Pre Birth Assessment Reflective Analytical Study

I was requested to complete a Pre-Birth Assessment with regards to Case BB. The referral was made by the Community Midwife to the Children and Families Area Team where I was on my placement. The Community Midwife’s concerns were BB’s age, she already had a child who was under one year, her partner was in prison and the Midwife was further concerned about BB’s lack of engagement with the health services particularly ante-natal services. The Midwife was also concerned with BB’s emotional state of mind. To consolidate what little information was on the referral I contacted BB’s current Health Visitor whereby I was subject to a litany of BB’s misdemeanours regarding her care of CA. Although the Health Visitor regarded BB’s care of CA as poor I noted that there had been no social work input requested from the Health Visitor and that the Health Visitor had quite a forceful personality. However, I took on board the information the Health Visitor provided with an objective mind.

BB is 19 years old and lives in a local authority house in a rural village with few local amenities. The village is not well served with public transport which makes it difficult for BB to access the main town. BB’s sole income is benefit based. BB now has two children, CA who is 15 months old and LA who is 3 months old. BB’s partner, BA (who is 22 years of age) is at present in prison, serving a sentence for Assault to Serious Injury. BA is not expected to return to the family home until October 2010. BA is the natural father to both CA and LA. My role was to complete a Pre-Birth Assessment with regards to convening a Pre-Birth Conference if necessary. This is in line with the local authority’s High Risk Pregnancy Protocol. My role was also to support and work in partnership with BB and her family in the longer term.

The context of my practice was that of a statutory role with statutory responsibilities. Therefore, I had to consider how to support the family by assessing BB’s strengths and pressures as well as promote the welfare of BB’s child and unborn child and in the wider sense to keep the family together. According to Hothersall (2008) these are principles inherent within the Children (Scotland) Act 1995 which themselves derive from broader principles surrounding the rights of the children and the importance of positive development as the basis for a meaningful life. Further to this Healy (2005) points out that within the practice context it is the legal aspect which has precedence over other aspects of practice. This incorporates the fulfilment of legal duties and responsibilities.

The Children (Scotland) Act 1995, as mentioned previously, is the underpinning legislation within Children and Families. This legislation with regards to parental responsibilities was I felt, pertinent to this case. For example, the responsibilities of a parent to a child under 16 are set out in Section 1 of this Act. They are to safeguard and promote the health, development and welfare of the child and to provide appropriate direction to the child according to age. These parental responsibilities were important to consider when completing the Pre-Birth Assessment in response to both BB and her partner BA’s capacity to parent. The Getting It Right For Every Child (GIRFEC) (Scottish Executive, 2005) policy was also crucial in my assessment. GIRFEC provides a practice model which promotes holistic assessment and planning for children, centred upon indicators of well-being and as a policy is about intervention as early as possible and provision of the right help at the right time. Within GIRFEC is the ‘My World’ assessment model which I used to help me complete the Pre-Birth Assessment particularly in relation to BB’s parenting skills with CA. I also utilised Getting Our Priorities Right (GOPR) – A Guide for Workers in Best Practice (Local Authority Child Protection Web Pages). Underpinning this assessment was Protecting Children and Young People – Framework for Standards (Scottish Executive, 2004).

Within the context of completing the assessment I was aware of the statutory legal responsibility involved and the requirement to work within the framework of current legislation and policy. During supervision discussion was centred around the issue of care and control from the perspective of my practice based on statutory responsibility. According to Thompson (2005) to ignore control is to run the risk of being ineffective, while to ignore care can lead to potentially abusive and oppressive practice. Further to this Banks (2006) points out that the reasons for many ethical dilemmas and problems stem from the social work role as…

“a public service profession dealing with vulnerable service users who need to be able to trust the worker and be protected from exploitation; and also from its position as part of state welfare provision based on contradictory aims and values (care and control…protection of individual rights and promotion of public welfare) that cause tensions, dilemmas and conflicts.”

(Banks, 2006, p.25)

As Banks also points out, in practice it is the rules of the agency that define who is to be regarded as a service user and provide the context in which the social worker operates. This, for me reflects that need to recognize the significance of discrimination and oppression in service users’ lives and for my practice to be ethically sound and develop a participatory approach to my practice.

