In this article
Midwives and allied health professionals play an essential part in ensuring that children and families receive the care, support and services they need to promote children’s health and development and the health and welfare of women under their care. Maternity staff are likely to have significant contact with families who may require support and interventions in relation to safeguarding children and babies who are particularly vulnerable to abuse. Midwives have a statutory responsibility to recognise, prevent and manage signs of patient harm, abuse and neglect including poor practice.
What is safeguarding?
Safeguarding adults, children and babies is an integral part of patient care. Safeguarding means protecting people from harm including physical, emotional, sexual and financial harm and neglect. Midwives have a duty to recognise the signs and symptoms of abuse and to act on any concerns. Duties to safeguard patients are required by professional regulators and service regulators and are supported by law.
Safeguarding adults at risk means protecting their right to live in safety and free from abuse and neglect.
Adults at risk means anyone aged 18 or over who:
- Has needs for care and support.
- Is experiencing, or is at risk of, abuse or neglect.
- As a result of those care and support needs, is unable to protect themselves from either the risk of or the experience of abuse or neglect.
Safeguarding children and young people’s welfare is defined in ‘Working Together to Safeguard Children’ as:
- Protecting children from maltreatment.
- Preventing impairment of children’s health or development.
- Ensuring that children grow up in circumstances consistent with the provision of safe and effective care.
- Taking action to enable all children to have the best outcomes.
Safeguarding also means that individuals are adequately supported to access care and support where this is needed, so that they are able to stay well and maintain a high quality of life. This is achieved by different organisations working effectively together to prevent and stop both the risks and experience of abuse or neglect. Safeguarding aims to balance the right to be safe with the right of the individual to make informed choices and to have their wellbeing promoted at all times.
The Care Act 2014 lists six key principles of safeguarding. These are intended to form a core set of standards for anyone who has a responsibility for safeguarding. Although these principles have been designed with a focus on vulnerable adults, they should be applied to any type of vulnerable individual, children included.
The principles are as follows:
- Accountability – in the event of a disclosure, if a young person entrusts you with information that you know could be indicative of abuse, you must be clear with the individual that you need to report what you have heard.
- Empowerment – it’s important for any person who has been a victim of abuse to feel that they have control over their situation. Support and encouragement are key to effective working with a victim of abuse or neglect.
- Partnership – it is important to work in partnership with your local authority and all services or organisations in your community that might be able to assist in detecting and reporting abuse.
- Prevention – it is sometimes possible to take action before harm has come to an individual. If you know the signs and indicators of abuse, you will understand when something is not quite right and will be better placed to report any concerns for an individual’s wellbeing.
- Proportionality – when a safeguarding incident occurs, you should report your concerns in a manner that is appropriate for the risk presented. For example, if you suspect that a child is in immediate danger, dialling 999 is the recommended response.
- Protection – it is crucial to be an ally for individuals who have experienced or who are at risk of abuse. Supporting and representing these individuals in the appropriate manner can help to protect them from further harm.
What risk factors make someone more likely to experience abuse?
Abuse and neglect can occur anywhere to anyone; however, there are risk factors that can make a person more vulnerable to abuse.
An adult at risk of abuse may:
- Have an illness affecting their mental or physical health.
- Be physically dependent on others.
- Have a sensory impairment.
- Have a learning disability.
- Suffer from drug or alcohol problems.
- Have low self-esteem.
- Be unable to make their own decisions.
- Have a previous history of abuse.
- Have negative experiences of disclosing abuse.
- Be frail.
- Have experienced a lack of access to health and social services or high-quality information.
Any child can be at risk of abuse; however, there are a number of factors that can increase a child’s vulnerability to abuse and neglect, including but not limited to:
- Socioeconomic factors such as poverty, poor housing and deprivation.
- Child factors, for example disabled children are more vulnerable to abuse or neglect.
- Family factors such as parental/carer substance misuse problems, parental/carer mental health problems and domestic abuse. These factors may be compounded if the parent/carer lacks support from family or friends and experiences social isolation.
- The parent or carer does not engage with services.
