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Concealed Pregnancies

This policy and procedure is for anyone who may encounter a woman who conceals the fact that she is pregnant or where a professional has a suspicion that a pregnancy is being concealed or denied.
The concealment and denial of pregnancy will present a significant challenge to professionals in safeguarding the welfare and well being of the foetus (unborn child) and the mother. While concealment and denial, by their very nature, limit the scope of professional help better outcomes can be achieved by coordinating an effective inter-agency approach. This approach begins when a concealment or denial of pregnancy is suspected or in some cases when the fact of the pregnancy (or birth) has been established. This will also apply to future pregnancies where it is known or suspected that a previous pregnancy was concealed.

Introduction

A concealed pregnancy is when a woman knows she is pregnant but does not tell any health professional; or when she tells another professional but conceals the fact that she is not accessing antenatal care; or when a pregnant woman tells another person or persons and they conceal the fact from all health agencies.
A denied pregnancy is when a woman is unaware of or unable to accept the existence of her pregnancy. Physical changes to the body may not be present or misconstrued; they may be intellectually aware of the pregnancy but continue to think, feel and behave as though they were not pregnant. In some cases a woman may be in denial of her pregnancy because of mental illness, substance misuse or as a result of a history of loss of a child or children (Spinelli, 2005).
For the purpose of this policy and procedure any reference to woman includes females of childbearing capacity (including under 18's). A pregnancy will not be considered to be concealed or denied for the purpose of this procedure until it is confirmed to be at least 24 weeks; this is the point of viability. However by the very nature of concealment or denial it is not possible for anyone suspecting a woman is concealing or denying a pregnancy to be certain of the stage the pregnancy is at.

Definition

Research into concealment and denial of pregnancy is relatively recent, in the last 40 years, and this work has attempted to understand the characteristics of women who conceal or deny their pregnancy. Research has also been carried out to explore links between concealed pregnancy and infanticide (killing of a child in the first year of life). Local Safeguarding Children Partnerships have conducted reviews of cases where concealment or denial of pregnancy has been identified as a factor in the death or serious injury of a child. The issue of concealment and denial of pregnancy, and infanticide/filicide (the killing of a child by a parent) can be evidenced throughout human history and archaeology.
A summary of thirty-five major child death inquiries (Reder P, 1993) highlighted evidence of considerable ambivalence or rejection of some of those pregnancies and a significant number with little or no antenatal care. A follow-up study (Reder P. D., 1999) also identified a small sub-group of fatality cases where mothers did not acknowledge that they were pregnant and failed to present for any antenatal care and the babies were born in secret.
Several studies (Earl, 2000); (Friedman S. M., 2005); (Vallone, 2003) highlight a well-established link between neonaticide - killing of a child by a parent in the first 24 hours following birth - and concealed pregnancy. A review of 40 Serious Case Reviews (DoH, 2002) identified one death was significant to concealment of pregnancy.
There are 4 studies that at some of the psychological dimensions of concealed and denied pregnancy (Brezinkha, 1994); (Earl, 2000) (Moyer, 2006) (Spielvogel, 1995). In some cases a woman may be unaware that she is pregnant until late in the pregnancy due to a learning disability. Concealment may occur as a result of stigma, shame or fear as felt by the woman because the pregnancy is the result of incest, sexual abuse, rape or as part of a violent relationship. Moyer notes that the majority of women who deny pregnancy do not have a mental health assessment.
There are links between denial of pregnancy and dissociative states brought about by trauma or loss; or denial stems from a woman misusing drugs or alcohol which can harm the foetus or because of mental illness, such as schizophrenia.
A number of studies have attempted to identify the frequency of concealment or denial of pregnancy (Nirmal, 2006); (Wessel, 2002).
They suggest concealment might occur in about 1:2500 cases (0.04%). A study by (Friedman S. H., 2007) showed a higher proportion with 0.26% of all pregnancies in their sample (approx 31000) to be concealed or denied. The characteristics of those in this study showed that 50% of those concealing the pregnancy and 59% of those denying the pregnancy were aged between 18 and 29 years. Only 40% of those concealing and 23% of those in denial of their pregnancy were under 18 years of age.
A recent study in France into the rate of neonaticide by looking back at judicial data (court cases and inquests) concluded that the rate was 2.1 per 100,000 births, a much higher rate that the official mortality statistics suggested. All of the pregnancies identified in the study were concealed but none were completely denied by the woman (no awareness of being pregnant). The characteristics of the women in the study were explored and over half of them lived with the child's father, and 13 of the 17 women identified were classed as professionally active with a status identical to that of the general population. The authors concluded that neonaticide appeared as a solution to an unwanted pregnancy that risked a family scandal or loss of a partner or lifestyle. (Tursz and Cook, 2010)
The majority of religious faiths traditionally expect pregnancy to follow after marriage. Dependent upon the culture and religious observance, a pregnancy outside of marriage may have serious consequences for the women involved. This can create a significant pressure on a woman to seek to conceal a pregnancy or for the psychological conditions to be present where a pregnancy is denied. In some local and national cases collusion between family or partners has occurred to facilitate and encourage concealment of the pregnancy from those outside of the family or wider culture/community. Some pregnant women, or their partners, who abuse drugs and /or alcohol may actively avoid seeking medical help during pregnancy for fear that the consequences of increased attention from statutory agencies can result in the removal of their child.

