Birthrights is very excited to be expanding our small team. Are you highly organised? Have experience of running a busy (virtual) office? Then you could be our new administrator! You will be the key to ensuring our organisation runs smoothly as our work continues to grow at pace. The role is part-time (22.5 hours), flexible and home-based. Closing date for applications is the 23rd June, with interviews in mid-July. Download the job description here for more details.
Three and a half years after the original publication of this article, the right to choose a caesarean section remains one of the most common enquiries we receive at Birthrights.
Today we are launching a campaign asking you to help us identify Trusts who have a public policy of not offering caesareans unless there is a medical indication, contrary to NICE guidance and their duties under human rights law.
NHS Trusts are under pressure to reduce their caesarean section rate and there are good public health reasons for this. However in their quest to meet targets some Trusts appear to be abandoning their duty to consider cases on an individual basis and to act in accordance with NICE guidelines unless they have good, necessary and proportionate reasons. Any blanket policy not to offer elective caesareans without a medical reason is unlikely to be lawful and the fallout is felt by the very small percentage of women who, even with support, feel incredibly distressed about the idea of a vaginal birth. The reasons cited by women trying to access caesareans for non-medical reasons include physical damage from a previous vaginal birth, extreme fear of childbirth, emotional trauma after a previously difficult birth or experience of sexual violence or other violent trauma.
Birthrights wants to hold to account Trusts that do not give women the individual consideration and respect they are entitled to, and we need your help. Have you been denied a caesarean yourself? Do you know if a Trust that states publicly that it does not offer elective caesareans for no medical reason? Then do email us today at email@example.com so that we can write to that Trust and explain to them their obligations under human rights law.
This article explains a woman’s rights to choose an elective caesarean:
A human rights-centred approach
Birthrights is regularly asked whether women are legally entitled to a cesarean section. The question is asked both by women who seek an elective c-section and by healthcare professionals who wish to understand their obligations towards women who choose c-sections.
While women have no statutory entitlement to any particular type of maternity care in the UK, the decisions of healthcare professionals about the care that they give to women must be lawful. That means decisions must be taken in accordance with the general principles of the law, and where the care is provided by the NHS, that includes the principles of public and human rights law.
It goes without saying that a decision not to perform a c-section where it is clinically necessary to avoid harm to mother or child could lead to a retrospective claim for damages for clinical negligence. Where there is a threat to the life of mother or child, hospitals and individual clinicians are obliged to take steps to save life under Article 2 of the European Convention on Human Rights, enacted in UK law by the Human Rights Act 1998. But these are not the concerns of mothers who request a c-section when there is no immediate clinical necessity for the operation.
The right to an informed choice
Women have a right to make choices about the circumstances in which they give birth. This simple but powerful principle was established by the European Court of Human Rights in Ternovszky v Hungary (2010) under the right to private life in Article 8 of the European Convention which encompasses rights to physical autonomy and integrity. Article 8 is a ‘qualified right’ and so limitations on the right are permitted. The Ternovszky case concerned the right to give birth at home, but the principle applies equally to all choices that women make about childbirth. The decision represents a profound challenge to medical authority: if women have a legal right to make a choice, any limitation on that right must be justified. The decision-maker, whether a hospital or a doctor or midwife, must give proportionate reasons for their decision based on the individual circumstances of the woman and their reasons can be tested in court before a judge.
A reasonable request
To take the experiences of a number of women who have contacted Birthrights, if a women requests a c-section after a previous traumatic vaginal birth and explains to her midwife and obstetrician that she is afraid of giving birth vaginally again, the reasons given to her for refusing to offer a c-section can be scrutinised and balanced against her reasons for requesting a c-section. A court has not considered this sort of case before (and it seems unlikely that a case would reach court given the cost of litigation versus the much lower cost of simply providing the surgery), but a judge would undoubtedly take into account the serious effects of refusing the operation on the mother alongside obstetric risk as assessed by the doctor and, potentially, the financial cost of a c-section.
Some cases would be stronger than others. As recent research by the Royal College of Obstetricians and Gynaecologists revealed, in some UK hospitals women have a 40% chance of an emergency c-section after an induction. If a woman requests a c-section in order to avoid the induction process and the high odds of an emergency c-section or instrumental birth, and consequent potential trauma, a decision to refuse to perform the operation might be hard to justify. (And, of course, a failure to explain the likelihood of a c-section in these circumstances disables the woman’s ability to make an informed choice and casts doubt on her consent to the induction.)