- There have been one or more previous episodes of child abuse or neglect.
- The parent or carer has a mental health or substance misuse problem which has a significant impact on the tasks of parenting.
- There is chronic parental stress.
- The parent or carer experienced abuse or neglect as a child.
- A family history of maltreatment.
- Being in care, a looked-after child.
- A history of offending, either parent or child.
These lists are not exhaustive, and other people might also be considered to be adults or children at risk.
The types of abuse adults can encounter
There are ten types of abuse listed in the Care Act (2014).
- Physical abuse – this may involve physical violence, misuse of medication, inappropriate restraint or sanctions.
- Sexual abuse – this can include verbal sexual abuse, non-consensual touching, fondling, physical restraint, cornering, tickling, kissing, excessive cleaning of genitals, enemas, intercourse, sodomy, oral sex, invasion of privacy and stalking.
- Psychological abuse – this includes emotional abuse, threats of harm or abandonment, deprivation of contact, humiliation, blaming, controlling, intimidation, harassment and verbal abuse.
- Financial or material abuse – including theft, fraud, exploitation, pressure in connection with wills, property, inheritance or financial transactions, and misuse or misappropriation of property, possessions or benefits.
- Neglect and acts of omission – including ignoring medical or physical care needs, failure to provide access to appropriate health, social care or educational services, withholding medication, and inadequate nutrition and heating.
- Discriminatory abuse – including racist or sexist abuse or abuse based on a person’s disability.
- Domestic abuse – including psychological, physical, sexual, financial and emotional abuse, and so-called honour-based violence.
- Modern slavery – includes slavery, human trafficking, forced labour and domestic servitude.
- Organisational abuse – including neglect and poor care practice within an institution or specific care setting such as a hospital or care home.
- Self-neglect – includes a wide range of behaviour neglecting to care for personal hygiene, health or surroundings and includes behaviour such as hoarding.
Statutory guidance across the four countries of the UK describes four main categories of child abuse, and these definitions will normally be reflected in local organisations’ policies and procedures.
The four categories are:
- Physical harm/abuse – this may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating, or otherwise causing physical harm to a child/young person. Physical harm may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces, illness in a child/young person. Harm can also occur due to practices linked to faith and culture, for example, Female Genital Mutilation (FGM).
- Emotional harm/abuse – this is the persistent emotional maltreatment of a child/young person such as to cause severe and persistent adverse effects on the child/young person’s emotional development. It may involve conveying to children that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person. It may include not giving the child the opportunities to express their views, deliberately silencing them or “making fun” of what they say or how they communicate. It may feature age or developmentally inappropriate expectations being imposed on children. These may include interactions that are beyond a child’s developmental capacity, as well as overprotection and limitation of exploration and learning, or preventing the child from participating in normal social interaction. It may involve seeing or hearing the ill treatment of another. It may involve serious bullying, including cyberbullying, causing children/young people frequently to feel frightened or in danger, or the exploitation or corruption of children/young people. Some level of emotional abuse is involved in all types of maltreatment of a child/young person, though it may occur alone.
- Sexual abuse – this involves forcing or enticing a child or young person to take part in sexual activities, not necessarily involving a high level of violence, whether or not the child is aware of what is happening. The activities may involve physical contact, including assault by penetrative acts, for example rape or oral sex, or non-penetrative acts such as masturbation, kissing, rubbing and touching outside of clothing. They may include non-contact activities, such as involving children in looking at, or in the production of, pornographic sexual images, watching sexual activities, encouraging children to behave in sexually inappropriate ways, or grooming a child in preparation for abuse, including via the internet. Sexual abuse is not solely perpetrated by adult males; women can also commit acts of sexual abuse, as can other children.
- Neglect – this is the persistent failure to meet a child/young person’s basic physical and/or psychological needs, likely to result in the serious impairment of the child/young person’s development. Neglect may occur during pregnancy, for example as a result of maternal substance abuse, maternal mental ill health or learning difficulties or a cluster of such issues. Where there is domestic abuse and violence towards a carer, the needs of the child may be neglected.
