Pre-Birth Protocol, Procedure and Guidance for Pre-Birth Assessment

Health professionals in contact with pregnant women should routinely assess the needs of the mother and the unborn baby.

Child care concerns which do not involve child protection can be referred, with the agreement of the parent for advice and support, for a Families First Assessment. It should be considered where a parent has moderate learning difficulties. This may be undertaken between the midwife, health visitor and any other relevant professionals. However, the health visitor will not be involved until after 28 weeks and with a reason to be involved. The midwifery services should coordinate the health needs until handover to the health visitor, from 10-days post-delivery. The health visitor may undertake targeted work antenatally. But this must not delay a Contact being made to Children's Services when the unborn baby is deemed to be likely to suffer significant harm.

Primary Care and Community Services are in a unique position to be in possession of historic and current family and/or extended family information. Where significant social history or risk related issues are evident that would have potential impact on the unborn child or parenting ability to meet the child’s needs it must be contained within any interagency and multi-agency communications and referrals. It is an expectation that concerns are communicated appropriately with other professional groups involved in the care of the unborn baby/carers.

2.2.1 Circumstances Requiring a Contact to Children’s Services

Any professional, working with expectant parents/carers who are concerned about the welfare of the unborn baby must discuss and analyse the issues with her/his line manager, supervisor or designated Safeguarding Officer, maternity safeguarding team. If this concludes that an unborn baby is likely to suffer significant harm, or the parents/carers will require significant support they must refer to Children's Services. A GP should discuss their concerns with the Safeguarding Lead within the practice, the Named GP for Safeguarding or the Designated Team within the relevant Integrated Care Board (previously CCG).

Hart (2000) indicates that there are two fundamental questions when deciding whether a pre-birth assessment is required:

• Will this new-born baby be safe in the care of these parents/carers?
• Is there a realistic prospect of these parents/carers being able to provide adequate care throughout childhood?

A pre-birth assessment will consider these questions.

Information should be shared with prospective parent(s) and consent obtained to contact Children's Services unless this action in itself may place the welfare of the unborn child at risk e.g. if there are concerns that the parent(s) may move to avoid contact. As applicable advocates or language communication interpreters will be made available to parent(s) throughout the process. Information can also be shared if consent is refused if there are safeguarding concerns for the unborn baby.

Some parents may refer themselves, as they have an understanding of the potential issues in relation to the unborn baby and are seeking help. Other prospective parents will need to be referred by others (including family and others in the community) because of concerns/support needs identified.

A Contact will be made to Children Services, by other agencies, and a consideration for a pre-birth assessment would be required in the following circumstances (please note this list is not exhaustive):

This list is not exhaustive and individual factors that may usually fit more comfortably at a targeted level may become more serious if there are a number of concerns grouped together. If a professional is in doubt about making a referral, s/he should always seek advice.

A verbal Contact should be made if there is an immediate risk, 0300123 4043, followed up immediately in writing (see Contacts and Referrals Procedure for full details and use Hertfordshire Child Protection Referral Form). Information Sharing and Confidentiality Procedure will be followed.

Information provided by the referring agency should include all relevant historic, social, criminal and family issues, information sharing consents and the lead/agency’s views/analysis of risks/needs posed to the unborn child. A Graded Care Profile should be attached to the referral where there are concerns of neglect. Of particular importance are details about all possible carers or partners of the expectant parent. These are frequently missing from referral information and subsequently from the assessment itself. Any issues of drug and alcohol use should be included, and issues of violence, both in respect of risk to the child, but also to staff working with the family. Services that have paternal/partner involvement only must have systems that routinely enquire about dependent children and refer accordingly in relation to risks e.g. Specialist Adolescent Services Hertfordshire (SASH), Primary Care, Mental Health, Multi-Agency Child Exploitation (MACE), Youth Offending Services, NPS/BeNCH, Police, HCT, Adult Care Services, Change, Grow, Live (Spectrum), Community Health and AF-DASH.

All referrals must include an analysis of relevant historic, social and family issues of significance to inform any future risk assessment and /or referral. Investigation/information sharing should be undertaken in respect of on both parents/partners and other possible carers, and all decisions made about information sharing should be recorded on agency records.