Evidence from Research and Serious Case Review

The implications of concealment and denial of pregnancy are wide-ranging. Concealment and denial can lead to a fatal outcome, regardless of the mother's intention.
Lack of antenatal care can mean that potential risks to mother and child may not be detected. The health and development of the baby during pregnancy and labour may not have been monitored or foetal abnormalities detected. It may also lead to inappropriate medical advice being given; such as potentially harmful medications prescribed by a medical practitioner unaware of the pregnancy e.g. some epilepsy medication.
Underlying medical conditions and obstetric problems will not be revealed if antenatal care is not sought. An unassisted delivery can be very dangerous for both mother and baby, due to complications that can occur during labour and the delivery. A midwife should be present at birth, whether in hospital or if giving birth at home.
Good practice in Antenatal care
<ul>
<li>Midwives and GPs should care for women with an uncomplicated pregnancy, providing continuous care throughout. Obstetricians and specialist teams should be brought in where necessary;</li>
<li>In the first contact with a health professional, a woman should be given information on folic acid supplements; food hygiene and avoiding food-acquired infections; lifestyle choices such as smoking cessation or drug use; and the risks and benefits of antenatal screening;</li>
<li>The booking appointment with a midwife ideally should be around 10 weeks. This appointment should help the woman plan the pregnancy, offer some initial tests and take measurements to help determine any specific risks for the pregnancy. The woman should be given advice on nutritional supplements and benefits;</li>
<li>Give information that is easily understood by all women, including those with additional needs, learning difficulties or where English is not their first language. Ensure the information is clear, consistent and backed up by current evidence;</li>
<li>Remember to give a woman enough time to make decisions and respect her decisions even if they are contrary to your own views;</li>
<li>Women should feel able to disclose problems or discuss sensitive issues with you. Be alert to the symptoms and signs of domestic violence and abuse.</li>
</ul>
Adapted from Antenatal care: Routine care for the healthy pregnant woman, NICE, 2008
An implication of concealed or denied pregnancy could be a lack of willingness or ability to consider the baby's health needs, or lack of emotional bond with the child following birth. It may indicate that the mother has immature coping styles or is simply unprepared for the challenges of looking after a new baby. In a case of a denied pregnancy, the effects of going into labour and giving birth can be traumatic.
Where concealment is a result of alcohol or substance misuse there can be risks for the child's health and development in utero as well as subsequently. There may be implications for the mother revealing a pregnancy due to fear of the reaction of family members or members of the community; or because revealing the identity of the child's father may have consequences for the parents and the child.

