5.18 Pre-Birth Protocol

1. Introduction

Research and experience indicate that very young babies are extremely vulnerable and that work carried out in the antenatal period to assess risk and to plan intervention will help to minimise harm. The antenatal assessment is a valuable opportunity to develop a proactive multi-agency approach to families where there is an identified risk of harm. The aim is to provide support for families to identify and protect vulnerable children and to plan effective care programmes, recognising the long-term benefits of early intervention and ensuring focus on the welfare of the child. This protocol supports practice that is located within documents such as The Munro Review of Child Protection, Maternity Matters, the Antenatal and Postnatal NICE Guidance and The Child Health Promotion Programme as well as Working Together to Safeguard Children 2010 (now archived) and should be used by all professionals when assessing pregnant women and not just in those cases that have already been identified with child protection issues.

Although the legal status of an unborn child is limited, the duty to safeguard remains a priority. If there is reasonable cause to suspect a child is at risk of harm before birth or following birth it is appropriate to take action to identify and address the risks. Working Together 2015 states that;

“If concerns relate to an unborn child, consideration should be given as to whether to hold a child protection conference prior to the child’s birth”.

Working Together 2015 guided that  “The involvement of midwifery services is vital in such cases”.

This protocol supports practice that seeks to protect babies but that is also sensitive to the needs of parents. It is not acceptable, unless there are compelling reasons, to leave an assessment until close to the baby’s or until after the baby is born. Professionals must ensure that they use the antenatal period to gather information and assess risk.

2. Care/Referral Pathway

2.1 Early Identification and Single Agency Assessments

It is important that all professionals understand the importance of comprehensive assessment, identification of needs and referral pathways in order to facilitate engagement, care and intervention.

Assessment during the antenatal period requires specific skills and knowledge. It is vital that professionals are aware of indicators that may suggest a child could be at risk of harm either before or following birth, or that the family will require a high level of support in order to parent the child safely and to promote their welfare.

2.2 Pregnancy and Young People

Pregnancy in a Young Person under the Age of 18 years

The young age of a parent should not automatically be seen as an indicator of risk. However, there are occasions when the young person themselves have needs which require assessment under child in need or child protection procedures. In this situation both prospective parents should be assessed and any on-going issues that relate to the young person rather than the baby should be seen as part of individual but parallel planning. When completing an assessment involving a young person under the age of 18 (the mother or father of the child, or partner of mother or father), professionals should ensure that they include all available information from previous records, e.g. Child Health Records, GP records and other sources. Consideration should be given to offering a referral to the Family Nurse Partnership if available within the area.

2.3 Pregnancy in a Young Person under the Age of 16 years

Professionals who become aware of pregnancy in a young person under 16 must give consideration to a consultation with or referral to Children’s Services. Sexual activity within this age group should always give reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm and when identified must always be discussed with a nominated child protection lead within the organisation.

2.4 Pregnancy in a Young Person under the Age of 13 years

Under the Sexual Offences Act 2003, penetrative sex with a child under 13 is classed as rape. These cases must be reported to Children’s Services and a strategy discussion held. Any pregnancy in a child of 13 years or under must be referred to Children’s Services.

All cases must be fully documented, including giving detailed reasons where a decision is taken not to share information.

2.5 If a family is already known to Children’s Services because:

  • Either parent or carer has been known to have compromised the welfare of a child in their care;
  • The mother is a looked after young person or is a care leaver;
  • The father or the mother’s current partner is a looked after young person or a care leaver; or is
  • Currently active to any Children’s Services Team.

When the allocated worker becomes aware of a pregnancy they should ensure Maternity Services are informed and engage other colleagues in the case as appropriate. A referral to Midwifery Services should take place at the earliest opportunity so that health advice can be given as soon as possible. The level of engagement and lead professional will differ depending on need and will be decided during the professional consultation.

3. Routine Care/Low Level of Concern

Pre-birth cases will be managed in a number of different ways depending on the family circumstances and the nature of the assessment carried out by professionals in contact with the family.

Midwifery assessments in the antenatal period should take into account family and social history as well as obstetric history and detail the family strengths as well as concerns. Emphasis should be placed on exploring areas such as domestic violence, substance misuse, mental health difficulties and care of previous children as well as other issues that may impact on parental capacity. Fathers and/or mothers partners should be included within this assessment as well as any other family members who may have a significant role to play in caring for the child or supporting the parents.

Health visitors are required to make contact with antenatal mothers between 28 & 36 weeks gestation. If the midwife identifies concerns in the early antenatal period, the health visitor should be contacted and a joint assessment completed between the health visitor and the midwife from 20 weeks gestation onwards.

