CEL 9: Reproduction & Pregnancy

Introduction
This unit considers the application of some general legal and ethical principles to the special
situations that arise around sexual and reproductive health and the medical care of pregnant
women. You will also learn about specific areas of legislation applicable to this area of medical
practice: The Human Fertilisation and Embryology Act, and the Abortion Act. This unit is designed to
revisit and build upon the work you did on this topic during the MVST course, now that you have had
the opportunity to gain clinical experience in the field.

In CEL Workshop 9 (during R&I Week G in January, or Week I in May, depending on when you
complete your Maternal & Child Health placement) you will have the opportunity to think about the
potential difficulties of balancing the interests of different parties affected by treatment – the
woman herself, her partner, the fetus. You will also be encouraged to consider different views about
the point in development when an embryo, fetus or neonate becomes a morally significant person.

Objectives
Having completed this unit, you should be able to demonstrate in practice an understanding of:

 an understanding of ethical and legal issues surrounding the status of the embryo and fetus,
and areas of contention and debate including possible maternal–fetal conflict
 an understanding of concepts of personhood
 an understanding of ethical, legal and professional aspects of contraception, artificial
reproductive technologies, termination of pregnancy and neonatal care
 an understanding of ethical issues associated with preimplantation/prenatal testing and
embryo selection, genetic testing and screening after birth
 an understanding of issues raised by the religious beliefs of patients, students and other
healthcare professionals and the role and limits of conscientious objection

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Logic and rhetoric
In this unit, we will be considering some of the most contentious issues in medicine. People have
strongly held views, and often express those views using powerful and persuasive language. Terms
like ‘designer babies’, ‘pro-choice’ and ‘pro-life’ can elicit a strong emotional response, perhaps
encouraging the inference that those of the opposite view are ‘pro-coercion’ or ‘pro-death’. Beware:
this sometimes masks a bad argument.

As doctors, we need to be able to provide good reasons for justifying our actions to our patients and
to society in general. This part of the course is an opportunity for you to think seriously about the
underlying arguments for and against the different uses of reproductive technologies and of
termination of pregnancy, about how to engage respectfully and productively with people whose
opinions differ from your own, and about how to help patients who may have made choices that you
disagree with, whilst maintaining both your integrity and your professionalism.

Assisted reproduction:

The more we can do, the more we have to decide what we should do

The on-going development of medical techniques to assist human reproduction has stimulated
debate about the ethics of assisted reproduction. Questions include:

• Does a right to healthcare include a right to assisted reproduction?

• Does a right to found a family extend to a positive obligation to assist those who cannot
found a family without medical assistance?
• If AR must be rationed, who should receive it? People who are most likely to have a live birth
after AR? People who don’t already have children? People who would be ‘good parents’?

Take a moment to articulate your own responses to these questions. Now spend a couple of minutes
considering the arguments for and against your own position. Addressing the ethical problems of
assisted reproduction is often a question of balancing justice with beneficence and autonomy.
However, the questions become more complex if we also consider the interests of any child brought
into being through the provision of AR – should the resources go to those best able to meet a child’s
needs? If so, how should such a judgment be made?

Sometimes, AR techniques are used to address problems other than impaired fertility. In pre-
implantation diagnosis, couples with a high risk of passing on an inherited condition may choose to
undergo in-vitro fertilisation, have the resulting embryos tested for the condition, and only implant
unaffected embryos.

Utilitarian ethics would suggest that this is almost certainly a good thing – it prevents the creation of
a child who will suffer because of the inherited condition, and provides the parents with the pleasure
of having healthy children. Others may argue that a value judgement about the worth of one life
over another inherent in this process. Does this represent a failure to value the lives of disabled
people alive now?

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If we consider it morally justifiable to select embryos that are free from a particular disorder, should
we also select embryos with the lowest number of genetic risk factors for disease later in life? Or
embryos with a genetic profile associated with positive outcomes such as higher intelligence or
greater physical strength? What about more subjective qualities such as physical beauty? Should we
be able to select the embryos that are most like us, with all our flaws? What about people who have
a condition that most people class as a disability, but that they themselves view as a difference
which brings benefits or strengths as well as problems?

