Pre Birth Assessment Procedure

1. Introduction

Research and experience indicate that very young babies are extremely vulnerable and that work carried out in the antenatal period to assess risk and to plan intervention will help to minimise harm.

In the thematic report of Ofsted's Evaluation of Serious Case Reviews from 1 April 2007 to 31 March 2011; Ages of concern: learning lessons from serious case reviews; of the 471 serious case reviews evaluated by Ofsted concerning 602 children, 210 (35%) children were babies under the age of one year.

The report identified recurring messages from the reviews that concerned babies less than one year old. In too many cases:

There were shortcomings in the timeliness and quality of Pre-birth assessments;
The risks resulting from the parents' own needs were underestimated, particularly given the vulnerability of babies;
There had been insufficient support for young parents;
The role of the fathers had been marginalised;
There was a need for improved assessment of, and support for, parenting capacity;
Practitioners under estimated the fragility of the baby.

Barlow et al (2014) states: Infants identified as being at significant risk of maltreatment need adequate protection within a time frame consistent with their developmental needs. This highlights the significance of an early response to pre-birth referrals and the need for a robust plan for support and protection at an early stage, to support secure development in the child's early stages, as well as detection of signs of neglect.

The Pre-birth assessment provides a valuable opportunity to develop a proactive multi-agency approach to families where there are acknowledged vulnerabilities/an identified risk of harm. The expected outcome is to:

Effectively identify and protect vulnerable children;
Positively support families;
Plan and implement effective care programmes;
Recognise the long term benefits of early intervention;
Ensuring focus is on the welfare of the child.

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

Will this new-born 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?

2. A Pre-birth Assessment is Required in the Following Circumstances

There is significant domestic violence or escalation during pregnancy and/or honour based violence;
A parent has significant mental health difficulties/diagnosis. S/he may be subject to an enhanced CPA. (Care Programme Approach);
A parent has moderate or severe learning disabilities;
A parent misuses substance/s - likely to have a significant impact on the health and development of the baby;
A parent has had a child previously removed from their care, has had contact restricted or has a child voluntarily accommodated;
A parent of 18 years and under with concerns about sexual exploitation, trafficking or abuse;
A parent is previously suspected of fabricated or induced illness;
A parent is suspected of being involved in a forced marriage;
A parent is suspected of being a victim or involved in spirit possession or witchcraft;
A parent whatever age is suspected or known to have previously been the victim of grooming and/or sexual exploitation, and the putative father is unknown or known to be the one who groomed them;
The parent is a victim or involved in honour based violence;
Incest is suspected;
If the parent is known to move authorities when professionals are involved;
A parent/relative or associate is someone who may represent a risk to children, or has previously harmed a child. (This would include issues such as a violent history; significant criminal history; sexual offences against adults or children etc.);
The baby once born will be living with or having contact with someone who may represent a risk to children (see above);
A sibling is subject to a child protection plan;
There are significant concerns about the home conditions, such that the baby may suffer physical neglect;
One or both parents' behaviour or circumstances during pregnancy indicates that they will be unlikely to protect or care for their baby appropriately e.g. living a chaotic lifestyle with no home base; significant emotional instability; lack of preparation/awareness of the impact of becoming a parent;
Late booking for maternity care with an inadequate explanation;
If Female Genital Mutilation (FGM) is a consideration.

This list is not exhaustive and there may be other situations which require a pre-birth assessment to be undertaken. All cases and presenting factors should be considered individually and the information analysed to ensure the needs of the unborn remain paramount.

3. Further Areas for Consideration

Pregnancy in a young person under the age of 16

Practitioners working with a young person under 16 who is pregnant must consider undertaking an assessment, as sexual activity under the age of legal consent should always give rise to the consideration of whether the child is suffering or likely to suffer significant harm or has been exploited.

Under the Sexual Offences Act 2003 penetrative sex with a child under 13 is classified as rape, these cases will always need to be subject to a strategy discussion and considered under Section 47 Children Act 1989;

Parents under the age of 18 years old

In all cases, the MASH will determine if the prospective parent(s), if under 18 years of age, require an assessment concerning their needs in their own right. If not, this should be recorded under a Management Decision record including a clear rationale for the decision;

Concealed Pregnancies

The reason for the concealment of a pregnancy will be a key factor in determining the risk to the child and that reason will not be fully known until there has been a Pre-birth assessment completed.