Once a child is born, neglect may involve a parent or carer failing to:
– Provide adequate food, clothing and shelter, including exclusion from home or abandonment.
– Protect a child/young person from physical and emotional harm or danger.
– Ensure adequate supervision, including the use of inadequate caregivers.
– Ensure access to appropriate medical care or treatment also including neglect of, or unresponsiveness to, a child/young person’s basic emotional needs.
What safeguarding issues do midwives need to be aware of?
The risk factors that midwives may specifically encounter that may trigger the need to raise a safeguarding concern may include, but are not limited to:
- Where the woman’s previous children have been removed by social care because they have suffered harm.
- A sibling(s) to the unborn is previously known or is an open case to social care.
- Previous or current domestic abuse experienced in this relationship.
- Concerns identified in relation to the woman’s parenting capacity including a learning disability or difficulty or where the woman has a lack of mental capacity.
- Any child under the age of 16 who is pregnant, child sexual exploitation.
- Any child or woman who has been a looked-after child themselves.
- The lifestyle choices of the expectant mother, including the association with risky adults who would be deemed a risk to the baby when born. For example, the unborn baby’s parents misusing alcohol and/or drugs.
- Pregnant women whose lifestyle may affect the baby’s development or where it is thought that an unborn child may be at risk of harm.
- Where the woman discloses that she has had Female Genital Mutilation and there is a significant/immediate risk to unborn or existing children, or one of the siblings has undergone FGM.
- Concealed or denied pregnancy.
- Serious mental health concerns, either previous or current, that remain unmanaged.
- Where a woman is at risk of modern slavery.
- Where a woman or her family are at risk of human trafficking.
- A colleague not complying with procedures to meet safeguarding needs.
- Issues to do with the health of a colleague which may affect their ability to practise safely.
The roles and responsibilities of a midwife in regard to adult safeguarding
Midwives will have an individual responsibility to safeguard people, to identify and respond to allegations of abuse and neglect. Health services have a duty to safeguard all patients, but provide additional measures for patients who are less able to protect themselves from harm or abuse; this includes the unborn baby. Safeguarding adults and children covers a spectrum of activity from prevention through to multi-agency responses where harm and abuse occurs. Multi-agency procedures apply where there is a concern of neglect, harm or abuse to a patient defined under the Care Act (2014) guidance as vulnerable.
A midwife’s role in safeguarding is to:
- Recognise – you should have a clear understanding of what the different signs and symptoms of potential abuse, harm and neglect can be. Robust safeguarding training can help you to spot these signs and symptoms.
- Respond – it is essential that you respond appropriately and do not ignore the situation.
- Report – concerns need to be reported without delay. Confidentiality is important, so only share information with those who are a part of the safeguarding process.
- Record – you should make precise, comprehensive notes that detail everything about your safeguarding concern.
- Refer – if the safeguarding risk is urgent and you suspect somebody is under immediate or severe threat, you should contact the relevant local authority or police services.
Midwives have a duty to make sure that:
- Safeguarding concerns are dealt with promptly, appropriately and reported in a secure and responsible way to all relevant agencies.
- Steps are taken to escalate or alert those able to protect patients and/or other adults or children at risk from harm and minimise the risk of abuse.
- Appropriate and proportionate measures are in place to protect from harm all those who work for, or with them, or come into contact with them.
- They have knowledge of and keep to the relevant laws and policies about safeguarding.
- They share information if someone may be at risk of harm, in line with the laws relating to the disclosure of information.
It is essential for midwives to exert professional curiosity when supporting women and their families. If something is out of the ordinary, it requires professional curiosity. It is essential that midwives look for warning indicators and should not take things at face value, recognising that people may say what they want the midwives to hear. A midwife is expected to ask questions about background, context and home life which might then trigger concerns and further action accordingly.
The safeguarding issues a midwife may come across
One of the most challenging safeguarding issues is when concerns arise during pregnancy. The concerns may relate to the care of previous children, or may relate to the health, behaviour, circumstances or history of the parents and how these may affect the unborn child.
