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Unborn Procedures and Guidance (Pre Birth Pathway)

SCOPE OF THIS CHAPTER

The purpose of the unborn procedures and guidance is to help identify all children who may have additional needs as early as possible in their lives, and to ensure that appropriate and timely multi-agency services are put in place and delivered in an integrated manner.

See also Pre Birth Pathway Diagram

Safer Sleep for Babies and Infants Fact Sheet


Contents

  1. Principles of the Pre Birth Pathway
  2. Guidance for all Agencies
  3. Thresholds of Need
  4. Vulnerability Screening
  5. Screening Review Points
  6. A Note on Timescales
  7. Consent
  8. Fraser Guidelines
  9. Responding to Concealed or Denied Pregnancy
  10. Referral where Screening Indicates Vulnerability
  11. Early Help
  12. Risk of Significant Harm
  13. Multi Agency Planning Meeting
  14. Assessment
  15. Review Meeting
  16. Child Protection Planning
  17. Child’s Plan for Health Professionals

    Appendix 1: Support Services

    Appendix 2: Pregnancy Vulnerabilities Risk Assessment

    Appendix 3: Vulnerability Toolkit

    Appendix 4: Supporting women with complex social factors (HEYHT 2016)

    Appendix 5: Child Letter Following Missed Appointments

    Appendix 6: Child’s Plan for Health Professionals

    Appendix 7: References


1. Principles of the Pre Birth Pathway

The Pre Birth Pathway has been developed and designed by a multi agency group, established under Hull Safeguarding Children Board (HSCB) 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.

The key principles of the Hull Safeguarding Children Board (HSCB) Pre Birth Assessment Pathway are:

  • Practitioners ‘think pregnancy, think midwife’;
  • Early Help and support is key;
  • Midwives complete a Pre Birth Vulnerability Screening Tool (Appendix 3: Vulnerability Toolkit) 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 HSCB Resolving Inter-agency Disagreements Guidance (Escalation Policy).


2. Guidance for all Agencies

2.1 Think pregnancy – Think Midwifery

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 to 10 weeks gestation. The direct access booking line number is 01482 605304.

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.

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

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)

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.


3. Thresholds of Need

The pre birth pathway follows the HSCB Thresholds of Need Guidance 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.

3.1 No Additional Need Threshold

Where no concerns have been identified and the woman is adequately supported by universal service provision (for example, GP, Midwifery, Health Visiting).

3.2 Additional Need Threshold

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 by one or several agencies (For example Midwifery, Health Visiting, Children’s Centres).

3.3 Complex Need Threshold

If a family is identified to have a number of additional needs/vulnerabilities then an Early Help Assessment can be used to assess need and may highlight that a number of agencies may be needed to support the child and their family.

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

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

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 Social Care. 

3.4 Risk of Significant Harm Threshold

This is where there may be multiple vulnerabilities experienced by a family which may put the unborn baby or the child once born at risk of significant harm.

The significant harm pathway ensures that where there are specific child protection concerns identified, appropriate steps are taken to protect the child, as early as possible in the pregnancy and once the child is born.


4. Vulnerability Screening

NICE Guidance (Ante Natal Care for Uncomplicated Pregnancies) outlines routine maternity care for the 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.

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.

Hull and East Yorkshire Hospitals Midwifery Service complete a Vulnerability Screening with all pregnant women from the moment of booking.

Where multiple vulnerabilities are identified, with explicit consent, the woman would be referred to the Vulnerability Midwife for an enhanced level of Midwifery care.

The Vulnerability Screening is based partly on the 2010 NICE guidance – Pregnancy and Complex Social Factors, and also takes into consideration locally identified vulnerability factors.

These are listed below:

  • Drug and/or alcohol use;
  • Mental Health Issues;
  • Disabilities and difficulties – Learning and Physical;
  • Domestic Abuse;
  • Asylum Seeker / Refugee or Recent Migrant (less than 12 months) / Language Barrier;
  • Homelessness – including living in temporary accommodation;
  • Child/Adult Exploitation / Human trafficking;
  • Female Genital Mutilation;
  • Honour Based Abuse / Forced marriage;
  • Other children in the family open to Children’s Social Care;
  • Existing child or children not in the care of parents;
  • Father not having contact / unsupervised contact with his children;
  • Past involvement with Children’s Social Care;
  • Pregnant woman or partner is Looked After Child or has been child in care (21 years old or younger, or 25 years if in education);
  • Mothers age 16 years or under;
  • Mother age 20 years and younger with additional vulnerability factors identified;
  • Late presentation / Concealed pregnancy; and
  • Non attendance or regular cancellation of appointments (both antenatal and postnatal)

Additional Information about Vulnerabilities can be found in Appendices 3 – 5:

Click here to view Appendix 3: Vulnerability Toolkit

Click here to view Appendix 4: Supporting women with complex social factors (HEYHT 2016)

Click here to view Appendix 5: Child Letter Following Missed Appointments


5. Screening Review Points

The Vulnerability Screening will be reviewed by Midwifery at 16 and 32 weeks, then again in the postnatal period following discharge from hospital.

