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.

Talking about human rights in maternity care helps the wider human rights debate

“What have human rights got to do with pregnancy?”

“I wouldn’t have thought you have any rights – isn’t it about what’s best for the baby?”

“That’s not an issue in this country, surely?”

Before embarking on a project for Birthrights earlier this year, i decided to conduct my own straw poll of women – of mothers – I knew. I explained what Birthrights did and asked them what they thought. I was expecting questions, positive interest and challenges but it was these three responses that really got me thinking. Why is it so hard to connect human rights with something as ordinary and commonplace as pregnancy and childbirth?

I’ve been working for human rights and equality organisations for almost 15 years, including directing campaigns at the leading UK pressure group, Liberty, so I’ve seen and heard first-hand some of the biggest myths and misconceptions that exist around these issues. Part of the problem is that there isn’t – there has never been – enough public education from the Government about what human rights are and how they protect us. Human and rights might sound pretty self explanatory but once you get into the dry, legalistic territory of the European Convention and the Human Rights Act 1998 and you definitely don’t “have me at hello.”

When translated into straightforward language, the Human Rights Act is difficult not to love. Why wouldn’t you want a right to life, to speak freely, to practise your religion, to personal privacy and family life? What’s so bad about treating every human being equally, with fairness, dignity and respect? Why wouldn’t you want protection against discrimination, torture and inhumane treatment and arbitrary detention? But when you start to talk about ‘articles’, qualified and limited rights and about lawyers and courts you lose people’s interest. Most people are lucky enough to go through life without ever having to defend their rights in court and without having to hold the state to account, so why would they relate? And even when a hugely important human rights case, like that of the Hillsborough families, becomes front page news, it can be difficult for campaigners to communicate the link between justice and human rights. Add to this the regular attacks on human rights lawyers by some politicians and sections of the press and you have a toxic mix.

One of the biggest misconceptions is that human rights are only about lawyers and courts – that human rights make ‘fat cat’ lawyers richer and society poorer. But nothing could be further from the truth. The Human Rights Act means that you can defend your rights in UK courts and has brought justice and answers for many but it also means that public organisations, including the Government, the police and local councils, must treat everyone equally, with fairness, dignity and respect.  The Human Rights Act has helped thousands of people protect their rights without going to court.  It means that local authorities have had to review policies to make sure they treat the vulnerable respect and users of a wide range of public services have used the Act as a tool to argue for better and fairer services.

This is why what Birthrights does is such an important part of the puzzle. Their work is about defending the human rights of all childbearing women, with a particular focus on vulnerable groups such as asylum seeking and refugee women, disabled women, women in prison and women with other, complex, social needs, who are most in need. Their work raises the importance of providing respectful, personalised care for all women and the benefits of this for safer and better births. And their work highlights that respect for human rights is fundamental to all healthcare and the legal imperative to respect the autonomy and dignity of women, whether in relation to maternity care or to abortion rights.

Human rights protect us all but it is people who are most vulnerable who are in most need of protection against abuse. This inevitably leads to negative and misleading narratives about human rights and the way that the law is applied and this can be difficult to challenge in a way that is meaningful and persuasive for people who are otherwise, unconvinced. Campaigners must engage people in thinking about and looking at rights in a different way, through the lens of situations which are relatable. If this helps begin a conversation, we have more hope of increasing understanding and respect. If safety, equality, autonomy and dignity matters to one woman during pregnancy and birth, then why wouldn’t it matter to all women? If we can’t start life with these principles in mind, then where do we go from here?

Sabina Frediani is a campaigner and freelance writer. She spent over a decade working for the human rights and civil liberties pressure group, Liberty, where she directed award winning public and political campaigns, and has recently been helping Birthrights with our organisational strategy.

Birthrights training eligible for Maternity Safety Training Funding

Last August, Birthrights, the President of the RCM, and others wrote to the National Maternity Review team stating our belief that “safe maternity care is contingent on respectful care” and asking Baroness Cumberlege to put human rights at the centre of the Review process.

