Pre-Birth Assessment

1. Introduction

Research and experience indicate that very young babies are extremely vulnerable to abuse and that work carried out in the ante-natal period to assess risk and to plan intervention will help to minimise harm. A pre-birth assessment is a proactive means of analysing the potential risk to a new-born baby when there are concerns about a pregnant woman and where appropriate, her partner and immediate family.

The purpose of a pre-birth assessment is to identify any potential risks to the new-born child, assess whether the parent(s) are capable of changing so that the identified risks can be reduced and if so, what support they will need. The pre-birth assessment must be of sufficient depth to inform future care planning. It must take into account family strengths as well as the risk factors to ensure that the newborn baby receives the necessary level of support to achieve their full potential and be protected from immediate and future harm.

Pre-birth assessments are a source of anxiety not only for parents, who may fear that a decision will be made to remove their child at birth, but also for professionals who may feel that they are not giving parents a chance. However, the Children Act 1989 is clear that there are grounds for intervention if there is a likelihood of Significant Harm and that the needs of the child (in these situations the unborn child) are paramount.

It is important that the reasons for the assessment are made clear to the parents at the outset and that there is clarity of understanding between professionals as to the purpose of the pre-birth assessment process. Care must be given to working collaboratively with parents as a means of drawing together a balanced, holistic assessment with due consideration of parental strengths and capacity to change as well as areas of concern. However, it is critical that the needs of the unborn child remain at the centre of the assessment as opposed to those of the parent/s. There needs to be good consistent dialogue between professionals, recognition of the strengths and expertise that individual practitioners bring to the process and constant focus that the needs of the unborn child are paramount.

This guidance aims to clarify what is meant by pre-birth assessments, their purpose and the circumstances in which one needs to be considered. This guidance should be read together with Knowsley Safeguarding Children Partnership, Managing Individual Cases where there are Concerns about a Child's Safety and Welfare.

2. Purpose of a Pre-Birth Assessment

The undertaking of a pre-birth assessment is a multi-agency task led by Children's Social Care in collaboration with parents/carers which "should help us move from a reactive, crisis-led response to a more considered, proactive, and needs led response" (Calder 2003).

The purpose of a pre-birth assessment is to gather and analyse the information and should be the foundation for future multi-agency planning. Therefore, it is important that all relevant agencies actively contribute to the assessment and that the completed assessment is mutually owned by the contributing agencies and is actively used as the means to first develop and then review the impact of multi-agency plans. It is important that the pre-birth assessment is well planned and completed in a timely manner.

3. Early Recognition Assessment and Intervention

Women who are pregnant may present initially via a number of different professionals, for example GP, hospital ante-natal services, community midwifery services, Community health 0-19 Service, health visitors, or via housing officers. Additionally, other health professionals or professionals from another agency may become aware of a pregnancy prior to a formal referral to the obstetric/midwifery services. It is important that all professionals are aware of the routes of referral to Children's Social Care.

All professionals should be aware of indicators that may suggest a child could be at risk of harm either before or following birth, or that the family will require either additional or intensive support in order to parent the child safely. For further information please refer to Knowsley Safeguarding Children Partnership Procedures and Working Together to Safeguard Children.

It is vital that assessments begin in the early ante-natal period. Undertaking the assessment during early pregnancy provides parents with the opportunity to show evidence of change. If the outcome suggests the baby would not be safe with the parents then practitioners have the time and opportunity to make clear and structured plans for the baby's future and set up support for the parents where necessary.

Consultation needs to take place between professionals already involved (i.e. midwife, GP, health visitor, etc.) to ensure that planning for the baby's arrival can be comprehensive and any referral to Children's Social Care can be made at an appropriate time. All professionals who have contact with the parents or who provide specialist services should be aware that they may be asked to assist in the assessment and analysis of need or risk.

Any assessment made in the early ante-natal period should take into account family and social history as well as obstetric history and details of the parents. The assessment should include details, where possible, regarding the mother's partner and his/her wider family and environment. The depth of the assessment will depend on the individual circumstances surrounding the parent/s and family and is a matter of professional judgement.

In normal circumstances, midwifery services will complete a booking in appointment with the expectant mother by the end of the first trimester (usually between 8-12 weeks gestation). Any safeguarding children concerns should be discussed with the safeguarding midwife/team at the earliest opportunity.

N.B. for any other professionals involved with parents expecting a child, they should refer the unborn child to the Knowsley's Multi Agency Safeguarding Hub (MASH) as soon as they are concerned or observe any risk factors that may affect the unborn child when born.

Where it has been identified that the parent/s may need additional support to meet the needs of their unborn child, the first stage in seeking to clearly identify what is needed can be identified at an Early Help level, see Knowsley's Thrive Document. In such circumstances an early Help Assessment will follow (see Appendix 1: Multi-Agency Pre-Birth Assessment Flowchart).

The development of any assessment and plan should follow the same principles of active multi-agency collaboration planning and review as advocated in this policy.

