This guidance is for managers and practitioners involved in work with families prior to the birth of a child where there are indications of identified needs/risk.
The guidance is intended to inform a sustained approach to assessment in which parents are engaged and supported throughout the ante-natal period. Identifying the needs of and potential risks to the unborn child at the earliest possible stage reduces the likelihood of last minute activity around the time of birth and enables help to be provided at the earliest possible stage.This guidance should be read in conjunction with The Pan Bedfordshire Child Protection Procedures, the information sharing guidance and the joint protocols on multi-agency working, all of which are available at http://bedfordscb.proceduresonline.com/.
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:
Hart (2000) states that there are two fundamental questions when deciding whether a pre-birth assessment is required:
Where there is reason for doubt about the above a pre-birth assessment is required.
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:
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, where routine antenatal assessment and screening processes are commenced. Antenatal care begins as soon as the pregnancy has been confirmed.
The Community Midwives, GPs and Obstetricians 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.
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.
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.
It is important to assess the needs and provide support for learning disabled parents as early as possible.
Parents with learning needs 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 violence, 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 professional 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 protocol 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 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 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.
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:
It is therefore crucial that professionals 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.
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 with drug and / or alcohol misuse are available across Bedfordshire. It is important that all professionals 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 on site pregnancy tests if requested. Referrals to the hub will be made if and when the pregnancy reaches 12 weeks.
Guidance around other vulnerabilities is available within the Pan Bedfordshire online Child Protection Procedures.
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:
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 Access and Referral hub (Children's Social Care) should be considered.
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 Care Professional 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.
Pre-birth Assessments should be considered on all pre-birth referrals where any of the following factors are present:
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. 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:
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:
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.
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:
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 from the Looked After Children Service 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.
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:
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:
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 (refer to Section 7.1, Strategy Meetings) as a matter of urgency with further consideration given to the attendance of a legal representative at this Strategy Meeting.
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.
There are many reasons why expectant mothers 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:
(Professional judgement to apply in context of what the current situation presents at that time.)
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 violence; maternal use of some prescribed medication.
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.
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.
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.
In all cases a referral should be made for a Family Meeting / Family Group Conference. The PLO process is also an opportunity to commission specialist assessments. These requests should be presented to the relevant Local Authority Resource Panel in the first instance for consideration and review and no later than 24 weeks gestation.
As part of a new joint initiative Children's Services is taking part with Children and Family Court Advisory and Support Service (CAFCASS) to try out a new way of working with parents before any Court proceedings are issued in respect of children. It is hoped that this new way of working might avoid Court proceedings having to be issued, and, it is hoped that it will reduce the length of time it takes for cases to be dealt with by the Courts if the cases are issued.
The Social Worker and Team Manager will present any such case at the Resource Panel as soon as possible after the social care Pre Birth Assessment has been completed. This must be no later than a gestation period of 24 weeks.
The request to Resource Panel is for a Legal Planning Meeting to be held and for an in principle decision that the unborn baby's case should be included in the CAFCASS Plus scheme.
Following the LPM a referral is to be made to CAFCASS, ideally between weeks 20-28 gestation. If the referral is made after 28 weeks gestation, the referral will be will accepted at the discretion of CAFCASS. After 32 weeks gestation CAFCASS will not accept the referral and the scheme cannot be utilised. Parents consent is required for the Family Advisor to become involved.
A Family Court Advisor should be allocated within 2 days of the referral.
At the first PLO meeting a Family Court Advisor from CAFCASS will also attend the meeting so that they can advise on what they also consider as being in the best interests of the unborn baby. The CAFCASS officer may visit the family and/or the Social Worker before the meeting so that they know more about the situation.
There should be no more than one review prior to the birth of the child. Any review meeting should include the Family Court Advisor.
Eight working days after the pre-proceedings meeting, the Family Court Advisor will provide a CAFCASS Plus report setting out an initial analysis and recommendations as to the way forward. This report will be forwarded to Children's Services and the parents.
In the event that proceedings are commenced then the same Family Court Advisor who has been involved in the pre proceedings to be allocated wherever possible and so becomes the allocated Children's Guardian. (Also refer to CAFCASS plus guidance for more detailed information).
The professional 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:
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.
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 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.
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 Access. 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
Please refer to your own Local Authority's internal Guidance.
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 professionals 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 professional 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 professionals such as midwives and health visitors is essential. Liaising with relevant substance misuse, mental health and learning disability professionals 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 professionals.
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.
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 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.
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'.
|Factor||Elevated Risk||Lowered Risk|
|The abusing parent||
|Non abusing parent||
|Family issues (marital partnership and the wider family)||
|Parent - baby relationships||
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 in the woman's home or at the GP's surgery. 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 professional 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 in the hospital. 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 professionals 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 professional - 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 some Health Visitors making contact with the mother in pregnancy. Following the birth of the baby most Health Visitors arrange a primary visit at 10 days postnatal, which coincides well with the handover of care from the midwives.
Only valid for 48hrs