Pan Bedfordshire Procedure and Guidance in relation to Pre-Birth Planning and Assessments

1. Introduction

Young babies are particularly vulnerable to abuse and work carried out in the antenatal period can help minimise any potential harm through early assessment, intervention and support (Brandon et al 2016).

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 an early stage;
• Understand the impact of parental risk factors to the unborn baby when planning for their future;
• Explore and agree safety planning options;
• Assess the family's ability to adequately protect the unborn baby and provide appropriate parenting once the baby is born;
• Identify if any assessments or referrals are required prior to birth;
• Ensure effective communication, liaison and joint working with any services working with the family;
• Agree plans for support which reduce the potential risk of harm to the unborn/new born;
• Support families and children's Social Care where a legal process is likely to be needed such as child protection planning or pre-proceedings;
• Avoid delay in care for the child where the Public Law Outline threshold is reached.

The National Maternity Review: Better Births (2016) identified that every person, every pregnancy, every baby and every family is different. Therefore, quality services must be personalised to meet the needs of the baby as well as the wider family; adopting a Think Family approach.

The vast majority of situations during pregnancy will have no safeguarding concerns, however in some cases, to ensure that the appropriate support is in place for the pregnant person and wider family members during the perinatal period, a co-ordinated response is required by agencies to best protect the baby, before and following birth.

In these cases, the National Service Framework for Children, Young People and Maternity Services (2004) recommends that Maternity Services and Children's Services adopt joint working arrangements which promote an appropriate multiagency response to concerns regarding the welfare of an unborn baby and his/her future due to the impact of parent's needs and circumstances.

2. Purpose

The aim of this guidance is to enable practitioners to work together with families to safeguard unborn babies where risk is identified. It sets out how to respond to concerns for unborn babies, with an emphasis on clear and regular communication between practitioners working with the pregnant person and their family.

It is important that all agencies involved in pre and post birth assessment and support fully consider the significant role of fathers, partners, wider family members or other significant adults in the care of the baby even if the parents are not living together and where possible involve them in any assessment.

Information should be gathered about partners who are not the biological father at the earliest opportunity to ensure any risk factors can be identified.

Where it has been identified that a women and her family are in need of support and or where there are safeguarding concerns the main purpose of a Pre-Birth assessment is to identify: 

• What the needs of and risks to the newborn child may be;
• Whether the parent/s are capable of recognising these and working with practitioners so that the needs can be met and the risks reduced;
• What support the parents may need;
• What plans need to be put in place to ensure the needs of the expected child are met and risks addressed.

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

• Will the 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?

Where there is reason for doubt about the above a pre-birth assessment is required.

3. Pre-Birth Assessment and Interventions

Pre-birth assessments should be multi-agency:

Early referrals (accepted from 12 weeks, ideally no later than the 15th week) are essential in order to ensure the following:

• Sufficient time is allowed in order to undertake a detailed assessment including the preparation of a detailed chronology;
• There is sufficient time for effective planning;
• Parents have time to contribute to any assessment and to increase the likelihood of a positive outcome to the assessment;
• Support services can be provided in a timely fashion;
• To facilitate an immediate Multi-Agency response at the earliest and most appropriate opportunity.

4. Multi Agency Pre-Birth Referral Guidance

A referral should always be made in these circumstances:

1. A parent, adult, relative or regular visitor to the household has been identified as posing a risk to children.
2. A sibling or child in the household is the subject of a Child In Need or Child Protection Plan.
3. A sibling or child has previously been removed from either of the parent's care, either temporarily or by court order.
4. There are domestic abuse issues.
5. The degree of parental substance misuse is likely to impact on the baby's safety or development.
6. The degree of parental mental illness/impairment is likely to impact on the baby's safety or development.
7. There are significant concerns about parental ability to self-care and/or to care for the child e.g. unsupported, young or learning difficulties etc.
8. A parent previously suspected of fabricating or inducing illness in a child or harming a child.
9. A child aged under the age of 13 years is pregnant.
10. There has been a previous unexpected or unexplained death of a child whilst in the care of either parent or other household member.
11. There are maternal risk factors e.g. denial of pregnancy, avoidance of antenatal care (failed appointments), non-cooperation with necessary services, non-compliance with treatment with potentially detrimental effects for the unborn baby.
12. Concealed pregnancy or late booking without adequate explanation.
13. If either parent expresses at any point that they wish to relinquish their baby. Additionally, a pre-birth risk assessment is required when parents change their mind about relinquishing their baby during the assessment process to be certain that they are fully able to care for their baby and have addressed their areas of previous uncertainty.
14. Any other concern that indicates the baby may be at risk of significant harm.
15. Concerns that the mother and/or father of the unborn are at risk from So-called 'Honour' Based Abuse.
16. Concerns that the baby may be subjected to Female Genital Mutilation.
17. Young people where the expectant mother or father is identified as having complex needs.
18. Parents are at risk of experiencing forced marriage.
19. Parents have been identified as being at risk of or experiencing Child Sexual Exploitation or Criminal Exploitation.
20. Incest is suspected.
21. Moving local authorities to avoid professionals.
22. There are significant concerns regarding parent's home conditions.

5. Pre-Birth Assessment and Interventions

The majority of women access their GP within 6-8 weeks of pregnancy leading to a booking appointment with Midwifery Services between 6 and 12 weeks of pregnancy. However, women can self-refer to hospital maternity directly without seeing GP. At this booking appointment a routine antenatal assessment and screening processes are commenced and antenatal care begins as soon as the pregnancy has been confirmed.

The Community Midwives, GPs and Obstetricians Health Visitor are in a key position to identify women and their families who are in need of early support or when there are child protection concerns. The Midwifery service will alert the Health Visitor Team of any known cause for concerns relating to mother and unborn child. If the Midwifery Service are already working with a family under a safeguarding plan, then they will continue to support the family during the antenatal period.

Other practitioners working in Children's or Adult Services may also be in contact with pregnant women or their partners. They should actively consider any support needs; whether any additional services are identified and could be provided through an Early Help Assessment, or if there is any child protection issues that warrant a referral to Children's Social Care.

All practitioners should refer to their agency records to establish whether information held in relation to a previous pregnancy or family history may have an impact on the current pregnancy.

It is vital that there is good communication with the pregnant women, the birth father and, if different, her current partner. Consideration must be given to the communication needs of the pregnant woman and her family, and communication aids, interpreters, sign language should be used as appropriate.

