The paper, published in PLOS One, is a systematic review of qualitative evidence of healthcare experiences of women and healthcare professionals during the perinatal period when child protection services are involved. The researchers analysed evidence from 41 international studies, mainly from the Global North. 

The perinatal period, before and up to a year after birth, is a time of change. For women with social risk factors, such as those experiencing mental illness, substance misuse or domestic abuse, child protection services may become involved during this time. This can complicate their interactions with healthcare providers, for example, causing feelings of fear, shame or judgement.  

I find a lot of them [nurses], you know, are not very sympathetic, they don't want to help you…I'm finding they need to train their staff more to be more understanding of us not just as parents and mothers, but as human beings, you know, how to interact with us with any situation and be more helpful when we're asking questions instead of judging us or looking at us weird

Postnatal woman, Canada, (Aston et al., 2021)

A common fear for women is around the risk of their child being placed in State Care. In the UK, rates of babies under the age of one being placed in State Care have nearly doubled over the last decade, reaching 5,540 in 2023 according to data from the Office of National Statistics. 

Lead researcher, Kaat De Backer, NIHR doctoral research fellow in maternal and perinatal mental health at King’s College London, and a member of the ARC’s maternity and perinatal mental health theme, said:

This study provides a holistic overview of the experiences of healthcare in the perinatal period when child protection processes are involved. Importantly, it includes a wide range of views from women and healthcare professionals from settings around the world

Kaat De Backer

Kaat De Backer, NIHR doctoral research fellow in maternal and perinatal mental health, King’s College London

Key findings from the review

The researchers found that women and healthcare professionals share a common goal at the start of healthcare interactions: doing what is best for the baby. However, this involved managing opposing risks. Women might be concerned about balancing the risk of their child being removed from them against securing the best healthcare for their child. For healthcare professionals, the challenge is around managing the risk of harm to the baby while maintaining a relationship with the mother.

How healthcare professionals managed this relationship was influenced by their confidence, expertise, personal beliefs and biases. The review showed that supportive supervision and access to training were critical for ensuring healthcare professionals could deliver high-quality, evidence-based and personalised care.

The review found that many women had previous adverse life experiences, including past experiences with child protection agencies. In most cases this was a ‘red flag’ on their medical record, which immediately shaped a perception of them as a risk and trouble-maker. As a result, women felt wary of healthcare and healthcare professionals, with little confidence in a positive outcome.

Another key finding was around the difficulty of navigating a fractured multi-agency system of care. Many studies in the review highlighted that this was challenging for both women and healthcare professionals, without oversight of agencies involved or clear communication between them. 

Overall the researchers identified three broad types of healthcare interactions: 

  • Relational care: where women and healthcare professionals engaged with trust and compassion
  • Surveillance: where women and healthcare professionals felt forced to follow outlined processes, resulting in a lack of shared decision-making and opportunity to disclose concerns
  • Avoidance: where women managed the risk of an unfavourable child protection outcome by avoiding healthcare professionals and the healthcare system

These interactions can shift between types and even coexist, highlighting the complex and reciprocal nature of healthcare experiences in this area. Also, these healthcare interactions are influenced by various factors at the individual, organisational and societal level, taking in everything from training and supervision, to individual feelings of self-worth and confidence, previous experiences and trauma, and wider factors such as systemic racism

Kaat De Backer

Kaat De Backer

Based on the findings, the researchers have made four key recommendations for improving care:

1. Building a trauma-informed workforce

Healthcare professionals need training and supervision to confidently safeguard women and babies while using sensitive trauma-informed care. This approach acknowledges women's past traumas and treats them with respect and compassion, which can support a sense of deserving motherhood.

“Misconceptions around vulnerabilities such as addiction, disabilities and homelessness can compound stigma that many women in these circumstances already face and often disregard the trauma they have experienced. Trauma-informed approaches in healthcare move away from such punitive attitudes, acknowledging previous trauma and adversity and its enduring consequences,” says Kaat De Backer.  

2. Addressing systemic racism

Women of Black or Indigenous backgrounds reported systemic racism when accessing health and social care, which they believed negatively impacted their child protection outcomes. The researchers emphasise the urgent need to address racism in both healthcare and child protection processes to reduce existing inequalities.

3. Improving multi-agency collaboration

The study revealed complexities and fragmentation in how different agencies work together when providing care to women facing child protection involvement. Poor information sharing between agencies has been identified as a factor that can lead to serious harm, abuse or death of a child.

4. Increasing transparency and clear communication

Women need to be informed about what to expect when child protection services become involved, including possible outcomes and next steps. While these conversations can be difficult, the findings suggest that transparency can reduce professional burden and provide a clear framework of mutual expectations between families and healthcare professionals than can increase engagement and trust.

Overall, the research highlights the need for healthcare systems to prioritise building trust, ensuring transparency and advancing equity in perinatal care when child protection services are involved. By addressing the recommendations, healthcare experiences and outcomes could be improved for women and babies.

[…] at first, I thought I was crazy. I thought something was wrong because I wasn't used to it.... People being nice to me about it. Not even just being nice, like, "Oh, good for you." It's like people just treating me just like a person, not like a drug addict, not a loser

Postnatal woman using opiates or illicit substances, USA, (Herriott, 2019)