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    1. Increase the maternity tariff. The existing maternity tariff, the money the government allocates for each birth does not pay for sufficient midwives for safe births, let alone for happy births
    2. Bring back bursaries for midwives and nurses
    3. Make full maternity care available to all mothers, no exceptions
    4. Ditch the sweet talking Maternity Review. No personal budgets. No loss of beds. We want a fully funded NHS maternity system, not a choice of private providers.
    5. Respect women’s choices in labour. Listen to the mother.
    6. Home birth, midwife unit or hospital birth, they all need to be in in the NHS with NHS staff fully supervised and in the training loop.
    7. Make obstetric care available in our local hospitals. No four hour journeys for women in labour.
    8. No pressure to give birth at home. Home birth must be a free choice, with full hospital back up available
    9. Full NHS insurance for all NHS home births. No handing over responsibility. No home births on the cheap.
    10. Give women more time with their midwives. More midwives per mother.
    11. No cuts in maternity beds
    12. No woman to be left alone in labour
    13. Help women with breast feeding. Mums need support after birth too. Breast feeding is far too low in UK, yet women want to breast feed for their babies.
    14. Support mums in the early days with baby.
    15. Invest in the start of life
    16. Support maternal mental health
    17. Train more paediatric doctors and nurses.
    18. Research reasons for premature birth
    19. Improve pediatic intensive care
    20. Staff our labour wards so no forced emergency closures. Plan staffing 8 months in advance. It’s kinda natural
    21. Nationalise the private maternity companies taking NHS contracts
    22. Fund research into still births, and birth injuries
    23. Improve procedures for induction of labour
    24. Fully fund neo natal intensive care
    25. Recruit more midwives, nurses and doctors,neo natal intensive care nurses and related staff.
    26. Ditch the STPs and their cuts
    27. Keep all our EU staff and make them very welcome
    28. Fund improved ambulance services and train all staff including dispatchers around birth issues.
    29. Fight maternal and child poverty

    For our babies, for our mothers, for our sisters, for our lovers

    By Save Liverpool Women’s Hospital


    The historic 1967 Abortion Act is 50 years old this month, yet this fundamental part of women’s health care continues to be a fiercely contested issue. There are still politicians who want to turn back the clock and win support for complete opposition to all abortions in any circumstances. Tory MP Jacob Rees Mogg declared this as his view only last month, although his position was swiftly undermined by revelations that he profits from shares in a pharmaceutical company that produces abortion pills.

    Rees Mogg’s desire to deny women any rights to legal abortion is a minority one in Britain. Here a clear majority, 70 percent in the most recent British Attitudes Survey, support a woman’s right to choose. But there is no room for complacency when women in one part of the UK, Northern Ireland, have no right to abortion unless they travel to Britain. The 1967 Act was never extended to Northern Ireland and thousands of women needing an abortion have had to cross the Irish Sea to access a legal termination. As an added injustice, until recently they also had to pay for it. This was only overturned in June after the snap general election when the Tories courted the anti abortion Democratic Unionist Party for support to win the Queens Speech. The ensuing outcry forced Theresa May to ditch the requirement for women from Northern Ireland to pay for terminations.

    Today the increasing vocal pro-choice side is highlighting the plight of women living in countries where abortion is banned, including on both sides of the Irish border. In the Republic of Ireland more than 40,000 people poured through the streets of Dublin on Saturday for the sixth annual March for Choice to demand a repeal of the eighth amendment to Ireland’s constitution. This amendment deems the rights of an embryo equal to those of the woman carrying it, at any stage of the pregnancy. This law against abortion doesn’t stop abortions happening, it simply exports them. Thousands of women are forced to travel to England to enable them to take control their own fertility. Over 200,000 women have travelled to Britain from Ireland to have an abortion since the 8th amendment was enacted in 1983.

    After last year’s March for Choice, the Irish government handed the issue to a Citizens’ Assembly to examine and debate. The Assembly came out with a clear call for a change in the law, showing just how much attitudes are changing in Ireland. Last week the government finally announced it would hold a referendum on the question in 2018. This provides opportunity to overturn more than a century of anti-abortion legislation in the country, which up to 2013 included the 1861 Offences Against the Person act. This archaic law is still in place in Britain and it makes having or carrying out an abortion a criminal act punishable by life imprisonment. The 1967 Abortion Act did not replace this act, instead it created exceptions to allow legal abortions when certain conditions are fulfilled.