5.1 Considering the Role of the Birth Father from the Beginning

Local Serious Case Reviews, for example the Myth of Invisible Men - Safeguarding children under 1 from non-accidental injury caused by male carers September 2021 have identified that practitioner's attention has often almost entirely focussed on the mother, with assessment of the father being through the mother's views or not obtained at all. Practice has indicated insufficient direct involvement of the father, or insufficient attention being paid to establishing his views and interest in the children, particularly when not living in the same household. This guidance therefore, deliberately aimed at also raising the profile of the father.

Within the early stages, in the context of assessing needs of the baby it is important to gather full information about the father of the unborn. Even if not living with the mother, the father and his family may be an important source of support and care once the child is born. In addition, there may be previous issues of concern in regard to the father which remain a threat or concern to both mother and baby.

Involving fathers in a positive way is important in ensuring a comprehensive assessment can be carried out and any possible risks fully considered.

When the mother is living with a partner who is not the father of the unborn, the implications of their involvement must also be taken into account. The partner must be included in the assessment, in the same way as the birth father.

5.2 Parents who have had a previous child removed (or who have previous children no longer living with them)

Even if previous children of the parents have recently been removed, the parents' ability to meet the needs of their unborn child may need to be reassessed. The unborn child may be to a new, more responsible, and supportive partner; the parents may have successfully tackled their drug and alcohol misuse; or the removal of previous children may be some years ago, and parents have matured, and/or are able to acknowledge and appreciate their previous failings. Calder (2000) provides a useful framework for considering families where there has been previous abuse stating that:

"The abuse of previous children is not a bar to caring for future children, although the parents' attitude to that abuse and their attitude towards the child is a factor where there would need to be significant change."

5.3 The impact of domestic abuse on unborn children

Research has showed that domestic abuse can begin or escalate during pregnancy, and it has been identified as a prime cause of miscarriage or still-birth, premature birth, foetal psychological damage from the effect of abuse on the mother's hormone levels, foetal physical injury and foetal death The mother may be prevented from seeking or receiving proper ante-natal or post-natal care. In addition, if the mother is being abused this may affect her attachment to her child, more so if the pregnancy is a result of rape by her partner.

In some cases though physical violence may stop during pregnancy as the abuser may make a conscious effort not to hurt the developing baby. However, it is important to remember that this does not necessarily indicate that abuse itself has stopped, simply the physical manifestation of it. In such cases it is likely that abuse will start again once the baby is born.

Control over pregnancy itself can also be used as a tool of abuse – this form of coercive control is called reproductive control. For example the abuser may remove or tamper with contraceptives, or deny access to family planning or emergency contraception. This is because an abuser can use a woman's pregnancy as a way of increasing her dependency and intensifying their control over her. Women who experience domestic abuse report a higher than average rate of unintended pregnancy. Risks of both unintended pregnancy and domestic abuse during pregnancy are higher for younger and teenage women. Pregnant women find it harder to leave, particularly because of concerns about finance and housing.

5.4 Parents with a Learning Disability/Difficulty

It is important to assess the needs and provide support for parents with a learning disability/difficulty as early as possible.

Parents with learning needs or a disability may need additional support to enhance and develop their knowledge and understanding, their experiences and skills of being able to meet the needs of their child. Such support is particularly important if they also experience additional stressors e.g. having a disabled child, domestic abuse, poor physical or mental health, substance misuse, social isolation, poor housing, poverty or a history of growing up in care.

The ability of parents with learning needs or a disability, to provide a reasonable standard of care to their children will depend on their own individual abilities, support network and circumstances.

The GP and/or midwife should make a referral to Adult Learning Disability Team (ALDT) for a Care Act assessment to assess the pregnant woman's needs, her capacity for self-care and her ability to provide adequate care for the baby. This assessment should consider strengths and the nature of any support available from family and partner.

If any practitioner or agency has any concerns about the capacity of the pregnant woman and her partner to self-care and/or to care for the baby, a referral should be made to Children's Social Care. The pre-birth procedure should be applied and followed in conjunction with adult services. It is crucial that the involvement and support of the adult services is put into place as early as possible.

Where evidence of a learning disability/difficulty is present in one or both parents, the paramount consideration of all the agencies will be the welfare and protection of the child/ren.

Parents with learning disabilities/difficulties are likely to require long term support to be able to meet their child's needs. Where this cannot be provided within the family or community, the parent may then require a specialist assessment to identify the support required from professionals.

For further information please visit the Pan Beds Interagency Child Protection Procedures chapter Children of Parents with Learning Disabilities.

5.5 Parents with Mental Health Issues

There are significant reasons as to why the mental health of the pregnant mother and those around are them are important to the well-being of the unborn baby and should be considered very seriously.

We know that:

• Exposure to maternal stress in utero can affect a child's ability to cope in stressful circumstances in later life. (Shonkoff et al, 2012);
• The importance of ultrasound examinations should not be underestimated in relation to the formation of bonds between the parents and an unborn child;
• After giving birth, severe mental illness may progress more quickly and be more serious than at other times.

It is therefore crucial that practitioners who are working with pregnant women are aware of the mental health history and if required ensure that the appropriate Adult Mental Health Services are involved. If they are not involved then the relevant referrals must be made as soon as practically possible. Community midwives will be aware of services available to support prospective parents at this time.

Mental Capacity Act Considerations

In UK law, a person's 18th birthday draws the line between childhood and adulthood (Children Act 1989). In health care matters, an 18 year old enjoys as much autonomy as any other adult. However, the Mental Capacity Act applies to 16 and 17 year-olds, who can also take medical decisions independently of their parents.

Young people aged 16 or 17 are presumed in UK law, like adults, to have the capacity to consent to medical treatment. However, unlike adults, their refusal of treatment can, in some circumstances be overridden by a parent, someone with parental responsibility or a court. This is because we have an overriding duty to act in the best interests of a child. This would include circumstances where refusal would likely lead to death, severe permanent injury or irreversible mental or physical harm.

A referral must be made to children's social care for any person under the age of 18 where safeguarding concerns are present. Where a young person under the age of 18 is pregnant and safeguarding concerns exists, a referral must be made in the interest of both their safety and the safety of the unborn baby.

For further information please visit the Pan Beds Interagency Child Protection Procedures.

5.6 Safe Sleeping

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.

