5.18 Pre-Birth Protocol
This policy was updated in March 2018.
Research and experience indicate that unborn and 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 provides a valuable opportunity to develop a proactive multi-agency approach to families where there are acknowledged vulnerabilities and an identified risk of harm. The expected outcome is to:
This protocol supports practice that is located within documents such as The Munro Review of Child Protection (2011), Maternity Matters and Better Births (2016), the Antenatal and Postnatal NICE Guidance (2014) and The Healthy Child Pathway (2016) as well as Working Together to Safeguard Children (2015) and should be used by all professionals when assessing pregnant women and not just in those cases where safeguarding concerns have already been identified.
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”.
Hart (2010) indicates that there are two fundamental questions when deciding whether a pre-birth assessment is required:
1. Will this new-born baby be safe in the care of these parents/carers?
2. Is there a realistic prospect of these parents/carers being able to provide adequate care throughout childhood?
This protocol supports practice that seeks to protect babies but that is also sensitive to the needs of parents/carers. It is not acceptable, unless there are compelling reasons, to leave an assessment until close to the baby’s birth or until after the baby is born. Professionals must ensure that they use the antenatal period to gather information and assess risk and plan to mitigate risk.
Assessment is a process and concerns may be apparent at any stage of pregnancy and should be acted on appropriately.
2.1 Early Identification and Single Agency Assessments
It is important that all professionals understand the importance of comprehensive holistic family 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 or other children in the family safely and to promote their welfare. Consideration should be given to the parenting capacity required to address any additional need for the child identified by antenatal diagnosis of conditions.
Professionals need to be curious and ensure that the needs of the unborn baby are paramount, taking into consideration the involvement of the father or others taking on the parenting role, any existing children of either parent and the wider family and the impact this has on the health and well-being of the unborn baby. Fathers can be unseen and it is essential to encourage the involvement of the father unless there are concerns that to do so would heighten any risk to the child and/or mother e.g. high levels of domestic abuse, stalking/harassment.
2.2 Pregnancy in a Young Person under the Age of 19 years
The young age of a parent should be considered but not automatically be seen as an indicator of risk. The age and maturity of the parents need to be taken into consideration when identifying risk. However, there are occasions when the young person themselves has 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 19 (the mother or father of the child, or partner of mother or father), professionals should ensure that they have an open and honest conversation with the young person and seek consent to include all available information from previous records, e.g. Child Health Records, GP records and other sources.
Referral to the Family Nurse Partnership or the specialist Midwifery service where available should be considered and discussed with young person and consent gained. If no consent is given, advice should be sought from your own agency safeguarding lead.
Risks regarding Child Sexual Exploitation should be considered in all under 18 years and appropriate action taken.
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 Social Care. Sexual activity within this age group should always make professionals curious and consider whether the young person is suffering, or is likely to suffer, significant harm and may be at risk of child sexual exploitation. When someone below the age of 16 years is identified as being pregnant this must always be discussed with a nominated child protection lead within the organisation. Consideration in regards to the potential parenting capacity must be given.
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 always be reported to the police and referred to Children’s Social Care. A strategy discussion will be held. Any pregnancy in a child of 13 years or under must be referred to Children’s Services.
All cases must be fully documented.
2.5 If a family is already known to Children’s Social Care
When any worker becomes aware of a pregnancy and the decision is to carry on with the pregnancy they should ensure Maternity Services are informed and engage other professionals in the case as appropriate. A referral to Midwifery Services should take place at the earliest opportunity so that health advice can be given and a joint assessment with the health visitor can be completed as soon as possible. The level of engagement and lead professional will differ depending on need and will be decided during the joint professional consultation, this will involve making a joint decision with all agencies involved.
For all Care Leavers and Looked After Children a joint health assessment between the Health Visitor/Family Nurse and Midwife will be completed. This should be completed in conjunction with the allocated Children’s Social Care Worker.
When professionals are completing the pre-birth assessment the following should be taken into consideration and thought about when deciding whether to follow the pre-birth protocol:
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 abuse, 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. However it is important to note that enquiries regarding domestic abuse shouldn’t be carried out when the partner is present as this can heighten the risk to the victim and any children.
Health Visitors/Family Nurse are required to make contact with antenatal mothers between 28 & 36 weeks gestation, with the NICE Guidance being 28 weeks. If the midwife identifies concerns in the early antenatal period, the health visitor should be contacted as soon as possible and a joint assessment considered between the Health Visitor/Family Nurse and the Midwife from 16 weeks gestation.
Where it has been identified that a joint pre-birth Midwifery and Health Visitor assessment should take place consent should be gained from the woman and concerns should be discussed prior to the joint visit. A discussion with the parents should take place and it should be clearly identified with the parents what the professionals are worried about and what needs to change to enable professionals to feel less worried. With consent communication and consultation with all professionals involved with the family should happen including contact and information sharing with primary care (GP) and a plan developed for future contact.
Where there have been mental health issues identified a referral can be made to the Specialist Perinatal Community Mental Health team. This is a pathway for vulnerable women, who have pre-existing mental health problems and where these emerge during the pregnancy.