On the 17th October, the Department of Health launched a Maternity Safety Action Plan. We believe as strongly as ever, that the roll out of a human rights framework in maternity care needs to be the touchstone of that Plan. The good news is that Birthrights training is eligible for funding from the £8m Maternity Safety Training Fund that will make £40-£80k available to each Trust to enable them to implement the Maternity Safety Action Plan. So if you are interested in Birthrights training, this is a great opportunity. You can find full details of our one-day “Creating a Safe Maternity Culture” course here. Do get in touch with us as soon as possible at info@birthrights.org.uk to check availability.

More information on the Fund itself can be found here. The deadline for applications is the 18th November.

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.

Help Us Start A New Chapter for Childbirth

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On 15th September Rebecca Schiller’s book Why Human Rights in Childbirth Matter will be published by Pinter and Martin. The book advocates for the human rights of all childbearing women here in the UK and around the globe, telling their stories and exploring the cultural and political forces surrounding birth in 2016. Insisting that women matter in the birth room, Rebecca shows how neglecting birth rights can have serious implications for women’s broader freedoms at home and abroad.

We need your help to seize this chance to start a new chapter for human rights in childbirth. Help Birthrights protect childbearing women by hosting a fundraising book club to put these issues firmly in the spotlight. We’re asking you to invite your friends and colleagues round to discuss Rebecca’s book and to make a small donation to support our work. We are suggesting you do this in the week commencing the 17th October and to join in the conversation using the #newchapter hashtag on social media.You can help us spread the word about what Birthrights does and why it matters.

As Birthrights starts a new chapter in its growth, we need to grow our income too. The funds you raise will help us continue to provide expert legal advice, give midwives and doctors the tools they need to provide respectful care, influence maternity policy and campaign for change for all women.

Register your interest in being a #newchapter book club host here.

You can find some information about hosting a #newchapter book club here, and also some questions to get discussion started.

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

Birthrights needs your support today.

Last chance to stand up for Supervisors of Midwives

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Tomorrow (17th June) this unassuming consultation on amendments to modernise midwifery regulation comes to an end:

Remarkably the key role that Supervisors of Midwives play in advocating for women doesn’t even get a mention in the consultation document. As an organisation we refer women to SoMs on a daily basis – they are crucial defenders of women’s human rights. Today we need to defend these defenders. That is why we have today submitted the response below to 3 key questions in the consultation. If you haven’t already – please join us in submitting a response…

Q1. Do you agree that this additional tier of regulation for midwives should be removed? 

No. At Birthrights, we believe that safe maternity care is contingent on respectful care and that a human rights-based approach offers the best means of improving maternity services in the UK.

In the current regulatory system in the UK, Supervisors of Midwives (known as SoMs) play a dual role: they are responsible for making sure that midwives under their charge abide by professional standards and they are responsible for supporting and facilitating women’s decisions about their pregnancy and birth. SoMs provide a critical protection for women’s rights in maternity care. They enable women who may have been refused access to specific services to obtain the care they want and need; they negotiate with obstetricians and other members of the maternity team to support women’s choices; they are at the heart of planning safe and respectful care for more complex births. Birthrights calls on the help of SoMs for the women we advise on a daily basis. Remarkably, this aspect of SoM’s role does not appear in the consultation document. Birthrights is deeply concerned about the consequences of removing the role of SoMs without giving any proper thought to how to maintain this critical function.

We recognise that improvements must be made to the current regulatory system. Morecambe Bay showed what can happen if the statutory supervision system is not well understood, supported and implemented. A weak supervisory system can be subverted to protect midwives rather than to advocate for women. However, we believe that the response to the tragic failures at Morecambe Bay and elsewhere must put respect for women at its heart. Safety can only be achieved by full recognition of women’s right to dignity and respect in maternity care. This entails much more than compliance with protocols or improved documentation; it means genuinely personalised care given by staff who listen to women and respect their individual needs. This requires ongoing access for women to an “expert” who understands the care setting and can help women to navigate it. The role of SoM, protected by statute, provides a healthy level of challenge to Trusts to ensure they remain focused on women’s needs, and fulfil their obligations under the NMC Code and human rights law.

