Concealed Pregnancy

The aim of this protocol is to provide frontline professionals with a knowledge base and action strategy for the assessment, management and referral of women and young girls who are concealing the fact that they are pregnant or where there is a known previous history of concealed or denied pregnancy.

For purposes of this guidance, a late antenatal booking is defined as 20 weeks gestation and after.

A late booking may indicate safeguarding concerns or no concerns at all. This guidance deals with cases where the pregnancy has been identified or suspected to be deliberately concealed.

Should a late booking not be due to concealment, it may be an indicator that further assessment is required leading to referral to other NHS or Children’s Social Care. This is dependent on professional judgement.

This guidance applies to women and girls of child bearing age.

A concealed pregnancy is when:

• A woman knows she is pregnant but does not tell anyone; or
• A woman appears genuinely unaware 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. This can become apparent at any stage of the pregnancy.

Concealment of pregnancy may be revealed:

• Late in pregnancy;
• In labour; or
• Following delivery. The birth may be unassisted and may carry additional risks to the child and mother's welfare.

A late booking is defined as presenting for maternity services after 20 weeks of pregnancy.

• The pregnancy may be undetected where both the mother and her health care providers are unaware that she is pregnant (e.g. a peri-menopausal woman with an abdominal lump initially suspected to be a tumour);
• It may be a conscious concealment where the mother is aware of her pregnancy and is emotionally bonded to the unborn baby but does not tell anyone;
• The pregnancy may also be denied, this may be conscious denial where the mother has physical awareness of her pregnancy, but lacks emotional attachment to the foetus; or
• Unconscious denial where the mother is not subjectively aware of her pregnancy and genuinely does not believe the signs of pregnancy or even the birth of the baby (e.g. Psychotic delusion).

Reasons for a Concealed Pregnancy

The reason for the concealment will be a key factor in determining the risk to the child and mother; that reason will not be known until there has been a holistic risk assessment.

Where there is concealment, there may be risks for the child's health and development in utero as well as subsequently, especially if this is a result of alcohol or substance misuse. There may be risks to the unborn baby from prescribed medications.

A pregnancy may be deliberately concealed in:

• Situations of domestic abuse which is more likely to begin or escalate during pregnancy. This could include the fear of being forced to have a termination by a partner, therefore the pregnancy may be denied or concealed until this no longer remains an option;
• As a result of previous children’s social care involvement resulting in removal of previous children;
• Religious or cultural disapproval;
• Migrant women may be unaware that they can access Maternity Care or fear of being presented with a large financial bill for care.

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. Young teenage women may conceal the pregnancy due to fear of recrimination from their parents or peers or professionals.

Implications of a Concealed Pregnancy

The implications of concealment are wide-ranging. Concealment of a pregnancy can lead to a poor outcome, regardless of the mother's intention.

Concealment may indicate ambivalence towards the pregnancy, immature coping styles, a tendency to dissociate, or serious mental illness (e.g. psychosis) all of which are likely to have a significant impact on bonding and parenting capacity.

Other possible implications for the child arising from mother's behaviour could be a lack of antenatal care resulting in:

• A lack of monitoring of the health and development of the baby during pregnancy and labour; underlying medical conditions, foetal abnormalities or obstetric problems will not be detected; or
• A lack of monitoring of the health and development of the mother during pregnancy and labour; underlying medical conditions or obstetric problems will not be detected or Inappropriate advice being given; or
• Investigations being undertaken, such as potentially harmful medications being prescribed by a medical practitioner unaware of the pregnancy or exposure to harmful substances such as x Rays.

An unassisted delivery can be dangerous for both mother and baby, due to complications that can occur during labour and the delivery.

Post-natal risks include:

• A lack of willingness/ability to consider the baby's health needs; or Lack of emotional attachment to the child following birth; or
• Poor adaptation and abandonment;
• Infanticide; this is the intentional killing of children under the age of 12 months (serious case reviews including Royal Borough of Windsor and Maidenhead).

All of the above highlight the increased safeguarding risks for the unborn child and during the neonatal period.

Young People aged under 16

If a young person under 16 years is thought to be pregnant and denying or concealing the pregnancy, the professional who has the concern should consider asking the young person if they are pregnant.

She should be supported to seek the attention of a medical professional to receive appropriate healthcare and investigations; if she is pregnant, she should be supported to make realistic plans for her pregnancy including offering support for informing her parents.

If the young woman refuses to engage in constructive discussion, in the face of clear reasons to continue to suspect that she is pregnant, the professionals involved should refer to children’s social care for a pre-birth multi-agency assessment according to Berkshire LSCP Child Protection Procedures. Additionally, the young woman should be referred to children’s social care for consideration of a safeguarding assessment in her own right.

In these circumstances, the potential risks to the unborn child and herself would outweigh the young woman's right to confidentiality.

Young People/Women Over 16

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, or any other medical examination, but in the event of refusal, professionals 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. A referral should be made to children’s social care for a pre-birth multi-agency assessment according to Berkshire LSCP Child Protection Procedures.

An unborn child has no legal standing in the UK. Law cannot force an expectant mother, to have any medical intervention at birth unless she lacks capacity and the medical intervention is judged to be necessary and in her best interest. 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.

In the situations where a young girl/woman presents during labour then consideration should be given to commencing a section 47 Inquiry.

If a young girl/woman presents following unassisted delivery at the end of a concealed pregnancy, then a Section 47 Inquiry must commence.

Immediate Protective Actions, following Berkshire LSCP child protection procedures

In normal circumstances this would be through a voluntary agreement, although clearly there could be circumstances in which it might be necessary 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.

In both situations Children's Social Care should consider allocating the assessment to a worker with mental health expertise.