5.7 Parents with Substance and Alcohol Misuse

Drug and alcohol misuse before and during pregnancy can be major risk factors for miscarriage, maternal and infant death and health inequalities.

The potential for harm from the use or abuse of substances such as drugs, tobacco and alcohol is particularly acute during pregnancy and can have a severe and damaging impact on pregnancy and the health of the baby. Substance misuse can significantly harm a foetus, yet pregnancy can act as an equally strong incentive to make a positive change in behaviour and lifestyle. It is important that this is both recognised and supported by early years and health practitioners who work with pregnant women. There is good evidence that early interventions can improve outcomes. (Maternal and Early Years, NHS Health Scotland).

Fear that their child or other children, maybe removed can increase the risk for these women to be reluctant in contacting or engaging with antenatal services and thus increase the possibility of further harm being caused to the unborn baby or even lead to a concealed pregnancy.

Local services for adults and young people with drug and / or alcohol misuse are available across Bedfordshire. It is important that all practitioners work together to support the parents of the unborn baby where they are using or misusing drugs and alcohol.

Substance misuse services will routinely ask their male and female service users if there is a possibility if they are or likely to be, expectant parents. They also offer onsite pregnancy tests if requested. Referrals to the relevant Children's Social Care will be made if and when the pregnancy reaches 12 weeks.

For further information please visit the Children of Parents who Misuse Substances Procedure.

5.8 Young Parents

Particular care should be taken when assessing risks where the prospective parents are themselves children i.e., under the age of 18 years and in particular if they are themselves Children Looked After. Attention should be given to evaluating the quality and quantity of support that will be available within the extended family and friends network, the needs of the parent(s) and how these will be met, the context and circumstances in which the baby was conceived, and the wishes and feelings of the child (or children) who are to become parents. If the prospective parent is a Child Looked After then attention should be paid to their long term plan and how assessing for independence should incorporate the thinking of 'independence with responsibility for a child'.

When it is established that a young person in care or a supported care leaver is pregnant, the referrer must ring for a consultation with the relevant Local Authority Single Point of Contact (SPOC for LAC). A decision can then be reached about the assessment process between both the referring team and the Assessment Team.

It should not be an automatic decision to complete a pre-birth assessment in relation to the pregnancies of all care leavers unless the thresholds are met as outlined above. Alternatively a referral for an Early Help Assessment should be considered.

If an assessment is required, the Corporate Parenting service should provide a full written history and chronology of the young person either at the point of referral or at the Strategy Meeting. The assessment should consider the Care Plan for the young person and any additional resources needed to support the young person throughout the pregnancy. The Independent Reviewing Officer should be kept up to date with the assessment process and should the needs of the (unborn) baby require changes to the care plan for the young person, a Looked After Child review should be convened at the earliest possible time.

If a young person is looked after by another Local Authority and living in Bedfordshire then the allocated social worker from that Local Authority should be invited to the Strategy Meeting.

If the young person's placement is out of county the Corporate Parenting Service must refer the unborn baby to the relevant Assessment Team within that area. Where a child is a mother/expectant mother and is accommodated or subject to leaving care arrangements (potentially up to 25 years), and is placed by the originating authority in another borough, the authority in which the mother is living is responsible for the baby.

However, in practice this is an area where there can sometimes be disputes regarding case responsibility. It is therefore important that case responsibility is negotiated at an early stage by managers.

5.9 Concealed, Late and/or Denied Pregnancy

Where:

• A person knows they are pregnant but does not engage with appropriate services; or
• A person who is genuinely unaware that they are pregnant
• Concealment may be an active act or a form of denial where support from appropriate carers and health practitioners is not sought out for a variety of reasons.

Concealment of pregnancy may be revealed:

• Late in pregnancy
• In labour; or Following delivery. The birth may be unassisted and may carry additional risks to the child and pregnant person's welfare.

Delayed or a late booking is defined as presenting for maternity services after 20 weeks of pregnancy.

• The pregnancy may be undetected, where both the pregnant person and their health care providers are unaware that they are pregnant
• It may be a conscious concealment, where the pregnant person is aware of their pregnancy and is emotionally bonded to the unborn baby but does not tell anyone
• The pregnancy may also be denied, this may be a conscious denial where the pregnant person has physical awareness of the pregnancy but lacks emotional attachment to the foetus, or;
• Unconscious denial, where the pregnant person is not subjectively aware of their pregnancy and genuinely does not believe the signs of pregnancy or even the birth of the baby (e.g. Psychotic disorder)

For the purposes of this guidance, late booking is defined as relating to women who present to maternity services after 13 weeks of pregnancy.

There are many reasons why women may not engage with ante-natal services or conceal their pregnancy, some of, or a combination of which will result in heightened risk to the child. Some of the indicators of risk and vulnerability are as follows:

• Previous concealed pregnancy;
• Previous children removed from the mother's or father's care;
• Fear that the baby will be taken away;
• History of substance misuse;
• Mental health difficulties;
• Learning disability;
• Domestic abuse;
• Previous childhood experiences/poor parenting/sexual abuse;
• Poor relationships with health professionals/ not registering with a GP;
• Cultural dilemmas.

N.B. This list is not exhaustive.

In cases where there are issues of late booking and concealed pregnancy, it is extremely important that careful consideration is given to the reason for concealment, assessing the potential risks to the child and convening a Strategy Meeting as a matter of urgency with further consideration given to the attendance of a legal representative at this Strategy Meeting.

Possible implications:

• Concealment of a pregnancy can lead to a fatal outcome (for both mother and/or child), regardless of the mother's and/or father's intention;
• Concealment may indicate uncertainty towards the pregnancy, immature coping styles and a tendency to dissociate, all of which are likely to have a significant impact on bonding and parenting capacity;
• Lack of antenatal care can mean that any potential risks to mother and child may not be detected. It may also lead to inappropriate advice being given, such as potentially harmful medications prescribed by a medical practitioner unaware of the pregnancy;
• The health and development of the baby during pregnancy and labour may not have been monitored and foetal abnormalities not detected;
• Underlying medical conditions and obstetric problems will not be revealed;
• An unassisted delivery can be dangerous for both mother and baby, due to complications that can occur during labour and the delivery;
• Lack of maternal willingness/ability to consider the baby's health needs, or lack of emotional attachment to the child following birth;
• Where concealment is a result of alcohol or substance misuse there can be risks for the child's health and development in utero as well as subsequently;
• There may be implications for the mother and/or father revealing a pregnancy due to fear of the reaction of family members or members of the community;
• Risks to the unborn baby from prescribed medications.

