The Unborn Pathway and Pre Birth Assessment

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

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

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

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

• Form relationships with a focus on the unborn baby;
• Identify risks and vulnerabilities at the earliest stage;
• Understand the impact of risk to the unborn baby when planning for their future;
• Explore and agree safety planning options;
• Assess the family's ability to adequately parent and protect the unborn baby and the baby once born;
• Identify if any assessments or referrals are required before birth;
• Ensure effective communication, liaison and joint working with adult services that are providing on-going care, treatment and support to a parent(s);
• Plan on-going interventions and support required for the child and parent(s).

In some circumstances, it may be anticipated that the unborn baby is suffering, or at risk of suffering, significant harm. If there is evidence to indicate this, a Pre-Birth Assessment is required. 

This assessment should incorporate the strengths, vulnerabilities, risk factors and environmental factors which will impact on the baby when he or she is born.  

For further guidance regarding assessments the Multi-Agency Assessment Guidance provides a comprehensive overview of what assessments must entail.

The principal purpose of The Children (Guernsey and Alderney) Law 2008 is that suitable provision be made to protect children from harm and to promote their proper and adequate health, welfare and development. An early and comprehensive Pre-birth Assessment can allow agencies to provide intervention to protect the child and implement multi-agency plans, to ensure the best interests of the child are safeguarded. 

Sometimes a single, violent episode may constitute significant risk, but more often it is an accumulation of significant events, both acute and longstanding, which interrupt, damage or change the child's development. 

Harm can be determined significant by comparing a child's health and development with what might be reasonably expected of a similar child. Although there are no absolute criteria for determining whether harm is significant, the Committee for Health and Social Care, Police, Education, and Health work with family members to assess the child and their circumstances, and a decision is made based on an analysis of the evidence gathered and professional judgement. 

Suspicions, or allegations that a child is suffering, or likely to suffer, significant harm should result in an assessment incorporating a Child Protection Investigation. 

Most pregnancies are identified within the first 3 months of gestation, and key information is collated during the booking interview with the midwife. The midwife will be able to assist women in making informed choices about the care they receive, advise on the suitability of their choices, and consider if there are any concerns for the unborn child. Other professionals involved with pregnant women still need to be mindful of safeguarding issues and should undertake their own assessment of risk - it should not be assumed that the parents are known to midwifery services. 

If there are concerns regarding parenting capacity or safety to the unborn baby, then the midwifery service should refer the unborn baby to the MASH for an assessment to be undertaken. The referral information should contain the expected due date, the names and addresses of parents and any other relevant health information pertinent to the risk analysis of the Committee for Health and Social Care. 

During the assessment process and during pre-birth interventions it is essential that midwives attend all Child in Need Review Meetings and Core Group Meetings and have their analysis incorporated within the Pre-birth Assessment. All assessment information must be shared with the midwifery staff.

If professionals are concerned that the unborn baby may be suffering, or at risk of suffering, significant harm, a Multi-agency Referral Form (MARF) should be sent to the Multi Agency Support Hub (MASH) at 12 weeks gestation. If referrals are received before this, advice will be given to re-refer concerns back to the MASH at the point the pregnancy reaches 12 weeks gestation, and early help support may be considered.  

The referral should be completed at the earliest opportunity to: 

• Enable the early provision of support services to facilitate optimum home circumstances prior to the birth;
• Enable the parents to have more time to contribute their own ideas and solutions to concerns and increase the likelihood of a positive outcome to assessments in line with restorative practices;
• Avoid initial approaches to the parents in the last stages of pregnancy, at what is already an emotionally charged time;
• Provide sufficient time for a full and informed assessment;
• Provide sufficient time to make adequate, robust, and effective plans for the baby's protection.

