6.22 Pre-birth

1. Introduction

Young babies are particularly vulnerable to abuse, and early assessment, intervention and support work carried out during the antenatal period can help minimise any potential risk of harm. This procedure sets out how to respond to concerns for unborn babies, with an emphasis on clear and regular communication between professionals working with the woman, the father / partner and the family.

All professionals have a role in identifying and assessing families in need of additional support or where there are safeguarding concerns. In the vast majority of situations during a pregnancy, there will be no safeguarding concerns.

However, in some cases it will be clear that a co-ordinated response by agencies will be required to ensure that the appropriate support is in place during the pregnancy to best protect the baby before and following birth.

The antenatal period provides a window of opportunity for practitioners and families to work together to:

• Form relationships with a focus on the unborn baby;
• Identify risks and vulnerabilities at the earliest stage;
• Understand the impact of risk to the unborn baby when planning for their future;
• Explore and agree safety planning options;
• Assess the family's ability to adequately parent and protect the unborn baby and the baby once born;
• Identify if any assessments or referrals are required before birth; for example the use of the Early Help assessments agreed locally;
• Ensure effective communication, liaison and joint working with adult services that are providing on-going care, treatment and support to a parent(s);
• Plan on-going interventions and support required for the child and parent(s);
• Avoid delay for the child where a legal process is likely to be needed such as Pre-proceedings, Care or Supervision Proceedings in line with the Public Law Outline.

Where professionals become aware that a woman is pregnant, at whatever stage of the pregnancy, and they have concerns for the woman or unborn baby's welfare, or that of siblings, they should not assume that Midwifery or other Health services are aware of the pregnancy or the concerns held.

Professionals should consider whether the new-born baby will be safe in the care of these parents/carers and if there is a realistic prospect of these parents/carers being able to provide 'good enough' parenting care throughout childhood. If not, a pre-birth assessment may be required.

Each professional should follow their agency's child protection procedures and discuss concerns with their safeguarding lead/named/designated professional for safeguarding.

2. Risks

Risk factors which could indicate that an unborn child may be likely to suffer significant harm and therefore be subject to a pre-birth assessment may include:

• Involvement in risk activities such as substance misuse, including drugs and alcohol;
• Perinatal/mental illness or support needs that may present a risk to the unborn baby or indicate that their needs may not be met;
• Victims or perpetrators of domestic abuse;
• Identified as presenting a risk, or potential risk, to children, such as having committed a crime against children;
• A history of violent behaviours;
• May not be able to meet the unborn baby's needs e.g. significant learning difficulties and in some circumstances severe physical or mental disability;
• Are known because of historical concerns such as previous neglect, other children subject to a child protection plan, subject to legal proceedings or have been removed from parental care;
• Currently 'Looked After' themselves or were looked after as a child or young person (care leavers);
• A history of abuse in childhood;
• Are teenage/young parents and are vulnerable;
• Recent family break up and social isolation/lack of social support;
• Any other circumstances or issues that give rise to concern.

The list is not exhaustive and, if there are a number of risk factors present, then the cumulative impact may well mean an increased risk of significant harm to the child. If in doubt, professionals should seek advice about making a referral.

3. Working with Fathers / Partners

Fathers play an important role during pregnancy and after. The National Service Framework for Children, Young People and Maternity Services (2004) states:

'The involvement of prospective and new fathers in a child's life is extremely important for maximising the life-long wellbeing and outcomes of the child regardless of whether the father is resident or not. Pregnancy and birth are the first major opportunities to engage fathers in appropriate care and upbringing of children' (NSF, 2004).

It is important that all agencies involved in pre and post-birth assessment and support, fully consider the significant role of fathers and wider family members in the care of the baby even if the parents are not living together and, where possible, involve them in the assessment. This should include the father's attitude towards the pregnancy, the mother and newborn child and his thoughts, feelings and expectations about becoming a parent.

Information should also be gathered about fathers and partners who are not the biological father at the earliest opportunity to ensure that any risk factors can be identified. A careful assessment of the role that the person has in relation to the woman and any other children in the household as well as their views about the future care of the baby should be undertaken.

A failure to do so may mean that practitioners are not able to accurately assess what mothers and other family members might be saying about the father's role, the contribution which they may make to the care of the baby and support of the mother, or the risks which they might present to them. Background police and other checks should be made at an early stage on relevant cases to ascertain any potential risk factors.

Involving fathers in a positive way is important in ensuring a comprehensive assessment can be carried out and any possible risks fully considered.

4. Protection and Action to be Taken

When any professional in Adult Services becomes aware that a woman (or the partner of a man with whom they are working) is pregnant and they are of the view that there will be a need for additional support for the unborn child, who might be vulnerable due to the circumstances of their service user, they should inform maternity services of their service involvement and highlight any vulnerabilities they have identified.

An Early Help (or similar) assessment can be undertaken in relation to the unborn child. If the mother is under 18, they should also be offered an Early Help Assessment.

Where a professional is concerned that an unborn child or other children in the family may be likely to suffer significant harm, they should seek advice from their agency Safeguarding Lead without delay. The Safeguarding Lead will consider with them whether to refer to Children's Social Care - see Multi Agency Safeguarding Hub (MASH) Procedure.

