Pre-Birth Assessments

1. Context

This chapter is intended to inform managers and practitioners involved in work with families prior to birth. It should be read by all social care staff. It is of particular relevance to staff members involved in conducting pre-birth assessments.

2. Purpose

The main purpose of a pre-birth assessment is to identify:

• The needs of, and risks to, the newborn child;
• Whether the parent/s are capable of recognising these and working with relevant professionals so that the needs can be met and the risks reduced with a package of support;
• What supports the parents may need.

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

• Will the newborn baby be safe in the care of these parents/carer?
• Is there a realistic prospect of these parents/carers being able to provide adequate care throughout childhood?

Where there is reason for doubt about either of the above a pre-birth assessment is indicated.

3. Principles

• Pre-birth assessments should be undertaken within a multi-agency approach;
• Early referrals should be encouraged in order to ensure the following:
  • Sufficient time is allowed in order to undertake a detailed assessment including the preparation of a detailed Chronology;
  • There is sufficient time to make effective care/protection plans;
  • Parents have time to contribute to any assessment and to increase the likelihood of a positive outcome to the assessment;
  • Parents are not being approached in the latter stages of pregnancy which is a stressful time in any event;
  • Support services can be provided in a timely fashion;
  • Late referrals receive the highest level of priority.

4. Initial Contact Stage

All new contacts/referrals will be made to the Children's Assessment Team (CAT), these will be screened and a decision made within 24 hours of receipt in order to ensure a consistent approach to the process. If there is insufficient information to establish whether the grounds are met for undertaking the assessment, further enquiries will  be made with the referring agency e.g. midwifery. Should the family be open to Social Care in respect of any siblings, a discussion will be held with the allocated social worker and a contact/referral created on the unborn child.

If it is considered that there are insufficient grounds for a Child and Family Single Assessment to be undertaken, consideration should always be given to signposting the case to other appropriate agencies.

It is important that the expected date of delivery (EDD) is ascertained from the Referrer at the point of referral and recorded on the electronic case file and within the written referral form completed by the referrer. If this is not established at the point of referral this will be a priority task for the allocated social worker.

The details of the father of the child and/or the male partner of the mother should also be obtained and recorded on the electronic case file and within the written referral form completed by the referrer.  If this is not established at the point of referral this will be a priority task for the allocated social worker.

There must be consultation with the health specialist within the screening process if there are any difficulties in establishing relevant health information, locating health visitors etc.

A contact/referral can be made at  any stage during the pregnancy, however referrals should always be made as soon as concerns are raised. If the outcome of the contact / referral is to proceed to a pre birth Child and Family Single Assessment, this will be undertaken within 15 working days of the contact/referral being made.

5. Child and Family Single Assessment Stage

Pre-birth Child and Family Single Assessments must be undertaken on all pre-birth referrals where the following factors are present:

• There has been a previous unexplained death of a child whilst in the care of either parent;
• A parent or other adult in the household, or regular visitor, has been identified as posing a risk to children;
• A sibling is the subject of a Child Protection Plan or Child in Need Plan;
• The parent is a Child Looked After;
• A sibling has previously been Looked After voluntarily or via a Court Order/ Police Protection;
• Domestic violence and abuse is known to have occurred;
• The degree of parental substance misuse is likely to have a significant impact on the baby's safety or development (see Multi-Agency Pregnancy Liaison and Assessment Group (MAPLAG): Roles and Responsibilities of Children's Social Care Procedure);
• The degree of parental mental illness/impairment is likely to have a significant impact on the baby's safety or development;
• There are concerns about parental maturity and ability to self care and look after a child e.g. an unsupported young mother;
• The degree of parental learning disability is likely to have a significant impact on the baby's safety;
• There are concerns about a parent's capacity to adequately care for their baby because of the parent's physical disability;
• A child under 13 is found to be pregnant;
• Any other concern exists that the baby may be likely to suffer Significant Harm including a parent previously suspected of fabricated or inducing illness in a child;
• A comprehensive pre-birth assessment should always be undertaken when a child has been removed from the care of a parent, or placed with other family members by a Court Order or family agreement, or a parent is deemed a risk or has a conviction against children. All unborn children under this category should be allocated from at least 12 weeks of pregnancy to ensure appropriate planning can take place. Should there be a delay in receiving a contact/referral that meets these criteria and the pregnancy is at 32 weeks plus, the case will be allocated immediately and a pre-birth Child and Family Single Assessment will be completed.

It is crucial to involve health visitors in the assessments. There should be at least one joint visit made with the health visitor and midwife during the course of the assessment and other joint visits with the health specialist and relevant agencies as appropriate.

