Safeguarding and child protection are everyone's responsibility (Fraser and Nolan 2004). During pregnancy, it is primarily the responsibility of the midwife and other professionals who may be providing care, to consider the need for protection of the unborn baby, in relation to the parent's ability to ensure the safety and wellbeing of the child (Powell, 2010) and is becoming increasingly a larger part of the midwives' workload. Fraser and Nolan (2004) suggest that many midwives find this unsettling as it may be contrary to their normal role of encouraging and empowering mothers and fathers, especially if they are leaving hospital without their child. Midwives come into contact with many vulnerable groups of people where parenting skills may be influenced by a number of factors such as: learning disability, mental illness, substance or alcohol misuse, being a child themselves or having a previous history of child maltreatment or neglect.
There are a number of national and international policy statements outlining the rights of children (United Nations (UN), 1989; Department for Children, Families and Schools (DCFS), 2010). The Children Act (2004) defines safeguarding as:
‘Protecting children from maltreatment, preventing impairment of children's health and development, ensuring that children are growing up in circumstances consistent with the provision of safe and effective care’.
The Act makes reference to the duty to act on any child welfare concerns, providing clear implications for child protection education and training, including multi-agency collaboration and requires local authorities in England to set out good practice in order for the guidance to be implemented. There is separate guidance for Scotland, Wales and Northern Ireland.
Guidance on child protection is based on a number of independent enquiries and government papers/legislation (Laming 2003; Department for Education and Skills (DFES), 2006) and has been updated following recent investigations and government papers (Laming 2009; DCFS, 2010). Since the death of ‘baby P’, a baby who died from more than 50 injuries inflicted over an 8 month period by his mother's boyfriend, the Munro review of child protection (Department for Education (DfE), 2011) identified that the system had become entrenched in rules and procedures and had lost focus of the needs of the children. Therefore many recommendations were made including the need to: revise statutory guidance on safeguarding children, clarify accountability, and improve safeguarding education.
There have been major initiatives designed to improve the health and wellbeing of children in England. The initiatives have expanded from child protection to safeguarding, which encompasses child protection but encourages wider support with early intervention strategies and the introduction of The Common Assessment Framework (Department of Health (DH), 2000). Midwives are guided by the rules and standards of the Nursing and Midwifery Council (NMC, 2012) and the Royal College of Midwives (RCM) and need to follow the policies and procedures produced by their Local Safeguarding Board, Health Authority and the hospitals where they practice.
Bull (2008) highlights that although midwives are well placed to identify families in crisis, in practice there is a lack of clear evidence-based guidance for midwives when they should report child protection concerns or how to engage with families perceived to be at risk. Although midwives are required to formerly report child protection concerns, there is a lack of in depth training. The RCM (2004) identified that lack of qualified staff and resources is a threat to the effectiveness of child protection practice.
The aim of this study is to discover the perceptions of UK midwives of the adequacy of preparation and support for their child protection role. It will also investigate the factors that influence the effectiveness fulfilling this safeguarding role.
Review methods
The following databases were used to conduct the literature review: British Nursing Index, CINAHL, Cochrane database, Ebsco host, Embase, Health business elite, Health Management Information Consortium, Medline, Menderley, MIDIRS and PsycINFO.
The search terms used were: child protection, child abuse, safeguarding, neglect and midwives, midwifery and health professionals. A number of combinations of these terms were employed. The papers reviewed were limited to original UK research, and the search period covered the years 2000–2012.
Several of the databases did not yield any results. Those that did are shown in Table 1.
| Database | Midwifery | Safeguarding | Original research |
|---|---|---|---|
| British Nursing Index | 8143 | 28 | 8 |
| CINAHL | 11815 | 19 | 5 |
| Ebscohost | 58646 | 68 | 28 |
| MIDIRS | 500 | 65 | 11 |
| Psych Info | 609 | 54 | 16 |
The search was for both qualitative and quantitative studies from the UK since 2001. Studies included related to: midwives views and experiences, education, training, policy, practices and interagency collaboration. Exclusion criteria are identified and explained in Table 2.
| Papers that were not UK based. This was because the purpose of the review was to explore the perceptions and experiences of UK midwives |
| Papers that were not specific to child protection and safeguarding |
| Papers that focused on elements that might have an effect on midwives' experiences of child protection (e.g. time constraints, workload, staff shortages) but these issues are not specifically related to the child protection role |
| Papers relating to child abuse identification in non-maternity areas such as accident and emergency and paediatrics |
After application of the exclusion criteria, a total of nine studies were included in this review (Bennett et al, 2001; Baird et al, 2005; Long et al, 2006; While et al, 2006; Bull, 2008; Wood, 2008; Leamon and Viccars, 2010; Lazenbatt, 2010; Bradbury-Jones et al, 2011). As Lazenblatt (2010) and Lazenblatt and Thompson-Cree (2009) were related to the same study, the later paper (Lazenblatt 2010) has been used in this article as it is a more comprehensive presentation of the study undertaken.