We are often asked whether NICE guidelines have legal force to compel a doctor to provide a c-section. The NICE guideline on elective c-sections without a clinical indication states that women ought to be offered a c-section after discussion and an offer of mental health support. NICE guidelines are not legally binding on medical professionals. However, where a decision is made to depart form a guideline, reasons need to be given and exceptions considered in each individual case.
With thanks to RightsInfo who re-published this article last week to mark International Week for Respecting Childbirth
In March, the Department of Health launched a consultation about one of the key recommendations in the Better Births report – introducing a Rapid Resolution and Redress scheme for families whose babies suffer severe injury due to negligent maternity care. These families currently wait an average of 11.5 years to receive compensation.
Birthrights believes there is a clear need for such a scheme. However it must be designed around the needs of the families and children it is intended to serve, and it must be sustainable. Birthrights feels that the exclusion of stillbirths and neonatal deaths is arbitrary and insensitive. We are also concerned that the proposal for the NHS Litigation Authority to administer the scheme will undermine its credibility and effectiveness.
You can read Birthrights’ full response here. Please feel to draw upon our response as a basis for your own. The consultation closes on the 26th May.
The Royal College of Midwives and Birthrights today launched a new i-learn module on human rights, which is available to all RCM members.
Birthrights CEO, Rebecca Schiller commented: “With the launch of A-EQUIP planning complex care will not longer be down to a specialist. Therefore all midwives and maternity workers need to understand how human rights law can empower them to advocate for women, and to plan individualised care. This i-learn module created by the RCM in collaboration with Birthrights is an important contribution to further training midwives for this role.”
You can see the full press release here.
Speaking after the release of a statement from IMUK this week (22/03/16), Rebecca Schiller, chief executive of Birthrights, said:
Birthrights supports the actions of this group of independent midwives and women who have announced their intention to bring a judicial review of a Nursing and Midwifery Council decision that has prevented some independent midwives from providing care to the women relying on them. We believe that the NMC’s decision has breached the rights of midwives to practise their profession and women to choose their care provider.
As I made clear in my January letter to its chief executive Jackie Smith, we do not believe that the actions of the NMC have been those of a responsible regulator. There have already been very damaging consequences of this incorrect decision. The NMC has jeopardised the safety of hundreds of women and babies by effectively severing each woman’s access to continuity in her midwifery care. Faced with the absence of any comparable NHS service in their area, or following previous traumatic experiences with local maternity services, I know of a number of women who now believe that their only choice is to give birth without any medical assistance.
The nature of this decision is also in direct opposition to the positive direction of current maternity policy, which has recognised how fundamental women’s decision-making and autonomy is to safe, quality services and is seeking to expand access to maternity services that allow women and their caregivers to build relationships.
For further information about IMUK or this legal action please contact: Kiran Nagendran (0203 772 2471, firstname.lastname@example.org)
Over the last few days we have been fielding enquiries from people either directly affected or concerned by the NMC’s decision about IMUK’s indemnity insurance, asking what they can do.
While we await the response to our letter to the NMC, the maternity community are really pulling together to support midwives and women affected.
The RCM yesterday put out a statement suggesting that honorary NHS contracts could be a solution for some independent midwives. Simon Mehigan, Birthrights Trustee and Deputy Director of Midwifery at Chelsea and Westminster NHS Foundation Trust, is meeting with a number of Independent Midwives to discuss how honorary contracts may be used to support local women.
“We will do anything we can to mitigate the impact on women who have chosen to hire Independent Midwives and now find themselves in a very uncertain and stressful position. I am in the process of offering honorary contracts to the Independent Midwives we work with and I will be sharing the details of these contracts with other London Heads of Midwifery. If anyone else would like further details I urge you to get in touch.”
If you have hired an Independent Midwife, you should speak to your midwife/IMUK about the options open to you. They will be able to update you on their own discussions with local Trusts. You could also consider speaking to a Supervisor of Midwives at your local NHS Trust about what NHS care can be offered.