Given the relatively short timescale of the pregnancy any decisions regarding the effectiveness and impact of a plan needs to be tightly managed. If it becomes evident that an Early Help plan is not having the desired impact because a parent is either not engaging with the plan, requires a more intensive plan, or steps need to be taken to safeguard the unborn child a referral should be made to Children's Social Care via the MASH (see Appendix 1: Multi-Agency Pre-Birth Assessment Flowchart).

All concerns and the actions taken should be clearly recorded by midwifery services and/or other professionals. This information needs to be included in the written referral to Children's Social Care. It will also contribute to the pre-birth assessment which will be led by Children's Social Care.

Examples where consideration would be given to managing a case at an Early Help level could include:

Parent/s are asking for help and support;
Food, warmth and other basics may not always be available;
Parent/s may struggle without the provision of support / resources;
Young, inexperienced parents with inadequate support from family / friends;
Parent/s occupied with other children with additional needs, e.g. disabilities, requiring additional support;
Family dynamics result in levels of instability;
Parent/s struggling to maintain standards of hygiene / repair with the family home;
Parent/s accruing rent arrears which may jeopardise tenancy if action not taken;
Failure to attend for ante-natal care (dependant on level of concern);
Homelessness;
Family just about getting by, but advent of new baby may exacerbate existing anxieties;
Mental health issues. Engagement with services is good, but parents are concerned about coping with new baby or there are concerns about the parents coping with a new baby;
Drug and alcohol issues. Engagement with services is good, but parental concern about coping with new baby as above;
Parent/s with learning disabilities. Engagement with services is good, but parents are concerned about coping with new baby or there are concerns about the parent/s coping with a new baby.

4. Referrals to Children's Social Care

Where agencies or individuals anticipate that prospective parents may need intensive support services to care for their baby, or that the baby may be at risk of significant harm, a discussion with the MASH should take place prior to a formal referral being made. The referral should be supported by copies of any previous assessments.

There are no definitive timescales for when an agency should refer to social care, however, research shows that parents are more likely to engage in the pre-birth assessment process at an early stage, therefore where it is anticipated that prospective parents may need intensive support services to care for their baby, or that the baby may be at risk of significant harm a referral to social care should be made immediately.

Referrals to Children's Social Care must always be made in the following circumstances:

The expectant mother is a care leaver who may be isolated and vulnerable;
The expectant mother is a child under the age of 13 years;
A pregnancy has been concealed;
There has been a previous suspicious unexplained death of a child;
A parent or other adult in the household is a person identified as presenting a risk, or potential risk, to children;
Children in the household / family currently subject to a Child Protection Plan or previous child protection concerns;
A sibling has previously been removed from the household either temporarily or by court order;
Where there is knowledge of parental risk factors including substance misuse, mental health needs, Domestic Abuse;
Where there are concerns about parental ability to self-care and/or to care for the child e.g. unsupported young or learning disabled mother;
Where there are maternal risk factors, e.g. denial of pregnancy, avoidance of antenatal care (failed appointments), non co-operation with necessary services;
Where there is a concern about chronic neglect that will impact upon the unborn child, in such a scenario a referral to Children's Social Care should be accompanied by a completed graded care profile;
Non-compliance with treatment with potentially detrimental effects for the unborn baby, including frequent moves e.g. area to area, hospital to hospital;
Concerns that the mother and or father of the unborn are at risk from honour based violence (see Knowsley Safeguarding Children Partnership Procedures Manual, Honour Based Violence Procedure);
Concerns that the baby may be subjected to Female Genital Mutilation (see Pan Merseyside Female Genital Mutilation (FGM) Protocol);
Any other concern exists that indicate that the baby may be at risk of significant harm.

Referrals to Children's Social Care must be made on the Council's Multi-Agency Referral Form, which can be located on the Knowsley Safeguarding Children Partnership Procedures.

Parent/s should be informed of the referral unless there is evidence that the unborn child has or is likely to suffer significant harm, i.e. child protection concerns exist. On these occasions the MASH Team Manager should be contacted for advice as to how to proceed on 0151 443 2600.

On receipt of the referral Children's Social Care will make a decision as to how to proceed within twenty-four hours of receipt, one hour if immediate action is required, i.e. Child Protection Enquiry, to safeguard the unborn child. Decisions will be based on the presenting evidence and the threshold criteria.

The referral will be sent to the relevant social care team, if a new case, then the relevant Child Protection Team. If a Child Looked After becomes pregnant and a pre-birth assessment is required the looked after social worker should make a referral to the MASH.

(See Appendix 2: Social Care Pre-Birth Assessment Flowchart).

Should the threshold for a service be met a Children and Families Assessment will be completed. The Assessment will make clear recommendations as to whether further action is required via an Early Help Assessment, or whether a pre-birth assessment should be completed. Social Care will feedback to the relevant agencies the outcome of the single assessment. If safeguarding concerns are identified at the assessment stage a strategy discussion should be held to determine if a Section 47 investigation should be progressed.

Dependent on the outcome of the Section 47 investigation, the children and family assessment will either form the basis of the social worker's evidence to a Child Protection Case Conference or will provide the terms of reference for the Pre-Birth Assessment under a child in need intervention. In either case the need for robust multi-agency planning and review is critical to the effectiveness of the process (see also Knowsley Safeguarding Children Partnership Procedures, Pre-Birth Child Protection Conferences Procedure).