The implications of concealment are wide-ranging and can lead to a fatal outcome, regardless of the mother's intention.

Concealment may indicate ambivalence 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 and underlying medical conditions and obstetric problems will not be revealed. The health and development of the baby during pregnancy and labour may not have been monitored and foetal abnormalities not detected.

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 are also risks to the unborn baby from prescribed / non prescribed medications.

If there is a concealed pregnancy referred to Children's Social Care, depending on the stage of the pregnancy, it is acknowledged that early timescales may not be possible. However the Pre-birth assessment should start immediately when the pregnancy is known, giving maximum time to gather all information about the family's current situation and history from other local authority's and partner agencies.

High risk situation where mothers may have had precious children removed, in care or adopted need to be considered as high risk and multi-agency planning needs to be robust putting out appropriate alerts;

Mental Health

Although most parents with psychiatric problems are able to care for their children appropriately, research has indicated that child-maltreating parents are often shown to have mental health problems e.g. depression, history of attempted suicide, schizophrenia etc. Non-compliance with medication without medical supervision is a cause for concern.

Children are at increased risk of abuse by psychotic parents when incorporated into their delusional thinking e.g. "(the baby) is trying to punish me for my sins".

Practitioners will obviously seek to obtain a psychiatric assessment in these cases, but must not become "paralysed" if that is not forthcoming. It is essential to continue the assessment based on the behaviour of the parent(s), not the diagnosis, and the potential risk of that behaviour to the new-born child. In addition, where there are mental health risk factors identified, ongoing re-evaluation of risk is essential;

Substance Abuse

Drug or alcohol misuse is not in itself a contra-indication that the parent(s) will be unable to care safely for the baby, but practitioners will need to analyse:

The pattern of drug use and alcohol misuse and the likely impact on the baby/child as they grow/develop;
Whether it can be managed compatibly with the demands of a new-born child;
Whether the parent(s) are willing to attend and successfully engage with treatment, and the consequences for the baby of the mother's substance misuse during pregnancy e.g. withdrawal symptoms.

When a pre-birth assessment is being undertaken, the child is, as yet, unborn and unknown but there may be indicators e.g.:

Antenatal Depression;
The child may be at risk of a premature birth and therefore vulnerable and likely to stay in hospital for a period after delivery;
Mother's misuse of substances may result in the child having withdrawal symptoms or foetal alcohol syndrome;
Circumstances that may lead to the child being perceived as unwanted by either parent.

It is essential that there is close liaison with the midwives and obstetricians in relation to these factors and that they should be involved in the assessment and invited to attend any relevant meetings i.e. CIN, Core Groups, CP;

Domestic Abuse and Violence

When assessing domestic violence and abuse the social worker will establish if the parent known to Multi Agency Risk Assessment Conference (MARAC), Multi-Agency Public Protection Panel (MAPPA) or Domestic Violence Officer (DVO) and ensure full forensic history of violence of each parent, or adult who will have significant contact with the unborn baby as possible given consents and whether being assessed under S17 or S47 or the Children Act.

The social worker will obtain evidence of the nature of violent incidents, their frequency and severity and the triggers for them.

Risks are greater when a parent with unresolved care and control conflicts is caring for a baby with particular characteristics which may make them harder to care for e.g. a poor feeder or sleeper, constant crying, a disabled child etc. (Reder and Duncan, 1995, p.49; Reder and Duncan, 1999, pp. 62-71).

It is important that social workers do not conduct assessments in isolation and ensure that a sit down meeting of all professionals is convened to share information and agree tasks and ongoing support / contact with the mother / parents. 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.

All Pre-birth assessments must incorporate household members including significant others who do not reside in the home e.g. partners, and be subject to relevant multi-agency checks, including police checks.

Research has shown that men play a very important role in children's lives and have a great influence on the children they care for. Despite this, they can be ignored by professionals who sometimes focus almost exclusively on the quality of care children receive from their mothers and female carers. Hidden men: learning from case reviews Summary of risk factors and learning for improved practice around 'hidden' men: NSPCC March 2015.