Anyone concerned about the NMC’s decision can:
– Write to Jackie Smith, CEO and Chief Registrar at NMC using Birthrights letter as a template
– Write to your MP and to Jeremy Hunt, Secretary of State for Health
– Sign this petition
Today is Human Rights Day 2016. Every year on the 10 December we commemorate the day on which, in 1948, the United Nations General Assembly adopted the Universal Declaration of Human Rights. So on this day, when we think about how we can stand up for human rights both here in the UK, and all over the world, we are sharing a guest blog post from Lina Duncan, a midwife (@MumbaiMidwife), who has written about her experience of childbirth in India…
Trigger warning – this piece discusses a stillbirth
I have lived and worked in urban India for nine years and during that time I have found that midwives are missing from the system. I have witnessed how hospital policies, mixed with religious or family tradition, harm women and their babies.
I have heard and read hundreds of stories about women in India who have been pressured into potentially unnecessary interventions with inaccurate, fear-mongering information. This breaks women. It damages them before they even begin to birth and care for their babies. Most women do not speak of these things because they are told that a healthy mother and baby is all that matters.
I have seen and heard of many tragic situations of pregnancy loss or stillbirth where the mother was not told the truth. In each case, the mother was told her baby was in the NICU. She was lied to and denied the right to meet her baby, to make memories, to grieve, to hold her baby. Mothers are too often then silenced in their grief.
I do not believe that a healthy mother and a healthy baby are all that matters. I believe that the truth also matters. Facts, and language, are vital, so that women have all the information they need to make informed decisions. This is especially the case when a care provider has to give difficult, or potentially devastating news.
Truth + Kindness + Compassion = (usually) Satisfaction and Comfort
Half-truths + Lies + Fear = Broken Trust, Fear and Trauma
I have a friend. She looks a little wild, maybe that’s why I liked her from the start. She often has a vacant look in her eyes. Frequently, she adjusts her clothes and shows me bruises from her alcoholic husband.
She doesn’t know her birthday, nor her age. She looked about 22 when I first knew her, pregnant with her first son who was born in a temporary shelter where she was living on a disused railway platform.
Fast forward a couple of years. I have not seen her for months. Her chaotic life is mostly about daily survival. She feeds her drunk husband first, of course. Then, her son, and then, her pregnant self. She has not had any antenatal check-ups. I persuade her to go with me to the government hospital, with son in tow because she is afraid to leave him with his father.
I show her what to do and entertain her lovely unruly son who is filthy. Everyone stares at me, and her, and it’s awkward and tedious. It takes about seven hours to get completely registered. She is prescribed vitamins, calcium, protein powder. I get her a few of the important ones and open them so they can’t be sold for liquor.
I don’t see her again for months and I worry.
One day she rocks up and calls my name. She is 39 weeks pregnant. She has had no antenatal care for 30 weeks. She does not want to go back to hospital but her husband thinks it’s a good idea. I go with her. The son stays at ‘home’.
The hospital wants to see a sonogram. The machine is broken. We have to pay 400 rupees (£4) for a private one. She has 10 rupees only. I pay. It takes forever.
I’m ‘not allowed’ in with her. Then the curtains are drawn back and I’m invited in. I know it’s not good news. ‘No heartbeat and only part of the brain,’ says the sonographer, to me. My heart sinks. I ask him to tell my friend as my Hindi is not good enough. He tells her and she smiles and says, ‘let’s go get lunch’. She has not understood.
We get food and find her husband, who is drunk, and her 3-year-old son, who has bloody knees and chin from playing alone in a building site. She is angry. I call my consultant doctor friend who works in a government teaching hospital. He invites us to go there immediately.
Another sonogram. Heavily pregnant woman with confirmed anencephalic baby. Drunk husband. Three-year-old doing somersaults all around the hospital wearing his father’s t-shirt and nothing else. We are a laughing stock and I am requested to stay and admit my friend for induction and then remove the husband and son.
She is disturbed that her son is alone with dad and they are not ‘allowing’ her out of hospital. The hospital requests that she fasts and start induction at 5am the following morning. I ask several times, politely, if I may accompany her but it is not allowed. Baby is breech and still alive. I have had lots of conversations with her about what to expect. It hasn’t sunk in. She either doesn’t understand or doesn’t want to.
That night, I tell her I will come and I will be outside the ward until she gives birth and they let me see her. I tell my friend that when she feels alone, she can know I am just on the other side of the wall. This breaks my heart. I am a midwife.
She has to go into the labour ward alone.