With the RCM, and others, we are concerned that putting supervision on a non-statutory basis will leave supervision at the mercy of employers to fund and implement. These changes move supervision from a must have to a nice to have. In the current financial climate of the NHS, that does not bode well. Indeed it could create many of the problems with supervision that were reported in Morecambe Bay where supervision was not prioritised, and where SoMs put their loyalty to their employer, and colleagues, above their loyalty to the Local Supervising Authority. Supervisors may be forced to tow the line of their employer or leave themselves exposed for standing up for women. Regulatory systems that fail to protect women also fail to protect midwives: Birthrights is aware of cases in other countries where midwives have faced criminal prosecution because they have supported women’s decisions to give birth in ways that are not supported by mainstream health providers. There is a real risk that eroding the distinctive system of regulation for midwives will leave women and midwives in a highly vulnerable position.

The proposal in the consultation document that supervision continues merely “as a vehicle for professional support and development” entirely fails to appreciate the distinctive role of SoMs in the provision of safe and respectful care for women. In their focus on the regulatory intricacies of supervision, the Department of Health and the NMC have overlooked this crucial aspect of safe care. They do so at the risk of endangering women and babies and degrading the quality of maternity services.

Birthrights calls for guaranteed access for women to SoMs who are explicitly charged with promoting respectful care and upholding the NMC Code.

Q2.Do you agree that the current requirement in the NMC’s legislation for a statutory Midwifery Committee should be removed? 

Birthrights does not agree that the statutory Midwifery Committee should be removed.

Midwifery is a distinct profession from nursing. It is not based on a curative model of care, but on a social model, which has significant implications for the way it is both practised and regulated. Midwifery puts the needs of women and their families at its heart; its does not treat a specific complaint but supports a woman in her transition to motherhood. The NMC must ensure that the unique characteristics of midwifery are respected and protected and maintaining the Midwifery Committee is the means of achieving this.

Furthermore, modern regulation should understand and meet the needs of the community that it regulates. It is contrary to best regulatory practice to create super-regulators that are distant from the professionals they serve. The abolition of the midwifery committee will lead to the loss of midwifery standards and ethics in regulation; and the assumption of nursing standards will be detrimental to the distinctive practice of midwifery.

Q13:Do you think that any of the proposals would help achieve any of the following aims: 

  • eliminating discrimination, harassment, victimisation and any other conduct that is prohibited by or under the Equality Act 2010? 
  • advancing equality of opportunity between persons who share a relevant protected characteristic and persons who do not share it? 
  • fostering good relations between persons who share a relevant protected characteristic and persons who do not share it?

No. Birthrights is concerned that the elimination of statutory protection for the role of Supervisor of Midwives will have a detrimental impact on pregnant women. Currently, pregnant women have access to a SoM who supports and facilitates their healthcare decisions. This role reflects the unique position of pregnant women in healthcare services; for the majority, they are not receiving treatment for a condition, but seeking support for a normal life process which requires support and respect for their decisions. If pregnant women are no longer able to access SoMs, they will undoubtedly receive less support, the quality of their care will diminish and their safety will be compromised.

These proposals should be changed so that the role SoMs play in supporting women is given proper recognition. This may be by maintaining statutory supervision or by placing an enforceable obligation on Trusts to ensure that women are given guaranteed access for women to SoMs who are explicitly charged with promoting respectful care and upholding the NMC Code.

