- 2 days ago
Thank you so much to everyone who attended our Webinar: 'End Coercion in Maternity Care in the UK'. There were some incredibly fruitful discussions and invaluable insights. Special shoutout to our super panel Hazel Williams, Laura Mullarkey, Leah Hazard, Amisha Abeyawardene and our fabulous chair and trustee Dr Annabel Sowemimo.
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LearningTranscript
00:00:00CEO, our own wonderful CEO, Hazel Williams, who recently joined Birthrights in November
00:00:122025, previously being Director of Justice Together, where she led a national program
00:00:19to improve anti-racist practice in the migration sector and expand access to justice for people
00:00:26navigating the immigration system. Hazel has also contributed in a voluntary capacity as co-director
00:00:33and elder at Jewelers Without Borders and is a trained birth dealer, so very welcome experience
00:00:39here at Birthrights. We also have on the panel Birthrights legal lead, Laura Malarkey. Laura is
00:00:46a senior lawyer who's spent 14 years working in corporate law in top global law firms. Throughout
00:00:52her career, she has acted on many human rights matters pro bono, focusing on women's and
00:00:57LGBTQ plus rights issues. So very appreciative for Laura's time this evening. We also have
00:01:07the wonderful midwife and author who has been in the media a lot lately, who wrote the forward
00:01:14to this report, Leah Hazard. Leah's an NHS midwife, best-selling author, activist, who is passionate
00:01:22about bringing midwifery and reproductive health into the public eye. And her next book, Birth Wars,
00:01:28will be published early next year. She also wrote The Phenomenal Womb, which is one of my favourite books.
00:01:34So definitely read that before we read Birth Wars. And last but by no means least, we're joined by the
00:01:44amazing Birthrights training coordinator and doula Amisha Abbe-Wardina, as well as her role as the
00:01:52training coordinator. Amisha is also a doula based in London, who is passionate about providing
00:01:59individualised and trauma-informed support to those most marginalised by healthcare systems,
00:02:04especially queer and trans black and brown people. Also very much encouraged by Amisha's amazing
00:02:13work in this sector, which is deeply, deeply needed. There seems to be some background noise. I'm not
00:02:20sure where that's coming from, but hopefully not causing too much disturbance. So just some brief
00:02:25housekeeping. You already probably had the Zoom record, and so we are going to record the webinar
00:02:32for those that aren't able to...
00:02:52Yeah, Annabelle, sorry, I don't think we can hear you. Somehow the microphone's just muted.
00:03:02Oh dear, always a technical problem.
00:03:16Annabelle, I think your mic is muted.
00:03:21Seems like she can't hear us.
00:03:23No, it seems like she can't hear us either, doesn't it? Is everybody else having the same
00:03:27problem that it sounds like Ruth and I are having. Annabelle, I think your mic is muted.
00:03:36We can't hear you.
00:03:39Yes, Annabelle, sorry, your sound cut off about a minute ago, so we missed the last minute or so
00:03:44of what you were saying. I don't know if you're able to come off mute and say the last bit
00:03:49again.
00:03:55Hello?
00:03:56Oh yes, you're back with us.
00:03:58I'm so sorry, I just went through my spiel and I've realised my sound. Potentially did it cut off at
00:04:03some point?
00:04:04It did, about a minute or so I would say of you talking, and we could see your lips moving,
00:04:09but I'm afraid we couldn't hear what you were saying.
00:04:11Oh no, technology fails us. Okay, in that case, where did you leave me?
00:04:19I think just as I finished, as I finished my introductions, did everyone get their phenomenal
00:04:24welcome? I think that I was just about to say, I think you had welcomed Amisha as the kind of
00:04:30last
00:04:31panellist, and then I don't know about everyone else, but I didn't hear you after that. Okay,
00:04:35that's fine. So the last bit was housekeeping, mainly. So just to say, you probably already heard
00:04:41the little sign from Zoom saying we are going to record tonight, just for people that aren't
00:04:47able to attend, and we'll share a copy round for those that signed up to Eventbrite. We are keen
00:04:52to hear your questions, so if you could keep questions until the Q&A section, that would be
00:04:57great. So if you could write them in the chat box, and then the team will be looking through and
00:05:02moderating them, and we'll find out who to address them to. Feel free to direct them to specific
00:05:08panellists, or more generally, I too will feed in my experience and answer some questions. So I'm going to hand
00:05:14over
00:05:15to our wonderful CEO, Hazel, to talk through the key reports findings, and then we'll go into a bit of
00:05:21a
00:05:21wider discussion about things. So over to you, Hazel. We'll try this for a second time.
00:05:28Thanks very much, Annabelle. I'm going to attempt to share my screen as well, which is also another
00:05:33disaster generally, isn't it? Can everyone hear me okay? Yes, we can. Super.
00:05:43And can everyone see the presentation? It just takes a while to click on.
00:05:51Yep, super. So welcome everyone. It's great to see so many faces, and on such an important
00:06:00topic as well, which affects so many women and birthing people. As Annabelle highlighted, it was
00:06:05something that was coming through our advice services very, very commonly. So my name is Hazel.
00:06:13I'm the Chief Executive Birthright, and I'm going to be talking through the report today, but also quite
00:06:18a bit around the course of action, and also the findings. And then I'll also give a little intro to
00:06:26that this is what we'll be talking about. And here's a little bit about birthrights for those
00:06:32people who don't know us. So we are the leading human rights charity for birthing, and we run a new
00:06:39Sorry to interrupt you, Hazel. We have not got you in screen share mode currently.
00:06:46Okay. So you're in, we're not in slideshow.
00:06:51Okay. Can you not see the slides?
00:06:53We can, but we can see your whole screen. We can't see them moving forward either, I think.
00:07:00Ah, okay. Right, let me stop for a minute.
00:07:09I've also got a horrible man, you know, when you can hear yourself twice.
00:07:15I'll tell you what, just, I'll try and show this way, see if that helps at all.
00:07:25Have a much look today over here.
00:07:33Voila, see if that looks better.
00:07:41Okay. What can you see from here?
00:07:47Can you see this one?
00:07:49Yes, that's better, thank you.
00:07:51Yes, okay.
00:07:51Yes.
00:07:52So we run advice and resources as we've got a service for healthcare professionals and women
00:07:59and birthing people to ask for information about their human rights in maternity care.
00:08:04We also run training and education, so that's primarily for healthcare professionals, but we're
00:08:10currently exploring more community-based training. And then the last one is why you're here today,
00:08:15which is we use all our kind of evidence and resources to research and campaign to influence
00:08:22changes in maternity care and policy. So why we're here today is the end coercive practices report,
00:08:30and the information for that came from around 300 people that shared our experiences of coercion with
00:08:37us, and that was through two online surveys. We also kind of went for all our information and advice
00:08:43service cases and our training activities and kind of gathered case studies and examples from there.
00:08:49We did a number of in-depth interviews where we got more detailed kind of information about what
00:08:54people are experiencing, as well as a number of kind of consultations with community groups.
00:09:02So coercion is quite a loaded word, I would say, you know, it talks to my family about it and
00:09:08we don't
00:09:08quite understand how it relates to maternity care. Well, exactly for the reason that it shouldn't
00:09:13relate to maternity care. But here are some of the kind of key themes that were coming out from the
00:09:19research about what coercion looks like and what it means to people who are experiencing it and feel
00:09:25like they're experiencing it in maternity care. So there's a few different themes. There's ones around
00:09:30language, you know, being told you're not allowed. And there's ones around information,
00:09:35so giving misleading information or having information withhold from you about what's
00:09:40happening during your birth. Also being, we've heard a lot about people being labelled kind of out
00:09:45with guidance and having their choices dismissed through that as well, or being put under pressure
00:09:51to undergo certain different things they didn't want to, such as vaginal examinations came up a lot.
00:09:57So that's a bit of an overview. So I'm going to talk now about the key findings.
00:10:02So the first key finding was around structural racism and discrimination in maternity care.
00:10:08So this came out really, really strongly and also mirrors what we found in our systemic racism not
00:10:14broken bodies report. So we found that black, brown, migrant and transgender communities particularly
00:10:20targeted for referrals. So I'll talk about that a bit later about kind of children's services,
00:10:26referrals, capacity assessments, and even in some instances police as well.