A colleague and I sit on the floor outside the labour room for 19 hours. Being a doula through a wall is very hard, especially knowing what she is about to face. No one should have to labour and birth without a companion.
Around 1am we are called into a little room to look at her little girl who has been born dead. I ask to take a picture for my friend. They assure me that she will be shown her baby but don’t let me in to be with her. I take pictures on my phone. They are lovely doctors but I am so angry.
At 4am they let me in to see her and ask me to buy her tea and food. It had been about 30 hours since she has eaten.
It is easy to find her, sitting up in bed with a big grin, announcing she is starving and asking where her food is. I ask her if she has seen her baby and she says, ‘not yet’. I ask her if she wants to see my photos and she says yes. I tell her that her baby was not born alive, that she was a girl, that her heart had stopped beating before she was born. I tell her the truth. She doesn’t ‘hear’ it. She smiles, asks me to come back in the morning and goes into a deep sleep.
In the early hours of the morning my phone rings. Sobs, deep sobs and demands. ‘Come now’, she says. ‘They have killed my baby,’ she says. My friend is distraught in a room full of mothers with their babies.
The day she is discharged I go to bring her home. She’s a darling and so feisty. She laughs and jokes until we walk arm in arm out of the ward. Then her body begins to shake. She says, ‘I came here to have a baby and I’m leaving with empty arms’. I have tears running down my face as well and passers-by gave us kind looks.
My colleagues and I make many visits over the following days and weeks. The family like to see the picture on my phone.
My friend has since had another baby. Her husband sold her when she was only 2 weeks old. This is one woman, one story and she represents many that live in a silent story of abuse and disrespect.
Many of us are longing for the Human Rights in Childbirth conference to be held in Mumbai, February 2017. We hope to hear many women’s stories, hear from researchers, and talk about how a midwifery model of care can be introduced in India. Do follow the conference, and join in the conversation. #breakthesilence
Today started as many of my days do with me going straight into a meeting, no time to grab a drink or check my emails. The meeting was discussing how we improve services for women accessing early pregnancy and gynaecology. By redesigning our estate we can improve the journey for these women. How does that relate to their human rights? Well, ensuring women are cared for in an area that’s private and appropriately staffed with skilled nurses and medical staff means women that are suffering a miscarriage or early complications in pregnancy are appropriately cared for and supported. Midwives working in a hospital setting often don’t have any dealings with women below 20 weeks so its important that I make sure that the way in which these women are cared for compliments the midwifery care they receive and promotes the ethos of women centred care. If the care we give is based on the needs and wishes of individual women then we are will be meeting their human rights.
Walking round the maternity unit I meet one of our new consultant midwives who talks to me about a women she has been caring for. This woman is very keen to have a vaginal birth but is being discouraged by some of the medical staff who have concerns about her risks. Midwives and obstetricians have an obligation to talk to woman about any risk factors they may have. Unfortunately every doctor this woman has met has felt the need to reiterate this woman’s risks factors. As she clearly states “ I know the risks, I’ve been told them, I’ve researched them, I just want the best chance to have a good birth experience”. The skill to being a woman centred midwife or doctor is to speak to women on an equal footing. To remove the power dynamic that is so often present in the relationship between health professionals and those they care for is one of the fundamental steps in building a trusting relationship. Trust is, I feel, one of the building blocks of a human rights based relationship with those we care for.
I meet a young woman who has recently given birth to her 1st child but is still here 6 days later. The baby has been under the care of the neonatologists. This intelligent woman has become a mother and has experienced first hand how the “just in case” approach and “doctor knows best” has led her to stay in hospital all this time. She’s a health professional and the work part of her has made her question the doctors, she doesn’t feel the treatment and the investigations her baby has had were necessary, but now she’s a mum and the very rational, logical, evidence based approach she uses every day at work has becoming clouded by the emotions that come with being a mother combined with all the changes taking place in her body following birth. We talk through how she feels, she comments on how the care she received was great until the baby was born and then it all “got out of control”. She has been told she can go home today so we agree that she will write to me, detailing her experiences as a mum and as a health professional. I can then use that to help me challenge some of the policies, procedures and behaviours that exist in the organisation that don’t support a culture of respecting the human rights of mothers and baby’s.
My afternoon is spent trying to support the managers in staffing the unit safely, rewriting a job advert for midwives focussing on attracting candidates that believe in women centred care and the role the midwife plays in facilitating choice and helping women and their families to have a positive birth experience. I then respond to a complaint from a woman who feels she wasn’t listened to when she was in pain, didn’t have her wishes respected or her beliefs.
