Tees Safeguarding Children Partnerships' Procedures Download Referral Form Consult 'The Framework of Need'

1. Introduction

1.1 The concealment and denial of pregnancy will present a significant challenge to professionals in safeguarding the welfare and well-being of the unborn baby (UBB) and the mother. While concealment and denial, by their very nature, limit the scope of professional help better outcomes can be achieved by coordinating 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.

 

2. Definition

2.1 A concealed pregnancy is when a woman knows she is pregnant but does not tell any health professional; or when she tells another professional but conceals the fact that she is not accessing antenatal care; or when a pregnant woman tells another person or persons and they conceal the fact from all health agencies.

2.2 A denied pregnancy is when a woman is unaware of or unable to accept the existence of her pregnancy. Physical changes to the body may not be present or misconstrued; they may be intellectually aware of the pregnancy but continue to think, feel and behave as though they were not pregnant. In some cases a woman may be in denial of her pregnancy because of mental illness, on-going substance misuse or as a result of the previous loss of a child or children (Spinelli, 2005). The woman may also believe she was unable to conceive.

2.3 For the purpose of this policy and procedure any reference to woman includes females of childbearing capacity (including under 18's). A pregnancy will not be considered to be concealed or denied for the purpose of this procedure until it is confirmed to be at least 24 weeks gestation; 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.

 

3. Implications of a Concealed or Denied Pregnancy

3.1 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. Several studies (Earl, 2000); (Friedman S. M., 2005); (Vallone, 2003) highlight a well-established link between neonaticide - killing of a child by a parent in the first 24 hours following birth - and concealed pregnancy. A review of 40 Serious Case Reviews (DoH, 2002) identified one death was significant to concealment of pregnancy.

3.2 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 or methadone.

3.3 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.

3.4 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.

3.5 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 and of Children’s Social Care becoming involved and the fear of the baby being removed.

3.6 The pregnancy may be concealed because revealing the identity of the father of the UBB may have consequences for the parents and the child or any siblings.

 

4. Where Suspicion Arises

4.1 This section outlines actions to be taken when a concealed or denied pregnancy is suspected (see Section 2, Definition). If a pregnancy is suspected of being concealed or denied, the woman should be strongly encouraged to go to her GP practice or contact the Community Midwifery Service to access ante-natal care. The GP may send an appointment for the woman to attend to be seen.

4.2 Professionals must balance the need to conserve confidentiality and the potential concern for the unborn child and the mother's health and wellbeing. Where any professional has concerns about concealment or denial of pregnancy, they should contact any other agencies known to have involvement with the woman so that a fuller assessment of the available information and observations can be made.

4.3 Where there is strong suspicion of a concealed or denied pregnancy, it is necessary to share this irrespective of whether consent to disclose can be obtained or has been given. In these circumstances the welfare of the unborn child will override the mother's right to confidentiality. A referral should be made to Children's Social Care about the unborn child - see Making Referrals to Children's Social Care Procedure. If the expectant mother is under 18 years, consideration will be given to whether she is a Child in Need if other vulnerabilities are identified. In addition, if she is less than 16 years then a criminal offence may have been committed and this needs to be investigated. If the mother was under 13 years old at conception a crime has definitely been committed. The Sexual Offences Act 2003 states that for children aged 12 and under cannot legally give their consent to any form of sexual activity, and the Police should be informed.

4.4 The reason for the concealment or denial of pregnancy will be a key factor in determining the risk to the unborn child or newborn baby. The reasons may not be known until there has been a multi-agency assessment. If there is a denial of pregnancy, consideration must be given at the earliest opportunity to a referral to enable the woman to access appropriate mental health services for an assessment.

Legal considerations about concealment and denial of pregnancy

Women who make an informed decision to not access maternity care should not be considered to be denying or concealing their pregnancy but safeguarding still should be considered.