In all pre-birth assessments the NSCB Threshold Guide: A Framework for Making Decisions and its supporting Supplementary Guidance should be referred to when making a decision on the outcome of the joint assessment.
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/Family Nurse. In these circumstances it may be useful for the identifying professional/agency to seek further advice or consultation from within their own agency or Children’s Social Care and if necessary a referral to MASH.
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.
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, Family Nurse, 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/Health Visitor/Family Nurse) 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 Social Care should be completed jointly with the Health Visitor/Family Nurse and Midwife and take place no later than 16 weeks gestation or as soon as possible for late bookings/emerging concerns. The joint NSCB1 should be completed and a decision to be made who will send this to MASH, this needs to be recorded on the Mother’s record. The GP should be informed of this referral.
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 NSCB Information Sharing Protocol.
Any relevant antenatal information pertinent to the baby’s health development and welfare should be documented in the child’s health record after birth by the Health Visitor/Family Nurse.
For further information please see Standards for Joint Pre-birth Assessments between the Midwife and Health Visitor/Family Nurse (Appendix 2) below.
5.2 Joint Assessment
The assessment completed by Children’s Social Care must include information gathered from Midwifery, Health Visitor/Family Nurse and Primary Care (GP) as well as, when appropriate, Mental Health, Learning Disabilities 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.
Children’s Centres play a vital role in supporting vulnerable pregnant women and should be considered to be part of the joint assessment where appropriate.
Assessments should be completed jointly with the Social Worker and the Named Health Visitor/Family Nurse and a joint decision will be decided once completion of this joint assessment has taken place. For further information please refer to the NSCB Procedure for Undertaking Joint Visits and Assessments by Social Workers, Health Visitors and Midwives for Children under 5.
5.3 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 37 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 Social Care should be engaged under Section 17 Children in Need procedures. In these circumstances the family must be involved and agree with this decision. If the family does not agree consideration should be given to the impact on the unborn child and whether this needs to be escalated to Section 47.
Strategy Discussion/Meeting (Section 47)
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. It is essential that all agencies providing a service to the pregnant women and her family are invited to be involved in the strategy meeting/discussion.
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 a Social Work Assessment or child protection procedures.
In high risk cases where there is evidence of significant harm the lead Midwife/Worker will need to let the ambulance service know via the Ambulance safeguarding hub office of any high risk 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 new-born child.
The Ambulance safeguarding hub will ensure that any known addresses for mum, are flagged with information about key worker/named midwife and details of concerns.
In order to achieve the above request, all of the following information is required in order to allow the flag to be applied to the addresses provided:
The method of contact is via secure e-mail or using a password protected document to email@example.com
The flag will remain for a period of up to 42 weeks gestation or upon notification that it is no longer required, whichever is sooner.
Family Support Process
The assessment may conclude that there is a level of concern/worry 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 with all relevant professionals will plan further assessment and intervention. The lead professional would normally be either a Midwife or Health Visitor/Family Nurse. Parents must be involved in this process and give their consent for the Family Support Process to be completed.
Initial child protection conferences may follow a section 47 enquiry. An initial child protection conference brings together family members with the supporters, advocates and professionals most involved with the family, to make decisions about the unborn baby’s future safety, health and development. If concerns relate to an unborn child, a child protection conference prior to the birth of the baby should be held.
The Child Protection Conference should be held as soon after 24 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.
6.1 The Child Protection Plan
A child protection plan should be made in the initial child protection 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/ren’s welfare. The plan must not specify the length of time that the baby will remain in hospital. A core group will ensure the child protection plan is adhered to and a review child protection conference will take place after 3 months.
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 initially at 3 months.
Please refer to Pre-birth Protocol Flow Chart (Appendix 1) below.
Professional challenge is an integral part to keeping vulnerable women and unborn babies safe. At any point of the pre-birth protocol where professional dispute or challenge is unresolved please refer to the NSCB Resolution of Professional Disagreement and Escalation Protocol.
Cases can be escalated when there is evidence of non-engagement of parents in voluntary processes or where there are emerging concerns which may adversely impact on the unborn baby’s welfare.
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.
Women who decide to have a termination are always encouraged to tell their GP or Midwife that this is their decision in regard to the pregnancy, however some women decide not to follow this advice. Where there is evidence of safeguarding concerns and the likelihood of significant harm to themselves or the unborn baby the following must apply:
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 action by completing the FGM risk assessment and consider a referral to MASH.
The FGM mandatory reporting duty is a legal duty provided for in the FGM Act 2003 (as amended by the Serious Crime Act 2015). The legislation requires regulated health and social care professionals and teachers in England and Wales to make a report to the police where, in the course of their professional duties, they either:
Report to Police telephone: 101 and complete a MASH referral.
The Government describe domestic abuse as any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality. The abuse can encompass, but is not limited to:
More than 30% of this abuse starts in pregnancy, and existing abuse may get worse during pregnancy or after giving birth. Domestic abuse during pregnancy puts the victim and the unborn child in danger. It increases the risk of miscarriage, infection, premature birth, and injury or death to the baby.
