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)
A Rapid Resolution and Redress scheme was one of the key recommendations coming out of the Better Births report. This month the Department of Health has launched a consultation on this proposal.
Currently families whose children have suffered severe injury due to negligent maternity care have to wait an average of 11.5 agonising years to receive compensation. A Rapid Resolution and Redress scheme should offer a shorter, more supportive option for parents.
Birthrights will be responding and will be publishing a guide to the proposals on our website in the next few weeks. If you have direct experience we would particularly urge you to respond to this consultation and use this opportunity to have your voice heard.
The closing date for the consultation is 26th May.
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.
I now have permission to share Jackie Smith’s response to my letter. You can read it in full here.
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.
On 8th March, Birthrights, alongside Queen Mary’s School of Law and 39 Essex Chambers, will be putting on a seminar taking a critical look at the recent trend of forced caesarean decisions in the Court of Protection.
The seminar (17.00 – 19.00) will feature an impressive line up of panelists including: Professor Lesley Page CBE, President of The Royal College of Midwives, Dr Daghni Rajasingam, Consultant Obstetrician, Guys and St Thomas’s NHS Foundation Trust, Dr Jo Black, Consultant Psychiatrist and Clinical Director for Perinatal Mental Health at NHS England, Polly Sands, specialist perinatal mental health midwife at Guys and St Thomas’s NHS Trust, Seaneen Molloy-Vaughan, writer, mental health blogger, and mum of one, in addition to Elizabeth Prochaska, Matrix Chambers and Birthrights and Victoria Butler-Cole, 39 Essex Chambers.
The event is primarily aimed at lawyers, and judges working in the Court of Protection but healthcare professionals and anyone else with an interest are more than welcome.
To reserve a place please contact: Beth Williams (email@example.com) / 020 7832 1155
More information about the event can be found here.
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
- 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
- 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
- Urgently making a public recommendation on what constitutes adequate insurance.