1. The Role of the Midwife in FGM Prevention Yana Richens Professional Global Advisor RCM Consultant Midwife University College London Hospital

2. The UK Law

3. Role of the Midwife Prevention with practising communities Identify who is at risk Who has undergone FGM Record Report Diagnosis: Physical and Psychological consequence Data Collection

4. 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

5. 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.

6. 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)

7. 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

8. Guidance for Midwives

9. What should midwives do if FGM is suspected?

10. 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

11. 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

12. 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.

13. Useful Resources http://www.e-lfh.org.uk/programmes/female-genital-mutilation FGM National Group Training DVD www.fgmnationalgroup.orgwww.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.ukwww.forwarduk.org.uk Daughters of Eve www.doeve.org Tackling FGM in the UK. Intercollegiate recommendations for identifying, recording and reporting. RCM. 2013