Concealed Pregnancies

The NICE Guideline for Antenatal Care (2012) recommends that the initial booking appointment should take place before 10 weeks gestation and prior to 12 weeks gestation. Women who present for antenatal care after 16 weeks gestation are consider as a late booking in pregnancy. However, those who book between 12-20 weeks gestation are not considered generally to have any added risks to the pregnancy and do not require a consultant referral. Whereas, those booking after and including 21 weeks gestation are defined as a concealed pregnancy and are referred for consultant led care; they should have serial growth scans to determine growth velocity.

A concealed pregnancy therefore occurs in the following circumstances:

• When a woman presents for Maternity Care after 21 weeks gestation in pregnancy and the woman is aware that she is pregnant but does not inform a health professional of the pregnancy;
• When the woman informs a professional that she is pregnant but conceals the fact she is not accessing antenatal care;
• When a woman informs another person that she is pregnant but conceals the pregnancy from all health and professional agencies.

For the purpose of this guidance the phrase concealed pregnancy is used for both denied and concealed pregnancies. 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; the individual may be intellectually aware of the pregnancy but continue to think, feel and behave as though they were not pregnant. In some cases, a woman may be in denial of her pregnancy due to mental illness, drug and/or alcohol misuse or as a result of a history of loss of a child or children.

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 20 weeks; this is the point of viability. However by the very nature of concealment or denial it is not possible for anyone suspecting a woman is concealing or denying a pregnancy to be certain of the stage the pregnancy is at. Due to the nature of the concealed pregnancy, it is important to note that the gestation of the pregnancy may be difficult to determine.

The concealment and denial of pregnancy will present a significant challenge to professionals in safeguarding the wellbeing of the foetus (unborn child) and the mother. There may be a multitude of reasons why a woman may conceal her pregnancy. For example:

• A woman or girl may conceal their pregnancy if it occurred as the result of sexual abuse, either within or outside the family, due to her fear of the consequences of disclosing that abuse;
• A pregnancy may be concealed in situations of domestic abuse, within a forced marriage or for a forced marriage to avoid shame on a family;
• There is growing intelligence that suggests pregnant women are exploited for sham marriages and benefit fraud, likewise the unregulated nature of the surrogacy industry puts women and children at risk of exploitation and trafficking and may therefore conceal their pregnancies due to control and coercion;
• Due to stigma, shame or fear through cultural or family pressures, concealment may be a deliberate means of coping with the pregnancy or avoiding bringing shame on the family;
• Fear of a child being removed where a woman has had a previous child removed, or asylum seekers and illegal immigrants who may be reluctant to inform the authorities that she is pregnant;
• In some cases the woman may be truly unaware that she is pregnant until very late in the pregnancy, either due to age or learning disability if they do not understand why their body is changing;
• There are links between denial of pregnancy and dissociative states brought about by trauma or loss; or denial stems from an expectant mother misusing drugs or alcohol which can harm the foetus or because of mental illness, such as schizophrenia.

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. This approach begins when a concealment or denial of pregnancy is suspected or in some cases when the fact of the pregnancy (or birth) has been established. This will also apply to future pregnancies where it is known or suspected that a previous pregnancy was concealed or denied.

The potential risks to a child through the concealment of a pregnancy are difficult to predict and wide-ranging. One key implication is that there is no obstetric history or record of antenatal care prior to the birth of the baby. Some women may present late for booking (after 20 weeks of pregnancy) and these pregnancies need to be closely monitored to assess future engagement with health professionals, particularly midwives and whether or not referral to another agency is indicated. In a case of a denied pregnancy the effects of going into labour and giving birth can be traumatic.

The reason for the concealment will be a key factor in determining the risk to the child and that reason will not be known until there has been a systematic multi-agency assessment. See Assessment Procedure

Possible implications:

• Concealment of a pregnancy can lead to a fatal outcome (for both mother and/or child), regardless of the mother's intention;
• Concealment may indicate uncertainty 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 can mean that any potential risks to mother and child may not be detected. It may also lead to inappropriate advice being given, such as potentially harmful medications prescribed by a medical practitioner unaware of the pregnancy;
• The health and development of the baby during pregnancy and labour may not have been monitored and foetal abnormalities not detected;
• Underlying medical conditions and obstetric problems will not be revealed;
• An unassisted delivery can be dangerous for both mother and baby, due to complications that can occur during labour and the delivery;
• Lack of maternal willingness/ability to consider the baby's health needs, or lack of emotional attachment to the child following birth;
• Where concealment is a result of drug and/or alcohol misuse there can be risks for the child's health and development in utero as well as subsequently;
• There may be implications for the mother revealing a pregnancy due to fear of the reaction of family members or members of the community;
• Risks to the unborn baby from prescribed medications.

