Objective
Where a concealment of pregnancy is discovered, professional will consider whether there may be safeguarding issues to be addressed for the unborn child or baby, the mother if under 18, any other children directly involved, and the implications for any future pregnancy
Relevant Legislation
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. The fact that the law does not identify the unborn baby as a separate legal entity should not prevent plans being made and put into place to protect the baby from harm both during pregnancy and after the birth.
In certain instances legal action may be available to secure medical intervention to protect the health and well-being of the mother and thereby, the unborn child. This may arise in cases where the young/ woman lacks capacity due to mental illness (acute or chronic), learning difficulty, her young age or some other circumstance. The absence of support for intervention from parents or carers may be overcome by the use of legal intervention. These measures can be secured in an emergency by application to the High Court. It is only possible to make appropriate contingency plans and to ensure that the woman/girl is fully aware of the consequences of her actions. In such circumstances, legal advice should be sought.
Care proceedings cannot be instigated for an unborn child. They are not likely to provide a mechanism for intervening even where the mother is under 17 years. A child assessment order will require the pregnant young woman’s agreement and the making of an interim care order will not transfer any rights to the relevant Children’s Social Care Department to override the wishes of the young woman in relation to medical help. It may however provide a solution where the problem can be addressed by removing her from abusive carers to a safe environment such as foster care.
If legal steps need to be taken to protect a newborn baby, the relevant Children’s Social Care Department. Acute medical services (maternity or A&E) may also need to seek urgent legal advice in order to safeguard the health of the woman in labour who does not cooperate with the medical intervention.
Definition
A concealed pregnancy is when a woman knows she is pregnant but does not tell anyone or those who are told conceal the fact from all caring and health agencies. Consideration should also be given if a woman appears genuinely not aware that she is pregnant. Concealment may be an active act or a form of denial where support from appropriate carers and health professionals is not sought. In exceptional cases the mother may not reveal the delivery and may conceal the baby even if it has died.
Concealment of pregnancy may come to light late in pregnancy, in labour or following delivery. The birth may be unassisted whereby there are additional risks to the child and mother’s welfare and long-term outcomes.
For the purpose of this document, late booking is defined as presenting for maternity services after 24 weeks of pregnancy.
Implications of a Concealed Pregnancy
The potential risk to a child through the concealment of a pregnancy is extremely hard to predict. One key implication is that there is no obstetric history or record of antenatal care prior to the birth of the baby. Some women may present late for booking (after 24 weeks of pregnancy) and these pregnancies need to be closely monitored to assess future engagement with health professionals, particularly midwives and whether or not referral to another agency is indicated. Research undertaken in other authorities has found that concealment appears to be reported equally across all ages; It is solely not a teenage phenomenon. Previous concealed pregnancy may also be regarded as an important indicator in predicting risk of a future pregnancy being concealed with a harmful outcome for the child.
Research also identified the following indicators.
- Previous termination, thoughts of termination and/or unwanted pregnancy.
- Loss of a previous child (i.e. adoption, removal under Care Proceedings)
- General fear of being separated from the child
There could be a number of reasons why women fear that they will be separated from their child. Research evidence suggests that substance-misusing women may avoid seeking help during pregnancy if they fear that this disclosure will inevitably lead to statutory agencies removing their child. It may be important to consider the role of collusion within the family. In some national and local cases, the family appeared to encourage the concealment and the mother’s own family were aware of the situation, and the pregnant daughter was allowed to develop high levels of privacy in the home.
Risks and protection issues
The reason for the concealment will be a key factor in determining the risk to the child and that reason will not be known until there has been a systematic multi-agency assessment.
The implications of concealment are wide-ranging. Concealment of a pregnancy can lead to a fatal outcome for both mother and child, regardless of the mother’s intention.
Concealment may indicate ambivalence towards the pregnancy, immature coping styles and a tendency to dissociate, all of which are likely to have a significant impact on bonding and parenting capacity.
Lack of antenatal care can mean that any potential risks to mother and child may not be detected. It may also lead to inappropriate advice being given; such as potentially harmful medications prescribed by a medical practitioner unaware of the pregnancy.
The health and development of the baby during pregnancy and labour may not have been monitored and foetal abnormalities not detected.
Underlying medical conditions and obstetric problems will not be revealed.
An unassisted delivery can be dangerous for both mother and baby, due to complications that can occur during labour and the delivery.