• Women are not obliged to accept any medical or midwifery care or treatment during pregnancy and childbirth and cannot be compelled to accept care unless they lack mental capacity to make decisions for themselves. Healthcare professionals should not refer a woman to Children’s Social Care solely on the basis that she has declined medical support, as she is legally entitled to do. Children’s Social Care referrals ought to be based on an assessment of whether there is a significant risk of harm to the child after it is born
• The threat of referral to Children’s Social Care should never be used to intimidate, bully or coerce women/parents into accepting maternity care or treatment. Article 8 of the European Convention guarantees the right to private life, which the courts have interpreted to include the right to physical autonomy and integrity.
• United Kingdom law does not legislate for the rights of unborn children and therefore an UBB 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 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 an 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.

 

5. When a Concealed or Denied Pregnancy is Revealed

5.1 Midwifery services will be the primary agency involved with a woman after the concealment 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.

5.2 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 by Children's Social Care and if necessary an Initial Child Protection (Pre-Birth) Conference convened to manage any concerns for the safety of the unborn baby - see Section 9, Pre-Birth Conferences of Initial Child Protection Conference Procedure 

5.3 When a pregnancy is concealed or denied until birth, a referral must be made by the midwife to Children's Social Care - see Making Referrals to Children's Social Care Procedure and a referral for mental health assessment should be considered.

 

6. Educational Settings

6.1 In many instances staff in educational settings may be the professionals who know a young woman best. There are several signs to look out for that may give rise to suspicion of concealed pregnancy:

• Increased weight or attempts to lose weight;
• Wearing uncharacteristically baggy clothing;
• Concerns expressed by friends;
• Repeated rumours around school or college;
• Uncharacteristically withdrawn or moody behaviour.

6.2 Staff working in educational settings should try to encourage the pupil to discuss her situation, through normal pastoral support systems, as they would any other sensitive problem. Every effort should be made by the professional suspecting a pregnancy to encourage the young woman to obtain medical advice. However where they still face total denial or non-engagement further action should be taken. It may be appropriate to involve the assistance of the Designated Lead Person for Child Protection/Safeguarding in addressing these concerns.

6.3 Consideration should be given to the balance of need to preserve confidentiality and the potential concern for the unborn child and the mother's health and wellbeing. Where there is a suspicion that a pregnancy is being concealed it is necessary to share this information with other agencies, irrespective of whether consent to disclose can be obtained.

6.4 Education staff may often feel the matter can be resolved through discussion with the parent of the young woman. However this will need to be a matter of professional judgment and will clearly depend on individual circumstances including relationships with parents. It may be felt that the young woman will not admit to her pregnancy because she has genuine fear about her parent's reaction, or there may be other aspects about the home circumstances that give rise to concern. If this is the case then a referral to Children's Social Care should be made without speaking to the parents first - see Making Referrals to Children's Social Care Procedure, however the young woman should be informed of the referral.

6.5 If education staff engage with parents they need to bear in mind the possibility of the parent's collusion with the concealment. Whatever action is taken, whether informing the parents or involving another agency, the young woman should be appropriately informed, unless there is a genuine concern that in so doing she may attempt to harm herself or the unborn baby.

6.6 If there is a lack of progress in resolving the matter in the setting or escalating concerns that a young woman may be concealing or denying she is pregnant, there must be a referral to Children's Social Care. Where there are significant concerns regarding the girl's family background or home circumstances, such as a history of abuse or neglect, a referral should be made immediately. As with any referral to Children's Social Care, the parents and young woman should be informed, unless in doing so there could be significant concern for her welfare or that of her unborn child.

 

7. Health Professionals

7.1 The local commissioners of health services are responsible for ensuring all its providers fulfil their statutory responsibilities for safeguarding children.

7.2 The health professionals whom may be involved include:

• Health Visitors;
• School nurses;
• General Practitioners and Practice nurses;
• Midwifes and Obstetricians/Gynaecologists;
• Mental Health Nurses;
• Drug and Alcohol workers;
• Learning Disability workers;
• Psychologists and Psychiatrists.