There may be risks to both mother and child if the mother has concealed the pregnancy due to fear of disclosing the paternity of the child, for example where the child has been conceived as the result of Sexual Abuse, or where the father is not the woman's partner.

For further information please see Concealed, Late and/or Denied Pregnancy.

5.10 Parental Non-Engagement

There are many reasons why expectant parents may fail to engage with the assessment, some of which relate to the factors outlined above. It is extremely important that parental non-engagement does not become the reason for delaying the assessment and the making of multi-agency contingency plans for the birth of the baby.

Consideration to be given for a Strategy Meeting to be convened in the event of:

• More than two failed social work visits;
• Disengagement from ante-natal process to include Midwifery and maternity care;
• Disengagement with other involved agencies to include Drug and Alcohol Services / Mental Health support.

Professional judgement to apply in context of what the current situation presents at that time.

5.11 Transient parents

In order to provide mobile families with responsive, consistent, high quality services, local authorities and partner agencies must develop and support a culture of joint responsibility and provision for all children.

Children and families who move more frequently between local authorities include homeless families, asylum seekers and refugees, gypsy, traveller and Roma families, looked after children and families experiencing domestic abuse. A parent's homelessness or placement in temporary accommodation, often at a distance from previous support networks, can result in or be associated with transient lifestyles. There is a risk the family will fall through the net and become disengaged from health, education and other support systems. There may also be a reduction in previously available family / community support.

Temporary accommodation, for example bed and breakfast accommodation or women's refuges, may present additional risks e.g. where other adults are also resident who may pose a risk to the child. Families that move frequently can find it difficult to access the services they need. For those already socially excluded, moving frequently can worsen the effects of this exclusion and increase isolation. Some families in which children are harmed move home frequently to avoid contact with concerned agencies, so that no single agency has a complete picture of the family.

Local agencies and professionals, working with families where there are outstanding child welfare concerns, must bear in mind unusual extended non-school attendance, missed appointments, or abortive home visits, may indicate that the family has moved out of the area. This possibility must also be borne in mind when there are concerns about an unborn child who may be at future risk of Significant Harm.

6. Early Help and Support

Where it has been identified that the parent/s may need additional support to meet the needs of their unborn child, a referral should be made for an Early Help Assessment as the means to clearly identify needs/strengths and the support required.

Families who may need early support and help include:

• Parent/s who are asking for help;
• Young parents or with limited support from family/friends, including care leavers;
• Families who dynamics result in a level of instability;
• Parent/s struggling to maintain standards of hygiene /repair with the family home;
• Families in poverty or where food, warmth and other basics may not always be available;
• Families where the advent of a new baby may exacerbate existing difficulties;
• Families with housing issues which places them at risk of homelessness or are currently homeless;
• Parent/s with mental health issues or drug and/or alcohol issues or with learning disabilities, where it is considered that this may impact on parenting;
• A parent has self harmed during pregnancy;
• Parents who may not be able to care for their baby adequately because of a physical disability;
• Parent has a mild learning difficulty;
• Where there is domestic abuse within the household;
• Late presentation / booking.

In all cases where there has been late presentation of pregnancy urgent consideration should be given to timely follow up and appropriate information sharing.

A review meeting should take place no later than at 20 weeks pregnancy to review the progress of the action plan. There should be an explicit discussion about whether the Early Help Assessment remains the most appropriate way to meet the unborn baby's needs. Given the relatively short timescales of a pregnancy, any decisions regarding the effectiveness and impact of the Early Help needs to be tightly managed. If the services involved with the family believe that they cannot meet the needs of the pregnant women and her family or additional services are required but unknown, a referral to the relevant Children's Services should be considered.

7. Initial Contact Stage

The Single Point of Access within each Local Authority will be responsible for screening all pre-birth referrals. This will be undertaken within 24 hours of receipt of the referral. If there is insufficient information to establish whether the grounds are met for undertaking the Pre-Birth assessment, the social work professionals, may liaise with the referring agency/ midwifery/GP and other relevant agencies, including Adult Services and the Mental Health Team if they are involved with the mother, or her partner.

(Refer to GOV.UK, Information Sharing advice for safeguarding practitioners for further information.)

If it is considered that there are insufficient grounds for a Pre-Birth Assessment to be undertaken, signposting to other appropriate agencies will take place through the Early Help Team to ensure that early help and support are in place.

It is important that the expected date of delivery (EDD) is ascertained from the referrer at the point of referral and recorded on the relevant Local Authority computer records system. If this is not established at the point of referral this will be a priority task for the allocated social worker or Early Help Officer.

All teenage parents and their unborn child must progress to separate Contacts on the relevant Local Authority records system so that there is the collation of information and an analysis of the current situation and necessary action in relation to each of them.

It is also expected that the father- to- be is entered on to the relevant Local Authority records system, as a "Relationship" if over 18, a strategy meeting should be considered. If under 18 a separate contact is to be created in his own right so we can determine if there are any significant issues in the relationship and if not, that he is then considered regarding any support needs he may have.

The details of the father of the child and the current partner of the mother if this is different must also be obtained and recorded on to the relevant Local Authority records system.

If there are any difficulties in establishing relevant health information, locating health visitors etc. there must be consultation with the lead safeguarding nurse at this stage.

It will be the responsibility of the allocated Social Worker to request any historical files/ court bundles etc. relating to the family that would be deemed necessary as part of the forthcoming pre-birth assessment.

8. Assessment Stage

Pre-birth Assessments should be considered on all pre-birth referrals where any of the following factors are present:

• There has been a previous unexplained death of a child whilst in the care of either parent;
• A parent or other adult in the household, or regular visitor, has been identified as posing a risk to children;
• A sibling is the subject of or has been a Child Protection Plan;
• The parent is or was, a Looked After child and where concerns have been identified;
• A sibling has previously been Looked After voluntarily or via a Court Order;
• Domestic abuse is known to have occurred or domestic abuse has occurred/been discussed during pregnancy and there other children in the home;
• The degree of parental substance misuse is likely to have a significant impact on the baby's safety or development;
• The degree of parental mental illness/impairment is likely to have a significant impact on the baby's safety or development;
• There are concerns about parental maturity and ability to self-care and look after a child e.g. an unsupported young mother and/or father;
• The degree of parental learning disability is likely to have a significant impact on the baby's safety;
• Both parents have mild or moderate learning difficulties;
• There are concerns about a parent's capacity to adequately care for their baby because of the parent's physical disability;
• A child aged under 14 and found to be pregnant – strategy meeting to be convened as soon as possible;
• Female genital mutilation victims;
• There are concerns relating to So-called 'Honour' Based Abuse;
• A child aged under 16 and found to be pregnant where there are concerns identified that cannot be met through Early Help;
• Where there may be concerns that the young person is at risk of child sexual exploitation;
• If there is a history or concerns regarding So-called 'Honour' Based Abuse or forced marriage;
• If the pregnant mother and/or father has No Recourse to Public Funds;
• Any other concern exists that the baby may be likely to suffer Significant Harm including a parent previously suspected of fabricated or inducing illness in a child;
• Suspicion of attempts to conceal the pregnancy.