From the NSPCC analysis of these case reviews, two categories of 'hidden' men emerged:

Men who posed a risk to the child which resulted in them suffering harm;
Men, for example estranged fathers, who were capable of protecting and nurturing the child but were overlooked by professionals.

The significance of both categories of father's will have an important impact on the assessment, especially informing in respect of the welfare, safeguarding and future planning for the child. If the assessment does not include the father / putative father / identified significant men, then considered and evidenced rationale as to why should be clearly recorded within the assessment.

Factors to be considered when undertaking a Pre-birth assessment must include strengths, protective factors as well as risk factors. Whilst guidance is provided to assist and inform an assessment as set out in this procedure, there will be other factors, which practitioners need to consider and each Pre-birth assessment must be conducted on an individual basis and in a child centred manner.

The social worker will undertake the Pre-birth Assessment by the 24th week of the pregnancy. The information shared by partner agencies during the assessment process discussions and the Manager's subsequent decision should be shared with the parents by the Social Worker. At the end of the assessment, the Manager will be responsible for determining which pathway the case then takes. There are 4 possible options:

i. Previous Children removed

In cases where a child has been removed from a parent's care because of abuse there are some additional factors which should be considered.

These include:

The ability of the perpetrator to accept responsibility for the abuse although this should not be seen as lessening the risk for additional children;
The ability of the non-abusing parent to protect. The fact that the child has been removed from their care suggests that there have been significant problems in these areas and pre-birth assessment will need to focus on what has changed and the prospective parent(s) current ability to protect.

Relevant questions when undertaking a pre-birth assessment when previous abuse has been the issue include:

The circumstances of the abuse: e.g. was the perpetrator in the household?
Was the non-abusing parent present?
What relationship/contact does the mother have with the perpetrator;
(Assuming the man as perpetrator - however, this is not always the case)
How did the abuse come to light? E.g. did the non-abusing parent disclose or conceal?
Did the child tell? Did professionals suspect?
Did the non-abusing parent believe the child? Did they need help and support to do this?
What are current attitudes towards the abuse? Do the parents blame the child/see it as their fault?
Has the perpetrator accepted full responsibility for the abuse? How is this demonstrated? What treatment did he/she have?
Who else in the family/community network could help protect the new baby?
How did the parent(s) relate to professionals? What is their current attitude?
In circumstances where the perpetrator is the prospective father or is living in the household, where there is no acknowledgement of responsibility, where the non-abusing parent blames the child and there is no prospect of effective intervention within the appropriate timescale, then confidence in the safety of the new born baby and subsequent child will be poor.

Circumstances where the perpetrator is convicted of posing a risk to children and is already living in a family with other children, (albeit with social work involvement), should not detract from the need for a pre-birth assessment. In all assessments it is important to maintain the focus on both prospective parents, and any other adults living in the household and not to concentrate solely on the mother.

ii. Non Abusing Parents Ability to Protect

When considering capacity of non-abusing parents to protect it is important to assess their own personal history and particularly their understanding in and perception as regards the abuse perpetrated by the partner. Smith, 1994 cited from Calder (2003) poses a number of relevant questions including:

How critical or uncritical are they regarding their partner's abusive behaviour?
To what extent were they party to or aware of their partner's abusive behaviour?
What has changed regarding their understanding of past abuse;
To what extent to they accept responsibility for failure to protect or collusion with the abuse?
What is the non-abusing parent's position regarding the abuse/conviction both at the time and now?
What information do they have regarding the abuse and who provided it?
Can additional information be provided to move the parent from any disbelieving position?
What feelings do they have to the child? E.g. anger, sympathy, blame?
To what extent does the non-abusing partner accept that their partner was responsible for the abuse?
To what extent can the non-abusing partner work with Children's Social Care and other agencies?
Could/can they choose their unborn child over abusing partner?
To what extent is the non-abusing partner dependent on the abuser?
How vulnerable is the non-abusing partner?
Do they have a history of violent or abusive relationships?
Does the non-abusive partner have other vulnerabilities i.e. disability, ill health, or other condition that isolates them from help?
To what extent do they recognise the existence of future risk to the unborn child;
What is their ability to manage this?
What level of knowledge do they have re the impact sexual offending behaviour in general and specific to partner?

iii. Pre-Birth assessment

A sound assessment will include what research tells us about risk factors, what practice experience tells us about how parents may respond in particular circumstances, and the practitioners' professional knowledge of this particular family.

