Pre-Birth Assessments

Some prospective parents may need additional support during the pregnancy and for the care of their baby or in some circumstances it may be anticipated that the baby yet to be born is likely be at risk of Significant Harm.

For those involved with pregnant women, irrespective of age, there is a need to be mindful of safeguarding issues, including a pregnancy as a result of sexual abuse, domestic abuse or if there are concerns about the parents / potential carers ability to look after the new baby/babies.

Where pre-birth involvement is a result of the mother’s learning difficulties causing uncertainty as to her ability to meet the needs of the child once born, the Court of Appeal in D (A Child) [2021] EWCA Civ 787 stressed the importance of effective planning during the pregnancy for the baby’s arrival, and of taking adequate steps to ensure that the mother understands what is happening and is able to present her case.

See also: Children of Parents with Learning Difficulties/Disabilities Procedure.

The below circumstances indicate an increased risk to an unborn child and a pre-birth assessment maybe required. Therefore, in order to make that decision a referral must be made to Children’s Social Care and a strategy meeting/professionals meeting needs decide whether a pre-birth assessment should be undertaken. Where there is an unborn baby the midwifery service must be invited to the strategy / professionals meeting.

• There has been a child who has previously died due to non accidental injuries in the care of a parent/carer - including the sudden and unexpected death of a child where any safeguarding concerns were raised (to avoid missing cases where there was no concluded injury as cause of death but could have been neglect of medical symptoms or lack of supervision);
• Where previous children have been removed from either parent, either temporarily or by court order, because they have suffered harm;
• Where concerns exist regarding either parent’s ability to protect;
• Where there are concerns regarding domestic abuse;
• A parent or other adult in the household, or regular visitor, has been identified as posing a risk to children;
• A child in the household is the subject of a Child Protection Plan;
• Either parent is a Child Looked After or are known to children’s social care;
• Either or both parents have mental health problems;
• Either or both parents have a learning difficulty, additional learning needs or diagnosed disabilities;
• Either or both parents are under 18 years;
• Either or both parents abuse substances, alcohol or drugs;
• If the pregnancy is denied or concealed. See Concealed Pregnancies Procedure.

All of the above should be noted on the file. If a decision is made not to undertake a pre-birth assessment, then this should be clearly recorded in all agencies’ files.

Women have the right to make an informed decision not to attend for maternity care. If the woman is choosing not to attend for antenatal or postnatal care, the risks of this must be discussed with the woman by a Midwife and/ or Obstetrician. The discussion, including all potential risks and the woman’s understanding of them, must be documented in the woman’s medical notes and alternative care arrangements recorded if any are agreed.

A mental capacity assessment must be completed if there are concerns the woman lacks capacity to make an informed decision about her care options.

If a professional believes that a woman is declining care under duress or to avoid services as there are safeguarding issues, this must be investigated. Support and advice can be sought from the professional’s adult and/ or children’s safeguarding teams and the Local Authority where the woman resides.

Most pregnancies are identified within the first 3 months. NICE guidelines recommend that women book for antenatal care by 10 weeks gestation. During the booking interview with the midwife the following information is collected, where Mother is willing to provide it:

• Name;
• Age/Date of birth;
• Address;
• Next of Kin;
• Marital Status;
• Details of the unborn baby’s biological father and exploration of contact between baby and biological father. (If father’s details not provided an information sharing form is raised internally due to concerns regarding hidden males);
• Partner Support;
• Family structure and support;
• Occupation;
• Ethnic origin;
• Visa status;
• Housing assessment (Homeless Duty to refer completed if at risk of homelessness - see Guidance: A guide to the duty to refer (GOV.UK));
• Planned/Unplanned pregnancy;
• Feelings about being pregnant;
• Diet;
• Medicines or drugs taken before and during pregnancy;
• Alcohol/cigarette consumption;
• Previous obstetric history including:
• Number of children, date of births of children, names, current health status;
• Do the children live in the household;
• Same partner as previous children;
• Any history of mental health issues;
• Any learning difficulty, additional learning needs or diagnosed disabilities;
• Family health history;
• Domestic Abuse;
• Evidence or risk of FGM – see Female Genital Mutilation Multi-Agency Protocol;
• Any current/previous social care involvement for patient/partner or any children of prospective parents.

