#Metoo shows we need trauma-informed maternity care

The outpouring of posts from survivors of sexual violence, assault and abuse as part of the grassroots #MeToo campaign underlines what many of us working in maternity care believe strongly. A significant number of women accessing important services in pregnancy and birth will have experienced trauma in their lives. And sadly, many of these individuals will have been traumatised by sexual violence which may impact on how safe they feel within services which might be triggering of their trauma.

Last week Birthrights was honoured to hold a seminar as part of the Sheila Kitzinger Programme, hosted by Green Templeton College Oxford. You can read more about it in our soon-to-be emailed newsletter. We met to consider how to make truly informed, lawful consent a reality in maternity care in the light of the landmark judgment in the Montgomery v Lanarkshire case. During the day it was clear to all that respectful maternity care, care that protects human dignity and autonomy, is of fundamental import to the physical and emotional wellbeing of women and their families. Moreover the group felt that an individual should not need to disclose previous trauma in order to access care that is sensitive to their needs. As part of our follow-up report we’ll be suggesting that a trauma-informed approach to maternity care, that ensures all services are sensitive to the needs of those who may contend with trauma in their lives, is essential.

Ahead of this report we are grateful to two anonymous survivors of sexual abuse for sharing their personal experiences and perspectives on maternity care with us and with those policy makers charged with the important work of transforming our maternity services. You can find their letters below.

Increasing continuity of carer, ensuring all birth place choices (including homebirth and maternal request caesarean) remain viable options and insisting that our midwives and doctors are given the time and skills within an appropriate organisational culture to be enabled to practice rights respecting care must remain a focus in the Maternity Transformation Programme.

We hope you will help us share their message and add your own below.

Trigger warning: please note that these letters discuss sexual abuse and birth trauma and some readers may find them triggering.

A letter from an anonymous survivor of sexual abuse for the attention of Birth Policy Makers

Another letter from an anonymous survivor of childhood sexual abuse for the attention of Birth Policy Makers

IMUK’s Judicial Review of NMC Decision: A Guest Blog

On 18th and 19th October, members of IMUK (the membership organisation for independent midwives in the UK) will bring to court their judicial review of the Nursing and Midwifery Council’s decision that their indemnity cover is inadequate.

In January Birthrights wrote to the NMC to express concern about the decision stating that their actions “appear designed to cause maximum disruption and damage to independent midwives and the women they care for,” adding that, “we do not believe that these are the actions of a responsible regulator.”

Ahead of their court date, IMUK Chair Jacqui Tomkins has shared her thoughts and hopes in this guest blog. 

I became an independent midwife almost 20 years ago. It has been an overwhelming joy to be able to determine my own volume of work and to work with women and families that I can take the time to listen to and get to know very well. This has also been hugely beneficial for my family who know that I will be at most of the big family events we want to share but if I do have to miss the occasional celebration they are to be found helping me pack the car inan excited state as I get ready to help another family welcome in their newest family member. 

I work with a collective of like-minded midwives who provide me with a wealth of knowledge and skills that are fast becoming lost to us as a profession and ultimately to women. We have a supportive network that holds us and lifts us when it’s needed and allows us all to thrive in a supportive and emotionally intelligent environment. It’s not all unicorns and rainbows but it is a safe space to work within and its the way forward for a lot of midwives who need to feel they can provide the care they have been trained to give with the time needed in order to give it. 

This way of working is so important to me, my colleagues and the women we work with as we all value the relationship that is at the centre of this very important life event. The women I have helped look after in the past and the present are shocked to understand that this right to choose for them, but also for midwives, is at risk of being lost forever. So many women have been telling me that they feel they have nowhere left to turn as for various reasons they feel they cannot use the local maternity providers. As Chair of IMUK I have also been hearing about how some of those women have made the difficult decision to birth alone during this enforced period of redundancy for self employed midwives. This is the most terrible consequence of the decision made around insurance supposedly and in the name of public protection as these woman had not set out to do this. 

As an organisation we are ready to move forward and resume our plans to help with the training of student midwives and help the government to deliver the vision of “Better Births” by supporting pilot NHS groups and continuing to work closely with NHS England. 