The Police must be notified of any child protection inquiries made by 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. Any assessments, immediate and ongoing should focus on the risk of harm to the baby, mother and indications of bonding, attachment and potential abandonment.

If the child has been harmed, has died or been abandoned, child protection procedures will apply and a joint investigation will be conducted with the relevant Children's Social care team.

Midwives and Maternity Services, including GPs, mental health professionals and health visitors

Midwives, health visitors, mental health professionals and GPs should ensure that they follow internal guidelines for concealment of pregnancy and ensure that:

• Information regarding the concealed pregnancy is placed on the child's records, as well as the mother's records, including notifying alerts as per internal guidance;
• The health visitor is informed to enable the required level of post-delivery targeted support;
• Should there be a concern that the mother has a learning disability the mother can be referred to the Community Team for People with Learning Disabilities (CTPLD). Additional support from health professionals, including community nursing and psychology can be provided that may help with enhancing the mother’s understanding of pregnancy and birth and provide emotional and psychological support before and after the birth of the child;
• The discharge summary from maternity services to primary care and to health visiting services must record if a pregnancy was concealed or booked late (after 20 weeks);
• Should there be concern about mental health, the mother must be offered a referral to perinatal mental health services including assessment of attachment and bonding to her newborn baby. This can be invoked during the antenatal period if discovered in time;
• It is unusual for a woman to refuse offers of extra support in these cases; therefore, in any event, if a mental health or perinatal assessment is judged necessary by a clinician and the woman declines to access it, this should increase the clinicians’ concerns about the baby’s wellbeing and strengthen the need to consider a referral to children’s social care;
• Enhanced targeted supported should be provided by midwifery and by Health visiting services as per internal agency procedures.

Following a concealed pregnancy or unassisted delivery, midwives, health visitors and GPs need to be alert to:

• An increased level of professional engagement required for the mother (and her extended family);
• Difficulties with bonding, attachment and post-natal mental health issues. The receptiveness to future contact with health professionals;
• An awareness of and vigilance for, disguised compliance.

Health Professionals (general)

A wide variety of health professionals may be in contact with women and girls of child bearing age and should consider, where circumstances suggest it, whether a pregnancy is being concealed. This includes those professionals working directly with the woman or young girl in inpatient, community or primary care settings.

Those professionals working in mental health and learning disability may also be involved with a woman who is concealing a pregnancy.

Mental illness, emotional problems, personality problems, a learning disability or substance misuse may all be contributory factors as to why some women conceal the fact that they are pregnant.

The health professional identifying the potential concealment of a pregnancy should inform the woman of plans to refer to Children’s Social Care in respect of a concealed pregnancy, unless to do so would place the unborn child at greater risk, and share the information with health colleagues including midwifery, GP and health visiting services to ensure access to appropriate services and support.

Document details of conversations and actions within the record contemporaneously.

Given that a previous concealed pregnancy indicates increased risk of further concealment, where this has been the case it should be highlighted in the G.P, midwifery, mental health and health visiting records.

As partner agencies of the LSCPs health professionals will be expected to participate in, and contribute to, a multi‐agency assessment of risk to the woman and her unborn baby and to the provision of additional support to the child and family as appropriate. At any stage, professionals should consider involving local specialist services who are experts in working with young people; for example sexual health outreach services and specialist midwifery team for vulnerable women.

Staff in Educational Settings

If a member of school staff is concerned that a pupil is attempting to conceal or deny a pregnancy or appears to be unaware that she may be pregnant, the following procedures should be followed:

• Inform the Designated Safeguarding Lead or Head Teacher;
• Discuss concerns with the pupil, unless in doing so you consider this may increase the risk of harm to the student or to her unborn child;
• Seek consent from the pupil to share your concerns with her parents or carers. If the pupil is reluctant to consent to her parents or carers being informed this must be treated with sensitivity and respect but the pupil must be informed that a referral will be made to Children’s Social Care;
• Inform the pupil and her parents of your intention to share your concerns with Children’s Social Care in the area in which the pupil resides;
• Document conversations with the pupil and her parents or carers contemporaneously and a copy of the written referral to Children’s Social Care, retained in the child’s confidential school record;
• As partner agencies of the LSCPs school staff will be expected to participate in, and contribute to, a multi-agency assessment of risk to the child and her unborn baby and to the provision of additional support to the child and family as appropriate.

Police

The Police will be notified of any referral that may require s47 enquiries to be made by Children’s Services Social Care following a concealed pregnancy.

Strategy discussions will determine further police involvement.

Other Agencies

All professionals from statutory and voluntary agencies who provide services to young people and women of child bearing age, should be aware of the risk indicators of concealed or denial of pregnancy and how to act on these concerns; for example, contact children’s social care, follow Berkshire child protection procedures.

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 it is known there is a history of previous concealed pregnancy, referral must be made to Children's Social Care as soon as any subsequent pregnancy is known. Women who have already concealed a pregnancy are at a particular risk of doing so in the future.

Children's Social Care will convene a multi-agency Strategy Meeting and make a plan to address any potential risk within a future pregnancy. Sharing information openly will be a critical factor in safeguarding the unborn child and professionals will need to accept this may be without the consent of the mother concerned.

Only when the underlying reasons for a previous concealed pregnancy are revealed, explored and addressed, can the risk associated with future concealment be substantially reduced.

Where there is a known plan in place, it should be activated as soon as professionals become aware of a subsequent pregnancy. The urgency of the meeting will depend on the stage of pregnancy. It is important that all key professionals working with the family are included. At any stage in the process, consideration must be given to the appropriateness of a full psychiatric assessment.

Flowchart for Management of Concealed Pregnancy