In cases of routine or low level concern, communication and consultation with all professionals involved with the family should happen including contact and information sharing with primary care and a plan developed for future contact.

3.1 Family Support Process/Lead Professional

The assessment may conclude that there is a level of concern/need and the family will benefit from additional intervention from other services. If this is the case the lead professional should complete a Family Support Process after which a multi-agency meeting or discussion will plan further assessment and intervention. The lead professional would normally be either a midwife or a health visitor. Parents must be involved in this process and give their consent for the Family Support Process to be completed.

4. Medium/High Level of Concern

In cases of medium/high level of concern, the pathway described within this protocol should be followed.

Concerns may be identified through knowledge of a family’s/mother’s past history, or identified during the antenatal period and arise from the assessment by midwife/health visitor. In these circumstances it may be useful for the identifying professional/agency to seek further advice or consultation. Further advice should be sought or a referral to Children’s services made if either parent or carer has been known to have compromised the welfare of a child in their care in the past.

Once concerns have been identified the lead midwife/worker will need to let the ambulance service know via the Ambulance safeguarding hub office of any concerns. This will need to be done in plenty of time to ensure that all 999 calls attended by the Ambulance service to mum will ensure mum is not left in a pre hospital setting or alone with the newborn child.

The Ambulance safeguarding hub will ensure that any known addresses for mum, are flagged with information about key worked/lead midwife and details of concerns.

5. Concealed Pregnancy

There is no typical set of circumstances associated with concealed pregnancy. The term however is used to describe a pregnancy in which the woman does not present to health professionals for antenatal care or advice. Concealment may be a conscious and deliberate decision by the woman, a denial of the pregnancy or because she is not aware that she is pregnant. Research and practice experience shows us that babies born as a result of a concealed pregnancy are extremely vulnerable and not infrequently result in the death of, or harm to, the baby. Any professional who becomes aware of or is told about what appears to be a concealed pregnancy must take advice using the processes described below.

6. Consultation within own Agency

Consultation, taking advice and timely sharing of information between agencies is vital to ensure the best use of professional expertise to facilitate decision making in the context of effective multi-agency working. It is important that consultation within your own agency is undertaken as part of the process and management of pre-birth cases.

7. Professional Consultation with Children Services

Professional Consultation between agencies/professionals who have concerns and Children’s Services will take place as part of the process and management of pre-birth cases, including facilitating compliance with assessment timescales. See Appendix 1: Consultation Leaflet.

Professionals who are uncertain as to whether their concerns meet the Significant Harm threshold should contact Children’s Services for a consultation. This consultation must result in a written record of the decisions taken, and the reason for those decisions, which will be held by both parties and placed in the child’s records.

Where the practitioner has concerns that the unborn child is likely to suffer significant harm a consultation will not necessarily be required. In these circumstances the completed agency assessment should be sent direct to Children’s Services and a strategy discussion will be convened in accordance with LSCB procedures.

Outcome of Consultation:

  • There may be a number of different outcomes agreed following the consultation;
  • Further single agency involvement;
  • Completion of a Family Support Process (possibly leading to engagement with other services);
  • Referral to Children’s Services;
  • Multi-agency planning meeting/discussion under Section 17;
  • Strategy meeting/discussion under Section 47.

8. Referral to Children’s Services for Assessment under Section 17 or Section 47

8.1 Referral

It is essential that when making a referral professionals gather as much information as is available from within their agency. Referrals from Health should include information from Midwifery, Health Visiting, Primary Care and any other Health professionals involved with the family, e.g. Learning Disability or Mental Health Services. The lead health professional (this is likely to be a midwife or health visitor) should be identified, and that person is responsible for co-ordinating the information gathering and ensuring completion of the appropriate assessment.

Referral to Children’s Services should take place as soon as possible after 20 weeks gestation.

Families should be informed of concerns and referrals, unless it is felt that to do so would put a child, unborn baby, or other person at risk of harm. All information should be shared in accordance with best practice and the LSCB Information Sharing Protocol.

8.2 Social Work Assessment

The Social Work Assessment completed by Children’s Services must include information gathered from midwifery, health visiting and primary care (general practitioner) as well as, when appropriate, mental health and drug and alcohol services. It may also be necessary to include information from other services having contact with the family and/or adults within the family and household.