5. Planning the Pre-Birth Assessment

Children's Social Care must always consider a Pre Birth Assessment:

Where previous children in the family have been removed because they have suffered harm;
Where there has previously been chronic neglect in the family;
Where a person posing a risk to children or someone found by an Initial Child Protection Conference to have harmed a child or has joined a family;
Where concerns exist regarding the mother's ability to protect;
Where there are acute professional concerns regarding parenting capacity, particularly where the parents have either severe mental health problems or learning disabilities (see Knowsley Safeguarding Children Partnership Procedures, Mental ill Health of a Parent or Carer Procedure);
Where alcohol or substance abuse is thought to be affecting the health of the expected baby (see Knowsley Safeguarding Children Partnership Procedures, Children of Drug and/or Alcohol Misusing Parents Procedure);
Where there are concerns about domestic abuse (see Knowsley Safeguarding Children Partnership Procedures, Domestic Abuse and Violence Procedure);
Where the expected parent is very young and a dual assessment of their own needs as well as their ability to meet the baby's needs is required. (If the expectant mother is a child/young person, or an open case to social care they must have an allocated Social Worker in their own right);
Where the expectant mother is not engaging in ante-natal care;
The pregnancy has been concealed;
Where the expectant mother is cared for or is a care leaver and does not engage with services;

Examples where consideration would be given to managing such interventions under Section 17 of the Children Act 1989 include:

Case previously managed via a Early Help Assessment but no or limited progress;
Where the expectant mother is in care or is a care leaver but does engage with services;
Financial issues have led to temporary loss of power/utilities, sporadic loss of heating and lighting;
Pregnant mother unkempt, e.g. poor hygiene, poorly maintained dental health at a level that cause ongoing concern, despite previous advice being given;
Concerns about the safety of the home environment and parents may need support to address these issues prior to the birth of the baby, e.g.: broken windows, doors, bare electrical cables, (see Section 7, Assessment Toolkit);
Failure to attend for antenatal care (dependant on level of concern);
Domestic abuse (dependant on level of concern/number and severity of recorded incidents);
Parental substance misuse with sporadic compliance with support agencies;
There is a history of mental health issues, sporadic engagement with services or where mental health issues may impact on parenting ability;
Homelessness and no progress being made.

Examples where consideration would be given to commencing a child protection enquiry in line with Section 47 of the Children Act 1989 include:

Concealed pregnancy (dependant on level of concern around this)
Pregnancy in a child under 13 years;
Non-compliance with ante-natal care (dependant on reasons and level of concern);
Disclosure of domestic abuse incident in pregnancy and mother is still with the perpetrator;
Serious concerns about substance misuse / non-compliance with services;
Significant concerns about maternal mental health with or without compliance with services;
Significant concerns about paternal mental health with or without compliance with services;
Significant concerns about any adult who may have access to the baby "poses a risk to children";
Significant concerns about the home environment and concerns not being addressed by parent;
Current / previous child protection plan for siblings;
Previous history Non Accidental Injury;
Previous children removed;
History of chaotic lifestyle with no indication of improvement;
Concerns about compromised parenting due to parents own history (evidence to support this);
Homelessness with no real effort to address this;
Decision taken to convene a Legal Gateway/Planning Meeting.

6. Management of the Pre-Birth Assessment

The Pre-Birth Assessment should be a standing item on individual practitioner supervisions and the progression/planning of pre-birth assessments should be monitored and tracked by both Team and Senior Managers.

The pre-birth assessment will be managed by multi-agency meetings, which includes parent and family members led by Children's Social Care. If the assessment identifies concerns of risk of significant harm, the child is subject to a plan, or subject to pre proceedings, this meeting should include the relevant Team Manager. The case should also be tracked by The Child Protection Chair. Where the pre-birth meeting identifies that support needs can be met through a Child in Need Plan, the Team Manager will determine if this meeting can be chaired by the allocated social worker (see Appendix 3: Pre-Birth Planning Meeting / Pre-Discharge Meeting).

The type of intervention will determine how the process is managed. Child protection interventions will commence with a Strategy Discussion followed by a Section 47 enquiry, child protection case conference and Core Group meetings. Those made on a child in need basis will be managed via Child in Need Meetings.

Where a case has reached threshold for social work assessment and at any point during or on completion of the pre-birth assessment, the social worker concludes that the unborn is at risk of significant harm, a Pre Birth Conference must be requested. This includes cases where the local authority is considering / seeking legal advice / convening a Legal Gateway/Planning Meeting (see Knowsley LSB Pre-Birth Child Protection Conference).

Strategy Discussions

The strategy discussion is a professionals' forum and family members are not involved. It is convened and chaired by Children's Social Care, and must take place as soon as it is decided that a child is suffering, or is likely to be suffering, significant harm. It can take the form of a telephone discussion, or - where the issues need more detailed discussion and planning over one or more meetings.

Strategy meetings must be chaired by a Children's Social Care Team Manager. Those in attendance should include the referring agency, Police, Health and any other relevant agency.