    Even 50 years ago these conditions were restrictive, now when the majority of abortions are carried out by taking pills they are an oppressive anachronism. The website Women on Web reported that they receive requests from women living in Britain for abortion pills because access to abortion services is limited by the requirements of the law. The reasons women gave for contacting the website included the distance from a clinic providing abortion care, long waiting times, childcare responsibilities and the difficulty of getting time off work. But any woman in Britain who uses pills bought online potentially risks a prison sentence because of the strict controls over how abortion services are provided.

    This is a situation that cannot hold. The Royal College of Obstetricians and Gynaecologists joined the British Medical Association and the Royal College of Midwives last week in calling for abortion in Britain to finally be removed from criminal law and be treated as simply a medical issue.

    Repressive laws and attitudes to women’s rights to control their own bodies are being challenged across the globe. While online access to sites such as Women on Web saves lives, millions have no access even to this service. The World Health Organisation estimates that 25 million abortions globally are unsafe, that’s almost a half of all terminations.

    In Britain the fight is on to defend the rights won by past generations but to also extend those rights to allow genuine reproductive choices. Whatever the utterances of anti abortion campaigners such as Rees Mogg, pro-choice activists are on the march and determined to win the long-running abortion wars.

    First published on the Policy Press blog

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    A new study of people attending abortion clinics finds that the presence of anti-abortion activists outside these clinics represents a significant source of distress for women seeking an abortion – even where the conduct of anti-abortion activists is itself peaceful and polite.

    The study, carried out by Dr Graeme Hayes and Dr Pam Lowe of Aston University, analyses comments made to the British Pregnancy Advisory Service (BPAS) by patients of their clinics between 2011 and April this year. It concludes that even where activists are peaceful and polite, the impact this has on those attending the clinics is significant.

    The study included analysis of more than two hundred separate user comments, across eleven clinics, and the findings were clear: a quarter of users made direct reference to the site of protests, and the same number said they felt clinic entrances were an inappropriate place for such actions.

    Dr Lowe, Senior Lecturer in Sociology at Aston University, commented:

    “It’s clear from the comments BPAS has received that some women find the decision to seek an abortion hard enough as it is, without the added stress of anti-abortion activists present outside clinics. The location of activists was a common theme in the responses we analysed, more so than the conduct of the activists themselves. The women felt that this was an unwarranted intrusion into a private decision and they were uncertain about the intentions of the anti-abortion activists.

    The study found users were conscious of the right of anti-abortion activists to express their views, but believed these rights ought to be balanced with the intimidating nature of their presence outside clinics – with presence rather than conduct the key factor for them. Even when perfectly lawful, the presence of anti-abortion activists can still cause alarm and distress.”

    Dr Hayes, Reader in Political Sociology at Aston University, added:

    “The rights to free assembly and free speech are a vital part of our society, and as we report in our study, the comments made by BPAS clinic users show that they are keenly aware of this. However, at the same time, they also feel their own rights to privacy and confidentiality in their healthcare decisions must be protected.

    “Actions outside clinics draw a great deal of public attention to what is a private healthcare decision. For individual women seeking to use clinic services, this is in itself a significant cause of emotional distress. As our report shows, many feel harassed. More widely, these actions put additional pressures on the delivery of public services. Our findings clearly illustrate the issue needs revisiting to ensure a fair balance is struck between competing rights.”

    In November 2014, BPAS launched the Back Off campaign to prohibit anti-abortion actions directly outside clinics. The campaign aims to reduce the distress of service users, uphold the right of healthcare privacy, and reduce the costs associated with the public policing of abortion clinics.

    A full copy of the study is available on the Aston University website:​

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    Over the last two years I have been part of a small team of maternity professionals contacting and visiting pregnant women who were being held in Yarl’s Wood Immigration Detention Centre in Bedford. We volunteer for a charity called Medical Justice, which aims to defend and promote the health rights, and associated legal rights, of immigration detainees in the UK. Medical Justice advocates for many vulnerable patients but, as midwives, we were assessing and providing medical reports just for pregnant women.

    Being a midwife is a huge part of my identity, my purpose and passion in life. I have worked for the NHS, volunteered for midwifery and mother’s groups and worked as a midwife in Malawi for a while. The stories of the women I met in Yarl’s Wood had the most profound effect on me. To offer what expertise and support 1 could was immensely rewarding, but the circumstances in which they were put were without a doubt the most shocking thing I have seen in my career,. All the more shocking is that this is happening in the UK, here, within our own health service.

