Guidelines for the Provision of Care in the Presentation of Concealed/Denied/Unknown Pregnancy or Late Booking in Pregnancy

This policy and procedure is for anyone who may encounter a woman or girl who conceals the fact that she is pregnant or where a professional has a suspicion that a pregnancy is being concealed, denied or unknown, or a woman or girl who significantly delays accessing antenatal care.

The concealment and denial of pregnancy may present a significant challenge to professionals in safeguarding the welfare and wellbeing of the unborn child and the mother. It is important that a multi-agency, engaging approach is taken.

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 or relevant agencies.

A denied/unknown 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 are 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, 2010).

For the purpose of this policy and procedure any reference to woman includes females of childbearing capacity (including under 18's). A pregnancy will not be considered to be concealed, denied or unknown for the purpose of this procedure until it is confirmed to be at least 24 weeks gestation (age of viability). However by the very nature of concealment or denial it is not possible for anyone suspecting a woman is concealing or denying a pregnancy to be certain of the particular stage of a woman’s pregnancy. Similarly, if a woman says she is unaware she is pregnant, it is not possible to be certain of the particular stage of the pregnancy.

Concealment of pregnancy may be revealed in pregnancy; in labour or following delivery.

The implications of concealment and denial of pregnancy are wide-ranging. Concealment and denial can lead to a fatal outcome, regardless of the mother's intention.

Lack of antenatal care can mean that potential risks to mother and child may not be detected. The health and development of the baby during pregnancy and labour may not have been monitored or foetal abnormalities detected. It may also lead to inappropriate medical advice being given; such as potentially harmful medications prescribed by a medical practitioner unaware of the pregnancy. Relevant advice in the ante-natal period cannot be given if professionals are unaware of the pregnancy. This includes health advice, i.e. taking folic acid as well as the opportunity to explore any social needs such as domestic abuse.

Underlying medical conditions and obstetric problems will not be revealed if antenatal care is not sought. Some women who conceal or deny their pregnancy, or are unaware they are pregnant, may go on to deliver their baby without medical assistance.

An unassisted delivery can be very dangerous for both mother and baby, due to complications that can occur during labour and the delivery. A midwife should be present at birth, whether in hospital or if giving birth at home.

Concealed pregnancy can potentially impact on a mother’s ability to meet their baby’s needs both in respect of emotional needs and ability to bond as well as physical needs. In a case of a denied pregnancy, the effects of going into labour and giving birth can be traumatic.

The reason for the concealment/denial will be a key factor in determining the needs and potential risk to the unborn/child and any other children in the household or family; these reasons can include but are not limited to:

• Mental Illness;
• Substance Misuse;
• Learning Disability;
• Domestic Abuse (which may begin or escalate during pregnancy);
• Sexual Abuse;
• Fear of social service involvement;
• Religion and cultural belief;
• Incestuous or extra marital paternity or other concerns relating to consequences for the parents and child due to identity of father;
• Fear of the reaction of family members or members of the community;
• Anti-medical intervention;
• Victim of trafficking/ modern day slavery and has been denied access to medical care.

Where concealment/denial is a result of alcohol or substance misuse there can be risks for the child's health and development in utero as well as subsequently.

If an appointment for antenatal care is made late (beyond 24 weeks), the reason for this must be explored and fully documented. It is important to consider that unless the woman has genuinely not been aware of the pregnancy up until the point of access to care, she has still concealed her pregnancy in the first instance. A woman who presents for antenatal care late in pregnancy should continue to be assessed with the reasons for delay in presentation and associated risks forming part of the overall assessment. Midwives and Obstetricians should consider whether a mental health referral is required. If an exploration of the circumstances suggests a cause for concern for the welfare of the unborn baby, a referral to Children's Social Care must be made - see Contacts and Referrals Procedure. The woman should be informed that the referral has been made. The only exception to this being in rare circumstances that by doing so would place her or her unborn baby at immediate risk of harm. Children's Services must also be involved in any circumstance outlined in the “Indicators for Contact to Children’s Services” within the Pre-Birth Protocol, Procedure and Guidance for Pre-Birth Assessment.

Please also refer to the Pre-Birth Protocol for further information. See Pre-Birth Protocol, Procedure and Guidance for Pre-Birth Assessment.