This list is not definitive and further discussion should take place with the appropriate Manager if required.

Best practise suggests that there should be at least one joint visit made with the health visitor and/ or midwife during the course of the assessment and other joint visits with the health specialist and relevant agencies as appropriate during the assessment.

Once the decision has been made for the Pre-Birth assessment to be undertaken, a Pre- Birth Multi Agency Meeting should be held within 20 working days. It is imperative that this meeting is held as early as possible to ensure that all risk factors and protective factors are considered as part of the Pre Birth Assessment.

The meeting should be attended by both the allocated social worker and their Manager or Senior Social Work Practitioner who would chair the meeting. The community midwife or safeguarding midwife should always attend and the Health Visitor should also be invited and prioritise attendance at the meeting (the Health Visitor should be invited via the following 0-19 Team email address - ccs.bedsandlutonchildrenshealthhub@nhs.net.) Parents should also be invited to this meeting so they can participate in the sharing of information.

Items for discussion at this meeting should include:

• Introduction of the presenting concerns by the chair of the meeting;
• Clarification of both parent's details and any siblings, including dates of birth, ethnicity and religion;
• EDD of the baby;
• Ante-natal care and obstetric history;
• Social care history, including parent's own childhoods;
• Current family structure, extended family and proposed support;
• The parental relationship, (including any DV history considering nature, frequency and severity of violent incidents, and triggers to violence);
• Family functioning: (lifestyle, roles and responsibilities and how they envisage adapting to the arrival of a new-born baby);
• Issues that may affect the baby: Risks and needs in relation to either parent's ability to understand a baby's needs. Any mental health issues for either/both parents. Risk of premature birth, likely to stay in hospital following delivery, risk of disability, indicators that parent-child relationship may not produce a secure attachment;
• What assessments and by whom, are required to ensure risk and need are identified comprehensively;
• Are there any factors that may trigger a premature birth; such as a mother under 19, drug use, domestic abuse or previous premature birth (this list is not exhaustive).

The midwife attending the meeting will be responsible for preparing and attending the meeting with the relevant obstetric history relating to any known previous pregnancies and that of this pregnancy that is required.

If the meeting is following a late referral and birth is likely within the next month the meeting should be convened as soon as possible, where the following questions should also be considered:

• Practical arrangements for mother (and/or father) and baby;
• Who will inform the social worker of the birth;
• Plans for out of hours/emergency birth;
• Discharge plans and a support package;
• Contact arrangements with parents and other family members;
• Parental attitudes to the plan;
• Management of parental non co-operation;
• Arrangements for legal planning/proceedings/removal;
• Health and safety issues;
• Consideration of why referral was late.

The Pre-Birth Assessment should be completed within 45 days of the referral.

Depending on the level of assessed risk and need for the family, the outcome could be either child protection procedures, child in need procedures or a step down to early help support.

A good plan should be developed to ensure that everyone is clear about what should happen when the baby is born. The pre-birth assessment conclusions must be reviewed once the baby has been born and the actual observation of parenting can be started.

The outcome of the assessment is to be shared with the Named Midwife, Health Visitor and any other relevant practitioner.

Please see Appendix 1: Multi- agency procedure and guidance for planning & completing pre-birth assessments

9. Child Protection Concerns

9.1 Strategy Meetings

It is important that the potential risks to the unborn child are flagged up as early as possible to inform effective planning and so that information can be gathered at an early stage including relevant Police checks.

If it is evident that there are reasonable grounds to believe that the unborn child may be likely to suffer Significant Harm, a multi-agency Strategy Meeting should be convened. A strategy meeting will be held towards the end (day 40-45) of the Child and Family Assessment to determine whether child protection procedures are needed.

There are exceptions to this:

• If at any time there are concerns regarding significant harm then a strategy meeting should not wait until the end of the assessment and should be held immediately.
• In the event of exceptional circumstances, i.e. high risk of premature labour or high risk flight risk, or where there has been an attempt by the mother and/or father to conceal the pregnancy (see Concealed, Late and/or Denied Pregnancy)

Social workers and managers should refer to the Pan Bedfordshire Child Protection Procedures in relation to the purpose and agenda for Strategy Meetings. These Strategy Meetings can be held in a variety of settings including the hospital/GP practices and should facilitate the attendance of all relevant professionals.

In cases where previous children have been removed by a Local Authority and continue to be Looked After, the allocated social worker must be invited to the Strategy Meeting in order to provide relevant background information and history.

In cases where previous children have been removed a legal planning meeting should be considered and an application to the resource panel should be requested in light of this.

In cases where Care Proceedings had been conducted, the Assessment worker should ensure that details of the proceedings including any assessments that have informed the court are known. (The previous court bundle should have already been requested).

The Strategy Meeting should consider the circulation of country-wide alerts including hospitals if it is thought if the baby may be born outside of the area and the allocated Social Worker will be responsible for issuing the alert.

Social workers need to request that Conference and Review Service send out these alerts on their behalf.

Where there are concerns that the mother may present at a local hospital other than the one she is booked into, social worker to ensure that copies of the strategy meeting should also be sent to the Safeguarding Midwife at those identified hospitals i.e. Luton and Dunstable, Bedford, Lister, Rosie, Hinchingbrooke, Stoke Mandeville and Milton Keynes Hospitals.

Any plan arising from a strategy should consider the following:

• Timescales for completion of an assessment;
• Securing the engagement of the Multi Agency network;
• Contingency planning;
• The need for an Initial Child Protection Conference;
• Whether the Public Law Outline process should be commenced – see Section 9 below.

