Pre-Birth Protocol

1. Introduction

The purpose of this protocol is to provide practitioners with a tool and a clear pathway to assist with the decision making process when undertaking pre-birth assessment. If there is reasonable cause to suspect a child is at risk of harm before birth or following birth it is appropriate to take action to identify and address the risks. When additional needs are identified before or following birth then appropriate action should also be taken to support these needs.

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. Evidence demonstrates that early intervention and effective prevention in childhood can lay the foundation for a healthy life (DH, 2009).

The Antenatal 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:

• Positively support families;
• Effectively identify and protect vulnerable children;
• Plan and implement effective care programmes;
• Recognise the long term benefits of early intervention; and
• Ensuring focus is on the welfare of the child;
• Ensure registration/contact with Children's Centre.

Hart (2010) indicates that there are two fundamental questions when deciding whether a pre-birth assessment is required:

1. Will this new-born baby be safe in the care of these parents/carers?
2. Is there a realistic prospect of these parents/carers being able to provide adequate care throughout childhood?

In addition practitioners must consider if there are additional needs that will require early support to prevent escalation and to provide the family support.

Where there is reason for doubt, a pre-birth multi-agency assessment is initiated, either through the early help protocol or by social care. This assessment should be carried out when there are additional needs or risk has been identified. Both these factors do not need to be present for an assessment to be completed and early support provided.

This protocol supports practice as described in:

• Better Births National Maternity Review (2016);
• NHS Long Term Plan (2019);
• Pregnancy and complex social factors (NICE 2010);
• Healthy Child Programme (DHSC 2009a);
• Hidden Harm (Home Office, 2003);
• Working Together to Safeguard Children.

This protocol is used by all practitioners and agencies when assessing all pregnant women and determining the level of risk.

The duty to safeguard the unborn child remains a priority despite UK law not legislating for the rights of the foetus (unborn baby).

Concerns should be addressed as early as possible to maximise time for full assessment, including establishing the whereabouts of any previous children, enabling a healthy pregnancy and supporting the parents towards providing safe care.

If any child (under-18) or vulnerable adult in your care has symptoms or signs of Female Genital Mutilation (FGM), or if you have good reason to suspect they are at risk of FGM having considered their family history or other relevant factors, they must be referred using standard existing safeguarding procedures. (See Female Genital Mutilation Procedure, Appendix 1: Advice for Regulated Professionals in Lincolnshire – FGM Mandatory Reporting).

For further information regarding FGM and your professional responsibilities, please refer to Safeguarding women and girls at risk of FGM.

2. The Roles and Responsibilities of Professionals in Respect of Unborn Children

All agencies, have a responsibility to protect and safeguard children and work collaboratively with Children's Services and other childcare professionals in contributing to assessments and interventions. Therefore, the professional who is first made aware of the pregnancy should initiate the pre-birth protocol and complete a Early Help Assessment, or make a referral for the unborn child to Children's Services.

All agencies are likely to come into contact with pregnant women through their duties. All staff will be alert to the additional needs of the mother where she declares a pregnancy and, by extension, to the needs of the unborn child, in relation to their core roles. Where staff have safeguarding concerns, they will follow their organisation's existing policy for reporting these in order that appropriate action is taken. This will almost always involve liaison with other agencies to ensure a holistic approach to the needs of mum, baby and the wider family. All agencies should liaise with the Midwifery Service

Please refer to Early Identification and Early Help Assessments for further role within Early Help.

3. Care Pathways

Pregnancy in a Young Person under the Age of 18

The young age of a parent should not automatically be seen as an indicator of risk. However, there are occasions when the young person may themselves have needs which require an assessment, either through a Early Help Assessment or by a social care assessment under Child in Need or Child Protection procedures (see Section 47 Enquiries and Social Work Assessments Procedure).