Implications of a Concealed or Denied Pregnancy

This section outlines actions to be taken when a concealed or denied pregnancy is suspected (see <a href="#definition">Section 2, Definition</a>). If a pregnancy is suspected of being concealed or denied, the woman should be strongly encouraged to go to her GP to access ante-natal care. The GP practice will help a woman register with midwifery services for ultrasound scanning and advice about pregnancy and birth.
Professionals must balance the need to conserve confidentiality and the potential concern for the unborn child and the mother's health and wellbeing. Where any professional has concerns about concealment or denial of pregnancy, they should contact any other agencies known to have involvement with the woman so that a fuller assessment of the available information and observations can be made.
Where there is strong suspicion of a concealed or denied pregnancy, it is necessary to share this irrespective of whether consent to disclose can be obtained or has been given. In these circumstances the welfare of the unborn child will override the mother's right to confidentiality. A referral should be made to Children's Social Care about the unborn child - see <a href="making-referrals-to-childrens-social-care">Making Referrals to Children's Social Care Procedure</a>. If the expectant mother is under 18 years, consideration will be given to whether she is a Child in Need. In addition, if she is less than 16 years then a criminal offence may have been committed and this needs to be investigated.
The reason for the concealment or denial of pregnancy will be a key factor in determining the risk to the unborn child or newborn baby.
The reasons will not be known until there has been a multi-agency assessment. If there is a denial of pregnancy, consideration must be given at the earliest opportunity to a referral to enable the woman to access appropriate mental health services for an assessment. Advice can be sought from the designated or named professional or from Children's Social Care. &nbsp; &nbsp; &nbsp; Legal considerations about concealment and denial of pregnancy:
<ul>
<li>United Kingdom law does not legislate for the rights of unborn children and therefore a foetus is not a legal entity and has no separate rights from its mother. This should not prevent plans for the protection of the child being made and put into place to safeguard the baby from harm both during pregnancy and after the birth;</li>
<li>In certain instances legal action may be available to protect the health of a pregnant woman, and therefore the unborn child, where there is a concern about the ability to make an informed decision about proposed medical treatment, including obstetric treatment. The Mental Capacity Act 2005 states that person must be assumed to have capacity unless it is proven that she does not. A person is not to be treated as unable to make a decision because they make an unwise decision. It may be that a pregnant woman denying her pregnancy is suffering from a mental illness and this is considered an impairment of mind or brain, as stated in the act, but in most cases of concealed and denied pregnancy this is unlikely to be the case;</li>
<li>There are no legal means for a local authority to assume&nbsp;Parental Responsibility&nbsp;over an unborn baby. Where the mother is a child and subject to a legal order, this does not confer any rights over her unborn child or give the local authority any power to override the wishes of a pregnant young woman in relation to medical help.</li>
</ul>

Where Suspicion Arises

This section outlines actions to be taken when a concealed or denied pregnancy is revealed. Midwifery services will be the primary agency involved with a woman after the concealment is revealed, late in pregnancy or at the time of birth. However it could be one of many agencies or individuals that a woman discloses to or in whose presence the labour commences. It is vital that all information about the concealment or denial is recorded and shared with relevant agencies to ensure the significance is not lost and risks can be fully assessed and managed.
When a pregnancy is revealed the key question is 'why has this pregnancy been denied or concealed'? The circumstances in each case need to be explored fully with the woman and appropriate support and guidance given to her. Where possible a full pre-birth assessment should be undertaken by Children's Social Care and if necessary an Initial Child Protection (Pre-Birth) Conference convened to manage any concerns for the safety of the unborn child - see <a href="initial-child-protection-conferences#pre-birth-conferences">Initial Child Protection Conference Procedure, Pre-Birth Conferences</a>.
When a pregnancy is concealed or denied to birth, a referral must be made by the midwife to Children's Social Care - see <a href="making-referrals-to-childrens-social-care">Making Referrals to Children's Social Care Procedure</a> - and to mental health agencies for a full multi-agency (including psychiatric) assessment.