The Antenatal booking summary reflects the application of the screening tool and is shared with the Health Visiting team and GP at 16 weeks. Any change in the assessment will be communicated with other agencies involved in supporting the parents / carers at the earliest opportunity.


6. A Note on Timescales

Meeting the timescales described in this pathway will be dependent on when vulnerability is identified during pregnancy. Where there is late presentation for booking or where vulnerability does not come to light until a later stage of the pregnancy, all agencies should follow the principles of the pathway in order for the right birth plan to be in place in as timely manner as possible.


7. Consent

Where it has been identified that a family may benefit from additional support services in the context of Early Help, any referral should be completed with the explicit consent of the parents / carers.

Where concerns have been identified for the unborn, these should be shared with prospective parent/s and consent obtained to refer to Children's Social Care unless obtaining consent 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 with agencies. For further information about consent please see the Effective Communication, Consent and Information Sharing Procedure.

Where agencies or individuals anticipate that prospective parents may need support services to care for their baby or that the baby may be at risk of significant harm, a referral to Children’s Social Care should be made.


8. Fraser Guidelines

When we are 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.

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

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 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 16’s competency this is measured by the Mental Capacity Act.


9. Responding to Concealed or Denied Pregnancy

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 coordinating 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.

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.

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).

For the purpose of this policy and procedure any reference to a woman includes females of childbearing capacity (including under 18's). A pregnancy will not be considered to be concealed or denied for the purpose of this procedure 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 is concealing or denying a pregnancy to be certain of the stage the pregnancy is at.

Protection and Action to be taken by agencies in relation to concealed or denied pregnancy

Where there is a strong suspicion there is a concealed or denied pregnancy, then it is necessary to share this irrespective of whether consent to disclose can be obtained or has been given. In these circumstances the welfare of the unborn child will override the mother’s right to confidentiality. A referral should be made to Children’s Social Care about the unborn child. If the woman is aged less than 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.

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

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;
  • Wearing uncharacteristically baggy clothing;
  • Concerns expressed by friends;
  • Repeated rumours around school or college; and
  • Uncharacteristically withdrawn or moody behaviour.

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 Child Protection Co-ordinator in addressing these concerns.

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.

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 Social Care must be made before disclosing the information about the pregnancy to her parents.

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.

Health

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

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

  • Health Visitors;
  • 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.

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.

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

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.

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 Social Care. The Emergency Duty team must be informed during the evening, on weekends or Public holidays.

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 Social Care.

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 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 in the early postpartum period.

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).

School Nursing

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 Social Care should be considered.

GPs and Practice Employed Staff

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.

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.

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 Social Care.

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.

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

Health Visitors

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

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

Mental Health and Learning Disability Services

Professionals working in mental health and learning disability may be more likely to be involved with a 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 young person, as appropriate, and contact their GP and/or Midwifery Services.

Professionals should also follow the process as highlighted above in the Protection and Action to be taken by agencies in relation to concealed or denied pregnancy section.

Children’s Social Care

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.

In the event that the young woman 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 woman’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.

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.

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.

If a woman 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.

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.

Any referral received by the Emergency Duty 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.

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.

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.

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

Police

The Police (Public Protection Unit) will be notified of any child protection concerns received by Children’s Social Care 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.

Factors to consider will be the age of the woman 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.


10. Referral where Screening Indicates Vulnerability

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.

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.

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.

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.


11. Early Help

Where additional needs have been identified, it may be that support can be provided by one or more universal services providing a time limited intervention, such as promoting access to children’s centre provision or providing a specialist referral to a single agency. It is important that agency responses are proportionate to the need of the parents and the unborn.

In order to meet the needs of the parents and the unborn where complex needs have been identified and where there may be a number of agencies involved, a Family Star or other Early Help Assessment should be started at the earliest opportunity. With parental consent, this could begin as soon as 16 weeks into the pregnancy. Any agency could take the lead for this assessment.

Should agencies working in universal services become 'stuck' at any point, the lead practitioner should arrange for the families situation to be considered at a Locality Early Help Action Meeting or Early Help Assessment Safeguarding Hub with consideration given to the involvement of a Targeted Pregnancy Support (TPS) worker.

Where complex needs have been identified which do not necessitate a referral to Children’s Social Care, but agencies are concerned that if parents do not access appropriate support services, this could lead to concerns of significant harm, it would be appropriate to refer into the Local Authority Early Help Action Meeting for allocation to a TPS worker. The TPS worker would be responsible for completing the Early Help Assessment and co-ordinating the multi agency support plan.

If consent cannot be obtained 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.


12. Risk of Significant Harm

Where there may be multiple vulnerabilities experienced by a family which may put the unborn baby or the child once born at risk of significant harm.