Practitioners working with a young person under 18 years must give consideration to a consultation with/ referral to Children's Services. See also Working Together/LSCP Procedures. Sexual activity under the age of legal consent should always trigger consideration as to whether a child is suffering, or is likely to suffer, Significant Harm. On identification the case must always be discussed with a manager/nominated child protection lead within the practitioner's organisation. Under the Sexual Offences Act 2003, penetrative sex with a child under the 13 is classified as rape.

Please also see: Child Exploitation Policy.

Information Sharing and Consent

All partners must ensure that they are aware of the guidance and legislation in place regarding information sharing when there are concerns about an unborn child. For further information, please see Protocol on Sharing Information in Order to Safeguard and Promote the Welfare of Children.

Discussion of Concerns about an Unborn Baby's Safety and Welfare

Professionals, who are uncertain as to whether their concerns meet the significant harm threshold, or have serious worries about an unborn child, should in the first instance discuss this with their Safeguarding Lead within their own Organisation. Safeguarding Leads should consider if a discussion with the Midwifery Safeguarding Lead is required. This discussion must result in a written record of the decisions taken, and the reason for those decisions, in line with their agencies internal process and procedures. See also: A Model for Assessment Procedure.

Practitioners should also consider a consultation with a social worker by calling the Customer Service Centre.

Records of previous children who are no longer in the care of their parents should, where possible, be reviewed and assessed to consider previous parenting history and any contributing risk factors.

Risk factors may also include, for example, drug and alcohol misuse, mental ill health, learning difficulties, social isolation, domestic abuse within the relationship, and where it is evident that mother is unwilling or unable to plan for the new baby. An assessment of factors can lead to a view that support, advice, counselling, Family Network Meeting or a Family Group Conference may assist. An Early Help Child and Family assessment should be completed and if required a TAC meeting should be initiated in order to address the identified needs. See also: Team Around the Child (Lincolnshire County Council Website).

Early Identification and Early Help Assessments

It is important that all practitioners working with pregnant women/women of child bearing age are aware of assessment needs and of routes of referral in order to facilitate engagement, care and intervention in accordance with their own Organisational Safeguarding Policies and Procedures and those of the LSCP.

Where it is considered that a child and/or family have additional needs (outside those provided universally) a Early Help Assessment should be completed (see Team Around the Child Supporting Documentation).

The assessment may conclude that there is a level of concern/need and the family will benefit from additional intervention from other services. If this is the case the professional working with the parent(s) should initiate a Team Around the Child (TAC) (see Team Around the Child Supporting Documentation) to promote a multi-agency response. As per the process, parent(s)/carer(s) should be fully involved. It is important that early services are offered and delivered to assist the parents during pregnancy and in making arrangements to enable them to be prepared for the birth and for parenting. Service provision should be co-ordinated through Team Around the Child processes.

The TAC process should run through the pregnancy.

If it is agreed that the unborn child may be a Child in Need or child at risk under the Children Act, then a referral should be made to Children's Social Care at 14 weeks or at any point afterwards that concerns arise. Prior to this service provision should be co-ordinated through the TAC. Families should be informed of concerns and referrals, unless it is felt that to do so would put a child, unborn child, or other person at risk of harm. All information should be shared in accordance with best practice guidance and the LSCP Information Sharing Protocol Team Around the Child (TAC) and LSCP Procedures. See Protocol on Sharing Information in Order to Safeguard and Promote the Welfare of Children.

Pre-birth cases will be managed in a number of different ways depending on the family circumstances and the nature of the assessment carried out by practitioners in contact with the family. See Appendix 1: Pre-Birth Protocol Flowchart for an overview of the different pathways.

Referral to Children's Social Care (CSC)

It is essential that professionals gather as much information as is available from within their agency when making a referral. A safeguarding referral form is required. The professional should contact the Customer Service Centre 01522 782111 who will clarify the details of the referral.

Where concerns about impairment to the child's health and development or the child suffering harm are substantiated through a Social Care assessment, the social worker will establish the best route to offering support and protection to the child and family. A locality Children's Social Work Team will  manage any  case where the unborn child is identified as a Child in Need or a Child in need of Protection (Children Act 1989). In these cases the social worker will be the keyworker.

