Concealed or denied pregnancy – advice for practitioners

In a concealed pregnancy, a woman is aware of the pregnancy but does not tell professionals, or may hide the fact that she is not accessing antenatal care.

In a denied pregnancy, the woman is unaware of, or unable to accept the reality of the pregnancy.

The term concealed pregnancy is used to cover both situations.

When concealed pregnancy is suspected, it is of course difficult to know the stage or gestational date of the pregnancy. A concealed pregnancy is defined as one where the pregnancy is first confirmed at more than 24 weeks gestation – this may be in late pregnancy, in labour, or after the birth of the baby.

A woman who presents at, for example, 22 weeks, is not considered to have concealed her pregnancy but may have additional needs or vulnerabilities, and should be offered appropriate assessment and support.

The MSB has adopted the Greater Manchester Safeguarding Partnership procedures regarding concealed pregnancies – these can be found in chapter 4.16 of the GMSP procedures.

Risks linked to concealed pregnancy
There are occasional cases – often well publicised – 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, in general the risks and issues are very similar for concealed and denied pregnancies, which cannot always be distinguished, and comprehensive assessment and support must be offered in all cases:

• Where a woman has not accessed antenatal care, the risk of pregnancy complications, illness and even death for mum and baby are increased – maternal deaths are rare, but when they do occur, a significant proportion are associated with concealed pregnancy.
• Pregnancy may be concealed deliberately because agencies already have concerns about the safety of the new-born in the care of parents, and concealment is part of a deliberate effort to prevent removal of the baby.
• Teenagers may conceal or deny a pregnancy because of fear of parental and wider social responses. For some women, pregnancy outside marriage may carry stigma or even risk and is concealed. Very vulnerable women, particularly those who have been trafficked or exploited, may not be able to access antenatal care.
• Concealment and denial of pregnancy may be linked to mental health difficulties or learning difficulties, and more broadly may reflect ambivalence to the pregnancy, and potential future difficulties in prioritising the baby’s needs, or in bonding with the baby. Careful assessment of family history and functioning is required to establish whether the baby can be safely cared for by parents

Nationally, there have been a number of serious case reviews where the baby has been killed following birth. There have been other cases where babies have later been significantly neglected or physically harmed following concealed pregnancy.

What to do when a concealed pregnancy is suspected

• familiarise yourself with guidance
• be aware of possible indicators of a concealed pregnancy
• be aware of the potential for repeated concealed pregnancies
• if you have concerns, seek advice from safeguarding leads
• encourage the woman to visit her midwife or GP
• when concealed or denied pregnancy is strongly suspected, a referral must be made to Children’s Social Care.

Policy and procedure for anyone who may encounter a woman who conceals the fact that she is pregnant or where a professional has a suspicion that a pregnancy is being concealed or denied can be found in the GMSP procedures.

Local Case History
Death of a very young child in January 2014, as the result of a severe head injury and multiple other injuries.

Learning from the SCR: insufficient professional curiosity given the concealment or denial of mother’s pregnancy; and the use of two different formats for inputting dates of birth onto electronic systems contributing to an error that prevented sufficient sharing of information.

Recommendations: the use of genograms by community-based practitioners as a tool to gather information and to prompt practitioners to be inquisitive; and simplification and consistency in data inputting formats and processes.

Read the Oldham LSCB overview report for this case on the NSPCC repository.