The significant harm pathway into Children’s Social Care ensures that where there are specific safeguarding concerns identified, appropriate steps are taken to protect the child, as early as possible in the pregnancy and once the child is born.

A referral to Children’s Social Care should be made at the earliest opportunity in order to:

  • Provide sufficient time to make adequate plans for the baby's protection;
  • Provide sufficient time for a full and informed 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.

Where the concerns centre around a category of parenting behaviour, e.g. substance misuse, the referrer must make clear how this is likely to impact on the baby and what risks are predicted.

The Strengthening Families domains can be utilised in order to consider the impact of vulnerability on the unborn prior to referral (see Documents Library)

If following a Request for service, Children's Social Care assess that there are no concerns of significant harm, discussions need to take place to establish whether a ‘step down’ to Early Help is appropriate or whether the pregnancy can be managed within universal services.


13. Multi Agency Planning Meeting

Where multiple vulnerabilities have been identified, a multi agency planning meeting should be convened by the lead worker no later than 20 weeks into the pregnancy and should involve each agency involved or likely to have information relating to the Pre Birth Assessment or who may contribute to a support plan during pregnancy. Those unable to attend the multi agency meeting should be asked for their contribution in writing. This meeting will form the basis of any assessment.

The meeting should be arranged at a time when parents and relevant professionals can attend. Within Midwifery afternoon meetings are significantly easier to attend due to clinic commitments.

The meeting should specify what type of multi-agency assessment is to be undertaken, who will complete it and the date that it will be completed in order to inform the birth plan.

The information that agencies should be prepared to bring to the multi agency planning meeting should include:

  • Family composition;
  • Agencies already involved;
  • Dangers /Risk factors (what factors are putting the unborn child / child once they are born at risk of significant harm?);
  • Complicating factors (what factors may contribute to difficulties for the unborn child / child when they are born);
  • Safety (factors that reduce the risks identified above);
  • Strengths (positive resources identified in the family);
  • Grey areas (areas of uncertainty);
  • Factors likely to change and why;
  • Factors that might change and why; and
  • Factors that will not change and why.

A multi agency discussion should take place, based on the information presented to the meeting by individual agencies. This will formulate the basis for a multi agency action plan, including the commencement and timeframes for any assessment. An appropriate review point will need to be agreed at the meeting.

The meeting should consider any referral to additional support services such as parenting programmes or specialist support. It should also ensure the delivery and oversight of important safety messages such as safer sleeping, crying baby and home safety.

Where there is an existing allocated Social Worker for other children within the family a multi agency planning meeting to consider the needs of the unborn and the impact of their birth on existing children is best practice. The pre birth meeting may involve different agencies / practitioners than an existing core group membership.


14. Assessment

Any assessment should be completed and shared with parents/partners by no later than 36 weeks gestation, and the birth plan completed and sent to the Safeguarding Midwifery Team. On completion of the assessment, if there is no further involvement required from Children’s Social Care to step down into Early Help agencies, via a multi-agency review meeting or in writing.

Whether in Early Help or Children’s Social Care, any assessment should identify:

  • Risk factors;
  • Strengths in the family environment;
  • Factors likely to change and why;
  • Factors that might change and how; and
  • Factors that will not change and why.

Assessments should also:

  • Consider family history;
  • Consider the role of wider family members and significant others;
  • Consider the role of fathers and partners; and
  • Be clear about recommendation regarding risk, need and support required.
Although a pregnancy may be confirmed at eight to ten weeks, it is neither practical nor humane to begin a social work Pre Birth Assessment at this stage. A pregnancy may be viable at 24 weeks where babies can be born and survive, so an assessment could commence at any time after this stage. Ideally all cases should be allocated by the time the mother is 26 weeks pregnant. (Wallbridge 2012)


15. Review Meeting

A review date will be set at the end of the planning meeting to take place no later than 34 weeks gestation, the review meeting will take place in order to share the outcome of the assessment and agree the multi agency plan.


16. Child Protection Planning

On occasions there may be sufficient, evidenced concerns regarding the risks posed to the unborn child, which may warrant the convening of an Initial Child Protection Conference, following a Strategy Discussion/Meeting. For more information see the HSCB Core Procedures.

The Child Protection Conference is the appropriate multi-agency arena to share the assessment to date and using the strengthening family’s model, will consider whether the unborn baby should become subject to a Child Protection Plan.

If a Child Protection Conference is assessed as necessary, the Consultant Social Worker and Social Worker must ensure that this is held well in advance of the estimated date of delivery and certainly no later than the 32nd week of pregnancy.

