Child protection during the perinatal period: Innovation in assessment and practice

Abstract

An optimal caregiving environment during the perinatal period is critical for healthy development. The first 1000 days (from conception until the second birthday) are now widely recognised as a time of extensive neurobiological and psychosocial development that lay down the foundations for children's subsequent trajectories and future life chances (Marmot, 2021). National and international bodies have responded to this evidence by establishing public health and more intensive targeted home visiting programmes for both indigenous and non-indigenous families, which are designed to reduce inequalities and promote optimal development during this period in order to ensure that every child has the best start in life.

Research conducted over the past decade has begun to highlight the impact of abuse and neglect during the first 1000 days, and the mechanisms by which such abuse can compromise the long-term development of children (e.g. McCrory et al., 2011). More recently there has been increasing awareness of the impact of maternal behaviours during pregnancy that may also have a detrimental impact on the unborn baby, including alcohol and substance misuse which are associated with a range of physical, cognitive and mental health problems (e.g. Easey et al., 2019; Mamluk et al., 2020), and domestic abuse, which can have life-changing and indeed fatal consequences for both the mother and the unborn baby (Cleaver et al., 2011).

Despite evidence about the long-term consequences of parenting behaviours on the infant in utero, little attention has been given in policy or practice to safeguarding unborn children. A recent study in England and Wales, for example, found that, although national guidance on assessments of need, risks of harm and reporting requirements now refer to unborn children, there is no national guidance that focuses specifically on safeguarding them from abusive or neglectful parenting behaviours that will affect their long-term development, or supporting parents whose infants are removed at birth (Ward et al., 2022).

Infants under the age of one are disproportionately likely to die or suffer life-changing injuries from abuse or neglect (NSPCC, 2021), and it is clear that some will need to be removed from birth parents in order to ensure their safety. However, increasing numbers are compulsorily removed from their parents at birth or in the immediate post-partum period: Broadhurst and colleagues (2018) found that in England, the number of newborns subject to care proceedings had more than doubled between 2008 and 2017. This is an international issue, with increasingly high numbers of infant removals in both high- and low-income countries (Backhaus et al., 2019). Recent evidence shows that, in England and Wales, vulnerable mothers whose infants are at risk of abuse receive too little support during the pregnancy to help them overcome the difficulties that prevent them from providing nurturing care. Furthermore, at all stages, the process of decision-making and removal is traumatic and often exacerbates the problems for which the mothers were referred (Mason et al., 2022). Broadhurst and colleagues (2018) identified a ‘hidden population’ of mothers who experience the consecutive removal of numerous infants because the problems that inhibit their parenting capacity are never adequately resolved.

This Special Issue draws together a number of papers that shed further light on some of these concerns and explores how they might be addressed. They report on research studies and practice innovations that cover infants' life trajectories, from conception to age 2, using a wide range of methodologies, from quantitative analysis of administrative data to qualitative analysis of interviews with birth parents. They are written by researchers and clinicians in Australia, England, France, the Republic of Ireland, and the USA, demonstrating that child protection in the perinatal period is an international concern.

The first question explored in this Special Issue is how far abuse and neglect in the perinatal period is identified, assessed and acted upon. Kenny and Mathews and Pathirana's paper reviewed laws and statutes in all states and territories in Australia and the USA, and compared mandatory reporting legislation in relation to perinatal substance use. They found numerous variations in reporting requirements; perinatal substance use was included in the legislation in only 20 states in the USA, and mandatory reporting was required in only one in Australia. Although the purpose of mandatory reporting may be to alert child welfare agencies to evidence of significant maltreatment and to provide support to parents, there are ongoing concerns that it may exacerbate parents' fears of being separated from their children or prosecuted, and therefore discourage them from seeking help or attending antenatal care. Although mandatory reporting can provide access to early intervention, it does not always do so. The study found that there is more emphasis on prevention and support in Australia than in the USA, where in some states parents' rights can be terminated if they refuse treatment.

Even when reporting is not mandatory, parents may be fearful of accessing routine support or engaging in the process of assessment. The paper by Chamberlain, Gray and Herrman highlights the fact that many parents whose infants may be at risk of harm have been abused and neglected themselves and have gone on to experience traumatic interpersonal experiences and adverse life events, as a result of which they are often suffering from complex post-traumatic stress disorder. By adopting a more positive public health perspective, the authors reframe the purpose of prebirth assessment from identifying risk of harm to the foetus to screening to identify complex PTSD during pregnancy. The objective is then to enable parents to access extra support from perinatal care services. However, historical injustices experienced by the Aboriginal and Torres Islander population mean that they are unwilling to be assessed, or often to access routine antenatal services. The paper describes the elements of a co-designed approach to identifying the key elements necessary to engage Aboriginal parents in prebirth assessment and take-up of services. It would be valuable to explore how such an approach might be replicated in other contexts in which parents are reluctant to trust professionals or engage with services because of previous experience of infant removal (Mason et al., 2022; Ward et al., 2014).

