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1.6 Pre-Birth Procedures and Guidance

Contents

Principles of the Pre Birth Procedure

1.6.1

This procedure has been developed and designed by a multi-agency group, established under the Buckinghamshire Safeguarding Children Board (BSCB) in order to develop a consistent Pre Birth Assessment Pathway which identifies vulnerability early and provides a clear route into appropriate support services.  The group have taken into account findings from local Learning Lessons and Serious Case Reviews as well as local and national research into good practice.

1.6.2

The key principles of the Buckinghamshire Safeguarding Children Board (BSCB) Pre Birth Assessment Procedure are:

  • practitioners ‘think pregnancy, think midwife’
  • Early Help and support is key
  • midwives complete a Pre Birth Vulnerability Screening Tool with all women at their booking;
  • the sharing of information is crucial to this process and all professionals are responsible for ensuring that they share information in a timely way
  • all appropriate professionals should contribute to a Pre Birth Assessment where one has been identified as being necessary
  • as needs are identified and assessed during pregnancy, there should be consideration to a ‘step up or step down’ approach so children and families are supported by the most appropriate services
  • all agencies will ensure that their own procedures are in line with the pathway and that practitioners within their organisations are briefed in its use; and
  • all staff to be aware that if at any point there is disagreement about the correct level of intervention reference should be made to the BSCB Escalation, Challenge and Conflict Resolution procedure.

Guidance for all Agencies

Think Pregnancy - Think Midwifery

1.6.3

All women who suspect that they may be pregnant should be advised to book in with Midwifery at the earliest opportunity. This is usually between 8-10 weeks of pregnancy if the pregnancy has been notified to the Midwife.  The booking appointment should be no later than the end of week 12.

1.6.4

The Midwife will be able to assist the woman in making informed choices about the care she receives, offer advice on the suitability of her choices and will be able to consider if there are any concerns for the unborn child and work with her to develop a safe plan of care.   

1.6.5

Other professionals must not assume that a family is known to Midwifery Services.  If any agency becomes aware that a woman is pregnant then contact needs to be made with Midwifery for booking in at the earliest opportunity.

1.6.6

Evidence indicates that women who have additional vulnerability are less likely to access antenatal care or stay in regular contact with maternity services. Where vulnerability has been identified, providing antenatal services in a more flexible way may encourage women to attend more regularly and therefore receive appropriate care and referrals. For further information please see Pregnancy and Complex Social Factors, NICE guidelines CG110, (2010).

1.6.7

If there are immediate concerns about an unborn child or an adult with care and support needs, existing safeguarding procedures need to be followed alongside encouragement to access maternity services.

Thresholds of Need

1.6.8

The Pre Birth Pathway follows the BSCB Thresholds Document and describes 4 types of response to meeting the needs of children and families.  As needs are identified and assessed during pregnancy, there should be consideration of a ‘step up or step down’ approach so children and families are supported by the most appropriate services.

Universal Services - Threshold Level 1

1.6.9

This is where no concerns have been identified, and the woman and her unborn child are adequately supported by universal service provision (for example, GP, Midwifery, Health Visiting).  There may be a need for limited intervention to avoid needs arising.

1.6.10

By 16 weeks of pregnancy the Named Midwife will complete a Health Visitor Liaison form for all antenatal patients. This will highlight any concerns and the Health Visitors will use the information to identify any vulnerable mothers. The form is then given to the Health Visitor Team for their locality. The form must be updated and re-sent to the health visiting team if changes occur during pregnancy.

1.6.11

Both the Midwives and Health Visitors should provide updates by phone if they become aware of relevant information during the antenatal or postnatal period. Health Visitors provide an antenatal visit at 28 weeks and another, if required, at 32 weeks. Health Visiting will try and have some continuity to see them postnatally.

Additional Support - Threshold Level 2

1.6.12

The family may require additional support because they may have personal or physical difficulties or may be affected by family crisis. Additional support can be provided through a single agency response and partnership working (for example Midwifery, Health Visiting, Family Nurse Partnership).

1.6.13

At booking with the Midwife eligible women will be referred to the Family Nurse Partnership Programme (FNP).  Women are eligible to be referred to FNP if:     

  • they are first time mothers aged 19 and under at conception
  • living in the agreed catchment area
  • previous pregnancies ended in miscarriage, termination, still-birth, multiple births included.
1.6.14

Women enrolled onto FNP (normally by the 16th week of pregnancy) receive the FNP intervention alongside their usual antenatal care provided by their Midwife.   Individuals do not have a Health Visitor; the Family Nurse delivers the Healthy Child Programme alongside the FNP intervention.   Close liaison takes place between the Family Nurse and the Teenage Pregnancy Liaison Midwife or Community Midwife. 

