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.

Childcare 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 visiting service, 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 their 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 newborn 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. Advocates or interpreters will be made available to parent(s) throughout the process. Information can also be shared if consent is refused if there are Level 4 concerns for the unborn baby or if the consent exception criteria are met for Level 2 and 3 needs.

Some parents may refer themselves, as they understand 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 few concerns grouped together. If a professional is in doubt about making a referral, they should always seek advice from their safeguarding lead.

An online referral to Children’s Services should be made(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 or the Partnership’s Neglect Multi Agency Checklist (MAC) 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, issues of control and coercion, 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. .

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 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. Due to their increased vulnerabilities, adverse childhood experiences, and potential social isolation, care leavers are at a higher risk of requiring social work intervention for their children. Early recognition of the parents’ needs can lead to additional support being provided before the baby’s birth, potentially eliminating the need for statutory intervention.

Initial contact should be made with the care leaver’s Personal Advisor (PA). The PA will liaise with their Team Manager and update the young person’s pathway plan, considering 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.

To ensure a holistic assessment of needs, the assessment needs to consider 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 PA; the PA will involve the CLA/CL’s midwife using the HSCP Pre-Birth Protocol criteria for referrals to Safeguarding.

The PA must contact the Children Looked After and Care Leavers Team herts.lacservice@nhs.net to inform them of the expectant parent and partner.

Where the Specialist Adolescent Services Hertfordshire (SASH), Care Leaving service, and Health identify safeguarding concerns or support needs with regards to the unborn child, this should be discussed with the parents and their consent gained, if possible, before the unborn child is 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, for sufficient time for relevant assessments to be undertaken.

The social worker will complete the Child and Family Assessment within 45 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:

• Support can be managed by relevant practitioners in the community. The child/ren will step forward to a Families First Assessment, and be reviewed by the appropriate Lead Professional;
• If the assessment identifies 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;
• If the assessment has found that the UBB 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. A Child Protection Plan should consider whether a community-based support plan will provide sufficient safeguards for the newborn 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 health colleagues, neonatal unit and 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 friend’s 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 baby would be at risk of significant and immediate harm in the community if in the care of parents 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 and this is ratified by the Practice and Resource Panel, 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 regarding their child. This should be assessed regarding 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 UBB, prior to presentation at an Initial Child Protection Conference (which will be a Review Conference for the siblings). The UBB cannot be made subject of a Child Protection Plan without this process being undertaken to provide the evidence that the UBB’s needs meet the threshold for the ICPC and to ensure that the evidence and decision making is fully recorded on the UBB’s LCS file.

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

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 UBB, 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 Services for Young People, 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) gained through a trauma-informed lens will inform the assessment;
• Consider the relevance, if any, of any past history of either parent/partner as having been a Child 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;
• Explore domestic abuse as part of the pre birth assessment.

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. Parents should be made aware of Claire’s Law when appropriate.

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. Information gathering should always take place through a trauma-informed approach.

It is also important to ascertain parent/partners’ 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?

Working with Fathers / Partners

• The reader is asked to consider parents within the wider context of inclusive practice including how a parent or partner self identifies, including but not exclusively gender identity and expressions, trans, intersex, and non-binary people.
• Fathers/partners 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/partners in a child's life is extremely important for maximising the life-long wellbeing and outcomes of the child regardless of whether the father/partner is resident or not. Pregnancy and birth are the first major opportunities to engage fathers/partners 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/partners 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/partner’s attitude towards the pregnancy, the mother and newborn child and their thoughts, feelings and expectations about becoming a parent;
• Involving fathers/partners in a positive way is important in ensuring a comprehensive assessment can be carried out and any possible risks fully considered;
• Information should also be gathered about fathers/partners who are not the biological parent 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 mother 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/partner’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, not just present but also historic which may include:
• People who have had a background of abusive, neglectful or inconsistent parenting themselves;
• People who have histories of impulsive behaviour and low frustration thresholds;
• People who abuse substances, especially drugs, to a degree that encourages increased levels of stress and anxiety, sleeplessness, lowered levels of frustration tolerance, heightened impulsivity, unstable emotional and behavioural regulation that may impact decision-making;
• People who mitigate their difficulties with others through an easy default to
• violence and controlling and angry behaviour;
• People experiencing external pressures such as those brought about by poverty, mounting debts, deprivation, worklessness, racism and often very unstable/unhealthy relationships with the mothers of the children.

