Concealment and Denial of Pregnancy

The concealment and denial of pregnancy presents significant challenge to professionals in safeguarding the welfare and wellbeing of the unborn child and the expectant mother. While concealment and denial, by their very nature, limit the scope of professional help better outcomes can be achieved by coordinating an effective inter-agency approach where possible. This approach begins when a concealment or denial of pregnancy is suspected or in some cases when the pregnancy (or birth) has been established. See Appendix 1: Concealed Pregnancy and Birth Flowchart: Suspicions Arise that a Pregnancy may be Concealed or Denied.

It is particularly important to take into account any history of concealed pregnancies (see Appendix 3: Concealed Pregnancy and Birth Flowchart: Possibility of a Future Pregnancy when there has been a known Concealed or Denial of Pregnancy). In some cases an expectant mother may be in denial of her pregnancy because of mental illness, substance misuse, incest, rape, or dissociative states brought about by previous traumatic loss of a child or children.

It is important to take into consideration the intellectual capacity of the expectant mother to understand that she might be pregnant. This is particularly relevant where it is known or suspected that she may have a learning disability. Some religious faiths traditionally expect pregnancy to follow after marriage. Dependent upon the culture and religious observance, a pregnancy outside of marriage may have serious consequences for the expectant mother. This can create significant psychological pressure on an expectant mother to seek to conceal or deny her pregnancy. In some local and national cases collusion between family and/ or partners has occurred to facilitate and encourage concealment of the pregnancy from those outside of the family or wider culture/community.

Some pregnant women, or their partners, who abuse drugs and /or alcohol may actively avoid seeking medical help during pregnancy for fear that the consequences of increased attention from statutory agencies could result in the removal of their child. Similarly some expectant mother might seek to conceal their pregnancies where they have previously had children removed from them by statutory services.

For the purposes of this procedure reference to “expectant mother” means a female of child bearing capacity (including under 18’s). A pregnancy will not be considered to be concealed or denied for the purpose of this procedure until it is confirmed to be at least 12 weeks. However by the very nature of concealment or denial it is not always possible to be certain of the stage the pregnancy is at.

A concealed pregnancy is when:

• An expectant mother knows she is pregnant but does not tell any professional; and/or
• She tells another professional but conceals the fact that she is not accessing antenatal care; and/or
• She tells another person/s and they conceal the fact from health or Social Care agencies.

A denied pregnancy is when:

• An expectant mother is unaware of, or unable to accept, the existence of her pregnancy. Physical changes to the body may not be immediately present or may be misinterpreted. Although the expectant mother may be at some level intellectually be aware of the pregnancy she may continue to believe, feel and behave as though she was not.

The implications of concealment and denial of pregnancy may be wide-ranging. Concealment and denial can lead to a fatal outcome for her or her unborn child, regardless of the mother’s intention.

Lack of antenatal care can mean that potential risks to mother and child may not be detected. The health and development of the baby during pregnancy and labour may not have been monitored or foetal abnormalities detected. It may also lead to inappropriate medical advice being given; such as potentially harmful medications prescribed by a medical practitioner unaware of the pregnancy e.g. some epilepsy medication.

Underlying medical conditions and obstetric problems will not be revealed if antenatal care is not sought. An unassisted delivery can be very dangerous for both mother and baby, due to complications that can occur during labour and the delivery. A midwife should be present at birth, whether in hospital or if giving birth at home.

Concealment of a pregnancy 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.

See also: Appendix 1: Concealed Pregnancy and Birth Flowchart: Suspicions Arise that a Pregnancy may be Concealed or Denied.

In some circumstances, agencies or individuals are able to anticipate the likelihood of significant harm with regard to an expected baby. Such circumstances should be addressed as early as possible to maximise time for full assessment, enable a healthy pregnancy and support parents so that (where possible), they can provide safe care.

Professionals must balance the need to observe the expectant mother’s right to confidentiality with the potential concern for the unborn child and the mother’s health and well- being. Where any professional believes the expectant mother to be concealing or denying a pregnancy then they should sensitively enquire of the expectant mother if she might be pregnant. It may be appropriate to ask a friend of the expectant mother or another professional who has a good working relationship with her to help. If a pregnancy is confirmed by the expectant mother then she should be strongly encouraged to go to her GP to access antenatal care. The GP practice will help an expectant mother register with Midwifery Services for ultrasound scanning and advice about pregnancy and birth.