All midwives are required to routinely ask every woman about domestic abuse at least twice during the woman’s pregnancy, as well as to adopt a targeted approach where signs or indicators of domestic abuse are observed at any time throughout maternity services, be it following the birth or during the post-natal period.
Human trafficking is a global crime which affects many individuals worldwide. Midwives may come into contact with women who are being trafficked, specifically those being sexually exploited. You may notice that an unknown person appears to be monitoring the movements of a woman or appears to be controlling them in some way. Often victims are physically abused. Does the person you are concerned about have any injuries which appear consistent with abuse or maltreatment? Do they appear scared or frightened?
Concealed or denied pregnancies. The potential risks to a child through the concealment of a pregnancy are difficult to predict and wide-ranging. One key implication is that there is no obstetric history or record of antenatal care prior to the birth of the baby. Some women may present late for booking after 24 weeks of pregnancy and these pregnancies need to be closely monitored to assess future engagement with health professionals, particularly midwives and whether or not a referral to another agency is indicated. In a case of a denied pregnancy the effects of going into labour and giving birth can be traumatic. The reason for the concealment will be a key factor in determining the risk to the child. If the woman is aged less than 18 years then consideration will be given to whether she is a Child in Need. If she is less than 16 years then a criminal offence may have been committed and needs to be investigated.
Children and babies need to be protected from injuries from dogs in the home, and the potential for severe injury must not be underestimated. Risk assessments should be undertaken and include issues such as the dog’s behaviour and overall hygiene.
Where should midwives go with a safeguarding concern?
Some concerns may be minor in nature but provide an opportunity for early intervention, for example advice to prevent a problem from escalating. Other safeguarding concerns may be more serious and need a response through multi-agency procedures and possible statutory intervention through regulators, the criminal justice system or civil courts.
Each midwife should follow their employer’s safeguarding policy and procedures and discuss concerns with their safeguarding lead / named professional for safeguarding. In the absence of a safeguarding lead / named professional for safeguarding, a referral should be made directly to the local authority children’s and/or adult social care.
Referrals to children’s social care about unborn babies should be made as early as possible in the pregnancy, as soon as concerns have been identified which indicate that the unborn is at risk of significant harm. Where identified concerns indicate risk of significant harm at any point during the pregnancy an immediate referral should be made either via the safeguarding lead or directly to children’s social care. Early referral will enable social care with other agencies involved to assess the family circumstances and plan any necessary actions and support required in a timely way. This includes whether any actions are required to safeguard the child once born.
You should also keep an accurate record of your concerns and action that you have taken, and you should always inform the designated safeguarding lead of your actions.
If you have raised your concern internally but feel it hasn’t been dealt with properly, or if you feel unable to raise your concern at any level in your organisation, you may want to get help from outside your place of work. You can raise your concerns through the NHS Whistleblowing Helpline 08000 724 725. The Nursing and Midwifery Council have a page on their website dedicated to whistleblowing, www.nmc.org.uk/whistleblowing.
Speaking up on behalf of people in your care is an everyday part of your role. Just as raising genuine concerns represents good practice, doing nothing and failing to report concerns is unacceptable. Failure to report concerns may bring your fitness to practise into question and put your registration at risk.
What legislation do midwives have to follow in regard to safeguarding?
The Care Act 2014 sets out statutory responsibility for the integration of care and support between health and local authorities. NHS England and Clinical Commissioning Groups are working in partnership with local and neighbouring social care services. Local authorities have statutory responsibility for safeguarding. In partnership with health, they have a duty to promote wellbeing within local communities.
Safeguarding Vulnerable Groups Act 2006 and the Protection of Freedoms Bill – this Act was passed to help avoid harm, or risk of harm, by preventing people who are deemed unsuitable to work with children and vulnerable adults from gaining access to them through their work. Organisations with responsibility for providing services or personnel to vulnerable groups have a legal obligation to refer relevant information to the Disclosure and Barring Service (DBS).
The Equality Act 2010 – this Act aims to protect people or groups of people who have one or more “protected characteristics”. These protected characteristics are features of people’s lives upon which discrimination, in the UK, is now illegal.