3.1.1 Unborn Babies of Care Leavers

Where information is received that a care leaver is pregnant, or a male care leaver’s partner is expecting a child, it is essential that immediate consideration is given to the requirements of a referral for the unborn baby.

Initial contact should be made with the care leaver’s Personal Advisor (PA). The Personal Advisor will liaise with their Team Manager and update the young person’s pathway plan, taking into account the skills and preparation needs specific to becoming a new parent as well as any concerns for the unborn baby or the young person’s ability to parent. This also needs to include the care leaver’s own experience of being parented and how this might impact on their practical and emotional parenting support needs.

In order to ensure a holistic assessment of needs, the assessment needs to take into account the other parent/partner of the unborn baby given their parenting role alongside the care leaver.

In considering whether a referral is made to the Hertfordshire Children’s Services, the referring professional should discuss the matter with the care leaver’s Personal Advisor; the Personal Advisor will involve the LAC/CL’s midwife using the HSCP Pre-Birth Protocol criteria for referrals to Safeguarding.

The PA must inform the Looked after Children and Care Leavers Team on 01438 843004 or herts.lacservice@nhs.net to inform them of the expectant parent and partner.

Where the Specialist Adolescent Services Hertfordshire (SASH), Leaving Care service, and Health identify safeguarding concerns or support needs with regards to the unborn child, the parents should be informed and the unborn child is to be referred to Hertfordshire Children’s Services. The MASH may request information sharing from partner agencies with regards to both parents/partners and any children and a further multi-agency consultation may be arranged involving SASH and Health to decide on further steps. The outcomes of the referral can be that a referral for a Pre-Birth assessment is required or that concerns/support needs are not significant enough to warrant this and therefore support and intervention should continue at a targeted and universal level for the family (see Section 4, Children's Services Response to Contacts).

It is imperative that any referrals are made as soon as the pregnancy is known and where the criteria for a Pre-Birth Assessment are met, in order for sufficient time for relevant assessments to be undertaken.

The social worker will complete the Child and Family Assessment within 35 days. The discussions from the inter-agency information sharing meeting/strategy meeting and the Team Manager’s subsequent decision should be shared with the parents/partners by the Social Worker, and at least three assessment visits should take place. At the end of the assessment, the Team Manager will be responsible for determining which pathway is best for the unborn baby. There are 3 possible options:

• Concerns are allayed and/or can be managed by relevant practitioners in the community. The child/ren will Step Down to a Families First Assessment, and be reviewed by the appropriate Lead Professional;
• If the assessment evidences concern about significant impairment to the child’s health and development a Child in Need plan will be developed and the child/ren will transfer to Family Safeguarding at the first review;
• The assessment has found that the unborn baby is suffering or likely to suffer significant harm a strategy discussion will be held (if this has not already taken place) and consideration given to convening an Initial Child Protection Conference (ICPC).

If baby is born during the pre-birth assessment process, particularly where there has been concern around concealed pregnancy or late booking, a discharge planning meeting must be held before baby goes home, and plan shared with the family and all relevant professionals, including the GP. This meeting will determine any concerns raised regarding parenting capacity and who will support.

The ICPC will require the attendance of all the involved professionals during the pregnancy which must include the Midwife and, from 28 weeks gestation, the Health Visitor. It should also include those to whom the child/ren will transfer following the birth e.g. Family Safeguarding Team Social Worker. Reports will be expected from all relevant practitioners, which should address, and analyse, agency concerns around the pregnancy and/or parenting capacity as well as areas of strength. The resultant Child Protection Plan should consider carefully the ability to manage a Protection Plan in the community and whether this will provide sufficient safeguards for the new born baby. Parents should also be encouraged to seek advice and advocacy from the Child Protection stage onward.

A pre-birth planning meeting will be held by 34 weeks gestation. All essential professionals and the prospective parents should attend, and a written plan constructed and shared with all relevant professionals, including the GP. This must consider:

• Practical arrangements for mother and baby-including post natal ward monitoring;
• Who will inform the Social Worker of the birth?
• Plans for out of hours/emergency birth;
• Contact arrangements with parents/partners and other family members;
• Discharge plans and support package-including out of area as relevant e.g. if discharging to extended family or friends address for any period or specialist setting;
• Contingency plans;
• Update on any legal advice/planning that has taken place;
• Parental engagement with the plan;
• Health and safety issues.