    The Centre is very like a prison, with tough security, locked door after locked door, isolation rooms and control over access to food and other basics of life. Because of their histories, most of the mothers we met were very vulnerable even before their detention. Sometimes the reasons they came to the UK (fleeing gender based violence for instance) made their pregnancies more fragile and worsened their mental health. Others had pre-existing health problems and complicated obstetric histories. 1 performed a review of cases for a nine-month period in 2013/2014, which comprised of all 21 pregnant women seen by Medical Justice during that period. There is no official record of how many pregnant women are detained, so we do not know what proportion of the total number of detained pregnant women that this review contained.

    I estimated that, compared to the urban multi-ethnic trust population in which I worked, the women seen by Medical Justice in immigration detention in the above review were around seven times more likely to have  ‘high risk’ pregnancies – that is pregnancies that we would typically refer for obstetric led care and multi-professional support (such as psychiatric assessment). Additionally, of course, disruption in antenatal care and being an asylum seeker in the first place would promote most of us to seek further specialist support for these women. The NICE (2010) guidelines clearly state that ‘Recent arrival in the UK’ ,’asylum seeker or refugee status’ and ‘difficulty speaking or understanding English’ are examples of ‘complex social factors’ which require more intensive support and care. Furthermore, the CMACE Report of 201 I finds that continuity of care is particularly important in asylum seeking women, due to their increased vulnerability.

    In short, these women were extremely vulnerable and often unwell. They showed remarkable courage and strength in the face of extreme adversity, but there is no doubt in my mind that the health, both mental and physical, of the women I met was worsened by detention.

    Immigration detention was created to be a short term ‘holding’ place for people who were to be immediately deported. In the review of cases above, I found that the mean length of detention of the pregnant women seen by Medical Justice was 50 days. The range was 10-122 days. All of the women in the review were eventually released by about 30 week; of pregnancy and none were deported until after the birth of their babies, or were not subsequently deported at all as their asylum claims were eventually accepted. Many of them were ‘not fit to fly’ which means that they did not meet the standard international aviation criteria for health and would not be allowed to board a plane during their pregnancies. Furthermore, it is not now legal for immigration personnel to use physical force to make a woman leave the Centre and board the plane, so if a woman refuses to go, there is no way of making her do so.

    Yarl’s Wood has a small health care unit, staffed 24 hours by nurses (not midwives) and managers, with a GP in attendance on most working days. The unit is run by a private healthcare company, but of course all of the clinical staff are registered with the relevant professional bodies. Sometimes the pregnant women I met with would be given kind and compassionate care. However, all too often a culture of disbelief seemed to prevail which, coupled with a lack of midwifery/ obstetric specialism, led to many worrying symptoms and alarming risk factors being dismissed by the staff. For example, I saw a case in which it seemed not to be recognised that the limits of normal blood pressure are different in pregnancy than in the non-pregnant woman.

    My major concern for these women was the denial of emergency assessment and treatment and delays in allowing women access to acute obstetric care. Cases that you or I would have immediately referred into hospital were left for days, sometimes weeks, with worrying symptoms ignored, or attributed to ‘attention seeking’. Once, a woman I was very concerned about, called herself an ambulance, as she was afraid for her health and for her baby, after several weeks of increasingly severe symptoms. The ambulance was cancelled by the health care staff, without her consent.

    The mothers I met told me of the extreme discomfort of being in the Detention Centre whilst pregnant. Most did not find the food palatable and the restrictions on when and what they were able to eat worsened pregnancy related sickness for many of them. Several also told me how frightened they were by the guards, and by a lack of privacy in the Detention Centre leading to sometimes feeling exposed and ashamed.

    As above, we do not know how many pregnant women are in Yarl’s Wood Immigration Detention Centre, though we suspect, from very rough estimates based on what women inside are able to tell us, that it is not a very large number. The pregnant women that we saw were not deported during their pregnancies due to health concerns, and were released without deportation making their detention pointless. In addition, the immense physical and mental stress of being in a detention centre had a negative impact on many of their pregnancies, not least because of the disruption to their pregnancy care and lack of access to emergency assessment and treatment. Detention is damaging for these mothers. It doesn’t really matter what you think about immigration. Perhaps you are in favour of tougher screening for asylum seekers and further limits in the number of migrants given permission to stay in the UK, or perhaps you have more lenient views. Either way you would realise that there will always be a process to follow to assess claims for asylum and immigration. Most people would be of the opinion that such a process should be fair (everyone gets treated the same), reliable (we are able to usually tell who is genuinely in need of asylum) and humane.

    Most people would also add that it should be efficient – at the lowest possible cost to the taxpayer.

