CPA text:Layout 1 · Wilkinson, 2000; Geary et al. 1997). Women who conceal pregnancy usually do not participate in the full range of antenatal care set down by current practices

Guidelinesfor Health Professionals working inMaternity Settings on the Care ofWomen with Concealed Pregnancy


ABOUT THE AUTHORCatherine Conlon graduated with an MA in Women’s Studies from UniversityCollege Dublin in 1994 and has since worked as a social researcher bothwithin the university sector at the Department of Sociology, Trinity CollegeDublin and WERRC, University College Dublin, as well as in the public sectoras Research Officer at the National Council on Ageing and Older People.Among other publications, she is co-author of Women and Crisis Pregnancy(1998) with Evelyn Mahon and Lucy Dillon and author of Mixed MethodsResearch of Crisis Pregnancy Counselling and Support Services (2005) andConcealed Pregnancy: A case-study approach from an Irish setting (2006).She is currently pursuing a PhD on the topic of Concealed Pregnancy forwhich she was awarded an Ad Astra Scholarship from UCD and a CrisisPregnancy Agency Doctoral Scholarship.

ACKNOWLEDGEMENTSThe preparation of these guidelines was greatly assisted by the input of thefollowing professionals who generously gave of their time and expertise togive us valuable feedback at draft stages: • Dr. Meabh Ni Bhuinneain and Dr. Ulrick Bartels, Consultant

Obstetricians at Mayo General Hospital• Dr. Anne Flood, Director, Centre for Nurse/Midwifery Education, St.

Conal’s Hospital, Letterkenny• Rosemary Grant, Principal Medical Social Worker, Coombe Women's

Hospital• Geraldine Keohane, Director of Midwifery, and her team at Cork

University Maternity Hospital • Loretto Reilly, Head Medical Social Worker, National Maternity Hospital,

Holles St.• Ann Marie Staunton, Assistant Director of Nursing and Midwifery, and

her team at Mayo General Hospital.

Thanks also to participants of the Forum convened in Ballinasloe in April2008 for valuable input into the drafting stages of the Guidelines. CatherineConlon extends her thanks to the Research and Policy Sub-committee of theCrisis Pregnancy Agency, to the Agency’s research staff – Dr. StephanieO’Keefe, Dr. Patricia Moriarty and Sarah Murphy and to the Social Workersfrom HSE West, Ann Doherty, Marie Finn and Maeve Tonge, for theircollaboration and support in carrying out this work.

CONTENTS

UNDERSTANDING CONCEALED PREGNANCY 7

INTRODUCTION AND BACKGROUND INFORMATION 7Definition of concealed pregnancy 8Incidence of concealed pregnancy today 8Profile of women concealing pregnancy 8Forms a concealed pregnancy may take 8Reasons why a woman may conceal pregnancy 9How women conceal pregnancy 10Implications of concealment 11Conclusion 12

GUIDELINES FOR RESPONDING TO WOMEN CONCEALING PREGNANCY 13Key components of the care pathway 141 The principles guiding the response 152 Letter of Intent 163 ‘Confidential Patient’ Policy 184 Special procedures for notification of birth 21

DETAILED GUIDELINES FOR EACH PROFESSIONAL GROUP 25Midwifery Team 27

Key Elements of Response 27First presentation of a woman concealing pregnancy 28Specific information for Antenatal Department Midwife caring for a woman concealing pregnancy 29Specific information for Labour Ward Midwife caring for a woman concealing pregnancy 29Specific information for Postnatal Ward Midwife caring fora woman concealing pregnancy 31

Social Work Team 33Key Elements of Response 33Assignment of Case 34First presentation of a woman concealing pregnancy 34Specific issues for Social Work Team caring for a woman concealing pregnancy 35

GUIDELINES FOR HEALTH PROFESSIONALS WORKING IN MATERNITY SETTINGSON THE CARE OF WOMEN WITH CONCEALED PREGNANCY

3

Obstetric Team 39Principles Guiding Response 39Specific issues for Obstetric Team caring for a womanconcealing pregnancy 39

Paediatric Team 43Principles Guiding Response 43Specific issues for Paediatricians caring for a woman concealing pregnancy 43

Antenatal/Parentcraft Education Team 45Principles Guiding Response 45Specific issues for Antenatal/Parentcraft Education Team caring for woman concealing pregnancy 45

Administration Team 47Principles Guiding Response 47Specific issues for Administration Team in Antenatal Department 47

Specific Issues for Birth Notification Clerk 47All departments: the Confidential Patient Policy 48Community-based Resources 49

REFERENCES 50

APPENDIX ONE: CONFIDENTIAL PATIENT FORM: EXAMPLE 52

4

SCOPE OF CARE PATHWAYThis Care Pathway is intended to provide a protocol for health-care staffworking in maternity settings, to improve their capacity to recognise,respond appropriately to and have understanding of and empathy for womenwho present concealing pregnancy.

The protocol is aimed at multidisciplinary professionals attached tohospital-based maternity services in antenatal outpatients, and prenatal,labour, postnatal and gynaecological wards.

The document is tailored for maternity settings where there is an on-siteMedical Social Work presence.1

1 The Crisis Pregnancy Agency is aware that further versions of this document are necessary to covermaternity-care settings that do not have an on-site social-work presence; as well as other hospitaldepartments, and other hospitals without maternity departments where women concealingpregnancy may present complaining of another condition.


5

NOTES

6

UNDERSTANDINGCONCEALED PREGNANCY

INTRODUCTION ANDBACKGROUND INFORMATION

DEFINITION OF CONCEALEDPREGNANCY

Concealed pregnancy may bedefined as where a woman whopresents for antenatal care past 20weeks’ gestation has neither:

• availed of antenatal care nor

• disclosed the pregnancy to hersocial network.

A woman may stop concealing thepregnancy at any point beforedelivery, may continue to concealuntil delivery or may even conceallong after giving birth by placing thebaby into the care of another, e.g.through adoption.

INCIDENCE OF CONCEALEDPREGNANCY TODAY

Concealed pregnancy continues to bea feature of Irish society. Statistically,it is relatively rare, but it may end inan unassisted birth, with all theattendant risks including seriousillness/trauma or even the death ofthe child and/or mother, or thenewborn infant may be abandoned.This makes it an issue of criticalimportance for health-care services.

Conlon (2006) noted an incidenceduring 2004-2005 of:

• one concealed pregnancy in

every 403 births in a rural Irishhospital

• one concealed pregnancy inevery 625 births in a Dublinhospital.

This suggests a higher incidence inrural settings. In the internationalcontext, a study from Wessel et al.(2002) estimated an incidence inGermany of one in every 475 births.

PROFILE OF WOMENCONCEALING PREGNANCY

Women of all ages concealpregnancy but younger women, aged16 to 24, predominate in studies.Most women are single but someare married or separated.Concealment of pregnancy has beenobserved among women of all socialclasses, levels of education andemployment and professionalstatus. A woman may repeatconcealment on a second or thirdpregnancy.

FORMS A CONCEALEDPREGNANCY MAY TAKE

Research has highlighted threeforms or typologies that a concealedpregnancy may take:

• An undetected pregnancy. Awoman whose pregnancy isundetected until advancedpregnancy or even labour

8

conceals the pregnancy withouteven being aware of it herself.

• A detected pregnancy that awoman actively denies. A womanconsciously denies herpregnancy when she recognisesshe is pregnant but denies this toherself and others, and does notdisplay emotions usuallyassociated with pregnancy.

• A detected pregnancy that awoman acknowledges butconceals. A woman consciouslyacknowledges the pregnancy,and in some cases evenwelcomes it, but does notdisclose it. Such women mayengage in a process of adaptingto the pregnancy and theprospect of motherhood, such asdisplaying emotions associatedwith pregnancy, engaging withthe foetus or makingpreparations to care for the babyafter delivery.