Overwhelming throughout the struggle for independent midwifery to survive, my concern has been both for the midwifery profession generally but also the thousands of women per year who seek out our care. This woman centred model gives women a skilled and safe option for their care, with a guaranteed assertion that they will know who is coming to support them on the day and that they trust that person implicitly to be able to turn up and of course will respect and protect their carefully thought out choices. 

The importance of clinical autonomy is fast being eroded within employed models and self employed midwives understand that this is the thing we must protect and enshrine within our profession at all costs. That is not to say we do not work collaboratively with other health professionals, we are very skilled at communicating our clients needs and best interests so will be making appropriate referrals and accompanying women when they need to make alternative care plans for their pregnancies and births. 
 

Midwives are fast becoming a scarce commodity so it makes no sense to remove the right to be self employed from the profession. We need help and support to be able to continue to practice and for there to be an understanding that these issues highlighted in court this week are not about safety but about finances. Finances that have been confirmed by two independent actuarial firms to be perfectly adequate for our scope of practice.

Four years ago when this board of IMUK decided not to accept the future in front of us, we had only midwifery experience between us.  Since then, the team and our members have been joined by supporters and experts from all walks of life, almost all of them having previously benefitted from independent midwifery in some way.  We have become very knowledgable about insurance, both its benefits and its restrictions, we have experienced the political arena, press and legal worlds all of which have given us surprising new life skills but most of all I’m proud of how far we’ve come as a small group of health professionals with a big problem and my hope is that next week we will find out that it has been enough.

Birthrights comments on midwives and normal birth

In response to this weekend’s news coverage of the Royal College of Midwives, Birthrights’ CEO Rebecca Schiller gave this comment to the Sunday Times:

“The RCM’s decision to change the name of its campaign to the ‘Better Births Campaign’ took place in 2014. I welcomed this and continue to value the RCM’s drive to ensure women have access to the very best births no matter their circumstances and whatever their wishes. Birthrights has worked closely with the RCM to train midwives across the country in their human rights obligations. These obligations make it very clear that – whatever the health care professional’s personal beliefs – women must always be provided with the best evidence available, pressure should never be put on them to do something they don’t want to and their decision is to be respected. Whether women want a home birth or an epidural, the RCM has demonstrated their commitment to promoting care that responds to women’s needs.

I welcome a shift away from the use of the term “normal”, as it’s a term that has caused unnecessary division and become needlessly politicised. No-one should tell a woman how she should give birth, but should listen to her and work with her to develop a plan that fits her needs and circumstances.

Intervention in childbirth can be life-saving and midwives work with obstetricians during complex pregnancies and births every day. However, the reality remains that many women want to avoid unnecessary intervention in childbirth as it comes with its own set of risks to their physical and emotional health. It is clear from the evidence base that, in our current maternity system, too many women who don’t want and need intervention end up with it – sometimes with long-lasting consequences. So it is essential that we ensure that midwives’ pivotal role in supporting physiological birth is protected, while remaining supportive of all women’s choices. We must also campaign with them for services that genuinely enable the women who want to, to access care that minimises their chances of having an intervention they didn’t need.

The current trend to use terms such as the “cult” of midwifery, pointing the finger of blame at midwives and seeking to devalue their profession, autonomy and valuable role in our maternity system is deeply concerning. The media focus on this three-year-old change of campaign name is just another example of the contemporary witchhunt of midwives that ultimately makes pregnancy birth less safe and more stressful for women at a vulnerable time in their lives.”

Ban on Northern Irish Abortion Upheld

In a judgment published today, we were disappointed to learn that a Supreme Court appeal, challenging the government’s refusal to provide NHS-funded abortion care in England for women resident in Northern Ireland, has narrowly failed. Birthrights joined coalition of reproductive rights charities, Alliance for Choice, the British Pregnancy Advisory Service (bpas), the Family Planning Association (FPA), and the Abortion Support Network (ASN), to intervene in the case.

The court was divided 3-2 against the appeal and, in a sensitive and thoughtful judgment which made it clear that the levels of distress and hardship endured by vulnerable women were real and unacceptable, the Court ruled that they couldn’t force the Secretary of State to fund the abortions of Northern Irish women.