Considering these points helped me formulate how I was going to engage with BB. I had an understanding of my statutory responsibilities from a legal and policy perspective and I had an understanding of my personal and professional values in terms of the tensions caused by care and control. Therefore, I needed to build a working relationship with BB which would allow me to build ‘a theoretical understanding of the interrelationship between the individual and society.” (Watson & West, 2006, p.13) This would help me complete a meaningful and insightful assessment of BB’s current difficulties with appropriate interventions.

To complete the assessment, I took into consideration Germain and Gitterman’s The Life Model of Social Work Practice (1996). Payne (2005) describes this model as a formulation of the ecological systems theory which is based on the relationship between people and their environment. The aim of social work is to increase the fit between people and their environment by alleviating life stressors and increasing people’s personal and social resources to enable them to use more and better coping strategies. Payne further points out that practice must be carried out through a partnership between worker and service user that reduces power differences between them. The environment and the demands of the life course should be a constant factor in making decisions.

By utilising Germain & Gitterman’s life model of practice (1996) I was able to create an accepting and supportive environment by describing my role clearly to BB and encouraging BB to give her thoughts about the referral. This elicited background information about her relationship with BA and support networks she had within her own extended family and with BA’s extended family. We discussed the birth of her second child particularly in respect of how BB felt she could cope with CA as well as with the new baby. BB identified this as a worry for her as she was concerned that she would not be able to manage. To make sense of this information Payne (2005) describes resources that people have in order to cope. These are self-efficacy, self-esteem and self-concept. BB had none of these emotional resources available to her at this time. Coupled with this she had no self-direction in the sense she did not feel she had any control over her life.

To allow me to elicit further information regarding BB’s parenting skills I observed her care of CA. The ‘My World’ model which draws on upon the work of Bronfenbrenner (1979) and encourages practioners to take an ecological approach to the assessment process helped me in this respect. By looking at the three domains of growth and development, what is needed from the people who look after me and my wider world I was able to elicit the positives in the situation and the areas of pressure in relation to the safety, well-being and development of the child. Further to this, attachment theory, which according to Schofield (2002) is “primarily a theory for understanding” (Schofield, 2002, p.29) was also useful in that although directly seeking to improve the quality of interaction between children and caregivers, the child’s sense of security, self-esteem and self-efficacy may also be increased by intervening in the systems around the family, for example providing social support to the mother or funding a place for the child in an activity group.

A visit with BA was also organised, who although in prison presented as a significant risk factor due to alcohol consumption and increasing levels of violence, albeit the incidents were not in or near the family home and did not involve BB nor his child. BA was at first uncommunicative which was understandable due to the setting and nature of the visit. Trevithick (2007) suggests that asking a range of different questions is central to interviewing however, before asking a question ‘we must be interested in the answer’. (Trevithick, 2007, p. 159) By careful use of open and closed questions I was able to draw out BA’s views on the assessment and gain some sense of a working relationship with him. However, what really opened the conversation was when I commented on how CA looked very like him.

BA then started to talk about CA and how he was looking forward to the birth of his next baby. During the course of the visit I was able to understand how BA supports BB by allowing her the freedom to take care of CA while he did the cooking and looked after the house. BA went on to explain that his relationship with BB was ‘sound’ but that he was aware he had let her down badly particularly as she was pregnant with his second child. BA was aware that he had missed a lot of CA growing up and he did not want this to happen with his second child. BA was also open about the circumstances leading to his arrest and he admitted that it was due to a feud between two different villages that had been going on since school. BA confirmed that the whole thing was ‘stupid’ and that he now realised he needed to ‘grow up’.

Taking into account the information gained and observations made during my visits with BB, CA and BA I was able to start to make sense of their environment, their strengths and pressures and the roles each of them had within the home and their community. Intervention at the initial stages of the process was I believe successful with regard to forming a working partnership with BB and to an extent with BA. Further visits with BB drew further information regarding informal support networks which in the main was her mother. BB’s mother was a source of practical support and advice and they were in contact daily. BB described her mother as ‘her ear’. Permission was sought from BB to meet with her mother. BB’s mother was keen for her daughter to gain support from social services as she realised how difficult her daughter was finding things at this time.

To complete the assessment and take into account risk factors and strengths I had to analyse and reflect on the information I had gained. According to Helm (2009) this information needs to be analysed before an understanding is developed which allows a judgement to be formed which can lead to an appropriate decision or action. Calder (2002) further offers a framework for conducting risk assessment by assessing all areas of identified risk and ensuring that each is considered separately e.g. child, parent, and surrounding environment each worrying behaviour should be assessed individually as each is likely to involve different risk factors. To counteract the risk factors present family strengths and resources should also be assessed, for example good bonding, supportive networks.