1.6.15

FNP has the potential to impact on the assessment process and is a therapeutic intervention which uses psycho-educational methods with a focus on changing behaviour.  A referral to Children’s Services is completed at the earliest opportunity in collaboration with the Midwife if it is deemed the threshold for Level 3 or Level 4 intervention has been met.

Complex Need / Specialist / Child in Need - Threshold Level 3

1.6.16

If a family is identified to have multiple needs/vulnerabilities requiring a multi-agency co-ordinated response an Early Help Assessment or Child and Family Assessment can be used to assess need and the type of support required.  A Multi Agency Referral Form (MARF) should be sent to Children’s Services First Response or call 01296 383962 (0800 999 7677 out of hours).

1.6.17

Children and families may require intensive help and support to meet their needs. Parents / carers or families should be demonstrating a willingness to accept support.

1.6.18

Interagency assessment and care planning for children with complex needs may be led by a lead professional through the Early Help process.

1.6.19

Where complex needs have been identified and parents / carers are not engaging with appropriate services then consideration should be given to ‘stepping up’ the agency response and a referral made without delay into Children’s Services First Response. 

Acute / Child Protection - Threshold Level 4

1.6.20

This is where there may be multiple vulnerabilities experienced by a family or an individual parent which may put the unborn baby, or the child once born, at risk of significant harm.  Children’s Services First Response should be contacted on 01296 383962 (0800 999 7677 out of hours), followed up with submission of a completed MARF.

1.6.21

The high risk pathway detailed in Appendix 1 indicates the steps to be taken to protect the child as early as possible in the pregnancy and once the child is born where there are specific child protection concerns identified.

Early Screening for vulnerabilities

1.6.22

NICE Guidance (Ante Natal care for uncomplicated pregnancies) outlines routine maternity care for healthy pregnant women.  Pregnant women with complex social factors may have additional needs. The NICE guidelines for pregnancy and complex needs contain a number of recommendations on standards of care for all pregnant women with complex needs.

1.6.23

These guidelines set out what healthcare professionals, and antenatal services, can do to address the needs and improve pregnancy outcomes in this group of women.

1.6.24

Midwives are well placed to gather important information about expectant mothers and their circumstances, early in the pregnancy.  A booking interview is carried out at around 8-10 weeks of pregnancy either in the woman’s home or at a location of her choice (for example the GP surgery, maternity unit or local Children’s Centre).  

1.6.25

During the booking interview, the lead midwife responsible for the patient’s care collects information to build into a full medical and social history.  This data helps the midwife to assist the woman in making informed choices about the care she receives and to offer advise on the suitability of her choices.  The midwife will discuss with the woman the pattern of care which is most suited to her needs and will work with her to develop a safe plan of care based on her preferences.

1.6.26

A holistic approach, taking into account the woman’s social history is provided. Gathering this information assists with identifying mothers for whom there are complex social factors that may impact on her and her partner’s parenting capacity. This information will be incorporated into a pre-birth assessment where appropriate.

1.6.27

Midwifery services will share information with the Health Visitor/Family Nurseduring the pregnancy.  Within Buckinghamshire, the Health Visitor/Family Nurse will complete an antenatal visit for all mothers between 28 and 32 weeks.  It is important that the named Health Visitor/Family Nurse is part of the pre-birth assessment.

1.6.28

Midwives may identify that a mother has, or may have been, subjected to female genital mutilation (FGM).  FGM can lead to birth complications such as prolonged labour, recourse to caesarean section, postpartum haemorrhage and tearing.  If FGM is identified, professionals must follow the procedures as set out in the guidelines developed by their agencies and BSCB’s Female Genital Mutilation Procedure and Guidance.

1.6.29

Buckinghamshire Healthcare NHS Trust Midwives meet regularly with Health Visitors/Family Nurses and GPs to share information to ensure that mothers are accessing appropriate care.  They will escalate any concerns to safeguarding leads within their own agencies, and to the relevant social worker. 

1.6.30

Bucks CCGs have commissioned and developed a universal, NICE (CG 192) compliant pathway for perinatal mental health along with a supplementary document to accompany this. GPs, Midwives and Health Visitors/Family Nurses are uniquely placed to screen for risk factors during the perinatal period. Prompt identification, assessment and treatment with referral to the most appropriate services will reduce the impact of the disorders on the mother, her child and family.

1.6.31

The Buckinghamshire multi-agency perinatal mental health network comprises partners from general practice, commissioning, Midwifery, Health Visiting, CAMHS, ReConnect (parent-infant service which works with parents and children with disorganised attachment issues), Healthy Minds (Psychological Services) and Adult Mental Health.  Its aim is to deliver accessible universal services to support women and families across the county when there are perinatal mental health concerns.

Information Sharing and Consent

1.6.32

Careful consideration must be paid to issues of consent and information sharing throughout any involvement with families.  Parents should be informed as soon as possible of the concerns and the need for a referral to Early Help or Children’s Services, except on the rare occasions where doing so may increase the risk to the unborn baby and/or mother or jeopardise evidential information.