 

The case was brought by a young woman, A, who in 2012 as a pregnant 15-year-old girl travelled with her mother, B, from their home in Northern Ireland to Manchester for an abortion at a cost of £900. Abortion is effectively banned in all but the most severe of circumstances in Northern Ireland. Despite being UK tax-payers, women from Northern Ireland in need of abortion care have had to fund both their travel to England and their treatment.

The Court’s ruling stated that – as Secretary of State – Mr Hunt holds the legal authority to grant women resident in Northern Ireland NHS-funded abortion care in England, but had decided against doing so – not due to financial constraints – but out of “respect” for the democratic decisions of the Northern Ireland Assembly, in which the largest party is the DUP.

The Secretary of State had previously stated that the Government’s policy was that “in general, the NHS should not fund services for residents of Northern Ireland which the Northern Ireland Assembly has deliberately decided not to legislate to provide.”

The judges expressed a profound sympathy for the “plight” of women in Northern Ireland facing an unplanned pregnancy. Lord Wilson, who did not rule in favour of the appeal, stated that the “embarrassment, difficulty, and uncertainty attendant on the urgent need to raise the necessary funds” added significantly to mother and daughter’s “emotional strain.”

In a comment piece to be published later today, our CEO Rebecca Schiller, is expected to highlight that Lady Hale’s dissenting opinion reflected many of the points we made in our intervention. Lady Hale pointed to autonomy and equality as the “fundamental values underlying our legal system.” Underpinning all of that she invoked the profound legal and moral imperative given by the respect for human dignity. “The right of pregnant women to exercise autonomy in relation to treatment and care,” said Lady Hale, “has been hard won but it has been won.”

Rebecca is also expected to ask for assurance from the Prime Minister that women’s rights are not threatened by any future alliance between the Conservatives and the DUP. To that end she has written to the Prime Minister on behalf of Birthrights, in a joint letter which you can read in full here.

In a statement this morning our Chair, Elizabeth Prochaska, added, “the government’s tolerance of this affront to women’s dignity is deeply concerning. For very little cost to the NHS, women in Northern Ireland could be given access to abortion care in Britain. We need immediate clarity from the Prime Minister that any alliance with the hardline DUP will not be allowed to undermine our commitment to women’s equality and reproductive rights.”

A and B are now expected to take their case to the European Court of Human Rights and, if they do, our coalition of reproductive rights charities will be ready to intervene to help protect the vulnerable and ensure their voices are heard.

You can read the press release from the Interveners here.

Independent Midwifery: An Update From Birthrights CEO

Following the recent NMC decision on the indemnity cover that IMUK members have taken out, Birthrights has been working to support women who now find themselves without the midwife of their choosing. I wanted to give you an update on what we have been doing to help and to respond to some requests for information.

Letter to the NMC
As you may know, I wrote to the NMC’s Chief Executive, Jackie Smith, as soon as the decision was made public to express my concerns and ask for clarification. I have now received a response from Ms Smith and am asking the NMC to allow me to make that response public. I hope to share it with you in due course.

UPDATE 14/02/17
I now have permission to share Jackie Smith’s response to my letter. You can read it in full here.

Bank Contracts
In the meantime Birthrights posted some information with suggestions about how independent midwives might seek honorary or bank contracts from their local NHS Trusts to enable them to continue to care for indviduals already booked with them. While some Trusts have been able to grant these contracts, others haven’t. I am in the process of writing to Heads of Midwifery who have refused to grant contracts to independent midwives along with the Trust Chief Executives and the MSLC chairs.

In my letters I am making it clear that NHS Trusts (and Head of Midwifery post-holders as Trust employees) are under a legal obligation to facilitate women’s right to make choices about birth (Human Rights Act and Article 8, European Convention on Human Rights). In order to discharge their obligations lawfully, they must diligently consider all the mechanisms in their power to enable women’s choices and decisions in childbirth to be respected. I am informing them that they must consider the individual circumstances of the woman and her particular situation rather than invoking a blanket policy, and insisting that when the Trust has made a decision it must give its full reasons for their decision and these reasons must be clearly justified.

Given that some Trusts have swiftly been able to arrange honorary and/or bank contracts with local independent midwives in this situation, it is not clear what justification other Trusts have for refusing to grant a similar arrangement. So, I am asking them to consider their legal obligations carefully, to investigate how other Trusts have been able to accommodate independent midwives and to reconsider the options available.

