The Role of the Midwife in FGM Prevention

Yana RichensProfessional Global Advisor RCM

Consultant Midwife University College London Hospital

The UK Law

Role of the Midwife

Prevention with practising communitiesIdentify who is at riskWho has undergone FGMRecord ReportDiagnosis: Physical and Psychological consequenceData Collection

• Lack of Awareness

– Of the practice

– Of health implications and legal status

• Lack of Clear Pathways and Protocols

• Scanty Evidence Base

• Information Sharing - confidentiality

• Interpreters

• Misplaced Cultural Sensitivities

Barriers for Midwives and Health Care Workers Taskforce – Health Aspects of Violence Against Women and Children 2010

Discuss FGM in the Antenatal Clinic

• All pregnant women regardless of ethnic origin should be asked about FGM

• Use sensitive and non-judgemental language:– Have you been cut? – Are you closed? – Have you been circumcised?

• Document in notes / computerised notes

• A genital inspection should only be done by someone experienced in FGM.

• Refer to FGM services:– Usually an FGM clinic in high prevalence areas– Designated midwife or obstetrician in low prevalence areas.

Specialist FGM Assessment

• Discussion with the woman and partner/family• Document discussion in notes including legal and health

aspects• Genital inspection and documentation of Type of FGM• Decision whether de-infibulation is required• Arrange or refer for de-infibulation• Safeguarding risk assessment of unborn child if female

– The police must be notified of all under-18s with FGM (whether pregnant or not)

– It is not mandatory to refer all pregnant women to social services unless there is a risk to a associated child(unborn or siblings)

– Different hospitals will have local guidelines for referral to social service of over 18s

• Complete Department of Health Enhanced FGM Data Set (www.HSCIC.gov.uk)

Accurate Identification of Type of FGM

• Probably only possible in:– Specialist FGM Clinics– Midwife/obstetrician or other health care professional

with previous FGM experience

• Even with Specialist Staff– Type 3 usually obvious – unless previously de-

infibulated– Type 1 and 2 can be more difficult to distinguish– Type 4 can be very difficult to detect at all

Guidance for Midwives

What should midwives do if FGM is suspected?

Data Reporting September – February 2015

126 of 157 eligible acute trust in England

3110 newly identified cases

46 newly identified under the age of 18

• 1.5 cm band of scar tissue across urethra incised. Repaired with a single figure of eight suture as it was bleeding

• Not re-infibulation or FGM• Jury took under 5 minutes to acquit

unanimously• Obstetricians and midwives anxious

about perineal repair after FGM• This may be detrimental to care of

women.

• RCN FGM Guidelines 2015:– “It is of course important to repair

a laceration or episiotomy to stem the bleeding”

– “The key is to ensure that both the urethra and introitus are able to be seen following repair”

Recent Case

Summary

• There are no health benefits to FGM and FGM increases risks to both mother and baby during pregnancy and delivery

• Pregnant women with FGM much be assessed by a midwife or obstetrician experienced in FGM.

• A management plan should be documented in the notes and should included whether or not a de-infibulation is required

• The assessment should include a safeguarding risk assessment.

• Pregnant women (over the age of 18) with FGM should only be referred to social services or police only if a child is at risk of FGM.

• Re-infibulation after delivery should never be done and care must be taken repair labial tears.

Useful Resources

• http://www.e-lfh.org.uk/programmes/female-genital-mutilation

• FGM National Group Training DVD www.fgmnationalgroup.org

• FGM Multi-agency Practice Guidelines www.dh.gov.uk

• RCN Female genital mutilation: An RCN resource for nursing and midwifery practice. Second edition 2015

• An RCN resource for nursing and midwifery practice

• RCOG Green Top

• Equality Now www.equalitynow.org

• FORWARD www.forwarduk.org.uk

• Daughters of Eve www.doeve.org

• Tackling FGM in the UK. Intercollegiate recommendations for identifying, recording and reporting. RCM. 2013