All subsequent Core Group/Pre-Birth Planning meetings should incorporate the above plan in its discussion and decisions.

If the social care team has concerns that the risks to the baby will be so serious that the baby cannot be protected in the care of its parents, in the community, they must consider the need for a Legal Planning Meeting at an early stage following the Pre Birth Assessment (or earlier in some cases). Where there is any professional disagreement, the Escalation of Concerns and Professional Disagreements about Decisions, including Convening an ICPC should be followed. This meeting should be held at around the time of the ICPC, and the relevant Family Safeguarding Team should attend. If the outcome of a Legal Planning Meeting is Public Law Outline, the meeting with parents should be arranged after the ICPC, and the parents should have received the letter before proceedings by the 24th week of pregnancy at the latest (if the pregnancy is known at this stage). Prospective parents/partners have a right to full information about the concerns professionals hold about their ability to parent their child, and a clear understanding of the action the Local Authority intends to take in regard to their child. This should be assessed with regard to flight risk.

When a mother has concealed her pregnancy Children’s Services should always be informed immediately and an assessment undertaken.

If a sibling group of children are already subject of a Child Protection plan and the mother is pregnant a Strategy Discussion and S47 Enquires must be completed in respect of the unborn baby, prior to presentation at an Initial Child Protection Conference (which will be a Review Conference for the siblings). The unborn baby cannot be made subject of a Child Protection Plan without this process being undertaken to provide the evidence that the unborn baby’s needs meet the threshold for the ICPC and to ensure that the evidence and decision making is fully recorded on the unborn baby’s LCS file.

If the unborn baby is made subject of a Child Protection plan in this way the CP flag will appear on his or her LCS record and the child’s details are added to CP-IS. This is an essential protection for the baby/unborn baby.

A sound assessment will include what research tells us about risk factors, what practice experience tells us about how parents may respond in particular circumstances, and the practitioners’ professional knowledge of this particular family.

It will collate factual evidence to evaluate relationships between parents, partners, extended family and the wider support network and between parents/partners and the unborn baby, the impact of personal history on current experiences and the current context within which the family live. This is consistent with the Framework for Assessment of Children in Need and their Families.

The Social Worker will:

• Identify a fundamental baseline of parenting capacity;
• Read case files of any child/ren who have received a service including from another Local Authority;
• Undertake relevant checks regarding parents/carers/new partners, within Local Authority area, including Probation, Police, Health, any relevant adult care services, schools, colleges and Connexions, and, if appropriate in other Local Authority areas;
• Construct a chronology;
• Interview parents/partners together and separately, test out parenting capacity and develop early engagement. Noting the dynamics between parents/partners. A parent may require significant discussion using a motivational approach when reviewing the professional and historical information. A clear history from the parents/partners of their previous experiences (including previous children and relationships) will inform the assessment;
• Consider the relevance, if any, of any past history of either parent/partner as having been Looked After or in receipt of Safeguarding services themselves;
• Risk assessment of the home environment and assessment of appropriate preparations made for the arrival of the baby;
• Risk assess any dog or other pet, and consult with RSPCA or similar as required.

Previous History

Practitioners should attempt to build up a clear history from the parents of their previous experiences – particularly experiences of parenting and the impact of a new baby. Relationships and any conflicts need to be understood.

It will be particularly important to ascertain the parent(s)/partners views and attitudes towards any previous children who have been removed from their care, or where there have been serious concerns about parenting practices. Relevant questions would include:

• Do the parent(s)/partners understand the nature, dynamics and impact of the previous concerns and outcomes?
• Do they acknowledge these concerns and the impact upon their children?
• Do they minimise, normalise or deny the concerns?
• Do they blame themselves?
• Do they blame others?
• Do they blame the child?
• Do they acknowledge the seriousness and impact of what happened in the past?
• Did they accept any treatment/counselling?
• What was their response to previous interventions? e.g. genuinely attempting to cooperate or disguised compliance?
• What are their feelings about that child now?
• What has changed for each parent/partner since the child was removed?

