1. How we care for women with FGM in Leeds Maternity Service Sarah Bennett Specialist Midwife BME Women November 6 2014

2. Aims & Objectives Define FGM Reveal the global and local prevalence of FGM Share the Leeds FGM service as an example of good practice

3. FGM: Definition “All procedures which involve, partial or total removal of the female external genitalia, or any other injury to the female genital organs, for non-therapeutic reasons” FGM Act 2003 “A person is guilty of an offence if s/he excises, infibulates or otherwise mutilates the whole or any part of a girl's labia majora, labia minora or clitoris. It is an offence for a UK national or permanent UK resident to aid, abet, counsel or procure this procedure for another person ”

4. Prevalence / Distribution: Global Traditional Practicing Communities Africa, Asia/M East - Iraq, Iran, India, Pakistan, Indonesia, Malaysia Migrant Communities Europe, USA, Canada, Australia, New Zealand England & Wales An estimated 137,000 women and girls living England and Wales have, or are at risk of FGM. FGM makes up 1.5% of all maternities each year 3

5. Prevalence / Distribution: Leeds FGM Clinic Data 2013 154 women reviewed 81% live in the most disadvantaged areas Ethiopia, Eritrea, Somalia, Sudan, Gambia, Guinea, Nigeria, South Africa, Kenya… 80% from Eritrea, Somalia, Sudan New Estimates Using the 2011 Census 1,003-2,667 women and girls in Leeds have undergone or are at risk of FGM

6. Rationale for FGM service Physical, Psychological, Sexual Health Consequences: Short Term Pain, severe bleeding, urine retention, infection, broken bones, death 10% Long Term Chronic pain, cysts, abscesses, ulcers, scarring, recurrent infections, sexual dysfunction, subfertility, chronic anxiety, phobias, depression, PTSD Pregnancy/Childbirth Mother Increased risk of: recurrent urine infections, LSCS, severe perineal/vaginal trauma, severe bleeding, extended hospital stay Baby Increased risk of: poor condition at birth, low birth weight, Still Birth, Neonatal Death

7. Protecting girls Where risk of FGM is identified, midwives have a legal and professional duty to share information between key agencies and to document responses 1, 4, 5 The Intercollegiate guidance recommends; 1.The NHS develop information sharing protocols and pathways about women and girls at-risk or who have undergone FGM with other health and social care agencies, the Department for Education and Police 1 2.All adult women presenting within the NHS must be considered potential victims of crime 1. They therefore must be referred to the FGM clinic where a through assessment of risk will be made and a decision to refer to police, Children Social Work Services (CSWS) and support services will be taken. 3.Risk of FGM must be assessed for any female child born to a woman with FGM1. All girls (under 18) presenting with FGM or considered at risk of FGM must be referred to CSWS and the police 1, 4, 6. Rationale for FGM service

8. Leeds Midwife led FGM Service Aims Reduce FGM morbidity & mortality Improve women’s maternity care experience Prevent FGM/Protect children Meet midwives/obstetricians training need Elements Training FGM Clinic LTHT FGM Clinical Guidelines/Care Pathway

9. Training Pre-registration training at University of Leeds undergraduate midwives Mandatory training for postgraduate midwives Shadowing/observation in FGM clinic Leeds Safeguarding Children Board training calendar

10. Leeds Maternity Care Pathway

11. Identification: Good Practice Points Always use an interpreter (if required) Confidentiality Self Awareness/Communication Create Respectful & Non-judgmental Environment Listen! Alert to social context Do not examine without good cause

12. Sensitive Identification Begin meeting with a general discussion Acknowledge you're aware of a traditional practice in her country of birth where girls genitals are cut Ask, is this practiced in your community? What do you call this practice? Explain, we call it circumcision in the UK. Explain this practice can cause severe health complications Use value neutral terms “Were you circumcised/cut as a child” Or use the word she uses to describe FGM “Did you have....?” Be direct, indirect questioning is confusing

13. What does a good FGM service consist of? Comprehensive, accessible guideline Timely referral process Dedicated clinic, with access to interpreters Documentation Internal communication Referral pathways to Social Care/Children’s Services/Police Postnatal communication – to GP and HV

14. What do the women say? Is very nice service, I really love it, thank you very much. God bless you It was good to see you today, we learned a lot. We can now share the knowledge we have with our community to help protect girls and stop circumcision from happening Everything is now good Friendly service, very informative

15. Contact details sarah.bennett4@nhs.net 0113 2066392 Any questions?

16. References 1.RCM 2013 Tackling FGM in the UK – Intercollegiate recommendations for identifying, recording and reporting RCM London https://www.rcm.org.uk/sites/default/files/FGM_Report.pdf 2.HM Government 2011 Multi-Agency Practice Guidelines: Female Genital Mutilation https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216669/dh_124 588.pdf 3.Macfarlane A, Dorkenoo E, (2014) FGM in England and Wales: Updated statistical estimates of the numbers of affected women living in England and Wales and girls at risk Interim report on provisional estimates. City University, London. 4.HM Government (2013) Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children, London, Stationery Office 5.NMC 2008 The code: Standards of conduct, performance and ethics for nurses and midwives http://www.nmc-uk.org/Documents/Standards/The-code-A4-20100406.pdf 6.West Yorkshire Consortium Procedures Manual April 2014 http://westyorkscb.proceduresonline.com/chapters/contents.html