Where a pregnancy is denied but the professional has reasonable grounds to suspect the pregnancy is concealed or denied a Referral to Children’s Social Care should be made. See Referring Safeguarding Concerns about Children Procedure.

Where a strong suspicion remains that there is a concealed or denied pregnancy, the welfare of the unborn child will override the mother’s right to confidentiality and irrespective of whether consent to disclose can or has been obtained a referral to Children’s Social Care must be made.

The baby should not be discharged until a multi-agency Strategy Discussions/Meetings Procedure has been held and relevant assessments undertaken. Children’s Social Care will convene a multi-agency strategy meeting /discussion (see Section 11, Strategy Meeting). The strategy discussion/ meeting will consider all the information available and may decide that the situation requires further investigation to determine the level of risk and how best to take the matter forward.

The reason for the concealment or denial of pregnancy will be a key factor in determining the risk to the unborn child or newborn baby. It is unlikely that the reasons will be fully understood until there has been a multi-agency assessment including in some circumstances a mental health assessment.

United Kingdom law does not legislate for the rights of unborn children and therefore a foetus is not a legal entity and has no separate rights from its mother. This should not prevent plans for the protection of the child being made and put into place to safeguard the baby from harm both during pregnancy and after the birth.

In certain instances legal action may be available to protect the health of an expectant mother, and therefore the unborn child, where there is a concern about the ability to make an informed decision about proposed medical treatment, including obstetric treatment. The Mental Capacity Act 2005 states that the person must be assumed to have capacity unless it is proven that she does not. A person is not to be treated as unable to make a decision because they make an unwise decision. It may be that an expectant mother denying her pregnancy is suffering from a mental illness and this is considered an impairment of mind or brain, as stated in the act, but in most cases of concealed and denied pregnancy this is unlikely to be the case.

There are no legal means for a Local Authority to assume Parental Responsibility over an unborn baby. Where the mother is a child and subject to a legal order, this does not confer any rights over her unborn child or give the local authority any power to override the wishes of an expectant mother in relation to medical help.

See also: Appendix 2: Concealed Pregnancy and Birth Flowchart: Pregnancy is Revealed and Appendix 3: Concealed Pregnancy and Birth Flowchart: Possibility of a Future Pregnancy when there has been a known Concealed or Denial of Pregnancy.

Midwifery Services will be the primary agency involved with an expectant mother after the concealment is revealed, late in pregnancy or at the time of birth. However it could be one of many agencies or individuals that an expectant mother discloses to or in whose presence the labour commences.

It is vital that all information about the concealment or denial is recorded and shared with relevant agencies to ensure the significance is not lost and risks can be fully assessed and managed.

In cases of full concealment followed by unassisted delivery, Children’s Social Care must always be informed and a multi-agency Strategy Meeting convened to assess any ongoing risks to the baby.

When a pregnancy is revealed the key question is “why has this pregnancy been denied or concealed”? The circumstances in each case need to be explored fully with the expectant mother and appropriate support and guidance given to her. Where possible a pre-birth Assessment should be undertaken led by Children’s Social Care and if necessary an Initial Child Protection Conference (Pre-birth or after birth) convened to manage any concerns for the safety of the unborn child.

If the mother is in labour when the pregnancy is revealed, the midwifery service must contact the Multi-Agency Safeguarding Hub (MASH) (or the Out of Hours Children’s Social Care Team) to gather information, including whether it is known if there have been previous births or children removed or subject to a Child Protection Plan or other service. If there are safeguarding concerns, an urgent Strategy Discussion/Meeting should be convened as outlined above – see Section 11, Strategy Meeting.

In many instances staff in educational settings may be the practitioners who know a young expectant mother 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 expressed by friends;
• Repeated rumours around school or college;
• Uncharacteristically withdrawn or moody behaviour;
• Signs consistent with morning sickness.

Staff working in educational settings should try to encourage the pupil to discuss her situation, through normal pastoral support systems, as they would any other sensitive problem. Every effort should be made by the practitioner suspecting a pregnancy to encourage the young expectant mother to obtain medical advice. However, where they still face denial or non- engagement further action should be taken. It may be appropriate to involve the assistance of the Designated Safeguarding Lead and School Nurse in addressing these concerns.

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 well-being. 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.

