Level 4 Pre-Birth Assessment and Planning Procedure

1. Introduction

We know that infants are particularly vulnerable to significant harm and are over-represented in cases subject to serious case reviews (Sidebotham et al., 2016). There is also research demonstrating the longer-term harm to infants who are not given adequate protection within a timeframe that is consistent with their developmental needs (Ward et al., 2012). We also know that the perinatal period is a crucial time for human development and provides a good opportunity to harness the desire of parents to be good parents to their expected child (House of Commons, 2019). This procedure sets out how Children’s Social Care should respond to concerns for unborn babies, with an emphasis on thorough assessment, alongside clear and regular communication between professionals working with the expectant mother, the father/partner, and the family.

Decision on the timing for the assessment to start:

Where it is necessary to refer the unborn baby to Children’s Services, the referral should be made between week 12-16 of pregnancy. If the case has been open to level 3 services, it is expected that an Early Help Assessment will have been completed and accompany the referral.

The earlier in the pregnancy the assessment starts, the more likely there is to be a supportive rather than a protective outcome, and the concerns that relate specifically to the pregnancy – such as substance use or domestic abuse, consequences of continued use of prescribed medications to manage mental health etc., can be addressed.

The importance of Early Intervention research highlights that:

• Early environment and the first three years of life play a significant role in shaping cognitive, social, and emotional development, and that the most important aspect of this environment is the child’s relationship with their caregivers;
• Pregnancy and the early years should be central to safeguarding practice both as the foundation for children’s development and as the optimal window for prevention and early intervention;
• Parents’ own early experiences can shape their parenting and that early relationship patterns are developed in interaction with primary carers, internalised and re- enacted within later relationships including those with partners, children, and professionals;
• Most of the brain cells responsible for regulating behaviour, thinking and emotions are unconnected at birth. Their connecting pathways are formed within the first two years of life;
• The processes of brain maturation are ‘use dependent’ and there are windows of opportunity for developing critical processes such as attachment, self-regulation, and language. If these windows are missed, then catching up is a much harder process;
• Exposure to chronic stress in early years also decreases the capacity of developing brains to regulate rage, anxiety, impulsivity, and aggression. Therefore, it is more effective to protect children from damage than to undo the neurological and psychological effects of early abuse and neglect. (Howe 2005).

Timely intervention during pregnancy provides a window of opportunity for practitioners and families to work together to:

• Establish a working relationship with parents before the baby is born; with a focus on the unborn baby;
• Ensure that vulnerable parents are offered support at that stage of their parenting rather than when difficulties have arisen;
• Identify risks and vulnerabilities at the earliest stage;
• Understand the impact of risk to the unborn baby when planning for their future;
• Explore and agree safety planning options;
• Assess the parent's ability to adequately parent and protect the unborn baby, and the baby once born;
• Identify if any family members are willing to be assessed as alternative carers should the baby not be able to be safely cared for by the parents;
• Ensure effective communication, liaison and joint working with adult services that are providing on-going care, treatment, and support to a parent(s);
• To plan for, and assist parents with, any of the problems that are impacting on their parenting;
• Avoid delay for the child where a legal process is likely to be needed such as Pre-proceedings, see Care or Supervision Proceedings in line with the Public Law Outline Procedure.

A co-ordinated response by agencies will be required to ensure that the appropriate support is in place during the pregnancy to best protect the baby before and following birth. Social Workers should ensure that if mother is not open to the Pre-birth and Infant Team (PBIT) or the Family Nurse Partnership (FNP) then the appropriate referral to PBIT is made via LL before 28 weeks gestation.