9.2 Pre-Birth Child Protection Conferences

If it is decided that a pre-birth Child Protection Conference should be held it should take place as early as assessed as required, as is practical and never later than 8 weeks before the due date of delivery, so as to allow as much time as possible for planning support to the baby and family. Where there is a known likelihood of a premature birth, the Conference should be held earlier. E.g. factors which may indicate possible premature labour include young mothers (19 and under); substance misuse; domestic abuse; maternal use of some prescribed medication.

9.3 Child Protection Plan

If a decision is made that the baby needs to be the subject of a Child Protection Plan, the plan must be outlined to commence prior to the birth of the baby.

The Core Group must be identified and should meet prior to the birth and prior to the baby's discharge home after a hospital birth to make detailed plans at both stages.

Following the completion of the pre-birth assessment normal child protection/core group meetings apply.

9.4 Pre-Birth Review Child Protection Conferences

The first review Conference should take place within one month of the child's birth or within three months of the due date of the Pre-birth Conference whichever is sooner.

9.5 Multi-agency Pre Birth Plan

A Multi-Agency Pre Birth Plan must be created by 34 weeks gestation (34 weeks being the latest) or as soon as appropriate once pregnancy is known. Discussions regarding to the plan may take place from 26 weeks pregnant if they are part of CIN/core group meetings. The plan is the responsibility of the Lead Practitioner (Social Worker if open to Children's Services) and should be made in agreement with their manager, the Safeguarding Midwife and any other relevant practitioner (including the Health Visitor). The plan will include the arrangements for delivery and the immediate post-natal period. Where there are concerns about a family irrespective as to whether the unborn baby is subject to a child protection plan, a multi-agency pre birth plan should be agreed. The agreed plan must be kept where practitioners can access its contents in and out of hours to enable midwives and Social Workers to know how to respond. The plan should be shared with parents unless to do so is felt to put the pregnant person/person who has had the baby or the baby at increased risk.

The multi-agency pre & post birth plan should include contact numbers and names of professionals' involved and clear directions as to where the infant should be cared for following delivery depending on the risk. Where Children's Services have the Lead Practitioner role, it is the responsibility of the allocated social worker to ensure that Children's Services 'Out of Hours' are made aware of the multi-agency plan. It is the responsibility of the midwife agreeing the multi-agency pre & post birth plan to ensure that other health practitioners involved are informed, for example the obstetrician, neonatologist, GP, HVs, Family Nurse and the safeguarding team within the relevant health agency. All agencies should know what role they have at this time and be clear about their responsibilities.

It is an expectation that the hospital uses interaction/behavioural charts once a baby is born to document attachment and interaction between baby and parents, and any concerning patterns raised need to be shared with the multi-agency network.

Annex B: Pan Beds Pre Birth Safeguarding Plan, Discharge Planning Agenda and Discharge Meeting template provides a template for the Pre Birth plan and Discharge Meeting agenda and template. These are useful templates at any other meeting where a safety plan needs to be developed.

Plans for discharge for babies identified by this guidance are usually made at the pre-birth planning meeting. Where this has not occurred, there are last minute changes to the plan or new or increasing concerns/risks have emerged, discharge plans should be discussed with Children's Services and or other involved agencies and a pre-discharge planning meeting arranged.

The plan should recognise that hospitals are not secure settings. As such the plan should consider contingency plans to include the period between birth and discharge from hospital. It should consider the role of the police in any immediate protection requirements. Where discharge is likely to be complex e.g. discharge to foster placement a pre-discharge planning meeting must be considered.

It must be recognised by all practitioners involved that multi-agency pre & post birth plans can change at short notice and can be fluid. Practitioners should exercise their professional judgement to keep the baby and others safe.

In situations where there is a delay in discharge of the person who has given birth and baby due to social reasons as opposed to medical requirements this needs to be agreed on an individual basis. If a hospital extension is required for social reasons only, risk assessments need to consider the role of the midwife and the risks to the baby. The hospital can, in these situations, charge the Local Authority for the extended stay. It must be remembered however that midwifery units are not a place of safety and supervision may need to be put in place by Children's Services.

The pre-birth risk assessment may conclude that the baby would be at risk of significant harm if the infant remains in parent's care following birth. In these circumstances Children's Services may plan to apply to the courts for an Order to remove the baby to a place of safety following birth. Due to legal reasons applications to court cannot be made prior to birth. It is the responsibility of the attending practitioner (normally the midwife) to inform Children's Services and where appropriate the police when labour starts and when the baby is born. It is, however, the decision of the courts whether to grant an Order and alternative care and management of the baby will need to be agreed by all multi-agency partners if this is refused (in this situation a Pre-Discharge Planning Meeting should always be convened to ensure robust plans are in place to keep the infant safe).

If Children's Services are applying to court for an Order the court will require a number of days to list a court hearing. There will need to be a safety plan for the new born baby between the application being made and the date of the hearing. Police Protection arrangements may need to be considered as part of the safety arrangements and the police should routinely receive a copy of the multi-agency pre & post birth plan in these circumstances. If Police Powers of Protection are agreed these can last up to 72 hours, but this is not automatic and there should be agreement in place detailing how long this will be required for and recorded as well as contingency plans in case police decide not to exercise their Powers of Police Protection.

9.6 Management of Emotionally Challenging Cases and Facilitating Removal of a New Born Baby from Parents' Care.

These are emotionally challenging cases and require sensitivity and effective management. There is no guidance currently available that outlines organisational and practitioner roles or responsibilities when removing babies from parents care. This may include how and when the removal takes place, by whom, the correct process of doing so and the support mechanisms needed to support the person who has given birth and practitioners afterwards.

Each case should be individually assessed and where possible should involve the parents in the process. The person who has given birth/parent's wishes should be ascertained and taken into account when deciding how the baby will be removed. There should be clear communication between the Social Worker, the Midwife in charge of the person who has given births' care and the parents (where possible) in order to identify in advance who will facilitate the separation of the baby from the parents and find an appropriate place for the separation to take place, ensuring the needs of the baby are prioritised at all times.

Support for Parents- Those who have a baby placed in alternative care are noted to have experienced reactions akin to the grief and loss of those whose babies have died. Practitioners should consider a trauma informed approach when supporting these parents and should consider the impact of physical recovery on a person's body post birth and how this may be particularly difficult for a person who has had their child removed from them at birth. Consideration should be given to working with the parents to create a HOPE Box, a memory box for women/families who are separated from their babies during the early postnatal period following Court intervention/decision for separation or parent's voluntary agreement to separation (s.20). For more information please access here.