This list is not exhaustive. There will be particular issues for the individual's family that require social workers and other practitioners to gather information about past history and review past risk factors.

It is also important to ascertain parent/partner’ feelings towards the current pregnancy and the new baby; relevant areas to explore and related questions should seek to understand:

• Is the pregnancy wanted or not?
• Is the pregnancy planned or unplanned?
• Is this pregnancy the result of sexual assault?
• Is domestic abuse, coercion or control present in the parents’ relationship?
• Feelings towards the new baby?
• Have they sought appropriate ante-natal care?
• Are they aware of the unborn baby’s needs and able to prioritise them?
• Do they have realistic plans in relation to the birth and their care of the baby?

If a child has been removed from a parent’s care because of sexual abuse and, or child sexual exploitation, the assessment should consider evidence of change and the prospective parent/carers current ability to protect. Confidence in the safety of the newborn baby will be reduced if the perpetrator is the prospective parent/partner or is living in the household, there is no acknowledgement of responsibility, where the non abusing parent blames the child and there is no prospect of effective intervention within the appropriate time-scale.

If the perpetrator is convicted for posing a risk to children, it needs to be established if s/he has served a custodial sentence for sexual offences and if s/he participated in a treatment plan. If the perpetrator is already living in a family with other children, (albeit with social work involvement), this will not detract from the need for a pre-birth assessment. Maintain the focus on both prospective parents, and any other adults living in or visiting the household and do not concentrate solely on the pregnant woman.

When a person 'who presents as a risk to children' has been previously assessed, the qualifications of the assessor and the quality of the assessment must be reviewed, as part of any current assessments.

Relevant questions when undertaking a pre-birth assessment when previous sexual abuse has been the issue include:

• The circumstances of the abuse: e.g. was the perpetrator in the household?
• Was the non-abusing parent present?
• Details of the abuse, and its impact?
• What relationship/contact does the mother have with the perpetrator?
• Assuming the man as perpetrator - however, this is not always the case, how did the abuse come to light? e.g. Did the non-abusing parent disclose or conceal?
• Did the child tell? did professionals suspect?
• Did the non-abusing parent believe the child?
• Did they need help and support to do this?
• What are current attitudes towards the abuse?
• Do the parents blame the child/see it as her/his fault?
• Has the perpetrator accepted full responsibility for the abuse?
• How is this demonstrated?
• What treatment did he/she have?
• Who else in the family/community network could help protect the new baby?
• How did the parent(s) relate to professionals? what is their current attitude?

In circumstances where the perpetrator is the prospective father/partner or is living in the household, where there is no acknowledgement of responsibility, where the non abusing parent blames the child and there is no prospect of effective intervention within the appropriate time-scale, then confidence in the safety of the newborn baby and subsequent child will be reduced.

Circumstances where the perpetrator is convicted for posing a risk to children (have they served a custodial sentence for sexual offences and did they participate in a treatment plan?) and is already living in a family with other children (albeit with social work involvement), should not detract from the need for a pre-birth assessment. In all assessments, it is important to maintain the focus on both prospective parents/partners, and any other adults living in the household and not to concentrate solely on the mother.

When a person 'who presents as a risk to children' has been previously assessed, the qualifications of the assessor and the quality of the assessment must be updated and reviewed, as part of any current assessments.

See Children of Parents with a Mental Health Problem Procedure.

Although most parents with mental health difficulties are able to care for their children appropriately, research has indicated that child-maltreating parents are often shown to have mental health problems e.g. depression, history of attempted suicide, schizophrenia etc. Non-compliance with medication without medical supervision is a cause for concern.

Children are at increased risk of abuse by psychotic parents when incorporated into their delusional thinking e.g. “(the baby) is trying to punish me for my sins”.

Practitioners will obviously seek to obtain a psychiatric assessment in these cases, but must not become “paralysed” if that is not forthcoming. It is essential to continue the assessment based on the behaviour of the parent(s), not the diagnosis, and the potential risk of that behaviour to the new-born child. In addition, where there are mental health risk factors identified, ongoing re evaluation of risk is essential.

