Appendix A: Pre Birth Assessment Tool

Family Structure

Names, addresses, ages etc. Extended family and potential support should be included.

Ante-Natal Care: Medical And Obstetric History

General Guidance

Antenatal care begins as soon as the pregnancy has been confirmed and midwives continue care in the postnatal period for at least 10 days following birth. A booking interview with the community midwife takes place ideally between 8-12 weeks gestation. This is usually in the woman's home or at the GP's surgery. It is at this interview that the midwife is able to assist women in their choices for childbirth and ensure they are informed of all the options available to them.

Women are given choices in early pregnancy of lead professional and place of birth:

Midwife-led care (MLC) means the midwife is the lead professional. All antenatal care would be conducted in the community and is often shared with the General Practitioner (GP). Women would have the choice of giving birth in the hospital under MLC or at home with midwives in attendance.

GP led care is less frequently offered and again all antenatal care is conducted in the community and is shared between GP and community midwife. The place of birth is rarely at home with the GP in attendance so most GP births occur in a low-risk hospital environment.

Consultant led care is offered to women who have recognised health risk factors or who choose to see the consultant team. These pregnancies require additional surveillance both pre-birth and in labour. Care is shared between the community midwife, GP and a hospital consultant team consisting of midwives and doctors specialising in care of high risk pregnancy. Delivery of the baby will take place in the hospital.

The booking interview is a time of collection of information and an opportunity for the midwife and mother to plan her care in pregnancy. It is an ideal time for the midwife to assess health and social needs of families and to consider packages of care and support suitable for individual needs.

Antenatal appointments are arranged to suit the individual clinical needs of the mothers and the initial choices may change if complications of pregnancy arise. A collaborative approach between all health professionals is encouraged with direct midwife referral to obstetrician being available at all times.

In the case of home births all postnatal care is provided in the home by the community midwife. For births in hospital - with either the midwife, GP or obstetrician as the lead professional - initial postnatal care is provided by midwives and support staff on the maternity wards. Hospital stays are getting shorter with many women going home within a few hours of birth but generally 12-48 hours are the more normal lengths of stay. On transfer home care is undertaken by the community midwife for at least 10 days following the birth. Care can be extended to up to 28 days if a particular clinical or social need is identified. Liaison between the Health Visitor attached to the GP's surgery and community midwife usually takes place during the antenatal period with some Health Visitors making contact with the mother in pregnancy. Following the birth of the baby most Health Visitors arrange a primary visit at 10 days postnatal, which coincides well with the handover of care from the midwives.

Assessment of Parents and Potential Risks to Child

Pregnancy can create special circumstances/influences for both parents, which need to be accommodated and understood by all professionals who come into contact with these families. Pregnancy will have a major impact on some people's lives and will affect both behaviour and relationships. Pregnant women's health and their responses to external factors often change in pregnancy - and the physiological, emotional and social influences that both cause and are affected by these changes can have a direct impact on their behaviour and health and how they manage in key relationships.

This section should be completed by an appropriate Health Professional. The central question is whether there is anything in the medical and obstetric history that seems likely to have a significant negative impact on the child? And if so, what?

Some basic details:

• Name, age, date of birth, and address of mother;
• Next of kin;
• Marital status;
• Occupation.

Assessment issues

• Are there any aspects of any of the following items that seem likely to have a significant negative impact on the child? If so, what, and how?
• Partner support?
• Family structure and support available (or potentially available or not available)?
• Whether pregnancy planned or unplanned?
• Feelings of mother about being pregnant?
• Feelings of partner / putative father about the pregnancy?
• Dietary intake - and related issues?
• Medicines or drugs - whether or not prescribed - taken before or during pregnancy?
• Alcohol consumption?
• Smoking?
• Previous obstetric history?
• Current health status of other children?
• Miscarriages and terminations?
• Chronic or acute medical conditions or surgical history?
• Psychiatric history - especially depression and self-harming?

This section will usually be completed by the Social Worker - but they will need to draw on help from a range of other professionals regarding some aspects of it.

Particular care should be taken when assessing risks to babies whose parents are themselves children. Attention should be given to a) evaluating the quality and quantity of support that will be available within the family (and extended family), b) the needs of the parent(s) and how these will be met) the context and circumstances in which the baby was conceived, and d) the wishes and feelings of the child who is to be a parent.

1. Relationships

• History of relationships of adults?
• Current status?
• Positives and negatives?
• Violence?
• Who will be main carer for the baby?
• What are the expectations of the parents re each other re parenting?

Is there anything regarding "relationships" that seems likely to have a significant negative impact on the child? If so, what?

2. Abilities

• Physical?
• Emotional? (including self control);
• Intellectual?
• Knowledge and understanding re children and child care?
• Knowledge and understanding of concerns / this assessment?