This information builds into a full medical and social history and when all the data is assimilated, the midwife not only will be able to assist the women in making informed choices about the care she receives, advise on the suitability of her choices but will be able to consider if there are any concerns for the unborn child. Equally other professionals involved with either parent may also be concerned when aware of a pregnancy, and must not assume that they are known to midwifery services and therefore undertake their own assessment of risk.

Where agencies or individuals anticipate that prospective parents may need support services to care for their baby they should clarify as far as possible, using the Early Help Assessment (EHA), what they already know about the family and their concerns in terms of how the parent's circumstances and/or behaviours that may impact on the baby and what risks are predicted. This could result in the EHA author calling a Team Around the Child (TAC) or other multi agency meeting under the relevant area's EHA procedures to help identify a multi-agency package of support for the baby and family. This should take place as soon as possible.

If the EHA author/TAC meeting is concerned that the unborn baby may be at risk of Significant Harm, a referral to Children's Social Care must be made - see the Making Referrals to Children’s Social Care Procedure. This will then be considered for a single Assessment. Once open to Children's Social Care the support to the unborn baby and family should be planned and monitored by a multi-agency plan, which may be a Child Protection Plan as appropriate.

A multi agency meeting and/or referral should be made at the earliest opportunity in order to:

• Enable the early provision of support services so as to facilitate optimum home circumstances prior to the birth;
• Enable the parents to have more time to contribute their own ideas and solutions to concerns and increase the likelihood of a positive outcome to assessments;
• Avoid initial approaches to the parents in the last stages of pregnancy, at what is already an emotionally charged time;
• Provide sufficient time for a full and informed assessment;
• Provide sufficient time to make adequate plans for the baby's protection.

Concerns should be shared with prospective parent(s) and consent obtained to refer to Children's Social Care UNLESS in doing so the unborn/sibling will be at an increased risk of significant harm. In those cases practitioners should liaise with named / designated professional for safeguarding for advice and support.

If an urgent response is required due to a concealed pregnancy or denied pregnancy a strategy meeting is required. See Concealed Pregnancies Procedure.

A pre-birth Assessment should take place when there is evidence to indicate the unborn child may be at risk of Significant Harm or a child in need as defined in the Children Act 1989.

Consideration needs to be given seriously as to when during the pregnancy the child protection procedures are invoked to ensure the appropriate support and monitoring can be put in place sufficiently early to enable appropriate preventative action in cases such as:

• The mother is identified as at risk of sexual exploitation;

• The lifestyle of the mother is putting the foetus at risk of harm e.g.: misuse of alcohol and/or other substances, particularly where there has been no response to brief interventions or engagement in specialist treatment services. (Alcohol or substance misuse may be identified by relevant local screening tools identifying the potential harm to the foetus as well as the potential harm to the mother, third party information, observed presentation of intoxication, smelling of alcohol, or signs of withdrawal);

• Planning protection for after the birth - if it is assessed that there is a need to provide particular support services or a change of living accommodation when the child is born.

The longer the time available for such a period of assessment the more thorough and comprehensive such an assessment can be.

The Pre birth Assessment should be completed within 45 working days and recorded on the social work assessment template. Relevant partner information should be included within the pre-birth assessment. It will commence as early as possible from the point that a referral is received. At this point a decision is to be made about the level of support required by the family via multi-agency professionals meeting, at which the assessment will be shared. This should include whether an Initial Child Protection Conference is appropriate, or a Legal Planning Meeting needs to be convened to consider initiating Public Law Outline prior to birth and/or initiating proceedings at birth (see Section 7, Public Law Outline).

There may be unusual circumstances when an assessment may be required to be undertaken expediently, e.g. a pre-conception assessment is requested; e.g. IVF, or if a pregnancy has been concealed, or denied.

In summary the Assessment should identify:

• Risk factors;
• Strengths in the family environment;
• Factors likely to change, reasons for this and timescales.

See Appendix A: Pre Birth Assessment Tool.

The assessment must make recommendations regarding the need, or not, for a pre-birth Child Protection Conference. The assessment should also make a recommendation about the need, or not, for a pre-birth Legal Planning Meeting.

When there are features of neglect in a case reference should be made to the use of the Graded Care Profile/Neglect Toolkit/Thriving Families Tool (where there are other children in the family) in order to create a base line assessment to measure progress.