(This is not an exhaustive list)

7.3 If a health professional suspects or identifies a concealed or denied pregnancy and there are significant concerns for the welfare of the unborn baby, (s)he must refer to Children's Social Care - see Making Referrals to Children's Social Care Procedure and inform all the health professionals, including the General Practitioner, involved in the care of the woman.

7.4 All health professionals should give consideration to the need to make or initiate a referral for a mental health assessment at any stage of concern regarding a suspected (or proven) concealed or denied pregnancy. Accident and Emergency staff or those in Radiology departments need to routinely ask women of childbearing age whether they might be pregnant. If suspicions are raised that a pregnancy may be being concealed, this should be recorded and an appropriate note made to the referring physician or GP for follow up with the patient.

7.5 Health professionals who provide help and support to promote children's or women's health and development should be aware of the risk indicators and how to act on their concerns if they believe a woman may be concealing or denying a pregnancy.

 

8. Midwives and Midwifery Service

8.1 If an appointment is for antenatal care is made late (beyond 24 weeks), the reason for this must be explored. Midwives and Obstetricians should consider whether a mental health referral is indicated. If an exploration of the circumstances suggests a cause for concern for the welfare of the unborn baby, a referral to Children's Social Care must be made - see Making Referrals to Children's Social Care Procedure. The woman should be informed that the referral has been made, the only exception being if there are significant concerns for her safety or that of the unborn child.

8.2 If a woman arrives at the hospital in labour or following an unassisted delivery, where a booking has not been made, then an urgent referral must be made to the Children's Social Care. If this is in an evening, weekend or over a public holiday then the Emergency Duty Team must be informed.

8.3 If the baby has been harmed in any way or there is a suspicion of harm, or the child is abandoned by the mother, then the Police must be informed immediately and a referral made to Children's Social Care.

8.4 Midwives should ensure information regarding the concealed pregnancy is placed on the child's, as well as the mother's, health records. Following an unassisted delivery or a concealed/denied pregnancy, midwives need to be alert to the level of engagement shown by the mother, and her partner/extended family if observed, and of receptiveness to future contact with health professionals. In addition midwives must be observant of the level of attachment behaviour demonstrated immediately after the child is born.

8.5 In cases where there has been concealment and denial of pregnancy, especially where there has been unassisted delivery, a referral for a full mental health assessment should be considered. In addition the baby should not be discharged until a multi-agency Strategy Meeting has been held, if appropriate, and immediate safeguarding undertaken. A discharge summary from maternity services to the relevant GP must report if a pregnancy was concealed or denied or booked late (beyond 24 weeks).

 

9. Children's Social Care

9.1 Children's Social Care may receive a referral from any source, which suggests a pregnancy is being concealed or denied. In all such cases, a multi-agency Strategy Meeting should be considered and if convened, involve the General Practitioner, midwifery services and other relevant agency to assess the information and formulate a plan. A pre-birth assessment will be undertaken unless the baby has already been born.

9.2 Where the expectant mother is under the age of 18, initial approaches should be made confidentially to the young woman to discuss concerns regarding the potential concealed pregnancy and unborn child. She should be provided with the opportunity to satisfy the professionals involved that she is not pregnant (by undertaking appropriate medical examination or investigation) or to make realistic plans for the baby, including informing her parents. There may be significant reasons why a young woman may be concealing a pregnancy from her family and a social worker should consider speaking to her without her parent's knowledge in the first instance.

9.3 In the event that the young woman refuses to engage in constructive discussion, and where parental involvement is considered appropriate to address the risk, the parent/main carer should be informed and plans made wherever possible to ensure the unborn baby's welfare. Potential risks to the unborn child or to the health of the young woman would outweigh the young woman's right to confidentiality, if there is significant evidence that she is pregnant.