00:10:31We also found a lot of racialised risk profiling. So this is a quote from somebody who responded to our
00:10:39survey. And it really outlines that kind of this lady's Asian and she's been very much profiled as
00:10:46being having a baby's too big, therefore she must have gestational diabetes. And that kind of led
00:10:51down the pathway for induction, which she wasn't consenting to. So this was kind of an example that
00:10:58mirrored other examples that were coming up in the research as well.
00:11:07So overarching across all the research, we found that there was widespread use of coercive practices.
00:11:13Now they were mostly verbal, but we also had examples of physical.
00:11:18And they, you know, as I said, there's like all the different types that can be done and they came
00:11:22out very, very strongly in the survey. So 90% of respondents reported that they were not provided
00:11:29with all the information they needed before making a decision about their care.
00:11:3581% of people were told they just weren't allowed to make a particular choice.
00:11:40And similarly, 81% reported that their birth was described and recorded as out of guidance,
00:11:47but really it was just their personalised needs and choices that were being made.
00:11:51So that came out very, very strongly across the board.
00:11:56And here are some more practical examples of what people were coming back with.
00:12:01So often we heard about people not consenting to a vaginal exam, but then being told,
00:12:06well, we can't care for you if you don't consent to it.
00:12:11This quote about the C-section, I think tells us quite a lot, you know, being told, well,
00:12:16you can choose to do it now or you can leave it a couple of hours and we're going to
00:12:20do it anyway.
00:12:21You know, that's very much feeling like, you know, it's very much coercion.
00:12:26And then the one that comes up very commonly is around being told, well, you know, if you do that,
00:12:32you'll be killing your baby, that came up time and time again.
00:12:36So it wasn't just women and birthing people that was telling us about coercion.
00:12:40The healthcare professionals that responded to the survey had lots and lots of examples, very similar.
00:12:46You know, they were just reporting on what they were saying as well.
00:12:50And I think here's a couple of quotes that I picked out that kind of highlighted that.
00:12:54Definitely the one around people feeling, witnessing, forced into kind of vaginal examinations.
00:13:02And then this one about not really having choice.
00:13:05You know, people are kind of language that's often used to scare people into.
00:13:10Again, induction came up really, really often in the examples.
00:13:19So another one was around routine and inappropriate facts of referral.
00:13:24I think the most common one that was coming up was around children's social services referrals.
00:13:29And 20% of surveys respondents talked about that.
00:13:33And it also comes up lots and lots of times within our advice service.
00:13:37So 54 cases in the last year about social services, safeguarding referrals.
00:13:43And I think, you know, we do talk about social services, safeguarding children's services,
00:13:48and it probably sounds quite confusing.
00:13:50But I think for the women and birthing people that are reporting it, it's often not clear to them,
00:13:54like, what's actually happening.
00:13:56But I think what is very clear is the absolute fear and terror that it instills in people who are
00:14:02going through pregnancy and then being told, you know, if you don't do this,
00:14:06we're going to report you because what that means often on a personal level is,
00:14:10they're going to take my baby off me.
00:14:12You know, people can spiral like that.
00:14:14And it's very, it's terrifying.
00:14:16So I think, you know, the language might not appear correct always,
00:14:19but it's because people don't understand.
00:14:21And it's the fear that instills, which is so important.
00:14:25So here's a couple of examples from people who responded to our survey.
00:14:29So here's one.
00:14:30I was told I had time for the antibiotics or else I would report to social services
00:14:35and police would step in after.
00:14:38And then there's another lady who's had three of my pregnancies and births,
00:14:42despite asking and being very clear.
00:14:44She was ignored in front of social services as well.
00:14:48So again, it's people who were, and that came out quite strongly with
00:14:52in the racialized element as well.
00:14:54We found that more black and brown women were being reported as well,
00:14:58or threatened with being reported.
00:15:02So last finding, but not least.
00:15:04So a lot of healthcare professionals spoke to us through the survey,
00:15:08but also for our training as well.
00:15:10We speak to a lot of healthcare professionals.
00:15:12And I think the thing that comes up really strongly is this kind of fear
00:15:16of reporting what they're seeing.
00:15:18So they're in a very pressurized environment and they're under, you know,
00:15:24a lot of pressure in terms of what they're able to work with women and birthing people.
00:15:28But then they're also under this kind of regulatory threat of consequences if they do that.
00:15:34So this quote kind of demonstrates that it was a healthcare professional who was sticking up for
00:15:39their values, what they believed in.
00:15:42The trust didn't like that and referred them to NMC who said, you know,
00:15:47said there was no, it upheld it and said it was totally unfounded.
00:15:50But then the trust weren't kind of held to account for that.
00:15:53And it's the knock on effect of what they'll have on that individual,
00:15:56but also their colleagues as well.
00:16:01Here's a couple more.
00:16:02So it's not just about us blaming individual healthcare professionals.
00:16:07It's absolutely not that. What the research has shown is the kind of systemic problem
00:16:12and also the structural failures that lead to coercion.
00:16:16So people not having enough time to spend with women and birthing people to explain
00:16:22all the kind of options and enabling people to make that informed choice.
00:16:28This also came up quite strongly about this risk of losing your jobs,
00:16:33especially in areas where there's quite a lot of competition for jobs.
00:16:36So people feel more into that kind of pressure.
00:16:39Here's a couple of examples of what newly qualified midwives have been saying,
00:16:45you know, they're underfunded, undervalued, they're not other structural value problems
00:16:50around training, like not seeing enough home births, not having that expertise,
00:16:54or being exposed to that expertise for different choices.
00:17:01What good looks like? Yeah, I do want to reiterate, it is really negative of a lot of the research,
00:17:07but we did, throughout all our work, we see some excellent practice in terms of human rights,
00:17:13respect and care, and to really listening to women and birthing people, and to making like all those
00:17:18adjustments and additional support to ensure people can have the births that they want.
00:17:24We do see lots of that happening, so I just want to, I guess, reassure people that there are some
00:17:28excellent pockets of good practice out there. So this is consultant midwife and academic doctor,
00:17:34Anna Madley, and she did a piece of research around this, and she kind of reiterates that,
00:17:39that she has seen pockets of excellence in non-coercive practice.
00:17:42And it's really those things around taking the time and space to help people make decisions,
00:17:49working with the teams and having a degree of preparedness. We've heard that a lot, you know,
00:17:54people maybe feel nervous about a choice, but how can we, how can healthcare professionals
00:17:59kind of train themselves up, have kind of additional support to facilitate those.
00:18:05So I'm going to end now on our calls to action. So there's lots in there, there's lots that was
00:18:12reported to us. And it came up again and again from healthcare professionals was to have a better
00:18:19understanding of like human rights, respect and care. But also it came up, you know, how can we expect
00:18:25staff who aren't treated with respect to always provide empathetic care. So really that fourth
00:18:31call to action around ensuring safe staffing and safe working environments, which I know Les
00:18:37has been working on as well, is really important for us as well. And also this thing around ensuring
00:18:45that there's proper safeguards in place against commercial practices, and of course ending racialized
00:18:50and discriminating practices, including the disproportionate social services referrals,
00:18:56something really needs to be done about kind of making sure those policies are in place and that
00:19:01people are achieving to them and they're not kind of unnecessary in terms of the referrals,
00:19:06given the fear that they can cause for women and birthing people. So a lot of our calls to actions
00:19:11are kind of aimed at trusts and ICBs. And then at the government, you know, we're asking for more
00:19:17ring-fence funding for safe staffing and to end NHS charging rules for groups of migrants that are
00:19:24subject to that. So I think that's probably me. I'm just going to say like, you know, a huge thank
00:19:31you
00:19:31for highlighting an issue that we really wish we didn't have to. And we want to bring it to an
00:19:36end
00:19:36and we'd really want everyone's help for that. And I'm going to pass over to Laura now, who'll give us
00:19:43some more legal context, including explaining what the law requires to satisfy informed consent.
00:19:50So Laura, do you want me just to do your slides for you?