8.3 Action Following Social Work Assessment under Section 17 & 47

Careful consideration should be given to the timing of both assessments and further discussions/strategy meetings. Whilst the normal timescale for a full time pregnancy is anywhere between 36 and 42 weeks, it is not unusual for babies to be delivered much earlier than this especially if there is a multiple or complicated pregnancy. The likelihood of the delivery of a pre-term baby must be taken into account during the planning and decision making.

Discussion/Meeting (Section 17)

The assessment may conclude that Children’s Services should be engaged under Section 17 Children in Need procedures. In these circumstances the family must be involved and agree with this decision.

Strategy Discussion/Meeting

The timing of the pre-birth strategy discussion is a matter of professional judgement and will be agreed within the multi-agency professional network. The effective management of pre-birth cases may require that more than one strategy meeting/discussion take place. Attendance and information sharing at the strategy meetings should take high priority to facilitate effective decision making.

If it is agreed that the case should go to child protection conference, it would be helpful to timetable both the assessment and the conference and agree the invitation list and date for the conference before the end of the meeting.

The strategy meeting should take into account the possibility of the child being born before the conference and a contingency plan agreed.

Consideration should always be given to other children in the household and whether they should be subject to an Social Work Assessment or child protection procedures (see Initial Child Protection Conferences Procedure).

9. Female Genital Mutilation

Female genital mutilation is unlawful in the UK. Any professional who becomes aware of an issue relating to this practice either in that the pregnant woman has been subject to female genital mutilation or there is a risk that the baby may be considered for female genital mutilation should take immediate advice by using the consultation process described within this protocol. Further information can be found by clicking on the following link:

Multi-Agency Practice Guidelines: Female Genital Mutilation Chapter 6 for Health

10. Worker Safety

Consideration of worker safety should be a high priority at all stages of the process. Any agency or professional who becomes aware of a worker safety issue should ensure that all services, both specialist and universal, are informed of the issues so that appropriate safety measures can be taken.

11. Child Protection Conference

Initial child protection conferences Following section 47 enquiries, an initial child protection conference brings together family members (and the child where appropriate), with the supporters, advocates and professionals most involved with the child and family, to make decisions about the child’s future safety, health and development. If concerns relate to an unborn child, consideration should be given as to whether to hold a child protection conference prior to the child’s birth.’
Working Together to Safeguard Children, 2015.

The Child Protection Conference should be held as soon after 30 weeks as possible and arranged at a time and place that facilitates attendance by the family and professionals. An earlier conference should be considered for multiple births or pregnancies where there are complications likely to result in early delivery.

All professionals should give high priority to attendance at pre-birth conferences if requested and must provide a report. If attendance is not possible, they should ensure that another professional from their agency takes the relevant information or that the information is presented to the Chair of the conference in report form. The conference may not be viable if relevant professionals are not present.

11.1 The Plan

A child protection plan should be made in the conference if the concerns are substantiated and there is reason to suspect that the unborn baby may be suffering or likely to suffer Significant Harm. The plan must consider the immediate safety needs of the child once it is born as well as future needs and details of any further assessments required. This plan will also seek to promote the child(rens) welfare. The plan must not specify the length of time that the baby will remain in hospital.

Where the unborn baby may not be considered to be suffering or likely to suffer Significant Harm but may none the less require services because of complex needs to promote his/her health or development, a child in need plan will be drawn up to ensure appropriate interagency working. This plan will be reviewed at least every 6 months.

11.2 After the Birth

All practitioners at every contact with the family and baby should review the risk to the baby and;

  • Inform other professionals of any change in the family circumstances, e.g. new partner, change of address etc;
  • Inform social worker, line manager or supervisor if it is felt that the plan has not been implemented or is not keeping the child safe;
  • Take immediate action if the risk to the child is felt to be increased.

12. Safe Sleeping

Falling asleep with a baby on a bed, sofa or chair can be extremely risky especially if the adult has consumed even moderate amounts of alcohol, taken drugs or is a smoker. Many parents are not aware of the risks of co-sleeping and practitioners should use every opportunity to warn them and help them plan for ensuring that their baby is put down to sleep in a safe and appropriate place.

13. Conclusion

Safeguarding and promoting the welfare of children – and in particular protecting them from Significant Harm – depends on effective joint working between agencies and professionals that have different roles and expertise. Individual children, especially some of the most vulnerable children and those at greatest risk of social exclusion, will need co-ordinated help from Health, Education, Children’s Social Care and quite possibly the voluntary sector and other agencies including Youth Justice Services.