1.6.33

Information sharing is vital to safeguarding and promoting the welfare of children and young people. A key factor identified in many serious case reviews (SCRs) has been a failure by practitioners to record information, to share it, to understand its significance and then take appropriate action. (DfE 2015).

1.6.34

The DfE’s Information Sharing (Advice for Practitioners providing safeguarding services to Children, Young People, parents and carers) provides guidance on sharing information and includes the ‘Seven golden rules to sharing information. Professionals should also refer to the BSCB Information Sharing Code of Practice

1.6.35

Other points to consider:

  • Is there a legitimate purpose for sharing information?
  • Does the information enable a person to be identified?
  • Is the information confidential? If so, do you have consent to share?
  • Is there a statutory duty or court order to share the information?
  • Is consent refused/are there good reasons not to seek consent?
  • Is there sufficient public interest to share information?
  • If the decision is to share, are you sharing the right information in the right way?
  • Have you properly recorded your decision?
1.6.36

Seeking information/advice and timely sharing of information between agencies is vital to ensure the best use of the available professional expertise to facilitate decision making in the context of effective multi-agency working. It is each practitioner’s responsibility to familiarise themselves with internal mechanisms of reporting, sharing information and escalation of concerns.

Fraser Guidelines

1.6.37

When trying to decide whether a child / young person is mature enough to make decisions, people often talk about whether a child is Gillick Competent or whether they meet the Fraser Guidelines.

1.6.38

The Fraser guidelines help to balance children’s rights and wishes with the responsibility to keep children safe from harm.

1.6.39

The Fraser guidelines and Gillick competency refer to a legal case which looked specifically at whether doctors should be able to give contraceptive advice or treatment to under 16 year olds without parental consent.  However since then, they have been more widely used to help assess whether a child / young person has the maturity to make their own decisions and to understand the implications of those decisions (NSPCC, 2016).

  • The capacity to consent depends on the woman / young person’s ability to understand and make an assessment of the advantages and disadvantages of the treatment proposed regardless of age.
  • The capacity to consent can be affected by changes in the woman / young person’s physical and mental health.
  • The Fraser guidelines are concerned with determining the child’s capacity to consent to medical treatment.
  • It is important that the practitioner assesses maturity and understanding on an individual basis.
  • The woman / young person may have the capacity to consent to some treatments but not others. This means the practitioner must make sure that all relevant information has been provided and thoroughly discussed before deciding whether or not a woman / young person has the capacity to consent.
  • Children under 13 are not legally able to consent to sexual activity. Engaging in sexual activity with a child under 13 years of age is always a criminal offence as the child is, in law, unable to consent.
  • In the case of over 16s competency, this is measured by the Mental Capacity Act.

Responding to Concealed or Denied Pregnancy

1.6.40

The concealment and denial of pregnancy will present a significant challenge to professionals in safeguarding the welfare and wellbeing 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 co-ordinating 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.

1.6.41

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.

1.6.42

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).

1.6.43

A pregnancy will not be considered to be concealed or denied for the purpose of these procedures and guidance 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 of concealing or denying a pregnancy to be certain of the stage the pregnancy is at.

1.6.44

If a woman arrives at the hospital in labour or following an unassisted delivery, where there is no evidence the pregnancy has been booked with maternity services or ante natal care accessed(pregnancy has been concealed or denied), then an urgent referral must be made to Buckinghamshire First Response by telephone and then followed up by a MARF being completed. If this is in an evening, weekend or over a public holiday then the Emergency Duty Children's Social Care team must be informed by telephone and the case discussed with a plan agreed prior to discharge. If the woman is under 18 years then consideration will be given to whether she is a Child in Need.  If she is less than 16 years then a criminal offence may have been committed and needs to be investigated.

1.6.45

The reasons will not be known until there has been an assessment.  If there is a denial of pregnancy then consideration must be given at the earliest opportunity to a referral for Mental Health Services.

Education

1.6.46

In many instances staff in educational settings may be the professionals who know a young person best.  There are several signs to look out for that may give rise to suspicion of concealed pregnancy:

  • increased weight or attempts to lose weight;
  • mearing uncharacteristically baggy clothing;
  • concerns expressed by friends;
  • repeated rumours around school or college; and
  • uncharacteristically withdrawn or moody behaviour.
1.6.47

Staff working in educational settings should try to encourage the young person to discuss her situation as they would any other safeguarding concern.  Every effort should be made by the professional suspecting a pregnancy to encourage the young person 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 Safeguarding Lead or School’s Designated Safeguarding Lead in addressing these concerns.

1.6.48

Consideration must be given to the balance of confidentiality and the potential concern for the unborn child and the mother’s health and well-being.  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.