    The detention of pregnant women is none of these things. The cost to their wellbeing is disproportionate because of their greater health needs .Their ability to cope is reduced by the normal but difficult symptoms of pregnancy and further by their higher risk of serious pregnancy complications; they are vulnerable. Furthermore, as deportation is more difficult when a woman is pregnant, because of airlines’ health related restrictions and because the immigration personnel are not allowed to use physical force on a pregnant mother, it becomes pointless. The high cost of keeping a woman in detention, potentially causing her and her baby to suffer, only to release her without deportation, is to needlessly spend money.

    I am first and foremost a midwife. My commitment to the NMC Code of Conduct (2015), as the bedrock of my professional integrity, is true no matter where a woman comes from, no matter where she is living or who is master of her. Whilst these vulnerable women are in the UK, their care must be held to the same standard that we pride ourselves on in our daily practices. I have reported my concerns through our supervisory system but since the women are almost ‘outside’ of midwifery, and can’t access midwifery care by themselves, it is hard to see what can change whilst they are still detained. The NMC Code states that we must:

    • Make the care of people your first concern, treating them as individuals and respecting their dignity
    • Work with others to protect and promote the health and wellbeing of those in your care, their families and carers, and the wider community
    • Provide a high standard of practice and care at all times

    (NMC Code 2015)

    This is demonstrably not always the case for the women we have met in Yarl’s Wood, and this has to change.

    How you can help

    • Become a midwife-volunteer for Medical Justice (see below or contact me)

    Donate to Medical Justice

    • Write to or email your MP with your concerns

    References and Links

    Centre for Maternal and Child Enquiries (CMACE) Saving Mother’s Lives: 2006-08. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom.BJOG, I 18 (suppl. I) 1-203.

    National Institute of Clinical Excellence (2010) Pregnancy and Complex Social Factors. London, NICE Guidelines.

    Nursing and Midwifery Council (2015) The Code. HMSO, London.

    Public Health England (2013) Guidelines for Malaria Prevention in Travellers from the UK. PHE publications gateway number: 2013054. London, HMSO.

    Medical Justice APPG 2015 report on detention and Expecting Change can also be found on their website.

    Tsangarides, N.,Jane Grant, J. (2013) Expecting Change, the case for ending the detention of pregnant women. Medical Justice, London.

    First published in Midwifery Matters ISSUE 145 Summer 2015

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    Is it different from England?

    Over many years I have found myself popping up in meetings in England and arguing that things are done differently in the NHS in Wales, and feeling a bit like Pollyanna.  So following much hostile criticism in the press and House of Commons over the past few months, I feel that I have to justify my case about the Welsh NHS and apply that to our maternity services.

    First of all, the health system in a devolved nation where the provisions of the Health and Social Care Act do not apply is now very different. In contrast to England, where the Health Secretary now has no responsibility to secure a comprehensive health service, there is one minister with overall responsibility for both the NHS and Social Services, (currently Mark Drakeford, a professor of social work, experienced in government and described by senior civil servants as clear and decisive). There are also Local Health Boards, (LHBs), and the role of the Chief Medical Officer is still a powerful one and, importantly, there is no split between purchaser and provider. The Assembly government and, it seems to me overwhelmingly, the public, believe that public services should be centrally coordinated, and planned towards shared social goals. If a local hospital is performing badly, and of course some do, people in Wales expect state action to improve it and do not want (especially in rural areas) to exercise personal choice to go to a competing hospital elsewhere

    Shared responsibility for both NHS and Social Services through LHBs has made it far easier to deliver integrated services.  David Sissling, chief executive of NHS Wales and director general of health and social services, said of LHBs, ‘They don’t have any allegiance to hospital-bed care and you can think about designing a care pathway without having to think about it in terms of transactions that bring two or three different organisations into the equation’ . Interestingly in May 2013, NHS England announced its intention to integrate all NHS and social care services by 2018, without any mention of the fact that Wales was already doing this.

    I won’t attempt to say whether patient care and outcomes are broadly better in Wales.  This is impossible to do and the argument has now become a political football, but the independent Nuffield review this year suggested that outcomes were broadly similar. Of course there is plenty of genuinely bad news about health in Wales, and some (though much less) good news about health care in Wales. The Welsh have been poorer and sicker than the English for at least 300 years. They have more of the principal causes of ill health and premature death: more heavy industry, more unemployment, and lower average earnings, and money is a major issue. Most people agree that Wales has been underfunded for years under the Barnett formula, which is the method for working out how much of the ‘tax take’ will be returned to Wales and Scotland: the NHS takes 40% of this block grant: there is a spend per patient of £1900 compared to the best comparator in terms of ‘need’, which is the North East of England, which receives  £2100, 10% more.