Since, in all these typologies, thepregnancy is concealed, the termconcealed pregnancy is usedthroughout the Care Pathway torefer to any of these situations.

There are subtle differences in awoman’s concealed pregnancyexperience and the course of herpregnancy according to which ofthese typologies she adheres. Care

responses always need, therefore, tobe tailored to the specifics of eachwoman’s pregnancy.

REASONS WHY A WOMAN MAYCONCEAL PREGNANCY

Physiological factors can contributeto a pregnancy being under-pronounced or not showing theusual or expected symptoms ofpregnancy. For example, there maybe continued periods/bleeding, nomorning sickness, or specificanomalies that make detectiondifficult.

The principal social/cultural factornoted in the research literaturerelates to women viewingthemselves as in the ‘wrong’ socialcircumstances for pregnancy, e.g.being unmarried or without apartner. Other social/cultural factorsinclude threats to their life chancesin terms of education, work andrelationships; anticipatingcondemnation or even abandonmentby parents or family, and risk to thestability of their existing family.Research suggests that familiesmay be complicit in their daughter’sconcealment of pregnancy eitherbecause they do not accept it orbecause they respect her decisionnot to disclose.

Women may conceal a pregnancy soas to retain control of the pregnancy.


9

They may want to take the time todecide on their preferred outcomeon their own and avoid pressuretowards another outcome, wherethey anticipate opposition fromparents or partners. For example, awoman with a disability may concealin order to avoid pressure fromothers who do not support herchoice to become a parent. Also,women who have had contact withchild-protection services mayconceal a pregnancy so that thebaby does not come to the attentionof the services. Women also concealpregnancy because they perceive athreat to their safety or that of thebaby, e.g. from a violent partner.

Psychological processes includewomen believing that pregnancy isinconsistent with their self-image tothe extent that they cast from theirmind the possibility that any of thesymptoms they note could becaused by pregnancy. This usuallymeans denial of the pregnancy.

Where a woman with a mental-health condition or a learningdisability becomes pregnant, theseconditions may hinder her capacityto identify that she is pregnant orcope with the pregnancy. The sameapplies where the woman has a drugor alcohol addiction.

HOW WOMEN CONCEALPREGNANCY

The process of denying andconcealing pregnancy takes a rangeof forms. The woman may believethat the pregnancy will neverbecome established or may end inmiscarriage. This means that shedoes not contemplate or anticipatethe prospect of motherhood.Instead, the delivery is seen as theend in itself and plans are made toplace the baby into the care ofothers, either through arrangingadoption or anonymously leaving thebaby in a place where it may befound and taken into the care ofothers.

Another strategy is to block outthoughts of pregnancy, using arange of means including:

• keeping busy physically andmentally

• explaining symptoms away (e.g.missed periods are attributed torecent stress or ill-health)

• drinking or misusing substancesin order to forget.

Concealing a pregnancy from othersinvolves a fine balance betweentaking action so as to hide thepregnancy, while at the same timenot appearing to look or act any

10

differently. This can include:

• wearing concealing orconstricting clothing

• isolating oneself (e.g. byprovoking arguments withfamily/partners)

• trying to contain the developmentof the pregnancy by exercisingand dieting

• hiding the signs of labour.

IMPLICATIONS OFCONCEALMENT

There is no conclusive evidence thatconcealing pregnancy duringgestation in itself leads to adversefoetal outcomes or obstetriccomplications (Wessel et al. 2003;Treacy et al. 2002; Sable &Wilkinson, 2000; Geary et al. 1997). Women who conceal pregnancyusually do not participate in the fullrange of antenatal care set down bycurrent practices in the medicalmanagement of pregnancy. This cancause difficulties in determining theestimated date of delivery or indetecting complications. As notedearlier, there are high risks if awoman gives birth withoutpreparation or midwifery orobstetric assistance.Denying pregnancy means that awoman does not adjust her lifestyle

or adapt mentally to the prospect ofbirth and motherhood. As a resultshe feels unprepared for these life-changing events when labourbegins. She may also engage inbehaviours that are not advisedduring pregnancy and even putherself and/or the baby at risk.

Concealing pregnancy places aninordinate emotional burden on awoman. She may experienceisolation and loneliness; fear;confusion, feeling scared andpanicked; disbelief and shock; lossand grief; feeling trapped; anger;guilt and shame; feeling judged;embarrassment. These wide-ranging emotions are often acutelyfelt by the woman, with eachcompounding the other so that theydeeply affect her and have enduringconsequences.

In the aftermath of concealment,women may feel that professionalcaregivers, their family, significantothers and the wider communitydisapprove of them for concealingthe pregnancy. Within the hospitalsetting, those caring for her aremost often not judgemental butrather express only good willtowards her. However a clumsy,inappropriate comment from oneindividual within the hospital canresonate strongly with a womanwhose sensitivities are heightened.


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There are also consequences for thewoman’s personal relationships.Misgivings and recriminations mayarise among partners, parents,siblings and friends in whom thewoman did not place confidence.

CONCLUSION

Women often report that when theydo disclose the pregnancy, a positiveoutcome most often ensues, andthat aid and support fromprofessionals can help greatly toheal damaged relationships.However, the fears that gave rise toa woman concealing her pregnancymay be realised so that, when shedoes disclose, she is rejected by herfamily or partner – which meansthat she has further need forsupport.

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GUIDELINES FORRESPONDING TO WOMENCONCEALING PREGNANCY

A woman concealing her pregnancymay present to a hospital at any ofthe following stages:

1. In advanced gestation (latebooker): at least past 20 weeksbut frequently much later,without having disclosed toanyone or attended any antenatalcare to date.

2. In labour (unbooked): withouthaving attended for any antenatalcare at either the hospital towhich she is now presenting orat any other hospital or GP.

3. Postnatally (unbooked), wherethe baby has been born beforearrival and both the mother andthe baby need assessment andcare. Serious issues may arisefor the woman and the baby, inparticular, if delivered withoutmedical assistance.

Research on concealed pregnancyhighlights how the situation forevery woman concealing herpregnancy is unique and requires atailored response.

In the hospital setting, an integratedmultidisciplinary approach toproviding for her and the baby’s careis important. Midwives, nurses,doctors, social workers, counsellors,antenatal educators andadministrative staff need to be made

aware of the specificities of eachwoman’s case and the care issuesthat these raise.

In responding to the woman, it isparticularly important to:

a) sensitively engage with her,particularly on her firstpresentation

b) strive for continuity of care ateach visit and to maintain asensitivity to her situation at alltimes

c) ensure that the multidisciplinaryteams under whose care thewoman comes communicateabout her specific situation andneeds

d) support the woman in disclosingthe pregnancy while respectingher wish to maintain theconcealment and herconfidentiality while in thehospital.

KEY COMPONENTS OF THE CAREPATHWAY

The key components of the carepathway for responding to womenconcealing pregnancy are:

1. Principles to guide how theprofessional responds to thepresentation of a woman

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concealing pregnancy.2. A Letter of Intent, drafted jointly

by the woman and aMidwife/Social Worker, that isplaced on the woman’s chart. Itoutlines her situation and wishesthroughout the pregnancy, birthand postnatal care, to inform allmembers of the multidisciplinaryteam with whom she comes intocontact.

3. A Confidential Patient Policy tosupplement existing hospitalpatient confidentiality policies,with specific safeguards forwomen concealing pregnancy.

4. Special procedures in theNotification to the Registrar ofBirths, General Practitioners andPublic Health Nurses.

1. THE PRINCIPLES GUIDING THERESPONSE ...

... if a woman concealing pregnancydiscloses to you

If you are the first person to whom awoman discloses her pregnancy,your immediate response is crucialin reassuring her and influencingher to engage with services, therebyaccessing further supports. Try to beguided by the following principles:

• Reassure the woman that youunderstand she is going through

a crisis and that you will supporther through it. Let her know thatyou have met other women inthis situation before who havecoped and got through thatcrisis. Assure her thatconcealing a pregnancy can be astrategy women use to deal witha very difficult time in their lives.