When a Concealed or Denied Pregnancy is Revealed

In many instances staff in educational settings may be the professionals who know a young woman best. There are several signs to look out for that may give rise to suspicion of concealed pregnancy:
<ul>
<li>Increased weight or attempts to lose weight;</li>
<li>Wearing uncharacteristically baggy clothing;</li>
<li>Concerns expressed by friends;</li>
<li>Repeated rumours around school or college;</li>
<li>Uncharacteristically withdrawn or moody behaviour.</li>
</ul>
Staff working in educational settings should try to encourage the pupil to discuss her situation, through normal pastoral support systems, as they would any other sensitive problem. Every effort should be made by the professional suspecting a pregnancy to encourage the young woman to obtain medical advice. However where they still face total denial or non-engagement further action should be taken. It may be appropriate to involve the assistance of the Designated Lead Person for Child Protection/Safeguarding in addressing these concerns.
Consideration should be given to the balance of need to preserve confidentiality and the potential concern for the unborn child and the mother's health and wellbeing. Where there is a suspicion that a pregnancy is being concealed it is necessary to share this information with other agencies, irrespective of whether consent to disclose can be obtained.
Education staff may often feel the matter can be resolved through discussion with the parent of the young woman. However this will need to be a matter of professional judgment and will be clearly depend on individual circumstances including relationships with parents. It may be felt that the young woman will not admit to her pregnancy because she has genuine fear about her parent's reaction, or there may be other aspects about the home circumstances that give rise to concern. If this is the case then a referral to Children's Social Care should be made without speaking to the parents first - see <a href="making-referrals-to-childrens-social-care">Making Referrals to Children's Social Care Procedure</a>.
If education staff engage with parents they need to bear in mind the possibility of the parent's collusion with the concealment. Whatever action is taken, whether informing the parents or involving another agency, the young woman should be appropriately informed, unless there is a genuine concern that in so doing she may attempt to harm herself or the unborn baby.
If there is a lack of progress in resolving the matter in the setting or escalating concerns that a young woman may be concealing or denying she is pregnant, there must be a referral to Children's Social Care. Where there are significant concerns regarding the girl's family background or home circumstances, such as a history of abuse or neglect, a referral should be made immediately. As with any referral to Children's Social Care, the parents and young woman should be informed, unless in doing so there could be significant concern for her welfare or that of her unborn child.

Educational Settings

The local commissioners of health services are responsible for ensuring all its providers fulfill their statutory responsibilities for safeguarding children.
The health professionals whom may be involved include:
<ul>
<li>Health Visitors;</li>
<li>School nurses;</li>
<li>General Practitioners and Practice nurses;</li>
<li>Midwifes and Obstetricians/Gynaecologists;</li>
<li>Mental Health Nurses;</li>
<li>Drug and Alcohol workers;</li>
<li>Learning Disability workers;</li>
<li>Psychologists and Psychiatrists.</li>
</ul>
(This is not an exhaustive list)
If a health professional suspects or identifies a concealed or denied pregnancy and there are significant concerns for the welfare of the unborn baby, (s)he must refer to Children's Social Care - see Making Referrals to Children's Social Care Procedure - and inform all the health professionals, including the General Practitioner, involved in the care of the woman.
All health professionals should give consideration to the need to make or initiate a referral for a mental health assessment at any stage of concern regarding a suspected (or proven) concealed or denied pregnancy.
Accident and Emergency staff or those in Radiology departments need to routinely ask women of childbearing age whether they might be pregnant. If suspicions are raised that a pregnancy may be being concealed, this should be recorded and an appropriate note made to the referring physician or GP for follow up with the patient.
Health professionals who provide help and support to promote children's or women's health and development should be aware of the risk indicators and how to act on their concerns if they believe a woman may be concealing or denying a pregnancy.

Health Professionals

If an appointment is for antenatal care is made late (beyond 24 weeks), the reason for this must be explored. Midwives and Obstetricians should consider whether a mental health referral is indicated. If an exploration of the circumstances suggests a cause for concern for the welfare of the unborn baby, a referral to Children's Social Care must be made - see <a href="making-referrals-to-childrens-social-care">Making Referrals to Children's Social Care Procedure</a>. The woman should be informed that the referral has been made, the only exception being if there are significant concerns for her safety or that of the unborn child.
If a woman arrives at the hospital in labour or following an unassisted delivery, where a booking has not been made, then an urgent referral must be made to the Children's Social Care. If this is in an evening, weekend or over a public holiday then the Emergency Duty Team must be informed.
If the baby has been harmed in any way or there is a suspicion of harm, or the child is abandoned by the mother, then the Police must be informed immediately and a referral made to Children's Social Care.
Midwives should ensure information regarding the concealed pregnancy is placed on the child's, as well as the mother's, health records. Following an unassisted delivery or a concealed/denied pregnancy, midwives need to be alert to the level of engagement shown by the mother, and her partner/extended family if observed, and of receptiveness to future contact with health professionals. In addition midwives must be observant of the level of attachment behaviour demonstrated immediately after the child is born.
In cases where there has been concealment and denial of pregnancy, especially where there has been unassisted delivery, a referral for a full mental health assessment should be considered. In addition the baby should not be discharged until a multi-agency Strategy Meeting has been held and relevant assessments undertaken. A discharge summary from maternity services to the relevant GP must report if a pregnancy was concealed or denied or booked late (beyond 24 weeks).