Early planning needs to consider the need for legal action through the formal Children’s Social Care process. Although not all referrals will go on to require legal proceedings, it is important to bear in mind the timescales laid out in the guidance as they will not be met unless referrals are made at an early stage in the pregnancy (see Statutory Guidance on Court Orders and Pre Proceedings, DfE, 2014)


17. Child’s Plan for Health Professionals

Any assessment should be completed and shared with parents/partners no later than 36 weeks gestation, and a child’s plan for health professionals (click here to view Appendix 6: Child’s Plan for Health Professionals) completed and sent to the Safeguarding Midwifery Team at hyptr.safeguardingchildren@nhs.net

When any Pre Birth Assessment has concluded that an expected child may be at future risk of significant harm, the Social Worker should ensure that a copy of the child’s plan for health professionals is also shared with the Immediate Help Team.

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.


Appendix 1: Support Services

Midwifery

There is a direct access number to Midwifery for any woman to contact when she becomes aware of her pregnancy 01482 605304

01482 382658 is a contact number for Community Midwifery services for professionals to contact if they are wanting to find out more information about appointments attended / offered - It would be the ideal if a professional would like to find out which Midwifery Team is caring for a woman so that appointments/ information can be shared.

Children’s Social Care

Early Help and Safeguarding Hub (EHASH) - 01482 448879
Immediate Help (out of hours) - 01482 300304

Early Help Safeguarding Hubs

West Locality - Priory Children’s Centre Tel: 305770
East Locality - Acorns Children’s Centre Tel: 708953
North Locality - Lemon Tree Children’s Centre Tel: 828901

Identification of an Adult with Care and Support Needs

To report abuse or discuss a concern call: 01482 616092 and speak to the Multi Agency Safeguarding Hub or call 01482 300304 after 5:00pm and at weekends

Health Visiting

Phone - 01482 336634 / Email - CHCP.phadmin0-11@nhs.net

Universal Service: Level of Health Visiting intervention encompassing all children in receipt of the ‘Healthy Child Programme’.

Universal Plus Service: where it has been identified that a rapid short term response from HV team with expert advice/ intervention is required.

Universal Partnership Plus: level of Health Visiting intervention is indicated where a family require long-term ongoing support for a multitude of complex problems plus support from a range of other services. All children where there are safeguarding concerns will fall within this service level.

On receipt of the antenatal booking form, a Health Visitor is allocated. An antenatal contact is offered as per the Healthy Child Programme.

The Healthy Chid Programme comprises: Antenatal contact, postnatal contact at 10-14 days, follow up support visit 6-8 weeks postnatally, 6-12 month developmental review, 2-2.5 year child development/health assessment and 3-4 year contact, which may be in the form of a questionnaire.

Family Nurse Partnership (FNP)

Women are eligible for FNP if:

  • They are 18 years or under when they find out they are pregnant; and
  • They are under 24 weeks pregnant and its their first pregnancy;
  • They live in Hull; and
  • They are not planning to have their baby adopted.

FNP is a voluntary program. Clients receive weekly or fortnightly visits from the same nurse from early pregnancy until the child is 2 years old (64 visits over 2½ years.)

Each visit has structure and planned content, covering 6 domains (personal and child health, parenting, personal goals, friends and family, environment, local services)

Interactive materials and approaches to learn, develop skills and do things differently within a safe environment

Targeted pregnancy support workers Hull City Council

  • Provide advice and information on potential parent/family support options for workers and other clients;
  • Provide short term assessment and/or support for the parents, to establish family needs in relation to parenting within the whole family approach;
  • Manage the transfer of a family when work is completed to a new agency or practitioner to meet their continued needs, where family issued have been addressed and other needs are outstanding;
  • Co-facilitate the agreed citywide parenting programmes (triple p, strengthening families, strengthening families 10 -14).

HEY Baby

HEY Baby: Free NHS antenatal education classes for pregnant women and their partners. Courses are delivered by trained Birth Educators and Midwives in local venues across Hull.

HEY Baby has a multi-agency carousel for women over 21 weeks pregnant bringing together all services to raise awareness women and their families of the services they may encounter during pregnancy and early days of parenthood.

Also from 28 weeks pregnant the main 3 week course can then be accessed in many venues across the city; consisting of sessions of 2 hours per week during the evening. Courses can also delivered in various languages dependant on demand, i.e. Polish, Somali, Arabic.

Pregnant women wishing to access the service must be registered with a Hull GP or live within the Hull boundaries.

Pregnant women can view upcoming course details and book-on through an online self-booking system (currently under construction) which will be located on the website https://www.hey.nhs.uk/maternity/ or they can call (tel.07769671449), or email (heybaby@hey.nhs.uk).