00:19:54Thank you, Hazel. Yeah, that would be great. And don't worry, everyone, I promise I'm not going to
00:20:01bore everyone and give chapter and verse on all the legal detail, but we thought it might be helpful.
00:20:06Just to do a kind of very brief recap on what the law requires in this area, because actually the
00:20:12legal standard is quite clear. And so actually, that's another reason I think why the extent of
00:20:19coercion that is shown in the report is so concerning. So what the case law following Montgomery and
00:20:31subsequent cases tells us in no onset in terms is that the decision maker about who decides for what
00:20:41care or treatment is accepted or not in maternity, as in all aspects of medical care, it is the pregnant
00:20:52woman or person themselves, they are the decision maker. Of course, there are kind of there's a narrow
00:20:59range of exceptions to this. So where somebody doesn't have capacity, for example, because
00:21:04they are unconscious at the time, a decision needs to be made. But, you know, broadly, most of the time,
00:21:10most of what we're talking about in maternity is not those esoteric situations. So really, we should
00:21:18all be very used now to the idea that the pregnant woman or person is the decision maker
00:21:24for decisions in maternity care. What is also really clear in law is that the requirement on healthcare
00:21:34professionals, therefore, is to offer a personalised dialogue to support that service user. And that
00:21:44dialogue should address the material benefits and risks of the recommended treatment or care option.
00:21:53And it should also address the material benefits and risks of all reasonable alternative options.
00:22:01That is intended to be a dynamic dialogue that takes into account both what a reasonable person in the
00:22:10particular service users shoes would be expected to find helpful, but also,
00:22:16we really need to take into account here what the particular service user would find helpful and is
00:22:23important to them in their scenario. So that's why, you know, having that real space and time
00:22:29for dialogue is a real non negotiable as a matter of meeting that legal standard.
00:22:36What is also absolutely imperative in all of that discussion is making sure that the service user
00:22:43understands what is being discussed. So there's no point having a really detailed discussion if
00:22:49actually none of it is, you know, using either the language that a service user speaks or language
00:22:56that practically they can understand and you know, taking into account the fact that different people
00:23:01process information and in different ways. And so for some people, having time to reflect receiving
00:23:07information that is an additional support, you know, in written form might be helpful. That's not at all to
00:23:16say that written information should be an alternative to the dialogue, the dialogue remains important as a
00:23:21way for the healthcare practitioner to ascertain and, you know, gain information from the service
00:23:29user as to what's important to them. But it might be a good way. It may be a good decision
00:23:34aid as well. So
00:23:37understanding is absolutely critical. But the final limb and you know, it comes as no surprise that this is
00:23:42the focus here today is that this, you know, what we call informed decision making under the law, what
00:23:49that what that requires is that all of this is all very well, but if it's all undermined by coercion,
00:23:56if
00:23:57it's all undermined by the fact that ultimately, the service user is being pushed very clearly, either through
00:24:03the information being provided or omitted, or through threats, or through being told certain options aren't
00:24:12available to make one particular choice, then that is coercion that under undermines informed decision
00:24:20making. And I think one of the points we made in the report is that it's ironic that so often,
00:24:27the
00:24:28reason that coercion seems to occur is because people are concerned about kind of regulatory or other
00:24:37consequences that might flow from somebody making the wrong decision. But in reality, the legal risk
00:24:43is caused by the coercive practice, not the supporting of an individualized choice, even if that
00:24:51choice might be out of guidance, or considered risky from a kind of clinically and medical perspective.
00:24:59I don't want to take up much more of your time. But but Hazel, if you could just move on
00:25:03to the
00:25:03second slide, I just think one other thing that's helpful, sorry, I think you have to click through
00:25:08all the options. I don't know why it does this. But I just wanted to kind of flag some, some
00:25:16examples
00:25:16of what coercive language can look and sound like what we would recognise you from it from a legal
00:25:21perspective as feeling like coercion. Many of those Hazel has already mentioned.
00:25:30Maybe a couple that haven't, we'll discuss it again, when you're 37 weeks, or you know,
00:25:35later on in your pregnancy, that sort of delays that that sort of shutting down of a conversation
00:25:39that somebody wants to have, and saying, Oh, well, you, you need to have that later on.
00:25:45And then by the time it's later on, then saying, Oh, but actually, now it's too late,
00:25:49you can't, we can't put you onto that pathway, because we've run out of time, or you haven't
00:25:52had a home birth risk assessment, you know, that's something we see commonly, unfortunately,
00:25:56and that's not acceptable, or saying, alternatively saying, if you're if you make that choice,
00:26:02you know, you now have to have for further conversations. You know, that that equally
00:26:08is very coercive. And the other type of like framing of, you know, if x thing hasn't happened
00:26:14by y date, then we will do, you know, this idea that there's no optionality for the person
00:26:21that should be the decision maker, it is also really problematic. And then I think that that
00:26:28sort of text on the right really highlights, you know, that we really do want to encourage the good
00:26:36here and the good practice. And here are some examples of things that we see. And I think
00:26:41particularly in contexts, as Hazel has already mentioned, where, you know, staff can feel very
00:26:48much under pressure, tight, you know, it can be really hard to feel like you've got the time to
00:26:52get all the information in, there are actually still some really simple phrases that can be uttered,
00:26:58you know, right at the beginning of these conversations that do not take long, you know,
00:27:02you're in control, you're the decision maker here, whatever you decide, we will support you.
00:27:08It doesn't take long, even in a very short time period to really try to reset the power imbalance
00:27:14that we unfortunately know exists, you know, within the most maternity service appointments,
00:27:21just by nature of the system, and not due to individual healthcare practitioner faults. So,
00:27:27you know, those kind of really empowering phrases can be so helpful.
00:27:31And I think the other, you know, equally asking really open questions, you know,
00:27:36tell me about what matters most to you? Is there anything you want to ask me?
00:27:39Again, that sort of reframing can really help to empower a really, really strong Montgomery
00:27:47compliant conversation that supports informed decision making. And I suppose the final thing I want
00:27:52to say is that the discussion never needs to include information that isn't available or doesn't
00:28:00exist. So I think sometimes people will say, well, how it feels unsatisfying, because then I'll just
00:28:07have to say to somebody, well, we don't have information for that, or, you know, we don't know,
00:28:11or the evidence is weak. But actually, that's okay. You know, what the legal standard requires is that
00:28:17we share the information that we have in a balanced, non-biased way that does not require you to
00:28:24share information that doesn't exist. It requires an open discussion. So I'm going to stop there.
00:28:31But I hope that's helpful. And I do also welcome questions in the chat as we go.
00:28:39Thank you very much for your presentation, Dora. And thank you very much, Hazel. And that was
00:28:48an amazing summary. And the report is very, very powerful. And unfortunately, the threats of social
00:28:56services and threats of poor outcomes is something that I am fortunately very familiar with hearing from
00:29:03patients. Just over 18 months ago, myself, I delivered my first child and unfortunately did
00:29:12experience a traumatic delivery. And there were elements of coercive practice involved in that
00:29:18outcome. As a consultant in sexual and reproductive health, I think it shows that, you know, nobody is
00:29:26spared. And these things unfortunately can happen to anybody. I think what comes out, and some of the
00:29:33things that you flag, particularly in your presentation, Laura, is the difficulties that arise with how
00:29:39medicine is taught in a very concrete way, and with strict pathways and guidance, and the need to document
00:29:49everything. And we're very much taught, if you don't document it as it is, it didn't happen, and that lack
00:29:57of
00:29:57flexibility. So now we're going to hear more from some healthcare providers, Leah and Amisha. I'm going to
00:30:06share some of their experiences. So I'm going to start off with Leah, if that's okay. Can you tell us
00:30:15a
00:30:15little bit about how staff experience coercive practices?
00:30:20Yeah, thanks, Annabelle. And thank you, Laura and Hazel, for your presentations, which are
00:30:25so powerful and just kind of go hand in glove with the report that's been released today.