After a thorough analysis and supervisory discussions I recommended that a Post-Birth Multi-Agency Conference not be convened. However, I recommended that a further assessment take place when BA returns to the family home and a Post-Birth Multi-Agency meeting to discuss future interventions be arranged as I was aware that the birth of the new baby could be a future pressure on BB. In line with anti-oppressive practice and partnership working, I discussed both the assessment and recommendations with BB and by letter with BA. Both were given the opportunity to put their views across and both were happy to continue to work voluntarily with the department for the present.

The reasons behind my recommendations were that BB although socially isolated had a strong supportive network with her extended family and BA’s extended family. Further to this BB has a close and supportive relationship with her mother whom she sees every day. According to Hill et al (2007) a vast array of research shows that parents in poverty, or facing other stresses, usually cope better when they have one or more close relationships outside the household and these are activated to give practical, emotional or informational support. Most often this is informal but, for isolated parents access to family centres or professionals including health professionals can make a great difference to both the parents and the social and emotional health of children. (Barlow & Underdown, 2005)

With regards to CA, BB had a good bond with her daughter and was quick to attend to her needs. BB also had a routine in place for CA regarding mealtimes and naps this also included a bedtime routine. CA was reaching her developmental milestones (Source: Sheridan’s Charts). CA had age appropriate toys and had the freedom of the living area. BB had erected a baby gate to stop CA from gaining access to the kitchen and the stairs. However, since CA started walking, BB has to continually keep an eye on CA due to the open fire and hearth in the living area which is proving stressful for BB.

Immediate interventions included obtaining Section 22 funding to purchase a safety fireguard and information was obtained regarding BB making applications for Sure Start and Healthy Eating Grants. These applications were successfully made by BB and allowed her to purchase essential items for the new baby. BB had highlighted this as a worry for her as she was struggling financially. Working in collaboration with the Community Midwife arrangements were made for BB to make the trip to the clinic on alternate weeks when her benefits were received. The Community Midwife visited her at home the other weeks.

I believe I managed to build a positive working relationship with BB. According to Wilson et al (2008) relation-based practice is the emphasis it places on the professional relationship with the service user. The social worker and service user relationship is recognised to be an important source of information for the worker to understand how best to help. In order to make informed decisions and critically evaluate practice, reflection and analysis of information should embrace all sources of knowledge which have to be drawn upon. Further to this, a potentially more informative, relationship-based and reflective response would be to articulate the service users’ feelings by which the service user can acknowledge their own responses to the situation. As Fook (2002) points out:

“Reflective practioners are those who can situate themselves in the context of the situation and can factor this understanding into the ways in which they practice…

(Fook, 2002, p.40)

Banks (2006) also indicates that part of the process of becoming a reflective practioner also involves being aware of one’s own position of power and how dominant discourses construct the knowledge and values we use to describe and work with situations and practice. This has been discussed in supervision with regards to BB’s Pre-Birth assessment and to visiting BA in prison.

It is difficult to evaluate whether aspects of my work were effective or not. However, in supervision we discussed how keen BB was to gain support and seemed to appreciate the partnership approach. This was discussed in relation to Hill et al’s (2007) research and Barlow and Underdown (2005). Small aspects of my intervention, such as the provision of the safety fireguard were described by BB as a ‘godsend’ and she was proud to show me the baby items she had purchased on receipt of the grants.

Discussion in supervision also centred round the next stage of intervention which was after the baby was born. I discussed with BB the opportunity for CA to attend a local authority nursery one day per week. This would help CA’s social and emotional development and at the same time allow BB to spend time with LA. This referral was successful as was gaining the services of a volunteer driver to transport CA. However, CA has only just started at the nursery and therefore difficult to gauge if this referral has been effective.

Reflecting on my work overall, I should probably have explored more with BB her social isolation and worked on strategies to get her more involved in the community. Further to this resources in this village are non-existent and the parenting groups which were suitable were not available locally. BB was interested but location of the Family Centre and lack of public transport negated this. I enquired with regards to Outreach Work but this was not available. Discussion with other colleagues in the team reflected the same theme regarding facilities for the outlying villages. Further discussion in supervision raised for me the difficulty of maintaining empowering and anti-oppressive practice within this context as assessment should be needs led not resource led.

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