 

 

Birthrights Responds to the National Maternity Review Report

Speaking in advance of the release of the NHS England National Maternity Review report’s release today, Birthrights Director Rebecca Schiller said, “the National Maternity Review report has a powerful message for all interested in improving maternity care. Birthrights agrees with the Review team’s vision that safe maternity care is personalised care and welcomes the recommendation that women should be in control of their care through the introduction of personal maternity care budgets.  In our August 2015 letter to the Review team we set out that safe maternity care is contingent on respectful care and that a rights-based approach offers the best means of improving maternity services in the UK.  We are therefore delighted to see that innovations to support women’s autonomy have been included in the plans. We echo the insistence throughout the report that genuine choice and unbiased information should be supported by healthcare professionals and service infrastructure.

It is now crucial that these ideas become a reality. We believe that the human rights legal framework and the values it promotes are vital tools in seeing this vision come to life.  Many of the report’s recommendations are supported by rights women should already enjoy. These rights arise from human rights law and existing policy and could provide a strong platform from which to demand that changes are made. The report’s ambition that all women are offered choice of place of birth by 2020 is a reality women should already expect, based on long-standing Department of Health policy which stipulates that women should be able to choose where to give birth. It is time for action to match rhetoric.”

Elizabeth Prochaska, Chair of Birthrights and human rights barrister adds, “As Birthrights set out to the Review team in our ‘Right to Choice in Maternity Care’ submission, legal protections on existing rights to choice could be strengthened and clarified by the simple step of amending the NHS Constitution and the 2012 Regulations so that maternity services are included in the right to choose a provider in the same way that choice is guaranteed to recipients of other health services. This would give women the confidence that they were entitled to receive choice and oblige providers and commissioners to accept their responsibilities for providing it.

Birthrights welcomes the Review’s recommendation that the Department of Health establishes an insurance scheme to provide redress to parents whose babies have suffered harm during birth. Families would obtain financial support without having to prove that a professional was at fault during the birth, sparing them years of litigation and emotional trauma, and the NHS would be freed from the devastating consequences of a litigation culture which has spread fear and defensive practice.

The Review has provided a once in a lifetime opportunity to get maternity care right. We hope that the government seizes the chance.”

Three Years Defending Dignity

Three years ago this month, Birthrights burst onto the maternity scene. At our launch, we declared our intention to ensure that all women receive the dignity and respect they deserve during pregnancy and childbirth. Since then we’ve worked hard to do just that. Free, expert legal advice direct to women, respectful care training for midwives and doctors, research, campaigns and accurate, unbiased comment in the media…

Providing clear and objective information on women’s rights in childbirth has remained a priority. Our factsheets continue to be a popular resource for women and healthcare professionals. Our email advice has provided much needed assistance to hundreds of women and their families and with your help we hope to launch a telephone advice line.

We have published groundbreaking research – such as the 2013 Dignity Survey – to improve the evidence on the importance of respectful care. This year we will be focusing on the rights of vulnerable groups of pregnant women, including migrants and those with disabilities.

Birthrights reaches out to healthcare professionals through our own events, such as our Dignity Forum and Fighting the Fear study day. We speak at conferences and seminars across the country as part of our popular and expanding training programme designed to give practical tools to midwives and doctors.

We also know that it’s imperative that the maternity service is designed to understand and respect women. So we continue to work closely with maternity leaders, the Royal Colleges and offer our perspective in relevant government consultations, NICE Guidelines and the National Maternity Review.

We believe our legal expertise should be used to strengthen and uphold the protections offered to pregnant and birthing women. Working alongside the British Pregnancy Advisory Service, Birthrights intervened in a critical Court of Appeal case that questioned a woman’s legal status while pregnant and her rights to make our own decisions. We were pleased that the court upheld these rights in their judgement.

Through this work Birthrights has also been a consistent voice of reason on women’s rights in the media, with appearances on Women’s Hour, the Today Programme, major TV news, radio, broadsheet and tabloids.

