Concealed Pregnancies

Research into concealment and denial of pregnancy is relatively recent and has attempted to understand the characteristics of women who conceal or deny their pregnancy. The research highlights that women who conceal their pregnancies have no clear typology (Chen et al 2007) and come from all social classes, irrespective of age, educational or marital status (Hatters Friedman et al 2007, Wessel et al 2007). Women who conceal or deny their pregnancy are often mischaracterised as primiparous teenagers with poor support systems and lack of long-term partnerships. However, Stenton & Cohen (2020) found that more than half of the women in their study were in long term relationships and nearly one third had had a previous pregnancy.

Denial of pregnancy is an important condition that is more common than expected, with an incidence at 20 weeks gestation of approximately 1 in 475. The proportion of cases persisting until delivery is about 1 in 2500, a rate similar to that of eclampsia. Denial of pregnancy poses adverse consequences including psychological distress, unassisted delivery and neonaticide (killing of a child by a parent in the first 24 hours following birth). It is difficult to predict which women will develop denial of pregnancy. (Jenkins et al, 2011)

The issue of concealment and denial of pregnancy, and infanticide/filicide (the killing of a child by a parent) can be evidenced throughout human history. Several studies (Earl, 2000); (Friedman S. M., 2005); (Vallone, 2003) (Tursz and Cook, 2010) highlight a well-established link between neonaticide and concealed pregnancy. A review of 40 Serious Case Reviews (DH, 2002) identified that one death was significant to concealment of pregnancy.

One study suggests that denial of pregnancy can be linked to trauma and risk factors such as rape, PTSD (post-traumatic stress disorder) and complex PTSD. The trauma can come from an early attachment trauma, a history of physical and sexual abuse as well as trauma associated with the conception of the denied pregnancy, or a combination (Kenner, Nicholson, 2015).

Local Safeguarding Children Boards (LSCB'S) have conducted safeguarding reviews of cases where concealment or denial of pregnancy has been identified as a factor in the death or serious injury of a child (Murphy, Tighe & Lola, 2015). Data around the frequency of concealment or denial of pregnancy is not freely available but does appear within the literature.

Wessel (2002) found 1 case of denied pregnancy in 475 births. Subsequent studies suggest that 1 might occur in about 1:2500 cases (0.04%). A study by Friedman (2007) showed a higher proportion with 0.26% of all pregnancies in their sample of approx. 31,000 women to be concealed or denied. The characteristics of those in this study showed that 50% of those concealing the pregnancy and 59% of those denying the pregnancy were aged between 18 and 29 years. Only 40% of those concealing and 23% of those in denial of their pregnancy were under 18 years of age.

Evidence from Research and serious case reviews taken from the Blackburn with Darwen, Blackpool and Lancashire Children's Safeguarding Assurance Partnership, Concealed and Denied Pregnancy Guidance.

In the following circumstances of a concealed pregnancy, a referral (see Cumbria Multi-Agency Thresholds Guidance and the supporting document Cumbria Understanding The Level of Need and Practice Response which can be used alongside the Threshold Guidance) to the Multi-Agency Safeguarding Hub may be appropriate in order that a multi-Agency assessment of risk can be determined:

• Children under the age of 13 (a referral is required in all circumstances where the child is under 13);
• Children between the ages of 13 and 16 years;
• Abuse of drugs/alcohol by the pregnant woman (or partner);
• Concerns about parenting capacity;
• Concern about how the women became pregnant and subsequent risk to the child;
• Victim of Domestic Abuse;
• Suffering from Learning Disabilities/Physical Disabilities where she may need additional support to provide for the child;
• Significant and enduring mental health issues.

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

• Increased weight or attempts to lose weight;
• Wearing uncharacteristically baggy clothing;
• Concerns or disclosures expressed by friends;
• Repeated rumours of pregnancy around school or college;
• Uncharacteristically withdrawn or moody behaviour;
• Missing from home or education;
• Child exploitation.

Staff working in educational settings, should try to encourage the pupil to discuss their situation, through normal pastoral support systems, as they would any other sensitive issue. Every effort should be made by the professional suspecting a pregnancy to encourage the young person to obtain medical advice. However, where they still face total denial or non-engagement further action should be taken. The Designated Lead Person for Safeguarding must be informed.

Consideration should be given to balance any need to preserve confidentiality and the potential concerns for the mother and unborn baby's health and wellbeing. Where there is a suspicion that a pregnancy is being concealed it is necessary to share this information with other agencies, irrespective of whether consent to disclose can be obtained. When a mother is under the age of 18 years, or an adult with care and support needs safeguarding concerns for the mother should also be considered and acted upon.

Prior to staff discussing concerns around a concealed or denied pregnancy with the parents of the young person a safeguarding risk assessment should be undertaken. It may be felt that the young person will not admit to their pregnancy because they has genuine fear about their parent's/carer reaction, or there may be other aspects about the home circumstances that give rise to concern, such as sexual or domestic abuse, exploitation,So-called 'Honour' Based Abuse, forced marriage and FGM. If this is the case, then a referral to Children's Social Care should be made without speaking to the parents/carers in the first instance.