• Offer confidentiality by outliningthe hospital’s general patientconfidentiality policy. Establish acontact number/address atwhich the woman is happy tohave staff from the hospitalcontact her about the pregnancy.

• Offer every support to enable herto disclose the pregnancy.However, if she maintains herwish to keep the pregnancyconcealed from her socialnetwork, outline the specificprovisions available to safeguardthe confidentiality of womenconcealing pregnancy.

• Be non-judgemental. Researchhas shown that women usuallyhave very good reasons forconcealing their pregnancy.Acknowledge her crisis andaccept that she feels she hasgood reasons for concealment.Reassure her that hospital staffwill respect her decision and thatshe can be supported. Even in asituation where her behaviour


15

gives rise to risks of harm forherself or the baby, avoid judgingher or attributing blame to her.

• Be non-directive in yourapproach and accept where thewoman ‘is at’ in her pregnancy atthe time. Allow her to considerwhat option is right for her atthis stage in her pregnancy.Inform her of specialist supportavailable to help her consider theoptions and, where appropriate,refer her to that support.

• Acknowledge the important stepshe has taken in presenting,whatever stage she may be at.Reassure her that a tailoredpackage of care can be put inplace to meet her specific needsas much as possible regardingthe pregnancy and her desire forconfidentiality at every stage –pregnancy, delivery andafterwards. Where the womanpresents for antenatal care,highlight the importance of hercontinuing to attend throughoutthe pregnancy.

• Outline the support servicesavailable to her, including:

- medical care from midwives anddoctors

- support, counselling, and help inconsidering options from socialworkers and counsellors

- additional support fromantenatal educators

- links with other support agenciessuch as HSE social workers,crisis pregnancy counsellingservices, parent support groups,adoption societies etc.

• Refer the woman to a Midwifeand/or Social Worker as early aspossible.

2. LETTER OF INTENT

Given the specific needs andvulnerabilities that often arise when awoman is concealing pregnancy,communication regarding herparticular situation and related needsis vital among all multidisciplinaryprofessionals involved in her care.

The woman’s chart is the keymedium for communication with themultidisciplinary teams. A Letter ofIntent, drafted jointly and co-signedby the woman and her SocialWorker, should be placed on thewoman’s chart to communicate hersituation and wishes. A copy of theletter should be offered to thepatient for her own records, if shewishes to take it.

• The content of the letter shouldinclude:- A contact address and/or

telephone number thathospital staff can use to

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communicate with the womanduring her pregnancy andafter delivery.

- A statement of the woman’swishes regarding care duringdelivery, contact with thebaby, rooming-in, andplacement into care orparenting of the baby.

- A statement of the woman’swishes regarding notificationto next of kin.

- A statement of the woman’swishes about disclosure andcontact with her family orpartner.

- Any directions aboutnotifications to the HSE BirthsNotification Office fornotification to the PublicHealth Nurse and theRegistrar of Births as well asto GPs at the postnatal stage.

- If applicable, a statement thatthe women has elected to be a‘Confidential Patient’.

• The letter should be drafted interms such as: ‘At this point it isthe woman’s intention to …’. Thisallows for her changing herposition at any time.

• The letter should acknowledgethat the woman can change hermind on any matter discussed init. The reader should be directedto respect her autonomy.

• The letter should be inserted onthe woman’s chart in anenvelope addressed to theClinical Midwife Manager of theantenatal, delivery and postnataldepartments.

• The letter should be marked withthe woman’s patient number incase it becomes detached fromthe chart. Use of a colouredsheet/envelope may help tohighlight the letter in thepatient’s chart. The letter can beformally updated on a regularbasis if changes are required. The woman should be advisedthat she can now say to any staffmember with whom she comesin contact that they may refer tothe letter on her chart tounderstand her situation andspecific needs. She should feelconfident that this letter willexplain these clearly. She shouldalso be informed that she canchange her mind regarding herstatus at any time which willresult in reversal of procedures.

Where a woman presents in labouror with baby born before arrival

Where a woman presents to thehospital while in labour or if thebaby is born before her arrival, thiscreates an emergency for midwifery,obstetric and paediatric staff andallows no time for advance


17

consultation with a Social Worker. Areferral to the Social Worker needsto be made immediately and thetiming of the involvement of theSocial Worker depends on thepatient’s needs.

In such a case, the Midwife caringfor the woman should try to outline,in a Letter of Intent placed on thewoman’s chart, the following:

- The woman’s wishes aboutcontact with the baby,rooming-in and placementinto care or parenting of thebaby.

- Her wishes about disclosureand contact with her family orpartner.

- Her wishes about contactingnext of kin if an emergencyarises.

- Any directions aboutnotifications to the HSE BirthsNotification Office fornotification to the PublicHealth Nurse and theRegistrar of Births as well asto GPs at the postnatal stage.

- A contact address and/ortelephone number thathospital staff can use tocommunicate with the womanafter discharge.

- If applicable, a statement thatshe has elected to be a‘confidential patient’.

The note should be drafted in terms

such as: ‘At this point it is thewoman’s intention to …’ to allow forthe woman changing her position atany time. The reader should beasked to respect the woman’sautonomy in the event that she doeschange her mind.

The woman should be advised thatshe can now say to any staffmember with whom she comes incontact that they can refer to thenote on her chart which explains hersituation and specific needs.

3. ‘CONFIDENTIAL PATIENT’ POLICY

Observance of hospital confidentialpolicy

Confidentiality is often a key concernfor a woman concealing pregnancy.It will be reassuring for her to betold that it is general hospital policythat all patient information istreated with absolute confidentialityat all times.

The usual hospital policy andprocedures for patientconfidentiality should bemeticulously observed for a womanconcealing pregnancy. In particular,it is imperative that:

• All medical and socialassessments be conducted inappropriate private spaces

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• Patient details or issues are neverdiscussed among staff memberswithin audible range of otherpatients or members of thepublic.

Specific ‘confidential patient’arrangements for womenconcealing pregnancy

Where a woman presents concealingpregnancy, the Social Worker orMidwife will discuss with her howshe can be supported in disclosingthe pregnancy to significant others.To encourage disclosure, it may bestressed that:

• Support from significant othersis important for any womangoing through pregnancy.

• It is important that children knowthe identity of both parents.

• It is likely that the woman willencounter a positive reactionfrom significant others.

In a small number of cases, thewoman may decide to maintainconcealment throughout gestation,delivery and placing the baby foradoption, these Guidelines proposespecific arrangements to facilitate awoman who so decides).

The specific ‘Confidential Patient’Policy is intended to optimise

confidentiality for women concealingpregnancy. It seeks to ensure thatno acknowledgement of a woman’spresence in the hospital will bemade in response to enquiries fromthe public, particularly thosepresenting as family or friends, as tothe well-being of an in-patient ortheir location in the hospital.

‘Confidential patient’ arrangements

The elements of a ‘confidentialpatient’ policy for women concealingpregnancy are:

1. If the woman, followingdiscussions about the supportsfor and benefits of disclosure,says she wishes to continueconcealing her pregnancy, theMidwife or Social Worker willoutline the special arrangementsavailable in the hospital tosafeguard her confidentiality inline with her wishes. AConfidential Patient form is co-signed by the woman and aMidwife/Social Worker (seeexample in Appendix 1). Thisform is placed at the front of thewoman’s hospital chart so allwho consult this can see she is a‘confidential patient’. Printingthe form on coloured paper orkeeping in a coloured envelopemay aid visibility of the form.

2. The hospital’s Patient


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Information System is configuredso that a patient’s record can bemarked: ‘Confidential Patient:no information to be given out’.This will be seen by allmidwifery, medical, social-workand administrative staffconsulting her record. They willknow not to acknowledge thepresence of or disclose anyinformation about the womaneither personally or by telephoneto any visitor/enquirer.