Is there anything regarding "abilities" that seems likely to have a significant negative impact on the child? If so, what?

3. Social history

• Experience of being parented?
• Experiences as a child? And as an adolescent?
• Education?
• Employment?

Is there anything regarding "social history" that seems likely to have a significant negative impact on the child? If so, what?

4. Behaviour

• Violence to partner?
• Violence to others?
• Violence to any child?
• Drug misuse?
• Alcohol misuse?
• Criminal convictions?
• Chaotic (or inappropriate) life style?

Is there anything regarding "behaviour" that seems likely to have a significant negative impact on the child? If so, what?

If drugs or alcohol are a significant issue, more detailed assessment should be sought from professionals with relevant expertise.

5. Circumstances

• Unemployment / employment?
• Debt?
• Inadequate housing / homelessness?
• Criminality?
• Court Orders?
• Social isolation?

Is there anything regarding "circumstances" that seems likely to have a significant negative impact on the child? If so, what?

6. Home conditions

• Chaotic?
• Health risks / insanitary / dangerous?
• Over-crowded?

Is there anything regarding "home conditions" that seems likely to have a significant negative impact on the child? If so, what?

7. Mental Health

• Mental illness?
• Personality disorder?
• Any other emotional/behavioural issues?

Is there anything regarding "mental health" that seems likely to have a significant negative impact on the child? If so, what?

If mental health is likely to be a significant issue, more detailed assessment should be sought from professionals with relevant expertise.

8. Learning Disability

Is there anything regarding "learning disability" that seems likely to have a significant negative impact on the child? If so, what?

If learning disability is likely to be a significant issue, more detailed assessment should be sought from professionals with relevant expertise.

9. Communication

• English not spoken or understood?
• Deafness?
• Blindness?
• Speech impairment?

Is there anything regarding "communication" that seems likely to have a significant negative impact on the child? If so, what?

If communication is likely to be a significant issue, more detailed assessment should be sought from professionals with relevant expertise.

10. Support

• From extended family?
• From friends?
• From professionals?
• From other sources?

Is there anything regarding "support" that seems likely to have a significant negative impact on the child? If so, what?

Is support likely to be available over a meaningful time-scale?

Is it likely to enable change?

Will it effectively address any immediate concerns?

11. History of being responsible for children

• Convictions re offences against children?
• CP Registration?
• CP concerns - and previous assessments?
• Court findings?
• Care proceedings? Children removed?

Is there anything regarding "history of being responsible for children" that seems likely to have a significant negative impact on the child? If so, what?

If so also consider the following:

• Category and level of abuse;
• Ages and genders of children;
• What happened?
• Why did it happen?
• Is responsibility appropriately accepted?
• What do previous risk assessments say? Take a fresh look at these - including assessments re non-abusing parents;
• What is the parent's understanding of the impact of their behaviour on the child?
• What is different about now?

12. History of abuse as a child

• Convictions - especially of members of extended family?
• CP Registration?
• CP concerns
• Court findings?
• Previous assessments?

Is there anything regarding "history of abuse" that seems likely to have a significant negative impact on the child? If so, what?

13. Attitude to professional involvement.

• Previously - in any context?
• Currently - regarding this assessment?
• Currently - regarding any other professionals?

Is there anything re "attitudes to professional involvement" that seems likely to have a significant negative impact on the child? If so, what?

14. Attitudes and beliefs re convictions or findings (or suspicions or allegations)

• Understood and accepted?
• Issues addressed?
• Responsibility accepted?

Is there anything regarding "attitudes and beliefs" that seems likely to have a significant negative impact on the child? If so, what?

It may be appropriate to consult with the Police or other professionals with appropriate expertise.

15. Attitudes to child

• In general?
• Re specific issues?

Is there anything regarding "attitudes to child" that seems likely to have a significant negative impact on the child? If so, what?

16. Dependency on partner

• Choice between partner and child?
• Role of child in parent's relationship?
• Level and appropriateness of dependency?

Is there anything regarding "dependency on partner" that seems likely to have a significant negative impact on the child? If so, what?

17. Ability to identify and appropriately respond to risks?

Is there anything regarding this that seems likely to have a significant negative impact on the child? If so, what?

18. Ability to understand and meet needs of baby

Is there anything regarding this that seems likely to have a significant negative impact on the child? If so, what?

It may be appropriate to consult with Health professionals re this section.

19. Ability to understand and meet needs throughout childhood

Is there anything regarding this that seems likely to have a significant negative impact on the child? If so, what?

It will usually be appropriate to consult with relevant Health professionals re this section.

20. Ability and willingness to address issues identified in this assessment

• Violent behaviour?
• Drug misuse?
• Alcohol misuse?
• Mental health problems?
• Reluctance to work with professionals?
• Poor skills or lack of knowledge?
• Criminality?
• Poor family relationships?
• Issues from childhood?
• Poor personal Care?
• Chaotic lifestyle?