1.6.49

Education staff may often feel the matter can be resolved through discussion with the parent of the young person however this will need to be a matter of professional judgement (unless the young person has not given consent to tell the parents).  It may be felt that the young person 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 a referral to Children’s Services must be made before disclosing the information about the pregnancy to her parents.

1.6.50

If education staff do engage with parents they need to bear in mind the possibility of parent’s collusion with concealment. Whatever action is taken, the young person should be appropriately informed, unless there is a genuine concern that in so doing she may attempt to harm herself or the unborn baby.

School Nursing

1.6.51

The School Nurse may be well placed to identify and work with school age girls who may be pregnant by offering a confidential service.  The School Nurse should liaise closely with the Consultant Midwife for Teenage Pregnancy in order to support the young person having gained consent from the young person.  If consent has not been obtained but there are still concerns for the young person/unborn child’s welfare, a referral to Children’s Services should be considered.

Health

1.6.52

If a health professional suspects or identifies a concealed or denied pregnancy a referral to Children’s Services must be made and all other health professionals that need to be involved in her care must also be informed.

1.6.53

The health professionals whom may be involved include (list not exhaustive):

  • Health Visitors/Family Nurses
  • School nurse
  • General Practitioners and Practice nurses
  • Midwifes and Obstetricians/Gynaecologists
  • Mental Health Nurses
  • Drug and Alcohol workers
  • Learning Disability workers; and
  • Psychologists and Psychiatrists.
1.6.54

All health professionals should give consideration to the individual need of the young person to make or initiate a referral for a Mental Health Assessment at any stage of concern.  Hospital Emergency Department staff or those in Radiology departments need to routinely ask women of child bearing age whether they might be pregnant.

1.6.55

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 young person may be concealing or denying a pregnancy.

Midwives and Midwifery Services

1.6.56

If an appointment for antenatal care has been made late (after 24 weeks) reasons for this must be explored.  Midwives and Obstetricians should always consider whether there is a need for a referral to Mental Health Services.

1.6.57

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 Children’s Services.  The Emergency Duty team must be informed during the evening, on weekends or Public holidays.

1.6.58

If the baby has been harmed in any way or there is a suspicion of harm, or the child is abandoned by the mother, the Police must be informed immediately and a referral made to Children’s Services.

1.6.59

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 must 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 in the early postpartum period.

1.6.60

In cases where there has been concealment and denial of pregnancy, especially where there has been unassisted delivery, consider a referral for a full Mental Health Assessment.  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 primary care must report if a pregnancy was concealed or denied or booked late (beyond 24 weeks).

GPs and Practice Employed Staff

1.6.61

Women who are concealing are unlikely to present at GPs for pregnancy tests.  However, they may present for another reason.  As a matter of good practice, the possibility of pregnancy should be a prime consideration for GPs where nausea/vomiting is a key presenting symptom in a female patient who is of an age/development where sexual activity is possible.  Appropriate examination and investigations should be performed.

1.6.62

In some instances, women may be genuinely unaware they are pregnant, but in others, the woman may be determined to conceal the fact, and may be extremely reluctant to agree to a pregnancy test or examination.

1.6.63

Where a GP has significant reason to believe a woman is pregnant, but further investigations are denied by the young person, action must be taken; where there are concerns about the potential welfare of the unborn child the GP should refer to Children’s Services.

1.6.64

Given that a previous concealed pregnancy indicates increased risk of further concealment, where this has been the case it should be documented within the GP records.

1.6.65

The GP may initiate a psychiatric assessment or be asked to make a referral by a colleague.

Health Visitors/Family Nurses

1.6.66

Health Visitors/Family Nurses in the course of their involvement with families will be aware of the circumstances of previous pregnancies, and need to be alert to the possibility that a woman may be concealing a pregnancy.  If the Health Visitor/Family Nurse believes the woman may be pregnant, they should encourage her to seek support.

1.6.67

As an initial step it may be helpful to discuss the matter with the Named Nurse for Safeguarding Children, the GP and liaise with the Midwife to consider a way forward or a referral to Children’s Services made if there is total denial of the pregnancy.

Mental Health and Learning Disability Services

1.6.68

Professionals working in mental health and learning disability may be more likely to be involved with a woman/young person who is concealing a pregnancy than other agencies.  Mental illness, emotional problems, personality problems, a learning disability or substance misuse may all be contributory factors for concealment.  If any professional working within these services identifies, or suspects a concealed pregnancy, they should seek to discuss this with the woman/young person, as appropriate, and contact their GP and/or Midwifery Services.

Children's Services

1.6.69

Where the expectant mother is under the age of 18 initial approaches should be made to discuss concerns regarding the potential concealed pregnancy and unborn child.  Social Workers should take measured steps to ensure that the young person is not pregnant via appropriate medical examination or investigation, or to make realistic plans for the baby, including informing her parents. In all cases a multi-agency discussion should be held, involving all the relevant agencies, to assess the information and formulate a plan.  A Pre-Birth Assessment will be undertaken.