00:30:31I'm conscious of time, so I've just made a couple of notes about how coercive practice gets embedded
00:30:37in midwifery practice from the earliest stages of training all the way through people's careers
00:30:42sometimes. And I'm sure this is maybe true for doctors as well. So when student midwives are
00:30:49training, you know, we have this expression, you can't be what you don't see. And if you're only
00:30:56ever seeing coercive practice, then you don't know that there's any other way. And as a student,
00:31:02you just automatically adopt or adapt the, you know, the manner of speaking, the language,
00:31:07the behavior that your mentors and supervisors are using around you. And you begin to think,
00:31:13okay, this is part of the culture, this is just the normal way to behave.
00:31:17Then when you qualify as a midwife, and you know, if you're hopefully a right minded person,
00:31:23and you kind of around a bit and think, okay, I'm not really happy with the coercion I'm witnessing
00:31:28amongst my colleagues, then we have what is described in the report, which can be a real
00:31:34fear of speaking up and these kind of toxic workplace cultures where if you dare to speak up
00:31:40or challenge coercive practices that you've witnessed, you might face things like being
00:31:45disciplined or just more informally being kind of ostracized, treated differently by your colleagues
00:31:50and your superiors, or other kind of like, you know, being moved to a different clinical area,
00:31:58like the ultimate punishment, or we're just going to move you, you're on the change list,
00:32:02because your face doesn't fit your behavior doesn't fit the culture anymore.
00:32:06And once you've been in that kind of system long enough, and you begin to feel the pressure of
00:32:12those constraints, you toe the line, don't you? Because you realize that the only way to
00:32:17survive in this course culture is to practice defensively and to continue to use this sort
00:32:24of language and behavior that you're witnessing other colleagues using. Now, this is all a really
00:32:29grim picture, I know, but the ultimate result is even more grim, which is when we think about retention
00:32:35of staff, you know, we often say, well, it's the good ones who leave, right? And this is what happens
00:32:42when you work in a maternity service, where coercion is the norm, and this is part of the culture,
00:32:50then ultimately, the moral injury of having to work in that system becomes too much, but it only becomes
00:32:55too much for the good ones, right? So the good ones who feel the pain of having to work that
00:33:00way,
00:33:01being expected to treat women and birthing people in that way, well, they leave, because it's too much,
00:33:06and they just can't deal with it anymore. And we see that in some of the anecdotes in the reports
00:33:10as
00:33:10well. So all of this just to illustrate that coercive practices, of course, harm the service
00:33:18user the most, but staff also feel the pressure and the consequences of this kind of culture from
00:33:24the earliest stage of their career, all the way through to the very end. And I think what was really
00:33:29powerful about your presentation, Laura, is that you've shown us sort of there is a better way,
00:33:33you know, in the language and the behaviour that we can utilise. And, you know, there is another way
00:33:38to practice, we just need to help our colleagues be more aware of that. So thanks, I'll hand it back
00:33:44to you, Annabelle. Thank you so much. And yeah, put so succinctly, and definitely there's an issue of
00:33:51kind of the socialisation process that goes on within, you know, our medical and training institutions,
00:33:58and that need to comply with what is, you know, the dominant thought processes and how hard it is
00:34:04to make your own, you know, practice that you agree with. And this is where it comes, I'd like to
00:34:11come to
00:34:12Amisha about the importance of training, and also the kind of experiences you hear about when you are
00:34:19doing training, and as your experience as a doula. Yeah, so I'm one of the training coordinators
00:34:27at Birthrights, and we do training to healthcare professionals, so anyone who's working maternity
00:34:32care, also to birthrights and dealers. Recently, we've been doing a lot of training with students
00:34:37and newly qualified midwives. So we train them to better understand human rights and maternity care,
00:34:43and how they can support rights, respect and care. We know that coercion often happens when healthcare
00:34:49professionals are stressed and burnt out. So we also explain how a human rights framework can be used
00:34:55as a tool to advocate for better working conditions for healthcare professionals.
00:35:01We know coercion invalidates consent, so we explore empowering language, as Laura described,
00:35:08so that healthcare professionals feel more confident to have conversations that facilitate
00:35:12informed consent. We also equip participants with tools to sensitively challenge workplace behaviour and
00:35:20colleagues, because often healthcare professionals might be the bystander in a situation, and how they
00:35:29can respond when these human rights breaches do occur. They're not just advocating in the moment,
00:35:36but they can also escalate and report these issues and incidents to prevent them happening in the future.
00:35:43I would also echo everything that Leah has said. So we know right now that there is a huge culture
00:35:50of fear.
00:35:51We often hear from midwives and doctors about them being fearful of losing their pin,
00:35:59and that can be one of the reasons why we see coercion, especially when women and birthing people are choosing
00:36:06decisions that go outside of guidance.
00:36:08So often they're worried if an adverse outcome did occur, that's going to fall back on me, and I'm going
00:36:17to be the one
00:36:18investigated and punished for this incident. So I've recently had conversations with students who said,
00:36:25if there's an adverse outcome at birth, when I go on my coffee break, I'm probably just going to hand
00:36:32in my pin and not qualify as a midwife,
00:36:34because I don't want to have to go through that very punitive, traumatizing investigation process.
00:36:41So yeah, that's, I would echo everything that Leah said.
00:36:48Thank you so much, Amisha. And yeah, a culture of fear is, you know, and Leah touched on it as
00:36:54well,
00:36:54is very, very hard to break, free from, and do the right thing in an environment where you feel like
00:37:03you're going to lose, lose something,
00:37:06but you know, your livelihood potentially will be ostracized. And I want to come back to you, Leah.
00:37:11You've touched upon training already, but I want to speak about it more within, I guess, this structure that exists
00:37:18in terms of medicine.
00:37:19And so I talk about medical education and things a lot. I use my own experience going into delivery, which
00:37:27was, you know,
00:37:28I said to the quite junior midwife, you know, I've assessed people before, I'm quite sure I'm in labor.
00:37:34She didn't, she wasn't quite sure. And she went off to ask, I said, don't ask your senior, essentially.
00:37:38And she asked her senior, and it was quite quiet, but she was told basically to send me home.
00:37:43And so medicine is quite hierarchical. And I wanted to get your idea of the importance of training,
00:37:50but also training the right people in terms of these structures, you know, there's,
00:37:56I would say that junior people are even probably a little bit better informed,
00:37:59but what does that look like? And what's, how, how do we train better?
00:38:03Yeah, thanks, Annabelle. It's a great question. And I'm so passionate about training the next generation
00:38:08of midwives to be, you know, informed around human rights and safe practice. And I would agree,
00:38:15actually, you know, I've had the privilege of teaching and working with lots of student midwives
00:38:19over the last kind of five, six years. And I would say they're actually much more up to speed with
00:38:24things like human rights and trauma informed care than a lot of our senior colleagues. And that's not
00:38:30to blame anyone. It's just saying that's maybe just more of kind of social awareness amongst that
00:38:34generation or just a change in the curriculum, change in training. So I would kind of flip it on its
00:38:40head
00:38:40and say, yes, as with the example you've given, it's actually now almost even more important to train
00:38:46the more senior staff because they've maybe missed out on that perspective or aren't aware of it or have
00:38:52been more institutionalized in these kind of more coercive practices. And we need to also bring that in at a
00:38:58management level. Somebody put in the chat, and we can come to this later, you know, are the powers
00:39:04that be aware of these issues? And I think they absolutely should be. So, you know, even or especially
00:39:13if management aren't on the shop floor, they need to be aware of this human rights framework so they can
00:39:19cascade these values down to the most junior member of staff. So yeah, really, that's a long way around
00:39:24of answering your question is that it really needs to be kind of embedded in every single sort of band
00:39:30of caregiver. Thank you so much for adding that personal perspective. And Misha, back to you.
00:39:39Obviously, you coordinate the training. And can you tell us a little bit more about this specific
00:39:45offering that the birthright provides? Yeah, so we offer training across the UK, mainly in England
00:39:54and Wales. We do it in person or online. As I said, for healthcare professionals to team to train
00:40:02together, we really encourage multidisciplinary training. So training where you've got obstetricians,
00:40:09anesthetists, midwives, students all in the room together, they can have those multidisciplinary
00:40:14discussions. And we go through the human rights framework, we talk about informed consent,
00:40:22and how healthcare professionals can be advocates for rights respecting care and maternity.
