to deliver in London) to be sure she could have her baby in Hong Kong. The charges were reasonable, she felt. Money is not an issue for them, remarked the clinic nurse as they left. Indeed it was not, nor for many of the other mainland mothers who complied with the new system. On the first day of the system alone, the Hospital Authority earned $28million from new bookings. The private sector is gaining from the beneficiaries of China’s phenomenal economic growth. At least six private hospitals, which demand a $40 000 deposit on booking, say their quotas are filled. Not only are the private obstetric beds filled, so too are the operating theatres. For many, part of the private package is a guaranteed date, time, and method—caesarean section—of delivery. With such a heavy demand for obstetric surgery, other surgeons are finding their theatre time curtailed, causing further resentment. “Nobody can get into theatre to do any other cases because of all the mainland mothers”, said a surgeon who declined to be named. The increased charges are not believed to be enough of a deterrent.
Moreover, it is feared they will drive more pregnant women underground, strengthening another trend. An increasing number of mainland women are turning up in emergency rooms in advanced labour, with no antenatal records or information about their rhesus, hepatitis, HIV, or diabetic status, and, according to the Hospital Authority’s accountants, no intention to pay for their care. In the 2004–05 financial year 1670 mainland women failed to pay $12·64 million in hospital bills. By 2005–06 that number climbed to 2138 women who failed to pay $28·58 million. So the new immigration rule to keep women close to term out of Hong Kong was also brought into force on Feb 1. Any pregnant mainland resident who appears to be beyond 28 weeks’ gestation will not be permitted to cross the border unless she can prove she is booked into a recognised obstetric unit. Putting this plan into action has not been easy. Border baby patrols— a one doctor, one nurse team stationed at the border crossings to physically examine women suspected of harbouring a post-28 week fetus—have been set up. Hong Kong’s borders are well set up for medical screening—thermal scanners are used to weed out those who may be harbouring SARS, avian influenza, or simply the common cold. But weeding out women in their third trimester is somewhat less high tech. The medical officers have been equipped with a tape measure and fundal height chart and instructed to give an opinion. “I have already briefed our doctors that they are only required to give a range—such as 28–32 weeks of pregnancy, or 30–32 weeks—to immigration officers”, Lam Ping-yan, Hong Kong’s director of health told local journalists. “It is then up to the immigration department how to act on this information.”
Margaret Harris Cheng www.thelancet.com Vol 369 March 24, 2007
Hong Kong attempts to reduce influx of pregnant Chinese The number of mainland Chinese women choosing to give birth in Hong Kong has risen rapidly over the past 10 years, putting health services in the region under pressure. Now new laws have been introduced in a bid to quell the influx. Margaret Harris Cheng reports from Hong Kong.
www.thelancet.com Vol 369 March 24, 2007
3 day stay in hospital. Extra services, including extra visits to the antenatal clinic, attract more charges. Anyone who fails to pay the new charge and simply turns up at a hospital in labour will be punished by being charged $48 000. It is a scheme buying into the community demand for some sort of sanction against women they see as abusing Hong Kong’s health service. Ironically, Hong Kong has one of the world’s lowest fertility rates. In 2005, the fertility rate for Hong Kong residents was 0·7 children per woman, well below replacement levels (2·1), prompting the territory’s chief executive, Donald Tsang, to exhort couples to have three children. However, the vacuum has been rapidly filled, not by civic-minded Hong Kong mothers but by mainland China’s younger, and increasingly wealthier women, who are crossing the border to have their babies in Hong Kong. Since Hong Kong became part of China in 1997 the number of mainland women giving birth in Hong Kong has risen rapidly from 7810 in 2001 to 19 538 in 2005. Added to that, changes to China’s immigration rules allowing mainland citizens to visit Hong Kong on tourist visas mean many such pregnant women arrive as tourists. Indeed, so-called maternity tours to Hong Kong are now big business with travel firms offering packages that include transport, accommodation in serviced flats near hospitals with obstetric units, and assistance getting to the emergency room when in labour. The reasons mainland women wish to give birth in Hong Kong vary. Some come to evade China’s onechild policy. Others are married to a Hong Kong resident, but are not automatically entitled to live there, so
deliver in Hong Kong to ensure their children benefit from what is thought to be a better educational and social welfare system than that available in mainland China. These mainland wives have been steady contributors to Hong Kong’s population. The change now worrying the Hong Kong community has been the rapid growth in the number of children born to parents who are both mainland Chinese and do not live in Hong Kong, and thus have no rights of residence. In 2001, 601 babies were born to mainland couples. By contrast, in 2005, 9500 children—almost half of all babies born to mainland women—had mainland fathers as well. And in 2006 the number continued to climb, with over 10 000 such births in the first 9 months of the year. Although their parents have no rights of residence, children born to mainland Chinese parents in hong Kong automatically become Hong Kong permanent residents with full rights to public education, health
The printed journal includes an image merely for illustration
Empics