If the parent is already known to mental health services, consent should be sought from the parent, to liaise with the care co-ordinator/ named professional. If there are concerns that a mother is experiencing moderate to severe mental health problems and she is not already under the care of a community mental health team, a referral to the Hertfordshire Community Perinatal Team can be made. Information regarding the Team and Referral forms may be accessed via the Hertfordshire NHS website.

If the parent is already under the care of a mental health team practitioners should consider liaising with the care coordinator in that team to seek to optimise the mental health of the mother.

See Children of Parents who Misuse Drugs or Alcohol Procedure.

Drug or alcohol misuse is not in itself a contra-indication that the parent(s) will be unable to care safely for the baby, but practitioners will need to analyse:

• The history with substance use and the current pattern of drug use and alcohol misuse and the likely impact on the baby/child as they grow/develop;
• Whether it can be managed compatibly with the demands of a new-born child;
• Whether the parent(s) are willing to attend for treatment, and the consequences for the baby of the mother’s substance misuse during pregnancy e.g. withdrawal symptoms.

When a pre-birth assessment is being undertaken, the child is, as yet, unborn and unknown but there may be indicators e.g.:

• Antenatal Depression;
• The child may be at risk of a premature birth and therefore vulnerable and likely to stay in hospital for a period after delivery;
• Mother’s misuse of substances may result in the child having withdrawal symptoms or foetal alcohol syndrome;
• Circumstances that may lead to the child being perceived as unwanted by either parent.

It is essential that there is close liaison with the midwives, obstetricians and drug & alcohol services in relation to these factors.

See Domestic Abuse Procedure.

When assessing domestic abuse the social worker will establish if the parent known to Multi Agency Risk Assessment Conference (MARAC), Multi-Agency Public Protection Panel (MAPPA), Domestic Violence Officer (DVO) or an Independent Domestic Violence Advisor (IDVA) and ensure full forensic history of violence of each parent, or adult who will have significant contact with the unborn baby as possible given consents and whether being assessed under S17 or S47 or the Children Act.

The social worker will obtain evidence of the nature patterns and cycle of the abuse or violence and whether there is any escalation in the abusive behaviours or their impact which presents an increase in feelings of feelings of fear or distress, or an increase in the risk of or actual harm.

Risks are greater when a parent with unresolved care and control conflicts is caring for a baby with particular characteristics which may make him/her harder to care for e.g. a poor feeder or sleeper, constant crying, a disabled child etc. (Reder and Duncan, 1995, p.49; Reder and Duncan, 1999, pp. 62-71).

Dutton, 1998, 1999; Dutton & Holtzworth-Munroe, 1997; Neller et al., 2005; Pomeroy, 1995 suggest that individuals who experience violence are likely to develop trauma symptoms, and these symptoms increase the likelihood of later violent behaviour by the victim. In fact, Milner et al. (2010) found that parent's unresolved trauma and trauma symptoms influence the risk of adult child abuse and the intergenerational transmission of child physical abuse.

A viability assessment will be undertaken of any adult who is not the child’s parent but who is expected to be part of a child protection plan to safeguard the child. This is typically a grandparent or members of the family and friends, with whom the plan is for the parent(s) and new born baby to live. The relative / friend who is given and accepts this role, will sign agreements to any child Protection Plan, be invited to all Child Protection meetings, Core Group/Pre-Birth meetings and be consulted by the child’s social worker.

Examination of the history of previous children who have been removed from the parent(s) care will indicate if there were particular characteristics which made that child harder to care for. It is essential to find out from the parent(s) what problems, if any, they identified in caring for that child.

Caring for a new born baby is difficult enough for any parent but can be particularly stressful if the parent(s) are isolated and do not have a network of support. It is important to identify whether partners are going to share responsibility or whether it will fall to one, usually the mother.

Research (Reder and Duncan,1999, p.69) has indicated that when children have been abused the trigger may often be a family crisis e.g. loss of home or job, marital problems or upheavals, physical exhaustion etc. However, there are many other triggers and factors that will need to be considered within an assessment.