Other possible implications for the child arising from mother’s behavior could be a lack of willingness/ability to consider the baby’s health needs, or lack of emotional attachment to the child following birth. Nirmal et al (2006) identify denial of pregnancy as a likely precursor of poor adaptation postpartum and highlights the need for increased monitoring in the postpartum period.
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 are also risks to the unborn baby from prescribed medications.
There may be risks to both mother and child if the mother has concealed the pregnancy due to fear of disclosing the paternity of the child, for example where the child has been conceived as the result of sexual abuse, or where the father is not the woman’s partner.
Where suspicion arises
It is important to balance the need to preserve confidentiality and the potential concern for the unborn child and the mother’s health and well-being. There will be a point at which the child’s welfare overrides the mother’s right to confidentiality. This is a relevant consideration even though the baby is in utero.
Where anyone has such concerns, they should contact other agencies known to have involvement with the young/woman so that a fuller assessment of the available information and observations can be made.
Where there is a strong suspicion that a pregnancy is being concealed, it may be necessary to share this information with other agencies, irrespective of whether consent to disclose can be obtained. Every effort should be made by the person alerted to suspicion of concealed pregnancy to encourage the (young) woman to obtain medical advice. If the response shows that this is unlikely referral should be made to the relevant Children’s Social Care Department so that effective service responses may be coordinated.
If concerns are such that a Child Protection referral needs to be made, it will be made on the unborn child. If the mother is under 16, she will also be the subject of a referral in her own right.
When concealment is revealed
Where a concealed pregnancy is identified, the key question is ‘why has the pregnancy been denied / concealed’? Referring to research and the commentary above, some effort should be made to identify likely reasons for the concealment. The circumstances leading to concealment of pregnancy need to be explored individually.
A referral to the relevant Children’s Social Care department must always be made where there are maternal risk factors e.g. denial of pregnancy, avoidance of antenatal care, non-co-operation with necessary services, non-compliance with treatment with potentially detrimental effects for the unborn baby.
In cases of full concealment followed by unassisted delivery, the relevant Children’s Social Care Department must always be informed and a full psychiatric assessment considered jointly by the agencies.
Health Professionals
- GPs and practice-employed staff
Where a G.P has significant reason to believe a woman is pregnant, but she refuses all attempts to persuade her to undertake further investigations, further action needs to be taken in the form of a referral to Children’s Social Care. This should include discussion with the Midwife, Health Visitor or School Nurse (as appropriate). It may also be helpful to discuss the concerns with the Designated (or Named) Doctor or Nurse for Child Protection.
Given that a previous concealed pregnancy indicates increased risk of further concealment, where this has been the case it must be highlighted within the summary in the G.P records.
The GP may initiate a psychiatric assessment or be asked to make a referral by a colleague.
- Health Visitors
Health Visitors may be aware of the circumstances of previous pregnancies, and need to be alert to the possibility that a woman may be concealing a pregnancy. If the Health Visitor believes a woman may be pregnant, they should encourage her to seek support.
Where a Health visitor has significant reason to believe a woman is pregnant, but she refuses all attempts to persuade her to undertake further investigations, further action needs to be taken in the form of a referral to the relevant Children’s Social Care Department. This should include discussion with the Midwife, G.P or School Nurse (as appropriate). It may also be helpful to discuss the concerns with the Designated (or Named) Doctor or Nurse for Child Protection.
- Midwives and Midwifery Services
- Very late for antenatal appointment
If an appointment is made very late for antenatal care (after 24 weeks of pregnancy), the reason for this must be explored. Midwives and Obstetricians should consider whether a psychiatric referral is indicated.
If there is a cause for concern a referral should be made to the Children’s Social Care or Out of Hours service. The young girl / woman must be informed that the referral has been made, unless there are significant child protection concerns.
- hospital arrival in labour or unassisted delivery, first occasion
If a woman arrives at the hospital in labour or following an unassisted delivery, where a booking has not been made, if this is the first occasion, an assessment of the circumstances should be made by the Midwife or Obstetrician. In consultation with the Trust’s Safeguarding Team, consideration should be given to referrals to Children’s Social Care or Out of Hours service, and for psychiatric assessment. The outcome should be communicated to the woman’s GP.
A Discharge Planning Meeting should be held, with invites sent to all agencies involved.