I have also included some information about the likelihood of some women feeling forced to freebirth, particularly in the absence of any equivalent provision for continuity of carer within the local NHS services. And I have expressed an urgent concern about the avoidable harm that could come to women and babies in this situation, as well as the difficult position that Trust staff could find themselves in should a disengaged and fearful woman need to access emergency care in labour or the broader perinatal period.

In these circumstances, the granting of honorary or bank contracts may represent the only way for vulnerable women to access any maternity care at a critical time in their pregnancies.

Concerns about midwives attending the births of friends and family
There has been recent publicity, linked to the independent midwives’ situation, concerning the legal position for all midwives attending a close friend or family member in the intrapartum or broader perinatal period.I am aware that, until now, it has been perfectly routine and accepted practice for midwives to attend their close friends and family members in labour, both in a supporter role and as a practicing midwife.However, Birthrights is not in a position to give legal advice to those seeking clarity on the current legal position on this matter. We suggest that midwives contact the RCM, the NMC and speak to their NHS Trust to get clarification on the situation in their area and their particular circumstances.

We will continue to do all we can in public and behind the scenes to support women and their midwives at this challenging time.

Rebecca Schiller

Birthrights Criticises NMC for Independent Midwives Decision

Birthrights strongly criticised today a decision by the Nursing and Midwifery Council (NMC) that prevents many independent midwives from caring for women in labour. The decision (which relates to the level of indemnity insurance arranged for many independent midwives by their umbrella body, IMUK) has resulted in the regulator instructing pregnant women to make immediate alternative arrangements for their birth care.
In an urgent letter to NMC chief executive Jackie Smith, Birthrights CEO Rebecca Schiller said that the NMC’s actions, “appear designed to cause maximum disruption and damage to independent midwives and the women they care for,” adding that, “we do not believe that these are the actions of a responsible regulator.”
Schiller adds that “the NMC has a key role to play in protecting public safety, yet this decision directly jeopardises the health and safety of the women it is supposed to safeguard. Beyond the very real physical health implications of this decision, it is causing emotional trauma to women and their families at an intensely vulnerable time. To date, it appears that the NMC has shown no concern for the physical and mental wellbeing of pregnant women who have booked with independent midwives.”
In the letter, Birthrights highlights the unnecessarily tight timescale imposed by the NMC and lack of attempt to communicate what constitutes adequate levels of insurance. Schiller expresses her concern that some women will now feel forced to give birth alone adding, “many women choose the care of an independent midwife because they are unwilling to access NHS services, often because of previous traumatic experiences. Without the support of their chosen independent midwife, women have already told us that they feel their only option will be to birth without any medical or midwifery assistance. We hope that you will share our urgent concern about the avoidable harm that could come to women and babies in this situation.”
Birthrights is urging the NMC to remedy the damage caused to date by taking urgent steps that include:
  1.  Guaranteeing that all women who are currently booked with independent midwives using the IMUK insurance scheme will be able to continue to access their services
  2.  Reassuring Birthrights, IMUK and the women who have already engaged the services of independent midwives that the midwives caring for them them will not face disciplinary action for fulfilling their midwifery role
  3. Urgently making a public recommendation on what constitutes adequate insurance.

Dubska ECHR judgment: disappointing but not the last word

The Grand Chamber of the European Court gave judgment today in Dubska v Czech Republic. We wrote about the earlier decision of Court here. The Court reaffirmed that women’s rights in childbirth are protected by Article 8 of the European Convention on Human Rights, further underlining the human rights protections that childbearing women should enjoy.

But in a disappointing and poorly reasoned judgment, the Court found that the Czech government was not obliged to regulate midwives to enable them to attend women at home births, despite the significant negative impact this may have on the safety and wellbeing of childbearing women. The Court accepted that care in Czech maternity hospitals was ‘questionable’ and expected the Czech government to keep its law and practice under “constant review so as to ensure that they reflect medical and scientific developments whilst fully respecting women’s rights in the field of reproductive health”.