Listed below are circumstances which indicate an increased risk to an unborn child, where a referral to the MASH should be made: 

• Where previous children in the family have been removed because they have suffered harm;
• A sibling has previously been removed from the household, either temporarily, or by Court Order;
• A child in the household is the subject of a Child Protection Plan;
• A parent or other adult in the household, or regular visitor, has been identified as posing a risk to children;
• Either parent is a child in care or they are known to Children's Social Care;
• A child is under the age of 16 years and found to be pregnant;
• Either, or both parents, are under 18 years of age;
• If the pregnancy is denied or concealed;
• Where there are concerns regarding domestic violence and abuse;
• Either, or both parents, have mental health problems or support needs that may present a risk to the unborn baby or indicate that their needs may not be met;
• Identified as presenting a risk or potential risk, to children, such as having committed a crime against children;
• Either, or both parents may not be able to meet the unborn baby's needs e.g. significant learning difficulties and in some circumstances severe physical or mental disability;
• A history of abuse in childhood;
• Recent family break up and social isolation/lack of social support;
• Either, or both parents, abuse substances, alcohol, or drugs;
• Any other concerns exist that the baby may be at risk of significant harm, including a parent previously suspected of fabricating, or inducing illness, in a child or harming a child.

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

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

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

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

Information should also be gathered about fathers and partners who are not the biological father at the earliest opportunity to ensure that any risk factors can be identified. A careful assessment of the role that the person has in relation to the woman and any other children in the household as well as their views about the future care of the baby should be undertaken.

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

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

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

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

A Pre-birth Assessment should take place when there is evidence to indicate the unborn child may be suffering, or at risk of, suffering harm. The Pre-Birth Assessment should commence as early as 12 weeks, but no later than 20 weeks into the pregnancy. It is important to undertake the assessment during early pregnancy so that the parents are given the opportunity to demonstrate their capacity to change. If the outcome of the assessment suggests that parenting capacity is affected in a negative way, there is then sufficient time to make clear and structured plans for the baby's future, together with support for the parents. 

A Pre-Birth Assessment is a sensitive and complex area of work, as parents may feel anxious about their child being removed from them at birth. It is therefore important professionals work restoratively with parents to create respectful and trusting relationships, maintaining a highly supportive, responsive, and challenging approach, enabling families to build upon and recognise their strengths and improve their circumstances. 

The Pre-birth Assessment should be completed within 45 days of the start date. The timescale for the completion of the Pre-birth Assessment will be dependent upon the gestation of the pregnancy and the level of risk surrounding the pregnancy.  The assessment should be complete before 28 weeks gestation and no assessment sessions should take place in the last 8 weeks of pregnancy. 

The Pre Birth Assessment should be completed using the work of Martin C Calder's Unborn Children: A framework for assessment and Intervention which is designed to help professionals to carefully consider a range of issues which could have a significant negative impact on the child.  Furthermore, assistance with pre-birth assessments can be found through this Pre-Birth assessment guidance and Research In Practice Pre-birth Guidance to ensure that assessments explore all necessary information to comprehensively inform future planning. The Pre-Birth Assessment should be completed on the Pre-Birth Assessment Template on Mosaic.

The Pre-birth Assessment should conclude with a recommendation around whether the unborn child is able to safely remain in their parent(s) care; whether a Child in Need Plan is required; whether a Child Protection Plan is required; or whether legal advice is sought to initiate care proceedings. It is vital that a referral for a Legal Planning Meeting is made at 26 weeks if the social work plan is to request legal advice as to whether care proceedings are necessary. Pre-birth assessments where the issues of relinquished babies, concealed pregnancies, female genital mutilation and honour-based violence are present must be brought to a Legal Planning Meeting to request legal oversight, even if the social work plan is not to initiate care proceedings.

When a pre-birth is referred into the Committee and one of the risk factors is significant domestic violence, substance misuse by mother during pregnancy, significant mental health difficulties (e.g. diagnosed schizophrenia) or parent(s) have had children removed from their care, they should transfer to the Children Safeguarding Team. 

If at least one of these factors are present it is highly likely that the baby will be subject to a Child Protection Plan at birth and early transfer to the Children's Safeguarding Team will ensure timely planning and intervention can occur and prevents the complications of late transfer, which complicates and reduces the effectiveness of planning. 