3. The hospital’s PatientInformation System is configuredso that a patient’s record doesnot appear on the enquiry list orin the computers operated byreception staff who deal withenquiries from the public, eitherby telephone or in person. Thismeans that if an enquiry about anamed woman is made toreception staff, their computerwill not retrieve informationabout her and they will informthe enquirer that no-one of thatname is a patient of the hospital.

4. Where ward noticeboards listingthe names of in-patients are inuse, a Confidential Patient’sentry will be listed as ‘Occupied’rather than using the woman’sname.

Limits to Confidential Patient policy

Women should be fully apprised ofthe implications of being marked aConfidential Patient, as follows:

• Should anyone ask for thewoman at the hospital reception,they will be told that no-one ofthat name is in the hospital. Ifthe woman has disclosed herpregnancy to particular peoplewho she wishes to visit her inhospital, she should advise herconfidantes that the reception orward staff will not acknowledgethat she is an in-patient whenthey visit.

• Due to the nature of the hospitalenvironment and the inability tocontrol who the woman mayencounter while in public spaces,the hospital cannot assurecomplete confidentiality. Sheshould be advised to be carefulabout circulating in publicspaces in the hospital, e.g. shopor smoking areas, in the interestof maintaining herconfidentiality.

• Where it is the professionaljudgement of a member ofhospital staff that there is a riskto the well-being of the womanand/or her child, they may – inthe interests of their protectionand safety – have to liaise withother professionals.

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• The age of the woman may alsocreate a limit to how far thehospital can adhere to her wishfor confidentiality.

Procedures for implementing theConfidential Patient policyFor a woman presenting forantenatal care

The Social Worker will:

• Explain the procedures availablefor being designated a‘confidential patient’ and discussthe implications of this fully withthe woman.

• Establish early in the woman’scare in the hospital herpreference on whether to bedeemed a ‘confidential patient’or not.

• Take the lead on implementation,that is: co-sign the form andplace it on the woman’s chart,and alter her Patient InformationSystem (PIS) record to read‘Confidential Patient’, andremove it from the receptioncomputer.

For a woman presenting in labouror with a baby born before arrival

The Midwife caring for the woman,or the Social Worker if the timing isappropriate, when taking the

woman’s history will: • Outline the procedures for being

designated a ‘confidentialpatient’ and the implications ofthis.

• Establish the woman’spreferenceon whether to elect to be a‘confidential patient’ or not.

• Take the woman through theConfidential Patient form, co-sign it and place it on her chart.

• Instruct Admissions to alter herPIS record to mark ‘ConfidentialPatient’ and remove it from thereception computer.

• Ensure that she is listed as‘Occupied’ rather than by nameon the ward noticeboard of thelabour and/or postnataldepartments.

• Notify the Medical Social Workdepartment that a woman hasbeen admitted and has requestedConfidential Patient status.

4. SPECIAL PROCEDURES FOR NOTIFICATION OF BIRTH

If a woman wishes to keep the birthof her baby concealed, the routinecommunications made to notifyoutside agencies of a birth may needto be modified according to her needand preferences. Time constraints


21

and deadlines for notifications needto be communicated.

To the Registrar of Births

The standard notification form to theRegistrar of Births includes theoption to mark the case as‘Sensitive’. If the woman is placingthe baby in alternative care, thisoption can be taken to alert theRegistrar so that:

1. The Registrar does not write toher address.

2. No notification is forwarded tothe Child Benefit Section of theDepartment of Social and FamilyAffairs.

If there is a change of mind on thepart of the mother, the above can bedisregarded.

To the Births Notifications Office

If the mother is considering placingthe baby for adoption, the BirthsNotifications Officer of the HealthService Executive (HSE) should becontacted directly and asked towithhold the birth notification fromthe local Public Health Nurse. Thisallows for the wishes of the motherto be clarified and the destination ofthe baby to be determined. Hospitalstaff should familiarise themselveswith how births are notified to theHSE in their particular hospital or

unit e.g. manually or electronically.In particular, hospital staff need tobe aware of the timing of the BirthNotification as it may be necessaryto act speedily for information to beblocked.

When the woman and/or baby isdischarged, the Births NotificationsOfficer should be contacted again toadvise of any of the following:

• The baby is being placed inalternative care and a PublicHealth Nurse (PHN) should visitat the baby’s place of residence.The mother does not wish toreceive a PHN visit, her identityremains confidential and noreferral for the mother is made.

• The baby is placed in alternativecare and a PHN is to visit thebaby there. The mother doeswish to be visited by a PHN forpostnatal care and her place ofresidence is given (this maydiffer from her usual address).The notification regarding themother will indicate that thepregnancy was concealed andthe baby has been placed inalternative care so that the PHNwill not expect to see a baby onthe visit.

To the General Practitioner

Hospital staff need to be aware of

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any letters generated automaticallyby the birth of the baby and thespeed with which these are sent out(e.g. manually/electronically).

The Midwife or Social Workershould:

• Ask the woman if she wishes tohave a letter sent to her GP ornot.

• Offer to give her a referral letterthat she can hand to any GP shemight wish to attend forpostnatal care.

To relevant hospital administrativedepartments

At the time of discharge, the Midwifeor Social Worker should:

• Establish what usual follow-upletters may be sent from thehospital (e.g. invoices).

• Contact the relevant departmentto advise of an appropriateaddress to which post can besent safely to the woman.


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24

NOTES

DETAILED GUIDELINESFOR EACH PROFESSIONALGROUP

GUIDELINES FOR EACHPROFESSIONAL GROUP CARINGFOR A WOMAN CONCEALINGPREGNANCY IN A MATERNITYHOSPITAL OR DEPARTMENT ARESET OUT BELOW. THEY AREORGANISED ACCORDING TO EACHDISCIPLINE.

These guidelines cover moredetailed issues specific to eachprofession and its role in caring for awoman during pregnancy. Theysupplement the overall carepathway and tailor it to eachprofessional group.

Where appropriate, the guidelinesare separated according to:

• antenatal department• delivery/birthing department• postnatal department

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SECTION

ON

E

MIDWIFERY

MID

WIFER

YM

IDW

IFERY

MID

WIFER

YM

IDW

IFERY

MID

WIFER

YM

IDW

IFERY

KEY ELEMENTS OF RESPONSE

1. Be guided by the followingprinciples in responding to awoman concealing pregnancy:

Reassure her that you willsupport her through this crisis

Offer confidentiality and outlinethe special arrangement forconcealed pregnancies

Be non-judgemental: womenusually have very good reasonsfor concealing their pregnancy

Be non-directive: accept whereshe ‘is at’ in her pregnancy at thetime

Acknowledge the important stepshe has taken in presenting forcare

Outline the supports: medical,social, counselling, both hospitaland community-based

Refer her to a Social Worker asearly as possible.

2. Explain the Letter of Intent to bedrafted jointly by her and aMidwife/Social Worker and placeit on her chart. It outlines hersituation and wishes –throughout the pregnancy, birthand postnatal care – for allmultidisciplinary teams withwhom she comes into contact.Implement this in conjunctionwith a Social Worker or alone, asapplicable.

3. Explain the Confidential Patientpolicy. If the woman opts to be a‘confidential patient’, take thelead on implementing the policyin conjunction with a SocialWorker or alone, as applicable.

4. Determine whether any specialprocedures are necessary inrelation to notifications to theHSE Births Notification Office fornotification to the Public HealthNurse and the Registrar ofBirths as well as to GPs at thepostnatal stage. Do this inconjunction with a Social Workeror alone, as applicable.


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MIDWIFERY TEAM

FIRST PRESENTATION OF AWOMAN CONCEALINGPREGNANCY

In addition to the usual midwiferyfunctions:

• Confirm that the woman fitswithin the Concealed Pregnancydefinition.