In each individual case, practitioners caring for both the person who is giving birth to the child and the baby (in discussion with social workers) should consider if offering mementoes such as pictures, handprints, footprints etc. would be appropriate and if copies should be provided for the baby's life story work. The following family support networks are available and should be offered if appropriate:

British Association for Counselling & Psychotherapy
www.bacp.co.uk

MATCH
www.matchmothers.org

Family Lives: 0808 800 2222
www.familylives.org.uk

Natural Parents Network
Facebook Group

National Association of Child Contact Centres
www.naccc.org.uk

CAFCASS: 0300 456 4000
www.cafcass.gov.uk

Woman's Aid: 0808 200 0247
www.womensaid.org.uk

Kinship: 0300 033 7015
www.kinship.org.uk

Family Rights Group: 0808 801 0366
www.frg.org.uk

Support for Staff - Practitioners who provide care for people who have given birth to a baby and whose babies are removed shortly after birth very often will need support following an emotionally challenging case. Supervision should be made available from a member of their agency for any staff member to give them the opportunity to reflect on their feelings of engaging with child protection processes which results in the removal of babies at birth.

10. Public Law Outline

In some cases the concerns relating to the unborn child will result in a Legal Planning Meeting. In all cases this meeting should consider all of the risk factors and strengths. Where it has been agreed at the Legal Planning Meeting that work should be undertaken under the Public Law Outline (PLO) framework, there should be as little delay as possible in sending out letters before Proceedings and holding PLO meetings. This is in order to avoid such approaches to the pregnant woman in the late stages of pregnancy and to work with the family to explore all options in order to preferably avoid initiating Care Proceedings.

11. Initiating Care Proceedings

The practitioner network should be kept fully appraised of the Local Authority plan. Where an Initial Child Protection Conference has been held this will be through the core group.

The purpose of the proceeding core group meeting will be to make a detailed plan for the baby's protection and welfare around the time of birth so that all members of the hospital team are aware of the plans. The community midwife will ensure that the midwives are fully appraised of the plan for the baby at birth.

The agenda for this meeting should also address the following:

• How long the baby will stay in hospital (a minimum of 7 days is usually recommended to monitor for withdrawal symptoms for babies born to substance using mothers);
• How long the hospital will keep the mother on the ward once medically fit;
• The arrangements for the immediate protection of the baby if it is considered that there are serious risks posed to the e.g. parental substance misuse and /or mental health; domestic abuse. Consideration should be given to the use of hospital security, informing the Police and other safety planning measures;
• The risk of potential abduction of the baby from the hospital particularly where it is planned to remove the baby at birth;
• The plan for contact between mother, father, extended family and the baby whilst in hospital. Consideration to be given to the supervision of contact – for example whether contact supervisors need to be employed. Hospital staff cannot be responsible for supervising contact;
• Consideration of any risks to the baby in relation to breastfeeding e.g. HIV status of the mother; medication being taken by the mother which is contraindicated in relation to breastfeeding;
• The plan for the baby upon discharge that will be under the auspices of care proceedings, e.g. discharge to father, extended family members; mother and baby foster placement/unit; foster care, supported accommodation;
• A visiting matrix on discharge;
• Where there are concerns about an unborn of a pregnant woman who intends to have a home birth, the Ambulance Service Lead should be invited to the Pre-Birth Planning Meeting. The safeguarding team in the hospital will email the East of England Ambulance service to place a marker on the address;
• How to manage a request for a home birth when there are concerns or the unborn child is subject to a child protection plan;
• Contingency plans should also be in place in the event of a sudden change in circumstances;
• Hospital staff should be given clear instructions regarding any birth that is likely to occur over a weekend or Bank Holiday;
• The Emergency Duty Team should also be notified of the birth and plans for the baby and the plans entered onto the relevant Authority records system;
• A copy of the plan should be given to all participants and the parents GP.

12. Birth and Discharge of a Newborn Baby

Discharge Plans should be identified in Pre-birth Planning meeting. Despite this, it must be recognised by ALL practitioners that plans can change at short notice and be fluid. Professional judgement is key to keeping the baby and others safe. If any new or increased risks emerge after agreeing Pre and Post Birth Plan, plans should be reviewed and discussed with Children Social Care and other agencies. As a result, a further pre-discharge planning meeting may need to be arranged. Discharge Planning Meetings are organised by the allocated Social Worker.

The hospital midwives need to inform the allocated social worker, or the Emergency Duty Team at weekends and Bank Holidays of the birth of the baby and there should be close communication between all agencies around the time of labour and birth. Maternity staff must keep contemporaneous notes to include visitors/basic care/maternal interaction/parenting style/ any unusual activity such as leaving the ward for extended periods. A Discharge Planning Meeting should always be held whether or not a baby is going into care or staying with parents & also whether or not the discharge plans have been included in the pre-birth planning.

During the out of hours periods, the social worker should ensure what role there is (isn't) for the Emergency Duty Team and whether they will need fully appraising of any potential decision making that maybe required or if maternity staff are simply notifying them of a birth. Equally, the safeguarding midwife should also ensure the midwifery /maternity staff are aware of any concerns / plans for the baby upon birth so that if they are contacting the Emergency Duty Team they are fully aware of why they are making this contact.

In cases where legal action is proposed or where the unborn child has been the subject of a Child Protection Plan, the allocated Social Worker should visit the hospital on the next working day following the birth. The Social Worker should meet with the maternity staff prior to meeting with the mother, father and baby to gather information and consider whether there are any changes needed to the discharge and protection plan. The Social Worker and Ward Staff should keep in contact and the Social Worker should visit the baby and the parents on the ward as detailed in the Pre-Birth Plan.

Whether the baby is subject to a Child In Need plan or a Child Protection plan, a Discharge Planning Meeting should be held to draw up a detailed plan prior to the baby's discharge home. If this is not possible, the CIN or Core Group should meet within 7 days of the baby's birth.

If a decision has been made to initiate care proceedings in respect of the baby, the Allocated Social Worker must keep the hospital up-dated about the timing of any application to the courts. The Safeguarding Midwife should be informed immediately of the outcome of any application and placement for the baby. A copy of any orders obtained should be forwarded immediately to the hospital.

