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Female Genital Mutilation (FGM): an Analysis of the Silences in Maternity Care Experiences of FGM Survivors and the Silences of Health Care Professionals Providing

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Female Genital Mutilation (FGM): an Analysis of the Silences in Maternity Care Experiences of FGM Survivors and the Silences of Health Care Professionals Providing Female Genital Mutilation (FGM): An analysis of the silences in maternity care experiences of FGM survivors and the silences of health care professionals providing maternity care to FGM survivors. Emma Danks RM BSc (HONS) This thesis is submitted in partial fulfilment of the requirements of the University of Wolverhampton for the degree of Doctor of Philosophy September 2019 This work or any part thereof has not been previously presented in any form to the University of Wolverhampton or any other body whether for the purposes of assessment, publication or any other purpose (unless otherwise indicated). Save for any express acknowledgements or references cited in this work, I confirm that the intellectual content of this work is the result of my own efforts and no other person. The right of Emma Danks to be identified as author of this work is asserted in accordance with ss.77 and 78 of the Copyright, Designs and Patents Act 1988. At this date, copyright is owned by the author. Signature: Date: Emma Danks 1 ABSTRACT The consequences of female genital mutilation (FGM) during the perinatal period are significant, but the experiences of FGM survivors accessing maternity care are under- reported in the literature. This thesis reports on the analysis of experiences of FGM survivors in maternity care and the experiences of health care professionals providing such care. This qualitative study was methodologically structured around the Sound of Silence framework which was developed for research with marginalised groups and communities. Two separate cohorts of participants took part in this study; 20 FGM survivors and eight health care professionals. FGM survivors met the inclusion criteria if, (i) they had given birth within the previous few days of data collection, (ii) they and their baby were of sufficient health to be discharged home and, (iii) were able to communicate in one of the languages identified for use in this study; namely Arabic, English and/or French. Health care professionals were excluded from this study if they had provided maternity care within the service where they FGM survivor participants had accessed care. Data analysis was conducted using a combination of thematic and discourse analysis to interpret overarching themes and elicit silences in the dominant discourses that were interpreted across the data. The findings from the analysis suggest that health care professionals’ education and training lacks the cultural context of FGM which seems to have an impact on the provision of maternity services for FGM survivors. Emma Danks 2 Although risk assessments appeared to be dominant in the discourse of maternity care, this discourse appears to constrain health care professionals in maternity services from providing culturally responsive care. This appeared to lead to a silence of cultural sensitivity when providing care to FGM survivors. Themes that were interpreted from the data suggest that mental health services are not seamless in maternity services for FGM survivors which appeared to relate to constraints in care provision as well as knowledge and education and communication issues with and amongst health care professionals. This finding led to the conception of a novel model of cultural silence around FGM which can be used to determine cultural dissonance in health care settings. Furthermore, recommendations include the development of working groups of FGM survivors and key stakeholders in the co- design and production of clinical guidance and education for health care professionals. Strategic planning for the implementation of mental health care collaboration in maternity services is recommended as well as the requirement of further research of mental health care in maternity services for FGM survivors. Emma Danks 3 GLOSSARY OF TERMS AWA – FC African Women Are Free to Choose BHRC Bar Human Rights Committee CQC Care Quality Commission DH Department of Health FGC Female Genital Cutting FC Female Circumcision FGCS Female Genital Cosmetic Surgery FGM Female Genital Mutilation FORWARD Foundation for Women’s Health, Research and Development HSCIC Health and Social Care Information Centre MBRRACE Mothers and Babies: Reducing the Risk through Audits and Confidential Enquiries GMC General Medical Council GP General Practitioner NHS National Health Service NICE National Institute of Health and Care Excellence NMC Nursing and Midwifery Council NSPCC National Society for the Prevention of Cruelty to Children PTSD Post-Traumatic Stress Disorder RCM Royal College of Midwives RCN Royal College of Nursing RCOG Royal College of Obstetricians and Gynaecologists SLWA-FC Sierra Leonean Women are Free to Choose Emma Danks 4 UDHR Universal Declaration of Human Rights UN United Nations UNESCO United Nations Educational, Scientific and Cultural Organisation UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund WHO World Health Organisation Emma Danks 5 ACKNOWLEDGEMENTS I dedicate this thesis to my entire family. First and foremost, my mother who has been a tower of strength throughout my life. She taught me to understand other people’s perspectives and to not make judgements without understanding why other people make decisions. My mother has always encouraged me to consider other people’s opinions and how both my, and their decisions, can affect people’s lives. She has also taught me that with hard work and dedication, we can accomplish anything. My father has encouraged me every step of my journey; from starting out in my career as a midwife, to completing this thesis. My late step-father taught me that the acquisition of knowledge is not only a gift, but it enables us to enhance and cherish every moment we have in this world. My late aunt, who gave me the gift of her time and her knowledge in sociology with endless debates on different cultures. Most importantly, I would like to wholeheartedly thank my husband and children. While I have sacrificed time with them during my career and studies, they have supported me on every step of my journey to completing this thesis; without their love and support it would not have been possible for me to complete this work. I owe them everything. Furthermore, I would also like to take this opportunity to express my gratitude to all of my research supervisors on this journey. Professor Laura Serrant encouraged me to look inside of my own mind, into places that I did not realise existed, to understand what and why I was searching for answers to questions that I did not know existed. Dr Sandra (Sandie) Sandbrook, who was initially one of my midwifery lecturers during my Bachelor’s (BSc) degree and introduced me to the subject of Female Genital Mutilation. Without Sandie, I would not have developed my quest for knowledge of the subject. During my midwifery training, Sandie was undertaking her own PhD and Emma Danks 6 inspired me to undertake this study in order to discover the answers to some of the questions that I began to ask regarding FGM. Sandie later became one of my research supervisors and, prior to her retirement, continued to encourage and support me beyond all of my expectations. Dr Angela Morgan and Dr Ranjit Khutan became my research supervisors in the last four years of my PhD. Both have encouraged and guided me to the completion of my studies and to a place that I thought that I would never reach; for that, I am eternally grateful. Emma Danks 7 Contents GLOSSARY OF TERMS .................................................................................................................... 4 ACKNOWLEDGEMENTS .................................................................................................................. 6 CHAPTER ONE: INTRODUCTION TO THE STUDY .................................................................. 16 1.0 Introduction .......................................................................................................................... 16 1.1 Use of terminology in this thesis .................................................................................... 18 1.1.1 Female Genital Mutilation (FGM) ..................................................................................... 18 1.1.2 FGM Survivor ....................................................................................................................... 20 1.1.3 Vulnerability and vulnerable ............................................................................................ 20 1.2 Description of FGM ............................................................................................................. 21 1.3 Reasons and rationale for FGM ....................................................................................... 23 1.4 Background to the study ................................................................................................... 24 1.5. Wider context ....................................................................................................................... 29 1.6 Global Prevalence ............................................................................................................... 31 1.7 Prevalence of FGM in England and Wales ................................................................... 33 1.8. First-hand accounts of FGM ............................................................................................. 36 1.9 Study justification ............................................................................................................... 40 1.10 Aims and objectives ..........................................................................................................
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