It’s been a busy three years and we’re proud of what we have achieved. We have big plans going forward: expanding our training, commissioning vital research and expanding our advice service so that we can ensure that dignity in childbirth is universally understood and respected.

But we can only continue this work with your help. As we celebrate our birthday please consider making a regular monthly donation to Birthrights as we defend the dignity of pregnant and birthing women. We ask you to continue to stand beside us for years to come.

 

Elizabeth Prochaska (Chair) and Rebecca Schiller (Director)

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Letter to the National Maternity Review

On 16th August the co-chairs of Birthrights and President of the Royal College of Midwives wrote to the members of the NHS England National Maternity Review. The letter (which was written in collaboration with and co-signed by senior lawyers, midwives, doctors and campaigners) asks that the Review makes the fundamental principles of respectful care and human rights a priority in its investigation of maternity services. We believe that safe maternity care is contingent on respectful care and that a rights-based approach offers the best means of improving maternity services in the UK.

A draft of the letter was presented and positively received at meeting with Baroness Cumberlege and Sir Cyril Chantler (who Chair and Vice-Chair the process respectively) earlier this summer. Now the group believe it is vital that all members of the Review process are aware that observing and building on human rights principles has the potential to transform maternity care.

You can read the fully referenced letter here (Human Rights Letter to National Maternity Review) or an un-referenced version below.

16 August 2015

Dear Baroness Cumberlege and the Maternity Review team,

We write to you as a group of health professionals, academics, campaigners and human rights lawyers who have a long-standing commitment to improving maternity care. As leaders in healthcare and human rights, we ask that the Review makes the fundamental principles of respectful care a priority in its investigation of maternity services. We believe that safe maternity care is contingent on respectful care and that a rights-based approach offers the best means of improving maternity services in the UK.

We outline the principles of respectful care and human rights below in the expectation that that they will inform the Review’s consultation process and discussion with stakeholders. We would be grateful for an opportunity to explore these issues with you in greater depth during the Review process.

Women’s fundamental human rights are at stake in maternity care

Pregnancy and childbirth are an intensely vulnerable time for women. Not only is the long-term physical health of women and babies at stake in the care they are given,women’s fundamental rights to human dignity and autonomy can be profoundly affected by their experience of maternity care.

The way a woman is treated during childbirth affects her at a time in her life when her identity as a mother is being forged. We know that many women experience anxiety,depression and post-traumatic stress disorder following childbirth and women with pre-existing mental health conditions may suffer a recurrence. Poor maternal mental health can affect the mother-child relationship and outcomes for children. Care providers have a critical role to play in ensuring that women emerge from childbirth physically and psychologically healthy and are able to develop a responsive and nurturing relationships with their children.

Dignity is the basis of respectful maternity care

Human dignity is the ultimate value on which respectful healthcare depends. It is most powerfully articulated in the imperative to treat a person as an end in their own right and not a means to an end. The relevance of this is clear in maternity care, when a woman risks being viewed as a means for the creation of life rather than as a person worthy of respect in herself. Dignity reinstates the woman as the central agent in childbirth. It means that her caregivers treat her as capable of making her own autonomous decisions about her child’s birth. Caregivers who protect women’s dignity listen to women and respect their perception of what it means for them to thrive as human beings.

Human rights law protects women’s health

The law protects people’s health by imposing obligations on governments and healthcare providers to respect human rights. Professional caregivers employed by NHS bodies are under a legal obligation to respect rights as set out in the European Convention on Human Rights. Article 2 of the Convention protects the right to life and requires the state to take positive action to ensure that critical healthcare services, including maternity care, are available to everyone.

Human rights do not stop at ensuring access to maternity services. The rights in the European Convention and under international treaties, including the Convention on the Elimination of Discrimination against Women and the Convention on Human Rights and Biomedicine, extend to protecting the way in which individuals are treated by their caregivers. These include the right not to be subjected to degrading treatment, the right to informed consent and the right to non-discrimination.

