10.13 Concealed Pregnancy
Last reviewed in February 2019.
Next review in Feb 2023
This procedure is for anyone who may encounter a women or girl who conceals the fact that she is pregnant, or where a professional has a suspicion that a pregnancy is being concealed or denied, or a woman or girl significantly delays access to antenatal care. While concealment and denial, by their very nature, limit the scope of professional help, better outcomes can be achieved by a coordinating an effective inter-agency approach. This will also apply to future pregnancies where it is known or suspected that a previous pregnancy was concealed.
- Risks/Protection Issues
- Recognition and Referral
- Planning and Intervention
- Future Pregnancies
A concealed pregnancy is when:
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:
A late booking is defined as presenting for maternity services after 20 weeks It is always important to remember that unless the women genuinely has not been aware she is pregnant she has still concealed her pregnancy up until the point she has accessed antenatal care. A booking appointment with a midwife should be around 10 weeks (NICE 2008). A woman who presents to antenatal care late in her pregnancy should continue to be assessed with the reasons for the delay in presentation and associated risks as part of the assessment, even once booked and attending for antenatal care.
For the purpose of this procedure a woman is referred to as any female of childbearing capacity (including under 18 year olds).
Migrant women: professionals should consider the set of circumstances for women who have presented late in pregnancy and been without access to health care; an interpreter should always be used in such circumstances where a woman’s language skills would prevent a risk assessment on booking into antenatal care.
Unassisted or free birth means a woman giving birth without medical or professional help. It is a criminal offence for anyone other than a registered midwife or doctor to attend a woman during childbirth except in an emergency. (Article 45 of the Nursing and Midwifery Order). Free birth in itself is not a reason to refer to children’s services; however should there be safeguarding concerns other than just the decision to free birth then a referral should be made.
The reason for the concealment will be a key factor in determining the risk to the unborn/child and any other children in the household or family; these reasons can include but are not limited to; mental illness, learning disability, domestic abuse, sexual abuse, fear of social services involvement, substance misuse, religion and culture believes, incestuous or extra marital paternity and anti-medical intervention. There may be risk to mother and unborn child, as well as other children in the family. Children’s social care history should be considered to help identify reason for concealment. Professionals need to consider the potential vulnerability of the woman and the impact on her baby.
Where there is concealment, there can be risks for the child's health and development in utero as well as postnatally, 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 concealed in situations of domestic abuse which may be more likely to begin or escalate during pregnancy.
There may be risks to both mother and child if the mother concealed the pregnancy due to fear of disclosing the paternity of the child, for example where the child was conceived as the result of sexual abuse, or where the father is not the woman's partner. Young teenage women may conceal their pregnancy due to fear of recrimination from others, such as their parents, peers and/or professionals.
Late booking can be the result of a women presenting for a termination of pregnancy but unable to have this procedure as the pregnancy is over 24 weeks. Professionals need to consider the reasons for presenting late to termination services, associated risk factors, and level of support needed when the woman continues with an unwanted pregnancy including her psychological support needs. Consideration should be given to a children’s social care referral.
The implications of concealment are wide-ranging. Concealment of a pregnancy can lead to a fatal outcome, 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 may mean that:
An unassisted delivery can be dangerous for both mother and baby, due to complications that can occur during labour and the delivery.
Postnatal risks include
All of the above highlight the need for an increased level of health services and ongoing assessment of mother and baby’s well-being, and monitoring safeguarding risks to the child/children in the period following the birth of the baby.
Recognition and Referral
All professionals are responsibility for supporting a woman to access and attend antenatal care at the point a concealed pregnancy is disclosed or suspected. Depending on the reasons given for concealment and/or denial, a women may need support accessing mental health services; including referral to perinatal mental health care.
Action on Suspecting Concealed Pregnancy
Young People aged under 18
If the professional has a concern that a young person could be pregnant and not accessing antenatal care, then they should make a referral to Children's Social Care 13.1 Local Contact Details for the young person and a Child and Family Assessment will be carried out. All professionals need to be mindful of the reasons and associated risks that contribute to why women may conceal their pregnancies see 8.10.6 and consideration given to safeguarding both the young person (under 18 years) and the unborn baby.
It is illegal for children under 16 years to be sexually active; professionals will assess whether the young person’s actions and decision making are Gillick competent and whether to involve safeguarding partners.
Please refer to Sexually Active Children procedure: 8.35 https://sussexchildprotection.procedures.org.uk/tkyyl/children-in-specific-circumstances/sexually-active-children
It may be appropriate for a professional from any agency to make initial approaches to the young person to discuss the possibility of her being pregnant, if her presentation and personal circumstances evidence this. Professional curiosity is essential to safeguarding children but will require sensitivity also, and consider requesting support from health colleagues.