It should be obvious to you by now that there are no clear-cut answers to these questions, which
remain an area of legitimate disagreement and debate. Nonetheless, like many contentious areas of
medical practice, AR is governed by a legal framework:

The Human Fertilisation & Embryology Act 1990, as amended 2008

This is a complex but important piece of legislation that reflects the complex ethical issues
associated with advances in reproductive technology and changing social mores. How do you see
attitudes developing in the future? You should be aware of the following clauses:
S4 (1) No person shall—

(a) store any gametes, or

(b) in the course of providing treatment services for any woman, use the sperm of any man unless the
services are being provided for the woman and the man together or use the eggs of any other woman, …

except in pursuance of a licence. (consent of donors is a licence requirement)

This means special permission is required for the storage of eggs and sperm, and for treatment using
stored eggs and sperm. One condition of granting such permission is that the consent of donors to
the storage and use of the eggs or stored sperm is always required. If consent is withdrawn at any
stage, treatment providers can no longer lawfully store the eggs, sperm or embryo. This can become
especially relevant after relationship break-ups.

S13(5) A woman shall not be provided with treatment services unless account has been taken of the welfare of
any child who may be born as a result of the treatment (including the need of that child for supportive
parenting), and of any other child who may be affected by the birth.

Contrast this with most areas of medical practice, where the doctor must be concerned with the
interests of the patient, rather than the interests of others. Note - the 1990 legislation required
treatment providers to take into account the need of any child born as a result of the treatment for a
father. The 2008 legislation amended this, to a requirement to take into account the need for
supportive parenting.

S13(6) A woman shall not be provided with treatment services… unless she and any man or woman who is to
be treated together with her have been given a suitable opportunity to receive proper counselling about the
implications of her being provided with treatment services of that kind, and have been provided with such
relevant information as is proper.

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Therefore, treatment providers are obliged to provide information about the potential implications
of treatment and to offer counselling to the woman being treated, and her partner (if she has a
partner who will co-parent the child).

S13(6)(C) In the case of treatment services … [that involve donor gametes or embryo] the information provided
by virtue of subsection (6)… must include such information as is proper about—

(a) the importance of informing any resulting child at an early age that the child results from the
gametes of a person who is not a parent of the child, and

(b) suitable methods of informing such a child of that fact.

The information provided to the woman and her partner must include advice about explaining to the
child that one or both of the parents are not the child’s genetic parents.

S13(6)(D) Where the person responsible receives from a person (“X”) notice… of X’s withdrawal of consent to
X being treated as the parent of any child resulting from the provision of treatment services to a woman (“W”),
the person responsible—
(a) must notify W in writing of the receipt of the notice from X, and

(b) no person to whom the licence applies may place an embryo or sperm and eggs in W, or artificially
inseminate W, until W has been so notified.

If therefore, prior to treatment, the woman’s partner changes his or her mind about being willing to
co-parent any child born as a result of the treatment, the treatment provider is obliged to inform the
woman before inserting eggs, sperm or embryos into her.

S13(6)(E) Where the person responsible receives from a woman (“W”) who has previously given notice… that
she consents to another person (“X”) being treated as a parent of any child resulting from the provision of
treatment services to W—

(a) notice… of the withdrawal of W’s consent, …

the person responsible must take reasonable steps to notify X in writing of the receipt of the notice...”

If the woman being treated changes her mind about the person who was her partner at the outset of
treatment co-parenting any child born as a result of treatment, then the treatment provider must try
to inform that person before continuing to treat the woman.

S13 (9) [When selecting donors for eggs or sperm, or when selecting embryos for implantation] Persons or
embryos that are known to have a gene, chromosome or mitochondrion abnormality involving a significant risk
that a person with the abnormality will have or develop—

(a) a serious physical or mental disability,

(b) a serious illness, or

(c) any other serious medical condition,

must not be preferred to those that are not known to have such an abnormality.