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.

• Previous concealed pregnancy is an important indicator in predicting risk of a future pregnancy being concealed;
• Previous termination, thoughts of termination and/or unwanted pregnancy;
• Loss of a previous child (i.e. adoption, removal under Care Proceedings);
• General fear of being separated from the child.

Drug and/or alcohol-misusing young people may avoid seeking help during pregnancy if they fear that this disclosure will inevitably lead to statutory agencies removing their child. It may be important to consider the role of collusion within the family.

Where there is a strong 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 - see Information Sharing Procedure. Every effort should be made to encourage the (young) person to obtain medical advice. All professionals who suspect the pregnancy is being concealed need to follow safeguarding procedures. An open assessment or previous referral to MASH and/or contact other agencies known to have involvement with the young person must also be established so that a fuller assessment of the available information and observations can be made.

Where the mother is, or may have been at the time of conception, under the age of 16, professionals should follow the processes outlined in Underage Sexual Activity Procedure.

If there is a referral to Social Care it will be made on behalf of the unborn child. If the mother is under 16, she will also be the subject of a referral as there will be a criminal offence to be investigated.

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 therefore 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.

Where a pregnancy is revealed to be denied and concealed it is vital the circumstances in each case are explored fully with the expectant mother and appropriate support and guidance offered to her. It is important to understand the reasons why the pregnancy has been denied or concealed.

When concealment occurs, it is imperative that analysis takes place to consider the strengths within the family, any potential risks to the unborn baby and associated complicating factors. This facilitates professional decision making, to ascertain whether a multi-agency assessment is required and referral to Children's Services is therefore indicated. Concealed and denied pregnancy has been a theme in recent local and national serious case reviews. There are challenges in identifying women or girls who may conceal or deny pregnancy, however, both concealment and denial of pregnancy presents a multitude of risks to the unborn baby.

In some circumstances, agencies or individuals are able to anticipate the likelihood of Significant Harm with regard to an expected baby which must be addressed as early as possible to maximise time for full assessment, enabling a healthy pregnancy and supporting parents so that (where possible) they can provide safe care.

All professionals should follow the Referrals Procedure process as well as this section.

Where there is strong suspicion that a young person is concealing or denying the pregnancy then it is necessary to share this information, irrespective of whether consent to disclose can be obtained or has been given. In these circumstances the safety and wellbeing of the unborn child will override the mother's right to confidentiality. A referral should be made to Children's Social Care about the unborn child. If the woman is aged less than 18 years then consideration will be given to whether she is a Child in Need. If she is less than 16 years then a criminal offence will have been committed and needs to be investigated.

The reasons will not be known until an assessment has been carried out. If there is a denial of pregnancy, consideration must be given, at the earliest opportunity, to refer the young person to an appropriate agency.

If professionals do not become aware of a pregnancy until the point at which the pregnant mother is ready to deliver, there needs to be some immediate consultation with Children's Services. Hospital staff should seek advice from First Contact to discuss whether a referral is required to either social care or early help services.

Consideration of the need for a multi-agency meeting must take place when it is a known family and there are concerns or suspicions about concealed pregnancy. This is to assist in the facilitation of any hospital alerts, professional curiosity and the assessment of any safeguarding risks.

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 unborn 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 secure medical intervention to protect the health and well-being of the mother and thereby the unborn child. This may arise in cases where the young person lacks capacity due to mental illness, learning difficulty, her young age or some other circumstance. The absence of support for intervention from parents or carers may be overcome by the use of legal intervention.

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 young person or give the local authority any power to override the wishes of a pregnant young person in relation to medical help.

Care proceedings cannot be instigated for an unborn child. They are not likely to provide a mechanism for intervening even where the mother is under 18 years. A child assessment order will require the pregnant young woman's agreement and the making of an interim care order will not transfer any rights to Children's Social Care to override the wishes of the young woman in relation to medical help. It may however provide a solution where the problem can be addressed by removing her from abusive carers to a safe environment such as foster care.