This protocol describes best practice when working with expectant parents about whom there are concerns regarding their unborn child. All women who are pregnant should be assessed in accordance with this protocol, and where there is an identified risk of harm to the unborn baby, agencies must work collaboratively in the antenatal as well as postnatal periods. All professionals have a responsibility to communicate effectively regarding families about whom there are concerns. Any professional who has a concern regarding an unborn baby and they are unsure as to what action they should take must seek advice either within their agency or from Children’s Services using the consultation process.

Professionals Roles and Responsibilities in Respect of Unborn Children

Section 11 of the Children Act 2004 requires agencies to have in place mechanisms to ensure that they are able to safeguard and promote the welfare of children.

All workers, whether adult or children services, have a responsibility to protect and safeguard children and work collaboratively with Children Services and other childcare professionals in contributing to assessments and interventions.

As part of these responsibilities key professionals have been identified with specific roles which are described below.

Midwife/Obstetrician

Midwives are responsible for providing midwifery care to woman and babies during the antenatal, intranatal and postnatal periods. They have a duty to ensure that the needs of the woman and baby are the primary focus of their practice. Throughout this time they have a responsibility to work with other health professionals in order to safeguard a baby from harm.

The Midwife/Obstetrician must follow the Pre-Birth Protocol for all pregnant women and the pre-birth assessment should involve consultation with all professionals who are known to have contact with the woman/family, e.g. GP.

Health Visitor

The role of the Health Visitor is to ensure that there is contact from the Health Visiting Service during the antenatal period enabling a pre-birth assessment to be undertaken. This may be done by themselves or jointly with the Midwife. Where there are known concerns this assessment should begin around the 20th week of pregnancy and around the 36th week of pregnancy in all other cases. A pre-birth assessment must involve consultation with all professionals known to have contact with the woman/family.

School Nurse

School nurses have a responsibility to safeguard children and young people through professional collaboration with Health colleagues and the multi-agency network. Girls in high school may present to the school nurse as the first point of contact where pregnancy is suspected or confirmed by the young women themselves. The role of the school nurse is to accurately assess the situation taking into consideration legal aspects and to initiate appropriate multi-agency involvement, e.g. general practitioner, Children Services etc.

General Practitioner

The role of the General Practitioner is to be alert to factors that affect the capacity of a parent and that may pose a risk to the unborn child, and to work with Midwife, Health Visitor and colleagues from other agencies, sharing information appropriately to ensure that the pre-birth assessment is fully informed.

Family Nurse Partnership

Family Nurse Partnership (FNP) is a specialist health service. It is a preventative programme offered to first time young mothers. It offers intensive and structured home visiting, delivered by specially trained nurses from early pregnancy until the child is two. FNP has three aims, to improve pregnancy outcomes, child health and development and parents’ economic self sufficiency.

At the heart of FNP is safeguarding and it is an evidence based programme known to prevent child maltreatment (Macmillan et al The Lancet, 3 Dec 08)

In Norfolk the referral criteria are that the young mother must be under 19 years old at conception and under 24 weeks gestation at referral. Referrals can be made by speaking to the FNP team on 01603 779386.

Norfolk County Council

Norfolk County Council provide a range of services to children and their families under the auspices of Children’s Services, including schools, teams that provide social care, education support, school attendance, youth and community support, child and adolescent mental health support services. All practitioners and managers have a responsibility to communicate and share all relevant information in order to safeguard children.

14. Factors to be considered when undertaking a Pre-birth assessment

Unborn Baby

  • Unwanted/concealed pregnancy;
  • Perceptions;
  • Awareness of baby’s needs;
  • Ability to prioritise baby’s needs;
    • Antenatal care.
  • Awareness of unborn baby’s health;
  • Parental expectations of new born baby;
  • Planning;
  • Parenting plans;
  • Special/extra needs;
  • Premature birth.

Parenting Capacity

  • Childhood experiences:
    • Positive childhood;
    • Multiple Carers.
  • Age – very young parent/immature;
  • Mental disorders or illness;
  • Learning difficulties;
  • Recognition of effects of own behaviour on others;
  • Physical disabilities/ill health;
  • Inability to work with professionals;
    • Cultural issues.
  • Drug/alcohol misuse;
  • Abuse/neglect of previous child(ren)
  • Positive mental health.

Family/Household/Environmental

  • Domestic violence;
  • Relationship disharmony/instability;
  • Violent or deviant network;
  • Multiple relationships;
    • Not working together;
    • Lack of community support;
  • Poor impulse control;
  • Unsupportive of each other;
  • Frequent moves of house/homelessness;
  • Poor engagement with professional services;
  • No commitment to parenting.

Appendices

Appendix 1: Consultation Leaflet

Appendix 2: Pre-birth Protocol Flowchart/Diagram

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