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It is lawful to use AR for pre-implantation genetic diagnosis, which involves testing embryos for a
genetic condition and implanting only unaffected embryos. It is not lawful to implant embryos that
are affected, if there are also embryos that may not be affected available for implantation.
Deaf parents have applied to select embryos to produce deaf offspring, on the grounds that they
consider deafness to be a difference with its own culture, membership of which confers certain
advantages as well as disadvantages, rather than a disability or serious medical condition. This has
not been permitted.

S13(10) Embryos that are known to be of a particular sex and to carry a particular risk, compared with embryos
of that sex in general, that any resulting child will have or develop—

(a) a gender-related serious physical or mental disability,

(b) a gender-related serious illness, or

(c) any other gender-related serious medical condition,

must not be preferred to those that are not known to carry such a risk.

Where there is a family history of a condition that affects one sex only, or affects one sex
significantly more than the other, embryos of the sex affected by the condition must not be selected
for implantation in preference to those of the unaffected sex. Effectively, this leaves open the
possibility for lawful sex selection in families with a history of a condition that tends to affect one
sex. If a couple are both carriers for Duchenne muscular dystrophy (an X-linked recessive disease),
they may choose to select only female embryos for implantation; they would not be permitted to
select male embryos in preference to female embryos. Sex selection for social reasons is not
permitted.

Termination of pregnancy: Ethical aspects

The difficulty in the abortion debate is often that different authors construct logically consistent and
reasonable answers based upon different opinions or beliefs about what makes a person morally
important. Whilst the arguments are all logical, they lead to radically different conclusions about the
morality of termination of pregnancy.

Some of the important arguments are outlined below. If you would like more information on using
philosophical reasoning to analyse these arguments, please go to MedEd, where you will find some
supplementary reading amongst the course materials for this Unit.

Arguments that focus on the moral significance of the fetus

It is possible to test whether a fertilised egg carries the human genome and therefore the potential
to develop into an adult human; to establish the stage at which a fetus develops the elements of a
nervous system that would enable it to perceive pain, and to say with some certainty the stage of

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gestation that a premature infant must have reached to stand a chance of surviving after delivery.
These are matters of fact.

Determining whether reaching any of those stages of development creates a (partial or absolute)
moral duty to refrain from intervening to end a pregnancy is a value judgment that requires further
deliberation and judgment. It is difficult to conceive of a scientific test that could prove whether or
not an embryo is a morally significant being with a strong claim to a right to life. This raises
important questions about tolerance of diverse views and the extent to which it is right to use the
law to regulate this aspect of human behaviour.

Which of these thresholds, which are all stages of human development, makes most sense to you as
a description of the kind of being that should not be killed?

1. A genetically human embryo

2. A being capable of experiencing pain
3. A viable human life
4. A self-aware being
5. A being capable of experiencing fear
6. A being that understands life and death

The first position derives from the principle of the sanctity of human life. Human life is something
special that must not be interfered with. A sanctity of life argument may often have a theological
basis, like John Locke’s argument in favour of an inalienable right to life: life is a precious gift that no-
one has the right to take away, even from themselves. Kant’s Enlightenment version of the
argument for respect for human dignity may also be relevant. In Kantian ethics, logic dictates that
human beings, whose reasoned deliberations are the source of our knowledge or moral law, cannot
justifiably be destroyed; if it were deemed permissible to take human life, this would be a universal
law, and under this universal law it would be possible to destroy the source of the law.

For some people, human life begins at conception. For others, the morally significant beginning of a
human life is when development has progressed beyond the point where two embryos could
develop from the fertilised egg.

A gradualist approach does not accept that an absolute right to life exists from the beginning of the
pregnancy, but accords the developing fetus more rights as it develops. At some point in
development, the fetus’ right to life increases to the point where it outweighs the pregnant woman’s
right to bodily self-determination.

However, the point at which rights should be accorded is open to debate, and leads onto further
questions. If ability to feel pain is the point that a right to life is respected, is abortion morally
permissible if the fetus is anaesthetised? What about the implications for other human beings with
diminished awareness of pain, existence and self, such as people in persistent vegetative states or
minimally aware states, people with severe dementia or profound intellectual disabilities, severely
disabled neonates? What about non-human beings with highly developed awareness of pain and
fear? Does this argument have implications for our beliefs about the permissibility of killing animals
for food or experimenting on animals to develop treatments for human diseases?

