Consultant Sexual and Reproductive Health Conifer Service CHCP CIC Overview Definition The law Prevalence Classification Management Safeguarding Management Clinical What the women want ID: 1043866
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1. FGM in HullDr Tonye WokomaConsultant Sexual and Reproductive HealthConifer Service CHCP CIC
2. Overview:DefinitionThe lawPrevalence ClassificationManagement – SafeguardingManagement – ClinicalWhat the women want?Post natal Contraception
3. 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”
4. FGM Act 2003 (updated from 1985):“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”
5. Serious Crime Act 2015Female Genital Mutilation Protection Order (FGMPO)1st order was obtained in July 2015Duty to notify Police of FGM (came into effect 31st October 2015)“regulated professions” – healthcare professionals, teachers, social care workersNotify the police on 101 non-emergency number if FGM discovered (in any girl under 18yrs) in course of work (disclosure and/or physical signs)Professionals should record all decisions and communicate sensitively with the girl/and or her familyAnonymity of victims
6. Key facts:A type of ‘Violence against Women and Girls’.No health benefitsPrevalent in 29 countries in Africa and Middle East. >125 million girls and women alive today have been cut.Usually performed sometime between infancy and age 18 and may be repeated. Fact sheet N°241, Updated February 2014 http://www.who.int/mediacentre/factsheets/fs241/en 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.
7. World wide distribution:Traditional Practicing Communities Migrant CommunitiesAfricaEuropeAsia/M East - Iraq, Iran, India, Pakistan, Indonesia, MalaysiaUSACanadaAustraliaNew Zealand
8. Countries where FGM is most common:Source: International Development Committee, June 2013CountriesPrevalence 35-39yrsPrevalence 15 – 19 yrsDjibouti94.7%89.5%Egypt96.4%80.7%Eritrea92.6%78.3%Gambia79.5%79.9%Guinea98.6%89.3%Mali 84.9%84.7%Sierra Leone96.4%75.5%Somalia98.9%96.7
9. National Prevalence 2011census dataFGM makes up 1.5% of all maternities each year. Macfarlane A, Prevalence of Female Genital Mutilation in England and Wales: National and local estimateshttp://www.city.ac.uk/__data/assets/pdf_file/0004/282388/FGM-statistics-final-report-21-07-15-released-text.pdf2011 (UK)No of womenPrevalence15-49 yrs103,0007.7/1000>50 yrs24,0002.3/10000-14 yrs10,0002.2/1000Total137,0004.8/1000
10. Local Prevalence 2011census data Macfarlane A, Prevalence of Female Genital Mutilation in England and Wales: National and local estimateshttp://www.city.ac.uk/__data/assets/pdf_file/0004/282388/FGM-statistics-final-report-21-07-15-released-text.pdfLocal AuthorityNo of womenPrevalenceHull2021.6/1000Yorkshire and the Humber5,6582.1/1000England134,6455/1000
11. Maternities to women with FGM2005-2013 Macfarlane A, Prevalence of Female Genital Mutilation in England and Wales: National and local estimateshttp://www.city.ac.uk/__data/assets/pdf_file/0004/282388/FGM-statistics-final-report-21-07-15-released-text.pdfLocal AuthorityTotal maternitiesNo of women% maternities to women with FGMHull32,2441620.50Yorkshire and the Humber580,7524,4410.76England5,91829197,5251.65
12. No of girls born to women with FGM2005 -2013 Macfarlane A, Prevalence of Female Genital Mutilation in England and Wales: National and local estimateshttp://www.city.ac.uk/__data/assets/pdf_file/0004/282388/FGM-statistics-final-report-21-07-15-released-text.pdfLocal AuthorityEstimated number of girls born to women with FGMTotal number of girls born% of girls to women with FGMHull7916,6960.48Yorkshire and the Humber2,277300,0560.76England49,7973,066,3111.62
13. Reasons for FGM:Toubia, N. (1993). Female Genital Mutilation: A Call for Global Action. New York: Women, Ink; pp. 21
14. Type I: Clitoridectomy partial or total removal of the clitorisType II: Excision partial or total removal of the clitoris and the labia minora, with or without excision of the labia majoraType III: Infibulation narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or labia majora with or without excision of the clitorisType IV All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterisationWHO definition of FGM:
15. Normal female genitalia:
16. FGM Type 1 - Clitoridectomy:
17. FGM Type 2 – removal of the clitoral hood and part of the labia:
18. FGM Type 3 - Infibulation:
19. FGM Type 3 - Infibulation:
20. Management - safeguarding:
21. Management – safeguardingIf pregnant, the welfare of the unborn child should be considered and action taken accordinglyReferral to the police should not be an automatic response to FGMRefer any child(under-18s) or vulnerable adult using standard existing safeguarding procedures:with symptoms or signs of FGMif it is suspected that they are at risk of FGMConsider family history or other relevant factorsNotify police if <18yrs
22. Management – clinical:History takingExaminationAppropriate referralSuitable interpreter vitalAll women should have the opportunity to be given support and guidance
23. Sensitive identification:Ask all women/children from high risk areas (some women have little/no recollection of the event!)Acknowledge awareness of a traditional practice in her country of birth where girls genitals are cut – Ask, What do you call this practice? Explain this practice can cause severe health complicationsUse value neutral terms “Were you circumcised/cut as a child” Or use the word she uses to describe FGM Be non- judgemental but direct
24. Short Term Health ConsequencesLong Term health Consequences Pregnancy/Childbirthpainchronic anxiety, phobias, depression, PTSDMothersevere bleedingcystsRecurrent infectionsurinary retentionchronic painLSCS infectionabscessesSevere perineal/vaginal traumabroken bonesulcers, scarringsevere bleeding death 10%recurrent infectionsextended hospital stay sexual dysfunctionBabysubfertilitylow birth weight, poor condition at birthstill birth, neonatal death
25. Specialist clinic - History sheet
26. Specialist clinic - History sheet
27. Focus group discussions:(with Refugee Council)23 womenMajority Somalian, 2 Congolese Age range 18yrs – 40 +yrsHad been in the UK 7 months – 12 yrs18 women had children, 8 born in the UKMajority had experienced FGM
28. Women reluctant to raise the subject themselvesWere not asked about FGMIf asked, they were not examined and no further info/advice offered“felt there was a general lack of knowledge”Focus group discussions cont:
29. Focus group discussions cont: What the women wantedEducation and information on practice & types of FGMInformation regarding potential future medical problemsWhether current problems were related to FGMInformation on issues regarding sexual intercourse & childbirthInformation on de-infibulation and to explain the process
30. Focus group discussions cont: What the women wanted?“the need to be listened to and wanting someone to examine them, explain what they should look like and what, if anything, could be done to rectify their appearance”
31. Challenges :Co-ordinated care for women affected by FGM“Good knowledge … education … support … practical systems … monitoring”Lack of mental health care resources for FGM survivorsAftercare of women who have undergone de-infibulationEngagement with communitiesFunding
32. Summary:Be sensitiveAsk direct questionsConsider safeguarding issuesSupport the woman - Refer to Community Gynaecology clinic if necessaryMandatory reporting
33. Useful websites and links:FGM RCOG Green top Guidelines No 53FGM National Clinical GroupDaughters of EveForward UKNSPCCNHS Choices – Information about FGMTackling FGM in the UK - a report and set of recommendations for identifying, recording and reporting FGM, produced by a coalition of Royal Colleges, trade unions and Equality Now
34. Who can you contact?The Police - call 999 or 101Hull City Council Children ServicesAccess and Assessment Team on 01482 448 879 during normal office hours. Emergency duty team on 01482 300 304 out of normal office hoursHull Safeguarding Children's Team - Tel: 01482 379 090Email: hscb@hullcc.gov.ukIf abroad you can call the Foreign & Commonwealth Office on +44 (0) 20 7008 1500.
