Concealed, Denied or Late Presentation of Pregnancy
Concealed Pregnancy: A concealed pregnancy is when a woman or girl knows she is pregnant but does not tell any health professional; or when she tells another professional but conceals the fact that she is not accessing antenatal care; or when a pregnant woman tells another person and they conceal the fact from all health agencies.
Denied Pregnancy: A denied pregnancy is when a woman is unaware of or unable to accept the existence of her pregnancy. Physical changes to the body may not be present or misconstrued; they may be intellectually aware of the pregnancy but continue to think, feel and behave as though they were not pregnant.
Late Presentation of Pregnancy: When a woman does not inform a health professional of pregnancy until 20 weeks or over.
Please note the above presentations are different from a woman who chooses to ‘free birth’ or a baby is born before arrival ( BBA)
Free birth: is where a woman chooses to give birth without the assistance of health professionals. In most instances the woman engages, to some degree, with antenatal care and post-natal care.
Born Before Arrival (BBA) is when a woman who has every intention of either having a hospital or planned home delivery and has engaged with maternity services in the planning of either, but where the birth of the baby has happened so rapidly that one of two scenarios happens:
Firstly the woman does not make it to the hospital setting/place of birth;
Secondly, and in the case of a planned home birth the midwife does not arrive at the home to support and witness the delivery as the birth has happened so rapidly.
For the purpose of this practice guidance the term concealed pregnancy will be taken to include concealed, denied or late presentation of pregnancy
The concealment of a pregnancy presents a significant challenge to professionals in safeguarding the welfare and wellbeing of the unborn child and the mother. While concealment, by its very nature, limits the scope of professional assessment and support, better outcomes can be achieved by coordinating an effective multiagency response once the pregnancy is confirmed and/or the child is born.
Many Local Safeguarding Children Partnerships nationally have conducted reviews of cases where concealment or denial of pregnancy has been identified as a factor in the death or serious injury of a child.
Concealment of a pregnancy may be identified late in pregnancy, during labour; or following delivery. The birth may be unassisted and may carry additional risks to the child and mother’s welfare.
Aim: The aim of this guidance is to provide practitioners from all agencies with clear direction regarding the appropriate safeguarding response when they are suspicious or become aware that a women or girl is concealing a pregnancy
Why might a pregnancy be concealed and what are the implications?
It is acknowledged that there are situations where women appear to have been unaware of their pregnancy until the unexpected arrival of a baby but adjust quickly to the arrival of a new baby and can parent safely and effectively.
However, possible underlying reasons for concealment must be fully explored as this will be a key factor in determining the potential safeguarding risk to the unborn baby or new-born child. These factors will not be fully understood until there has been a holistic assessment involving all relevant practitioners/ agencies. .
Possible reasons for concealment of pregnancy may include:
- Mental health issues/ illness
- Current or history of substance misuse
- Conception following rape
- Incestuous paternity
- Extra marital paternity
- Learning disability
- Religious / cultural disapproval
- Previous Children’s Social Care involvement – fear of removal of another child
- Poor social network
- Anti-medical intervention and desire to be ‘natural’
- Domestic abuse within a relationship; domestic abuse can escalate in pregnancy therefore to deny pregnancy from partner may protect the mother from further/additional abuse
- Fear of disapproval of the pregnancy eg maternal age. Should you become aware the pregnancy was conceived when a young person was under the age of 13 years this must lead to an automatic referral to Children’s Social Care North Yorkshire MAST or City of York MASH)
- Women who may have been trafficked or exploited with subsequent denial of access to antenatal care
Note this is not an exhaustive list and professional judgement may determine a level of concern that requires exploration
The implications of concealed of pregnancy are wide-ranging. Concealment can lead to a fatal outcome, 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 identified. It may also lead to inappropriate medical advice being given; such as potentially harmful medications prescribed by a medical practitioner who is unaware of the pregnancy
An unassisted delivery can be very dangerous for both mother and baby due to complications that can occur during labour, the delivery and during the immediate postnatal period.
Following the birth of the baby mother may demonstrate ‘mixed feelings’ towards her baby and there may be potential future difficulties in prioritising the baby’s needs or in bonding with the baby
Safeguarding response to concealed pregnancy
Late presentation: If an appointment for antenatal care is made late (beyond 20 weeks), the reason for this must be thoroughly explored with the women or girl. The practitioner must also discuss the case with the safeguarding lead within your organisation. If an exploration of the circumstances suggests there may be a safeguarding concern for the unborn baby a referral to Children’s Social Care must be made via NY MAST or CoY MASH. The woman should be informed that the referral has been made, the only exception being if there are significant concerns for her safety or that of the unborn child.
Concealed or denied pregnancy: If a practitioner suspects that a woman or girl is pregnant, and they are concealing or denying the pregnancy they should make every effort to support the women or girl to access appropriate antenatal care. Should the women or girl continue to deny the pregnancy and the practitioner believes the pregnancy is ongoing the practitioner must seek advice from the safeguarding lead in their organisations and make a referral to Children’s Social Care via the NY MAST or CoY MASH . Consideration should be given to if the woman needs a mental health assessment and referral to mental health services.
Presentation in labour or unassisted delivery: If a women or girl arrives at hospital in labour or following an unassisted delivery, where a booking has not been made, the health care practitioner must contact safeguarding team in the Trust for advice.
If the presentation is out of hours you must contact the Children’s Social Care Emergency Duty Team (03 00 131 2 131) to discuss the case, seek advice and agree actions. During this conversation you must:
- Be clear why you are calling
- Request a review of any previous or current children’s social care involvement
- Share all concerns regarding the presentation
- Agree if a child protection strategy meeting is required and document the outcome of these discussions
- Agree if it is safe to discharge the mother and baby from hospital, including any plans for enhanced home visiting by maternity services in the immediate post natal period.
- You must clearly and accurately document the time, date, and name of the person that you have liaised with and how the decisions for management of the situation have been reached
You must then share details of the case and actions taken with the safeguarding team in the Trust at the earliest opportunity
It should be noted that no health care professional can prevent a mother with capacity from discharging herself. However, if there is concerns about the immediate welfare of the child and the mother removes the child from the hospital Children’s Social Care should be informed and the police called as a police protection order may be indicated
If the person concealing the pregnancy is under 18 years, consideration must be given to the safeguarding needs of this girl as well as the unborn or new born baby. As such, it may be appropriate to refer the young person as well as the unborn or new born child to Children’s Social Care via the NY MAST or CoY MASH .
In all subsequent communication regarding the birth, for example with the GP, Community Midwife or Health Visitor, you must ensure you clearly describe the circumstances around the delivery and any safeguarding concerns. The Community Midwife and Health Visitor must undertake a home environment assessment prior to or at the point of discharge from hospital.
Associated procedures and guidance
This guidance must be read in conjunction with:
North Yorkshire Safeguarding Children Partnership procedures (www.safeguardingchildren.co.uk)
City of York Safeguarding Children Partnership Procedures (www.saferchildrenyork.org.uk)
Safeguarding Unborn Babies Multiagency Practice Guidance https://www.safeguardingchildren.co.uk/professionals/practice-guidance/safeguarding-unborn-babies/