If there is a lack of progress in resolving the matter in the setting or escalating concerns that a young person may be concealing or denying they are pregnant, there must be a referral to Children's Social Care. It must not be forgotten that where the mother is under 18, they may also be considered a Child in Need or Child in Need of Protection. Where there are significant concerns regarding the girl's family background or home circumstances, such as abuse or neglect, negative childhood experiences of being parented, risk of/victim of exploitation, a history of missing from home and/or education, a referral should be made. As with any referral to Children's Social Care, the parents/carers and young person should be informed, unless in doing so there could be significant concern for their welfare or that of their unborn child.

Staff working in an Early Help environment may come across or suspect a concealed or denied pregnancy in a young person, or in a woman of a family they are working alongside. Staff should use professional curiosity and try to encourage the person to discuss their situation with them if they suspect concealed or denied pregnancy. Every effort should be made by the professional suspecting a pregnancy to encourage the person to obtain medical advice. However where they still face total denial or non-engagement further action should be taken and safeguarding policies and procedures followed. It must not be forgotten that where the mother is under 18, they may also be considered a Child in Need or Child in Need of Protection.

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

Early Help involvement is likely to be beneficial and may include (Local services may differ)

• Early Help Assessment and offer of support and practical help regarding preparing for birth, parenting skills and other routine family maintenance and coping mechanisms;
• Referral to services for emotional health and wellbeing support;
• Regular team around the family meetings bringing agencies together.

If Early Help Services engage with the young person's parents/carers they need to consider the possibility of the parent's collusion with the concealment. Whatever action is taken, whether informing the parents or involving another agency, the young person should be appropriately informed, unless there is a genuine concern for the wellbeing of the mother and their unborn baby.

Providers of healthcare are also responsible for ensuring they fulfil their statutory duties for safeguarding.

The health professionals who may be involved include:

• Paediatric staff in hospitals;
• Emergency department staff;
• Out of hours health services;
• Health Visitors;
• School nurses;
• Sexual Health and GUM services;
• General Practitioners and Practice nurses;
• Midwives and Obstetricians/Gynaecologists;
• Mental Health Nurses;
• Substance Misuse services;
• Learning Disability workers;
• Psychologists and Psychiatrists;
• SUDC (Sudden or Unexpected Death in Childhood) Nurses;
• Ambulance service;
• Commissioned unplanned pregnancy services.

This is not an exhaustive list.

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

If at the point of the discovery of a concealed pregnancy, there are suspicions the birth may have already taken place – Immediate steps need to be taken to confirm the whereabouts and well-being of the baby/fetus. The actions required will be to inform police and ambulance via a 999 response by the health professional who has the information.

Emergency Department staff or those in radiology departments need to routinely ask women of childbearing age whether they might be pregnant. If suspicions are raised that a pregnancy may be being concealed, these staff should follow the relevant safeguarding procedures.

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

GP practices should consider adopting a flagging system and record the concealed pregnancy on both the mothers and baby's notes. Once born the child should also have this information recorded on their record as it may be relevant in future safeguarding decision making.

Research suggests there is often a poor outcome with post-partum emotional disturbance and increased risk of abuse, neglect, or infanticide (Jenkins et al, 2011). Further research is required to understand the impact of concealed or denied pregnancy on maternal/ infant attachment. There should be extra vigilance by health professionals (midwives, health visitors, GPs) in the post-natal period to monitor mental health and mother - infant relationships and referrals made to mental health and/ or perinatal mental health services (Murphy et al, 2015).

All health professionals should practice professional curiosity and consider the need to make or initiate a referral for a mental health assessment at any stage of concern regarding a suspected or revealed concealed or denied pregnancy.

Staff in primary care should remain professionally curious when seeing women that appear pregnant but are not accessing antenatal care. This is particularly important if the woman has known vulnerabilities, has a history of a concealed or denied pregnancy, and/or is known to children social care themselves or for any of their children in their care or previously in their care.

Women known to have sought advice about termination of pregnancy are particularly vulnerable if they have had to continue the pregnancy for whatever reason. As such a woman continuing their pregnancy after seeking advice about termination, must be considered as a possible higher risk pregnancy. Primary care should therefore have robust systems and processes in place to ensure women continuing their pregnancy receive the appropriate healthcare and support whilst they are pregnant to ensure the welfare of the unborn baby remains paramount.

If an expectant mother presents to Maternity services late, then midwives should exercise their professional curiosity to ascertain why they have booked late and refer to Children’s Social Care if any safeguarding concerns are identified.

If an appointment for antenatal care is made beyond 24 weeks, the reason for this must be explored. If an exploration of the circumstances suggests a cause for concern for the welfare of the unborn baby, a referral to Children's Social Care must be made.

The expectant mother should be informed that the referral has been made, the only exception being if there are significant concerns for their safety or that of the unborn child.

If an expectant mother arrives at the hospital in labour or following an unassisted delivery, where a booking for antenatal care has not been made, then a referral to Children's Social Care must be considered to ensure the safety of the baby. If this is in an evening, weekend or over a public holiday then referring to Children's Social Care Emergency Duty Team should be considered.