If Social Care is made aware of an unborn baby before 14 weeks gestation, where the history of the parent/s is considered a risk factor, then the Social Care team is responsible for notifying the Midwifery Safeguarding Lead. This will ensure that the Midwifery Safeguarding Lead is aware of high risk pregnancies and can liaise with the Midwifery Service and Social Care team as required.

Children's Social Care will follow one of the three pathways listedbelow when planning intervention in relation to an unborn child.

The support plan for the unborn child and parents may step up or down between these pathways, as informed by the continuous process of assessment and review within the social work intervention. When a social worker is allocated to an unborn child, Children's Social Care will always retain case management responsibility.Which case pathway is followed will remain a decision for Social Care to make; however, Children's Social Care will rely on the support and cooperation of all partner agencies to make both their professional opinion and recorded evidence available to inform the social work  assessment, including any relevant past history in relation  to the parents or other close family members.

Action under Section 17 (Children Act 1989)

The Child in Need (CIN) process will be followed see Lincolnshire Children's Services Procedures Manual, Child and Family Progress Plans and Meetings Procedure. A case can be stepped down to TAC at any stage where it is assessed as being relevant and suitable to meet the unborn child and the parents' needs. A case can be escalated to a strategy discussion or social care can seek legal advice  at any stage where it is assessed that the potential risks to the unborn baby (or baby once born) are such that the threshold is met. These decisions will be made by Social Care and the provision of information and advice from professional partners is essential in assisting Social Care to make the correct plans for the Unborn child/child once born.

Action under Section 47 (Children Act 1989)

If the assessment of the available information, including that from partner agencies and consideration of both parents' history, indicates a potential risk  of significant harm to the unborn baby or baby once born, then the child protection policy (see Initial Child Protection Conferences Procedure) will be followed.

Because of the extreme vulnerability of unborn/newly born children, where a strategy discussion is deemed necessary these will be held as formally chaired meetings with all relevant partner agencies invited to participate. At a bare minimum every strategy meeting must be chaired by a senior social work professional (G11 or above) and involve the Police, Children's Health and the Midwifery Safeguarding Lead. In cases which seem likely to follow the child protection pathway the strategy meeting must take place at 28 weeks gestation and where the significant harm threshold is deemed met and ICPC should be convened but no earlier than at 30 weeks gestation. In the event of late presentations or concealed pregnancies the strategy meeting must be convened as a matter of urgency.

Consideration of Legal Proceedings under the Public Law Outline (PLO)

If the assessment of the available information, including that from partner agencies and consideration of both parents' history, is such that legal proceedings may be required once the child is born, then Social Care will follow their internal process for seeking legal advice. Social care alone are responsible for the decision to initiate a pre-proceedings pathway under the Public Law Outline. It is however important to underline that social care rely on professional partners making relevant information pertaining to risks to children and strengths within the family support network, available to assist their decision making.

The decision to step a case up into a pre-proceedings pathway can be made at any point where the assessment of risk indicates legal intervention is proportionate. However, it is recommended that if following the referral at 14 weeks there is indication that legal intervention is likely to be necessary once a child is born, then the local authority should seek to secure legal advice by 21 weeks gestation. Where social care make the decision  that the case should by managed under a pre-proceedings pathway  they must also convene a multi-agency strategy meeting to which all involved agencies must be invited. This strategy meeting must be chaired by a senior social worker (G11 or above) and as a bare minimum must include the police, children's health and the safeguarding midwifery lead. The purpose of the strategy meeting is to provide  a multi-agency forum that  facilitates the involvement of all partner agencies in the sharing of information for the purposes of safeguarding the unborn child. The strategy meeting will enable all agencies to identify their roles in the delivery of support and assessment services prior to the baby's birth. Where the pre-proceedings pathway is initiated, the expectation is that agencies will use the strategy meeting to share information with social care to test the significant harm threshold and provide support to the social work assessment process. Within this protocol, the multi-agency agreement is that cases within pre-proceedings will be managed as a CIN s17 case. This is because the pre-proceedings pathway is set in law as the 'last chance' intervention with a family before social care seek a court order to protect a  child. Under the public law outline a very clear letter of expectations is provided to parents and these expectations are managed and reviewed by a series of legal meetings where parents and the local authority are legally represented, thus the LSCP have taken the decision that within the pre-birth protocol cases in this pathway do not require an ICPC to be convened.