If the baby has been harmed in any way, or abandoned as a result of the mother’s actions (or non action), a referral must always be made to the police by the midwife or appropriate medical practitioner. The baby should not be discharged from hospital until a strategy discussion has been held and relevant assessments undertaken. A Strategy Discussion should be held as soon as possible after birth.
- hospital arrival in labour or unassisted delivery, second or further occasions
If a woman arrives at the hospital for a second or further occasion in labour or following an unassisted delivery, where a booking has not been made, the Midwife or Obstetrician should consult the Trust Safeguarding Team and make referrals to Children’s Social Care (in respect of the child) or Out of Hours service, and for psychiatric assessment. The outcome should be communicated to the woman’s GP.
A Discharge Planning Meeting should be held, with invites sent to all agencies involved.
If the baby has been harmed in any way, or abandoned as a result of the mother’s actions (or non action), a referral must always be made to the police by the midwife or appropriate medical practitioner. The baby should not be discharged from hospital until a strategy discussion has been held and relevant assessments undertaken. A Strategy Discussion should be held as soon as possible after birth.
In all cases, Midwives should ensure information regarding the concealed pregnancy is placed on the child’s records, as well as the mother’s records, and a summary letter should be sent to the family GP.
Children’s Services
The referral to the relevant Children’s Social Care should be made in the name of the young girl if under 16 years. An Initial Assessment will be considered to assess the needs of the young person and the unborn baby.
Where the expectant mother is under 16, initial contact should be confidential with the young woman to discuss concerns regarding the unborn child. She should be provided with the opportunity to satisfy social workers she is not pregnant, by undertaking appropriate medical examination or investigation, or to begin to make realistic plans for the baby. In the event the young woman refuses to engage in constructive discussion, and where parental involvement is considered necessary to address risk, the expectant mother’s parents or carers should be informed and plans made wherever possible to protect 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 an expectant mother thought to be pregnant is over 16, the referral will be made in the name of the unborn baby and again, an Initial Assessment will be made to consider the needs of both unborn baby and mother by Children’s Social Care.
Where the expectant mother is over 16, every effort should be made to resolve the issue of whether she is pregnant or not. Clearly no woman can be forced to undergo a pregnancy test, nor any other medical examination, but in the event of refusal, social workers should proceed on the assumption that the woman is pregnant, until or unless it is proved otherwise, and endeavour to make plans to safeguard the baby’s welfare at birth.
Where there are additional concerns, e.g. lack of engagement, possibility of sexual abuse, or substance misuse, the referral should be dealt with under child protection procedures (Section 47 investigation). It may be appropriate to convene a pre-birth child protection conference.
If a woman has arrived at hospital, either in labour or following an unassisted birth, a referral must be made to Children’s Social. An Initial Assessment will be started and if necessary a strategy discussion convened. The same analysis of risk should be applied to women who book late (after 24 weeks gestation), arrive in labour or following an unassisted delivery.
Where a baby has been found to have been harmed, died /or deemed to have been a still born or has been abandoned, a referral will be passed on to Children’s Social Care immediately and an investigation under Section 47 of the Children Act will commence. The Police must be notified immediately
Where the referral is received out of hours, in relation to a baby born as the result of a concealed pregnancy, the Emergency Out of Hours Service will take steps to prevent the baby being discharged from hospital until an Initial Assessment has been undertaken. In normal circumstances this would be through a voluntary agreement, although clearly there could be circumstances in which it would be appropriate to consider an application for an Emergency Protection Order, or to seek the assistance of the Police in preventing the child from being removed from the hospital.
Police
The Police will be notified of any Child Protection inquiries made Children’s Social Care following a concealed pregnancy.
Consideration will be given to whether a joint investigation is needed. This will be dependent upon whether an offence may have been committed or if the child is at serious risk of significant harm.
If the child has been found to have been harmed, died /or deemed to have been still born, child protection procedures will apply and a joint investigation will be conducted with Children’s Social.
Future Pregnancies
Following a concealed pregnancy where significant risk has been identified, Children’s Social Care should take the lead in developing a multi agency contingency plan, to address the possibility of a future pregnancy. This will include a clearly defined system for alerting Children’s Social Care if a future pregnancy is suspected.
Where there is a known plan in place, it should be activated as soon as professionals become aware of a subsequent pregnancy.