1.6.70

In the event that the young person refuses to engage in constructive discussion, and where parental involvement is considered appropriate to address 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 person’s right to confidentiality, if there was significant evidence that she was pregnant.  There may be significant reasons why a young woman may be concealing a pregnancy from her family and a Social Worker may need to consider speaking to her without her parent’s knowledge in the first instance.

1.6.71

If the young woman refuses to engage in constructive discussion then the Social Worker will need to inform her parent/s or carers and continue to assess the situation with a focus on the needs /welfare of the unborn baby as well as those of the young woman, who should be considered a Child in Need.

1.6.72

Where there are additional concerns (to the suspected concealed or denied pregnancy) such as a lack of engagement, possibility of sexual abuse, or substance misuse; a Section 47 Enquiry should be undertaken.  An outcome of this may be to convene an Initial pre-birth Child Protection Conference. Where a woman under age 18 is suspected of being pregnant it must be recognised that she is also a Child in Need.

1.6.73

If a young person has arrived at hospital either in labour (when a pregnancy has been concealed or denied) or following an unassisted birth an initial assessment must be started and a multi-agency Strategy Discussion held.  In all cases the need to convene a Child Protection Conference must be considered.

1.6.74

Where a baby has been harmed, has died or has been abandoned then a Section 47 investigation must be completed in collaboration with the Police.

1.6.75

Any referral received by the Emergency Social Work 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, then steps may need to be taken to prevent the baby being discharged from hospital until a multi-agency Strategy Discussion / Meeting has been held and a plan for discharge agreed.  This would ordinarily be done by voluntary agreement with the woman, although clearly circumstances may arise when it may be appropriate to seek an Emergency Protection Order. Alternatively the assistance of the Police may be sought to prevent the child from being removed from the hospital.

1.6.76

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.

1.6.77

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.

1.6.78

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 young person’s GP.  The referral should make clear any issues of concern for the young person’s mental health and issues of capacity.

Police

1.6.79

Thames Valley Police will be notified of any child protection concerns received by Children’s Services where concealment or denial of pregnancy is an issue.  A Police representative will be invited to attend a multi-agency Strategy Meeting and consider the circumstances and to decide whether a joint Section 47 Enquiry should be carried out.

1.6.80

Factors to consider will be the age of the person whom 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, Police and Social Care will 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.

Referral where vulnerability is indicated

1.6.81

If vulnerability is identified, early referral to appropriate support services will promote positive working relationships between both parents and key professionals.  Early referrals can also help to ensure there is clarity around roles and responsibilities, and that appropriate early help and support is provided when considering the birth plan.

1.6.82

Early assessment of need and the identification of appropriate support services is good practice and ensures that a planned and structured approach is taken and parents feel fully supported and are clear that if there are any concerns, what these are and how they will be addressed from the beginning of the process.

1.6.83

At the beginning of any intervention it is important to identify whether the pregnant woman has any communication needs.  At the earliest opportunity, access to translation or advocacy services should be considered.

1.6.84

If at any stage it becomes known that a pregnancy is no longer viable this information needs to be sensitively communicated in a timely manner to all involved agencies and consideration given to referral for access to bereavement support for parents as appropriate.

Early Help assessment and support

1.6.85

Early intervention is essential in ensuring that unborn babies for whom risks or support needs are identified are given the best possible chances to reduce the need for statutory intervention. The outcome of this work will determine whether a referral to Children’s Services is necessary. Any intervention should be considered taking into account the thresholds laid down in Buckinghamshire’s Threshold document.

1.6.86

The Thresholds document will provide guidance on the types of family circumstances to be supported under Levels 1 – 4.  If it has been identified that the parent/s may need additional support to meet the needs of their unborn child, this is the first stage in seeking to clearly identify these and the resources to address them. The Guidance in BSCB’s and the Referral Flowchart ‘What to do if you have a concern about a child in Buckinghamshire’ should be followed.

1.6.87

If it is deemed appropriate through a multi-agency decision to manage the case via a ‘Family Plan’, a robust Early Help assessment should be completed by the lead professional identified and an early help plan developed.

1.6.88

The development of an Early Help assessment and plan should follow the same principles of active multi-agency collaboration, planning and review as advocated in this procedure.  Contributing professionals should be mindful that the Early Help plan may form the evidential basis for future intervention to safeguard the child either before or after birth.

1.6.89

The early help planning and review process needs to be clear and robust. Given the relatively short timescale of the pregnancy, the decisions regarding the effectiveness and impact of an Early Help plan should be tightly managed. If it becomes evident that an Early Help plan is not having the desired impact because a parent is either not engaging with the plan, requires a more intensive plan, or steps need to be taken to safeguard the unborn child; a referral should be made to Children’s Services.