There should be consideration to a referral for a Family Group Conference or holding a family meeting at this juncture to identify support and any potential alternative carers.

Social Workers should consider if referrals to other services are required so relationships can be built, and support provided at an early stage.

On occasion there will be sufficient concerns about the future risks to an unborn child to warrant the convening of a Child Protection Conference to consider the need for the baby to be the subject of an inter-agency Child Protection Plan.

This decision will normally follow on from a pre-birth assessment. This conference should have exactly the same status as any Initial Child Protection Conference.

A pre-birth conference must be held:

• When a pre-birth assessment gives rise to concerns that an unborn child may be at risk of Significant Harm;
• Where a previous child has died or been seriously injured or been removed from parent(s) as a result of Significant Harm;
• Following assessment where a child is to be born into a family or household which already have children subject to a Child Protection Plan;
• Following assessment where a person known to pose a risk to children resides in the household or is known to be a regular visitor.

Other risk factors which must be considered are:

• The impact of parental risk factors such as mental ill health, learning disabilities, alcohol and/or substance misuse and domestic violence and abuse, as well as non-attendance, lack of engagement or recurring lapses, evidence of superficial compliance, or persistently not recognising the impact of parental risk factors on child’s needs and potential consequences;
   
• Either parent aged 16 years or under about whom there are concerns regarding their ability to care for themselves and/or to care for the child.

All agencies involved with pregnant women should consider the need for an early referral to the local Children's Social Care team so that assessments are undertaken and family support services provided as early as possible in the pregnancy.

The pre-birth conference should be convened in time to pool and share information and identify an inter-agency Child Protection Plan where necessary. The timing of the conference should take into account the expected date of delivery. Ideally the pre-birth conference should take place by 32 weeks gestation, or earlier if there is a history of premature birth. Professionals should note that a pregnancy is considered to be full term at 37 weeks and therefore planning arrangements should be cognisant of this.

If a decision is made that the unborn child will be made the subject of a Child Protection Plan from birth, the main cause for concern should determine the category of the Child Protection Plan. The Core Group must be established at the initial conference and meet prior to the birth and certainly prior to the baby's return home after a hospital birth. The first Child Protection Review Conference will take place within three months of the pre-birth conference or within one month of the birth whichever is the sooner.

The Safeguarding Unit will record the pre-birth conference decision and expected date of delivery as part of the plan prior to the birth.

The Safeguarding Unit must be notified of the child's name and correct birth date immediately following the birth.

If it is not possible to hold a Child Protection Conference before the birth of a baby who is considered at risk of Significant Harm, contact should be made with the relevant Children's Social Care team for immediate action to protect the child, and consideration should be given to them convening an Initial Child Protection Case Conference at the earliest opportunity.

If the unborn baby is made subject of a Child Protection Plan, then the CP-IS marker will be added to the mother’s NHS number. CP-IS will notify Children’s Social Care if the Mother attends acute hospital and/or urgent care settings.

In cases where it has been agreed at Legal Planning Meeting that work should be undertaken under the Public Law Outline framework, there should be as little delay as possible in sending out Letters before Proceedings and holding Pre Proceedings meetings. This is in order to avoid such approaches to the pregnant woman in the late stages of pregnancy and to work with the family to explore all options in order to preferably avoid initiating Care Proceedings. There is also an opportunity to commission specialist assessments at this stage.

In cases where there is a recommendation to initiate Care Proceedings at birth, cases should be booked into the Legal Planning Meeting at the earliest possible date prior to the birth. The Child and Family Assessment and full Chronology must be available at the Legal Planning Meeting and should include all relevant agency information. There should be discussion about the appropriateness of a referral for a Family Group Conference.

In the case of late referrals meeting the threshold for legal planning, the social worker and practice manager can request an emergency Legal Planning discussion rather than waiting until the next available date for a Legal Planning Meeting.

If there are concerns that parents may go missing or conceal the birth utilising the CP-IS as above should be considered to afford the unborn child the protection of a Child Protection plan until the Care order has been secured.

If the decision of the Legal Planning Meeting is that the unborn baby should be the subject of Care Proceedings, a Birth Planning Meeting should take place.

The purpose of the Birth Planning Meeting is for professionals to be clear about their roles and responsibilities and to agree a multi-agency plan to safeguard the baby once born.

The social worker with case responsibility will attend this meeting, along with the midwife and/or safeguarding team, other relevant professionals involved with the family and GMP where appropriate.