Five of the judges dissented, expressing a joint opinion that disagrees with the Grand Chamber’s judgment. These judges found that the Czech system effectively forces women to give birth in hospital and could not be justified by any public health argument. They noted the observations of the CEDAW Committee on disrespectful and abusive practices in Czech hospitals. As they said, citing the UK Supreme Court’s decision in the Montgomery case,  ‘Patronising attitudes among health personnel should not be taken lightly, as they may constitute a violation of an individual’s right to self-determination under the Convention.’

This judgment is a missed opportunity to offer appropriate, safe and rights-respecting choices to Czech women. Women giving birth in obstetric units in the Czech Republic face a range of unsafe and rights-violating practices, meaning that for some choosing to birth at home is the only way of avoiding degrading, painful, lonely and de-humanised care. Routine practices in these units include: separation from their babies, a lack of access to facilities that support physiological birth, no involvement in decisions about their care, routine episiotomy, lack of pain-relief options, giving birth without a partner unless they pay an additional fee. Without regulated and state-supported access to out-of-hospital birth it is likely that some women will now feel forced to give birth without medical assistance. When hospital births that undermine a woman’s basic human dignity are the only option, there are significant safety issues at stake.

For women in England the judgment has no impact on their right to choose where to give birth. Choice of place of birth is enshrined in policy and practice, and underpinned by the recent report of the National Maternity Review. But for women in eastern Europe this will create a significant bend in the road that activists, mothers and health care professionals will need to navigate with clarity and purpose to minimise the damage.

Thankfully the clamour for childbirth rights, and a shared understanding of how to promote them, is growing across Europe. More cases on abuse during childbirth will undoubtedly reach the Court and other recent ECHR judgements (such as Konovalova v Russia) still stand; robustly upholding women’s rights to make decisions about childbirth.

Given the forceful dissent, and the Court’s demand that the government keep pace with change, this is unlikely to be the last word on homebirth in the Czech Republic.

“Safety” must include a maternity system that supports respectful care

In a statement responding to the Health Secretary’s announcement today of a package of measures aimed at improving safety in maternity care, Birthrights CEO Rebecca Schiller said:

Birthrights welcomes innovation and investment in maternity care. We are particularly pleased to see the Health Secretary’s commitment to the Better Birth report’s recommendation that a ‘rapid redress and resolution’ compensation system is introduced. We frequently see the negative impact of a culture of fear on healthcare practitioners, and the women they care for, and believe that this new model has the potential to improve transparency and practice in maternity care as well as the lives of people whose babies are damaged during birth.
 
Investment in maternity care is desperately needed but we are concerned that a narrow focus on ‘safety’, at the expense of a maternity system that enables midwives and doctors to provide respectful, personalised care, will not deliver the high-quality, safe service we need for all women in England. We urge those taking this initiative forwards to ensure that the vision of the National Maternity Review, which recognises that safe care is only possible in a system that wraps around the individual women, remains a key driver for positive change.

Maternity Care Failing Some Disabled Women

Research published today (15/09/16) by Bournemouth University and commissioned by Birthrights highlights how maternity care may not be meeting the needs of some pregnant disabled women.

A survey of women with physical or sensory impairment or long term health conditions highlighted how  – despite most women rating the support they received from maternity health carers positively – only 19% of women thought that reasonable adjustments or accommodations had been made for them. Some found birth rooms, postnatal wards and their maternity notes and scans “completely inaccessible”,  while a quarter of women reported that they felt they were treated less favourably because of their disability. Most strikingly, more than half (56%) felt that health care providers did not have appropriate attitudes to disability.

Just over half of the participants expressed dissatisfaction with one or more care providers, particularly their awareness of the impact of disability and their perception that their choices in pregnancy and birth were being reduced or overruled. One participant with a physical impairment and a long-term health condition stated, “No one understood my disability. No one knew how to help or who to send me to for support.” Another added, “I didn’t have any control or any choice. Everything was decided for me.” And one woman said, “They did not listen to me. I advised them on the unique way my body works. They did not listen to my advocates.”

Speaking in advance of the publication of her book Why Human Rights in Childbirth Matter and the Birthrights #newchapter campaign linked to the launch, Rebecca Schiller, chief executive of Birthrights said, “this interim report suggests that there are significant human rights issues at stake for disabled pregnant women in the UK and Ireland. More than a quarter of women we surveyed felt that their rights were either poorly or very poorly respected. This is unacceptable and we will be working hard to address this over the coming years.