Healthcare professionals commonly consider the law to have a negative and distracting influence on care. The climate of litigation, particularly in maternity care, can make the law appear punitive. In fact, a human rights-based approach offers the potential for transformative impact on healthcare. The principles of dignity, autonomy and respect can create the foundation for a maternity service that is truly fit for purpose.

Human rights are an essential basis for safe health care

Respectful care is an essential component of safe care. Caregivers who listen to women, provide them with accurate information and respect their choices make a fundamental contribution to a safe maternity service. As the investigations into failing hospitals have repeatedly shown, lack of respect for patient dignity has gone hand in hand with clinical and systemic failings that have compromised patient safety.

The recent decision of the UK Supreme Court in Montgomery v Lanarkshire Health Board (2015) reveals the interdependence of safety and respectful care. Mrs Montgomery’s doctor treated her with condescension and withheld important information about the risks of vaginal birth for diabetic mothers. As a consequence, her right to make a safe choice was denied to her and her baby was damaged during birth. The Court found that clinicians must adopt a woman-centred approach to advice giving during pregnancy. It deprecated the use of consent forms and information leaflets and held that the law required clinicians to have detailed and personalised discussions with women that enabled them to make their own decisions on the basis of information about ‘all material risks’. The Court explained that it was necessary to impose legal obligations of this sort, so ‘that even those doctors who have less skill or inclination for communication, or who are more hurried, are obliged to pause and engage in the discussion which the law requires.’

The Montgomery decision has profound consequences for the interaction of the principle of informed consent, clinical practice and the structural implementation of choice in maternity services. If the Court’s judgment is to be upheld, professional carers must be given the time to discuss choices with women in their care and must respect the decisions that women choose to make.

At a global level, there is increasing awareness that protection of women’s human rights in maternity care offers the best chance for progress in maternity services. The recent Bohren systematic review on the mistreatment of women in health facilities provides powerful evidence that childbirth is a particularly vulnerable time for human rights abuses globally (that seemingly developed/ industrialised democracies and countries shouldn’t forget or need to continually guard against). As the WHO stated in 2014, ‘Rights-based approaches to organizing and managing health systems can facilitate the provision of respectful, quality care at birth.’3 In countries as diverse as Nigeria and Venezuela, which have legislated for human rights in maternity care,services are being configured with respectful care at their heart.

In the UK, in response to systemic failures, the NHS is increasingly using dignity principles not only to improve patient experience but as means to ensure patient safety. Queen’s Hospital Romford experienced a cluster of maternal deaths in 2011, blamed in part on poor culture and disrespectful behaviour amongst staff. The midwives acted to introduce mandatory respectful care training based on the White Ribbon Alliance Respectful Care Charter. It has had a measurable impact on the quality of care, reduced complaints, improved communication and staff behaviour. We believe that the response to the tragic failures at Morecambe Bay and elsewhere must put respect for women at its heart.

Safety can only be achieved by full recognition of women’s right to dignity and respect in maternity care. This entails much more than compliance with protocols or improved documentation; it means genuinely personalised care given by staff who listen to women and respect their individual needs.

Services built on human rights provide the best start in life

Human rights and high quality, safe maternity care are inseparable. The provision of maternity services that have the capability to provide appropriate, affordable, accessible and safe services that lead to the best start in life to all women and their babies require models and systems that provide care respectful to the dignity and autonomy of each woman and respond to individual and community needs.

The capability to provide respectful care that leads to healthy physical and psychological outcomes as well as supporting strong family relationships and reducing the impact of inequalities, requires structured development of culture and care pathways in models of care that meet each woman and baby’s health, personal and social needs and preferences.

This more personal and appropriate care should reduce variations in outcomes between services, while providing care that is tailored to each individual woman’s needs, values and preferences.