    All of this applies to maternity: ‘the overarching principles in a National Health Service that is cash strapped are first to do no harm, use evidence based treatments and co-produce‘ [users of the service must be integrally involved in the the design and delivery of the service], (Jones Chris, Deputy Chief Medical Officer Welsh Government. Policy Forum for Wales Keynote Seminar June 10th 2014.). All of these absolutely apply to maternity particularly after the draft NICE intrapartum guidelines of June 2014, which recognise the need to reduce medical intervention in birth.

    The underlying commitment is to an integrated service, which, with all of its faults and shortcomings, can feel very enabling in such a small country. Good leadership is possible, in a situation where Heads of Midwifery can and do meet regularly, and in turn meet with public health practitioners and obstetricians: vision and agreement can potentially be achieved.

    Shortages of midwives have never been quite so damaging as in some parts of England: the Assembly government ensures that the whole of Wales is birth-rate plus compliant, but despite that there is no spare capacity and midwives are, in my view often overstretched. As a result there is little room for initiatives involving training the workforce, although some initiatives can be implemented. ‘Future proofing of supervision’, for example, is the Welsh attempt to improve and safeguard midwifery supervision by employing fulltime supervisors of midwives who were appointed in early 2014.  Like everywhere else in the UK there is much reduced antenatal education and postnatal care, but still on average 3 postnatal visits from a midwife compared to 1 in London.

    There are huge on-going problems, for instance, of data collection where sometimes not enough is collected, or what is available is not helpful, patient episode data are not appropriate for maternity; provision of specialist services in the rural north and west is difficult and expensive but also dealing with a population comparatively poor, and suffering from the problems that arise from that, including complications of smoking, obesity and malnourishment, has its own challenges for midwives.

    Nevertheless there is much optimism and commitment to women within midwifery and one of the first demarcating moves by the new devolved government was to set a 10% target for home birth in Wales to be met by 2009, before the Birthplace Study, and well before the new NICE draft guidelines and this, I think, showed the clear commitment to a belief in normal birth. The target was missed by a long way but the rise in home birth was for a considerable time the fastest in the UK and it served to change the culture to some extent. Quietly, and often in rural areas midwives have found ways to provide quality woman-centred care.

    In June 2010 I visited the Glan-y-mor team, in the quiet seaside town of Porthcawl. This is a long established team with a marvellous local record, which included a home birth rate of 25%: despite radical reorganisation they had managed to retain a working environment that they felt was successful in giving women what they needed, while safeguarding their own family life. They did this by working hard to support one another with some stunning examples of high morale and loyalty in the team. They asserted that flexibility is the key, and they described sharing the ‘same brain’ that is decision-making, accomplished often by phone calls from the bath at home when they were feeling creative.

    We’re there to promote the best care for women in what could be the best or the worst experience of their lives, we don’t know in advance what the outcome will be’, This is a group practice characterised by continuity, knowing the women and supporting them. Parents in Partnership was a new project of theirs, whereby 80 local mothers had recently been peer support trained for breastfeeding; covering preconception, diet, contraception, obesity and weaning.

    Midwives in the team are socially close:  they often go walking together; for many years, they have cooperated by picking up each other’s children and now they are repeating that with their grandchildren.

    There are other examples across Wales, the West has taken pride in its high home birth rate and the large, sparsely populated county of Powys has for many years had no obstetric unit – so women have birthed at home or in tiny Midwife Led Units and considered it the norm. In Cardiff, a dedicated home birth team was set up at the end of 2013 with the aim of raising the rate from only around 1% to 3% within the year.

    Things are not rosy in Wales but a commitment to a communitarian philosophy with pooling of risk to protect the vulnerable means that for the moment at least it feels as if shared action for the common good is possible. Over 30 years ago, Welsh Valleys GP Julian Tudor-Hart, saw that areas of social deprivation, containing high proportions of people from lower social groups, tend to have access to less good health services, even though their need for such services is greater than that of higher groups. His conclusion was summed up in the ‘Inverse Care Law’, which states that: ‘The availability of good medical care tends to vary inversely with the need of the population served.’ . The Welsh Government is battling against the UK and European trend to reduce universal care, a trend that results in targeted facilities for some groups and a two-tier health service. Instead the driving force underlying policy is to remember that health inequalities are not simply, or even mainly due to failings in the Health Service, nor individual failings, but rooted in poverty and inequality in material wellbeing, and create a politics that can counter the inverse care law.

    This article first  appeared in the AIMS Journal Vol:26 No: 3 2014 and is reprinted with the permission of the Association for Improvements in the Maternity Services.

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