The LPM does not have to wait until the strategy meeting is held and this should also not delay the commencement of Pre-Proceedings Meetings (PPM). A PPM is a meeting between Social Care and their legal representatives and the family and their legal representatives.

Concurrently with the PLO process Social Care will manage the case at Child in Need s17. This will ensure that regular multi-agency meetings take place.

Post Birth

If the case has been managed under PLO then Social Care are responsible for making any applications to the Court in a timely manner.

A Discharge Planning Meeting (DPM) (see Discharge Planning from Physical Healthcare Hospitals when there are Safeguarding Concerns about a Child) must be held if the case is being managed within Child Protection or PLO. Consideration for a DPM must be given if the case is managed in CIN or TAC.

It should be noted that at any point in the different pathways then a case may escalate or step down, this includes from the PPM pathway. This change of pathway can happen at any point and the decision to do so is made by the social care team who have case management oversight.

4. Conclusion

Safeguarding children and protecting them from harm is everyone's responsibility (Working Together to Safeguard Children).
This protocol describes best practice for Professionals when working with expectant parents about whom there are concerns regarding their unborn child. All women who are pregnant should be assessed in accordance with this protocol and where there is an identified risk of harm to the unborn baby, agencies must work collaboratively alongside other agencies in the antenatal as well as postnatal periods.

Where members of staff from any agency feel concerns regarding a child are not being addressed it is expected that the Professional Resolution and Escalation Policy and Processes should be used until a satisfactory conclusion is achieved.

See Professional Resolution and Escalation Protocol.

This protocol is used by all practitioners and agencies when assessing pregnant women and determining the level of risk.

5. References

• HM Government (2018) Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children, HM Government, July 2018;
• Department of Health and Social Care (2009a) Healthy Child Programme; Pregnancy and the first five years of life; London, DH;
• Department of Health and Social Care (2009b) Getting it right for children and families: Maximising the contribution of the health visiting team 'Ambition, Action, Achievement'; CPHVA, Unite; NHS, November 2009;
• Hart, D (2010), Assessment Before Birth' in Howarth, Jan (Ed) (2010) 'The Child's World Second Edition: The Comprehensive Guide to Assessing Children In Need', Jessica Kingsley Publishers, London, (Chapter 14);
• Hidden Harm: Responding to the needs of children of problem drug users. ACMD (2003);
• Howard, L et al (2011) Antenatal domestic abuse, maternal mental health and subsequent child behaviour: a cohort study BJOG: An international journal of obstetrics and gynaecology;
• National Institute for Health and Care Excellence (2014) Antenatal and Postnatal Mental Health: Clinical Management and Service Guidance;
• National Institute for Health and Care Excellence (2014) Clinical guideline [CG37] Postnatal care up to 8 weeks after birth;
• National Institute for Health and Care Excellence (2016) Maternity Matters and Better Births Public Health England;
• National Institute for Health and Clinical Excellence (2010) Pregnancy and complex social factors: A model for service provision for pregnant women with complex social factors, NICE clinical guideline 110, September 2010;
• Department of Health and Social Care (2015) Female Genital Mutilation Risk and Safeguarding Guidance for professionals;
• NHS Long Term Plan 2019.

Appendix 1: Pre-Birth Flowchart

Click here to view Appendix 1: Pre-Birth Protocol Flowchart.