See The Myth of Invisible Men: Safeguarding Children Under 1 Year Old From Non-accidental Injury.

The opportunity for the early identification of fathers/partners who might need extra support and those who might present a potential risk is often not adequately or consistently recognised. In those circumstances men can sometimes be viewed in a binary way, good or bad, supportive or a risk. Men can often be both and this requires an approach that is characterised by support and challenge, by both listening to them and holding them to account.

If a child/young person 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/young person and there is no prospect of effective intervention within the appropriate timescale.

If the perpetrator is convicted for posing a risk to children or young people, it needs to be established if they have participated in a treatment plan. If the perpetrator is already living in a family with other children or young people, (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 mother.

When a person 'who presents as a risk to children or young people' 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 each parent have with the perpetrator?
• 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 or young person?
• Did they need help and support to do this?
• What are current attitudes towards the abuse?
• Do the parents blame the child/young person or see it as their fault?
• Has the perpetrator accepted full responsibility for the abuse?
• How is this demonstrated?
• What treatment did they 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?

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 and young people 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”.

The expectation is that practitioners would seek advice from the relevant healthcare professionals. Any delays in obtaining this information must not impact the assessment process.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 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 Partnership Foundation Trust.

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 spectrum disorder (FASD);
• Circumstances that may lead to the child being perceived as unwanted.

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.

All pre birth assessments should ask questions regarding Domestic Abuse, including violence, coercion and control. When assessing domestic abuse the social worker will establish if the parent is or has been known to Multi Agency Risk Assessment Conference (MARAC), Multi-Agency Public Protection Panel (MAPPA), Police, or an Independent Domestic Violence Advisor (IDVA). They will seek a full forensic history of abuse, including coercive and controlling behaviour, for each parent, or adult who will have significant contact with the unborn UBB. Consent for information sharing will be impacted by whether the child’s needs are 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 fear or distress, or an increase in the risk of actual harm.

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

Examination of the history of previous children/young people who have been removed from the parent(s) care will indicate if there were particular characteristics which made parenting more challenging. It is essential to find out from the parent(s) what challenges, if any, they identified in caring for that child or young person.

Caring for a newborn baby is difficult enough for any parent but can be particularly stressful if the parent(s) are isolated with a limited network of support. It is important to identify the role that each parent will play in the newborn baby’s care,

and 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 analysis. This should be a shared process with other agencies.

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.

Safe Sleeping

Sudden Unexplained Death in Infancy (SUDI), which is commonly referred to as 'cot death', is the sudden and unexplained death of a baby where no cause is found. Although SUDI is rare, it still accounts for a small but significant percentage of deaths among infants across the UK every year. Every one of these deaths is a tragic and unexpected loss for a family. Research has shown that co-sleeping is a significant factor in SUDI.

Although there is no clear cause or explanation for why SUDI happens, research has identified a simple set of key messages for parents and carers that may help reduce the risk of it happening to their baby. Please see Safer Sleep For Babies:  A Guide For Professionals (Lullaby Trust)

Open in-depth conversations between professionals and the parents and carers of the UBB should be held around safer sleeping with the baby once it is born; this might involve planning around reducing any risks, as well as avoiding risks to the baby. During these conversations, information should be provided around safer sleeping practices to protect babies. Discussions should also include exploration around peer and support networks for parents to reinforce the information and provide practical advice.