Three previous literature reviews were identified during the search process (Table 3).
| Review and reference | Focus of literature review | Main findings and comments |
|---|---|---|
| Daniel, Taylor, Scott (2010) Recognition of neglect and early response: overview of a systematic review of the literature. Child and Family Social Work15: 248-257 | Relates mainly to policy and guidance |
Systematic review guidelines (Centre for Reviews and Disseminations); Suitable databases used; inclusion exclusion criteria identified; 63 papers reviewed and analysed |
| Keys (2009) Determining the skills for Child Protection Practice: Emerging from the Quagmire. Child Abuse Review18: 316-332 | Focus on education; absence of research To establish the evidence base on which to base the skill components of child protection education | 1st stage of the review identified only 6 papers; 11 Australian, 1 UK paper, 3 North American, 1 Finnish |
| Wood (2007) Child protection issues: the role of the midwife in safeguarding children Midirs Midwifery Digest17(2): 169–174 | What are the experiences of midwives relating to child protection issues and the safeguarding of children? | Appropriate medical, nursing and voluntary service databases used |
Daniel et al (2010) carried out a systematic review of policy and guidance in safeguarding. They identified many gaps in the evidence relating to child protection. They found that professionals needed to be more proactive in seeking supportive, structured and creative ways to question parenting concerns, and that clearly defined policy, resources and guidance were needed to support professionals' assessment skills. They also identified the need for more research. The review by Keys (2009) supports these findings. However, Keys (2009) was unable to achieve its aim of establishing the evidence on which the skill components for child protection education are based, due to an absence of research in this area. This study did identify that the majority of published studies focused on the outcomes of professional practice, rather than exploring the required skill base. In the studies, where the use of skills was the focus, there was an assumption about what skills were required without any empirical evidence to support this. Wood's (2007) study related more to midwives experiences of child protection issues. It identified the role of interagency working including conflict and communication problems. The main finding supports the other two reviews that there was a dearth of evidence in this area.
Findings
Research methods used
Six of the studies identified in the literature search used qualitative methods (Bradbury-Jones, et al 2011; Leaman and Viccars, 2010; Long et al, 2006; While et al, 2006; Wood et al, 2006; Bull, 2008) and three of the studies used mixed-methods (Lazenblatt, 2010; Baird et al, 2005; Bennett et al, 2001). All of the surveys had been validated, had good sample sizes and used national or regional cohorts providing maternity care or Higher Educational Institutions (HEIs) that provide pre- and post-registration nursing and midwifery education. The response rate for surveys in all studies were good. The study by Marchant et al (2001) targeted all NHS services in England and Wales, although the respondents had been chosen by the heads of midwifery or senior midwives at the individual trusts, which reduced randomisation and may have introduced establishment bias from those cohorts. The studies by Lazenbatt and Thompson-Cree (2009) and Bennett et al (2001) may demonstrate regional bias as the former was carried out in only Northern Ireland and the latter in the North of England. A survey by Baird et al (2005) was undertaken solely in England.
Long et al (2006) was part of a larger DH funded project and triangulated three methods of research—document research, structured questionnaires and interviews—combining both quantitative and qualitative methods. Bull's (2008) study had a small cohort of only 29 cases that had been referred to the child protection advisory team at a London hospital; the results were analysed using descriptive statistics. Although single cases contribute to an understanding of wider situations the results cannot be generalised to the wider population.
Qualitative research aims to explore meaning and is intended to develop an in depth understanding of the data. This makes it appropriate for giving insight into the experiences of professionals working within their natural setting (Aveyard 2010). All the studies that included qualitative data collection used semistructured interviews; Leamon and Viccars (2010) combined these with focus groups. While et al (2006) also used focus group methodology. Three studies combined quantitative and qualitative methods (Bennett et al 2001; Baird et al 2005; Long et al 2006) but gave little description about their qualitative methodology and their results are based mainly on the quantitative element, with the qualitative data being used to provide more in-depth information.