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The capacity to be born and survive has been treated as relevant in English law since 1929. Indeed,
the time limit for terminations carried out under s1(a) of the Abortion Act was reduced from 28
weeks to 24 weeks after advances in neonatal care allowed babies born at 24 weeks to survive. If a
pregnancy ends, either spontaneously or induced, before 24 weeks, the baby will not survive. After
24 weeks, late induced abortion involves delivery of a baby who may have been capable of survival
with medical care. If a woman goes into spontaneous labour at the same stage, the medical team
will try to save the baby’s life. It is this contrast that seems to lie at the heart of the viability
argument – it seems intuitively wrong that the survival of the baby at this stage depends solely on
the mother’s wishes. Is it reasonable to confer a moral right on the fetus on the basis of that
intuition? Can the moral significance of a being really depend on the current state-of-the-art in
neonatal care?

An alternative gradualist position is found in expressions of the personhood argument. These are
based on the idea that it is not human life per se that is deserving of special protection, but human
(or even potentially non-human) life that has developed the qualities, shared by most human beings,
that give us reason to believe that human beings deserve respect, protection and universal human
rights. Arguably, Kantian ethics might lead us to this position, and not to the sanctity of life position
after all. Utilitarian ethics, which depend upon the presence of people capable of having their
happiness increased or decreased as a consequence of a decision, will tend not to include the
interests of a fetus in calculations regarding the utility of abortion. The question that remains is this:
what is the property that make a person deserving of respect? Is it capacity for reason, capacity for
happiness or some other capacity? And what are the implications for human beings who have lost or
never developed those capacities?

Arguments that focus on the rights of pregnant women

Regardless of the point at which we believe that a fetus should be accorded moral rights, pregnant
women have interests and rights throughout the pregnancy. As a general rule, people are accorded a
right to bodily self-determination (a say over what happens to their bodies) and to equitable access
to necessary healthcare interventions. Is there a moral justification for limiting those rights in
pregnancy?

Does the fact that the fetus is dependent upon the woman for its survival give the fetus a right to
survival that the woman is obliged to respect? If this is the case, then pregnancy fundamentally
alters the general right to bodily self-determination. What about Kant’s argument that we should
never treat a human being solely as a means to an end? Does this prohibit us from requiring a
woman to carry an unwanted pregnancy to term?

What about cases where are pregnancy puts the woman’s health, or even her life, at risk? Whose
interests should prevail? If it’s a matter of balancing the vital interests of the woman and the fetus,
how grave does the risk to the woman’s health need to be before termination of the pregnancy is
morally justified?

If we accept that a pregnant woman is obliged to relinquish some of her autonomy rights because
the fetus is dependent upon her for survival, this raises further questions about the limits of self-
determination when the survival of others is in the balance. Are parents obliged to offer to become

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live kidney donors for their children? Should blood donation be mandatory for everybody? What
about registration for bone marrow donation?

Do the circumstances of the pregnancy affect the degree to which the women’s rights are affected?
If you knowingly run the risk of becoming pregnant, do you accept responsibility for carrying that
pregnancy to term? Do your responsibilities end there?

Does a woman whose contraception failed through no fault of her own retain a greater right to
bodily self-determination in pregnancy than a woman whose pregnancy was the result of failure to
use contraception in the heat of the moment? What are the rights of a woman who is pregnant as
the result of a rape? Again, the difficulty involved in reaching consensus about any of these
questions raises important issues about tolerance of diverse views

A note of caution: None of this should be taken as suggesting that it is impossible to develop a valid,
sound, potentially convincing argument for or against the moral permissibility of termination of
pregnancy. It is merely intended to illustrate why we should listen carefully to such arguments and
not be too quick to accept or dismiss them.

Maternal-fetal conflict
How far does a woman’s moral obligation to the fetus extend? Should she refrain from doing
anything that could adversely affect the fetus? Should she do everything in her power to ensure its
healthy development? And if she doesn’t, is it society’s responsibility to intervene? Such questions
arise when a pregnant woman refuses medical treatment that is necessary for a healthy live birth.

