Pre-Birth

Research has established the importance of good ante-natal care and the possible risk for women and unborn babies who are exposed to violence and forms of physical neglect, which can include the harm resulting from parental substance misuse during this period. In addition, it is clear that a range of developmental consequences are associated with psychological trauma during utero. Early assessment, intervention and support work carried out during the antenatal period plays a vital part in helping minimise any potential risk of harm. This procedure sets out how to respond to concerns for unborn babies, with an emphasis on clear and regular communication between professionals working with the mother, the father, partner and the wider family/support network.

All professionals have a role in the early identification of families in need of additional support and can help assess circumstances during a pregnancy where safeguarding actions may need to be taken.

Case reviews have highlighted the importance of multi-agency co-ordination that ensures the appropriate support is in place during the pregnancy to best protect the baby before and following birth.

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

• Form relationships with a focus on the unborn baby;
• Identify risks and vulnerabilities at the earliest stage;
• Understand the impact of risk to the unborn baby when planning for their future;
• Explore and agree safety planning options;
• Assess the family's ability to adequately parent and protect the unborn baby and the baby once born;
• Identify if any assessments or referrals are required before birth; for example the use of an Early Help assessment agreed locally;
• Ensure effective communication, liaison and joint working with adult services that are providing on-going care, treatment and support to a parent(s); including the need to ensure the GP and the HV service is aware of all potential concerns;
• Plan on-going interventions and support required for the baby and parent(s);
• Avoid delay for the child where a legal process is likely to be required in order to ensure adequate protection at the time of the birth.

Where professionals have concerns for the mother or unborn baby's welfare, or that of siblings, they should not assume that Midwifery, or other Health services, are aware of the pregnancy or the concerns held.

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

Each professional should follow their agency's child protection procedures and discuss concerns with their safeguarding lead/named/designated professional for safeguarding but should not delay alerting local children's social care services to established safeguarding concerns.

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

• Involvement in risk activities such as substance misuse, including drugs and alcohol;
• Perinatal/mental illness or support needs that may present a risk to the unborn baby or indicate that their needs may not be met;
• Victims or perpetrators of domestic abuse;
• Identified as presenting a risk, or potential risk, to children, such as having committed a crime against children;
• A history of criminality which could pose a risk to children;
• May not have the capacity to meet the baby's needs e.g. learning difficulties and in some circumstances physical, neurodivergent or mental disability;
• Past concerns for parenting capacity such as previous neglect or previous children have been subject to a child protection plan/legal proceedings/removed from parental care;
• Known because of parental involvement as a child or adult with Children's Social Care;
• Currently a Child in Care themselves or were looked after as a child or young person (care leavers);
• Ability to parent appears to be limited due to age/capacity;
• Recent family break up and socially isolated/lacking social support;
• Female genital mutilation/forced marriage;
• Any other circumstances or issues that give rise to concern. This could include a late/concealed pregnancy.

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

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 babGuide 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,starting in the ante-natal period and to be re-iterated once the baby 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 the parents understanding of the advice, and the available peer and support networks for parents to reinforce the information and provide practical advice.

It is important that all agencies involved in pre and post-birth assessment and support, fully consider the role of fathers, partners and wider family members in the care of the baby even if the parents/partner are not living together and, where possible, involve them in the assessment. This should include the father's/partner’s attitude towards the pregnancy, the mother and newborn child.

Involving fathers and partners 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 parent at the earliest opportunity to ensure that any risk factors can be identified.

A failure fully assess all adults within an unborn baby’s life may mean that practitioners are not able to accurately assess 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. Consideration should be given to background checks such as police and others  by Children’s Social Care at an early stage to ascertain any potential risk factors which may include:

Those who have had a background of abusive, neglectful or inconsistent parenting themselves,

• Those who have histories of impulsive behaviour and low frustration thresholds;
• Those 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;
• Those who mitigate their difficulties with others through an easy default to violence and controlling and angry behaviour;
• Those experiencing external pressures such as those brought about by poverty, mounting debts, deprivation, worklessness, racism and often very poor relationships with the mothers of the children.

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

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

When any professional becomes aware that a woman (or the partner of a person with whom they are working) is pregnant and they have identified parental risk factors that may indicate increased risk to the unborn, they should consider threshold for referral and liaison with other professionals supporting the family including health. 

An Early Help (or similar) assessment can be undertaken in relation to the unborn baby. If the mother is under 18, they should also be offered an Assessment.

Where a professional is concerned that an unborn baby or other children in the family may be at risk of, or suffering, harm, they should seek advice from their agency Safeguarding Lead without delay who will consider whether to refer to Children's Social Care - see Referrals Procedure.

A pre-birth conference (see Child Protection Conferences Procedure) may be required if Children's Social care assess that the child is at risk of significant harm. A pre-birth conference should share relevant information and develop a Child Protection Plan if required.

If a decision is made that the unborn baby will be made the subject to a Child Protection Plan , a Core Group should be established at the Initial child protection conference to support the family with the Child Protection Plan.

If the Assessment concludes that the child may not be safe in the care of their parents. Children's Social Care should obtain legal advice about an application for an Emergency Protection Order and/or an Interim Care Order. The application to the court can only be made once the child is born but there should be no delay in seeking the order. Children's Social Care should co-ordinate the required actions to ensure there is no delay in protecting the child and where feasible ensure a Pre-Birth Planning Meeting is held involving all relevant agencies.

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

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

A Pre-Birth Planning Meeting should be arranged following the outcome of the decision at the legal planning meeting to remove the child. The meeting should agree a detailed plan to safeguard the baby around the time of birth which should include:

• Arrangements to ensure women can travel to hospital;
• Contingency plans for home births;
• How long the baby will stay in hospital (for babies born to substance using mothers there needs to be a period of time to monitor for withdrawal symptoms);
• How long the mother will remain on the ward;
• Any risks to the baby in relation to breastfeeding e.g. HIV status of the mother;
• The arrangements for the immediate protection of the baby if the risk assessment has highlighted serious risks to the child e.g. from parental substance misuse, mental health concerns, domestic abuse. This should also include contacting the police or the use of hospital security;
• The risk that the parents might seek to remove the baby from the hospital especially if the plan is to remove the baby at birth;
• The plan for managing contact with the baby by the mother, father or an extended family and who will supervise the contact;
• The plan for the baby upon discharge, and what visits will be made upon discharge and by whom;
• Contingency plans should be in place in the event of sudden change in circumstances e.g. unplanned home births. These should include instructions for hospital staff if the birth happens over the weekend or a Bank Holiday, and who to contact if the birth takes place after hours. The Emergency Duty Team should also be notified of the pre-birth plans for the baby.

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

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

There are some potential issues that can arise. The involvement of social care (especially if there is a decision to remove the baby at birth) can result in the parents going missing or the mother not attending hospital at the time of birth.

It may have an adverse effect on the parents' mental or physical health or heighten the risks that had raised the concerns in the first place. The fear of losing the baby may undermine the attachment and bonding process between the parent and child. This may significantly impact maternal mental health and professionals should consider signposting to mental health and GP services for advice and support.

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

Legislation, Statutory and Government Non-Statutory, Guidance

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

Good Practice Guidance

Born into Care: Best Practice Guidelines

NSPCC Learning Infants: Learning from Case Reviews

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

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

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

NICE Postnatal Care - Quality Standard

Useful Websites

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