Is there anything regarding "ability and willingness to address issues" that seems likely to have a significant negative impact on the child? If so, what?

It will usually be appropriate to consult with other professionals re this section.

21. Any other issues that have potential to adversely affect or benefit the child.

E.g. one or more parent aged under 16? Context and circumstances of conception?

22. Planning for the future

• Realistic and appropriate?

Use should be made of the "Framework for Assessment" described below.

The assessment report should address the following issues:

1. Concerns identified;
2. Strengths or mitigating factors identified;
3. Is there a risk of significant harm for this baby?
   It is crucial to clarify the nature of any risk - of what? From whom? In what circumstances? etc - and to be clear how effective any strengths or mitigating factors are likely to be in reality;
4. Will this risk arise:
   1. Before the baby is born?
   2. At or immediately following the birth?
   3. Whilst still a baby (up to 1 year old)?
   4. As a toddler? or pre-school? or as an older child?
      If there is a risk that the child's needs may not be appropriately met:
5. What changes should ideally be made to optimise well-being of child?
   If there is a risk of significant harm to the child...
6. What changes must be made to ensure safety and an acceptable level of care for child?
7. How motivated are the parent's to make changes?
8. How capable are the parent's to make changes? And what is the potential for success?

Framework taken from an adaptation by Martin Calder in 'Unborn Children: A Framework for Assessment and Intervention' of R. Corner's 'Pre-birth Risk Assessment: Developing a Model of Practice'.

Framework for Practice: Risk Estimation

Factor	Elevated Risk	Lowered Risk
The abusing parent	Negative childhood experiences, inc. abuse in childhood; denial of past abuse; Violence abuse of others; Abuse and/or neglect of previous child; Parental separation from previous children; No clear explanation No full understanding of abuse situation; No acceptance of responsibility for the abuse; Antenatal/post natal neglect; Age: very young/immature; Mental disorders or illness; Learning difficulties; Non-compliance; Lack of interest or concern for the child.	Positive childhood; Recognition and change in previous violent pattern; Acknowledges seriousness and responsibility without deflection of blame onto others; Full understanding and clear explanation of the circumstances in which the abuse occurred; Maturity; Willingness and demonstrated capacity and ability for change; Presence of another safe non-abusing parent; Compliance with professionals; Abuse of previous child accepted and addressed in treatment (past/present); Expresses concern and interest about the effects of the abuse on the child.
Non-abusing parent	No acceptance of responsibility for the abuse by their partner; Blaming others or the child.	Accepts the risk posed by their partner and expresses a willingness to protect; Accepts the seriousness of the risk and the consequences of failing to protect; Willingness to resolve problems and concerns.
Family issues (marital partnership and the wider family)	Relationship disharmony/instability; Poor impulse control; Mental health problems; Violent or deviant network, involving kin, friends and associates (including drugs, paedophile or criminal networks); Lack of support for primary carer /unsupportive of each other; Not working together; No commitment to equality in parenting; Isolated environment; Ostracised by the community; No relative or friends available; Family violence (e.g. Spouse); Frequent relationship breakdown/multiple relationships; Drug or alcohol abuse.	Supportive spouse/partner; Supportive of each other; Stable, or violent; Protective and supportive extended family; Optimistic outlook by family and friends; Equality in relationship; Commitment to equality in parenting.
Expected child	Special or expected needs; Perceived as different; Stressful gender issues.	Easy baby; Acceptance of difference.
Parent-baby relationships	Unrealistic expectations; Concerning perception of baby's needs; Inability to prioritise baby's needs above own; Foetal abuse or neglect, including alcohol or drug abuse; No ante-natal care; Concealed pregnancy; Unwanted pregnancy identified disability (non-acceptance); Unattached to foetus; Gender issues which cause stress; Differences between parents towards unborn child; Rigid views of parenting	Realistic expectations; Perception of unborn child normal; Appropriate preparation; Understanding or awareness of baby's needs; Unborn baby's needs prioritised; Co-operation with antenatal care; Sought early medical care; Appropriate and regular ante-natal care; Accepted/planned pregnancy; Attachment to unborn foetus; Treatment of addiction; Acceptance of difference-gender/disability; Parents agree about parenting.
Social	Poverty; Inadequate housing; No support network; Delinquent area.
Future plans	Unrealistic plans; No plans; Exhibit inappropriate parenting plans; Uncertainty or resistance to change; No recognition of changes needed in lifestyle; No recognition of a problem or a need to change; Refuse to co-operate; Disinterested and resistant; Only one parent co-operating.	Realistic plans; Exhibit appropriate parenting expectations and plans; Appropriate expectation of change; Willingness and ability to work in partnership; Willingness to resolve problems and concerns; Parents co-operating equally.