00:40:30Thanks so much. And lastly, just coming back to yourself, Leah, for those that are not familiar with
00:40:36Leah's work. Recently, specifically on Instagram, has been sharing a lot of the stories, so I'm getting
00:40:45a bit of echo feedback, a lot of stories for midwives and their experiences on the ward. And I think
00:40:52it's
00:40:52very easy to forget that the systems that people are working in are time pressured, they're time poor,
00:41:01and it can be challenging also as a healthcare provider to maintain kind of compassion and
00:41:08person facing care when you have all these other things going on. So you've talked about the importance
00:41:14of psychologically safe working environment. How important is that? And what does that look like?
00:41:22Yeah, I mean, I don't think we can, you know, overstate the importance of staff being psychologically
00:41:28safe. And that just means feeling able to ask questions, feeling able to challenge and explore
00:41:35different modes of care. And almost most importantly, being able to practice in a way that is in accordance
00:41:42with your deeply held beliefs around what care is and what care you would like to provide.
00:41:48You know, again, go back to this concept of moral injury. When midwives are roughed off their feet,
00:41:54don't feel safe, can't challenge practice, that can be deeply distressing. And that is one of those
00:42:02things that that prompts people to leave. So, you know, we've got a situation where staff are
00:42:11working in incredibly difficult circumstances, they are under enormous amounts of pressure.
00:42:17And although that's not at all an excuse or a justification for coercion,
00:42:23I can see how it happens, right? We can see how, you know, I've got, you know, 12 patients to
00:42:32see
00:42:32or 12 service users to see in the next hour. It could be tempting to take a shortcut when I'm
00:42:38explaining people's options or, you know, guiding them along a certain path of care. Not that that's
00:42:44correct at all, ever. Somebody's asked, is coercion ever okay? I would still say no. But I'm just saying,
00:42:51you know, to your question, when we're working in this incredibly frenetic, non-person-centered,
00:42:57industrialized environment, coercion easily becomes a shortcut. And, you know, when that happens,
00:43:03nobody wins.
00:43:06Thank you so much. And I'll just add on the end of that, because we don't have obstetric
00:43:13representation on the panel.
00:43:18Annabelle, your sound's gone out again.
00:43:22Oh, no, has it?
00:43:25I don't know. It was just me, but you're back now. Yeah.
00:43:28Am I back now?
00:43:29Yeah.
00:43:30How strange. So sorry that this keeps happening. It has to be on a webinar. It never happens usually.
00:43:35I was just going to say thank you, Leah, for that. And just to add, because we don't have
00:43:39obstetric representation on the panel, but I'm sure we do on the webinar participants, that it's very
00:43:43similar in terms of we are working in this system that is under duress. And similarly, we get
00:43:49obstetric violence and so forth emerging. But we also have to think that there are these
00:43:55environmental factors that make people push for what we call, you know, concrete ways of thinking.
00:44:02So one of the phrases Laura used in her presentation was, you know, we'll re-discuss this at 37 weeks
00:44:08and people can document quite concrete things in the notes because it's quicker.
00:44:12Right. So to write something flexible obviously takes more time. And if somebody is pressured,
00:44:17they want to write something concrete for the next person. Right. But it obviously doesn't bode well
00:44:22to personalised care and obviously outcomes in the long run. So thank you very much, both of you,
00:44:30for your contributions. And we are going to turn to questions now. Hopefully there's some that have come
00:44:39through in the chat. So, give me a second.
00:44:54Lovely. Okay. So, so the first question, and I think I'll open this just, you know, everybody feel free to
00:45:03chip in.
00:45:05My person's first question is if we think coercion is ever justified, e.g. in an emergency situation.
00:45:17I'm happy to speak to kind of what the law would say on that. And then, you know, because I
00:45:22think
00:45:22justified is a is a broader question. Right. And maybe that covers ethics and, you know, broader birthright
00:45:28stance. But just in terms of the law, no, you know, decision making must always be the, you know,
00:45:37the decision maker always must be the woman or birthing person, assuming that they have capacity,
00:45:42which is the legal presumption. As I say, there are some exceptions to that, like where somebody is
00:45:48unconscious, but absent that, then no, the decision is that person's and it must remain that person's.
00:45:55That said, the law recognizes that, of course, the level and detail of information that you would be given
00:46:00in an emergency situation will be very different to what you might receive if you're having a, you know,
00:46:06chat at your 24-week antenatal appointment when you have time to discuss things in kind of far more detail.
00:46:14Equally, in other respects, there might be more detail that can be provided at that sort of point in time
00:46:21when a particular fat pattern has become relevant, because that might have been unlikely to occur.
00:46:25So it wasn't discussed antenatally and now needs to be. So the, what the law requires is very much
00:46:31dynamic to the particular situation. Coercion is never okay, but that's not to say that the information
00:46:37is totally static in all scenarios.
00:46:42Thank you. And just to add to that, I would just say that very much in medicine,
00:46:47particularly in emergency situations, you're thinking about the immediate best interest, right?
00:46:53So you think about what most of your peers also would do in that situation and in line with that.
00:47:04And then because it's, you're thinking on a short timeframe, you would then subsequently,
00:47:09obviously address the fallout later, essentially, because that's how you're taught to practice medicine.
00:47:15And if people want insight into that, and there aren't, you know, necessarily medics on the call,
00:47:19that is how we're taught to frame our decision outside kind of a legal.
00:47:25Yeah, I think I just moved to add to two points that I think the first one I would say
00:47:29in sort
00:47:29of maternity and be really interested in Leah's insights, particularly on this. But something I
00:47:36find is that we often get asked this question a lot. But what about, you know, in an emergency?
00:47:39And you know, there's no time. And actually, very often in maternity, that yes, there might be
00:47:45that moment. But actually, there might have been quite a lot of moments before that, you know,
00:47:50where maybe there was a slightly concerning trace for a while, and then something else was happening,
00:47:53and then this, and then they were struggling to pick up. And so actually, there were points along
00:47:57the way, where a calmer, more nuanced discussion could have been had rather than no discussion
00:48:03up until the point of crisis. And that is not to deny the stress of those crisis moments,
00:48:08but just to kind of ask people to be sort of intellectually curious and consider because
00:48:13if earlier discussions can be had, that's obviously helpful for, you know, good quality
00:48:18decision making. And the other thing I would say is just to kind of, again, be being really clear
00:48:26from a legal perspective about capacity, because it's only when capacity has been lost that a
00:48:31best interest decision is appropriate to make. So up until the point that that capacity has been
00:48:39lost, the decision maker remains the woman or birthing person. And so, you know, the, of course,
00:48:47there should be a clinical recommendation, but reasonable alternatives should also be being discussed.
00:48:53And that should include all reasonable alternatives that the that the care provider thinks are
00:48:59appropriate to provide, which, of course, requires you to think about what you would do,
00:49:02what you think your peers would do, and what would be genuinely reasonable alternatives. It's not
00:49:07everything ever. But yes, the decision maker is still the woman or birthing person.
00:49:14Thanks a lot for elaborating, Laura. I just want to know, Leah, did you want to come in or add
00:49:18anything to that question?
00:49:21Yeah, thanks. It's a really interesting question. I mean, emergencies are fascinating from an ethical
00:49:27point of view. And, you know, I would agree that most emergencies develop over time. Absolutely, there are
00:49:38situations where an emergency will come completely out of the blue, and it will be incredibly acute, and
00:49:42suddenly you have an issue that you need to discuss with with the person in front of you. But quite
00:49:48often, yeah, there has
00:49:49been space leading up to that to say, well, how would you feel? Or, you know, what would your choice
00:49:53be in this situation? So, for example, let's say somebody is in early labor, and you're talking
00:49:59about their birth preferences, and you're saying, okay, well, after the baby is born, and you've said
00:50:04you want delayed cord clamping and skin to skin. That's fantastic. Just to let you know, if baby needs help
00:50:12to breathe, it might be suggested that we cut the cord and take the baby over to the resuscitator. Would
00:50:18that be okay
00:50:19with you? Do you know what I mean? So you can sort of, like, preempt what could be a really
00:50:23scary,
00:50:24sudden, dramatic situation by already laying the groundwork for choice and consent. The thing about
00:50:30capacity is fascinating in an emergency situation, because quite often in labor, somebody is maybe
00:50:37in quite a lot of pain, and maybe extremely depressed, not depressed, distressed. So, you know,
00:50:44you have that other sort of layer of challenge of how do I convey information in a respectful,
00:50:52rights-informed way, and to get a sort of, you know, capacitous, reasonable response to somebody
00:51:00who is incredibly distressed, and maybe not taking in everything I'm saying. And in my experience,
00:51:07just of observing, you know, other people's practice, that is quite often when coercion can happen.
