Concealment and Denial of Pregnancy and Birth

1. Purpose

The purpose of this guidance is twofold in that it is primarily aimed at raising awareness amongst practitioners in all organisations and encouraging vigilance and professional curiosity when it comes to concealed and denied pregnancy. Secondarily it is in response to learning from a Serious Case Review, namely Baby W, which highlighted the importance of considering concealed and denied pregnancy and the risks associated to child safeguarding.

2. Introduction

This guidance is for anyone who may encounter a woman, child or young person who conceals or denies the fact that they are pregnant, or where a professional has a suspicion that a pregnancy is being concealed or denied. This guidance should be read in conjunction with Part 4, Managing Individual Cases where there are Concerns about a Child's Safety and Welfare – Procedures - Lincolnshire's LSCP multi-agency procedures for safeguarding children. 

For agencies that do not have any policies or procedures that relate to the concealment or denial of pregnancy then this guidance should be treated as a protocol and embedded within agency safeguarding policies and procedures.  However, for those agencies that already have an existing policy and procedure in place this guidance should be used to complement what already exists.

The concealment and denial of pregnancy will present a significant challenge to professionals in safeguarding the welfare and well-being of the foetus (unborn child) and the mother. While concealment and denial, by their very nature, limit the scope of professional help, better outcomes can be achieved by co-ordinating an effective inter-agency approach. This approach begins when a concealment or denial of pregnancy is suspected or in some cases when the fact of the pregnancy (or birth) has been established. This will also apply to future pregnancies where it is known or suspected that a previous pregnancy was concealed or denied.

It is important to acknowledge that concealment and denial of pregnancy and birth is an under researched area and therefore poses a challenge when it comes to developing an all-encompassing multi-agency protocol. 

3. Definition

For the purpose of this guidance, the definition of concealed and denied pregnancy is as below:

• Concealment — a full knowledge of the pregnancy, but active measures taken to keep that knowledge from others;
• Conscious denial — the woman is aware of the pregnancy at some level, but does not act (in a way society would expect) on that awareness;
• Undetected — the pregnancy, when discovered, is a complete surprise to the woman (and those providing her care). Ali. E.A. & Paddick. S.M. (2009). An exploration of the undetected or concealed pregnancy. British Journal of Midwifery, 17 (10), pp.647-651.

For the purpose of this guidance any reference to a woman includes a female of child bearing capacity (including under 18's). A pregnancy will not be considered to be concealed or denied for the purpose of this guidance until it is confirmed to be at least 24 weeks; this is the point of viability. However, by the very nature of concealment or denial, it is not possible for anyone suspecting a woman is concealing or denying a pregnancy to be certain of the stage the pregnancy is at.

Whilst research is limited it should be acknowledged that concealment or denial of pregnancy is a significant risk factor in respect of child safeguarding and its relevance should be considered when assessing and working with individuals. (See Appendix 1: Evidence from research and Serious Case Reviews for detailed research undertaken as part of the development of this guidance – including evidence from academic articles and serious case reviews.)

4. Picture in Lincolnshire

According to midwifery records, within United Lincolnshire Hospital Trust between the dates of 1st January 2019 and 30th September 2021, the following concealed and denied pregnancies were recorded.

A total of 205 concealed and denied pregnancies were documented within Lincoln and Boston Hospital Birth Registers, of those:

• 114 were booked between 24 and 29+6 weeks gestation (70.2%);
• 48 were booked between 30 and 34+6 weeks gestation (23.4%);
• 36 were booked between 35 and 39+6 weeks gestation (17.5%);
• 7 were not booked at time of delivery, all were aware of pregnancy (3.4%). 

Of the above:

• 98 were Non-British (47.8%);
• 27 were under 20 years of age (13.1%);
• 61 were First baby (29.7%);
• 3 were known substance misuse (1.4%)
• 49 were recorded as having Social Concerns (23.9%);

It should be noted that Midwives document the date of booking and date of delivery in the birth register, therefore it is not clear whether the non-British women accessed care in another Country prior to seeking maternity care in England or whether the date of booking documented was when they accessed care in this England.