If the baby has been harmed in any way or there is a suspicion of harm, or the child is abandoned, then the Police must be informed immediately via 999 and a referral made to Children's Social Care.

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

Neither baby nor the mother should be discharged until they have had full assessment of their needs, including identification of risks and a multi-agency discharge planning meeting held if required. A discharge summary from maternity services to the relevant GP and Health Visitor must report if a pregnancy was concealed or denied or booked late.

If the baby is born at home the midwife or ambulance service (which ever professional is present), should ensure the baby is admitted to hospital even if the mother declines their own admission.

Children's Social Care / Emergency Duty Team may receive a referral from any source, which suggests a pregnancy is being concealed or denied. Consent for further enquires should be sought from the mother unless to do so would place the baby at risk. Safeguarding processes must be implemented and following further enquiries a decision on whether a child and family assessment is required.

Where the expectant mother is under the age of 18, initial approaches should be made confidentially by the most appropriate person (e.g. school teacher, social worker)to the young person to discuss concerns regarding the potential concealed or denied pregnancy and unborn child. The woman should be provided with the opportunity to confirm the pregnancy by undertaking appropriate tests or to make plans for the baby. There may be significant reasons why a young person may be concealing a pregnancy from their family and a professional should consider speaking to them alone without their parent/carer's knowledge in the first instance.

Where there are clear reasons for suspecting pregnancy in the face of continuing denial or concealment, professionals will need to continue to assess the situation with a focus on the needs /welfare of the mother as well as the unborn child. It must not be forgotten that where the mother is under 18, they may also be considered a Child in Need or Child in Need of Protection. Such a situation will require very sensitive handling.

Regardless of the age of the expectant mother where there are additional concerns (i.e. in addition to the suspected concealed or denied pregnancy) where risk factors are present, including ongoing/previous child protection concerns, Children's Social Care will consider undertake an appropriate safeguarding assessment. This could be in the form of further multi agency enquiries (e.g. MASH Assessment) or if the perceived risks and unmet needs are significant a Child and Family Assessment.

If an expectant mother has arrived at hospital either in labour or following an unassisted birth when a pregnancy has been concealed or denied, an assessment of risks will be made by health service who have had contact with the mother. A referral to Children’s Social Care may be made and consideration of appropriate safeguarding assessment

Where a baby has been harmed or has been abandoned a Section 47 enquiry must be completed in collaboration with the Police. When a baby has died the SUDC process should be followed and consideration to implementing safeguarding procedures in relation to any siblings.

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

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

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

Factors to consider will be the age of the expectant mother who is suspected or known to be pregnant, and the circumstances in which they are living and to consider whether they are a victim or potential victim of criminal offences. In all cases where a child has been harmed, been abandoned, died, or expected to die it will be incumbent on the Police and Children's Social Care to work together to investigate the circumstances. This will involve the SUDC team in the event of a child death or where the prognosis is poor. Where it is suspected that neonaticide or infanticide has occurred then the Police will be the primary investigating agency.

It must not be forgotten that where the mother is under 18, they may also be considered a Child in Need or Child in Need of Protection.

All practitioners in probation services who provide services to, or are in contact with women and girls of child bearing age should be aware of the issue of concealed or denied pregnancy and follow this guidance, and own agency safeguarding procedures when a suspicion of concealed or denied pregnancy arises. This could also relate to the partner of a service user who may be concealing or denying a pregnancy.

If an ambulance crew attends a female in labour and a concealed or denied pregnancy is suspected or revealed/ confirmed then the patient must be transported to the nearest maternity unit, and consideration given to raising a safeguarding concern. If birth has taken place then the mother and baby must be transferred to the local maternity unit. If the baby is born at home the midwife or ambulance service (which ever professional is present), should ensure the baby is admitted to hospital even if the mother herself declines their own admission

If at the point of the discovery of a concealed pregnancy, there are suspicions the birth may have already taken place – immediate steps need to be taken to confirm the whereabouts and well-being of the baby/fetus. The actions required will be to inform Police and Ambulance via a 999 response by the member of staff who has the information.

All Pregnancy Advisory Services that provide termination of pregnancy services (either directly delivered by NHS services or charities commissioned by the NHS) have a responsibility to safeguard patients at risk of concealed/ denied pregnancy.

Pregnancy Advisory Services must work with external statutory agencies to notify them of patients who seek termination of pregnancy care but do not proceed with treatment. This could be for a variety of reasons such as DNA/ WNB (did not attend/ was not brought), cancellations of appointments, scanning over the legal limit.

This is particularly important for patients who seek termination of pregnancy care at later gestations (past 19 weeks), who are under the age of 18 and who have safeguarding concerns/ vulnerabilities, who are considered higher risk of concealed/ denied pregnancy.

Pregnancy Advisory Services must complete external statutory agency checks for all possible concealed/ denied pregnancies, this must include at first instance, GP’s and maternity services. This is to ensure that patients who do not obtain treatment after seeking termination of pregnancy care- go on to get appropriate antenatal care even if they appear to have no vulnerabilities.

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