Assessment is of little value unless it leads to action, and there is now a growing initiative to develop intensive treatment programmes, tailored to meet the needs of parents whose infants are at risk of significant harm during the perinatal period. Chamberlain et al.’s paper demonstrates the importance of establishing trusting relationships between professionals and parents who have experienced trauma, a point developed further in Jondec and Barlow's paper. This focuses on an intensive perinatal attachment and mentalisation-based intervention for pregnant women who have previously experienced the removal of a child (the Daisy programme). Fundamental to the intervention is the mentalising relationship between the parent and their key worker, built on the establishment of trust. It is through this relationship that the parent is enabled to understand how their own traumatic experiences have affected their subsequent life choices, develop reflective capacities that may improve their parenting, and repair or develop stronger relationships with formal and informal support networks.

The Daisy programme is offered to pregnant women at 12–16 gestational weeks, who have had at least one child previously removed from their care. Pregnancy can provide a window of opportunity in which mothers may benefit from interventions designed to address issues that compromise their parenting capacity and to increase their ability to nurture a baby; it is also a time when many women may be more receptive to change. However, there is a growing body of evidence to show that, in England and Wales, many local authorities do not accept or act on referrals of unborn children until too late in the pregnancy for interventions to be accessed, or for mothers to demonstrate capacity to change (Lushey et al., 2017; Mason et al., 2022; Ward et al., 2022). Octoman's paper reports on a study that analysed administrative data collected for a cohort of infants in one Australian state, reported as being at risk of harm before their birth, and followed until they were 2. They found that child protection concerns continued for over three-quarters of the cohort after they were born. The most common pathway showed that most children remained with their birth parents, but that there were multiple reports of abuse and neglect, indicating sporadic and ineffective access to services.

Corbett and colleagues' paper on child protection pathways for newborn infants in the Republic of Ireland sheds further light on this issue. They undertook an audit of files in a large maternity hospital and identified a cohort of infants for whom there had been child protection concerns before or immediately after birth. When concerns were identified, mothers were referred to the medical social work team who were able to provide some immediate support and/or refer them to other services. Although two-thirds of the children were discharged to their mothers' care, the data concerning older siblings indicated that the majority would be living outside the parental home by the time the next baby was born. The authors suggest that there is a strong case to be made for developing additional perinatal services, which might most appropriately be based in maternity hospitals.

Findings reported in Corbett and colleagues' paper also demonstrate the extreme vulnerability of infants identified as at risk of harm before birth. The cohort they studied were significantly more likely to be born prematurely and have low birth weight than the national population. Antenatal care had been poor, and three-quarters of them were born with health problems, including neonatal abstinence syndrome. About one in five were born to mothers who tested positive for hepatitis C or HIV. Findings such as these are the rationale for the Pegase Progamme, presented in Toussaint and Rousseau's paper. This initiative is informed by evidence of the extensive physical and mental health needs of abused and neglected children (Turney & Wildeman, 2016). It builds on previous research by one of the authors who found that premature infants who were placed in care in France had disproportionately more positive outcomes (Rousseau et al., 2016). These infants had benefited from the intensive follow-up and enrichment programme offered to all premature infants in France from birth until they are 7. The Pegase programme is modelled on this intervention and is designed to offer similar levels of intensive physical and mental health support to all infants and young children in care up to the age of 5. Progress is monitored at regular intervals, and each child has an individual care package, tailored to meet their needs. As with the initiative discussed in Chamberlain et al.’s paper, a public health approach ensures that all eligible children are included in the assessment and provision of services. The programme is currently being piloted and evaluated in 15 sites in France.

The papers by Chamberlain and colleagues, Jondec and Barlow, and Corbett and colleagues all highlight high levels of mental health problems and post-traumatic stress in mothers whose infants are at risk of harm. Yet a recent study undertaken in England and Wales found that the process of infant removal is frequently harsh and insensitive and often serves to compound the mother's distress (Mason et al., 2022). Mason, Ward and Broadhurst's paper explores data from interviews with mothers who have experienced infant removal and identifies a number of common themes. These include isolation, shame, acute trauma and overwhelming grief. Many of these mothers have minimal if any support from family, friends or professionals after discharge from hospital and the problems that had led to the removal of their infant become exacerbated. The loss of their maternal identity and the perceived illegitimacy of their grief are powerful contributors to their distress. The paper discusses the Hope box initiative, designed to reduce mothers' trauma by helping them build up and preserve memories and retain a connection with their infant.

Taken together the papers in this Special Issue provide a wide range of information on current issues concerning assessment and practice when child protection concerns are identified in the perinatal period. They also identify further areas for improvement including the collection and analysis of more comprehensive administrative data, and the need to establish training in trauma-informed practice. There are numerous evidence-informed messages for policymakers and practitioners. The papers come from five countries, but they cover common issues; and they have been brought together as part of a programme of work undertaken through the International Research Network on Infants and Child Protection (www.irnicp.org), a group that aims to develop an evidence base, promote knowledge transfer, and accelerate systems change with regard to how child welfare agencies respond to infants during the perinatal period so as to optimise their development and wellbeing.