The Doula Project

is a befriending/support service that supports women through pregnancy and up to 12 weeks post natally Contact Janet Burton telephone: 01482 497811

Substance Misuse

Renew community 0800 1615700
Renew criminal justice 01482 620013
Refresh (young people) 01482 331059

Mental Health

Primary care
Let’s Talk, 01482 247111
Duty clinician 01482 335627
01482 335629

Secondary care
Single Point of Access 01482 617560

Peri-natal Mental Health

The Peri-natal Mental Health team can be accessed through the ‘single point of access telephone: 617560 and are based at Miranda House. This team would be involved if there was a severe mental health diagnosis and they would offer a higher level of intervention. Peri-natal Mental Health Team direct telephone: 01482 617735

Domestic Abuse

Domestic Abuse Partnership 01482 318759
http://www.hulldap.co.uk/
The Domestic Violence and Abuse Directory

Smoking Cessation Advice and Support

Healthy Midwife:
Tel: 01482 382666
Email: Caroline.Clarke@hey.nhs.uk
Local websites are:
www.readytostopsmoking.co.uk this is the site for our local stop smoking services
www.smokesnojoke.com this site has lots of information, video, games, lesson plans etc covering all the issues related to tobacco. It is mainly for children, young people, parents and teachers, but a good source of information for anyone wanting to find out a bit more about the issues.
www.breathe2025.org.uk this is a regional site with information, access to national documents and an area for people to make pledges.

Nationally:
www.ash.org.uk this site has a lot of information about all the issues

Bereavement Support

Child Bereavement UK

Support families and educates professionals when a baby or child of any age dies or is dying, or when a child is facing bereavement. They provide confidential support, information and guidance to families and professionals. 

  • Professionally trained bereavement support workers are available to take calls 9am - 5pm Monday-Friday;
    Tel: 0800 02 888 40;
  • The support team can also be contacted at: support@childbereavementuk.org.

The Miscarriage Association (National Charity)

Provides support and information to anyone affected by pregnancy loss, through:

  • A staffed helpline Tel: 01924 200799 (helpline Mon-Fri 9am-4pm) and e-mail support info@miscarriageassociation.org.uk;
  • Support network: a UK-wide network of support volunteers, who have been through the experience of pregnancy loss themselves and can offer real understanding and a listening ear;
  • An online forum is a safe space for people to share thoughts, feelings and experiences about miscarriage, ectopic pregnancy and molar pregnancy;
  • A range of leaflets that talk about the facts and feelings of miscarriage, ectopic and molar pregnancy. They are all available to download from this website. 

Life Charity (National Charity) 

Whatever the circumstances of your pregnancy loss, whether through miscarriage, ectopic pregnancy, hydatidiform mole, or stillbirth. Call counsellors on the National Helpline or text via the Text-to-Talk service.

Email: sam@lifecharity.org.uk Tel: 0808 802 5433 (National helpline 9am-3pm) Text: LIFECARE to 88020 (Text to Talk)

Child Death Helpline

A national free phone helpline, originated from Alder Hey and Great Ormond Street hospitals Provides a Free phone service to anyone affected by the death of a child of any age – whether they are parents, grandparents, siblings, family members, friends or involved professionals.

The Child Death Helpline is staffed by volunteers, all of them bereaved parents and open every day of the year for anyone affected by the death of a child of any age, and offer a confidential, safe environment within which a caller can talk openly about the child’s life and death.

Telephone: 0800 282 986 or mobile 0808 800 6019
Monday to Friday - 10am to 1pm
Tuesday and Wednesday - 1pm to 4pm
Every evening - 7pm to 10pm

SANDS is the stillbirth and neonatal death charity. We operate throughout the UK, supporting anyone affected by the death of a baby, working to improve the care bereaved parents receive, and promoting research to reduce the loss of babies’ lives.
Tel: 020 7436 5881

BLISS Support, including after bereavement, for the family of a premature baby.
Helpline 0808 801 0322

Additional local Services

House of Light (mental health) - 01482 580499
Purple House (domestic abuse) - 01482 790310
Together Women - 01482 218125
(Issues from accommodation, alcohol/drugs, relationships, debt etc.)
Humber All Nations Alliance - 01482 491177
(Promoting the wellbeing of the black and minority ethnic communities.)
Doorstep (homeless) - 01482 345006


Appendix 2: Pregnancy Vulnerabilities Risk Assessment

Click here to view Appendix 2: Pregnancy Vulnerabilities Risk Assessment


Appendix 3: Vulnerability Toolkit

Click here to view Appendix 3: Vulnerability Toolkit


Appendix 4: Supporting women with complex social factors (HEYHT 2016)

Drug and Alcohol Misuse

Substance misuse and inadequate utilisation of antenatal care services have been shown to be associated with increased odds of maternal death from specific causes in the UK (Nair, Kurinczuk et al. 2015).

“For this population group, early access to antenatal care provides an opportunity for women to receive addiction treatment earlier in pregnancy. Of all substance abuse related deaths, the majority took place after 42 days of birth. Offering support and preventive interventions in the antenatal period is therefore crucial in planning care for this population.” NICE (2010)

  • Refer to Vulnerabilities Toolkit for guidance;
  • On admission and discharge and on a substitute prescription, call prescribing agency and pharmacy to ensure when last dose was taken, and confirm dose. This will also enable the prescription to be suspended and reinstated this will reduce the risk of overdose;
  • Multi-agency discharge meeting may be required;
  • If baby is not planned to go home into mothers care, consider her mental health and offer appropriate referral, consider further support from other agencies;
  • During home visits be aware of the need to assess parenting skills, household environment and document household members;
  • Refer to specialist contraceptive nurse for vulnerable adults;
  • Refer to Hull and East Yorkshire Hospitals NHS Trust, Substance Misuse Guidelines.