2. Risks

Risk factors which could indicate that an unborn child may be likely to suffer Significant Harm and therefore be subject to a pre-birth assessment may include:

• Involvement in risk activities such as substance misuse, including drugs and alcohol;
• Perinatal/mental illness or support needs that may present a risk to the unborn baby or indicate that their needs may not be met;
• Victims or perpetrators of Domestic Abuse;
• Identified as presenting a risk, or potential risk, to children, such as having committed a crime against children;
• A history of violent behaviours;
• May not be able to meet the unborn babies needs e.g., significant learning difficulties and in some circumstances severe physical or mental disability;
• Are known because of historical concerns such as previous neglect, other children subject to a child protection plan, subject to legal proceedings or have been removed from parental care;
• Currently 'Looked After' themselves or were looked after as a child or young person (care leavers);
• A history of abuse in childhood;
• Are teenage/young parents and are vulnerable;
• Recent family break up and social isolation/lack of social support;
• Any other circumstances or issues that give rise to concern.

The list is not exhaustive and, if there are several risk factors present, then the cumulative impact may well mean an increased risk of significant harm to the child.

3. Working with Fathers / Partners

Fathers/partners play an important role during pregnancy and after. Audit activity demonstrates that we do not do enough to engage with and involve fathers. The National Service Framework for Children, Young People and Maternity Services (2004) states:

'The involvement of prospective and new fathers in a child's life is extremely important for maximising the life-long wellbeing and outcomes of the child regardless of whether the father is resident or not. Pregnancy and birth are the first major opportunities to engage fathers in appropriate care and upbringing of children' (NSF, 2004).

It is important that all agencies involved in pre-birth and post-birth assessment and support, fully consider the significant role of fathers/partners and wider family members in the care of the baby, even if the parents are not living together and where possible, involve them in the assessment. This should include the father's attitude towards the pregnancy, the mother and new-born child, and his thoughts, feelings and expectations about becoming a parent.

Information should also be gathered about fathers and partners who are not the biological parent at the earliest opportunity to ensure that any risk factors can be identified. A careful assessment of the role that the person has in relation to the woman and any other children in the household as well as their views about the future care of the baby should be undertaken.

A failure to do so may mean that practitioners are not able to accurately assess what mothers and other family members might be saying about the father's/partner’s role, the contribution which they may make to the care of the baby and support of the mother, or the risks which they might present to them. Background police and other checks should be made at an early stage on relevant cases to ascertain any potential risk factors.

Involving fathers/partners in a positive way is important in ensuring a comprehensive assessment can be carried out and any possible risks fully considered.

See: Working effectively with men in families - including fathers in children's social care (Research in Practice)

4. Pre-Birth Assessment – Martin C Calder (2015; 2020)

The earlier in the pregnancy the assessment starts, the more likely there is to be a supportive rather than a protective outcome, and the concerns that relate specifically to the pregnancy – such as substance use or domestic abuse, consequences of continued use of prescribed medications to manage mental health etc. – can be addressed.

The pre-birth assessment is now on Liquidlogic and must be used in place of a single assessment in the following circumstances:

• Referral for a pre-birth assessment from the Pre-Birth Liaison Group, (see also Pre-Birth Liaison Terms of Reference in Section 8, Further Information and Appendix 2: Pre-Birth Liaison (WPBL) Meeting Flow Chart Process;
• Previous children no longer in the care of the expectant mother;
• Where an expectant parent has been denied contact with a previous child due to an identified safeguarding issue;
• Any other concerns that would be considered a safeguarding nature.

The assessment is used to address the following concerns:

• Is the parent’s current lifestyle putting the development of the unborn child at risk?
• Will the baby be safe in the care of these parents/carers once born?
• Is there a realistic prospect of these parents/carers being able to provide adequate care throughout childhood?

The purpose of pre-birth assessments is to allow social workers and the professional network to:

• Identify sources of harm to the unborn child and predict future harm;
• Enable work with parents that helps them reflect on the pregnancy and how the child’s birth will affect them;
• Identify support parents may need to help strengthen parenting capacity to meet the child’s needs once born;
• Plan for the child’s care and make decisions on interventions to keep the child safe in the present as well as long-term decisions on the child’s future care.