The purpose of the discussion is to agree whether Section 47 inquiry is required and, if so, what actions are needed to complete this. A decision will also be made at the strategy discussion as to whether a further strategy meeting is required, if the case should be managed on a child in need basis or if child protection case conference should be convened.

Child Protection Case Conference

If it is agreed that a child protection conference is necessary this should take place within 15 working days following the initial strategy discussion. The social worker will be responsible for completing the subsequent single assessment which is the basis of the Child Protection Case Conference Report. This will draw together the professional concerns and should include information from the Pre-birth Risk Assessment. It will also contain relevant information gained from midwifery services, background information from the prospective health visitor, GP and other relevant agencies.

The aim of the child protection conference is to enable professionals with particular expertise (even if they are not currently involved with the family), those most involved with the family, and the family itself to assess all relevant information and plan how to safeguard the unborn child and promote his or her welfare. There must be representation from the midwifery services, health visiting and other professionals as appropriate.

It should be noted that should the unborn child be made subject to a child protection plan the pre-birth assessment must always have been completed by the first Child Protection Case Conference Review Meeting (held within three months of the Initial Child Protection Case Conference).

Child Protection Plan

The full Child Protection Plan must be drawn up within ten working days, i.e. at the first core group following the child protection case conference. The point within the pregnancy is likely to determine the focus of the plan i.e. completion of the pre-birth assessment and the minimisation of risk to the unborn child during the antenatal period, or the planning for the immediate safety of the child once delivered and the management of risk during the post-natal period.

Hospital staff and the lead midwife responsible for the patients care should be involved with the development of the Child Protection Plan as well as any other professional identified within the Child Protection Case Conference. There should be a clear communication pathway within each service to ensure the professionals involved e.g. Midwife/Health Visitor are fully up to date with the plan and Core group meeting dates.

The Child Protection Plan may need to consider any steps necessary to secure the immediate safety of the child when born. A pre-birth planning meeting will need to be considered together with the use of the police or legal options, following legal advice. In the majority of cases parents will have been involved from the outset and be aware of the level of concern. Staff at the hospital where the baby is likely to be delivered should be kept informed of the plan and any assessed risk to either the baby or staff. The Emergency Duty Team and Police should also be alerted to the child protection plan to cover situations that may arise out of office hours.

Child-in-Need Planning Meeting

A Child in Need planning meeting would be convened if there are concerns; but the concerns are not sufficient to lead to the likelihood of significant harm and there is meaningful family co-operation and agreement regarding concerns and the way forward. The focus of the child in need plan will be dependent on the stage of the pregnancy. It will either plan the completion of the pre-birth assessment and a support package to the parent/s prior to the birth or it will focus on the provision of support once the baby is born.

Pre-Discharge Meeting

If the assessment identifies concerns of risk of significant harm, the child is subject to a plan, or subject to pre proceedings, a Pre-discharge meeting following the baby's birth should be convened and held at the hospital where the child was born. The meeting (face to face/or virtual, due to covid concerns/guidance) should be chaired by the relevant Team Manager. Where the pre-birth meeting identifies that support needs can be met through a Child in Need plan, consideration should be given to holding a discharge meeting or whether a CIN meeting, no later than 10 days after the birth of the baby should be convened (see Appendix 3: Pre-Birth Planning Meeting / Pre-Discharge Meeting).

7. Assessment Toolkit

There are a host of assessment tools that can be used to aid the writing of a pre-birth assessment. See Risk Assessment and Planning Procedure.

The model provides a framework to routinely screen cases for risk and supports the practice of social workers by drawing together the elements of a risk assessment into a professional record. It meets the need of social workers to produce professional risk assessments and enhances effective communication in multi-agency work. It supports decision making and professional judgement.

Stage 1 Risk Assessment, the Risk Assessment Matrix can be found in the Risk Assessment and Planning Procedure and on ICS.

The Impact of Parental Mental Health including Learning Disabilities, problem alcohol and drug use and domestic abuse on children's development – checklist Unborn Child.

Checklist of factors that elevate or lower risks to children where parental carer or substance misuse exists.

Model of Change, The Comprehensive Model of Change (Change Model is a Specialist Assessment Tool developed as part of the Risk Assessment Model).

It is based on material originally presented in "The Child's World". The material has been adapted and a number of tools developed to support the application of the conceptual Change Model into practice.

8. Conducting the Pre-Birth Assessment

The remainder of this document considers the area's that should be addressed within a pre-birth assessment. It provides a range of questions that may be posed to gain a fuller understanding of the prospective parent's capacity to meet the need of the new born child and the extent to which the unborn may be at risk of significant harm following the birth.

These questions and area's for consideration will supplement the prompts within the Stage 1 Risk Assessment,

It may be as part of the pre-birth assessment, social workers or other lead practitioners may want to include the graded care provide also

The mandatory risk tools used must be incorporated within the final Pre Birth Assessment Report as appendices Pre-Birth Assessment. An electronic version of the Pre Birth Assessment Report should be completed and can be found on ICS.