Refusals of caesarean section that may result in still birth are particularly emotionally charged.
However, the law is clear that interventions solely in the interests of baby are not permitted. In law,
you do not become a person with rights until you are born. Therefore, the legal rights in play are
those of the pregnant woman. Re MB, a case concerning a woman with a needle phobia who
repeatedly withdrew consent for a caesarean section at the point when a cannula needed to be
inserted, is a leading case. The judgement made clear that pregnant women who are adults with
capacity have the right to refuse treatment regardless of the consequences. If a woman lacks
capacity, then a decision must be made in her best interests. However, it is the interests of the
woman, not the baby, that are determinative. Achieving a live birth may well be in the interests of
the woman, but only if this actually is the case can the caesarean section be authorised.

N.B. Be clear how the Mental Capacity Act applies in pregnancy:

 It is the best interests of the woman, not the fetus, that you must use to guide your decision-
making
 Don’t conflate child protection decisions with decisions about the best interests of the
mother
 Unwise decisions are not proof of a lack of capacity
 Women must be presumed to have capacity until proven that a ‘disorder or dysfunction of
mind or brain’ renders them unable to make a decision

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The legal regulation of termination of pregnancy
In this section, the current legal framework for the regulation of termination of pregnancy is
outlined. Three Acts of Parliament address the issue: two set out a general prohibition on abortion,
and the third creates an exception to that prohibition, enabling doctors to carry out terminations,
provided certain circumstances apply.

Offences Against the Person Act 1861

S58 Administering drugs or using instruments to procure abortion.
Every woman, being with child, who, with intent to procure her own miscarriage, shall unlawfully administer to
herself any poison or other noxious thing, or shall unlawfully use any instrument or other means whatsoever
with the like intent, and whosoever, with intent to procure the miscarriage of any woman, whether she be or
be not with child, shall unlawfully administer to her or cause to be taken by her any poison or other noxious
thing, or shall unlawfully use any instrument or other means whatsoever with the like intent, shall be guilty of
felony

S59 Procuring drugs, &c. to cause abortion.

Whosoever shall unlawfully supply or procure any poison or other noxious thing, or any instrument or thing
whatsoever, knowing that the same is intended to be unlawfully used or employed with intent to procure the
miscarriage of any woman, whether she be or be not with child, shall be guilty of a misdemeanour

Effectively, this means that (with the exception of cases provided for by law, which we shall come
onto shortly) it is a serious criminal offence (felony) for a woman who believes herself to be
pregnant to attempt to induce a miscarriage.
Anyone who assists a woman believed to be pregnant to induce a miscarriage i.e. to terminate the
pregnancy, is guilty of a less serious criminal offence (a misdemeanour).
This law is still in place. However, since 1861 we have developed pregnancy tests. What might once
have been diagnosed as a late period and treated to ‘restore the menstrual cycle’, thereby
circumventing the prohibition on abortion, is now undeniably a first trimester termination.

Infant Life (Preservation) Act 1929

S1 Punishment for child destruction.
(1)Subject as hereinafter in this subsection provided, any person who, with intent to destroy the life of a child
capable of being born alive, by any wilful act causes a child to die before it has an existence independent of its
mother, shall be guilty of felony, to wit, of child destruction, and shall be liable on conviction thereof on
indictment to penal servitude for life:

Provided that no person shall be found guilty of an offence under this section unless it is proved that the act
which caused the death of the child was not done in good faith for the purpose only of preserving the life of
the mother.
(2)For the purposes of this Act, evidence that a woman had at any material time been pregnant for a period of
twenty-eight weeks or more shall be primâ facie proof that she was at that time pregnant of a child capable of
being born alive.

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The 1929 Act created the serious offence of child destruction, which applied to terminations carried
out after a gestational stage at which the child could have survived if delivered . Performing a
termination at this stage becomes a felony, rather than a misdemeanour. Thus, viability was treated
as having moral significance, with potentially viable fetuses being afforded greater legal protection.
However, the Act also incorporates the idea that the pregnant woman also had a right to life that
must be balanced against that of the fetus. When the fetus must be killed to save the woman, it is
the woman’s rights that prevail.