Romero-Martinez et al. (2014) research notes that the timing of history of physical abuse in parents, the presence of continuous history of physical abuse, the parent's gender and low socio-economic resources and abilities, are relevant factors to disrupt parenting practices and contribute to a higher likelihood of occurrence of physical abusive strategies in parents who have experienced frequent physical maltreatment from a primary caregiver in childhood. Indeed, both the history and frequency of childhood maltreatment increase the risk of child maltreating as parents (Dym Bartlett et al. 2016).

It is therefore important to identify the support networks the parent(s) have, as well as their financial and housing position. Clear guidelines are outlined in the Framework for Assessment of Children in Need and their Families.

Once the information has been collected it needs careful analysis. This should be a shared process with the other agencies involved, particularly the midwives and obstetricians. This will be primarily the task of the inter-agency information sharing meeting and the core group.

If the assessment identifies that there are clear risks to a newborn baby then key judgements will be:

• Whether there is evidence of the parent(s’) capacity to change;
• Will the provision of support and services be sufficient to enable the parent(s) to care safely for their baby?
• Will they be able to change in time for the baby’s birth?
• Whether the parents have appropriate support networks.

Across the county, communication is sent to Primary Care (GP Practices) to inform them of all booked pregnancies, with a documented request for information sharing in the event of known safeguarding concerns. Where safeguarding concerns are known at the point of initial or subsequent attendance for maternity care, a dedicated communication is forwarded with relevant information as necessary. Information is shared with other health and multi-agencies as appropriate.

A similar communication, for those women attending for maternity care outside of Hertfordshire is sent to the relevant organisations.

Across the county health liaison and information sharing meetings take place at regular intervals. Multi-agency attendance at the meetings is decided according to organisational and case preference and/or need. It is an expectation that Children’s Services are represented, according to need.

• Perinatal psychiatry, Crime Reduction Initiative, Domestic Abuse Investigation and Safeguarding Unit Officer (DAISU Officer), Herts Community Health Service Learning Disabilities, Hertfordshire Partnership Trust’s Community Mental Health Team and teenage pregnancy co-ordinators should be invited to share relevant information or attend as appropriate.

N.B. In addition to the usual information sharing arrangements, information in relation to any historic involvement of agencies and older children being subject to assessments, plans, Court proceedings, risks associated to new partners (from current or previous Local Authority) is crucial to full risk assessments and follow up planning.

The purpose of these meetings is to:

• Discuss risk and assess unborn baby concerns, and to consider threshold for referral to safeguarding teams for pre-birth assessment; and
• Gain updates from CS in respect to progression of pre-birth assessments/pre-birth plans and discharge plans where unborn child is allocated to a social worker within CS.

Any issues regarding attendance should be addressed through the established HSCP escalation process.

It is an expectation that ongoing information sharing and liaison is undertaken between practitioners who work directly with parents/care givers to ensure regular review and the implementation of robust plans.

Social Care Safeguarding Advice

Each Assessment team will identify a lead pre birth social worker who can mentor and support other social workers completing pre birth assessments.

A named lead pre birth social worker across each district will be available to offer telephone consultations to other professionals. The geographical areas that they cover will be:

Broxbourne; East Herts; Dacorum; St Albans; Stevenage; North Herts; Watford; Three Rivers; Wel/Hat; and Hertsmere.

In some areas there will be one named pre-birth social worker for a double district.

Early Intervention Advice

For child/ren that do not meet the threshold for social care intervention, advice and guidance is available to practitioners through the Families First Portal. Local support is available for FFA and Team Around the Child arrangements.

In the event of child/ren not meeting threshold for Social Care intervention or where there is little or no positive or willing engagement with statutory services, the expertise of local specialist services e.g. IDVAs, substance misuse services, mental health services etc should be consulted for advice and guidance where appropriate.

Regular re evaluation of the plan, especially immediately after the birth, will be critical, and a re referral into social care should be made if the situation deteriorates or professionals are in any doubt about the safety of the baby.

In case of disputes between professionals about how a child/ren should be managed and/or under which process, professionals should follow the agreed dispute resolution procedures within their own agencies, ultimately adhering to the HSCP escalation process.

Specific inter-agency Safeguarding training will be provided around pre birth assessment through the HSCP Learning and Development programme, where this protocol will be fully explained.