The pre-birth assessment should be completed by 22 weeks gestation in order for the Social Worker to understand what the issues are and to make a plan for support. If a Legal Gateway meeting is required, this assessment needs to be available. Parents must be supported to understand what needs to change prior to the birth of their baby and what support will be provided. The pre-birth assessment should be updated by 34 weeks gestation with the outcome of work undertaken in the preceding months. This is an update assessment, not a full reassessment. It should highlight what the outcome of the pre-birth was, what has been tried since and what the current situation is, including what is going well and the current risks. This assessment will contain final recommendations for the plan post birth and will be presented to the final Legal Gateway meeting.

The Pre-Birth and Infant Team worker can support the Social Worker with aspects of the pre-birth assessment and also provide a report for Court setting out their work.

If the parent is under 18 and has an allocated Social Worker, then the unborn baby must be allocated to a different Social Worker.

If parents are known to, or suspected to have, a learning disability the Social Worker should consider the need for a cognitive assessment which will indicate how best to work with the parent and including whether a more specialist assessment such as a Parent Assess, PAMs or psychological assessment is required. When working with parents with a known or suspected learning difficulty the Social Worker must ensure they consider the Good Practice Guidance on Working with Parents with a Learning Disability (2007) updated for 2021 by the Working Together Partnership Network.

See Appendix 1: Pre-Birth Assessment Process Map.

Resources available to support the pre-birth assessment

Please access the Local Resources section of the online procedures for resources to support assessment of all risk areas. See Pre-Birth Assessments – Supporting Tools and Resources.

Open access resource from Research in Practice: Supporting parents who have experienced recurrent care proceedings (researchinpractice.org.uk)

5. Planning

An initial multi-agency Pre-Birth Planning Meeting should take place by 18 – 20 weeks gestation to ensure all known issues, concerns and strengths for the parents and wider family can be shared. Progress on the pre-birth assessment should be discussed and any gaps in information and how to obtain this need to be identified. The meeting should also discuss any barriers to engagement for the parents, and solutions to overcome them need to be considered. The background and history of the parents should be fully considered in light of professional knowledge and understanding of the impact of trauma and the links with perceived “non engagement”.  Pre-birth tracking meetings are facilitated by the Practice Improvement Team and midwifery at approximately 25 and 35 weeks gestation to ensure assessments and planning are on track.

Where the outcome of the Pre-Birth Assessment indicates that a Child in Need plan is required, the Child in Need Procedure should be followed, however review meetings should be held at least 6-weekly rather than at least 8-weekly to ensure progress and changes are closely monitored.

A Pre-Birth Conference (see Wirral Safeguarding Children Partnership, Initial Child Protection Conferences Procedure) may be required if Children's Social Care assess that the child is likely to suffer significant harm.

The timing of child protection and public law outline processes must allow adequate space for parents to prepare emotionally and practically for a possible separation following the birth and to consider alternative carers for their baby within their family and friends networks.

A Pre-Birth Conference should share all the relevant information and develop a Child Protection Plan if required. The timing of the conference should take into account the expected date of delivery and ideally take place by 30 weeks gestation, or earlier if there is a history of premature birth. This will require:

• A Strategy Meeting to have taken place by week 27; and
• A Section 47 Enquiry to have been completed to include an update on progress since the pre-birth assessment at Conference.

The Pre-Birth Assessment can be used to inform the S47 Enquiry.

If a decision is made that the unborn child will be made the subject of a Child Protection Plan from birth, a Core Group should be established at the Initial Child Protection Conference. The Core Group should meet prior to the birth within 10 days from the Conference date. Where an unborn child is made subject to a Child Protection Plan at a Pre-Birth Conference, the first Review Conference must be scheduled to take place within 4 weeks of the child’s birth or 3 months after the Initial Child Protection Conference, whichever is sooner.

Pre-Proceedings

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 regarding an expected baby. Although the law does not identify an unborn baby as a separate legal entity, this should not prevent plans being made and put into place to protect the baby from harm both during pregnancy and after the birth.