Consideration should be given to the expected date of delivery and other ongoing investigations when planning the timing of the meeting. The decisions of this meeting should be recorded in the patient’s records by the lead midwife in consultation with the named midwife for safeguarding, who will ensure that the midwives are fully appraised of the plan for the child.

The agenda for this meeting should address the following:

• How long the baby will stay in hospital. A minimum of 3-4 days for observation. If a baby is showing signs of withdrawal then their length of stay will depend on the clinical need of the baby;
• How long Mum may need to be supported on the ward;
• The arrangements for the immediate protection of the baby if it is considered that there are serious risks posed from parental alcohol consumption, substance misuse; mental ill health and/or domestic abuse/violence. Consideration should be given to the use of hospital security; informing the Police;
• The risk of potential abduction of the baby from the hospital particularly where it is planned to remove the baby at birth;
• How parents can be supported to access the Court Hearing while at hospital if it is virtual (location, private room, etc.);
• The plan for contact between mother, father, extended family and the baby whilst in hospital. Consideration to be given to the supervision of contact – for example whether contact supervisors need to be employed. This is particularly important when there are risks posed by registered sex offenders as this needs careful planning and supervision;
• Consideration of any risks to the baby in relation to breastfeeding e.g. HIV status of the mother; medication being taken by the mother which is contraindicated in relation to breastfeeding;
• The plan for the baby upon discharge that will be under the auspices of Care Proceedings, e.g. discharge to parent/extended family members; mother and baby foster placement; foster care, supported accommodation. The parents should be involved in the logistics of baby’s removal from the ward if this is assessed to be safe and appropriate;
• Consideration should be given to whether or not North West Ambulance Service NHS Trust should be notified to facilitate safe transfer to hospital and effective communication with partner agencies. Information sharing should include an assessment of risk including violence and aggression. Please contact 01228 403000 or 01204 498400 to speak to the NWAS Safeguarding Team;
• Contingency plans should also be in place in the event of a sudden change in circumstances;
• Who to contact should the baby be born out of hours;
• The Children’s Out of Hours Service should also be notified of the birth and plans for the baby.

The hospital midwives should inform Children’s Social Care of the birth of the baby as soon as possible (ideally the allocated Social Worker will be informed once the expectant mother is admitted in established labour).

In cases where legal action is proposed or where the unborn child has been the subject of a Child Protection Plan, the allocated Lead Social Worker should visit the hospital on the next working day following the birth. The Lead Social Worker should meet with relevant maternity staff prior to meeting with the mother and baby to gather information and consider whether there are any changes needed to the discharge and protection plan. The midwife with access to the health records should record a brief note of the Social Worker’s visit on the child’s medical notes, which should include the time, key points of the discussion, agreements and social work contact details. The Lead Social Worker should visit the baby and parents on the ward in accordance with the agreed child protection plan and birth plan.

Ward staff should keep a daily record of any visitors to the child and details of any concerns that emerge whilst on the ward. This could be important information for child protection planning or evidence needed for care proceedings.

If the baby is the subject of a Child Protection Plan, a Core Group discharge meeting should be held to draw up a detailed plan prior to the baby’s discharge home as per child protection planning arrangements.

If a decision has been made to initiate Care Proceedings in respect of the baby, the Lead Social Worker must keep relevant maternity staff updated about the timing of any application to the Courts. The Safeguarding midwife or child’s designated doctor should be informed immediately of the outcome of any application and placement for the baby. A copy of any Orders obtained should be forwarded immediately to the hospital if they are not being discharged that same day.

PLEASE NOTE: The application to court can only be made once the baby is born. If there are immediate child protection concerns prior to the order being granted then contact the police.

When it is established that a young person in care or a supported care leaver is pregnant, the referrer must ring for a consultation with the respective Local Authority’s Contact and Referral Team. A decision can then be reached about the assessment process between both the referring team and the Contact and Referral Team (the contact and referral team is the ‘front door’ of Children’s Social Care and may be referred to by another name depending on the borough).

It should not be an automatic decision to complete a pre-birth assessment in relation to the pregnancies of all care leavers unless the thresholds are met as outlined above. 

If the Section 47 threshold is met and a Strategy Meeting convened, relevant staff from the children in care teams should be included.