5. Legal Considerations about Concealment and Denial of Pregnancy

United Kingdom law does not legislate for the rights of unborn children and therefore a foetus is not a legal entity and has no separate rights from its mother. This should not prevent plans for the protection of the child being made and put into place to safeguard the baby from harm both during pregnancy and after the birth.

In the case of F (in utero) 1988 the Court of Appeal was asked to make a foetus a ward of court by a Local Authority concerned for the welfare of the child. The pregnant woman's previous child was in foster care and she was described as having a mental disturbance, nomadic lifestyle and occasional drug use. The Court was entirely opposed to the proposed action, with one judge stating that the purpose was to control the woman's actions to protect the unborn child to the extent that she would be ordered to stop smoking, imbibing alcohol and refraining from all hazardous activity (Royal College of Obstetrics and Gynaecology, 2006)

In certain instances legal action may be available to protect the health of a pregnant woman, and therefore the unborn child, where there is a concern about the ability to make an informed decision about proposed medical treatment, including obstetric treatment. The Mental Capacity Act 2005 states that person must be assumed to have capacity unless it is proven that she does not. A person is not to be treated as unable to make a decision because they make an unwise decision. It may be that a pregnant woman denying her pregnancy is suffering from a mental illness and this is considered an impairment of mind or brain, as stated in the act, but in most cases of concealed and denied pregnancy this is unlikely to be the case.

There are no legal means for a Local Authority to assume Parental Responsibility over unborn baby. Where the mother is a child and subject to a legal order, this does not confer any rights over her unborn child or give the local authority any power to override the wishes of a pregnant young woman In relation to medical help.

6. Implication of a Concealed or Denied Pregnancy

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

Lack of antenatal care can mean that potential risks to mother and child may not be detected. The health and development of the baby during pregnancy and labour may not have been monitored or foetal abnormalities detected. It may also lead to inappropriate medical advice being given; such as potentially harmful medications prescribed by a medical practitioner unaware of the pregnancy e.g. some epilepsy medication.

Underlying medical conditions and obstetric problems will not be revealed if antenatal care is not sought. An unassisted delivery can be very dangerous for both mother and baby, due to complications that can occur during labour and the delivery. A midwife should be present at birth, whether in hospital or if giving birth at home.

An implication of concealed or denied pregnancy could be a lack of willingness or ability to consider the baby's health needs, or lack of emotional bond with the child following birth. It may indicate that the mother has immature coping styles or is simply unprepared for the challenges of looking after a new baby. In a case of a denied pregnancy the effects of going into labour and giving birth can be traumatic.

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 may be implications for the mother revealing a pregnancy due to fear of the reaction of family members or members of the community; or because revealing the identity of the child's father may have consequences for the parents and the child.

7. Good Practice When Working with Concealed or Denied Pregnancy

For all agencies:

The learning themes from the research undertaken indicate that the following is a model of good practice when working with concealed or denied pregnancy:

• Demonstrate professional curiosity when undertaking home visits including those adults where there is requirement for any new or emerging intimate relationships to be disclosed to professionals;
• Positively engage sexually active teenagers;
• Be open and confident to explore carefully with the mother the reasons for concealment;
• Attend closely to ongoing child development milestones;
• Purposefully follow up missed appointments;
• Follow procedures in relation children missing from education (unauthorised and authorised absences);
• Thoroughly investigate other concerns –such as bruising on the child or Neglect;
• Consider parental child attachments and emotional bonding;
• Have underpinning knowledge and confidence to address social, cultural and religious issues of relevance to concealment and to ongoing child safeguarding concerns;
• Be especially alert where there has been a previous concealed or denied pregnancy.

If concealment or denial is linked to sexual trauma then there is support available through a new project called Mybodyback delivered at the Royal London Hospital in partnership with Barts Health NHS Trust. Women can self-refer and in the first instance need to email maternity@mybodybackproject.com to make an appointment.