Pre-birth Assessments will also be completed by the Child in Need team if they do not reach the threshold to transfer through to the Children Safeguarding team.

As stated above, the Pre Birth Assessment should be completed using Martin C Calder Martin C Calder's Unborn Children: A framework for assessment and Intervention. 

Here is a list of practice tips to support you when completing Pre-birth Assessments:

• Compiling a full chronology and family history is important in terms of assessing the risks and likely outcomes for the child. Where there have been previous children in the family removed, the previous court documents such as copies of final court Judgments and assessment reports should be accessed at an early stage.
• Social Workers should try to compile a clear history from both parents about their previous, personal experiences to find out more about their emotional, social, and psychological histories, and whether they have any unresolved conflicts that may impact on their parenting of the child. It is important to find out their views around previous children being removed too, and whether they have demonstrated sufficient insight and capacity to address difficulties, move on, and create meaningful and sustainable change. 
• Find out parents' feelings towards the unborn baby, and the meaning the child may have for them. For example, the pregnancy may have coincided with a major crisis in a parent's life, which could potentially impact upon their feelings towards the child.  
• A genogram of the family network should be complied. Genograms are useful in identifying key people and wider support networks for the family who may be involved in safety planning for the child. These people can attend any potential family network meetings and may be identified as potential alternative carers for the child.  
• Working with extended families is crucial to the assessment process and achieving positive outcomes for unborn children. Consideration should always be given to convening family network meetings in any case where there is a possibility that the parent may be unable to meet the needs of the unborn child.  Family network meetings can enable families to be brought together to make alternative plans for the care of the child, thus avoiding the need for care proceedings. Parallel viability assessments of family members can prevent delays in care planning for the child. 
• It is crucial to seek information about fathers/partners whilst conducting assessments and to involve them in the assessment process. They too will have family members and support networks who could be invited to family network meetings, and who may be identified as potential alternative carers for the child. Background police checks and other checks should be made at an early stage to ascertain any potential risks. 
• It is important that social workers do not carry out pre-birth assessments in isolation. Working closely with professionals such as midwives, health visitors, family support workers, substance misuse/mental health/learning disability support professionals, is crucial. Remember, multi-agency working is not just about professionals sharing information, it is about professionals working together to assess risk and make decisions. What are the professionals' views about the potential risks faced by the baby? What are the professionals' views about parenting capacity, and the quality of care the parent(s) can offer? 

When a Pre-Birth Assessment gives rise to concerns that there is reasonable cause to suspect that an unborn child may be suffering, or at risk of suffering, significant harm, an Initial Child Protection Conference should be held from 20 weeks of pregnancy. 

Where older siblings have been subject to a Child Protection Plan, the same Reviewing Officer should be allocated to the unborn baby. 

An Initial Child Protection Conference should always be held:

• Where a previous child has died, been seriously injured, or been removed from parent(s) as a result of significant harm;
• Following assessment, where a child is to be born into a family or household where there are already children subject to a Child Protection Plan;
• Following assessment, where a person known to pose a risk to children resides in the household or is known to be a regular visitor;
• Where there is a mother under the age of 16 years where there are concerns regarding her ability to care for herself and/or to care for the child. 

Other risk factors which should be considered are: 

• The impact of parental risk factors such as mental ill health, learning disabilities, alcohol and/or substance misuse and domestic violence and abuse, as well as non-attendance, lack of engagement, or recurring lapses, evidence of superficial compliance, or persistently not recognising the impact of parental risk factors on the child's needs and potential consequences. 

Following the Initial Child Protection Conference, regular Core Group Meetings should take place within statutory timescales to review the effectiveness of the Child Protection Plan. 

Professionals should meet prior to the birth of the child to discuss the pre-birth hospital management plan and the baby discharge plan.  These plans should be recorded on Mosaic. This is to be uploaded via a word document in attachments.

An agreement is to be set out for Conference attendees that Child Protection Plans should not be ended for unborn babies prior to them being born, as the birth is a significant change, and therefore risk can emerge. 