When conducting the pre-birth assessment consideration should be given to the following areas:

Definition of the problem. What is the purpose and scope of the assessment?
Ante-natal care: medical and obstetric history;
Full social history;
Current family structure, extended family and potential support;
The parental relationship and family support;
Family functioning and strengths;
Previous abuse or convictions, including any resulting previous assessments;
Family attitudes towards previous action / professional involvement, and ability to engage them in the current intervention process (Note: It is important to engage both parents in the assessment process);
Assessment of non-abusing parent's ability to protect;
Understanding of expected baby's needs and ability to meet them
Parents with mental health problems;
Parents with a learning disability;
Teenage pregnancy;
Drug and alcohol using parents and anticipated health problems;
Concerns around domestic abuse;
Future plans;
Measuring the family's potential for, and motivation to, change.

Antenatal Care: Medical and Obstetric History

When considering these issues, it is important to be aware that the named lead midwife will have provided the expectant mother with choices about the place of birth and type of care they would like to receive. ‘A booking interview is carried out at around 8-12 weeks of pregnancy either in the womean's home or at a local Children's Centre'.

During the interview the lead midwife, responsible for the patients care, collects information which will build into a full medical and social history. When all the data is collated the midwife is able to assist the women in making informed choices about the care she receives and advises on the suitability of her choices. The midwife will discuss with the women the pattern of care which is most suited to her needs. A holistic approach, taking into account the women's social history will be provided. This needs to be incorporated into the pre-birth assessment.

It is important to be aware that midwifery services will make a formal referral for a Health Visitor during the pregnancy. Within Knowsley, the health visitor will complete an antenatal visit on all first time mothers and those deemed vulnerable parents. It is critical that the named health visitor is part of the pre-birth assessment.

Social History

When planning a pre-birth assessment it is vital to review any previous history. This will include: the quality of their parenting; their early life experiences; social, educational, medical, marital, occupational, criminal (and sexual) history. Consideration should be given to any complications during the pregnancy and birth; any developmental issues and milestones; peer and sibling relationships; school performance; family relationships; drug and alcohol abuse; general impulsivity; anger levels; self-esteem; social skills and competence; and past psychiatric history.

This will entail reading the case files on any siblings/children including those any have been removed from the parents care. In addition searches must be done on any new partners in the household or those who are playing a significant role in the life of the family, particularly checking if they have children with whom they no longer live with and/or have contact to ascertain the reasons for this.

A chronology of significant events must be included within the Pre Birth Assessment Report.

Practitioners must be mindful that repeated Child Safeguarding Practice Reviews point to failures in drawing information together, analysing it and identifying patterns that, when seen together, actually changes the perspective of the case. It is essential that agency colleagues contribute fully to this process.

Reder and Duncan (1999) propose that maltreating parents may experience "care" and/or "control" conflicts in which the parents' own experiences of adverse parenting left them with unresolved tensions that spilled over into their adult relationships. Care conflicts arise out of experiences of abandonment, neglect or rejection as a child, or feeling unloved by parents. They show in later life as excessive reliance on others and fear of being left by them; or by the adult distancing themselves from others; being intolerant of a partner's or child's dependency; unwillingness to prepare ante-natally for an infant's dependency needs; or declining to respond to the needs when the child is born.

Control conflicts are based on childhood experiences of feeling helpless in the face of Sexual Abuse, Physical Abuse or Neglect, or inappropriate limit setting. In adult life they may be enacted through: violence; low frustration tolerance; suspiciousness; threats of violence; or other attempts to assert power over others. Violence or control issues can become part of their relationship with partners, children, professionals or society in general.

Unresolved conflicts can influence the meaning that a child has for its carer. For example: the child's birth may have coincided with a major life crisis e.g. as a consequence of the mother being raped, being abandoned by a partner, or a child born of incest, following which the child becomes a constant reminder of the associated feelings. The child may be blamed for problems in the parent's life or expected to help resolve them.

The Social Worker should attempt to build up a clear history from the parents of their previous experiences in order to ascertain whether there are any unresolved conflicts and also to identify the meaning any previous children had for them.

Area's for enquiry when completing a social history should include:

Family of origin:

Both parent's culture of origin;
Parental criminal / ante-social behaviour;
The extent of any parental alcohol and substance misuse and its consequences for them and their family;
Presence and degree of any parental conflict including physical violence;
What caused this violence? Who was it directed towards?
What were the consequences of that violence then and now?
What did their parents enjoy doing together?
Extent of parental separations and family bereavements?
Family interests and activities?
Allocation of roles and responsibilities?
Family demonstration of feelings?

Childhood:

The nature and quality of family relationships and the type and adequacy of role modelling;
What was it like to be a child in their family home?
Who was special to them and who cared for them the most?
What was their place in the family?
Were they abused or neglected, if so, who by, for how long?
What was the emotional and behavioural consequence for them?
Had there been any referrals to professional agencies?
Any periods of time in local authority care?

School:

Mainstream or special schooling?
Subject to any statement of special educational needs?
Any academic difficulties, behaviour or attainment issues?
School achievements, aptitude, abilities and qualifications?
Existence of any attendance issues?
Reasons for any changes in schooling, moves or exclusions etc?
Any other significant events?