If the young person’s placement is out of borough the Children’s Social Care service must refer the case of the unborn baby to the relevant Contact and Referral Team in the area in which the mother and baby are currently living/residing.

In any event, the Strategy Meeting will consider risk/need in the context of the young person being pregnant and plans will be agreed accordingly.

The Team Manager will be responsible for the initial screening of all pre-birth cases referred to the respective Local Authority’s Contact and Referral Team. A decision about allocation will be made within 24 hours of receipt of the referral.

Cases where siblings of unborn children are already open to other Services or in Care Proceedings will continue to be allocated within those Services with the exception of the 16+ and After Care Service. Cases of unborn children continue to be allocated in the Children’s Social Care Service if there are current Care Proceedings in progress in respect of the siblings. In cases where the court proceedings have concluded, the pre-birth assessment will be referred to the Team that managed these proceedings if they fall within a 3 month period. Outside of the 3 month timescale the case will be allocated within the Child Protection & Child in Need team.

In order for work to be done with the family during the pregnancy appropriate cases should be referred to the MASH team to access appropriate local support services. Children’s Social Care will accept cases for allocation, without delay as soon as a referral has been received.

The importance of conducting pre-birth assessments has been highlighted by numerous research studies and Serious Case Reviews which have shown that children are most at risk of fatal and severe assaults in the first year of life, usually inflicted by their carers.

Pre-Birth Assessment is a sensitive and complex area of work. Parents may feel anxious about their child being removed from them at birth. Referring professionals may be reluctant to refer vulnerable adults and be anxious about the prospective parents losing trust in them.

However, professionals must recognise the importance of undertaking the assessment as soon as possible so that the parents are given the opportunity to demonstrate the capacity to change. If the outcome of the assessment suggests that parenting capacity is affected in a negative way there is an opportunity to make clear and structured plans for the baby’s future together with support for the parents.

Social Workers undertaking the assessments should have access to appropriate resources, liaison with key professionals and undertaking joint assessment visits can be requested.

It is important that social workers do not conduct assessments in isolation. Working closely with relevant professionals such as midwives and health visitors is essential. Liaising with relevant substance misuse, mental health and learning disability professionals is also crucial. A multi-disciplinary offer of support should be considered pre and post birth. The liaison mental health worker will also offer advice on cases with a mental health component and become involved in liaison with mental health professionals.

The importance of compiling a full chronology and family history is particularly important in assessing the risks and likely outcome for the child. Where there have been previous children in the family removed, the previous Court documents such as copies of Final Court Judgements and assessment reports should be accessed at an early stage. If there have been Social Workers involved from the Children’s Social Care Services, they should be consulted and invited to relevant meetings.

Workers should try to compile a clear history from the parents about their own previous experiences in order to find out whether they have any unresolved conflicts, for example that may impact on their parenting of the child. It is important to find out their feelings towards the newborn baby and the meaning that the child may have for them. For example, the pregnancy may have coincided with a major crisis in the parent’s life, which will affect their feelings towards the child.

It is also important to find out the parents’ views about any previous children who have been removed from their care and whether they have demonstrated sufficient insight and capacity to change in this respect.

It is crucial to seek information about fathers/partners whilst conducting assessments and involve them in the process. Background Police and other checks should be made at an early stage on relevant cases to ascertain any potential risk factors.

Working with extended families is also crucial to the assessment process and achieving positive outcomes for unborn children. Consideration should always be given to convening Family Group Conferences in any cases where there is a possibility that the mother may be unable to meet the needs of the unborn child.

Family Group Conferences can enable the families to be brought together to make alternative plans for the care of the child thus avoiding the need for Care Proceedings in some cases. Parallel assessment of alternative family carers can prevent delays in Care Planning for the child.

A pre-birth assessment tool is attached to this guidance to help social workers (and partner agencies) consider the key questions to address when undertaking assessments.

Before commending any assessment sessions, the social worker should devise an assessment schedule in partnership with parents and other professionals, so that dates, times, locations and content of sessions is clear and transparent for everyone.

Note: this Tool is designed to help professionals to carefully consider a range of issues and to tease out issues that have potential for having a significant negative impact on the child. This tool draws extensively on the work of Martin C Calder - as described in "Unborn Children: A Framework for Assessment and Intervention.”

Click here to view Appendix A: Pre Birth Assessment Tool.