It is widely known that there are challenges that face parents with the arrival of a new baby however it is fundamental that the baby is always at the heart of everything that we do. The ‘Leadsom Report’ (HM Government 2021) highlights the lifelong impact on babies and children due to adverse childhood experiences’ (ACEs) as a result of exposure to poor parental mental health, abuse, neglect and parental drug misuse, parental conflict amongst other risk factors. It is therefore fundamental that parents and carers of babies get the right type of support, at the earliest opportunity to help them give their babies the best start in life.

Where a woman is pregnant all agencies must ensure they consider the history from both parents/ or carers who parent, and ensure they share and receive relevant agency information to support a risk assessment, which considers any support needs for the adults, or potential risks for the baby and any other children (please see Information Sharing and Confidentiality Procedure).

All agencies should always take actions to consider, in partnership with parents/partners, any support needs and/or safeguarding risks and ensure appropriate referrals are made in line with the HSCP Continuum of need Procedure.

See also: GOV.UK, The best start for life: a vision for the 1,001 critical days.

If a woman arrives at the hospital in labour or following an unassisted delivery, where a booking has not been made, these cases should be seen as high risk. The safeguarding alerts folder must be checked. A referral must be made to Children’s Social Services. If this is in an evening, weekend or over a public holiday then the Safeguarding Out of Hours Service must be informed.

In cases of concealment, if the baby has been born outside the hospital setting, then mother and baby must be transferred to hospital to ensure appropriate health checks and screening can be carried out on both mother and baby. A referral must be made to Children’s Services.

If the baby has been harmed in any way or there is a suspicion of harm, or the child is abandoned by the mother, then the Police must be informed immediately and a referral made to Children’s Social Services. Similarly, if the mother declines a transfer to the hospital when there are concerns about the baby’s wellbeing or the mother’s wellbeing (suspected mental health or complex social issues), a referral must be made to Children’s Services.

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/unknown pregnancy, midwives need to be alert to the level of engagement shown by the mother, and her partner/extended family if observed, and of receptiveness to future contact with health professionals. In addition midwives must be observant of the level of attachment behaviour demonstrated immediately after the child is born.

In cases where there has been concealment and/or denial of pregnancy, especially where there has been unassisted delivery, seek advice from a mental health specialist and strongly consider a referral for a full mental health assessment must be made. Preferably this should be done while the woman is an in-patient by the hospital attached mental health team. In circumstances where this is not possible, a referral may be made to the Perinatal Mental Health Service. Jenkins et al. (2011) has stated that concealed pregnancy should be viewed as a ‘red flag‘ and trigger psychiatric assessment including assessment of maternal capacity. Contact should also be made to the mother's GP to share information about any historical concerns. In addition the baby should not be discharged until a multi-agency Strategy or discharge planning Meeting has been held and relevant assessments undertaken. A discharge summary, containing relevant information from maternity services must be shared with the GP and Public Health Nursing Team.

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

• Increased weight or attempts to lose weight;
• Wearing uncharacteristically baggy clothing;
• Concerns expressed by friends;
• Repeated rumours around school or college;
• Uncharacteristically withdrawn or moody behaviour.

The age of the young woman is also an important factor – see Pre-Birth Protocol, Procedure and Guidance for Pre-Birth Assessment for referring mothers aged under 16.

Staff working in educational settings should try to encourage the pupil to discuss her situation, through normal pastoral support systems, as they would any other sensitive problem. Every effort should be made by the professional suspecting a pregnancy to encourage the young woman to obtain medical advice. However where they still face total denial or non-engagement a referral to Children’s Services will be needed. Depending on age, informing her parents of the referral also needs to be considered.

A multi-agency Discharge Meeting must take place, and shared with all agencies involved (including the GP), to ensure a safe discharge from hospital for both the baby and the mother following identification of a concealed or denied pregnancy. Post-natal care should be provided in line with the NICE Guidelines.

If a woman is pregnant for a second or subsequent time and there is knowledge of a definite previous concealed/denied pregnancy, then a referral to Children’s Services should be made, in line with recommendation within the Pre-Birth Assessment. See Pre-Birth Protocol, Procedure and Guidance for Pre-Birth Assessment.