Occupational/social/recreational history:

Degree of success in establishing adult relationships, social, intimate, employment and the degree of satisfaction with these?
Employment history, evidence of any dismissal and extent to which this may indicate social incompetence, problems with authority or substance misuse?
Types of jobs, performance, satisfaction and level of responsibility and dependability;
Types of leisure activities/hobbies/clubs etc. and extent to which these reflect their social skills and self-image?

Criminal history:

Number of previous offences? (One of the best predictors of future abuse is the number of previous offences);
Are the offences against people or property, social rule violations e.g. drink driving?
What is the frequency, circumstances and motivation of the offending behaviour?
When did they become known to the Police/other criminal agencies? What were the circumstances?
Details of previous disposals and the responses to these?
Are they entrenched in their behaviour and what does this mean for the expectant baby?
Is their evidence of escalation in criminal behaviour?
What were their modus operandi and antecedent conditions or behaviours?
Details of victim; ages, offences and consequences for the adult/child?

Current Family Structure and Sources of Support

It is essential to establish the full details of the immediate and extended family and that relevant child protection checks are completed as a means of aiding the assessment and future care planning, if required. In line with signs of safety it may be a family network meeting is convened.

It is important following the signs of safety model, that consideration is given to the family strengths and their potential ability to harness these to produce positive change for the unborn child, as well as the risks that may be prevalent within the household. Examples of relevant questions would include:

What is the family's culture now and that of their origin?
How the parents met?
Why they stay together?
How their relationship has developed and changed?
The positive and negative attributes that exist within the relationship?
Individual parents physical/emotional/intellectual abilities?
Previous parental experiences i.e. number of children?
Extent of disputes and violence in previous relationships?
Extent of abuse substance misuse in previous relationship?
Potential impact of previous problematic adult relationships on couple?
Parents hopes, aspirations, strengths and talents?
Parents range of support networks?
Extent to which parents engage with professional agencies?
Parent's ability to use family strengths to produce positive change?

Attitudes to Previous Interventions

It is particularly important to ascertain the parent(s) views and attitudes towards any previous children who have been removed from their care, or where there have been serious concerns about the parenting practices. Examples of relevant questions would include:

Do the parent(s) understand and give a clear explanation of the circumstances in which the abuse occurred?
Do they accept responsibility for their role in the abuse?
Do they blame others?
Do they blame the child?
Do they acknowledge the seriousness of the abuse?
Did they accept any treatment/counselling?
What was their response to previous interventions? E.g. genuinely attempting about that child now?
What has changed for each parent since the child was abused or removed?

It is important to ascertain the parents' feelings towards the current pregnancy and the new baby including:

Is the pregnancy wanted or not?
Is the pregnancy planned or unplanned?
Is this pregnancy the result of sexual assault?
Is domestic abuse an issue in the parents' relationship?
Is the perception of the unborn baby different/abnormal? Are they trying to replace any previous children?
Have they sought appropriate ante-natal care?
Are they aware of the unborn baby's needs and able to prioritise them?
Do they have realistic plans in relation to the birth and their care of the baby?

Previous Abuse and Acceptance of Responsibility

In cases where a child has been removed from a parent's care because of abuse there are some additional factors which should be considered.

These include:

The ability of the perpetrator to accept responsibility for the abuse although this should not be seen as lessening the risk for additional children (see Section 7, Assessment Toolkit));
The ability of the non-abusing parent to protect. The fact that the child has been removed from their care suggests that there have been significant problems in these areas and pre-birth assessment will need to focus on what has changed and the prospective parent(s) current ability to protect.

Relevant questions when undertaking a pre-birth assessment when previous abuse has been the issue include:

The circumstances of the abuse: e.g. was the perpetrator in the household?
Was the non-abusing parent present?
What relationship/contact does the mother have with the perpetrator? (Assuming the man as perpetrator - however, this is not always the Case);
How did the abuse come to light? E.g. did the non-abusing parent disclose or conceal?
Did the child tell? Did professionals suspect?
Did the non-abusing parent believe the child? Did they need help and Support to do this?
What are current attitudes towards the abuse? Do the parents blame the child/see it as her/his fault?
Has the perpetrator accepted full responsibility for the abuse? How is this demonstrated? What treatment did he/she have?
Who else in the family/community network could help protect the new baby?
How did the parent(s) relate to professionals? What is their current attitude?
In circumstances where the perpetrator is the prospective father or is living in the household, where there is no acknowledgement of responsibility, where the non-abusing parent blames the child and there is no prospect of effective intervention within the appropriate timescale, then confidence in the safety of the new-born baby and subsequent child will be poor.

Circumstances where the perpetrator is convicted of posing a risk to children and is already living in a family with other children, (albeit with social work involvement), should not detract from the need for a pre-birth assessment. In all assessments it is important to maintain the focus on both prospective parents, and any other adults living in the household and not to concentrate solely on the mother.