1.6.90

If consent cannot be obtained for an early help assessment and plan, then a decision will need to be made as to the impact of not receiving services and whether this would escalate concerns to the threshold of risk of significant harm or whether there are enough strengths, support and monitoring in place to work at a universal level.

Risk of significant harm

1.6.91

Where there may be multiple vulnerabilities experienced by a family which could put the unborn baby, or the child once born, at risk of significant harm, a referral to Children’s Services should be made at the earliest opportunity after 13 weeks gestation in order to:

  • provide sufficient time to make adequate plans for the baby's protection
  • provide sufficient time for a full and informed pre-birth assessment
  • avoid initial approaches to parents in the last stages of pregnancy, at what is already an emotionally charged time
  • enable parents to have more time to contribute their own ideas and solutions to concerns and increase the likelihood of a positive outcome for the baby
  • enable the early provision of support services so as to facilitate optimum home circumstances prior to the birth.
1.6.92

All referrals to Children’s Services should be made via the Multi-Agency Referral Form (MARF). Upon receipt of the referral, Children’s Services will make a decision as to how to proceed.  More complex cases will be considered by the Multi-Agency Safeguarding Hub (MASH) for information sharing to help decide which service is appropriate to safeguard the unborn child. Decisions will be based on the presenting evidence and the threshold criteria.   The referrer will receive feedback on what action is to be taken within one working day.

1.6.93

If the decision is taken that an assessment is required, the unborn child will follow one of two Pathways (see flowchart in Appendix 1 to this document).

  • For those unborn babies considered NOT to be at high risk, the assessments will be undertaken by the Assessment Team. Should a Child In Need (CIN) Plan be required after the pre-birth assessment, then the unborn child will be transferred to the CIN Service, where a CIN Plan will begin.  The outcome of the pre-birth assessment could be that parent/s are supported via an Early Help Plan. 
  • For unborn babies that are considered to be at high risk, they will be sent to the Child Protection/Court Team for the pre-birth assessment. This will involve input from the Family Assessment and Support Team (FAST)
  • Where one or both parents who is a child in need in their own right (ie subject to a CIN Plan, a Child Protection Plan, is a child in care or a care leaver) there will be dual responsibilities of social care. The separate Social Workers involved will be responsible for information sharing and liaison across the different social work teams and ensuring all agencies involved with the unborn child and expectant mother/parents are aware of their dual responsibilities across the different planning processes. 

Family Assessment and Support Team (FAST)

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FAST offers pre and post birth assessment around practical parenting, parenting support and focussed intervention.  FAST workers can work alongside the social worker to undertake parenting assessments under child protection plans, pre-proceedings and care proceedings.  Workers are trained in undertaking PAMs assessments with parents who have learning difficulties.   

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FAST will continue to work systemically within a professional network alongside the case holding Social Work team, including attending the Initial Child Protection Conference to gather information and inform their response.  All work undertaken is time limited and planned to specifically focus around the family’s individual needs using a range of interventions, tools and resources.  The focus of this would be to provide intense and immediate support to families in need; to reduce the likelihood of their needs escalating and a Child Protection Plan or legal proceedings started.

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If a Looked After Child becomes pregnant and a pre-birth assessment is required, the looked after social worker should make a referral to First Response.

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Social Care will feed back to the referrer and relevant agencies the outcome of the pre-birth assessment.  If safeguarding concerns are identified at the pre-birth assessment stage, a strategy discussion should be held to determine if a Section 47 investigation should be progressed.

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Dependent on the outcome of the Section 47 investigation the pre-birth assessment will either form the basis of the social worker’s report to an Initial Child Protection Conference or will act as a basis for pre-proceedings under the Public Law Outline.

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A pre-birth assessment must be undertaken when the following factors are present:

  • a parent or other person in the household is a person identified as presenting a risk, or potential risk, to children
  • child/children in the household/family are currently subject to a child protection plan or previous child protection concerns
  • there has been a previous child death in the household of either parent, which raises concerns about future parenting and risk of significant harm to the unborn baby
  • a sibling (or other child in the household of either parent) has previously been removed from the household either temporarily or by court order, or remains at home under a court order
  • there is knowledge of current, or a history of significant parental risk factors associated with, mental illness or disorder, domestic violence or substance misuse
  • there are concerns about parental ability to self-care and/or to care for the child e.g. unsupported young parent or learning disabled mother/parents
  • there are maternal risk factors e.g. denial of pregnancy, unwanted or ambivalent towards pregnancy, avoidance of antenatal care (failed appointments), non-co-operation with necessary services, non-compliance with treatment with potentially detrimental impact upon the unborn baby, including frequent moves e.g. area to area, hospital to hospital
  • evidence that the mother and/or father of the unborn are at risk of honour based violence or forced marriage
  • the parent is currently a child in care or a care leaver
  • the expectant mother is a child under the age of 14 years
  • there are concerns that the baby may be subjected to Female Genital Mutilation
  • any other concern exists that the baby may be at risk of significant harm
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Relinquished babies will transfer immediately to the Child in Care Service.