Previous Drug or Alcohol Misuse

  • Refer to Vulnerabilities Toolkit for guidance;
  • If baby is not planned to go home into mothers care, consider her mental health and offer appropriate referral, consider further support from other agencies;
  • During home visits be aware of the need to assess parenting skills, household environment and document household members;
  • Refer to specialist contraceptive nurse for vulnerable adults;
  • Refer to Hull and East Yorkshire Hospitals NHS Trust -Substance Misuse Guidelines.

Mental Health Issues

“The majority of women who develop mental health problems during pregnancy or following delivery suffer from mild depressive illness, often with accompanying anxiety. Such conditions are probably no more common than at other times.”

“The risk of developing a serious mental illness (bipolar disorder, other affective psychoses and severe depressive illness) is reduced during pregnancy but markedly elevated following childbirth, particularly during the first 3 months.”

“Pregnancy is not protective against relapses of pre-existing serious mental illness, particularly if the woman has stopped her usual medication at the beginning of pregnancy” (CMACE 2011, MBBRACE 2015)

Minor mental health problems or adversity stressors

  • Refer to Vulnerabilities Toolkit for guidance;
  • Refer to Hull and East Yorkshire Hospitals NHS Trust, Perinatal Mental Health guideline.

Moderate mental health problems e.g. History of recurring depression, previous postnatal depression requiring medication, previous suicide attempt:

  • Refer to Vulnerabilities Toolkit for guidance;
  • Refer to specialist contraceptive nurse for vulnerable adults;
  • During home visits be aware of the need to assess parenting skills, household environment and document household members.

Severe mental health problems; diagnosed mental health disorder, e.g. bi-polar disorder, puerperal psychosis, manic depression, severe personality disorder

  • Refer to Vulnerabilities Toolkit for guidance;
  • If baby is not planned to go home into mothers care, consider her mental health and offer appropriate referral, consider further support from other agencies;
  • Refer to specialist contraceptive nurse for vulnerable adults;
  • During home visits be aware of the need to assess parenting skills, household environment and document household members.

The following are “red flag” signs for severe maternal illness and require urgent senior psychiatric assessment:

  • Recent significant change in mental state or emergence of new symptoms;
  • New thoughts or acts of violent self-harm; and
  • New and persistent expressions of incompetency as a mother or estrangement from the infant.

2014 NICE guidance – Maternal Mental Health – Everyone’s Business

Unfortunately despite 10-15% of women being affected by mental illness during pregnancy, not all receive the support they need. The top barriers to receiving proper treatment are the lack of recognition by both women themselves and health professionals, the social stigma associated with mental illness (shame), lack of personal resources and the lack of trained clinicians, as well as patchy perinatal services across the UK.

Disabilities and Difficulties Learning and Physical

People with learning disabilities are less likely to access healthcare and healthcare advice. MENCAP (2004)

  • Refer to Vulnerabilities Toolkit for guidance;
  • Ensure that midwives consider the individuals capacity to make decisions at the time they need to be made and therefore is both time and decision specific and therefore may need to be repeated. Refer to Mental Capacity Act Deprivation of Liberty Safeguards Consent and Physical Restraint Policy;
  • The assessment of capacity must be recorded in the women’s maternity notes and Midwifery documentation;
  • If baby is not planned to go home into mothers care, consider her mental health and offer appropriate referral, consider further support from other agencies;
  • During home visits be aware of the need to assess parenting skills and capacity, household environment and document household member;
  • Refer to specialist contraceptive nurse for vulnerable adults.

Learning Disability

Learning Disability includes the presence of:-

  • A significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence), with:
  • A reduced ability to cope independently (impaired social functioning);
  • Which started before adulthood, with a lasting effect on development?

This means the person will have;

  • Experienced difficulties either from birth or emerging during childhood; if difficulties do not present until the person is over 18, the person will not be considered to have a learning disability;
  • Had great difficulties with school work and are likely to have attended a special school;
  • Considerable and consistent difficulty in many areas of everyday life, meaning that they require practical support from others to manage in adult life.

Note: Learning Difficulties are not the same as Learning Disability.