Non Abusing Parents Ability to Protect

When considering capacity of non-abusing parents to protect it is important to assess their own personal history and particularly their understanding in and perception as regards the abuse perpetrated by the partner. Smith, 1994 cited from Calder (2003) poses a number of relevant questions including:

How critical or uncritical are they regarding their partner's abusive behaviour?
To what extent were they party to or aware of their partner's abusive behaviour?
What has changed regarding their understanding of past abuse?
To what extent to they accept responsibility for failure to protect or collusion with the abuse?
What is the non-abusing parent's position regarding the abuse/conviction both at the time and now?
What information do they have regarding the abuse and who provided it?
Can additional information be provided to move the parent from any disbelieving position?
What feelings do they have to the child? E.g. anger, sympathy, blame?
To what extent does the non-abusing partner accept that their partner was responsible for the abuse?
To what extent can the non-abusing partner work with Children's Social Care and other agencies?
Could/can they choose their unborn child over abusing partner?
To what extent is the non-abusing partner dependent on the abuser?
How vulnerable is the non-abusing partner?
Do they have a history of violent or abusive relationships?
Does the non-abusive partner have other vulnerabilities i.e. disability, ill health, or other condition that isolates them from help?
To what extent do they recognise the existence of future risk to the unborn child?
What is their ability to manage this?
What level of knowledge do they have re the impact sexual offending behaviour in general and specific to partner?

Understanding of expectant baby's needs and ability to meet them

When looking at the parents capacity to understand and meet their new born baby's needs. Consideration should be given to the expertise of Family Support Workers in carrying out this task and those relating to practical preparation for the baby and parental insight into the development of routines and baby's basic needs. Suggested tools for this are; 'You and Your Baby 0-1 Year' and 'The Wonder Year: First Year Development and Shaping the Brain' DVD. (See Bibliography for further details).

Mental Health Problems

Although most parents with mental health needs are able to care for their children appropriately, research has indicated that child-maltreating parents are often shown to have mental health problems e.g. depression, history of attempted suicide, schizophrenia etc. Non- compliance with medication without medical supervision is a cause for concern. Children are at increased risk of abuse by psychotic parents when incorporated into their delusional thinking e.g. "(the baby) is trying to punish me for my sins".

Calder (2003) notes that the practitioner needs to be aware that:

Parental illness affects children, but not necessarily adversely;
Mental illness can affect the capacity of parents to parent and the resulting parent/child relationship;
Parents may not be able to address the needs of their new-born child safely or adequately as a result of their illness;
Caring for children affects the mental health of the parent. The challenges of parenting can precipitate and influence parental mental illness;
Children's mental health and development needs have an impact on parental mental health.

If mental health is likely to be a significant issue, more detailed assessment should be sought from professionals with relevant expertise. While the practitioner will need to obtain a mental health assessment in these cases it is important not to become "paralysed" if that is not forthcoming. It is essential to continue the assessment based on the behaviour of the parent(s), not the diagnosis, and the potential risk of that behaviour to the need to include the risk to unborn to new-born child. In addition, where there are mental health risk factors identified, ongoing revaluation of risk is essential (see Section 7, Assessment Toolkit).

There it is suspected that a prospective parent may have a learning difficulty that may result in significant harm to the new born child a more detailed assessment should also be sought from professionals with the relevant experience.

Substance and Alcohol Misuse

Social workers must always use the expertise with community alcohol and substance misuse teams as well as other relevant health professionals when considering the implications of drug and alcohol misuse on the unborn child and the impact post-delivery.

While Drug or alcohol misuse is not in itself a contra-indication that the parent(s) will be unable to care safely for the baby, excessive parental substance and alcohol misuse is likely to have a detrimental impact on the unborn child. Cleaver et al (1999).

The Social Worker will need to give consideration to the following:

What type of substances is the prospective parent/s dependent upon?
What is the route/amount/duration/pattern of the substance misuse?
The consequences for the baby of the mother's substance misuse during pregnancy e.g. withdrawal symptoms, and for the parenting of any other children in the household.
The history of parental substance misuse, current dependency.
Any evidence of being incapacitated/comatose or paranoid/overtly psychotic?
Is the prospective parent engaged with drug and alcohol services?
Motivation to engage with drug and alcohol services?
What is the prospective parent/s understanding of the potential effects of their substance misuse on the unborn and new born child?
Can parental substance misuse be managed compatibly with the demands of a new-born child?
What has been the impact of parental substance misuse been on other children/sibling within the household?

Domestic Abuse and Other Violent Behaviours

A current and/or previous history of domestic abuse and or violent behaviour should be carefully evaluated. When addressing these issues it is recommended that the Multi-Agency Domestic Abuse Guidance for Working With Children should read and applied.

Detail should be obtained about:

The nature of violent incidents;
Their frequency and severity;
Information on what triggers violent incidents;
The non-abusing/non-violent parent's recognition of the potential risks as a result of the history of or current domestic abuse / violent behaviour see 'Domestic Abuse assessment' in tools.

Some babies may be more difficult to care for than others. Research has indicated that the risks are greater when a parent with unresolved care and control conflicts is caring for a baby with particular characteristics which may make him/her harder to care for e.g. a poor feeder or sleeper, constant crying, a disabled child, etc.

During the pre-birth assessment increased risk factors may be prevalent for example:-

Domestic abuse incidents in the pregnancy;
Parent/s may exhibit aggressive behaviour;
There may be pregnancy complications that could lead to e.g. pre-term delivery with the result of a baby that will require a higher level of care.