• When taking her history, besensitive to her reticence orinability to give completeinformation.

• Discuss with the woman thesupports available for and thebenefits of disclosing herpregnancy to significant others.Where she wishes to maintainconcealment, inform her of theConfidential Patient policy. If sheopts for this, take the lead inputting the arrangements inplace where time or the woman’swishes do not allow for SocialWorker involvement.

• Emphasise the importance ofcontinued contact with thehospital and note down hercontact details so that she can bereached during her pregnancyand postnatally.

• Encourage the woman to confidein a trusted other.

• Establish her preferences aboutcontacting next of kin (NOK) in anemergency.

• Outline the role of the MedicalSocial Worker (MSW) and,following discussion with thewoman, and within the maternityunit, make a referral in a timelymanner. Liaise directly with theMSW. Advise the Obstetricianunder whose care the woman isplaced of her situation.

• While the woman is an in-patient, try to offer her a choiceof ward type, where possible.Ideally, this should be a privateroom or group ward, dependingon what is available.

• Where any complications oradverse outcomes for the womanor baby arise, the situation needsto be handled sensitively, inliaison with the Obstetricianand/or paediatrician. Even if thewoman’s behaviour in concealingthe pregnancy gave rise to risks ofharm for herself and/or the baby,it is important to avoid judgingher or attributing blame to her.Women should be reassured thatthe Midwife and doctors areconcerned for her well-being andthat they understand thatconcealing a pregnancy is a verytraumatic event that can lead totragic outcomes the womannever intended.

28

SPECIFIC INFORMATION FORANTENATAL DEPARTMENTMIDWIFE CARING FOR A WOMANCONCEALING PREGNANCY

• Discuss the usual chart handlingprocedure, particularly wherewomen are generally offered theoption of taking the chart home.Make special arrangements ifnecessary.

• Discuss and encourage thewoman to link with antenataleducation, refer the woman ifshe wishes and liaise directlywhere necessary.

• Discussing how a care plan canbe tailored for her, takingaccount of the stage ofpregnancy at which she haspresented.

• Where a woman plans to givebirth in another hospital, stronglyadvise that she take a copy of herantenatal chart to the MaternityDepartment of that hospital.

SPECIFIC INFORMATION FORLABOUR WARD MIDWIFE CARINGFOR A WOMAN CONCEALINGPREGNANCY

Women presenting unbooked orwith baby born before arrival

• Note that the attendingMidwife(s) will be under pressureto catch up on some of the usualpreparations for childbirth andpaediatric care – i.e. to take thewoman’s history and administertests usually administeredduring antenatal care.

• Be aware that the woman hashad no preparation for labour.She is unlikely to have a birthingpartner and will require muchemotional support.

• Establish her wishes aboutcontact with the baby, rooming-in and feeding the baby.

• A note of her wishes about thebaby and about informing next ofkin in an emergency should bemade on her chart, instead of ina Letter of Intent.

• If necessary, provide basicprovisions such as personal careitems and nightdresses for thewoman and/or clothing for thebaby.


29

• If the woman decides to discloseto someone that she is inhospital giving birth, she shouldbe offered any facility possible –e.g. a phone and/or a privatearea from which she can contactsomeone as she wishes.

• The woman may need to contactfamily or friends to explain herabsence, to facilitateconcealment where she had notexpected to be admitted tohospital. Any facility possible –e.g. a phone and/or a privatearea – should be made available.Note that she needs to call froman area where background noisewould not reveal where she is(e.g. pagers going off).

• Women who conceal a pregnancyand have made no mentalpreparations for the delivery canfind the experience traumaticand overwhelming. Researchhas shown that some womenmay not engage with the birthingexperience and find ittherapeutic if their attendingMidwife can debrief on the birthat some later time.

• The Medical Social Workdepartment should be informedof the woman’s admission and, ina sensitive and timely manner,following discussion with thewoman, be involved in the case.

Women who attended for antenatalcare

• When the woman is admitted inlabour, check her Letter of Intentto establish her wishesregarding: - a birthing plan- postnatal accommodation- references on the in-patient

noticeboard- rooming-incontact with the baby - feeding the baby

• Check with her if the wishes sheexpressed in the letter still holdand allow her the autonomy tochange them at this point shouldshe wish.

• Inform her Social Worker assoon as you can that she hasbeen admitted in labour.

Issues for both groups

If the woman has opted to be a‘Confidential Patient’, ensure that hername is not listed on any noticeboard.Instead list her entry as ‘Occupied’.

30

SPECIFIC INFORMATION FORPOSTNATAL WARD MIDWIFECARING FOR A WOMANCONCEALING PREGNANCY

• The woman may go throughemotional turmoil after the birthand the act of concealing isexhausting. This can representan enormous release andwatershed at the end of verydifficult months throughout theprocess of concealment. It maycoincide with the disclosure ofthe pregnancy to family and/or apartner, who may or may not besupportive. The woman mayneed extra emotional support.

• Contact between the woman andher baby is an event that womenconcealing pregnancy are oftenunprepared for. Some womenmay opt not to have any contactwith the baby. Midwives cangently encourage the woman toexplore this option further,suggesting, for example, that shevisit the baby just to see it, holdit, or gradually become involvedin caring for it. There isconsensus that, even where awoman places a baby intoalternative care directly afterbirth, contact with the baby canbe therapeutic for her as shecomes to terms with this difficulttime in her life during themonths and years ahead.

• Where ward noticeboards listingthe names of in-patients are inuse, a Confidential Patient entryshould be listed as ‘Occupied’rather than the woman’s namebeing used.

• If the woman is consideringplacing the baby in alternativecare, the Midwife should liaisewith the clerk handlingnotification of births to theRegistrar of Births to ensure thatthe form giving notice of thisbirth is marked ‘Sensitive’ and toensure that the woman’s wishesregarding notification to the HSEBirths Notification Office fornotification to the Public HealthNurse and the Registrar ofBirths as well as to her GP at thepostnatal stage are followedthrough.

• The standard proceduresregarding Notification to GeneralPractitioners may need to bemodified. Both following deliveryand at the point of discharge, theMidwife should consult the letteron the woman’s chart to seewhat her stated preference at thetime of writing was regarding thesending of a letter to her GPoutlining medical details inrelation to the pregnancy, birthand baby. S/he should discusswith the woman whether this isstill her preference and withholdthe letter if she requests this.


31

32

NOTES

SOCIAL WORK

SECTION

TWO

MID

WIFER

YSO

CIAL W

OR

K

KEY ELEMENTS OF RESPONSE

1. Be guided by the followingprinciples in responding to awoman concealing pregnancy:


Offer confidentiality and outlinethe special arrangement forconcealed pregnancies


Be non-directive: accept whereshe ‘is at’ in her pregnancy at thetime


Outline the supports: medical,social, counselling, both hospitaland community-based

Refer the woman to a Midwife asearly as possible. If the SocialWorker is the first point ofcontact for the woman, s/heshould refer the woman to aMidwife or doctor as soon aspossible.

2. Explain the concept of the Letterof Intent, to be drafted jointly bythe woman and a SocialWorker/Midwife and placed onher chart. It outlines hersituation and wishes –throughout the pregnancy, birthand postnatal care – for theinformation of themultidisciplinary team withwhom she comes into contact.Implement this in conjunctionwith the Midwife or alone, asapplicable.

3. Explain the Confidential Patientpolicy. If the woman opts for this,take the lead in implementing itin conjunction with a Midwife oralone, as applicable.

4. Determine whether any specialprocedures are necessary innotifications to the HSE BirthsNotification Office for notificationto the Public Health Nurse andthe Registrar of Births as well asto GPs at the postnatal stage, inrelation to this case. Do this inconjunction with a Social Workeror alone, as applicable. TheSocial Worker needs to ascertainthe next of kin situation.