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Dependent on the level of concerns about a child or family the local authority may have to consider  if they need to initiate Care or Supervision Proceedings.  If they do a Legal Planning Meeting should be held (at 24 weeks gestation).  At the Legal Planning Meeting, a decision will be made in principle about whether the threshold criteria has been met and whether it is in the best interest of the child to provide a further period of support for the family, with the aim of avoiding proceedings;  or care proceedings should be initiated immediately. It is important that parents have been involved from the outset and be aware of the level of concern.  Professionals involved in the assessment up to this point may be asked to provided written evidence to court

Family Group Conferences

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A Family Group Conference (FGC) should take place where there is a possibility that parents may not be able to care for baby.  The FGC is a decision-making meeting in which a child’s whole family network considers how they can support the child to be cared for within the family network and they develop a plan.  The plan will address the future arrangements for the child to ensure that they are safe and their well-being is promoted.  Holding a FGC will allow the family to engage in planning for the expected child and to identify what support is realistically available from the extended family or friends.   Early identification of significant relatives or family members who might be able to support or provide primary care is essential.

ReConnect - Oxford Health - (Improving relationships between parents and children)

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ReConnect is a service aimed at improving outcomes for the most vulnerable children under the age of two.  This group will include children, as well as any unborn children, who are at high risk of developing a disorganised attachment through experiencing parenting breakdown, neglect and abuse, or parental mental health problems that impact on the child’s emotional needs.

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ReConnect aims at breaking the cycle of repeated abuse and neglect through offering intensive early intervention to high risk parents.

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ReConnect will work alongside multi-agency partners as part of the pre-birth assessment (as part of Child Protection plan) and provide early intervention that may improve the parenting capacity of mothers and improve the likelihood of them being able to parent their baby when born.  In situations where a mother is unable to show sufficient improvement in her parenting and her baby is removed and permanently placed away from parents, ReConnect can continue with their work in the hope that improvements can be made in time for any future pregnancies.  ReConnect will work with mothers with learning difficulties and will tailor their work to suit the mother’s level of understanding.

Parents and child placements

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Consideration can be given to the suitability for a parent and child placement as soon as professionals become aware of the pregnancy.  A parent and child placement is a fostering arrangement where a parent and their child are placed together in a fostering family.   The placement is usually made following the birth of a baby with the aim of supporting the mother to develop the parenting skills needed to care for their baby and the ability to put the needs of their baby first.  Placements are also offered to fathers and babies if the father is to be the main carer. 

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The Fostering Service should be contacted for further consultation, when discussing suitability of a parent for a parent and child placement.  In the event that there are suitable vacancies, a worker should be invited to the looked after child /permanency planning meetings to discuss plans for the child when born.  Placements will be made voluntarily with the agreement of the parent(s), however most placements are made as a result of care proceedings and decisions made at court.   

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The reasons when a parent and child placement may be considered suitable are when:

  • there is a young parent or child in care indicating they may need support
  • mother is known to use drugs and/or alcohol heavily
  • there is a child or older sibling who is subject to a Child Protection or Child in Need Plan or who is looked after
  • there is a parent with learning needs/difficulties
  • there is the potential that parenting will be a concern
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Referrals to the Fostering Team for a parent and child placement can be made for cases that are currently open to Children’s Services for:

  • one parent and one child only
  • where contact is expected neither parent or partner have a history of violence or aggression
  • there is sufficient information to complete an effective risk assessment
  • the Social Worker is aware of the requirements of parent and child placements, having attended the training and can provide the proactive support necessary in the early stages of the placement

Midwifery and Children's Services Liaison meetings

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Midwifery and Children’s Services Liaison Meetings take place every 6 weeks. The meeting is attended by a Social Care Team Manager and Midwives from the Midwifery Safeguarding Team, including the Safeguarding Midwife, Teenage Pregnancy Midwife or Mental Health Midwife.  Discussions take place about unborn babies that are about to be referred or have been referred to Children’s Services, in order to gain an update on the assessment, planning and support being offered to parents.  Relevant information is shared by the Safeguarding Midwifes about the mother and the pregnancy. Prior to the meeting, the Social Care Team Manager liaises with social workers to gain information about the social work intervention so far. 

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Unborn babies are discussed in detail after 24 weeks gestation and a general overview discussion takes place on unborn babies after 13 weeks gestation.  Complex assessments can be discussed in detail earlier than 24 weeks to ensure effective planning.  Following the meeting any issues raised by the Safeguarding Midwifes are shared with the Social Work team and responses fed back.  These meetings also provide an opportunity to offer consultation on safeguarding issues including thresholds.