It is essential that there is close liaison with the midwives and obstetricians in relation to these factors. It is also important to examine the history of previous children who have been removed from the parent(s) care. This will indicate if there were particular characteristics which made that child harder to care for. It is essential to find out from the parent(s) what problems, if any/they identified in caring for that child.

Support Networks

Caring for a new born baby is difficult enough for any parent but can be particularly stressful if the parent(s) are isolated and do not have a network of support. A social worker should complete the support network questionnaire that is held on ICS. It is important to identify whether partners are going to share responsibility or whether it will fall to one, usually the mother.

Research has indicated that when children have been abused the trigger may often be a family crisis e.g. loss of home or job, marital problems or upheavals, physical exhaustion, etc. (Reder and Duncan, 1999, p.69). However, there are many other triggers and factors that will need to be considered within an assessment.

It is therefore important to identify the support networks that the parent(s) have, their financial and housing position. Clear guidelines are outlined in the Framework for Assessment of Children in Need and their Families. In addition signs of safety guidance can also be followed when considering a family network meeting to identify who can support parents caring for their unborn child, post birth.

Teenage Pregnancy

The demands of caring for a baby at a time when young people themselves are making the difficult transition from adolescence to adulthood are significant. Consequently teenage mothers and young fathers need additional support from family, partners and services if they and their children are to avoid the poor outcomes that many currently experience.

The poor outcomes experienced by teenage mothers and their children include:

Poorer outcomes for children born to teenage mothers, both in terms of their health, but also in regard to their behaviour, attainment and future economic well-being;
Poor emotional health and well-being; and
Poor economic well-being.

Risk factors associated with teenage pregnancy, such as socio-economic deprivation; limited involvement in education; low educational attainment; limited access to consistent, positive adult support; being a child of a teenage mother; low self-esteem; and experience of sexual abuse, are to be found more often in the looked after population than among children and young people who are not in care.

Parent's Potential for and Motivation for Change

Parental capacity and motivation for change is a critical part of the pre-birth assessment and is critical to future care planning. The Risk Assessment Model 'Change Tool' provides clear guidance which should be followed when considering this issue. See Section 7, Assessment Toolkit.

Analysis

Once the information has been gathered through the pre-birth assessment process it needs to be written up a final report on the template.

Information will have been gleaned from a range of different sources much of which will be contained within the mandatory risk assessment tools and the single assessment completed as part of the process. Supplementary tools should have been completed to further evidence the existence of risk and protective factors. All of the risk assessment tools used should be attached to the final report as appendices.

Critical to the final report is a detailed and robust analysis. It is important to recognise that analysis is far more than a description or summary of the assessment. The aim of the assessment is to accurately identify the level of anticipated risk and look at whether this risk is manageable or not. (Calder, p.82 2008).

The analysis needs to be logical, evidenced based and must focus on the impact of parental capacity and environmental factors on the unborn child. It needs to consider both parental strengths and weaknesses and any reoccurring patterns of parental behaviour. The analysis should draw some conclusions as to the parents motivation to change and what actions need to be taken to either safeguard the child or provide the necessary levels of support to enable the unborn child to thrive once born and fulfil their full potential.

Finally the Pre-birth Assessment Report should make clear recommendations to aid future planning. It is these recommendations that will be considered by a Child Protection Case Conference and subsequent Core Group Meetings, a Child in Need Meeting or the Court.

The outcome of the Pre-Birth Assessment should be shared with parents and all agencies involved with the assessment.

Once child is born, he or she should not be discharged from hospital until a pre-discharge meeting chaired by a Team Manager from social care has been arranged and everyone involved is aware of the plan.

9. Non Compliance with the Pre-Birth Assessment

If a parent/s do not engage in the pre-birth assessment, this may be due to a number of factors which will need to be explored, i.e. it may be a care leaver is fearful of engaging because of past experiences, and the worker will need to work hard to engage the parent/s building up a trusting working relationship (see Knowsley Engaging Families Toolkit). In some cases it may be that the parent/s are just not complying with the assessment, i.e. may not be home for assessment visits, in this case the worker should refer to the No Access Visit Guidance, as the parent/s may be avoiding professional involvement and in such a scenario the worker will need to alert their supervisor and a strategy meeting may need to be convened. The Department for Education has released the updated version of Working Together to Safeguard Children.

The changes will be reflected in this manual at the next update.

10. Escalation

If agencies are not in agreement with how the pre birthpre-birth assessment is progressing or do- not agree with the assessments or plans for an unborn child then Knowsley Children's Safeguarding Partnership Escalation procedure should be implemented, see Appendix 5: Knowsley Childrens Safeguarding Partnership Escalation Procedure.

Appendices

Appendix 1: Multi-Agency Pre-Birth Assessment Flowchart

Appendix 2: Social Care Pre-Birth Assessment Flowchart

Appendix 3: Pre-Birth Planning Meeting / Pre-Discharge Meeting

Appendix 4: Risk Estimation - A Framework for Practice (Calder 2008)

Appendix 5: Knowsley Childrens Safeguarding Partnership Escalation Procedure