Domestic Abuse

The term “domestic abuse and violence” is used to mean any incident or pattern of incidents of controlling behaviour, coercive behaviour, or threatening behaviour violence or abuse between those aged 16 or over who are family members or who are in, or have been, intimate partners. This includes psychological, physical, sexual, financial and emotional abuse. (NICE 2016)

Of the 295 maternal deaths across the UK reported in the 2003–2005 trienniums, 70 occurred in women who had experienced domestic abuse. 19 of those women were murdered. Identifying women who are experiencing domestic abuse and supporting them to engage with and maintain contact with the appropriate services is therefore crucial. (NICE 2010)

Pregnancy and the puerperium represent periods of higher risk of domestic abuse. Any woman reporting a previous history of domestic abuse should therefore be considered at high risk. (MBRRACE-UK 2015)

Abused women use health care services more than non-abused women and they identify health care workers as the professionals they would most likely speak to about their experience. Healthcare workers are all well placed to identify abuse. They have the opportunity to intervene early and direct victims to the most appropriate statutory and non-statutory services. The new NHS Mandate recognises the vital role of the NHS in tackling abuse and violence and expects NHS England to ensure the NHS helps to identify violence and abuse early and supports victims to get their lives back sooner (HM Government 2016)

  • Refer to Hull and East Yorkshire Hospitals NHS Trust, Domestic Abuse guidelines;
  • Refer to Vulnerabilities Toolkit for guidance;
  • Continue to make/ consider routine enquiry throughout the antenatal and postnatal period even when there are no indicators of violence and abuse (NICE2014);
  • Ensure that women presenting to frontline staff with indicators of possible domestic abuse are asked about their experiences in a private discussion;
  • When an interpreter is needed for discussion about domestic abuse this should be with a trust approved interpreter. Family or friends must not act as interpreter for enquiries or discussion;
  • If baby is not planned to go home into mothers care, consider her mental health and offer appropriate referral;
  • Refer to specialist contraceptive nurse for vulnerable adults.

Child Exploitation/Adult Exploitation and Human Trafficking

  • Act immediately – contact the Police via 101 unless immediate risk – call 999;
  • Immediate referral to Children’s Social Care;
  • If baby is not planned to go home into mother’s care, consider her mental health and offer appropriate referral;
  • Consider and assess all physical and mental health needs;
  • Refer to Vulnerability Midwife;
  • Refer to specialist contraceptive nurse for vulnerable adults.

Previous Children open to Children’s Social Care or History of Children’s Social Care

In the CMACE report (2011) of the thirteen young women who died, two were in the care of Children’s Social Care and another five were well known to Social Care. Two were described as being “learning disabled”, two used illegal drugs and one was considered to be homeless, having recently been discharged from Social Care.

  • Refer to Vulnerabilities Toolkit for guidance;
  • Ask if partner has any children and if he has unsupervised contact;
  • Share information with health visitor so that they are aware of the family situation;
  • If baby is not planned to go home into mothers care, consider her mental health and offer appropriate referral, consider further support from other agencies;
  • Refer to specialist contraceptive nurse for vulnerable adults;
  • During home visits be aware of the need to assess parenting skills and capacity, household environment and document household member.

    Pregnant woman or her partner is currently a “Looked after child” or has been a child in care, now up to 21 years of age or 25 if remains in education
  • This would include any woman who has been in care at any point in her childhood;
  • Refer to Vulnerabilities Toolkit for guidance;
  • If additional vulnerability factors refer to Vulnerabilities Midwife / Haven clinic At the home visit make holistic assessment of parenting skills and capacity, monitor household members;
  • Refer to specialist contraceptive nurse for vulnerable adults.

Looked After Young People

If a Looked After Child becomes pregnant it is important that an early Pre Birth Assessment takes place to ensure that an appropriate plan is put in place around them and their child. The individual circumstances will be considered and not all will be Child Protection concerns however their status as a Looked After Child warrants a Social Worker taking the lead to complete the assessment. The child protection pathway would be followed for timescales but with a clear exit route if there are no child protection concerns for the wellbeing of the baby to manage at either Child in Need level or Early Help.

It is considered good practice that a different Social Worker to the Looked After Child's worker is allocated to complete the pre birth assessment so ensuring support to the Looked After Child as well as the unborn baby.

16 Years or Younger or Under 20 Years with Additional Vulnerabilities

“Young women and men who become parents are often affected by social exclusion and need support to achieve their potential. Meeting their needs more effectively will improve the life chances of the young parents and their children” DOH (2015)

  • Refer to Vulnerabilities Toolkit for guidance;
  • All pregnant women under 19 will be referred by the Vulnerability Midwife to the Family Nurse Partnership;
  • During home visits be aware of the need to assess parenting skills and capacity, house hold environment and document other household members;
  • Ensure that the health visitor is informed of other support services.

‘Saving mothers’ lives’ (2007) highlighted that late booking for antenatal care was a feature in 17% of women who died from direct or indirect causes, compared with 2% of the general population.

Concealed or Denied Pregnancy

  • Refer to Vulnerabilities Toolkit for guidance;
  • Delayed pregnancy care could be an indicator of possible domestic abuse (NICE 2016);
  • During home visits be aware of the need to assess parenting skills and capacity, household environment and document household members;
  • Refer to specialist contraceptive nurse for vulnerable adults.

Please see Section 9, Responding to Concealed or Denied Pregnancy, for more information.