Where family plan to move or have moved at any point in the process

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Where there are significant concerns and the whereabouts of the mother are not known, the details must be passed to the Local Authority Child Protection Business Support Specialist team and the Designated Manager will ensure that other agencies and local authorities are informed in accordance with the procedures about a missing child, adult or family.

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Where there are significant concerns and the case is being transferred to another local authority, procedures across authorities must be followed. Transfer should not deter the originating authority from initiating or continuing Care Proceedings. In those circumstances, legal advice needs to be sought around jurisdiction issues and appropriate transfer points.

Post Birth Planning

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Early planning is essential, particularly if there is a risk of baby being born pre-term. There should be a multi-agency meeting at 36 weeks which includes ward staff and any other professionals who may be relevant to the plan, immediately after birth. This meeting should ensure that there are plans that predict possible developments when the baby is born, including commencing Care Proceedings, seeking an Emergency Protection Order or Police Protection; in case parental agreement is withdrawn unexpectedly.

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If abduction is a possibility the contingency planning for this would not be shared with the family.

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The Child Protection Plan/Discharge plan should always address the following issues:

  • Who can visit the baby, and for how long?
  • Who can visit the mother and for how long?
  • Indicate the level of personal care for the baby that mother, father and other family members should undertake
  • What supervision of the mother, father and other family members is required?
  • Arrangements for information sharing, with absolute clarity for staff about who to update
  • Clear guidance to all involved about action to take if parents refuse to co-operate with the plan or part of the plan.
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Where vulnerability is identified late in the pregnancy it is essential that there is a clear plan regarding the birth of the baby. It is crucial that hospital discharge arrangements are clarified at the earliest opportunity.

Related Policies, Procedures and Guidance

Useful References

Assessing Parents’ Capacity to Change: A Structured Approach. Frontline Briefing. Research in Practice/Dartington. 2013

Ages of concern: learning lessons from serious case reviews: A thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to 31st March 2011. Ofsted:

Brown L, Moore S and Turney D (2012) Analysis and Critical Thinking in Assessment: Revised (2014) by Brown. L and Turney, D. Dartington: Research in Practice.

Children’s Needs – Parenting Capacity. Child Abuse: Parental mental illness, learning disability, substance misuse and domestic violence. 2nd Edition, London, The Stationery Office. (2011)

Domestic Violence and Pregnancy. www.refuge.org.uk

Fowler, J (2003) A Practitioner’s Tool for Child Protection and the Assessment of Parents. Jessica Kingsley Publishers: London.

Hart, Di (2000), Assessment Before Birth’ in Howarth, Jan (Ed) (2010) ‘The Child’s World Second Edition: The Comprehensive Guide to Assessing Children In Need’, Jessica Kingsley Publishers, London, (Chapter 14);

Huth-Bocks (2004). The impact of domestic violence on mothers’ prenatal representations of their infants, Infant Mental Health Journal, Michigan USA

Hart, Di (2001) and (2010), Assessment Prior to Birth’ in Howarth, Jan (Ed) (2010) ‘The Child’s World: Second Edition: The Comprehensive Guide to Assessing Children In Need’, Jessica Kingsley Publishers, London, (Chapter 14)

Hidden Harm – Responding to the needs of children of problem drug users.  2003

Information Sharing: Advice for practitioners providing safeguarding service to children, young people, parent and carers. DfE 2015.

Munro E (2011) The Munro Review of Child Protection: Final report. A child-centred system. London: Department for Education.

NICE: Pregnancy and complex social factors – a model for service provision for pregnant women with complex social factors (2010) NICE guidelines CG110.

Population Matters: Teenage Pregnancy in England and Wales. May 2016

Reder, P. and Duncan, S. (1999) Lost innocents: a follow-up study of fatal child abuse, London: Routledge.

Rayna,G. Dawe, S and Cuthbert, C. (2011) All babies count: Spotlight on drugs and alcohol. NSPCC

Shemming, D, Rayns, G, Rickman, C and Mountain, G. (2016). Attachment: Understanding and supporting parent/carer bonding before birth and in infancy. Research in Practice.

Safeguarding Children and Young People from Sexual Exploitation: Supplementary guidance to Working Together to Safeguard Children

Turney, D. Analysis in Critical thinking in Assessment: A literature review. Dartington. RiP 2014

Wallbridge, S. Guide to pre-birth assessments. CC Inform. March 2012 (Reviewed March 2016).

Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children, March 2015.

Engaging men in the life of their families- a practice agenda can be found in A Framework for conducting Pre-Birth assessments: Martin C Calder: 2008. This document also includes over 20 other references for practice guidance and research papers, so provides excellent source material in this area of work.

Appendix

Pre-Birth Flowchart

 

This page is correct as printed on Saturday 24th of August 2019 10:07:54 PM please refer back to this website (http://bscb.procedures.org.uk) for updates.
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