If the young person refuses to engage in constructive discussion, in the face of clear reasons to continue to suspect that she is pregnant, it may be in the young person’s interest to involve their parents/carer in the conversation but also be mindful in some circumstances this could put the young person in greater risk, for example Honour Based Abuse. In these circumstances a conversation with the young person’s GP would be in their best interest.
If the young person continues to refuse to engage in constructive discussion, and the professionals have clear reasons to suspect pregnancy in the face of continuing denial then Children's Social Care should carefully consider if informing her parents/carers is in the best interest of the young person and continue to assess the situation with a focus on the needs/welfare of the unborn baby as well as the young person. Caution is required with all disclosures to a young person’s parents that a professional is not putting the young person at further risk, for example Honour Based Abuse.
Young people presenting late in pregnancy should be assessed by maternity services at the booking appointment and potential risks highlighted and considered in relation to safeguarding the young person (under 18 years) the unborn baby and any other children in household or family. This will inform the decision as to whether to refer to children’s social care, and consider what early help services could support the family.
Women Over 18
Where the 'expectant mother' is over 18, every effort should be made to resolve the issue of whether she is pregnant or not. The vulnerability of the adult needs to be considered and signposted to appropriate services, which may include adult social care.
No woman can be forced to undergo a pregnancy test, or any other medical examination, but in the event of refusal with clear reasons to suspect the women is pregnant, professionals should proceed on the assumption that the woman is pregnant until or unless it is proved otherwise. A referral to children’s social care 13.1 Local Contact Details will be required for a multi-agency decision and assessment to make plans to safeguard the baby's welfare at birth. All professional referrals should include an assessment of risk.
Women presenting late in pregnancy, after 20 weeks, should be assessed by maternity services at the booking appointment and potential risks highlighted and considered in relation to safeguarding the unborn baby and other children within the household or family;. This will then inform the decision if referral to children social care is required and consider what early help services would support this family.
Actions On Concerns That A Woman Is Concealing A Pregnancy
Multi-agency liaison should occur involving the GP, midwife, health visitor and any other relevant agency to assess the information and to construct a plan.
It may be appropriate to invite a representative from Mental Health Services (child or adult as appropriate) so that support, advice and/or consultation are available at an early stage.
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 (see Section 47 Enquiries Procedure), which may include convening a pre-birth Child Protection Conference (see Pre-Birth Child Protection Procedure).
Planning and Intervention
An unborn child has no legal status. Law cannot force an expectant mother, to have any medical intervention at birth unless she is deemed not 'of sound mind'. It is only possible to make appropriate contingency plans and to ensure that the woman/child/young person is fully aware of the consequences of her actions. In such circumstances, legal advice should be sought.
Only when the underlying reasons for a previous concealed pregnancy are known, understood, explored and addressed, can the risk associated with future concealment be substantially reduced.
Assessments should identify clear expectations of parents/carers and ensure that should they fail to comply this would constitute a significant risk factor and point to the need to activate further child protection processes and/or Care Proceedings. Under such circumstances legal advice should be sought.
Police must be notified of any child protection inquiries made by children's social care following a concealed pregnancy. Consideration must be given as 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 risk of significant harm.
Action on Presentation In Labour Or Following An Unassisted Delivery Of A Concealed Pregnancy
Action by Maternity Staff
In all cases where a child/young person/woman arrives at hospital in labour or following an unassisted delivery, as a result of a concealed pregnancy, an immediate referral must be made to children's social care - see Making a Referral Procedure.
The baby should not be discharged until a Strategy Meeting has been held and appropriate assessments undertaken. The Strategy Meeting must consider the initiation of a psychiatric assessment; mental health representation should be included in this strategy meeting.
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 children's social care have been informed and given their approval for discharge, in most instances this would be until after a Strategy Meeting has been undertaken. The baby should not be discharged out of hours.
Action by Children's Social Care Staff
In situations where a child/young person /woman presents during labour then consideration should be given to commencing a Section 47 Enquiry.
If a child/young person /woman presents following unassisted delivery at the end of a concealed pregnancy then a Section 47 Enquiry must commence.
Immediate Protective Actions
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, e.g. Police Protection, 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.
Police must be notified of any child protection inquiries made by children's social care following a concealed pregnancy. Consideration must be given as to whether a joint investigation is needed. This will depend on whether an offence may have been committed or if the child is at risk of significant harm.
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.
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 must include a clearly defined system for alerting children's social care if a future pregnancy is reported or suspected.
Where there is a known history of previous concealed pregnancy, consideration for a referral to Children's Social Care as soon as any subsequent pregnancy is known. Women who have already concealed a pregnancy are at an increased risk of doing so in the future. A referral should also be considered when a previous pregnancy was booked late into antenatal care; considering the reasons given and associated risks to the woman and unborn child.
Children's social care must convene a multi-agency Strategy Meeting and agree a plan to address any potential/identified risks resulting from 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 risks associated with future concealment be substantially reduced.
Where there is a known plan in place, it must 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.