The Bourne Defence

In 1938, London gynaecologist Aleck Bourne performed an abortion on a fourteen-year-old girl,
pregnant as a result of rape. He reported himself to the police and was put on trial on charges of
procuring abortion. He was acquitted, and the judge described his actions as ‘an example of
disinterested conduct in consonance with the highest traditions of the profession.’ The case set a
precedent that doctors could not be successfully prosecuted for performing an abortion in cases
where the pregnancy would probably cause ‘mental and physical wreck.’

Abortion Act 1967(as amended by the HFEA 2008)

The Abortion Act 1967 was introduced as a Private Member’s Bill by David Steele MP. It created
important exceptions to the general prohibition on termination outlined in the 1861 and 1929
legislation, making termination of pregnancy lawful provided certain criteria are met:

s1.“. a person shall not be guilty of an offence…when a pregnancy is terminated by a registered medical
practitioner, if two registered medical practitioners are of the opinion, formed in good faith: …

Only doctors may lawfully terminate pregnancy, either by prescribing medication or by performing a
surgical procedure (they may be assisted by non-medical staff). Also, before the termination can
lawfully be carried out, two doctors must both state that one of the conditions laid out in s1a-d of
the Act is met.

a. In a pregnancy of <24 weeks, continuance of the pregnancy would involve risk ( greater than if the
pregnancy were terminated), of injury to the physical or mental health of the pregnant woman or any
existing children of her family

In 2016, 92% of abortions were carried out at under 13 weeks gestation and 81% were carried out at
under 10 weeks, which is slightly higher than in 2015 at 80%, and considerably higher than 2006 at
68%. (Source: Department of Health)

Most terminations are carried out before 24 weeks, on the grounds that the conditions laid out in
s1a are met. In fact, if a woman seeks a termination before 24 weeks, s1a will generally apply. This is
because a planned termination, especially early in the pregnancy, is a relatively low risk procedure
compared with the risks to the health of a woman associated with the later stages of pregnancy and

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the puerperium. Statistically, at this stage it is safer to have a termination than to continue a
pregnancy to full term.

Nonetheless, it is not acceptable to ‘pre-authorise’ terminations at less than 24 weeks by signing

forms for another doctor to use in clinic, essentially relying on the other doctor’s assessment of the
case without making your own assessment. Following a GMC and police investigation in 2012, which
found that the practice of signing HSA1 forms in advance, for a colleague to co-sign after reviewing
women attending clinic had become commonplace, guidance was issued to confirm that this is
unlawful. Lawful termination requires that two doctors both assess the case and arrive at a decision
as to whether this particular woman’s situation meets the criteria.

Whilst the vast majority of terminations are carried out in the earlier stages of pregnancy,
termination may be lawful at any stage of pregnancy, up to the point of birth, under particular
circumstances laid out in ss1 b-d

b. Termination is necessary to prevent grave permanent injury to the physical or mental health of the
pregnant woman
c. Continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if
pregnancy were terminated
d. That there is a substantial risk that if the child were born it would suffer from such physical or mental
abnormalities as to be seriously handicapped

S1c echoes the principle that emerged in the 1929 Act i.e. that it is permissible to terminate a viable
pregnancy in order to save the life of the pregnant woman.

Ss1b&d have a consequentialist feel to them: a viable pregnancy may be terminated on the grounds
that allowing it to continue would have serious adverse consequences, in terms of suffering that
either the pregnant woman or the child would endure.

Terms such as ‘grave injury’, ‘substantial risk’ and ‘serious handicap’ are not defined within the Act,
leaving them open to interpretation by medical practitioners and the Courts.

In practice, around 2% of terminations are carried out on the grounds of fetal abnormality (source:
DoH).

Terminations carried out for any other reason than those give in s. 1a-d remain unlawful. This
includes termination for sex selection, which must not be undertaken at any stage.

Conscientious objection
S4.1 No person shall be under any duty, whether by contract or any other statutory or other legal
requirement to participate in any treatment authorised by this Act to which he has a conscientious objection.