A Review Child Protection Conference is to be held 8 weeks after the baby has been born due to the birth being a significant change in the family's circumstances.  

The Committee should be notified of the child's name and correct birth date following the child's birth and whether the father is named on the Birth Certificate, and this should be recorded on Mosaic.

When a Pre-Birth Assessment gives rise to concerns that there is reasonable cause to suspect that an unborn child may be suffering, or at risk of suffering, significant harm, an Initial Child Protection Conference should be held from 20 weeks of pregnancy. 

Where older siblings have been subject to a Child Protection Plan, the same Reviewing Officer should be allocated to the unborn baby. 

An Initial Child Protection Conference should always be held:

• Where a previous child has died, been seriously injured, or been removed from parent(s) as a result of significant harm;
• Following assessment, where a child is to be born into a family or household where there are already children subject to a Child Protection Plan;
• Following assessment, where a person known to pose a risk to children resides in the household or is known to be a regular visitor;
• Where there is a mother under the age of 16 years where there are concerns regarding her ability to care for herself and/or to care for the child. 

Other risk factors which should be considered are: 

• The impact of parental risk factors such as mental ill health, learning disabilities, alcohol and/or substance misuse and domestic violence and abuse, as well as non-attendance, lack of engagement, or recurring lapses, evidence of superficial compliance, or persistently not recognising the impact of parental risk factors on the child's needs and potential consequences. 

Following the Initial Child Protection Conference, regular Core Group Meetings should take place within statutory timescales to review the effectiveness of the Child Protection Plan. 

Professionals should meet prior to the birth of the child to discuss the pre-birth hospital management plan and the baby discharge plan.  These plans should be recorded on Mosaic. This is to be uploaded via a word document in attachments.

An agreement is to be set out for Conference attendees that Child Protection Plans should not be ended for unborn babies prior to them being born, as the birth is a significant change, and therefore risk can emerge. 

A Review Child Protection Conference is to be held 8 weeks after the baby has been born due to the birth being a significant change in the family's circumstances.

The Committee should be notified of the child's name and correct birth date following the child's birth and whether the father is named on the Birth Certificate, and this should be recorded on Mosaic.

Where there are concerns that a child is suffering, or likely to suffer, significant harm, and they may be unable to remain in the care of their parents, the case should be presented to a Legal Planning Meeting from 22 weeks of pregnancy. The purpose of this is to seek legal advice as to whether the threshold criteria has been met to explore alternative legal options or care proceedings.

In situations where it is agreed Care Proceedings should be initiated, social workers should be mindful that the child's case will also need to be presented at a Permanency Planning Meeting, which aims to identify the right permanence plans for children, and to enable early planning. 

In presenting at a Legal Planning Meeting the social worker should come with a clear plan, who the baby will be cared for and present the discounted options. These discounted options should include parents, connected persons, a family arrangement where parents and baby move into family members' home, a mother and baby unit and a mother and baby foster placement. 

Prior to presenting at a Legal Planning Meeting a Letter of Concern should be provided to parents outlining the risk identified by the Committee.

The purpose of the hospital management plan and discharge planning meeting is for professionals to be clear about their roles and responsibilities, and to agree a multi-agency plan to safeguard the baby once born. The allocated social worker should attend this meeting, and the plan should be recorded on the child's file on Mosaic.  

The agenda for this meeting should address the following:  

• How long the baby will stay in hospital. If a baby is showing signs of withdrawal, then their length of stay will depend on their clinical needs;
• Consideration of any risks to the baby in relation to breastfeeding e.g. maternal drug use;
• The arrangements for the immediate protection of the baby, if it is considered that there are serious risks posed from parental alcohol consumption, substance misuse, mental ill health and/or domestic violence. Consideration should be given to the use of hospital security/informing the Police if required;
• The risk of potential abduction of the baby from the hospital, particularly where it is planned to remove the baby at birth/upon discharge from hospital;
• The plan for contact between mother, father, extended family, and the baby whilst in hospital;
• Any plans for the baby upon discharge that will be under the auspices of Care Proceedings, e.g. discharge to parents/extended family members, mother and baby residential/foster placement, placement in foster care;
• Contingency plans in the event of a sudden change in circumstances.