33

SOCIAL WORK TEAM

ASSIGNMENT OF CASE

When a concealed pregnancyreferral is received by the SocialWork department, thePrincipal/Senior Social Workershould assign it to a member of staffwho is likely to be available toprovide continuity of care to thewoman throughout her pregnancy.The Social Worker should provide aone-to-one session as early aspossible. The more advanced ingestation a woman is at firstpresentation, the more important itis to do this.

FIRST PRESENTATION OF AWOMAN CONCEALINGPREGNANCY

A Social Worker’s first meeting witha woman concealing pregnancy canbe at any stage: advanced gestation,in labour or on admittance after herbaby was born before arrival. At the first meeting, the SocialWorker should:

• Learn as much as is possibleabout the woman’s situation,including her living situation,employment, education, familyand relationship status and anypregnancy-related issues.

• Explain the role of a SocialWorker. It is particularlyimportant to:

- give the woman accurateinformation about all theoptions available to her

- explain the resourcesavailable to support herconsideration of her options

- clarify the role of the medicalSocial Worker as a linkbetween the woman, her babyand the medical teams andagencies outside of thehospital.

• Discuss with the woman thesupports available for and thebenefits of disclosing herpregnancy to significant others.Where she wishes to maintainconcealment, tell her about theConfidential Patient Policy and, ifshe opts for this, take the lead inputting the arrangements inplace.

• Emphasise to the woman theimportance of continued contactwith the hospital. Note down hercontact details so that she can bereached by the hospital duringher pregnancy and postnatally.

• Where a woman has presentedthrough Accident and Emergencyor another hospital department,staff there should be briefed onthe woman’s wishes about howthey should respond to requestsfor information from people whoenquire about her.

34

• Prepare the Letter of Intent withthe woman (as outlined above)and place it on her chart.

SPECIFIC ISSUES FOR SOCIALWORK TEAM CARING FOR AWOMAN CONCEALINGPREGNANCY

• Discuss the woman’s optionsregarding the pregnancy. Outlinethe supports available to her, asappropriate, including: - The crisis pregnancy

counselling and supportservice, where the womanwishes to explore her optionsfurtherand/or

- The adoption agencies andHSE Social Workers, wherethe woman is consideringplacing her baby in alternativecare.

Explain the procedures forreferral to appropriate agencieswhere available, including theprovision of letters ofintroduction as required.

• Encourage the woman to confidein a trusted person. Outline theimportance of the support thatany woman going throughpregnancy and birth needs, aswell as the need for us all to besupported through a crisis.

• Particular consideration needs to

be given to informing andinvolving the father of the baby.In general, women areencouraged to name the father ofthe child in registrationdocuments and to involve him tosome extent in the life of thechild. This is considered to be inthe child’s best interests, to helpensure the forming of a positiveidentity and to make availablefull information on hereditaryhealth conditions. Relevant legaland policy issues also need to beexplained clearly – for example,the legal requirements regardingthe role of fathers when a baby isbeing placed for adoption and theduty to pursue partners formaintenance support where awoman submits a claim forsocial-welfare supports.

• Where necessary, in addition tothe Letter of Intent, the SocialWorker should liaise with theManagers/Consultants of allrelevant departments/teams andbrief them on specific issuesconcerning the woman’ssituation that will improve theircapacity to be empathetic andreassuring to the womanthroughout her care in thehospital. TheseManagers/Consultants include:

- The Administration Manager- The Clinical Midwife Manager


35

of the Antenatal,Labour andPostnatal Departments

- The Antenatal/ParentcraftEducation DepartmentManager

- The Obstetrician andPaediatrician.

• Where the woman indicates aninterest in adoption, outline theprocedures for arranging thisand the support servicesavailable. Make appropriatereferral to HSE Social Workers oradoption agency Social Workers.(See the ‘Adoption’ section in‘Responding to Crisis Pregnancy:Information and ServiceDirectory for Community andHealth Professionals’ on theCrisis Pregnancy Agencywebsite:

http://www.crisispregnancy.ie/KC_Westwebversion.pdf.)

• Where a woman plans to parenther baby, inform her of locallyavailable support services.Highlight community-basedservices to support mothers,such as young mothers’ groupsor community mothers’schemes. (See ‘AfterChildbirth/Parenting Support’ inSection One of ‘Responding toCrisis Pregnancy: Informationand Service Directory forCommunity and Health

Professionals’ on the CrisisPregnancy Agency website:

http://www.crisispregnancy.ie/KC_Westwebversion.pdf

Contact with a woman concealingpregnancy during antenatal care

• Arrange to have contact with thewoman at each antenatal visit orat agreed intervals during hercare.

• Ensure that the Letter of Intent,drafted jointly by the woman andher Social Worker and whichexplains her situation andspecific needs, is continuallyupdated.

• Where a woman has arranged togive birth in another hospital,discuss whether she wishes youto liaise with the Social WorkDepartment there to apprisethem of her situation.

Contact with a woman concealingpregnancy during postnatal care

In addition to the usual functions,the following additional steps shouldbe undertaken:

• Where necessary, the SocialWorker should liaise with theClerk handling notification ofbirths to ensure that the formgiving notice of this birth ismarked ‘Sensitive’ to ensure that

36

the woman’s wishes regardingHSE Births Notification Office fornotification to the Public HealthNurse and the Registrar ofBirths as well as to GPs at thepostnatal stage, are followedthrough.

• Assess the woman’s continuingneeds for emotional, social andpractical support after she isdischarged from the hospital.Women should be offeredpostnatal counselling to addressissues such as grief overplacement of the baby foradoption or feelings of guiltabout concealment of thepregnancy.

• Where possible, women shouldbe offered the option of being‘debriefed’ about the birth of thebaby. The concealment processcan affect the experience ofchildbirth in specific ways; forexample, the woman’s capacityto recall the birth may bediminished. For a debrief, theSocial Worker would, ideally,convene a meeting at which thewoman, her attending Midwifeand the Social Worker would talkher through her birthingexperience.


37

38

NOTES

OBSTETRICS

SECTION

THR

EE

MID

WIFER

YM

IDW

IFERY

OB

STETRIC

S

A woman concealing a pregnancymay particularly benefit fromtransferring to another hospital.Staff should ensure that the unit thewoman presented to is the correctone to attend for an increased senseof confidentiality.

PRINCIPLES GUIDING RESPONSE

Be guided by the following principlesin responding to a womanconcealing pregnancy:


Offer confidentiality, outliningthe special arrangement forconcealed pregnancies


Be non-directive: accept wherethe woman ‘is at’ in herpregnancy at the time


Outline the supports available:medical, social, counselling, both

hospital and community-basedRefer the woman to a SocialWorker as early as possible.

SPECIFIC ISSUES FOR OBSTETRICTEAM CARING FOR A WOMANCONCEALING PREGNANCY

From the perspective of theobstetric team, the difficulties thatarise where a woman presents latein pregnancy (after 20 weeks)include:

• The likelihood of gaps in themedical history available.

• No established estimated date ofdelivery.

• Difficulty in managing conditions(e.g. blood pressure) orestablishing the severity of theirimpact.

• The risk of unassisted birth.

The later in pregnancy a womanpresents, the greater thesignificance of these issues.

• Where a woman concealingpregnancy is attending forantenatal care, a Letter of Intent(drafted jointly by herself and her


39

OBSTETRIC TEAM

Social Worker) may be insertedon her chart. This provides abriefing on her situation and anyspecific needs she has.

• If she has opted to be a‘confidential patient’, a signedConfidential Patient form isplaced at the front of her chart.

• Where women present in labour,they will usually have made noplans or preparation for labour.Because of the stress ofconcealing pregnancy, thewoman may be in a distressedstate. However, the obstetric andpaediatric team will not haveavailable to them the informationand results arising from thestandard tests and checksusually administered duringantenatal care.

• The Obstetrician may be willingto see a woman concealing herpregnancy in an alternative Clinicfrom the usual Antenatal clinice.g. a Gynaecological Clinic or ata different time to allow for agreater sense of confidentiality.