DNA’s and Regular Cancellations – Not attending for antenatal / postnatal care

“(14%) of women who died were poor attenders for care, giving a total of 26% of the mothers who died from Direct and Indirect causes who were poor or non-attenders and, as a result, had less than optimal antenatal care.” CMACE (2011)

  • DNA – not attending for care in the community or hospital setting, refer to–Booking appointment and supporting antenatal care guideline. See letter in Appendix 5 (Appendix 5: Child Letter Following Missed Appointments);
  • If the woman’s attendance is poor, advise her that there are links between poor attendance and poor outcomes for women and babies. Due to this there will be discussion with multi-agency colleagues. If there is no contact then liaise with Children’s Social Care for further advice;
  • Refer to specialist contraceptive nurse for vulnerable adults.

Female Genital Mutilation

“Female genital mutilation is not a requirement for any religion but it is a practice that reaches across numerous cultures to alter the lives of many women and girls” HMIC 2015

  • Refer to Children’s Social Care if woman has had FGM or is at risk of FGM;
  • If under 18 years old ring the Police via 101 (this is the practitioner’s personal responsibility) or 999 if there is immediate risk;
  • Refer to specialist contraceptive nurse for vulnerable adults.

Honour Based Abuse

“Honour-based violence (HBV) is the term used to refer to a collection of practices used predominantly to control the behaviour of women and girls within families or other social groups in order to protect supposed cultural and religious beliefs, values and social norms in the name of ‘honour’. (HMIC 2015)

“Healthcare professionals should keep a closer eye on newly arrived brides, especially those who are unable to speak English and without any family members in the UK. This should particularly be the case if they book late or are poor attenders for care”. CMACE (2011)

  • If concerned about Honour Based Abuse act immediately; Contact the Police 101/999 remember the one chance rule;
  • Do not share any information with other agencies other than the Police unless previously agreed. All information sharing to be kept on a need to know/minimum basis;
  • Refer to Vulnerabilities Toolkit for guidance.

Recent Migrants, Asylum Seekers or Refugees

“Overall, 42% of Direct maternal deaths occurred in women of Black and minority ethnic groups and 24% of Indirect deaths, giving an overall percentage of 31% of women who died of maternal causes declaring themselves to be from non-white ethnic groups.” CMACE (2011)

“A particular problem for women who are recent migrants, refugees, asylum seekers or for women with little or no English is that women do not know their rights with regards to maternity services or how antenatal services are structured and this may be a significant barrier to accessing care”. NICE (2010)

  • Provide accessible information about pregnancy and how to access services;
  • Refer to Vulnerabilities Toolkit for guidance;
  • Work in partnership with other agencies such as the Refugee Council;
  • Consider referral to Humber All Nations Association (HANA). In cases of social isolation, accommodation and relationship issues etc. HANA work with fathers, particularly when, in the country of origin fathers do not share parenting;
  • Refer to specialist contraceptive nurse for vulnerable adults.

Homelessness

  • Refer to Vulnerabilities Toolkit for guidance;
  • Ensure current abode is checked at each contact with maternity services. Make enquiry if the woman feels safe in current living environment;
  • If baby is not planned to go home into mothers care, consider her mental health and offer appropriate referral;
  • Refer to specialist contraceptive nurse for vulnerable adults.


Appendix 5: Child Letter Following Missed Appointments

Click here to view Appendix 5: Child Letter Following Missed Appointments


Appendix 6: Child’s Plan for Health Professionals

Click here to view Appendix 6: Child’s Plan for Health Professionals


Appendix 7: References

  • Ante-natal Care Guidelines NICE CG62 (2008);
  • Cleaver, H et al (2011) Children’s Needs – Parenting Capacity;
  • Calder, M (2013) Assessment in child care;
  • Fair Society Healthy Lives, the Marmot Review, Institute of Health Equity.org;
  • Getting Maternity Services Right for Pregnant Teenagers and Young Fathers, Public Health England (2015) Spiby;
  • MBRRACE-UK Saving Lives, Improving Mothers Care (2015);
  • Multi-site implementation of trained volunteer doula support for disadvantaged childbearing women: a mixed methods evaluation Health Services and Delivery Research, vol 3 issue 8 ((2015) Spiby ET el.;
  • NSPCC;
  • Pregnancy and Complex Social Factors, NICE guidelines CG110, (2010);
  • Strategic Review of Health Inequalities in England Post 2010;
  • Sue Wallbridge Guide To pre-birth assessments March 2012;
  • The depths of dishonour: Hidden voices and shameful crimes;
  • An inspection of the Police response to honour based violence, forced marriage and female genital mutilation HMIC (2015);
  • Treat Me Right – Better healthcare for people with a learning disability. MENCAP (2004);
  • Working Together to Safeguard Children, HM Government, (2015).

Amendments to this Chapter

In January 2017, a new Section 9, Responding to Concealed or Denied Pregnancy, was added.

End.