Midwives and Midwifery Service

Children's Social Care may receive a referral from any source, which suggests a pregnancy is being concealed or denied. In all such cases, a multi-agency Strategy Meeting should be convened, involving the General Practitioner, midwifery services and other relevant agency to assess the information and formulate a plan. A pre-birth assessment will be undertaken.
Where the expectant mother is under the age of 18, initial approaches should be made confidentially to the young woman to discuss concerns regarding the potential concealed pregnancy and unborn child. She should be provided with the opportunity to satisfy the professionals involved that she is not pregnant (by undertaking appropriate medical examination or investigation) or to make realistic plans for the baby, including informing her parents. There may be significant reasons why a young woman may be concealing a pregnancy from her family and a social worker should consider speaking to her without her parent's knowledge in the first instance.
In the event that the young woman refuses to engage in constructive discussion, and where parental involvement is considered appropriate to address the risk, the parent/main carer should be informed and plans made wherever possible to ensure the unborn baby's welfare. Potential risks to the unborn child or to the health of the young woman would outweigh the young woman's right to confidentiality, if there is significant evidence that she is pregnant.
Where there are clear reasons for suspecting pregnancy in the face of continuing denial or concealment, the professionals will need to continue to assess the situation with a focus on the needs /welfare of the unborn baby as well as those of the expectant mother. It must not be forgotten that where the mother is under 18, she should also be considered a Child in Need. Such a situation will require very sensitive handling.
Regardless of the age of the woman, where there are additional concerns (i.e. as well as the suspected concealed or denied pregnancy) such as a lack of engagement, possibility of sexual abuse, or substance misuse; then a Section 47 Enquiry should be undertaken and a pre-birth Child Protection Conference should be convened.
If a woman has arrived at hospital either in labour (when a pregnancy has been concealed or denied) or following an unassisted birth, an Assessment must be started and a multi-agency Strategy Meeting convened. In all cases the need to convene a Child Protection Conference must be considered.
Where a baby has been harmed, has died or has been abandoned then a Section 47 Enquiry must be completed in collaboration with the Police.
Where any referral is received by the Children's Social Care Emergency Duty Team in relation to a baby born following a concealed or denied pregnancy, or where a mother and baby have attended hospital following an unassisted delivery, steps should be taken to prevent the baby being discharged from hospital until a multi-agency Strategy Meeting has been held and a plan for discharge agreed. This would ordinarily be done by voluntary agreement with the mother, although where the mother's consent is not freely given, consideration should be given to whether there are grounds for seeking an Emergency Protection Order to ensure the baby remains in hospital until a the discharge plan is agreed. Alternatively the assistance of the Police - via Police Protection - may be sought to prevent the child from being removed from the hospital.
In undertaking an assessment the social worker will need to focus on the facts leading to the pregnancy, reasons why the pregnancy was concealed and gain some understanding of what outcome the mother intended for the child. These factors, along with the other elements of the Assessment Framework, will be key in determining risk.
Accessing psychological services in concealment and denial of pregnancy may be appropriate and consideration should be given to referring a woman for psychological assessment. There could be a number of issues for the woman, which would benefit from psychological intervention. A psychiatric assessment might be required in some circumstances, such as where it is thought she poses a risk to herself or others or in cases where a pregnancy is denied.
The pathway for psychological or psychiatric assessment, either before or after pregnancy, is the same. A referral should be made using the single point of entry to mental health services and the referral letter copied to the woman's GP. The referral should make clear any issues of concern for the woman's mental health and issues of capacity.

Children's Social Care

The Police will be notified of any child protection concerns received by Children's Social Care where concealment or denial of pregnancy is an issue. A police representative will be invited to attend the multi-agency Strategy Meeting and consider the circumstances and to decide whether a joint Child Protection investigation should be carried out.
Factors to consider will be the age of the woman who is suspected or known to be pregnant, and the circumstances in which she is living to consider whether she is a victim or potential victim of criminal offences. In all cases where a child has been harmed, been abandoned or died it will be incumbent on the Police and Children's Social Care to work together to investigate the circumstances. Where it is suspected that neonaticide or infanticide has occurred then the Police will be the primary investigating agency.