Mr Ng was furious. The proud prospective father had brought his wife to one of Hong Kong’s major public hospitals for her first antenatal visit only to be told that because his wife was mainland Chinese he had to come up with HK$39 000 before she could set foot in the clinic. Mr Ng, an itinerant worker, asked if he could pay in instalments. But the clerk behind the glass panel was adamant: no money, no baby. “Donald Tsang Yam-Kuen [Hong Kong’s Chief executive] tells us to have three children. But if the fees are so high how can I have more children?”, demanded Mr Ng, leaving the hospital with no booking. “If there is any accident I will ask the government to compensate us”, he threatened. Mr Ng was caught on the first day of a financial trap set at Hong Kong’s hospitals and borders to deter what the Hong Kong authorities, and much of the community, see as a social disaster in the making: a flood of mainland Chinese women choosing to give birth in Hong Kong. From Feb 1 this year, not only are any non-Hong Kong residents obliged to pay the $39 000 antenatal booking fee, no woman with a pregnancy beyond 28 weeks’ gestation can cross the Hong Kong-mainland China border unless she can prove she has made such a booking either privately or publicly. Although Hong Kong effectively has a free public hospital service, there have always been hospital fees. The differences are that the new fees are much higher than before and that mothers classified as nonentitled persons are required to pay for an obstetric package, which covers one visit to an antenatal clinic, delivery (vaginal or operative), and a
Mainland Chinese women are choosing to give birth in Hong Kong
981
World Report
Empics
The printed journal includes an image merely for illustration
Hong Kong’s high medical and nursing standards and well equipped hospitals are attractive to couples
and welfare services, all of which are cheaper than those available on the mainland. This is a result of the Chong Fungyuen case, in which the Hong Kong Court of Final Appeal ruled, in 2001, that Article 24 of the Basic Law (Hong Kong’s mini-constitution) entitled all Chinese citizens born in Hong Kong to Hong Kong permanent residency, irrespective of their parents’ residency status. Article 24, which has come back to haunt the Basic Law drafters, was put in as a bit of a titfor-tat because before July, 1997, in then British Hong Kong, Chinese did not have an automatic right of abode in Hong Kong, but any British citizen did. Although much has been made of mainlanders abusing Hong Kong’s welfare system, there is another subgroup in the mainland mother population with the potential to cause even more resentment. These are the mothers of the new China: seriously wealthy young women who can, and do, choose to have their babies wherever they wish to. Hong Kong, with its high medical, nursing, and technological standards, well equipped hospitals is attracting more and more such high-end mothers. As the distraught Mr and Mrs Ng left the Queen Elizabeth Hospital, an elegantly dressed, beautiful young woman attended by her equally 982
elegant husband, explained to the clinic nurse that she had come all the way from Guizhou (a landlocked province in south-eastern China—a journey akin to leaving Germany to deliver in London) to be sure she could have her baby in Hong Kong. The charges were reasonable, she felt. Money is not an issue for them, remarked the clinic nurse as they left. Indeed it was not, nor for many of the other mainland mothers who complied with the new system. On the first day of the system alone, the Hospital Authority earned $28million from new bookings. The private sector is gaining from the beneficiaries of China’s phenomenal economic growth. At least six private hospitals, which demand a $40 000 deposit on booking, say their quotas are filled. Not only are the private obstetric beds filled, so too are the operating theatres. For many, part of the private package is a guaranteed date, time, and method—caesarean section—of delivery. With such a heavy demand for obstetric surgery, other surgeons are finding their theatre time curtailed, causing further resentment. “Nobody can get into theatre to do any other cases because of all the mainland mothers”, said a surgeon who declined to be named. The increased charges are not believed to be enough of a deterrent.
Moreover, it is feared they will drive more pregnant women underground, strengthening another trend. An increasing number of mainland women are turning up in emergency rooms in advanced labour, with no antenatal records or information about their rhesus, hepatitis, HIV, or diabetic status, and, according to the Hospital Authority’s accountants, no intention to pay for their care. In the 2004–05 financial year 1670 mainland women failed to pay $12·64 million in hospital bills. By 2005–06 that number climbed to 2138 women who failed to pay $28·58 million. So the new immigration rule to keep women close to term out of Hong Kong was also brought into force on Feb 1. Any pregnant mainland resident who appears to be beyond 28 weeks’ gestation will not be permitted to cross the border unless she can prove she is booked into a recognised obstetric unit. Putting this plan into action has not been easy. Border baby patrols— a one doctor, one nurse team stationed at the border crossings to physically examine women suspected of harbouring a post-28 week fetus—have been set up. Hong Kong’s borders are well set up for medical screening—thermal scanners are used to weed out those who may be harbouring SARS, avian influenza, or simply the common cold. But weeding out women in their third trimester is somewhat less high tech. The medical officers have been equipped with a tape measure and fundal height chart and instructed to give an opinion. “I have already briefed our doctors that they are only required to give a range—such as 28–32 weeks of pregnancy, or 30–32 weeks—to immigration officers”, Lam Ping-yan, Hong Kong’s director of health told local journalists. “It is then up to the immigration department how to act on this information.”
Margaret Harris Cheng www.thelancet.com Vol 369 March 24, 2007