00:51:13Because, again, it's a shortcut, right? In that moment, it feels like, well, I'm just going to say,
00:51:19this is better for you, or do this now, or X will happen. And hopefully that's not ethically okay,
00:51:26but you can see how in these situations, shortcuts happen, and people maybe don't behave in an optimal
00:51:33way. Yeah, so that would be my kind of two cents worth for that.
00:51:37Thank you so much, both. And just to say, very meaty question to start off with.
00:51:44And I think one of the take-homes is that, particularly when it comes to delivery,
00:51:50it usually progresses over a period of time. So there are multiple points of intervention, right?
00:51:55So, and the other thing I just add from a personal perspective is that even when it's an emergency,
00:52:01as I have an emergency section, there are still decisions about that emergency, right?
00:52:06Because sometimes, yes, it's go, go, go. But often with delivery, there are still elements to make
00:52:12decisions within that, right? And that also should still be given, you know, what that looks like.
00:52:19You can still have music, for example, in an emergency section, but also more important decisions,
00:52:26right? Like clamping, stuff like that. Okay. And then moving on to the second question.
00:52:32Are the powers that be in maternity services listening to this? So.
00:52:45Lost you again, Annabelle. Sorry, someone muted me there.
00:52:49I was just going to say, it might be worth actually hearing a little bit from Hazel or
00:52:55Laura about your interactions, I guess, with more senior people, what birthrights are doing
00:53:00on an advocacy level. Yes.
00:53:05Yeah, I'll have a go with Laura Chippin. I mean, they're definitely listening. So that's happening.
00:53:10I guess what we're more concerned about is whether they're acting on what they're listening about.
00:53:14So we've had a, you know, pre-meet with NHS England, where we presented the findings to them.
00:53:20We'll meet with NMC as well. We'll go through it. And I think what we're noticing is there's a real
00:53:27fear from them as well, you know, quite responsive to media and the kind responsive to this kind of
00:53:34safety narrative, you know, profiling people as risk and then seeking to kind of control rather than
00:53:41seeking to respect human rights. So we're definitely worried about that challenge and
00:53:46like how that's playing out. And it's also kind of how it's more broadly playing out across society,
00:53:52I guess, around kind of governments wanting to control people's bodies and how they
00:53:56how they have choices over them. So that's the kind of underlying concern. But I would say
00:54:03when I presented it last week, you know, they were very concerned. It was no surprise to them.
00:54:09There are some good practices going on in terms of nationally, in terms of
00:54:14there's an anti-discrimination programme. We've got the Race and Health Observatory doing some great work
00:54:18around kind of training and learning with senior leadership as well.
00:54:22And this kind of equity and quality action plans we're now seeing across all trusts and
00:54:27there's programmes around learning for cultural safety. So there are things happening.
00:54:31I think for birth rights, our main kind of problem with all that is that the human rights framework is
00:54:39not embedded across the board. You know, a lot of this would be semi resolved if the people could just
00:54:46look at things from a human rights framework and put that as a basis for the way decisions were being
00:54:51made. So I think that would be where we don't think they're listening and acting as much as we would
00:54:57like, if I'm being honest. But on the safe staffing, I mean, I would see if Leah wanted to come
00:55:02in on
00:55:02that. There was an all parliamentary group meeting around safe staffing today. So there's definitely
00:55:08a momentum on that. And we'd hope that they're definitely listening. Again, it's whether there's
00:55:12the funding budget to put to that. But yeah, I don't know if Laura or Leah want to come in
00:55:17as well.
00:55:22I'll let Leah go. But I know, Hazel, just to mention, I guess, on Baroness Amos's inquiry
00:55:28specifically, I know that this information went to that team as well. And we also, when we met as part
00:55:38of
00:55:38the National Maternity and Neonatal Collective, and Leah was also present in that meeting, and one of the
00:55:45points that we really highlighted generally, for for West Streeting and for Baroness Amos in that
00:55:53meeting is the absence of human rights in the narrative around maternity generally. And, you
00:56:01know, this coercion is one is one symptom of that absence, and a really important one. So we will
00:56:09continue to kind of bang that drum. But Leah, yeah, I don't know if you want to come in on
00:56:12safe staffing.
00:56:14Yeah, thanks. Laura, you're being very humble. Laura was absolutely brilliant speaking in that
00:56:19meeting and really put for human rights framework so eloquently. So West Streeting and Baroness Amos
00:56:26can't say they didn't know, or we didn't tell them. I mean, this is the thing, really, they have all
00:56:31the
00:56:31information, they know how dangerous staffing often is, and how difficult workplace culture often is.
00:56:38I've just been informed just this evening that the information I've been gathering about midwives
00:56:43working conditions will be included as evidence in the national investigation, which is gratifying.
00:56:50But at this time, I'm very pessimistic about
00:56:55any actual substantial positive change, because that would require long term commitment and funding from
00:57:03the government. We live in hope. And I think today's report from birthrights just adds to that really
00:57:09significant body of evidence for the government so that they, you know, they cannot say they didn't
00:57:13know that these things were happening, and they really have no excuse for not addressing them or
00:57:18including them in any future service design.
00:57:25Thanks a lot for that. I'm not sure if, no, I think you've answered quite clearly in terms of it,
00:57:32how it aligns with the national inquiry and the Amos investigation ongoing.
00:57:43There was a fourth question regarding how this links to wider violence against women and girls,
00:57:49and what's being done to interlink these issues of coercion and obstetric violence at its core,
00:57:54and violence against women and people of minoritized genders.
00:58:00I just also want to come back to this issue in terms of the framing, and really at the heart
00:58:08of this,
00:58:08for me, is bodily autonomy, right? And this idea that even as a clinician, it's something, you know,
00:58:17that I struggle with, but that our way of thinking or the guidelines we give have to be adhered to
00:58:23rigidly,
00:58:24and that if you deviate, or you step outside the system in any way, that you're a problem,
00:58:31and to be blamed. So I guess, yeah, who wants to amnesia, potentially in terms of training,
00:58:37how the work that you're doing links to these wider issues, any connections that you're forming,
00:58:44or how people in training respond to that?
00:58:50The wider issues around kind of coercion with women and girls.
00:58:56Yeah, sorry, I'm not sure.
00:59:00Does it come up in training?
00:59:01Does it come up in training? Do people talk about this or against, I guess, wider systems of violence and
00:59:08coercion?
00:59:09I think what is kind of interesting, and it also ties into someone else's question, Nicola,
00:59:13and it says, are you aware of similar coercion issues happening elsewhere in healthcare?
00:59:18And what we generally don't see these kinds of issues of coercion and other aspects of healthcare
00:59:23outside of emergency. And in a way, so if, for an example, if there was a patient who had cancer,
00:59:33and was on an end of life kind of care plan, if they decided not to proceed with whatever the
00:59:39treatment option is for, that is recommended by the doctor, they aren't generally receiving the same
00:59:46kind of level of coercion. Usually the healthcare professional is more understanding, giving them
00:59:51what, like, supporting them and what their options are. But we see this in maternity care, which tends
00:59:56to have a more patriarchal lens around people's bodies, people's, the rights people have over their
01:00:05bodies. And, yeah, that is very kind of specific to maternity care. Laura, Ollie, I don't know if you
01:00:13have other ideas on that.