6. Child Protection Route

6.1 Late Bookings and Concealed Pregnancy

For the purposes of this guidance, late booking is defined as relating to women who present to maternity services after 24 weeks of pregnancy.

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

Some of the indicators of risk and vulnerability are as follows:

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

N.B. This list is not exhaustive.

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

The Strategy Meeting should take place at the hospital where the pregnant woman is or should have been 'booked' to deliver her baby.

Any plan arising from a Strategy Meeting should decide on the following:

• Timescales for completion of an assessment;
• Contingency planning;
• Whether the Public Law Outline process should be commenced.

Following a contact/referral made to Social Care the allocated social worker must contact the Midwifery Service and set up an immediate home visit within 3 working days to meet with the pregnant woman. Any home visit should set out clear expectations of engagement under a written working agreement.

6.2 Parental Non-Engagement

There are many reasons why expectant mothers may fail to engage with the assessment, some of which relate to the factors outlined above. For example, a parent suffering from mental health problems may be reluctant to attend appointments or be compliant with medication. It is extremely important that parental non-engagement does not become the reason for delaying the assessment and making multi-agency plans and contingency plans for the birth of the baby.

6.3 Pre-birth Child Protection Conferences

If it is decided that a pre-birth Child Protection Conference should be held it should take place as early as is practical and never later than 6 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. N.B. Drug using pregnant women are more likely to give birth prematurely, therefore early conferencing in such cases is vital. This may not be possible in all cases dependant on when the referral has been made. Should immediate risks be identified following the Child and Family Single Assessment and the expected date of delivery is within 6 weeks, a strategy discussion/meeting should take place immediately and a child protection conference convened.

6.4 Child Protection Plan

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

The Core Group must be identified and should meet prior to the birth and within 10 days of the baby's discharge home after a hospital birth to make detailed plans at both stages and ensure the appropriate support is in place.

6.5 Pre-birth Review Child Protection Conference.

The first Review Conference should take place within 1 month of the child's birth or within 3 months of the date of the Pre-birth Conference whichever is sooner.

7. Public Law Outline

In cases where it has been recommended by the Team Manager that the proposed plan following the outcome of the assessment is to initiate the Public Law Outline or Initiate Proceedings this will be recommended by the social worker and team manager within the Child Protection Initial Conference and report submitted that the plan is to attend Gateway Panel. Views from the agencies involved will also be considered. There should be as little delay as possible in attending Gateway Panel to seek senior management approval. The Gateway Panel will consider whether the Public Law Outline Framework subject to timescales should be initiated prior to Proceedings. Should the Public Law Outline be agreed there should be no delay in sending out letters before Proceedings and holding Pre Proceedings 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 and consider potential further assessments of family members who may be in a position to offer appropriate care for the child when born. There is also an opportunity to commission specialist assessments at this stage.

In cases where there is a recommendation to initiate Care Proceedings at birth, the full Pre-birth Assessment and full chronology must be available for the Gateway Panel and a referral for a Family Group Conference completed or considered and addressed in the Gateway Panel report if not appropriate see also Family Group Conferences Procedure.

In the case of late referrals meeting the threshold for convening an Initial Child Protection Conference and the concerns raised and initially assessed are of significant concern with the recommendation to initiate Care Proceedings and removal at birth then it may not be possible to convene a Initial Child Protection Conference in the first instance if the unborn child's birth is imminent. An urgent request to attend the Gateway Panel should take place to seek approval.

8. Birth Planning Meeting

If the decision of the Gateway Panel is that the unborn baby should be the subject of Care Proceedings, a Birth Planning Meeting must take place at the hospital. This is a professionals meeting which should be chaired by Children's Social Care.

The purpose of the meeting is 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 agenda for this meeting should address the following:

• How long the baby will stay in hospital (a minimum of 7 days is usually recommended to monitor for withdrawal symptoms for babies born to substance using mothers);
• How long the hospital will keep the mother on the ward and the level of supervision required;
• The arrangements for the immediate protection of the baby if it is considered that there are serious risks posed to the e.g. parental substance misuse; mental health issues, significant physical or sexual risk;
• Health; domestic violence. Consideration should be given to the use of hospital security; informing the Police etc;
• The risk of potential abduction of the baby from the hospital particularly where it is planned to remove the baby at birth;
• The plan for contact between mother, father, extended family and the baby whilst in hospital, including identifying any adults who should not have contact. Consideration to be given to the supervision of Contact - for example whether Contact supervisors need to be employed;
• Consideration of any risks to the baby in relation to breastfeeding e.g. HIV status of the mother; medication being taken by the mother;
• The plan for the baby upon discharge that will be under the auspices of Care Proceedings, e.g. discharge to parent/extended family members; mother and baby foster placement; foster care, supported accommodation;
• Where there are concerns about an unborn of a pregnant woman who intends to have a home birth, the Ambulance Service Lead should be invited to the Birth Planning Meeting;
• Contingency plans should also be in place in the event of a sudden change in circumstances;
• Hospital staff should be given clear instructions regarding any birth that is likely to occur over a weekend or Bank Holiday;
• The Emergency Duty Team should also be notified of the birth and plans for the baby.