Education staff may often feel the matter can be resolved through discussion with the parent of the young expectant mother. However this will need to be a matter of professional judgment and will clearly depend on individual circumstances including the relationship with parents. It may be felt that the young expectant mother will not admit to her pregnancy because she has genuine fear about her parent’s reaction, or there may be other aspects about the home circumstances that give rise to concern. If this is the case then a Referral to Children’s Social Care should be made without speaking to the parent’s first. For more information, see Referring Safeguarding Concerns about Children Procedure.

If education staff do engage with parents they need to consider the possibility of the parent’s collusion with concealment. Whatever action is taken, whether informing the parents or involving another agency, the young expectant mother should be appropriately informed, unless there is a genuine concern that in so doing she may attempt to harm herself or the unborn baby.

If there is a lack of progress in resolving the matter in any circumstances or escalating concerns that a young expectant mother may be concealing or denying she is pregnant there must be a referral to Children’s Social Care. Where there are significant concerns regarding the girl’s family background or home circumstances, such as a history of abuse or neglect, a referral should be made immediately.

As with any referral to Children’s Social Care, the parents and young expectant mother should be informed, unless in doing so there is reasonable cause to believe this could increase the risks for her welfare or that of her unborn child.

The health professionals who may be involved include:

• Health Visitor;
• School nurse;
• General Practitioner (GP) and Practice nurse;
• Midwife and Obstetricians/Gynaecologist;
• Accident and Emergency staff;
• Mental Health Nurse;
• Drug and alcohol worker;
• Learning Disability worker;
• Psychologist and Psychiatrist;
• Children’s Nurse;
• Paediatrician;
• CAMHS workers.

(This is not an exhaustive list.)

If a health professional suspects or identifies a concealed or denied pregnancy they must speak to their Line Manager, Named Nurse or Named Doctor for safeguarding who will advise on the appropriateness of a Referral to Children’s Social Care. For more information, see Referring Safeguarding Concerns about Children Procedure.

All health professionals should give consideration to the need to make or initiate a referral for a mental health assessment at any stage of concern regarding a suspected (or proven) concealed or denied pregnancy. Accident and Emergency (A&E) staff or those in Radiology departments need to routinely ask women of child bearing age whether they might be pregnant. If suspicions are raised that a pregnancy may be being concealed or a pregnancy is confirmed, Midwifery Services should be contacted. Where the pregnancy is confirmed the expectant mother should be transferred to the labour ward for a full assessment of need. Should the patient refuse transfer to the labour ward a Midwife should attend the A and E department to ensure an appointment for a scan and community midwife is made prior to discharge. This must be recorded in the discharge notes and an appropriate note made to the referring GP for follow up with the patient.

Where a GP has significant reason to believe an expectant mother is pregnant, but she refuses all attempts to persuade her to undertake further investigations, further action needs to be taken. This should include discussion with the Midwife, Health Visitor or School Nurse, (as appropriate) and a Referral should be made to Children’s Social Care. It may be helpful to discuss the concerns with the named nurse or named doctor for safeguarding.

If the woman presents late (beyond 18 weeks) for Midwifery and Obstetric Services in the antenatal period, a thorough social and medical history needs to be taken. There may be many reasons why the woman has concealed the pregnancy and the midwife needs to ensure the possibility of domestic abuse and mental health issues are explored. For more information, see Safeguarding Children at Risk because of Domestic Abuse Procedure and Safeguarding Children at Risk where a Parent has a Mental Health Problem Procedure.

Also see:

• Safeguarding Children of Alcohol Misusing Parents Procedure;
• Safeguarding Children of Drug Misusing Parents Procedure;
• Children of Parents with Learning Disabilities Procedure.

If an exploration of the circumstances suggests a cause for concern for the welfare of the unborn baby then a Referral to Children’s Social Care should be made and other agencies informed as appropriate.

The expectant mother should be informed that the referral has been made except if this might increase the concerns for her safety or that of the unborn child.

If the woman is aged 18 or under she should be referred to the specialist midwife for teenagers and a referral made to the Multi-Agency Safeguarding Hub (MASH) for her (with her consent) as a Child in Need.

An urgent scan must also be booked to determine the gestation of the baby.

If an expectant mother arrives at the hospital in labour or following an unassisted delivery, where a booking has not been made, then an urgent referral must be made to the Multi-Agency Safeguarding Hub (MASH). If this is in an evening, weekend or over a public holiday then Children’s Services Out of Hours Team must be informed. See Rotherham Children's Social Care Out of Hours Team. For more information, see Referring Safeguarding Concerns about Children Procedure.

If the baby has been harmed in any way or there is a suspicion of harm, or the child is abandoned by the mother, then the Police must be informed immediately and an immediate referral made to MASH.