01:00:16Yeah, I'd love to come in. I have started this drum hard and often, because I actually would argue the
01:00:26state of maternity care in the NHS in the UK is an institutional form of violence against women and
01:00:34girls, just the whole state of it. Because the way things are now is a reflection of a conscious
01:00:41decision, or decisions, plural, over and over and over again by successive governments to underfund,
01:00:50undervalue and deprioritise maternity. And in that being a series of conscious decisions, that,
01:00:58that to me constitutes violence. And yes, it is affecting women, girls, and, you know, other people
01:01:04who give birth. So I think the question about, is coercion maternity part of the broader issue of
01:01:12violence against women and girls, I think, yes, coercion is a part of violence against women and
01:01:18girls, but as part of this broader kind of backdrop of an inherently kind of institutionally violent
01:01:25system. I know that sounds a bit of a sort of woof, that's a bit of a kind of provocative
01:01:29idea.
01:01:30But I think that's it in black and white. I feel that strongly about it. And I've started saying it
01:01:37and explicitly like that and framing it in that way when I have these conversations in the media
01:01:42or in my writing. And because I think that's a message that really needs to get across. I think
01:01:46we we could make a much more powerful argument and have a more powerful lobby and maternity
01:01:51we connected it with the broader issue of violence against women and girls.
01:01:57Thanks a lot, Leah. And actually, to come in on that, thank you for this question, because I'm
01:02:03going to go even bigger than Leah and say my real issue with this, actually, is that it's not actually
01:02:10just maternity care, what it is about reproduction as a whole. OK, and I don't think we've quite got to
01:02:17fix with reductive coercion at all or what it means. I think we are only understanding it as
01:02:23a tip of the iceberg issue. And some people don't want to connect it in terms of we have to
01:02:28really
01:02:29be thinking about the right to have a child, also not to have a child and all the resources to
01:02:34parent
01:02:34a child because you can't just make a decision about giving birth in isolation. So we do need to
01:02:40connect the issues. And I would say it manifests more violently during delivery because of the
01:02:46other vulnerabilities that people have and people's focus goes to the unborn child and the kind of state
01:02:54that has in society. However, this issue is not isolated to maternity. It starts well before then,
01:03:03how people are coerced into having children, who's coerced into not having children,
01:03:07children, how people feel about that person's motherhood, is the person trans, is the person
01:03:14disabled, is the person black or brown, how people feel leading up to their pregnancy in their
01:03:20antenatal care, way before that point. And how people feel about their interactions with the healthcare
01:03:27system well before they get pregnant. So for me, I think, you know, having maternity task forces and
01:03:34things like that is vitally important. But I think there's a missing piece that we fail to
01:03:39contextualize this within the reproductive life course. And unfortunately, I see a lot of those
01:03:45that go through traumatic births, experience coercion, and I see them in between their deliveries where,
01:03:51you know, they have trauma, they can't get, you know, gynecological examinations,
01:03:55they didn't get any perinatal mental health, they're not having sex anymore, all of those things.
01:04:02So I think it is a lot bigger than the maternity. And I think we're doing a real injustice when
01:04:08we
01:04:09continue to narrow in and home in just on it as a maternity problem. Actually, sorry. I've gone on
01:04:18my little tangent there. But I do think it's a very important question. And thanks for adding it.
01:04:22In the interest of time, I'm going to move on and also hand over to others.
01:04:28In fifth question, what paths can people take on an individual level when they receive incorrect
01:04:34and coercive information from a healthcare professional? So a very practical question
01:04:40in terms of, I suppose, when you don't think that what you're being told is correct,
01:04:44and you do have time to intervene, maybe antenatally, or you're not, or you're even delivering,
01:04:50how does somebody advocate for themselves? And where are the resources?
01:04:58Shall we throw that? Is that Laura, maybe?
01:05:00Yeah, I can take that and others can chip in. I'm sure Amisha will have really good thoughts on this
01:05:07one.
01:05:07And I think, well, first to say that this is a brilliantly timed question, and we are actually
01:05:15in the process of producing some resources that I hope will go some way to address this and to be
01:05:23kind
01:05:23of there and very readily accessible for people to have that sort of instant guide in your pocket,
01:05:31so to speak. And I think, I think one of the single most important things that people can do
01:05:39is ask questions. And I know that can feel really challenging. And so for some people, you know,
01:05:46feeling that they have support, whether that's in the form of a family member, a doula, somebody with
01:05:51them who's kind of on their side can really help that feel easier. But I guess I would just, you
01:05:59know,
01:05:59add that it's absolutely your right to be asking those questions and to be expressing if you're
01:06:04feeling that you're being coerced to make a certain decision. Something we often refer to in
01:06:10in our training sessions is we make use of a particular sort of graded tool that's called
01:06:19PACE that allows you to kind of increasingly challenge and it starts, you know, very gentle with
01:06:25just kind of gentle probing questions. And then it enables you to kind of, and there are many
01:06:29similar models to this, but I get, I think what I would flag is that sometimes it can feel terrifying
01:06:36to say anything. But actually even just gently questioning what's like, you've just said,
01:06:42you know, my baby is going to die if I don't get induced, for example. Can I just check
01:06:49what you meant by that? Did I misunderstand? I always, not that you should have to do this,
01:06:55but I think everyone has their own frame, framing and phraseology that works for them.
01:06:58I've always personally found it helpful to kind of say, did I, I'm sorry, I'm probably being really
01:07:03silly. Did I just misunderstand? And then repeating back to somebody what they have just said can be a
01:07:08kind of very simple, powerful tool to make somebody who perhaps for all the reasons we've all been
01:07:14talking about was distracted and kind of giving you a fob off answer rather than intentionally
01:07:20coercing might just give them that time to pause and reflect and do a bit better.
01:07:26That's only a partial answer I recognise. And as I say, you know, there are kind of great tools of
01:07:32assertiveness. The other thing, of course, to say is you're always very welcome to reach out to the
01:07:36Birthrights Advice and Information Service. You know, we're absolutely there for you, whether you are
01:07:41the woman or birthing person, whether you are the supporter of a woman or birthing person,
01:07:45whether you're a healthcare professional who's seeing this happening and feeling powerless
01:07:49to kind of change, you know, please do reach out to us. But Amisha, I'm probably missing all sorts
01:07:55of things. What do you think?
01:07:57I thought that was great. I would also add, especially kind of thinking through it from the
01:08:03racialised lens of black and brown people and coercion, whether that be mental capacity assessments
01:08:11or social services that can feel really difficult to challenge when you know there is a kind of
01:08:17inherent power dynamic. So that's what Laura said about trying to find advocates. So advocates in your
01:08:23community, trusted people that could be doulas who could support you with advocating or potentially
01:08:29making a complaint to the hospital, because sometimes it's not until you make a complaint
01:08:35that people actually, this kind of gets raised within the system and escalated and looked at
01:08:41and definitely getting in touch with the Birthrights Advice Service if you do feel like it has gotten
01:08:47to that level where you need more of a legal input. Yeah.
01:08:51Thank you. That was actually my question. And I think the complaints process is a really important
01:08:57part of that because I think, you know, people do need to be held to account. And I experience everyday
01:09:05people, my clients, people that speak to me being told like genuinely incorrect information with the
01:09:12purpose of persuading them to do something. And I would like to be able to say to people,
01:09:19you need to report, you need to contact Pulse. You need to, you know, report them to the NMC.
01:09:25Like, I think we need, people need to have the power to kind of act upon this as well. Because
01:09:30obviously they have to find the right information and continue on their pregnancy journey. But I also
01:09:38think people should be held accountable if they are truly giving out incorrect information with the
01:09:44intent of persuading people. Absolutely. And I would say I'm a massive fan of
01:09:49standing up. Thank you for adding that, Charlotte. I'm a massive fan of, not a fan, we shouldn't have
01:09:54to be a fan of, well, Sarah Ahmed. Some of you might have read some Sarah Ahmed, an amazing feminist
01:10:00writer. And she has a whole book coming out about complaints. But she also says, you know, when you
01:10:05point out a problem, you become the problem. But complaint is very powerful as well in highlighting
01:10:10problems. And I do think people should complain. Just add, because I think it would be useful to know.
01:10:16What about, because I tell people to use for general practice and things like that,
01:10:21voting with your feet? Because it can be very difficult, can't it, in maternity care,
01:10:25when you're not getting what you want. Can you move hospital? Do any of you have thoughts around
01:10:32that? Or can you just ask for another team? I think that's highlighted in the report,
01:10:37somebody's response when they tried to ask to see somebody else. Maybe that's for Leah.