The protected characteristics listed in the Act are:
- Sexual orientation
- Gender reassignment
- Marriage and civil partnership
- Pregnancy and maternity
- Religion and belief
Under the Act:
- Every individual has the right to be treated equally and fairly and not be discriminated against regardless of any “protected characteristics”.
- Every individual has the right to be treated with respect and dignity.
- Health services have a duty to ensure that services are fair and meet the needs of everyone, regardless of their background or current circumstances.
Sexual Offences Act 2003 – this Act modernised the law by prohibiting any sexual activity between a care worker and a person with a mental disorder while the relationship of care continues. A relationship of care exists where one person has a mental disorder and another person provides care.
It applies to people working both on a paid and an unpaid basis and includes:
- Nurses, including midwives
- Care workers in homes
- Workers providing services in clinics or hospitals
The Mental Capacity Act 2005 – in order to protect those who lack capacity and to enable them to take part as much as possible in decisions that affect them, the following statutory principles apply:
- You must always assume a person has capacity unless it is proved otherwise
- You must take all practicable steps to enable people to make their own decisions
- You must not assume incapacity simply because someone makes an unwise decision
- Always act, or decide, for a person without capacity in their best interests
- Carefully consider actions to ensure the least restrictive option is taken
Working Together to Safeguard Children 2010 – the way that agencies and organisations should work together to carry out their duties and responsibilities under the 1989 Children Act and other legislation is set out in a document called Working Together to Safeguard Children.
It sets out the responsibilities of all agencies in the protection of children, and is aimed at staff in organisations that are responsible for commissioning or providing services to:
- Children, young people and adults who are parents/carers
- Organisations that have a particular responsibility for safeguarding and promoting the welfare of children and young people
UK law does not legislate for the rights of the unborn baby. In some circumstances, agencies or individuals are able to anticipate the likelihood of significant harm with regard to an expected baby. Although the law does not identify an unborn baby as a separate legal entity, this should not prevent plans from being made and put into place to protect the baby from harm both during pregnancy and after the birth. The National Service Framework for Children, Young People and Maternity Services (2004) recommends that Maternity Services and Children’s Social Care have in place joint working arrangements to respond to concerns about the welfare of an unborn baby and their future, due to the impact of the parents’ needs and circumstances.
The General Data Protection Regulations (GDPR) and the Data Protection Act 2018 introduced new elements to the data protection regime, superseding the Data Protection Act 1998. Practitioners must have due regard to the relevant data protection principles which allow them to share personal information. However, the GDPR and Data Protection Act 2018 do not prevent, or limit, the sharing of information for the purposes of keeping vulnerable individuals safe.
Why is safeguarding training important?
It is important that we all understand safeguarding, and know what to do should safeguarding concerns arise.
Safeguarding induction and training is essential for all staff appropriate to their role, including:
- Information on types of harm, abuse and neglect
- How to spot abuse
- How to respond to concerns
- Who to report concerns to
Training should be directly applicable to the responsibilities and daily practices of the person being trained, and to the care and support needs of the patients that they are working with. An example of appropriate safeguarding training includes Safeguarding Vulnerable Adults (SOVA) Level 2, designed for people who are working with vulnerable adults and teaches the skills needed to safeguard people who are at higher risk of abuse, and Safeguarding Children Level 2, designed for people who are working with children and teaches the skills needed to safeguard children who are at higher risk of abuse.
Managers should evaluate changes in understanding and confidence before and after training, assessing this:
- Immediately after the training
- In regular long-term evaluations, for example as part of supervision sessions
- Annually, for example as part of the performance management/appraisal process
Line managers should provide feedback through supervision and appraisals, acknowledging how midwives have learned from their experience of identifying, reporting and managing safeguarding concerns.
How often should midwives renew their safeguarding training?
Managers should assess midwives’ safeguarding knowledge annually, and run refresher training if needed. To help midwives increase their confidence in managing safeguarding concerns, they should at a minimum refresh their safeguarding training at least every 2 years and participate in continuing professional development (CPD).