Midwives should 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 her 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 early postpartum period.

In cases where there has been concealment and denial of pregnancy, especially where there has been unassisted delivery, a referral for a mental health assessment should be considered. In addition the baby should not be discharged until a multi-agency Strategy Discussion has been held and relevant assessments undertaken. A discharge summary from Midwifery Services to primary care must report if a pregnancy was concealed or denied or booked late (beyond 18 weeks).

There may be occasions during the course of their work when staff working with adults come across a concealed or denied pregnancy. In these circumstances a discussion must take place between the staff member and their Line Manager who will agree what action is required. In most cases the Safeguarding Standards Manager for Adult Social Care should be advised and a Referral to Children’s Social Care made.

For more information, see Referring Safeguarding Concerns about Children Procedure.

Also see:

• Safeguarding Children at Risk because of Domestic Abuse Procedure;
• Safeguarding Children at Risk where a Parent has a Mental Health Problem Procedure;
• Safeguarding Children of Alcohol Misusing Parents Procedure;
• Safeguarding Children of Drug Misusing Parents Procedure;
• Children of Parents with Learning Disabilities Procedure.

See also:

• Appendix 1: Concealed Pregnancy and Birth Flowchart: Suspicions Arise that a Pregnancy may be Concealed or Denied;
• Appendix 2: Concealed Pregnancy and Birth Flowchart: Pregnancy is Revealed;
• Appendix 3: Concealed Pregnancy and Birth Flowchart: Possibility of a Future Pregnancy when there has been a known Concealed or Denial of Pregnancy;
• Strategy Discussions / Meetings Procedure.

Children’s Social Care may receive a referral from any source which suggests a pregnancy is being concealed or denied.

The Child Protection - Information Sharing Project (NHS Digital, CP-IS) should be accessed to check whether the mother (or other children) are known to Social Care in any other part of the country.

If appropriate a multi-agency Strategy Discussions/Meetings Procedure will be convened, involving the General Practitioner, Police, Midwifery Services, Named Nurse safeguarding children, legal advisor and other relevant agencies such as the Ambulance Service to assess the information and formulate a plan. The Strategy Meeting must consider the ongoing risks to the child and specifically consider risks surrounding the discharge arrangements. Where a plan is agreed it should include the frequency of contacts to be attempted with the parents and agreed contingencies if planned contact fails. As part of the subsequent plan agencies should flag their records to indicate the nature of the concern. See Safeguarding Unborn and Newborn Babies Procedure for more information.

If necessary, steps must be taken to prevent the baby being discharged from hospital until a multi-agency strategy meeting has been held and a plan for discharge agreed. This would ordinarily be done by voluntary agreement with the expectant mother, although clearly circumstances may arise when it may be appropriate to seek an Emergency Protection Order. Alternatively the assistance of the Police may be sought to prevent the child from being removed from the hospital.

Where an expectant mother is aged under 18 then professionals must also consider that she is a Child in Need.

In undertaking an assessment the social worker will need to focus on the facts leading to the pregnancy, reasons why the pregnancy was concealed and gain some understanding of what outcome the mother intended for the child. These factors along with the other elements of the Assessment Framework are key in determining risk. See Safeguarding Unborn and Newborn Babies Procedure, Pre-birth Assessment for more information.

The Police must be notified of any child protection concerns received by Children’s Social Care where concealment or denial of pregnancy is an issue. A police representative will be invited to attend a multi-agency strategy meeting to consider the circumstances and decide whether a joint Section 47 investigation should be carried out.

The Police may wish to consider whether the expectant mother is a victim or potential victim of a criminal offence. In all cases where a child has been harmed, been abandoned or died it will be incumbent on police and Children’s Social Care to work together to investigate the circumstances.

Where it is suspected that neonaticide or infanticide has occurred then the Police will be the primary investigating agency.

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

All referrals will be made to Children’s Social Care initially as a referral on an unborn child. Where the expectant mother is under 18 years of age she will be considered as a Child in Need and assessed accordingly.

Appendix 1: Concealed Pregnancy and Birth Flowchart: Suspicions Arise that a Pregnancy may be Concealed or Denied

Appendix 2: Concealed Pregnancy and Birth Flowchart: Pregnancy is Revealed

Appendix 3: Concealed Pregnancy and Birth Flowchart: Possibility of a Future Pregnancy when there has been a known Concealed or Denial of Pregnancy