This meeting will be recorded and a copy of the minutes shared with all relevant agencies. A copy of this meeting will be held on the child's electronic case file and the mother's patient's record.

9. Birth and Discharge of a Newborn Baby

The hospital midwives need to inform the allocated social worker or the Emergency Duty Team of the birth of the baby and there should be close communication between all agencies around the time of labour and birth.

In cases where legal action is proposed, the allocated Lead 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 must keep the hospital up-dated about the timing of any application to the Courts. The lead midwife/ward staff 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. The social worker and ward staff/midwife should ensure they keep in regular contact.

If the baby is the subject of a Child Protection Plan and proceedings are not to be initiated, the Core Group should meet within 10 days of the baby's birth. The social worker and ward staff/midwife should keep in regular contact. A visit may be required to the hospital by the social worker if there are significant concerns prior to the birth or any concerns raised by the ward staff/midwife.

10. Pregnancy of Young People in Care

When it is established that a young person in Care or a supported care leaver is pregnant, the referrer must ring the child's social worker/pathway worker (if known) to ensure they are aware of the pregnancy and a contact/referral should be made to the Children's Assessment Team (CAT). The Children's Assessment Team will be responsible for decisions made regarding the unborn child and should a Child and Family Single Assessment proceed this will be jointly undertaken with the mother's allocated worker.

11. Allocation and Case Transfer

The Deputy Team Manager will be responsible for the initial screening of all pre-birth cases referred to the Children's Assessment Team (CAT). A decision of further action will be made within 24 hours of receipt of the referral. The referrer will be informed of the decision whether the case is to be allocated for a pre-birth assessment or that the case does not meet the criteria to undertake a pre-birth assessment and there is no further role for Social Care.  

12. General Guidelines for Conducting Pre-birth Assessments

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

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

It is important that workers undertaking the assessment have a clear understanding of the background history. One of the early tasks should be to complete a chronology detailing the history.  Information can be gathered from a variety of sources including; children's and adult social care files and electronic records, including those of other local authorities, interagency discussions e.g. Police, Health, Education.  In addition it may be useful to meet with previous social workers.

Where English is not the first language or there are literacy issues, this should be taken into account at the planning stage. Workers should ensure that written information is provided in a format that can be understood e.g. obtaining a foreign language translation, using an advocate or an interpreter. Time needs to be set aside to make sure that written information is understood.

An interpreter may be required for the assessment sessions themselves.

Workers need to be aware of any risks to their own safety during the assessment and these may need to be addressed in supervision.

Where the decision has been made to undertake a comprehensive pre-birth assessment it is good practice to draw up a working agreement between Children's Social Care and the parents. The agreement should outline the reason for the assessment, its purpose and aims, and how the assessment will be carried out:

• Dates, times, venues of sessions and who will attend each session;
• Areas to be covered in the assessment;
• How the assessment will be shared and who with;
• Expectations of those participating in the assessment.

Parents should be seen individually and as a couple, and extended family members may need to be contacted. Assessment sessions will normally take place at the family home and local area office. One of the sessions in the family home should assess the home environment and preparations made for the baby's arrival. The main focus of the meeting to share the working agreement is to clarify expectations, identify tasks and clarify boundaries. Any anxieties there might be around the assessment can be dealt with and openness encouraged. It should be clearly stated that part of the process will be to liaise with other agencies. Time needs to be set aside at the end of the assessment for writing the report and allowing for any subsequent timescales of meetings, e.g. Initial Child Protection Conference.

It is important to undertake the assessment during early pregnancy 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 there is an opportunity to make clear and structured plans for the baby's future together with support for the parents.

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 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.

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 families is also crucial to the assessment process and achieving positive outcomes for unborn children. Consideration should always be given to convening Family Group Conferences in any cases where there is a possibility that the mother may be unable to meet the needs of the unborn child.

Family Group Conferences 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.