Antenatal Services:

• Midwives and GP's should care for expectant mother with an uncomplicated pregnancy, providing continuous care throughout. Obstetricians and specialist teams should be brought in where necessary;
• In the first contact with a health professional an expectant mother should be given information on folic acid supplements; food hygiene and avoiding food-acquired infections; lifestyle choices such as smoking cessation or drug use; and the risks and benefits of antenatal screening;
• The booking appointment with a midwife ideally should be around 10 weeks. This appointment should help the expectant mother plan the pregnancy, offer some initial tests and take measurements to help determine any specific risks for the pregnancy. The expectant mother should be given advice on nutritional supplements and benefits;
• Needs, learning difficulties or where English is not their first language. Ensure the information is clear, consistent and backed up by current evidence;
• Remember to give an expectant mother enough time to make decisions and respect her decisions even if they are contrary to your own views;
• Expectant mother should feel able to disclose problems or discuss sensitive issues with you. Be alert to the symptoms and signs of Domestic Abuse.

(The above has been adapted from Antenatal care: Routine care for the healthy pregnant expectant mother, NICE, 2008).

8. Pathways for Support

Please see Appendix 2: Factors Associated With the Occurrence of a Concealed/Denied Pregnancy for factors associated with the concealment or denial of pregnancy, which is a quick reference for practitioners and includes things to consider such as previous life events, day to day presentation, reasons for concealment and circumstances requiring heightened professional curiosity.

This section outlines actions to be taken when a concealed or denied pregnancy is suspected.

UK law does not legislate for the rights of the unborn baby. In some circumstances, agencies or individuals are able to anticipate the likelihood of Significant Harm with regard to an expected baby. Such circumstances should be addressed as early as possible to maximise time for full assessment, enable a healthy pregnancy and support parents so that (where possible), they can provide safe care.

Professionals must balance the need to observe the expectant mother's right to confidentiality with the potential concern for the unborn child and the mother's health and well- being. Where any professional believes the expectant mother to be concealing or denying a pregnancy then they should firstly sensitively enquire of the expectant mother if she might be pregnant. If a pregnancy is confirmed by the expectant mother then she should be strongly encouraged to go to her GP or midwifery services to access ante-natal care. The professional should also talk to the woman about her circumstances and try to find out what support the woman needs in order to feel more comfortable about her pregnancy.

An Early Help Assessment will be undertaken with the woman and a TAC initiated with the appropriate practitioners invited if required, including an education setting if the woman is under the age of 18 and therefore a child or young person themselves.

In all circumstances where a concealed or denied pregnancy is suspected or subsequently disclosed then please refer to the pre-birth protocol for pathways to follow.

The role of the General Practitioners (GPs):

Women concealing or denying a pregnancy are unlikely to see a GP for a pregnancy test but may present for other reasons. With any female presenting with symptoms such as nausea or weight gain, consider the possibility of pregnancy.

Where a GP has reason to believe that a woman is pregnant but she refuses all attempts to persuade her to undertake investigations or referral, further action needs to be taken. This may involve discussion with a health visitor, Child & Young Person Nurse, Named Midwife or Named Doctor/Nurse for Safeguarding Children. Information may need to be shared without consent of the patient.

A GP may need to refer the patient for a psychiatric assessment or may be asked to make such a referral by a colleague. GPs should also be prepared to work with other agencies including, but not limited to, Children's Social Care, maternity services, mental health services and drug and alcohol services.

In cases of full concealment or denial, if the woman delivers 'out of hours' or the baby is seen at out of hours, urgent referral to and discussion with Children's Services is needed. (See Lincolnshire Children's Services Procedures Manual, Emergency Duty Team Procedure). 

As a previous concealed or denied pregnancy indicates a risk of a further concealment or denial, ensure that it is read coded within the GP summary record, both for the mother and child.

Following a concealed or denied pregnancy, GPs should be aware that there may need to be an increased level of engagement with the mother and her family and of the potential for post-natal mental health issues.

The role of the Health Visitor:

The Health visitor will visit during the antenatal period if pregnancy is known to the service, and will complete a holistic assessment of the family need. Concealed and denied pregnancy is recognised as a risk factor to the child. LCHS will flag the records of children where pregnancy was concealed or denied and this flag will stay on the mother and child's record until they are 2 years of age to ensure it forms part of the ongoing assessment of the child. Please also see the guidance below from when patients do not attend a Health Visitor or Child & Young Person Nurse appointment.