It will collate factual evidence to evaluate relationships between parents/carers and between parents/carers and the unborn baby. The impact of personal history on current experiences and the current context within which the family live. This is consistent with the Framework for Assessment of Children in Need and their Families.

The Social Worker will:

Identify a fundamental baseline of acceptable parenting skills against which change can be monitored;
Read case files of any child/ren who have received a service including from another Local Authority;
Undertake searches regarding parents/carers/new partners, within Local Authority area, including Probation, police, any relevant adult care services, schools, colleges and Connexions, and, if appropriate in other Local Authority areas;
Construct a chronology, using input from other agencies, analyse and note patterns;
Interview parents together and separately, test out parenting capacity and develop early engagement. Note if one parent is articulate and controlling, disempowering the other parent from making an open contribution to the assessment. A parent may require significant challenge when reviewing the professional and historical information. A clear history from the parents of their previous experiences should ascertain if there are unresolved conflicts and their understanding of previous decisions the meaning of any previous children to them and the meaning of the expected baby;
Consider the relevance, if any, of any past history of either parent as having been Looked After or in receipt of Safeguarding services themselves;
Risk assess any dog or other pet, and consult with RSPCA or similar as required.

iv. Previous History

Practitioners should attempt to build up a clear history from the parents of their previous experiences in order to ascertain whether there are any unresolved conflicts and also to identify the meaning any previous children had for them and the meaning of the new born baby.

It will be particularly important to ascertain the parent(s) views, understanding and attitudes towards any previous children who have been removed from their care, or where there have been serious concerns about parenting practices. Relevant questions would include:

Do the parent(s) understand and give a clear explanation of the circumstances in which the abuse occurred?
Do they accept responsibility for their role in the abuse?
Do they blame others?
Do they blame the child?
Do they acknowledge the seriousness of the abuse?
Did they accept any treatment/counselling?
What was their response to previous interventions? e.g. genuinely attempting to cooperate or tokenistic compliant?
What are their feelings about that child now?
What has changed for each parent since the child was abused/removed?

This list is not exhaustive. There will be particular issues for individual cases that require social workers and other practitioners to gather information about past history and review past risk factors.

It is also important to ascertain parents' feelings towards the current pregnancy and the new baby relevant questions include:

Is the pregnancy wanted or not?
Is the pregnancy planned or unplanned?
Is this child the result of sexual assault?
Is severe domestic violence an issue in the parents' relationship?
Is the perception of the unborn baby different/abnormal? Are they trying to replace any previous children?
Have they sought appropriate ante-natal care?
Are they aware of the unborn baby's needs and able to prioritise them?
Do they have realistic plans in relation to the birth and their care of the baby?
Has their understanding, treatment, circumstances changed their ability to care for this child?

4. Referrals to Children's Social Care

If at pre 12 weeks of the pregnancy concerns are raised about the parent's ability to care for the unborn baby then health professionals should consider and provide Early Help Support.

At 12 weeks of the pregnancy professionals should consider if the threshold for a referral to Children's Social Care via MASH is needed. Consultation via the MASH consultation line is advised if there is any further guidance needed to consider the threshold of the presenting need.

It is essential that professionals gather as much information as is available from within their agency when making a referral to Children's Social Care. The referrer should confirm the referral in writing within 24 hours repeating all relevant information and agreed actions. The referrer will be notified of the outcome of the decision within 24 hours of making the referral.

All referrals made to MASH beyond the first 12 weeks of pregnancy or those 'stepped up' from Early Help Intervention, where there is a risk that the unborn child's safety and welfare may be compromised upon arrival, will be accepted by MASH.

Upon receipt of a referral, the MASH will decide on and record the next steps of action within one working day. This will include making a decision on whether or not to share or gather information with or from other agencies.