• Where there is any adverseoutcome for the woman and/orher baby, this needs to behandled sensitively in liaison withthe Midwife. Even if the woman’sbehaviour in concealing thepregnancy gave rise to risks of

harm for herself and/or the baby,it is important to avoid judging orblaming her. Try to reassure herthat you are concerned for herwell-being and the baby’s.Understand that concealing apregnancy is a very traumaticprocess that can lead to tragicoutcomes that the woman neverintended.

• Where an emergency ariseswhich would usually requirecalling next of kin, note that thisis not possible where a woman isconcealing the pregnancy fromher family and does not wish forcontact to be made. Given thatresearch has shown that womenusually have good reasons forconcealing pregnancy, everyeffort should be made to respecttheir wishes in this regard. In amedical emergency, a doctor canintervene on the grounds of thehealth and safety of the womanand her child. Thus there is noneed to breach confidentiality bycontacting her next of kin.

• Specific concerns arise in thecase of a young woman underthe age of medical consent (16years), particularly in relation toher capacity to consent for non-life-saving but medicallyindicated procedures. In thissituation, the decision will begoverned by:

40

- in the first instance, thehospital’s policies andguidelines on the treatment ofpeople under 16 years

- secondly, the guidelines onmanaging pregnancy amongwomen under 17 adopted byeach hospital according to theprovisions of the statutorydocument ‘Children First’.

While working within theseguidelines, however, Obstetriciansshould take into account theheightened wish for confidentialityof a young woman concealingpregnancy.


41

42

NOTES

PAEDIATRICS

SECTION

FOU

R

MID

WIFER

YM

IDW

IFERY

MID

WIFER

YPAED

IATRIC

SM

IDW

IFERY

MID

WIFER

Y



Reassure her that you will supporther through this crisis

Offer confidentiality, outlining thespecial arrangement for thecontinued concealment of herpregnancy

Be non-judgemental: womenusually have very good reasons forconcealing their pregnancy

Be non-directive: accept where thewoman ‘is at’ in her pregnancy atthe time

Acknowledge the important step shehas taken in presenting for care

Outline the supports available:medical, social, counselling, bothhospital and community-based

Refer the woman to a Social Workeras early as possible or liaise with theSocial Worker if one is alreadyinvolved.

SPECIFIC ISSUES FORPAEDIATRICIANS CARING FOR AWOMAN CONCEALINGPREGNANCY

Research suggests that a womanconcealing pregnancy can engage inbehaviour that women are usuallyadvised to avoid during pregnancy –for example; smoking, drinking,lifting heavy objects, working longhours. In addition, womenconcealing pregnancy attendantenatal care later or not at all sothat routine opportunities to detectfoetal abnormalities are oftenmissed. These factors work againstthe particular concern ofpaediatricians – the well-being ofthe baby. However, research showsthat women conceal pregnancy forvery good reasons, in dealing with awoman in such a situation, aPaediatrician should have regard tothis.

• Where a woman concealingpregnancy has attended a SocialWorker during antenatal care, aLetter of Intent, drafted jointly byherself and her Social Worker, isinserted on her chart. It providesa briefing on her situation andany specific needs she has.Where women present in labour,


43

PAEDIATRIC TEAM

this should be drafted with aMidwife where time allows.

• If a woman has opted to be a‘Confidential Patient’, this isindicated on her chart by thepresence of a signed ConfidentialPatient form.

• Note that, where a womanpresented in labour, thepaediatric team may not haveavailable to them the informationand results arising from thestandard tests and checksusually administered duringantenatal care.

• The Paediatrician may need tomake special follow-uparrangements for care of thebaby or for adoption.

• Where there is any adverseoutcome for the baby, this needsto be handled sensitively inliaison with the Midwife and withthe Social Worker.

Even if the woman’s behaviour inconcealing the pregnancy gave riseto risks or harm for herself and/orthe baby, it is important to avoidjudging or blaming her. Womenshould be reassured that theMidwife and doctors are concernedfor her well-being and understandthat concealing a pregnancy is a verytraumatic process that can lead totragic outcomes that the womannever intended.

44


ANTENATAL/PARENTCRAFT

SECTION

FIVE

MID

WIFER

YM

IDW

IFERY

MID

WIFER

YM

IDW

IFERY

ANTEN

ATAL/PAR

ENTC

RAFT

MID

WIFER

Y




Offer confidentiality, outlining thespecial arrangement for thecontinued concealment of herpregnancy





Refer the woman to a Social Workeras early as possible.

SPECIFIC ISSUES FORANTENATAL/PARENTCRAFTEDUCATION TEAM CARING FOR AWOMAN CONCEALINGPREGNANCY

• A woman concealing pregnancymay present at any stagebetween 20 weeks’ pregnancyand labour, or may present aftergiving birth. Where she isattending antenatal care andunder the care of a SocialWorker, a Letter of Intentoutlining her situation will beplaced on her chart to brief allstaff with whom she comes intocontact about her specificsituation and needs. In addition,a Midwife or Social Worker underwhose care she has come maysupplement this, if appropriate,with a dedicated briefing to theAntenatal/Parentcraft EducationTeam.

• A woman concealing pregnancymay need a tailored package ofcare from the Antenatal/Parentcraft Education Team,either because she is presentinglater than the point at which thisintervention is usually offered orbecause of the social, emotional,


45

ANTENATAL/PARENTCRAFTEDUCATION TEAM

confidential or other issuesassociated with the concealment,or for both of these reasons.

• Some elements of the antenataleducation programme may needto be handled sensitively, inrecognition of the fact thatwomen concealing pregnancymay have been in denial of thepregnancy until very recently,and may still feel unprepared forlabour, meeting their baby andmotherhood.

• Where a woman is concealingpregnancy, her needs from thisdepartment are best determinedin discussion with her. Thefollowing should be considered:

- The option of one-to-one orgroup antenatal educationsessions.

- Her capacity to attend anumber of sessions, orwhether one session is mostappropriate (if, for example,she wants to minimise herattendance at hospital).

- An antenatal educationprogramme tailored to hersituation and needs, takingparticularly into account thestage of gestation reached –this may be very advanced andrequire an acceleratedprogramme.

- The woman should beassessed for her need forspecific interventions toprepare her for first contactwith her baby.

- Whether providing a parentingeducation programme is inaccordance with her decisionabout parenting or placing thebaby in alternative care.

46




Offer confidentiality, outlining thespecial arrangement for concealedpregnancies





Refer the woman to a Midwife orSocial Worker as early as possible.

SPECIFIC ISSUES FORADMINISTRATION TEAM INANTENATAL DEPARTMENT

Where a woman presents late inpregnancy and displays anyreticence about impartinginformation, she should beimmediately referred to a Midwife.

The Midwife can later be approachedto confirm whether the woman willbe attending the hospital formaternity care and to relay theinformation necessary to enter thewoman on to the hospital system.

SPECIFIC ISSUES FOR BIRTHNOTIFICATION CLERK

The form for notifying the Registrarof Births includes the option to marka case as ‘Sensitive’. In the contextof concealment, this option can betaken to alert the registrar torelevant issues, as follows: • The pregnancy was concealed

and the woman has requestedthat the Registrar does not writeto her address.

• The baby is being placed inalternative care; notificationshould not be forwarded to theChild Benefit Section of theDepartment of Social and FamilyAffairs.


47

ADMINISTRATION TEAM

• The baby is being placed inalternative care; the appropriatePublic Health Nurse (PHN)needs to be notified of the baby’splace of residence and visits thebaby there. Arrangements needto be made at a local level for theappropriate HSE staff to benotified of the possibility that ababy is to be placed in alternativecare.

• If the mother does not want avisit from the PHN, her identityremains confidential, and noreferral for her is made. Thepossibility of returning to thehospital for follow-up careshould be outlined to her.