The Children's Emergency Duty Team/Out of Hours Service should also be notified of the birth and plans for the baby via a duty alert.

The Committee for Health and Social Care should be notified of the birth of the baby as soon as possible. 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 liaise with the Lead Midwife for Safeguarding, to gather information and consider whether any changes are needed to the discharge and protection plan. The allocated Social Worker should visit the baby and parents in accordance with the agreed Child Protection Plan and Birth Plan. 

Ward staff should keep a record of any visitors to the child and details of any concerns that emerge whilst on the ward. This could be important information for child protection planning, or potential evidence needed for care proceedings. 

If a decision has been made to initiate Care Proceedings in respect of the baby, the Social Worker should keep the Lead Midwife for Safeguarding / Hospital updated about the timing of any application to Court. A copy of any Orders obtained should be made available immediately to the hospital if they are not being discharged that same day.  

PLEASE NOTE: The application to court can only be made once the baby is born and this application needs to be timely. If there are immediate child protection concerns prior to the order being granted, then the Social Worker is to contact the Police. 

When it is established that a young person in care or a supported Care Leaver is pregnant, the referrer should contact the MASH and engage in a consultation. A decision can then be reached about the assessment process - it should not be an automatic decision to complete a Pre-Birth Assessment in relation to the pregnancies of all Care Leavers. 

If there is reasonable cause to suspect that the unborn baby is suffering, or likely to suffer, significant harm then a Strategy Meeting should be convened, and the relevant staff from the Child in Care Team should be included. 

The Strategy Meeting will consider risk/need in the context of the young person being pregnant, and plans will be agreed accordingly.

In a High Court Judgment (Nottingham City Council v LW & Ors [2016] EWHC 11(Fam) (19 February 2016), Keehan J set out five points of basic and fundamental good practice steps with respect to public law proceedings regarding pre-birth and new born children, particularly where Children's Services are made aware at an early stage of a pregnancy.  

1. Any birth plan should be rigorously adhered to by Social Workers, Managers and Local Authority Legal Departments;
2. A Risk Assessment of the parents should in this case have been commenced immediately upon the Social Worker being made aware of the mother's pregnancy, with the assessment completed at least 4 weeks before the expected date of delivery and updated to take account of relevant pre and post-delivery events.  The Assessment should have been disclosed forthwith to the parents and, if instructed, to their advocate;
3. The Social Work Team should provide all relevant documentation to the legal department no less than 7 days before the expected date of delivery; the legal department must issue the application on the day of birth and, in any event, no later than 24 hours after birth (or, as the case may be, after the date on which the local authority is notified of the birth);
4. Immediately upon issue, if not before, the application and supporting documents should be served on the parents and, if instructed, their advocates.
    
5. Immediately upon issue, the local authority should seek an initial hearing date on the best time estimate that can at that point be provided. 

The monitoring of any pre-birth assessments will be undertaken through the "pre-birth tracking spreadsheet" and the case files of all unborn children will be audited monthly. This audit will be completed by the Children's Proceedings Case Manager and the outcome of the audit will be emailed to the Team Manager and Service Manager. The outcome of the Audit will be marked green, amber, or red on the following criteria:

• Evidence of multi-agency working;
• Quality of visits;
• Quality of multi-agency meetings;
• Timeliness of intervention and plan;
• Voice of the child;
• Family Network Meetings;
• Multi-Agency and historical information gathering.

The inability to respond effectively to outcomes of audits will be subject to normal escalation process.

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.

Legislation, Statutory and Government Non-Statutory, Guidance

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

Good Practice Guidance

Born into Care: Best Practice Guidelines

NSPCC Learning Infants: Learning from Case Reviews

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

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

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

NICE Postnatal Care - Quality Standard

Useful Websites

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