Assessment and Risk in the Ante-Natal and Peri-Natal Period

The aim of this guidance is to present an approach to the assessment of risk to an infant's welfare, antenatal and in the immediate post birth period. 

There are three sections to the material that follow: an initial section which looks at referrals and procedures within Oxfordshire so that risk assessment in the antenatal and peri-natal period can be seen in context, the second section which discusses general principles of risk assessment in this period, and a final section which presents a framework for examining specific aspects of risk.

Throughout we have emphasised the welfare of the child, or child to be born, within a context of both child protection and the needs of the child. We have also been as concerned with those factors which lessen or ameliorate risk as with those which elevate it. We are cognisant of the fact that risk assessment is not an exact process, far less a science, but we have attempted to base this assessment approach firmly within the context of the consensus of research findings and clinical writings. We provide a reference and further reading list at the end of the document.

Figure 1 presents an overall framework for organising the evaluation of risk in this period.

Figure 1 is amplified in Figure 2. In undertaking a risk assessment we would not necessarily consider all of the items listed in the enclosed matrix, but we would suggest a consideration of each of the six major headings. 

These major headings are:

• The parent as an individual;
• The parent's history of providing care for any previous children;
• The relationship between the parent and the unborn or newly born child;
• Issues to do with the foetus or new baby;
• Family or household dimensions; and finally;
• Wider social and neighbourhood facts.

In all cases where substantive risk assessment is undertaken each of these six dimensions will need to be considered, although the particular items which will need to be examined in the individual case will vary. Each of the items has some consensus from research or clinical work behind it, indicating that it is a factor that may either elevate or lower future risk to the infant.

Any particular item will need to be seen in context, balanced against other items. Furthermore its salience in the individual case will be weighted as part of the process of decision-making. 

Thus it is very rare that a single issue or item would tip the balance one way or the other with respect to risk assessment. Normally items will be weighed and balanced and a total picture will emerge. There are occasions when a single item will of course have such overwhelming salience that it genuinely does outweigh other factors. This may happen on the positive side of the scale as well as the negative.

Finally the factors are listed which are known to ameliorate risk or protect the infant from harm, as well as those on the negative side of the equation. For further details and reviews of the clinical and research literature upon which this matrix is based, see References.

Summary of Factors in Antenatal & Peri-natal Risk Assessment

Elevated Risk

Parent

• Negative childhood experiences maltreatment;
• Violence/abuse of others;
• Age – very young parent – immature;
• Mental disorders or illness;
• Learning difficulties;
• Physical disabilities/ill health;
• Non compliance.

Lowered Risk Including Protective Factors

• Positive childhood or understanding of own history;
• Recognition and change in previous violence pattern;
• Maturity;
• Capacity for change;
• Presence of another (good enough) carer;
• Compliance.

History of Parenting

• Abuse and/or Neglect of previous child;
• Antenatal/postnatal neglect;
• Abuse addressed in treatment;
• Presence of non abusing parent.

Parent/baby Relationship

• Maltreatment and/or attachment difficulties with unborn baby;
• Lack of awareness of unborn baby's needs;
• Unreal expectation;
• Postnatal depression;
• Attachment to unborn baby;
• Appropriate awareness care of baby's needs;
• Breast-feeding.

Baby

• Special or extra needs;
• Perceived as different;
• Stressful gender issues;
• Easy baby;
• Acceptance of difference.

Family/household

• Relationship disharmony/instability;
• Violent or deviant network;
• Supportive spouse/partner;
• Protective supportive extended family or friends.

The following notes expand and explain the items listed in Figures 1 & 2.

1. The baby

Under this section we focus on the infant as an individual. The infant's sex may be a stressful issue for the parent. Such an issue may be disclosed by the parent or known by professionals through the parent's relationship with previous children of this sex. The perception of the infant as "normal" or "abnormal" is likely to be just as important as the fact of whether the child has particular needs or disabilities.

2. The Parent

Here we are concerned with all the adults who are likely to take a primary care-taking role for the infant. We consider the parents individually, and examine their past history of parenting and their relationship with the baby in ensuing sections. Certain items may need further elaboration, as follows.

Childhood experiences – childhood experiences of the parent need to be considered not only in terms of what occurred but their salience for the individual. Hence denial or nonchalance about past abuse carry a higher risk than childhood abuse experiences which are more appropriately understood by the individual.

Physical disabilities are only considered a risk to the extent to which they affect mobility and the capacity to physically care for the infant. This factor will have to be considered in relation to the existence of community care resources and social supports for the individual with a disability.

Learning difficulties may raise the risk for infant welfare especially when combined with significant personality disorder or psychiatric disturbance.

By false compliance we mean those individuals who appear to comply but lack "genuineness".

3. History of Parenting

Under this section we consider how the individual parent has cared for other children in the past. These may be their birth children or children for whom they have had responsibility, perhaps through baby-sitting, care of siblings, or as step parents.

Medical Neglect refers to the neglect of essential medications for a previous child, which led to Significant Harm to that child.

Abuse or Neglect of a previous child is not necessarily a bar to caring for the current infant, especially if there has been significant change since the last time, and/or the ameliorating influence of a non abusive partner.

4. The Parent/Infant Relationship

We are as concerned here with maltreatment and negative feelings towards the unborn baby in the antenatal period as to the more evident problems in the immediate post partum. Sometimes maltreatment is direct through deliberate injury to the foetus, and at other times indirect through risk taking behaviour or the intake of drugs or alcohol with a known deleterious effect on the infant. The parent's developing sense of attachment to the baby yet to be born can be a useful key to understanding the quality of the initial attachment between parent and infant in immediate post partum.

5. Family/Household

Here we are concerned with the immediate household and extended families surrounding the infant. We concentrate on those with frequent contact and who provide the context within which the infant will be cared for. Naturally, family violence is particularly relevant and/or being cared for within a highly disharmonious household or adult partnership.

6. Social

Under this section we are concerned with the wider social network within which the family operates. There may be direct effects of poverty and inadequate housing, compromising the care of the infant. Equally the family may be part of a deviant network of persons, who collectively pose a significant risk to an individual child. Examples might include drug abusing networks or networks with extreme anti-social or violent characteristics. Some neighbourhoods are more supportive for young parents than others, dependent on such resources as Drop-In-Centres, Telephone Advice Lines and the existence of an ethos of supportive social contacts between parents with young children. Sometimes poverty or inadequate housing at the time of birth may be countered by the optimistic prospect of change in the short or medium term so that the risk to the infant is lowered by this.

Jones DPH (1991) The Effectiveness of intervention. In Adcock M, White R, & Hollows A. (Eds) Significant Harm. Croyden, Significant Pubs.

Cicchetti D & Carlson V (1989) Child Maltreatment: Theory and Research on the Causes and Consequences of Child Abuse and Neglect. Cambridge, Cambridge University Press.

Gough D (1993) Child Abuse Interventions A Review of the Research Literature. London, H.M.S.O.