A significant study of over 13,500 women undertaken by Kings College, London’s’ Institute of Psychiatry noted a strong link was found between antenatal violence and violence post-birth; 71% of women who experienced antenatal domestic violence pregnancy also experienced violence in the postnatal period, continued exposure to domestic abuse once the child is born can impact on his or her emotional and cognitive development (Howard et al 2011).
Good practice indicates that any current and/or previous history of domestic abuse should be carefully assessed. Detail should be obtained about the nature of the abuse in terms of:
Royal College of Nursing states that health practitioners need to make sensitive enquiries of people presenting with indicators of domestic abuse as part of a private discussion and in an environment in which the person feels safe. It is essential that this routine enquiry is asked on a regular basis and not just once. It is best practice to record who has accompanied the women at each contact. If an interpreter is needed as English is not the first language it is important that a professional interpreter is used and not a member of the family, interpreters should not be left alone with the women.
It is essential that practitioners take into account that victims may minimise the degree, the severity and the impact of the domestic abuse on the unborn baby. Practitioners should consider seeking advice/supervision or complete a DASH assessment and if necessary a MARAC referral.
For further support and advice in regard to domestic abuse is needed please contact the 24hr helpline number 0808 2000 247 or
As part of the midwifery assessment it is essential to identify if there is any current or a past history of any substance misuse with either parent or carer who plans to take a parenting role.
Hepatitis C is not routinely screened, therefore Midwives should encourage mothers in these circumstances to undertake the screening for Hepatitis C as this can be treated and there is a small risk of transmission to the unborn baby.
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. All agencies will also have their own lone worker policy which needs to be followed.
All practitioners at every contact with the family and baby should review the risk to the baby and;
Safe sleep advice and guidance is regularly updated by UNICEF (Baby Friendly Initiative) based on recently published research and the latest findings from the Office of National Statistics on Sudden Infant Death Syndrome (SIDS). Professionals need to be aware of the current evidence so that they can provide parents with the most accurate information available.
NICE Postnatal care up to 8 weeks after birth- CG37 (2014) have advised that co-sleeping is associated with SIDS professionals needs to have a discussion with parents and carers to inform them of this. These risks increase when taking into consideration factors such as premature/low birth weight babies, and parents who smoke, use drugs or drink alcohol. Although SIDS is very rare, it is more likely to happen in some circumstances, such as sleeping on sofa or a chair or when a break in routine such as an overnight stay happens.
UNICEF suggest that professionals need to acknowledge that co-sleeping may occur intentionally or unintentionally and parents need to be empowered and equipped with pertinent information so that they can make informed choices tailored to their own personal circumstances. Professionals need to take time to discuss issues and help look for practical solutions and remember to use up-to-date, evidence based leaflets (UNICEF) and apps (lullabytrust) to assist in these conversations.
Safeguarding and promoting the welfare of children – and in particular protecting them from Significant Harm – depends on effective collaborative working between agencies and professionals bringing together their different roles and expertise.
This protocol describes best practice when working with expectant parents about whom there are concerns regarding their unborn child or other children in the family. 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 or other children in the family and they are unsure as to what action they should take must seek advice either within their agency or from Children’s Social Care using the consultation process.
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 in contributing to assessments and interventions where appropriate.
As part of these responsibilities key professionals have been identified with specific roles which are described below.
Midwives are responsible for providing Midwifery care to woman and babies during the antenatal, intrapartum 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 role of the Health Visitor is to ensure that there is contact from the Norfolk Health Child Programme (HCP) 0-19 team during the antenatal period enabling a pre-birth assessment to be undertaken. Where there are known concerns a joint assessment will be completed between the health visitor and the midwife from 16 weeks gestation, or earlier if needed. A pre-birth assessment must involve consultation with all professionals known to have contact with the woman/family.
School Nurses are part of the Norfolk Healthy Child Programme 0-19 team and 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.
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. All referrals can be made to ‘Just One Number’ on 0300 300 0123.
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.
Other Professionals who may be involved could include; Housing, Drug and Alcohol Services, Child and Adolescent Mental Health Service (CAMHS) or Norfolk and Suffolk Foundation Trust (NSFT) who provide the mental health service in Norfolk. It is essential to include all agencies involved in the family when completing a pre-birth assessment.
Department for Education (2011) Munro Review of Child Protection: Final Report- A Child Centred System
Department for Education (2015) Working Together to Safeguard Children
Hart, D. (2010) Assessment Prior to Birth. In: Horwath, J., ed. The Child’s World, Assessing Children in Need. London: Jessica Kingsley Publishers
Howard, L et al (2011) Antenatal domestic violence, maternal mental health and subsequent child behaviour: a cohort study BJOG: An international journal of obstetrics and gynaecology
National Institute for Health and Care Excellence (2014) Antenatal and Postnatal Mental Health: Clinical Management and Service Guidance.
National Institute for Health and Care Excellence (2014) Clinical guideline [CG37] Postnatal care up to 8 weeks after birth
National Institute for Health and Care Excellence (2016) Maternity Matters and Better Births
Public Health England (2016) Healthy Child Pathway 0-19: Health Visitor and School Nurse Commissioning