Police

All professionals or volunteers in statutory or voluntary agencies who provide services to women of child bearing age should be aware of the issue of concealed or denied pregnancy and follow this procedure when a suspicion arises.
All referrals will be made to the Children's Social Care initially as a referral on an unborn child. Where the expectant mother is under 18 years of age she will be considered as a Child in Need and assessed accordingly.

Other LSCP Member Agencies (including the Voluntary Sector)

Brezinkha, C. H. (1994). Denial of Pregnancy: obstetrical aspects.&nbsp;Psychosomatic Obstetrics and Gynaecology,&nbsp;1-8.
DoH. (2002). Learning from Past Experience - A Review of Serious Case Reviews. London: Department of Health.
Earl, G. B. (2000).&nbsp;Concealed pregnancy and child protection. Childright Volume 171, 19-20.
Friedman, S. H. (2007). Characteristics of Women Who Deny or Conceal Pregnancy.&nbsp;Psychosomatics, 117-122.
Friedman, S. M. (2005). Child murder by mothers: A critical analysis of the current state of knowledge and a research agenda.&nbsp;The American Journal of Psychiatry, 1578-1587.
Moyer, P. (2006). Pregnant Women in Denial rarely receive Psychaitric Evaluation.&nbsp;Medscape Medical News&nbsp;(p. Abstract NR930). APA 159 Annual Meeting (May 25 2006).
Nirmal, D. T. (2006). The incidence and outcome of concealed pregnancies among hospital deliveries: an 11 year population based study in South Glamorgan.&nbsp;Journal of Obstetrics and Gynaecology, 118-121.
Reder, P. (1993).&nbsp;Beyond blame; Child Abuse tragedies revisited.&nbsp;London: Routledge.
Reder, P. D. (1999).&nbsp;Lost Innocents: A follow-up study of fatal child abuse.&nbsp;London: Routledge.
Royal College of Obstetrics and Gynaecology. (2006).&nbsp;Law and Ethics in relation to court authorised obstetric intervention. London: RCOG.
Spielvogel, A. H. (1995). Denial of Pregnancy: a review and case reports. Birth, 220-226.
Spinelli, M. (2005). In S. Friedman,&nbsp;Infanticide.
Tursz, A., &amp; Cook, J. M. (2010, December 6).&nbsp;<a href="http://fn.bmj.com/content/early/2010/11/25/adc.2010.192278" target="_blank" rel="noopener">A population-based survey of neonaticides using judicial data</a>. Retrieved October 3, 2011, from Arch Dis Child Fetal Neonatal Ed
Vallone, D. H. (2003). Preventing the Tragedy of Neonaticide.&nbsp;Holistic Nursing Practice, 223-228.
Wessel, J. B. (2002). Denial of Pregnancy: Population based study.&nbsp;British Medical Journal (International Edition), 458.

Bibliography

Antenatal Care: Routine care for the healthy pregnant woman, Quick Reference Guide. National Institute for Clinical Excellence, 2008
Law and Ethics in relation to court-authorised obstetric intervention; Ethics Committee Guideline No.1. Royal College of Obstetricians and Gynaecologists.