• The mother does wish to bevisited by the PHN for postnatalcare and her given place ofresidence may differ from herusual address. Where the babyhas been placed in alternativecare, the PHN is informed so thats/he will not expect to see a babyon the visit.

ALL DEPARTMENTS: THECONFIDENTIAL PATIENT POLICY

The Confidential Patient Policy is akey feature of the care pathway. If awoman opts to be a ConfidentialPatient:

• Her name is excluded from theenquiry list/computer inreception.

• Her record in the PatientInformation System is marked‘Confidential Patient: noinformation to be given out’.

• If someone enquires after her byphone or in person to thehospital reception staff, staff willretrieve no record of her whenthey enter her name into thecomputer.

• If someone enquires after her byphone or in person to the wardshe is in, they will be told thatno-one of that name is on theward.

• All staff need to regularly reviewhow cases of concealedpregnancy are dealt with andadopt protocols to newinformation.

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THE SOCIAL WORKER SHOULDDRAW ON COMMUNITYRESOURCES AVAILABLE TOSUPPORT WOMEN WITH A CRISISPREGNANCY.

The Crisis Pregnancy Agency hasproduced a Key Contact resourcepack ‘Responding to CrisisPregnancy: Information and ServiceDirectory for Community and HealthProfessionals’, in conjunction withfour HSE areas (to date):

• Information and ServiceDirectory for Community andHealth Care Professionals,developed in conjunction with theHSE Dublin North City andCounty/HSE North-Eastern Area.

• Information and ServiceDirectory for Community andHealth Professionals, developedin conjunction with the HSEWest.

• Information and ServiceDirectory for Community andHealth Professionals, developedin conjunction with the HSESouthern Area (only available inhard copy).

In addition, there is a dedicatedresource pack on SupportedAccommodation and ReproductiveHealth Information aimed at Migrantwomen.

• Directory of SupportedAccommodation for WomenExperiencing a Crisis Pregnancy.

• Reproductive Health Informationfor Migrant Women: PregnancyPrevention, Crisis PregnancyOptions, Related Health Matters.This document is available in anumber of languages: Arabic,Chinese, English, French, Polish,Romanian and Russian.

All the above publications can beaccessed at the following link:www.crisispregnancy.ie/about_support.html

Treoir, the National Federation ofServices for Unmarried Parents andtheir Children, has also produced an‘Information Pack for Parents whoare not married to each other’ whichgives details on rights andentitlements.

This publication can be accessed atthe following link:www.treoir.ie/publications.html


49

COMMUNITY-BASEDRESOURCES

REFERENCESConlon, C. (2006). Concealed Pregnancy: A Case Study Approach from anIrish Setting. Crisis Pregnancy Agency Report No.15, Dublin.http://www.crisispregnancy.ie/pub/conceal.pdf

Craig, M. (1997). ‘Perinatal risk factors for neonaticide and infant homicide:can we identify those at risk?’, Journal of the Royal Society of Medicine, Vol.97, 57-61.

Drescher-Burke, K., Krall, J. and Penick, A. (2004). Discarded Infants andNeonaticide. A review of the literature. Berkeley, CA: National AbandonedInfants Assistance Resource Centre, School of Social Welfare, University ofCalifornia at Berkeley.

Finnegan, P., McKinstry, E. and Erlick Robinson, G. (1982). ‘Denial ofPregnancy and Childbirth’. Canadian Journal of Psychiatry. Vol. 27,December 1982, 672-674.

Foster, J. E. and Jenkins, M. (1987). ‘A Schoolgirl with Onset of AnorexiaNervosa during a Concealed Pregnancy’, British Journal of Psychiatry, Vol.150, 551-553.

Geary, M. (1997). ‘Comparison of Liveborn and Stillborn Low Birth WeightBabies & Analysis of Aetiological Factors’, Irish Medical Journal, Vol. 90 (7).

Green, C.M. and Manohar, S.V. (1990). ‘Neonaticide and Hysterical Denial ofPregnancy’, British Journal of Psychiatry, Vol. 156, 121-123.

Sable, M. and Wilkinson, D. (2000).‘Impact of Perceived Stress, Major LifeEvents and Pregnancy Attitudes on Low Birth Weight’, Family PlanningPerspectives, Vol. 32 (6), 288-294.

Spielvogel, A. and Hohener, H. (1995). ‘Denial of Pregnancy: A Review andCase Reports’, Birth, Vol. 22 (4), 220-246.

Spillane, H., Khalil, G. and Turner, M (1996) .‘Babies Born Before Arrival atthe Coombe Women’s Hospital, Dublin’, Irish Medical Journal, 89(2), 58-9.

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Spinelli, M. (2001). ‘A Systematic Investigation of 16 Cases of Neonaticide’,American Journal of Psychiatry, Vol. 158, 811-813.

Treacy, A., Byrne, P.J. and O’Donovan, M. (2002). ‘Perinatal Outcome inUnbooked Women at the Rotunda Hospital’, Irish Medical Journal, Vol.95(2).

Vallone, D. and Hoffman, L. (2003). ‘Preventing the Tragedy of Neonaticide’,Holistic Nursing Practice, Vol. 17(5), 223-230.

Wessel, J. and Buscher, U. (2002b). ‘Denial of pregnancy: population-basedstudy’. British Medical Journal. Vol. 324, 458.

Wessel, J., Endrikat, J. and Buscher, U. (2002a). ‘Frequency of denial ofpregnancy: results and epidemiological significance of a 1-year prospectivestudy in Berlin’. Acta Obstetrica and Gynecologica Scandinavica. Vol. 81,1021-1027.

Wessel, J., Endrikat, J. and Buscher, U. (2003). ‘Elevated risk for neonataloutcome following denial of pregnancy: results of a one-year prospectivestudy compared with control groups’. Journal of Perinatal Medicine. Vol. 31,29-35.


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APPENDIX ONECONFIDENTIAL PATIENT FORM: EXAMPLESometimes, for personal reasons, a woman may wish to keep totally confidentialthe fact of her pregnancy, delivery and presence in the hospital.

If you wish to do this we will help you by:1. excluding your name from the enquiry list/computer in reception2. trying to ensure that no member of staff will provide any information about

you, either by phone or face-to-face, to any enquirer or visitorThis means that, if you are a Confidential Patient, no-one from outside thehospital will be given any information about you. • If someone arrives at hospital reception and enquires about you, they will be

told that no-one of your name is in the hospital. • If someone arrives on the ward where you are a patient and enquires about

you, they will be told that no-one of your name is on the ward.

If you wish certain people to know the details of your baby’s birth, therefore, it isup to you to inform them of your location within the hospital. Your chosen visitorsshould not enquire about you by phone or in person as they will be told that youare not a patient in the hospital.

Staff will do all that they can to honour your wish for this degree of confidentiality.However, since hospitals are public places, we cannot control the situation totally.It is important to minimise your visits to public parts of the hospital e.g. shop orsmoking area.

I understand the above and wish to avail of the Confidential Patientarrangements.

Signed:

Date:

Witnessed by: (Midwife or Social Worker)

If at any stage your circumstances change and you no longer wish for this degreeof confidentiality while in the hospital, please inform a hospital Midwife or SocialWorker.

I no longer wish to avail of this degree of confidentiality.

Signed:

Date:

Witnessed by: (Midwife or Social Worker)

CRISIS PREGNANCY AGENCY

4th Floor89 – 94 Capel StreetDublin 1

www.crisispregnancy.ie

T +353 1 814 6292F +353 1 814 6282

HEALTH SERVICE EXECUTIVE

Dr. Steevens’ Hospital Dublin 8

www.hse.ie

T +353 1 6352000F +353 1 6352823

Documents

CPA text:Layout 1 · Wilkinson, 2000; Geary et al. 1997). Women who conceal pregnancy usually do not participate in the full range of antenatal care set down by current practices