Pre-Birth Practice Guidance

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

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

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

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

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

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

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

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

Parental risk factors that may indicate an increased risk to an unborn child and which may mean that a pre-birth assessment is required:

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

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

Where pre-birth involvement is a result of the mother's learning difficulties causing uncertainty as to her ability to meet the needs of the child once born, the Court of Appeal in D (A Child) [2021] EWCA Civ 787 stressed the importance of effective planning during the pregnancy for the baby's arrival, and of taking adequate steps to ensure that the mother understands what is happening and is able to present her case.

See also Children of Parents with Learning Disabilities Procedure.

Sudden Infant Death Syndrome (SIDS), which was formerly called 'cot death', is the sudden and unexplained death of a baby where no cause is found. Although SIDS 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 SIDS.

Although there is no clear cause or explanation for why SIDS 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 (lullabytrust).

Open in-depth conversations between professionals and the mother and father/partner of the unborn baby should be held around safe 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 safe 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.

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

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

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

Involving fathers 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 and partners who are not the biological father at the earliest opportunity to ensure that any risk factors can be identified.

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

• Men who have had a background of abusive, neglectful or inconsistent parenting themselves;
• Men who have histories of impulsive behaviour and low frustration thresholds;
• Men who abuse substances, especially drugs, to a degree that encourages increased levels of stress and anxiety, sleeplessness, lowered levels of frustration tolerance, heightened impulsivity, poor emotional and behavioural regulation and poor decision-making;
• Men who mitigate their difficulties with others through an easy default to violence and controlling and angry behaviour;
• Men experiencing external pressures such as those brought about by poverty, mounting debts, deprivation, worklessness, racism and often very poor 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 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.

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

An Early Help (or similar) assessment can be undertaken in relation to the unborn child. If the mother is under 18, they should also be offered an Early Help Assessment. Where a professional is concerned that an unborn child or other children in the family may be at risk of, or suffering, harm, they should seek advice from their agency Safeguarding Lead without delay who will consider whether to refer to Children's Social Care - see Referrals Procedure.

All agencies should be involved in the development of a safeguarding risk assessment where undertaken. Any risk assessments should be completed at least 4 weeks (by week 33 of pregnancy) before the expected delivery date (where term is 37 weeks). All discussions, decisions and actions should be clearly documented in the appropriate agency record, including dates and names of professionals involved.

A pre-birth conference (see Child Protection Conferences Procedure) may be required if Children's Social care assess that the child is at risk of significant harm. A pre-birth conference should share relevant information and develop a Child Protection Plan if required. The timing of the conference should take into account the expected date of delivery and ideally take place by 24 weeks of the pregnancy, or earlier if there is a history of premature birth.

If a decision is made that the unborn child will be made the subject of a Child Protection Plan pre birth, a Core Group should be established at the Initial child protection conference and ideally meet prior to the birth and certainly prior to the baby's return home.

If the Assessment concludes that the child should be removed at birth, Children's Social Care should seek legal advice at this point about an application for an Interim Care Order. The application to the court can only be made once the child is born but there should be no delay in seeking the order.

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

The circumstances of the mother and other relevant adults should be reviewed regularly to allow for ongoing assessment of need and risk and consider any further action required. This is especially so where these events could affect an initial conclusion in respect of risk and care planning of the child.

A Pre-Birth Planning Meeting should be arranged where there are concerns for the unborn child. The meeting should agree a detailed plan to safeguard the baby around the time of birth which should include:

• How long the baby will stay in hospital (for babies born to substance using mothers there needs to be a period of time to monitor for withdrawal symptoms);
• How long the mother will remain on the ward;
• Any advice to be given, re the risks to the baby in relation to breastfeeding due to substance miss use or infections. And if this was provided in the antenatal period;
• If national alerts for missing persons are required, or local ambulance alerts in the event that a mother may choose to birth at home to avoid the removal of the baby at birth or the immediate postnatal period;
• The arrangements for the immediate protection of the baby if the risk assessment has highlighted serious risks to the child e.g. from parental substance misuse, mental health concerns, domestic abuse. This should also include contacting the police or the use of hospital security;
• The risk that the parents might seek to remove the baby from the hospital especially if the plan is to make an application to court for the removal of baby at birth;
• The plan for managing contact with the baby by the mother, father or an extended family and who will supervise the contact;
• The plan for the baby upon discharge, and what visits will be made upon discharge and by whom;
• Contingency plans should be in place in the event of a sudden change in circumstances. These should include instructions for hospital staff if the birth happens over the weekend or a Bank Holiday and who to contact if the birth takes place after hours. The Emergency Duty Team should also be notified of the pre-birth plans for the baby.

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

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

There are some potential issues that can arise. The involvement of social care (especially if there is a decision to remove the baby at birth) can result in the parents going missing or the mother not attending hospital at the time of birth in these circumstances the process outlined in the Children and Families who go missing procedure (including unborn children) should be followed.

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

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

Legislation, Statutory and Government Non-Statutory, Guidance

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

Good Practice Guidance

Born into Care: Best Practice Guidelines

NSPCC Learning Infants: Learning from Case Reviews

Promoting Safer Sleeping for Babies in England (University of Oxford, Department of Social Policy and Intervention - recommends that open conversations between parents and professionals could be used to support safer sleep for babies who have a social worker.

Co-sleeping and SIDS - a Guide for Health Professionals (UNICEF)

Antenatal and Postnatal Mental Health: Clinical Management and Service Guidance - NICE guidelines [CG192]

NICE Postnatal Care - Quality Standard

Useful Websites

Birth Companions - Birth Charter for women with involvement from children’s social care

Pre Birth Assessments - Practice Guidance