Concealment and Denial of Pregnancy

1. Definition

The concealment of a pregnancy represents a challenge for professionals in safeguarding the welfare and the wellbeing of the foetus (unborn child) and the mother. There is no national agreed definition of what constitutes a concealed pregnancy, however a coordinated multi-agency approach is required once the fact of a pregnancy has been established; this will also apply to future pregnancies where there has been a previous concealed pregnancy. Concealment of pregnancy may be revealed late in pregnancy, in labour or following delivery. The birth may be unassisted (no midwife) whereby there might be additional risks to the child and mother's welfare and long-term outcomes.

A concealed pregnancy is when:

• An expectant mother knows she is pregnant but does not tell any professional; or
• An expectant mother tells another professional but conceals the fact that she is not accessing antenatal care; or
• A pregnant woman tells another person or persons and they conceal the fact from all health 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; they 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, substance 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 24 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.

In some cases a woman may be unaware that she is pregnant until late in the pregnancy due to a learning disability. Concealment may occur as a result of stigma, shame or fear because the pregnancy may be the result of incest, sexual abuse, rape or as part of a violent relationship.

2. Risks

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 24 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 alcohol or substance 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.

Additional Risk Factors

In the following circumstances of a pregnancy, a referral (see Referrals Procedure) to children's Social Care 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);
• Mother not thought to be able to care for the child;
• Unable to provide for herself or her baby;
• Subject of Domestic Abuse
• Suffering from Learning Disabilities/Physical Disabilities where she is unable to care/provide for the child and has little or no support.

3. Indicators

• 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.

Substance-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.

4. Referrals/Issues

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.

Where there is a strong suspicion that a pregnancy is being concealed, it may be 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. If this is unlikely a referral should be made to Children's Social Care. If there has been a previous referral to MASH or other agencies have been in contact with the child/young person, this information must be obtained to ensure a complete assessment is carried out.

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 may also be a criminal offence to be investigated.

If Consent is obtained then a referral may be appropriate.

5. When Concealment is revealed

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.

The circumstances leading to concealment of pregnancy need to be explored individually as there may be potentially serious child protection outcomes as a result of a concealed pregnancy and a detailed interagency assessment should be undertaken. All agencies should ensure that information about the concealment is shared with other relevant agencies, to ensure its significance is not lost and to ensure that potential future risks can be fully assessed and managed.

6. Protection and Action to be Taken by Agencies

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 welfare 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 may 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 CAMHS.

7. Issues

UK law does not legislate for the rights of the unborn baby. In some circumstances, agencies or individuals are able to anticipate the likelihood of significant harm with regard to an expected baby. Although the law does not identify an unborn baby as a separate legal entity, this should not prevent plans being made and put into place to protect 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.