01:10:44Yeah, you know, can you vote with your feet? It's a really good question. And I think it's
01:10:47easier in some places than others. I'm up here in Scotland, I would say up here as if it's like,
01:10:53you know, not there. And I think it's a little bit easier to move hospital or kind of change teams
01:11:01up
01:11:01here than it is in some places in England. I've heard in London, it's especially hard right now.
01:11:06So that's, that's necessarily for everyone. And to do quite a lot of logistical and emotional
01:11:14labour to kind of transfer your care and chase up appointments and so on, it can be quite stressful
01:11:18and difficult. And in terms of changing team, that might be a little bit easier if you're in a unit
01:11:25that
01:11:25use this kind of continuity teams or regional teams. And, and it's something actually that,
01:11:33that I think about sometimes, I know that continuity of care is often held up as the gold
01:11:38standard of, you know, maternity model, and it is, it has, you know, overwhelming evidence that it
01:11:42improves outcomes. One thing I do worry about for some people is what if you are in a continuity system,
01:11:49and the midwife that you are linked with continuously is using coercive behaviour, or is
01:11:56racist, or, you know, is in some other way, unprofessional or inappropriate, and you're kind
01:12:01of stuck with that person, then, because continuity is meant to be, you know, the best thing.
01:12:06How is it for you to then push back against that and say, actually, I don't want to see this
01:12:11person
01:12:11all the way through my pregnancy. And, you know, maybe easier in some areas or trusts than others
01:12:17to push back against that, if that's being held up as like the model that everybody belongs in.
01:12:23So yeah, I don't know that, you know, it's, it's very dependent on your, your area and local practices,
01:12:29but if you feel you have the capacity to vote with your feet, and to chase that up and to
01:12:35push it
01:12:36through and make it happen, I would absolutely recommend that.
01:12:40Thank you so much for adding. You're absolutely right. We always say we have national health
01:12:44service, but we have a postcode lottery. And depending on where you are, it's very, it's not
01:12:49as easy to implement these things as others. And I know people that have literally moved across the
01:12:54country for maternity care, because they think they'll get a better service. It's not, it's not
01:12:59right. And it's not, not fair. So winding up to our last kind of few questions and comments,
01:13:05we're going to have to come to a closely, but this is vitally important.
01:13:10When it comes specifically to the NMC, and some of what comes out in the report and how people
01:13:16are regulated, how do we challenge when the regulator punishes midwives for respecting women's choices?
01:13:24Is there any work that birthright's doing specifically in that area?
01:13:31So to change it up a bit, Hazel or Laura, first of all, is birthright's doing anything around this?
01:13:38And then, Leah, maybe more practically, what can be done?
01:13:46I'll make a start with the caveat that I only joined in November, so I'm still catching up on
01:13:51what we have done. But we did a lot of work for NMC about developing the principles and we weren't,
01:13:56and there was some challenges with that as well. I would say that we have, from what I understand,
01:14:02historically done some work around when NMC of challenging them on individual cases. But I think
01:14:09as it's evolved and it came out so strongly in the research, it is something that we could look
01:14:13back at doing more of. And I think at the moment we haven't totally committed to that, but I do
01:14:18feel
01:14:18like it could be quite a concrete thing that we could then, because we meet with NMC fairly regularly
01:14:23at senior level, so it feels like something more practical that we could do more of. But I don't
01:14:28want to over-promise for the team, so maybe if Laura wants to chip in.
01:14:33No, I think that's right, Hazel. I think to an extent it's also just happened to depend on who has
01:14:42come to us, and recently that hasn't been something that has, we haven't had people recently coming to
01:14:49us on very many occasions. But yeah, certainly open, and if people are in that situation,
01:14:57again, please do reach out to us and we can see what we can do here. As Hazel says, not
01:15:05wanting to
01:15:05over-promise, but certainly wanting to be open and to see if there are ways and avenues where we might
01:15:12be able to support usefully. Thanks so much. And we're going to have to wind up shortly. I think
01:15:18there was one comment just, and we touched upon anyway, about similar coercion happening across
01:15:24healthcare. And I think we touched on reproduction, which is still in a similar realm, but I think
01:15:29under-acknowledged. So we see a lot of coercion. I write and talk about contraceptive coercion. So, for
01:15:36example, people having to have a certain method of contraception, particularly when they're taking
01:15:40medication that can lead to fetal abnormalities. So people not seeing, you know, termination as an
01:15:47option. So they kind of make them take medication, particularly around epilepsy. But I do think medical
01:15:53coercion is an issue in terms of medical teaching. It manifests in a range of different areas. It does
01:16:02manifest even in oncology, which Amisha talked about, you know, people not really fully
01:16:07comprehending that some people don't want chemo or want palliative care and people then feeling
01:16:13they don't get the treatment they deserve. So I think this conversation is much bigger.
01:16:17And I think we've had such a wide-ranging conversation. The report is so fantastically
01:16:24broad in the issues it brings up. Before we end, I just want to seek any final comments from the
01:16:31panel
01:16:32this evening. If there's anything that you wish to add or any, like, last calls to action that you might
01:16:39have.
01:16:42I mean, I would just say thanks so much. This has been a really interesting and kind of thought-provoking
01:16:47conversation. And although the report is really grim reading, I mean, the silver lining, I always say,
01:16:57of things being so bad at this particular moment in time in maternity in many ways is that we also
01:17:03have unprecedented momentum for change. So, you know, hopefully this report sits against that backdrop
01:17:11of a movement for change, of raising awareness, of illustrating exactly where the problems are.
01:17:16And I would encourage anyone who's feeling a bit hopeless to know that this actually is a really
01:17:21opportune moment to shout about these things and to try and make a change. So yeah, unusually for me,
01:17:28a little bit of positivity at the end there. So thank you so much for having me.
01:17:35Thank you so much for those final words. Anything else Laura or Hayley would like to add
01:17:45before closing or Ramesha there?
01:17:49Just to like absolutely echo that kind of bit of hope because it just feels like
01:17:56the crisis mode has been going on for quite a few years now and it has absolutely reaching
01:18:01crescendo. There is so much media presence around like what is happening in the maternity system.
01:18:06There seems like so much more awareness about what's happening and the impacts
01:18:09that it has on people's lives and very broad spectrum and that includes healthcare professionals who
01:18:15are, we all know are leaving in droves. So it does feel like this is a specific moment and we're,
01:18:23you know, across, you know, we work across all of the UK and we have people contacting us from
01:18:27local community groups who are taking action and it really is inspiring to see that kind of combination
01:18:32of like community action and then we can legally challenge and then we have midwives and healthcare
01:18:38practitioners rising up as well all with the same message. It just feels really, really powerful.
01:18:44Thank you so much. So thank you so much everybody for joining us today
01:18:51on our End Coercive Practices in Maternity Care webinar and please do have a read of the more
01:18:58detailed report. Birthrights has tried to keep the report quite simple with four key calls to action.
01:19:04As a reminder, they are end racialized and discriminatory practices, including disproportionate social
01:19:11services referrals, unnecessary drug testing and NHS charging rules. Introduce safeguards against
01:19:18coercive practices, including routine monitoring of consent practices, clinical note accuracy,
01:19:25safeguarding referral patterns and guidelines, development and usage. Improve healthcare professionals'
01:19:32knowledge about rights-based care, informed choice and consent with mandatory training on human
01:19:38rights laws across maternity staff, including obstetrics, anaesthetics and neonatal care. And lastly,
01:19:44ensure safe staffing and safe working hours and environments in all elements of maternity services,
01:19:51ensuring staff can raise concerns without fear of reprisal, are enabled to facilitate
01:19:56rights-centred to personalised care rather than defensive practices. We know there is much more to be
01:20:03done, but we hope that these recommendations offer some tangible solutions to start changing a culture
01:20:08which can result in lasting trauma for women, birthing people and healthcare professionals alike.
01:20:14Thank you so much for joining us this evening and it's been such a rich conversation. Thank you so much.
01:20:20Yeah, thank you.
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