Additional Reading

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&rsquo;s learning difficulties causing uncertainty as to her ability to meet the needs of the child once born, the&nbsp;<a href="https://www.bailii.org/ew/cases/EWCA/Civ/2021/787.html" target="_blank" rel="noopener">Court of Appeal in D (A Child) [2021] EWCA Civ 787</a>&nbsp;stressed the importance of effective planning during the pregnancy for the baby&rsquo;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:&nbsp;<a href="children-of-parents-with-learning-difficulties-disabilities">Children of Parents with Learning Difficulties/Disabilities Procedure</a>.
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&rsquo;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.
<ul>
<li>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);</li>
<li>Where previous children have been removed from either parent, either temporarily or by court order, because they have suffered harm;</li>
<li>Where concerns exist regarding either parent&rsquo;s ability to protect;</li>
<li>Where there are concerns regarding domestic abuse;</li>
<li>A parent or other adult in the household, or regular visitor, has been identified as posing a risk to children;</li>
<li>A child in the household is the subject of a&nbsp;Child Protection Plan;</li>
<li>Either parent is a Child Looked After or are known to children&rsquo;s social care;</li>
<li>Either or both parents have mental health problems;</li>
<li>Either or both parents have a learning difficulty, additional learning needs or diagnosed disabilities;</li>
<li>Either or both parents are under 18 years;</li>
<li>Either or both parents abuse substances, alcohol or drugs;</li>
<li>If the pregnancy is denied or concealed. See&nbsp;<a href="concealed-pregnancies">Concealed Pregnancies Procedure</a>.</li>
</ul>
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&rsquo; 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&rsquo;s understanding of them, must be documented in the woman&rsquo;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&rsquo;s adult and/ or children&rsquo;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:
<ul>
<li>Name;</li>
<li>Age/Date of birth;</li>
<li>Address;</li>
<li>Next of Kin;</li>
<li>Marital Status;</li>
<li>Details of the unborn baby&rsquo;s biological father and exploration of contact between baby and biological father. (If father&rsquo;s details not provided an information sharing form is raised internally due to concerns regarding hidden males);</li>
<li>Partner Support;</li>
<li>Family structure and support;</li>
<li>Occupation;</li>
<li>Ethnic origin;</li>
<li>Visa status;</li>
<li>Housing assessment (Homeless Duty to refer completed if at risk of homelessness - see&nbsp;<a href="https://www.gov.uk/government/publications/homelessness-duty-to-refer/a-guide-to-the-duty-to-refer" target="_blank" rel="noopener">Guidance: A guide to the duty to refer (GOV.UK)</a>);</li>
<li>Planned/Unplanned pregnancy;</li>
<li>Feelings about being pregnant;</li>
<li>Diet;</li>
<li>Medicines or drugs taken before and during pregnancy;</li>
<li>Alcohol/cigarette consumption;</li>
<li>Previous obstetric history including:</li>
<li>Number of children, date of births of children, names, current health status;</li>
<li>Do the children live in the household;</li>
<li>Same partner as previous children;</li>
<li>Any history of mental health issues;</li>
<li>Any learning difficulty, additional learning needs or diagnosed disabilities;</li>
<li>Family health history;</li>
<li>Domestic Abuse;</li>
<li>Evidence or risk of FGM &ndash; see&nbsp;<a href="female-genital-mutilation-multi-agency-protocol">Female Genital Mutilation Multi-Agency Protocol</a>;</li>
<li>Any current/previous social care involvement for patient/partner or any children of prospective parents.</li>
</ul>
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.

Early Information

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 <a href="making-referrals-to-childrens-social-care">Making Referrals to Children&rsquo;s Social Care Procedure</a>. 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:
<ul>
<li>Enable the early provision of support services so as to facilitate optimum home circumstances prior to the birth;</li>
<li>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;</li>
<li>Avoid initial approaches to the parents in the last stages of pregnancy, at what is already an emotionally charged time;</li>
<li>Provide sufficient time for a full and informed assessment;</li>
<li>Provide sufficient time to make adequate plans for the baby's protection.</li>
</ul>
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 <a href="concealed-pregnancies">Concealed Pregnancies Procedure</a>.

Sharing Concerns

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:
<ul>
<li>
The mother is identified as at risk of sexual exploitation;
</li>
<li>
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);
</li>
<li>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.</li>
</ul>
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 <a href="#public-law-outline">Section 7, Public Law Outline</a>).
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:
<ul>
<li>Risk factors;</li>
<li>Strengths in the family environment;</li>
<li>Factors likely to change, reasons for this and timescales.</li>
</ul>
See&nbsp;<a href="#appendix-a-pre-birth-assessment-tool">Appendix A: Pre Birth Assessment Tool</a>.
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.