The PLO pre-proceedings process represents a genuine opportunity to work closely with families by offering help and support to address their recognised needs in a bid to negate the need to issue care proceedings. Working in partnership with families requires a collaborative approach to identifying issues together and co-producing a plan to support change (Public Law Working Group-Good Practice Guidance, 2021). Timely identification and assessment are vital to ensure this process is effective and fair. There should be no surprises for parents during this process, they must remain informed at all stages.

If either parent has a child who has been subject to care proceedings previously or the Pre-Birth Assessment is indicating that the parent may not be able to safely care for the baby, then Pre-Proceedings must be given serious consideration at an early stage. Completing further specialist assessments, commissioning any testing required, (e.g., cognitive/drug and alcohol), and undertaking assessments of alternative carers are all tasks that will need to be completed prior to the birth in order for there to be a clear plan recommended in good time prior to the birth of the baby. It is vital for parents to have a clear understanding of the concerns of the Local Authority early on, to have had ample time to address issues and for them to have access to appropriate legal advice throughout the process. It is right and proper that parents are fully aware of the outcome of assessments and the recommended plan of the Local Authority in good time.

Pre-Birth cases where parents have had a child removed from their care previously, have any convictions or findings against them that indicate they may pose a risk to children, or where the pre-birth assessment is indicating care proceedings may be necessary must be presented to Legal Gateway (LGM) by 24 weeks gestation at the latest, sooner where possible. If agreed as an outcome, the first Pre-Proceedings meeting (PPM) should be held by 26 weeks gestation at the latest. A PPM review should be held by 32 weeks gestation with a final recommended plan being in place and agreed in LGM by 35 weeks gestation. All the necessary paperwork required to initiate proceedings must be filed with the LA Solicitor by 36 weeks gestation.

If there is a late referral or concealed pregnancy where there is a likelihood of proceedings being issued at birth, there must be no delay in presenting the case to LGM. In these cases, it may not be possible for the Pre-Birth Assessment to be fully completed prior to attendance at LGM, however as much information should be gathered from agencies involved and the Social Worker to present.

Please also see Wirral SCP, Concealed Pregnancies Procedure.

Family Group Conference (FGC)

Completing a genogram with family members as part of the Pre-Birth Assessment and arranging a FGC is vitally important in Pre-Birth cases, not only to identify support for the parents but also to identify alternative carers to be assessed should the plan be to instigate care proceedings. A referral for an FGC should be made during the Pre-Birth Assessment and certainly by the first PPM. It is important to explain to parents that at this stage of the process assessing alternative family members is purely a contingency plan, but one that could ensure a child is kept within the family from birth if parents are not able to care for their child. Equally if family options are exhausted early on, alternative placement options need to be considered including foster to adopt and concurrent planning, depending upon the individual issues and level of risk. (See Family Group Conferences Procedure).

Decision to Instigate Care Proceedings at Birth

If following the Pre-Birth Assessment and Pre-Proceedings process it is agreed at LGM that the Local Authority should instigate Care Proceedings, the parents must be informed in a sensitive and clear manner. Social Work Evidence Template (SWET) should be written and provided to Legal Services by 36 weeks gestation. A placement request must also be made to Fostering Services to ensure that all available options have been appropriately analysed and are available to the Court at the first hearing. The application to the court can only be made once the child is born but there should be no delay in filing the application with the Court. The plan of the Local Authority should be included in the Pre-Discharge Planning Meeting and incorporated into the plan.

The completed Pre-Birth Assessment should be shared with the parents and, if instructed, with their solicitor to give them opportunity to challenge the proposed care plan and assessment.

The circumstances of the woman and other relevant adults should be reviewed regularly to allow for ongoing assessment of need and risk and consider any action required to safeguard the child. The Assessment should be updated to take into account relevant events pre-and post-delivery where these events could affect an initial conclusion in respect of risk and care planning of the child.