Decisions will take account of referral information, information held in existing records, discussions with the family (where possible and appropriate) and information provided by other professionals or services as deemed necessary.

The MASH Manager will review the information and decide what further action is needed in accordance with Swindon's Threshold of Need Document.

Where Children's Social Care decides to take no further action at this stage, feedback should be provided to the referrer, who should be told of this decision and the reasons for making it.

5. Referral Outcomes

Recommendation for Statutory Assessment

If the content of the referral highlights history of a safeguarding nature, previous social care intervention, previous children removed from the parents care or presenting actions and behaviours of the parent(s) that would impact on the care afforded to the unborn, then the referral will be considered under Section 17 of the Children Act 1989, with a recommendation for a 15 day Assessment to be completed to inform further decision making. This Assessment will ensure that the history, the current concerns and consideration of any future risk of significant harm to the baby both pre and post birth is clearly documented and where relevant, evidence provided in the assessment. The information collated within the assessment should then provide a rational, analysis and clear recommendations as to the considered recommendations:

If no assessed ongoing safeguarding concerns are identified, having considered the history and the parenting capacity to provide safe nurturing care to the baby pre/post birth then the assessment will be completed within the allocated timescale of 30 days, having considered the holistic needs of the unborn baby and the individual parents and any additional support considered to support the family.

If whilst undertaking the assessment the collated information supports further need for an assessment to fully identify the needs of both the family as a unit and the unborn needs both pre and post birth, without immediate safeguarding concerns, the ACP social worker will continue with the statutory assessment and provide a conclusion and recommendation as to the ongoing level of intervention for the family.

If the assessment recommends that there is a need for ongoing Child in Need (Section 17) support (Level 3) for the family, then the case will be placed on the weekly transfer list and transferred across to the Locality Team at the first Child in Need Meeting arranged within 10 days of the transfer meeting.

If the assessment recommends that there is a need for targeted support (Level 2) for the family, then a referral will be made to the Early Help Hub for appropriate support and the case will be closed to Children's Social Care. All Pre-birth cases stepped down to Early Help/Universal Services should conclude with a multi-agency step-down meeting with the parent(s) and key involved professionals. The step-down plan should be agreed and documented with a named Lead Professional.

If by the 15th day, the statutory assessment identifies that there are presenting safeguarding issues or the history supports the need for further assessment then the case will be transferred to the relevant Locality Team with a recommendation to undertake a Pre-birth assessment. The case will be added to the first weekly transfer meeting following the completion of the assessment, with a child in meeting arranged with all relevant professionals / family within 10 days of the transfer meeting.

Threshold of Child Protection

If during the assessment or on completion of the Pre-birth assessment, concerns of Significant Harm or risk of Significant Harm (Section 47) are identified then a decision will be made to convene a pre-birth Strategy Meeting. The timing of this meeting is a matter of professional judgement and will be agreed within the multi-agency professional network (please refer to Pre-Birth Flowchart).

When arranging the strategy meeting consideration should be given to maximum attendance by the professionals network (including the family's General Practitioner) involved in the care planning and decision making in respect of both the unborn child and the mother.

If at the strategy meeting it is agreed that the unborn baby is at likely/risk of Significant Harm, then a Section 47 investigation will be initiated. Strategy meetings should also take into account the welfare of any other children within the household and should consider all identified risk factors, including previous history, concealed pregnancies, home births without medical involvement, or risk of flight. The strategy meeting should also take into account the possibility of the child being born prematurely and a contingency plan agreed, which must include specific risk assessment and detailed safety planning.

If significant concerns are identified and it is felt that the new born baby will be at risk of significant harm an Initial Child Protection Case Conference (ICPC) should be convened as soon as assessments are completed. This Conference should take place as soon as practicable after 24 weeks gestation, to allow as much time as possible for planning support and services for the baby and family.

The ICPC will require the attendance of all the involved professionals during the pregnancy and those to whom the case will transfer following the birth e.g. Locality Social Worker, midwife or Health Visitor. Reports will be expected from all relevant practitioners, which must address concerns around the pregnancy and/or parenting capacity as well as areas of strength. The resultant Child Protection Plan should consider carefully the ability to manage a Protection Plan in the community and whether this will provide sufficient safeguards for the new born baby. Parents should also be encouraged to seek advice and advocacy from the Child Protection stage onward by the child's social or the midwife.