See Standard Operational Procedure for Universal Service (Health Visiting and School Nursing) for Core Offer Appointments where the client does not attend.

The role of Midwifery:

The ULHT Safeguarding Midwife will ensure a flag is placed on a woman's records should information be provided from other agencies that she may be concealing/denying a pregnancy. Should this information be confirmed, the Community Midwife may attempt to make contact with the woman, this is dependent on many factors including risk to safety of Midwife, risk to the woman should she be concealing the pregnancy from the her Partner /family.

If a child or young adult under the age of 18 years is suspected to be suffering, or is likely to suffer Significant Harm (including any mistreatment or abuse) a referral to the Children's Services, Children's Social Care (CSC) will be undertaken. If it is outside normal office hours the Emergency Duty Team will be contacted. A Safeguarding Referral Form will be completed and submitted.

Following delivery the Community Midwife will offer routine postnatal appointments but may offer extra visits if deemed necessary or if requested by the woman. If there are concerns regarding a woman's mental health she would be offered a referral to the Perinatal Mental Health Team or may be assessed by the Mental Health Liaison Team.

It is expected that on discharge from hospital the GP will be notified via the Electronic Discharge Document process that is completed by the hospital Midwives, the Health Visitor will be informed via the Community Midwife. Should the Community Midwife be denied access to the woman's property in the postnatal period, the Maternity Non Attendance for Antenatal Care, Induction of Labour or Elective LSCS and No Access for Community Midwifery Staff policy will be followed and a further referral will be made to Children’s Services if there is not already an allocated Social Worker.

Midwives recognise the potential safeguarding implications of concealment or denial of pregnancy and ensure that appropriate referrals are made and other relevant agencies informed.

The Role of Educational Settings:

It is possible for a student at a school/educational setting to be concealing a pregnancy or denying that they are pregnant. Schools should apply professional curiosity and enquire of any behaviour that could be indicative of this. Behaviour could include being late for school, unwillingness to explain illness, isolation or lack of participation in physical activity. Any absences, authorised or unauthorised must be followed up by the school. All school staff should have an understanding of the nature of concealed and denied pregnancy so that they may take up opportunities to question behaviour patterns when they arise. If the school suspect that a student is concealing or denying a pregnancy, they can discuss this with an Early Help consultant who will advise them what to do next. Once the pregnancy is revealed, the school should complete a risk assessment to determine if there are additional risks to the unborn child due to the current lifestyle of the student. The risk assessment should also consider how or if the parents/carers of the student will be informed of the pregnancy at this point. If the school is the only agency with knowledge of the pregnancy, a referral to children's services may be appropriate.

As a preventative measure, education settings should include information on concealed and denied pregnancy within their healthy relationships programme outlining the support offered within the school for teenage pregnancies.

9. When a Concealed or Denied Pregnancy is Revealed

This section outlines actions to be taken when a concealed or denied pregnancy is revealed. Midwifery services will be the primary agency involved with a woman after the concealment or denial is revealed, late in pregnancy or at the time of birth. However it could be one of many agencies or individuals that a woman discloses to or in whose presence the labour commences. It is vital that all information about the concealment or denial is recorded and shared with relevant agencies to ensure the significance is not lost and risks can be fully assessed and managed.

When a pregnancy is revealed the key question is 'why has this pregnancy been denied or concealed'? The circumstances in each case need to be explored fully with the woman and appropriate support and guidance given to her. 

Where possible a full pre-birth assessment should be undertaken, please refer to the pre-birth protocol.

10. Quality Assurance

As part of the quality assurance and audit principles within Lincolnshire, the LSCP is committed to continuous development of policies and procedures. Consequently it is important that new guidance or protocols are assessed to ensure they are being used effectively, that professionals are familiar with the guidance and that amendments are made to improve new protocols and guidance through the feedback from professionals in practice.

With this in mind agencies will be asked to devise a policy impact assessment to complete within 6 months to a year of the publication of the guidance.

Appendices

Appendix 1: Evidence from Research and Serious Case Reviews

Appendix 2:  Factors Associated With the Occurrence of a Concealed/Denied Pregnancy