9.4 Where there are clear reasons for suspecting pregnancy in the face of continuing denial or concealment, the professionals will need to continue to assess the situation with a focus on the needs /welfare of the unborn baby as well as those of the expectant mother. It must not be forgotten that where the mother is under 18, consideration should also be given to making a referral on her for an assessment in her own right. Such a situation will require very sensitive handling.

9.5 Regardless of the age of the woman, where there are additional concerns (i.e. as well as the suspected concealed or denied pregnancy) such as a lack of engagement, possibility of sexual abuse, or substance misuse; then a Strategy Meeting should be undertaken to determine if a Section 47 Enquiry needs to be conducted.  

9.6 If a woman has arrived at hospital either in labour (when a pregnancy has been concealed or denied) or following an unassisted birth, an Assessment must be started and a multi-agency  Strategy Meeting convened. 

9.7 Where a baby has been harmed or has been abandoned then a Section 47 Enquiry must be completed in collaboration with the Police. Where a baby has died, the Child Death Protocol must be followed. 

9.8 Where any referral is received by the Children's Social Care Emergency Duty Team in relation to a baby born following a concealed or denied pregnancy, or where a mother and baby have attended hospital following an unassisted delivery, steps should be taken to prevent the baby being discharged from hospital until a multi-agency Strategy Meeting has been held and a plan for discharge agreed. Ideally, this would be done by voluntary agreement with the mother, although where the mother's consent is not freely given, consideration should be given to whether there are grounds for seeking an Emergency Protection Order to ensure the baby remains in hospital until a the discharge plan is agreed. This course of action will not be achievable out of hours therefore the assistance of the Police - via Police Protection - may be sought to prevent the child from being removed from the hospital.

9.9 In undertaking an assessment the social worker will need to focus on the facts leading to the pregnancy, reasons why the pregnancy was concealed and gain some understanding of what outcome the mother intended for the child. These factors, along with the other elements of the Assessment Framework, will be key in determining risk.

9.10 Accessing psychological services in concealment and denial of pregnancy may be appropriate and consideration should be given to referring a woman for psychological assessment. There could be a number of issues for the woman, which would benefit from psychological intervention. A psychiatric assessment might be required in some circumstances, such as where it is thought she poses a risk to herself or others or in cases where a pregnancy is denied.

9.11 The pathway for psychological or psychiatric assessment, either before or after pregnancy, is the same. A referral should be made using the single point of entry to mental health services and the referral letter copied to the woman's GP. The referral should make clear any issues of concern for the woman's mental health and issues of capacity.

 

10. Police

10.1 The Police will be notified of any child protection concerns received by Children's Social Care where concealment or denial of pregnancy is an issue. A police representative will be invited to attend any multi-agency Strategy Meeting and consider the circumstances and to decide whether a joint Child Protection investigation should be carried out.

10.2 Factors to consider will be the age of the woman who is suspected or known to be pregnant, and the circumstances in which she is living to consider whether she is a victim or potential victim of criminal offences. In all cases where a child has been harmed, been abandoned or died it will be incumbent on the Police and Children's Social Care to work together to investigate the circumstances. Where it is suspected that neonaticide or infanticide has occurred then the Police will be the primary investigating agency.

 

11. Other Relevant Agencies (including the Voluntary Sector)

11.1 All professionals or volunteers in statutory or voluntary agencies who provide services to women of child bearing age should be aware of the issue of concealed or denied pregnancy and follow this procedure when a suspicion arises.

11.2 All referrals will be made to the Children's Social Care initially as a referral on an unborn child. Where the expectant mother is under 18 years of age she will be considered as a Child in Need and assessed accordingly.

 

12. Bibliography

Spinelli, M. (2005). In S. Friedman, Infanticide.

 

13. Additional Reading

Antenatal Care: Routine care for the healthy pregnant woman, Quick Reference Guide. National Institute for Clinical Excellence, 2008

Law and Ethics in relation to court-authorised obstetric intervention; Ethics Committee Guideline No.1. Royal College of Obstetricians and Gynaecologists.

 

14. Relevant Links

• Safeguarding the Unborn Baby