The ability of all carers to provide personalised care, supporting informed consent and offering genuine choices requires evidence-based information and information aids. All professionals must be able to convey information in an understandable way and work with the woman without prejudicing her decisions. This unified approach may be supported by human rights-based interdisciplinary education. It will also require that choices are available and visible. Time to talk and listen, not only to women but also to other professionals when consulting, referring and transferring care, is crucial.

Continuity of carer is the model of care that promotes human rights and a safe maternity service

Continuity of carer is the most appropriate means of enabling personalised care that respects women’s human rights. By developing services that ensure that every woman is cared for by named midwifery and medical staff, it is possible to create a relationships of trust that prevents fragmentation in care and reduces risk for women and babies. Continuity of carer is a critical part of a human rights based approach to maternity services because it enables respectful and safe care that is responsive to the woman and her family’s needs.

Preventive or public health approaches to reduce inequalities and the impact of social economic deprivation may be built in part by strengthening current community midwifery services, through the development of models of continuity of carer to provide more personal services, and integration of the pathway between primary care, social services and acute hospital based services.

What is quality and safety in maternity care?

The assessment of high quality, safe maternity care goes beyond measures of mortality or morbidity and encompasses multiple outcomes.For example, the most commonly used definition globally, and which is used by the WHO includes the
following dimensions: women’s experience and woman-centred care, effective, efficient, equitable, timely and safe care.

Using this definition, safer care is focused on services that do no harm to those who use or work in them, rather than just focusing on the potential risk that women or staff create.

This inclusive approach to safety encompasses a positive experience of care in which the woman is respected and listened to, secure relationships between woman and baby and within the family, the capacity to mother and care for the newborn and reduction in mental health problems. Healthy outcomes require respectful support for physiological processes, with medical intervention when needed or desired. The culture and systems of healthcare must ensure that women and their babies are given optimal chances of healthy outcomes without threat to their personal and legal
autonomy.

Conclusion

Respect for human rights is fundamental to all healthcare. It is particularly critical in maternity care, given the transformative nature of childbirth and the moral and legal imperative to respect the autonomy and dignity of women. Moreover, quality maternity care improves experiences for the woman and her family, and affects a baby’s start in life and subsequent life chances. Every mother and baby should have an equal access to quality care. We have described some principles that will enable professional carers to provide respectful, woman-centred, personalised care which, we argue, will contribute towards optimal physical and psychological outcomes and secure family relationships. Observing and building on human rights principles has the potential to transform maternity care.

We look forward to further discussion on this topic and thank you in advance for your time.

Elizabeth Prochaska
Barrister and Co-chair, Birthrights

Rebecca Schiller
Co-chair, Birthrights

Lesley Page
President, Royal College of Midwives

Beverley Lawrence Beech
Honorary Chair, Association for
Improvements in the Maternity Services

Susan Bewley
Professor of Complex Obstetrics, King’s
College London

Sheena Byrom OBE
Freelance Midwifery Consultant

Miranda Dodwell
Health researcher, maternity services user
representative and co-founder,
BirthChoiceUK

Ann Furedi
Chief Executive, British Pregnancy
Advisory Service (BPAS)

Carolyn Johnson
Consultant Anaesthetist, St George’s
NHS Trust

Helen Mountfield QC
Barrister and trustee, Birthrights

Amali Lokugamage
Consultant Obstetrician and
Gynaecologist, Whittington Hospital

Mary Newburn
Consultant, health researcher/ public &
parent involvement

Simon Mehigan
Clinical Director, One to One Midwives
and Chair of National Consultant
Midwives Group

Jane Sandall
Professor of Social Science and Women’s
Health, King’s College London

Rineke Schram
Chief Medical Officer and Consultant
Obstetrician, East Lancashire Hospitals
NHS Trust

Beverley Turner
Writer, broadcaster and founder, The
Blooming Bunch

Jim Thornton
Professor of Obstetrics and Gynaecology,
University of Nottingham

Denis Walsh
Associate Professor in Midwifery,
University of Nottingham