All agencies should be involved in the development of a safeguarding assessment with a clear focus on the child's needs. Any risk assessments should be completed at least 4 weeks before the expected delivery date. All discussions, decisions and actions should be clearly documented in the appropriate agency record, including dates and names of professionals involved.

A pre-birth conference (see Pre-birth Child Protection Conferences Procedure) may be required if Children's Social Care assess that the child is likely to suffer significant harm.

A pre-birth conference should share all the relevant information and develop a Child Protection Plan if required. The timing of the conference should take into account the expected date of delivery and ideally take place by 24 weeks of the pregnancy, or earlier if there is a history of premature birth.

If a decision is made that the unborn child will be made the subject of a Child Protection Plan from birth, a Core Group should be established at the Initial Child Protection Conference. The Core group should meet prior to the birth within the locally stipulated days from the Conference date and certainly prior to the baby's return home from hospital.

Decision to Share Parental Responsibilty with Parents in Order to Safeguard a New Baby

If a Child Protection pre-birth Conference or social work pre-birth assessment concludes that the unborn child is at risk of significant harm, and the Local Authority should share parental responsibility with a parent to ensure the unborn child is safeguarded when born,  Children's Social Care should seek legal advice at this point about an application for an Interim Care Order. A legal planning meeting, chaired by a head of service should be convened. The application to the court can only be made once the child is born but there should be no delay in seeking the order. A Pre-Birth Planning Meeting should be arranged.

The Assessment should be shared, when completed, with the parents and, if instructed, to their solicitor to give them opportunity to challenge the proposed Care Plan and assessment.

The circumstances of the woman and other relevant adults should be reviewed regularly to allow for ongoing assessment of need and risk and consider any action required to safeguard the child. The Assessment should be updated to take into account relevant events pre-and post-delivery where these events could affect an initial conclusion in respect of risk and care planning of the child.

In some circumstances a legal planning meeting should be convened in Children’s social care to consider if a new born should be subject to pre proceedings, this a process, if agreed by where parents are informed of the Local Authorities concerns about their child by letter and a plan is put into place to advise the parents/carers of what needs to happen to prevent the Local authority applying to court to share parental responsibility. In this scenario parents/carers have the right to be legally represented as they do in court proceedings.

5. Pre-birth Planning Meeting

A Pre-Birth Planning Meeting should be arranged by a social worker as soon as possible once a pre-birth assessment starts. The meeting should agree how parents/carers will be supported and a detailed plan should be agreed to safeguard the baby around the time of birth which should include:

• How long the baby will stay in hospital (for babies born to substance using mothers there needs to be a period of time to monitor for withdrawal symptoms);
• How long the woman will remain on the ward;
• Any risks to the baby in relation to breastfeeding e.g. HIV status of the woman;
• The arrangements for the immediate protection of the baby if the risk assessment has highlighted serious risks to the child e.g. from parental substance misuse, mental health concerns, domestic abuse. This should also include contacting the police or the use of hospital security;
• The risk that the parents might seek to remove the baby from the hospital especially if the plan is to remove the baby at birth;
• The plan for managing contact with the baby by the woman, father or an extended family and who will supervise the contact;
• The plan for the baby upon discharge, and what visits will be made upon discharge and by whom;
• Contingency plans should be in place in the event of a sudden change in circumstances. These should include instructions for hospital staff if the birth happens over the weekend or a Bank Holiday. It should be clear who to contact if the birth takes place after hours. The Children's Social Care Emergency Duty Team should also be notified of the pre-birth plans for the baby.

All agencies attending the meeting should receive a copy of the plan as well as other relevant agencies for example the parents' GPs. The Lead Midwife should inform midwifery staff of the details of the plan.

5.1 Pre-discharge Meetings

A pre discharge meeting which is usually held at the hospital where a child is born, should take place prior to any new born leaving the hospital to ensure the family and all professionals are aware of the plan for the new born.

6. Issues

A detailed pre-birth assessment can provide an early opportunity to develop a good working relationship with parents during the pregnancy, especially where there are concerns. It can mean that vulnerable parents can be offered support early on, allowing them the best opportunity to parent their child safely and effectively. Importantly, it helps identify babies who may be likely to suffer significant harm, and can be used to develop plans to safeguard them.

There are some potential issues that can arise. The involvement of Children's Social Care (especially if there is a decision to remove the baby at birth) can result in the parents going missing or the woman not attending hospital at the time of birth.

It may have an adverse effect on the parents' mental or physical health or heighten the risks that had raised the concerns in the first place. The fear of losing the baby may undermine the attachment and bonding process between the parent and child. There is a danger that the woman may end up harming herself or her unborn baby or seeking to terminate her pregnancy.

It is vital that there is good communication with the pregnant woman, the birth father and, if different, her current partner in order to reduce the chance of such issues arising.

7. Further Information

This document should be read in conjunction with the Knowsley Pre-Birth Assessment.

NICE guidelines [CG192] Antenatal and postnatal mental health: clinical management and service guidance