35. Post natal ContraceptionDr Tonye WokomaConsultant Sexual and Reproductive HealthConifer Service CHCP CIC
36. Unintended PregnancyUnintended Pregnancy in the United States Guttmacher Institutehttp://www.guttmacher.org/pubs/FB-Unintended-Pregnancy-US.html
37. Unplanned pregnanciesUnplanned pregnancies in Hull and East Yorkshire are common among women undergoing IA 75.8% (95%)Unplanned pregnancies in Hull and East Yorkshire are uncommon among women attending ANC (5.5%)1/3rd of women not using contraception reported that they were unable to obtain the method they wanted1/3rd of women using contraception stated that they were not using the method they would have preferredBexhell H, Guthrie K, Cleland K, Trussell JContraception. 2015 Oct 28. pii: S0010-7824(15)30105-0. doi: 10.1016/j.contraception.2015.10.004. [Epub ahead of print]Unplanned Pregnancy and Contraceptive Use in Hull and East Yorkshire.
38. Post natal Contraception“Women born outside the UK were significantly more likely to die than those born in the UK (RR 1.77, 95% CI 1.39-2.24)”>1/3rd (34%) of women were born outside the UKTime in the UK - 4 years (range 1 month to 21years)>70% Asia (mainly India, Pakistan, Bangladesh and Sri Lanka)Africa (mainly Nigeria, Somalia and Ghana)Saving mothers live 2014
39. Key messagesWHO recommends interbirth-interval – 2yrsIt is important to reach women before they are at risk of an unintended pregnancywith information about return of fertilitytheir options to space or limit future pregnanciesthe benefits to their own and their baby’s health of doing soLARC methods should be encouraged
40. Effectiveness ChartWhen - AntenatallyContraception should be discussed with all women while they are still pregnantHow - Women should be provided with informationListen to the womanDispel misconceptionsAvoid undue pressureAllow the opportunity to discuss with family members if she wantsShe is more likely to continue with a method she is happy withThe method of contraception chosen should be documentedCondoms reduce the risk of STIs and HIV
41. How can we do better?Increased awareness of staff on cultural issuesconsider their beliefs and customsUse of appropriate interpretersListen to what women want – Patient feedbackExpanded coverage
42. Opportunities When - AntenatallyContraception should be discussed with all women while they are still pregnantHow - Women should be provided with informationListen to the womanDispel misconceptions – many worry about return of fertility, they might not be allowed to remove the LARCAvoid undue pressureAllow the opportunity to discuss with family members if she wantsShe is more likely to continue with a method she is happy withThe method of contraception chosen should be documentedCondoms reduce the risk of STIs and HIV
43. Outreach nurseDedicated nurse for Contraception and Sexual HealthVisits the postnatal wardReferrals MidwivesHealth visitors Doula’sSelf referrals from women (husbands ring due to language barrier)Fast track service for LARC methodsDomiciliary visits (attend with health visitors sometimes)
44. Outreach nurseSomali lady seen at home6 children. Last child 18/12 old2/52 postnatalDiscussion with husband’s agreementNexplanon fittedHusband said no contraception available in their country at all.The couple wanted a space between children.
45. Thank you!Any Questions?
46. References:Toubia, N. (1993). Female Genital Mutilation: A Call for Global Action. New York: Women, Ink; pp. 21Fact sheet N°241, Updated February 2014 http://www.who.int/mediacentre/factsheets/fs241/en 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, LondonFGM Multi Agency practice Guidelines https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/380125/MultiAgencyPracticeGuidelinesNov14.pdfFemale Genital Mutilation Prevention Programme: Requirements for NHS staff, Department of Health and NHS England Statement 8/12/2014
47. References:Female Genital Mutilation Risk & safeguarding: Guidance for professionals DOH March 2015 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/418564/2903800_DH_FGM_Accessible_v0.1.pdfSerious Crime Act 2014 Factsheet FGM https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/416323/Fact_sheet_-_FGM_-_Act.pdf