6. Unborn Baby where Sibling is Subject of a Child Protection Plan

If a sibling group is already subject of a child protection plan and the mother is pregnant a Strategy Discussion and S47 Enquires must be completed in respect of the unborn baby, prior to presentation at an Initial Child Protection Conference. If possible this will be the Review Conference for the siblings and if not possible the Conferences will be aligned by the first Review Conference. The unborn baby cannot be made subject of a Child Protection Plan without this process being undertaken to provide the evidence that the unborn baby's needs meet the threshold for the ICPC and to ensure that the evidence and decision making is fully recorded on the unborn baby's ICS file.

If the unborn baby is made subject of a child protection plan in this way the CP flag will appear on his or her ICS record. This is an essential protection for the baby/unborn baby.

The first core group meeting will be designated a pre-birth planning meeting. All essential professionals and the prospective parents should attend, and a written plan constructed. This must consider:

Practical arrangements for mother and baby-including post-natal ward monitoring;
Who will inform the Social Worker of the birth?
Plans for out of hours/emergency birth;
Contact arrangements with parents and other family members;
Discharge plans and support package-including out of area as relevant e.g. if discharging to extended family or friends address for any period or specialist setting;
Management of parental non-co-operation;
Arrangements for legal proceedings/removal;
Parental attitudes and views towards the plans;
Health and safety issues.

All subsequent Core Group/Pre-Birth Planning meetings should incorporate the above plan in its discussion and decisions.

7. Legal Action

Presentation to the Care Panel

Where safeguarding concerns have been identified following the completion of a Pre-birth assessment or where a Child Protection Plan recommends that it is appropriate to consider entering Care Proceedings the Local Authority will consider the need for legal advice and progressing a case under the Public Law Outline. A case discussion will be had with the allocated social worker's Head of Service and agreement sought to present the case, based on presentation of evidenced based practice of significant harm, to the weekly Care Panel.

If at the Care Panel it is agreed that threshold has been met and the Public Law Outline is to be initiated then a Legal Planning Meeting should be held. This meeting should be held at around the time of the ICPC at week 24 of the pregnancy. The Public Law Outline meeting with parents should be arranged after the ICPC, and the parents should have received the letter before proceedings by the 24th-28th week of pregnancy at the latest. Prospective parents have a right to full information about the concerns professionals hold about their ability to parent a child, and a clear understanding of the action the Local Authority intends to take in regard to their child. This should be assessed with regard to flight risk.

8. Bibliography

Brandon,M, Howe,D, Belderson, P, Black, J, Dodsworth, J, Gardner, R and Warren, C (2008) Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003-2005, London, DCSF;
Calder MC and Hackett S (eds). (2003) Assessment in childcare: Using and developing frameworks for practice. Dorset: Russell House Publishing;
Hart, Di (2000), "Assessment Prior to Birth" in Horwath, Jan (Ed) (2000) The Child's World: assessing children in need - Reader, Department of Health, NSPCC, University of Sheffield;
Reder, Peter and Clare Lucey (1995) "Significant Issues in the Assessment of Parenting"; (1995) in Reder, Peter and Clare Lucey 1995) Assessment of Parenting: psychiatric and psychological contributions (1995) Routledge, London;
Reder, Peter and Sylvia Duncan (1999), Lost Innocents: a Follow-Up Study of Fatal Child Abuse, Routledge, London;
Ofsted (2008) Learning lessons, taking action: Ofsted's evaluations of serious case reviews 1 April 2007 to 31 March 2008, London, Ofsted;
Ofsted (2009) Learning lessons from serious case reviews: year 2, London, Ofsted;
Rose,W and Barnes, J (2008) Improving Safeguarding Practice: Study of Serious Case Reviews 2001-2003, London, DCSF/Open University;
Sinclair, R and Bullock, R (2002) Learning from Past Experience – A Review of Serious Case Reviews, London, DoH.