This clause provides for doctors (and other people who may be directly involved in terminations such
as nurses) who feel unable to participate in lawful termination of pregnancy, because this would

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entail carrying out an action that they consider morally wrong. Often, though not inevitably, this will
be because they adhere to a religious faith that prohibits termination of pregnancy.

If this applies to you, you are under no obligation to participate in terminations and should not be
pressurised in any way to do so. However, you remain under an obligation to behave professionally
and make the care of your patient your first concern. You must not prevent or hinder patients from
accessing lawful terminations; you should politely explain that you do not participate in this aspect
of medical treatment but that you will refer them promptly to a colleague who does.

Female Genital Mutilation

The WHO, UNICEF and UNFPA issued a joint statement in 1997 defining FGM as "all procedures
involving partial or total removal of the external female genitalia or other injury to the female
genital organs whether for cultural or other non-therapeutic reasons". Late complications include
scarring, leading to strictures and obstruction. Cervical evaluation during labour may be impeded
and labour prolonged or obstructed. Third-degree laceration (tears), anal-sphincter damage and
emergency caesarean section are more common in infibulated women.

In the UK, FGM is prohibited by:

 The Prohibition of Female Circumcision Act (1985)

 The Female Genital Mutilation Act (2003) England, Wales, NI
 The Prohibition of Female Genital Mutilation Act (2005) Scotland

It is a crime, punishable by a maximum penalty of 14 years imprisonment, to:

 Excise, infibulate or otherwise mutilate the whole or any part of the labia majora or labia
minora or clitoris of another person
 Aid, abet, counsel or procure a girl to mutilate her own genitalia
 Aid, abet, counsel or procure another person who is not a UK national to mutilate a girl’s
genitalia outside the UK

Health & social care professionals and teachers in England & Wales also have a statutory duty to
report ‘known’ cases of FGM in girls under the age of 18 to the police. The duty to report applies if,
in the course of their professional duties, they:

 are informed by a girl under 18 that an act of FGM has been carried out on her; or
 observe physical signs which appear to show that an act of FGM has been carried out on a
girl under 18 and have no reason to believe that the act was necessary for the girl’s physical
or mental health or for purposes connected with labour or birth.

It doesn’t mean that police will take action without consulting appropriately with social care
professionals and other relevant professionals. It won’t require professionals to report cases to the
police where they suspect FGM may have been carried out or think a girl may be at risk. The duty
also doesn’t apply to women aged 18 or over. Professionals will follow existing safeguarding
procedures in these cases.

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Obstetric care for women following FGM – repair of tears

‘It is possible that obstetricians and midwives may be asked to re-infibulate a woman following
vaginal delivery. Any repair carried out after birth, whether following spontaneous laceration or
deliberate defibulation, should be sufficient to appose raw edges and control bleeding, but must not
result in a vaginal opening that makes intercourse difficult or impossible. The WHO recommends
suturing of raw edges to prevent spontaneous reinfibulation.’ (Source: RCOG Green-top Guideline
no.53)

It is important to follow these guidelines. The first prosecution for FGM in the UK was a case against
a trainee obstetrician who used a single continuous suture in a figure-of-eight to repair a midline
episiotomy in a woman who had previously undergone FGM in Somalia at the age of 7. The
episiotomy was necessary to ensure the safe Ventouse delivery of the baby, and bled continuously
after delivery.

The doctor had never treated a woman who had undergone FGM before, but worked in a hospital
which treated around 130 such women every year. He had not read the hospital policy, which states
that the labia should never be stitched together during repair after childbirth, and he did not consult
the on-call consultant before proceeding with the repair.

The doctor was found not guilty – his intention was to stop the bleeding, not to restore the FGM.
The SUI investigation following the incident recommended more training and a period of reflection
for the doctor concerned.

Take home messages:

 Be familiar with the guidance on peri-natal care of women who have undergone FGM
 Get appropriate training if you are working in O&G in a hospital that regularly treats women
who have undergone FGM
 If in doubt, and it is safe to do so, get advice from a senior before repairing an episiotomy or
spontaneous tear in a woman who has undergone FGM.

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