13. Allocation and Case Transfer for Children's Social Care

Please refer to your own Local Authority's internal Guidance.

14. General Guidelines for Conducting Pre-Birth Assessments

The importance of conducting pre-birth assessments has been highlighted by numerous research studies and Serious Case Reviews which have shown that children are most at risk of fatal and severe assaults in the first year of life, usually inflicted by their carers.

Pre-Birth Assessment is a sensitive and complex area of work. Parents may feel anxious about their child being removed from them at birth. Referring practitioners may be reluctant to refer vulnerable adults and be anxious about the prospective parents losing trust in them.

It is important to undertake the assessment during early pregnancy (following the 12 week scan) so that the parents are given the opportunity to show that they can change. If the outcome of the assessment suggests that the baby would not be safe with the parents then there is an opportunity to make clear and structured plans for the baby's future together with support for the parents.

Where the concerns have not met the threshold for a Pre-Birth Assessment a referral for an Early Help Assessment should be considered by the relevant Health practitioners in order to ensure appropriate early help is in place.

It is important that social workers do not conduct assessments in isolation. Working closely with relevant practitioners such as midwives and health visitors is essential. Liaising with relevant substance misuse, mental health and learning disability practitioners is also crucial. The mental health safeguarding lead will also offer advice on cases with a mental health component and become involved in liaison with mental health practitioners.

The importance of compiling a full chronology and family history is particularly important in assessing the risks and likely outcome for the child. Where there have been previous children in the family removed, the previous Court documents such as copies of Final Court Judgements and assessment reports should be accessed at an early stage. If there have been Social Workers involved from the Looked After Children service, they should be consulted and invited to relevant meetings. Please access the following guidance Chronologies and Genograms Procedure and Multi- Agency Chronologies as good practice.

Workers should try to compile a clear history from the parents about their own previous experiences in order to find out whether they have any unresolved conflicts, for example that may impact on their parenting of the child. It is important to find out their feelings towards the newborn baby and the meaning that the child may have for them. For example, the pregnancy may have coincided with a major crisis in the parent's life, which will affect their feelings towards the child.

It is also important to find out the parents' views about any previous children who have been removed from their care and whether they have demonstrated sufficient insight and capacity to change in this respect.

It is crucial to seek information about fathers/partners whilst conducting assessments and involve them in the process. Background Police and other checks should be made at an early stage on relevant cases to ascertain any potential risk factors.

Working with extended family members is also crucial to the assessment process and achieving positive outcomes for unborn children. Consideration should always be given to convening a Family Meeting/Family Group Conference in any cases where there is a possibility that the mother and/or father may be unable to meet the needs of the unborn child.

Family Meetings can enable the families to be brought together to make alternative plans for the care of the child thus avoiding the need for Care Proceedings in some cases.

Parallel assessment of alternative family carers can prevent delays in Care Planning for the child.

A pre- birth assessment tool is attached to this guidance to help social workers consider the key questions to address when undertaking assessments. It is important to provide an analysis of the likely impact of parental issues on the unborn child rather than just providing a description. For example, the likely impact of parental substance misuse on both the unborn and the newborn child needs to be spelled out explicitly.

Appendix 1: Pre-Birth Assessment Tool

Click here to view Appendix 1: Pre-Birth Assessment Tool.

Appendix 2: Pre Birth Planning Template

Click here to view Appendix 2: Pre Birth Planning Template.

Annex A: Framework for Practice: Risk Estimation

Framework taken from an adaptation by Martin Calder in 'Unborn Children: A Framework for Assessment and Intervention' of R. Corner's 'Pre-birth Risk Assessment: Developing a Model of Practice'.

Annex B: Pan Beds Pre Birth Safeguarding Plan, Discharge Planning Agenda and Discharge Meeting template

Click here to view Annex B: Pan Beds Pre Birth Safeguarding Plan, Discharge Planning Agenda and Discharge Meeting template

Annex C: General Guidance Regarding Ante Natal Care

General Guidance regarding ante natal care

Antenatal care begins as soon as the pregnancy has been confirmed and midwives continue care in the postnatal period for at least 10 days following birth. A booking interview with the community midwife takes place ideally between 8-12 weeks gestation. This is usually at the Hospital. It is at this interview that the midwife is able to assist women in their choices for childbirth and ensure they are informed of all the options available to them.

Women are given choices in early pregnancy of Lead Practitioner and place of birth:Midwife-led care (MLC) means the midwife is the Lead Professional. All antenatal care would be conducted in the community and is often shared with the General Practitioner (GP). Women would have the choice of giving birth in the hospital under MLC or at home with midwives in attendance.

GP led care is less frequently offered and again all antenatal care is conducted in the community and is shared between GP and community midwife. The place of birth is rarely at home with the GP in attendance so most GP births occur in a low-risk hospital environment.

Consultant led care is offered to women who have recognised health risk factors or who choose to see the consultant team. These pregnancies require additional surveillance both pre-birth and in labour. Care is shared between the community midwife, GP and a hospital consultant team consisting of midwives and doctors specialising in care of high risk pregnancy. Delivery of the baby will take place as per the mother's choice. The booking interview is a time of collection of information and an opportunity for the midwife and mother to plan her care in pregnancy. It is an ideal time for the midwife to assess health and social needs of families and to consider packages of care and support suitable for individual needs.

Antenatal appointments are arranged to suit the individual clinical needs of the mothers and the initial choices may change if complications of pregnancy arise. A collaborative approach between all health practitioners is encouraged with direct midwife referral to obstetrician being available at all times. In the case of home births all postnatal care is provided in the home by the community midwife. For births in hospital - with either the midwife, GP or obstetrician as the Lead Practitioner - initial postnatal care is provided by midwives and support staff on the maternity wards. Hospital stays are getting shorter with many women going home within a few hours of birth but generally 12-48 hours are the more normal lengths of stay. On transfer home care is undertaken by the community midwife for at least 10 days following the birth. Care can be extended to up to 28 days if a particular clinical or social need is identified. Liaison between the Health Visitor attached to the GP's surgery and community midwife usually takes place during the antenatal period with all expectant mothers being offered an ante natal assessment between 28-32 weeks gestation by the Health visiting service.

Following the birth of the baby the health visitor should make telephone contact with the mother between 5-10 days postnatal to arrange a new birth visit. The new birth visit should be completed between day 10-14 days postnatal, which coincides well with the handover of care from the midwives.