(See also Care and Supervision Proceedings and the Public Law Outline Procedure, Pre-Birth Planning and Proceedings)

Placement options to consider:

• Mother/parent and baby placements;
• Connected Carer placements-must ensure viabilities and Reg.24 assessments are completed and authorised in advance of the final LGM.;
• Fostering to adopt;
• Concurrent planning.

Discharge Planning Meeting (for CP/PPM/ICO)

The birth arrangements and plan for the baby after birth must be shared at a timely point. The birth arrangements must contain sufficient detail of the management of risk. A discharge Planning Meeting should be arranged to discuss the birth arrangements no later than 36 weeks gestation. Choice and control are offered to parents wherever possible, including arrangements around separation if this is the proposed plan of the Local Authority. The meeting must include the Social Worker, a representative from midwifery and the parent(s). The meeting could also include anyone else involved in the plan for the baby post birth, for example a FSW or supporting relative. The meeting should agree a detailed plan to safeguard the baby around the time of birth and the plan must be shared within 48 hours of the meeting.

All agencies attending the meeting should receive a copy of the plan as well as other relevant agencies for example the parents' GPs. The Lead Midwife should inform midwifery staff of the details of the plan. This must be available on the unborn child’s CSC file, the mother’s maternity record and EDT must be made aware.

See Appendix 3: Wirral Children’s Social Care Pre-birth Discharge Meeting and Plan.

6. Hope Boxes and Silver Birch Hub

Wirral maternity services are a pilot area for the HOPE Boxes initiative. The initiative is an intervention to help support women who are separated from their baby close to birth due to safeguarding concerns. The HOPE Boxes intervention has been co-produced with a group of women with lived experience and builds on research findings from the Born into Care: Developing new national guidelines when the state intervenes at birth project. More information about the research and the project findings can be found HERE. Where the LA plan is for separation, please sensitively check that the midwife has spoken to the parent about Hope Boxes and record their preference in the Pre-Discharge meeting.

Maternal Mental Health Service (Silver Birch Hub)

Silver Birch Hub (Merseycare) is a free NHS support service working with women, birthing people, and families to offer psychological and emotional support. Their service has therapists, psychologists, assistant psychologists, specialist midwives and peer support workers. Their role is to identify distress that has come from the service user’s maternity, neonatal or reproductive journey.

They work to support trauma, loss and fear around pregnancy and the maternity setting.

For more information, visit Maternal Mental Health Service (Silver Birch Hub).

7. Issues

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

There are some potential issues that can arise. The involvement of Children's Social Care (especially if there is a decision to remove the baby at birth) can result in the parents going missing or the woman not attending hospital at the time of birth. These concerns need to be discussed as soon as we are aware, with a clear plan of response put in place.

It may have an adverse effect on the parents' mental or physical health or heighten the risks that had raised the concerns in the first place. The fear of losing the baby may undermine the attachment and bonding process between the parent and child. There is a danger that the woman may end up harming herself or her unborn baby or seeking to terminate her pregnancy.

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

8. Supervision for Pre-Birth Cases

Providing the assessing Social Worker with reflective supervision is extremely important, especially in relation to Pre-Birth Assessment work. Social Workers need the opportunity to consider the ethical issues and emotional impact of such work within supervision. Social Workers are making predictions regarding future risk, and they need support and the benefit of their supervisor’s experience to support their analysis. All supervision in Pre-Birth cases should be monthly and needs to provide reflection and support for the social worker, including agreeing timescales and planning.

Consider the use of Wonnacott’s Matrix or the Five Anchor Principles from the Defensible Decision-Making resource by Research in Practice.

9. Further Information

• Pre Birth Liaison Terms of Reference;
• Supporting documents for pre-birth assessment and planning are available in Local Resources;
• The Birth Charter for women with involvement from children’s social care.

Appendices

Appendix 1: Pre-Birth Assessment Process Map

Appendix 2: Pre-Birth Liaison (WPBL) Meeting Flow Chart Process

Appendix 3: Wirral Children’s Social Care Pre-birth Discharge Meeting and Plan