Assessment

In a High Court judgment (Nottingham City Council v LW &amp; Ors [2016] EWHC 11(Fam) (19 February 2016)) Keehan J set out five points of basic and fundamental good practice steps with respect to public law proceedings regarding pre-birth and newly born children and particularly where Children&rsquo;s Services are aware at a relatively early stage of the pregnancy.
In respect of Assessment, these were:
<ul>
<li>A risk assessment of the parent(s) should &lsquo;commence immediately upon the social workers being made aware of the mother&rsquo;s pregnancy&rsquo;;</li>
<li>Any Assessment should be completed at least 4 weeks before the mother&rsquo;s expected delivery date;</li>
<li>The Assessment should be updated to take into account relevant events pre - and post delivery where these events could affect an initial conclusion in respect of risk and care planning of the child;</li>
<li>The Assessment should be disclosed upon initial completion to the parents and, if instructed, to their solicitor to give them the opportunity to challenge the Care Plan and risk assessment.</li>
</ul>
(See&nbsp;<a href="https://traffordcs.trixonline.co.uk/chapter/care-and-supervision-proceedings-and-the-public-law-outline" target="_blank" rel="noopener">Care and Supervision Proceedings and the Public Law Outline Procedure</a>).

Pre-birth ‘Good Practice Steps’

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:
<ul>
<li>When a pre-birth assessment gives rise to concerns that an unborn child may be at risk of&nbsp;Significant Harm;</li>
<li>Where a previous child has died or been seriously injured or been removed from parent(s) as a result of Significant Harm;</li>
<li>Following assessment where a child is to be born into a family or household which already have children subject to a Child Protection Plan;</li>
<li>Following assessment where a person known to pose a risk to children resides in the household or is known to be a regular visitor.</li>
</ul>
Other risk factors which must be considered are:
<ul>
<li>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&rsquo;s needs and potential consequences;
<div>
<div>&nbsp;</div>
</div>
</li>
<li>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.</li>
</ul>
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.

Pre-Birth Conference

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&rsquo;s NHS number. CP-IS will notify Children&rsquo;s Social Care if the Mother attends acute hospital and/or urgent care settings.

Timings of Conference

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.

Public Law Outline

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&rsquo;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:
<ul>
<li>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;</li>
<li>How long Mum may need to be supported on the ward;</li>
<li>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;</li>
<li>The risk of potential abduction of the baby from the hospital particularly where it is planned to remove the baby at birth;</li>
<li>How parents can be supported to access the Court Hearing while at hospital if it is virtual (location, private room, etc.);</li>
<li>The plan for contact between mother, father, extended family and the baby whilst in hospital. Consideration to be given to the supervision of contact &ndash; 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;</li>
<li>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;</li>
<li>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&rsquo;s removal from the ward if this is assessed to be safe and appropriate;</li>
<li>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;</li>
<li>Contingency plans should also be in place in the event of a sudden change in circumstances;</li>
<li>Who to contact should the baby be born out of hours;</li>
<li>The Children&rsquo;s Out of Hours Service should also be notified of the birth and plans for the baby.</li>
</ul>

Birth Planning Meeting

The hospital midwives should&nbsp;inform Children&rsquo;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&nbsp;Lead Social Worker&nbsp;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&rsquo;s visit on the child&rsquo;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&nbsp;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&rsquo;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&rsquo;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.

Birth and Discharge of a Newborn Baby

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&rsquo;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 &lsquo;front door&rsquo; of Children&rsquo;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.&nbsp;
If the&nbsp;Section 47&nbsp;threshold is met and a&nbsp;Strategy Meeting&nbsp;convened, relevant staff from the children in care teams should be included.
If the young person&rsquo;s placement is out of borough the Children&rsquo;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.

Pregnancy of Young People in Care

The Team Manager will be responsible for the initial screening of all pre-birth cases referred to the respective Local Authority&rsquo;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&rsquo;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.&nbsp;Outside of the 3 month timescale the case will be allocated within the Child Protection &amp; 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&rsquo;s Social Care will accept cases for allocation, without delay as soon as a referral has been received.

Allocation and Case Transfer

The importance of conducting pre-birth assessments has been highlighted by numerous research studies and&nbsp;Serious Case Reviews&nbsp;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&rsquo;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&rsquo;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&rsquo;s life, which will affect their feelings towards the child.
It is also important to find out the parents&rsquo; 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&nbsp;Family Group Conferences&nbsp;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.

General Guidelines for Conducting Pre Birth Assessments

Note:&nbsp;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.&rdquo;
<a href="appendix-a-pre-birth-assessment-tool">Click here to view Appendix A: Pre Birth Assessment Tool.</a>