After Birthrights’ dignity in childbirth survey (2013) we became concerned that the needs of disabled women in the system were not being met. Though it’s heartening to see how overall most women were satisfied with their care and hear some positive stories of excellent practice there is clearly progress to be made. The women surveyed asked overwhelmingly to be listened to. It is crucial to listen to and trust women to ensure the system is genuinely meeting their requirements and that they are at the heart of decisions about their maternity care. The Equality Act 2010 places a duty on the public sector to provide services that meet the diverse needs of those who use them yet participants indicated worrying lack of attention to accessibility of maternity services and facilities for women with a range of disabilities.

The survey is indicative of a wider problem around women’s rights in childbirth that can impact on all women and often most forcefully on the most vulnerable . This month Birthrights is launching a campaign for a #newchapter in pregnancy and childbirth to ensure safe, quality, respectful care is available to all women. Pregnancy and childbirth are a vulnerable time and the physical and emotional impact on women and their babies of a negative journey through pregnancy and childbirth can be severe.”

Professor Vanora Hundley of Bournemouth University added, “while this is a small survey the findings echo the recommendations of the National Maternity Review published earlier this year, which highlighted the importance of personalised, woman-centred care with continuity of carer. It is clear that these are important considerations for all women, but particularly for those women who have a disability.”

Read the full interim report here. We expected the full report to be released in January 2017 when the qualitative research is completed. With thanks to the Matrix Causes Fund for supporting this work.

Human dignity after the EU referendum

In the volatile political, economic and social climate of post-referendum UK many of us are anxious and uncertain about the future. As a charity Birthrights did not take a position on the referendum and it would be wrong for us to do so now.

What is clear to me today is that we are presented with a range of opportunities at a challenging time. For some these are opportunities for division, discrimination, violence, extremism and hate. As an organisation founded on respect for basic human dignity, we deplore those who have exploited these opportunities and the acts of xenophobia, racism and violence we have seen over recent days. The murder of women’s rights champion Jo Cox MP is a tragic testament to the consequences of allowing these divisions to widen.

But this isn’t all that lies within reach. Whatever our beliefs (and however the consequences of last week’s vote unfold) there is now a chance to reinforce and promote another set of values: respect, dignity, equality, justice and fairness. The values of the human rights movement.

The need for an understanding of our human rights framework has never been greater. As we cast about for an anchor in this storm we can hold on to the legal protection of our rights as individuals and the specific provisions for vulnerable groups. These protections exists in UK law (particularly in the Human Rights Act 1998) at a European level (through the European Convention on Human Rights which is not directly threatened by our leaving the EU, contingent as it is on our membership of the Council of Europe) and at an international level.

The values that underpin the human rights movement and the legal scaffolding that gives them teeth are vital now more than ever. Yesterday the United Nations expressed “serious concern” about the impact of UK’s pre-existing austerity policies on the most marginalised and disadvantaged. As we face the prospect of further economic disruption and begin to imagine how this could affect vulnerable groups, it is important to know we are not in a vacuum. Our government has key human rights obligations and it must fulfil them.

With this in mind Birthrights will continue to defend the human rights of all childbearing women, with a particular focus on those vulnerable groups who need us most. Whatever the impact of the referendum on the NHS, on midwives, doctors or on the vulnerable migrant women whose risk of maternal death or stillbirth is so high, we will continue to advise women and families, champion their rights, inspire and train their caregivers and use the power of the law to protect them.

Pregnancy and childbirth are an intensely vulnerable time for an individual. The way they are treated during birth affects them at a time in their lives when their identities as mothers are being forged and when they are developing their relationship with the next generation. The long-term physical health of women and babies is at stake in the care they are given and women’s fundamental rights to human dignity and autonomy can be profoundly affected by their experience of maternity care.

Human dignity matters in the post-referendum UK. It should be the principle we live by and the basis of the world we aspire to live in. The safety, equality, respect and dignity of each woman during pregnancy and birth will always be a strong foundation for that aspiration.

Rebecca Schiller, CEO, Birthrights

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