All of the above makes my day sound pretty depressing but actually its full of positive stuff. I see midwives and doctors supporting women, being kind, communicating well and appropriately. I see staff members supporting each other with guidance and tips on how to manage particular situations and I see many, many happy faces of women, their partners and their families who have recently met the latest arrival to their family.
I haven’t laid a hand on a pregnant woman’s abdomen, or caught a baby as its mother pushes it out or helped a new dad figure out how to put a nappy on his new child. That doesn’t make me any less of midwife nor does it mean I’ve not been able to act in a way that promotes the human rights of childbearing women.
What makes a “human rights centred midwife’?
Kindness, compassion, consideration, respect, honesty and a fundamental belief in a woman’s right to choice.
You know what’s interesting? You could take out “human rights centred” because these are all the qualities that make a great midwife and having spent 22 years working in maternity services the overwhelming majority of midwives I have met have all those qualities. Unfortunately sometimes the services they work in, the culture of the organisation in which they are employed doesn’t support them in demonstrating all these qualities. Fear of litigation, of not following guidelines or off being labelled a “maverick” midwife by supporting choices women make that might not be the norm make some midwives act towards women in a way that they don’t fell comfortable with. This makes some midwives move on, some leave the profession all together and some give in, become part of the culture.
My words of wisdom…..
Be brave, be strong…….be a midwife…..
Simon Mehigan is Deputy Director of Midwifery at Chelsea and Westminster Hospitals NHS Foundation Trust, and a Trustee of Birthrights. This blog post was first published as part of the Growing Families Conference blog series.
On the 2nd November, Helen Mountfield QC will be intervening, on behalf of Birthrights and a coalition of charities, in an important appeal, R (A and B) v Secretary of State for Health to be heard at the Supreme Court challenging the Secretary of State’s decision to bar women who travel from Northern Ireland to England from NHS-funded abortion care.
The case, was originally brought in 2014 by a young woman, A, and her mother, B. At the time of her abortion, A was a 15 year old girl resident in Northern Ireland, who travelled to Manchester in 2012 with her mother to end her pregnancy, at a cost of £900. While their case was originally unsuccessful at the High Court and the Court of Appeal, A and B have been granted permission to appeal to the Supreme Court.
Birthrights is part of a coalition which also comprises Alliance for Choice, the British Pregnancy Advisory Service (bpas), FPA, and the Abortion Support Network. They are represented at the Supreme Court by two barristers; Helen Mountfield QC, from Matrix chambers, and Jude Bunting, at Doughty Street Chambers; and the leading firm of solicitors, Leigh Day & Co.
Speaking in advance of the appeal, Rebecca Schiller, CEO of Birthrights, said:
“It is shocking that the human rights rights of Northern Irish women are still being contravened to such a degree in 2016. It is unacceptable that women must choose between keeping an unwanted pregnancy, risk prosecution by purchasing illegal abortion pills or spend significant sums to travel to England. We hope that the outcome of this appeal will be the beginning of Northern Irish women’s human rights being upheld; both at home and in England.”
You can read our written intervention here.
Birthrights can provide press spokespeople – please see our Press page for more details.
It’s a busy week for human rights in childbirth activists….
Firstly, its #newchapter book club week when nearly 80 book clubs will be meeting to discuss Why Human Rights in Childbirth Matter! We are absolutely delighted that so many people are showing their support for Birthrights in this way. #Newchapter book clubs are not only raising the profile of human rights in childbirth they are also raising funds to help us continue our work. So we want to say a big thank you to all our book clubbers, both here in the UK and across the globe!
Don’t forget to share your photos and posts using the hashtag #newchapter!
At the same time, our Chair, Elizabeth Prochaska, and our CEO Rebecca Schiller, are on their way to Strasbourg for the Human Rights in Childbirth Summit. The chosen topics for the summit are informed consent and midwifery/out of hospital birth. Elizabeth and Rebecca will be reporting on the situation in the UK and hearing about the experience of other countries. More on the Summit to follow…
To coincide with our #newchapter campaign, the Human Rights in Childbirth Summit, and a generally busy autumn for human rights in childbirth, look out for our new series of guest blogs, starting with a look at childbirth in India…