All of the studies used thematic analysis following an identified framework. Both Wood (2008) and Bradbury–Jones et al (2011) analysed taped recordings of their interviews. This allowed the researchers analyse the data in its original context. It also minimised misinterpretation and interviewer bias. Leamon and Viccars (2010) did not use tape recordings but relied on transcribed notes. This could have affected the quality of the data through paraphrasing or taking the comments out of context. Data from While et al (2006) were coded and analysed independently by two separate researchers, the results then discussed together until a consensus was reached. Bowling (2009: 411) suggests that ‘in order to ensure rigor, a third independent coder should be used’. This was the case in Bradbury-Jones et al (2011), but is unclear in Wood (2008) or Leamon and Viccars (2010).
Themes
Four themes emerged from the literature. These were:
Midwives perspectives
Bennett et al (2011), Bull (2008) and Lazenbatt and Thompson-Cree (2009) identified the importance of the safeguarding role in midwifery. Wood (2008) found that many health professionals did not identify their role in safeguarding as being important. Although Lazenbatt and Thompson-Cree (2009) found that 92% of hospital-based midwives felt they had a role to play in safeguarding, they also identified a 10% gap between definite cases of child abuse being identified and those which had been reported. They found that effective practice was more challenging for hospital-based midwives than for community midwives who were more aware of the mechanisms for reporting abuse. The qualitative element of the study suggested that community midwives were more skilled in noticing the subtle cues and signs of abuse due to greater continuity and the ability to develop relationships within the clients' family and wider environment.
Wood (2008) found that midwives often feel unsupported with regard to child protection and some had felt threatened, although no episodes of violence had been reported, some had been emotionally affected for years following difficult cases. This study also found that support from colleagues was invaluable.
Education perspectives
Education and training was an important issue highlighted in the majority of the studies. Long et al (2006) identified that no agency in England dealing with child protection developed standards specifically for training in interagency working within their pre-qualification programmes. A few agencies did have standards for safeguarding but they were not widespread or explicitly clear to so as to be enforceable in professional practice. This finding was supported by Baird et al (2005) whose study relating to child protection identified a wide range of teaching practices, time structure, approach and level of skill between different institutions.
Long et al (2006), Bull (2008), Lazenbatt and Thompson-Cree (2009), Baird et al (2005), Bennett et al (2001) and Wood (2008) all identified that professionals have a need for more training in safeguarding issues. Baird et al (2005) found that pre-registration students had more taught hours in safeguarding than post-registration. The findings from these studies suggests that there is a need for improvement in training relating to safeguarding to enable midwives to understand their roles and responsibilities of safeguarding children.
Baird et al (2005) identified the need for students to see qualified staff putting the training into practice, although the evidence from these studies suggests that qualified staff may have less training in this area. Lazenbatt and Thompson-Cree (2009) suggests that qualified midwives need ongoing education and training in order to develop the appropriate safeguarding knowledge and skills. This study identified that only 40% of the midwives surveyed had received training on child abuse. Long et al (2005) found a need for all staff to have ongoing training. Wood's (2008) study into the experiences of midwives involved in situations where there was a need to remove babies from mothers shortly after birth, reported insufficient training and lack of opportunity for training being available, and concluded that multidisciplinary and multiagency training was necessary to explore these difficult issues.
Bull (2008) suggested that midwives required advanced levels of child protection training in order to support and counsel parents in a non-judgemental way, as well as developing skills in the identification of the subtle cues and signs of a family in crisis. Lazenbatt and Thompson Cree (2009) identified training needs in the area of how to interact with abused mothers and how to sensitively ask questions. This study suggests that improved training would improve professional's confidence, enabling them to be more effective when intervening and reporting safeguarding issues.
Interagency working
The importance of improved education and training in the area of multi-agency collaboration has already been discussed. Leamon and Viccars' (2010) small study identified the positive benefits of good interagency working. By bringing midwives, among other professionals, to the Sure Start Centre they found there was improved client engagement including that of ‘hard to reach’ families, with more families accessing health and social care at the children's centre. Although this study was limited to one children's centre, the authors claim it echoes the findings of the National Evaluation of Sure Start Centres (DFES, 2008). Bennett et al's (2001) study identified that midwives acknowledged that strong relationships with other professionals were beneficial. This was supported by Bull (2008), who found that rapid interagency collaboration is essential to prevent poor outcomes.
Long et al (2006) discovered that the language and terminology used in organisational standards collected from different agencies emphasised organisational differences rather than identifying common practice. None of the standards promoted collaboration between professionals or enhanced a common approach. Bennett et al (2001) identified there was a fear of crossing professional boundaries, and Lazenbatt and Thompson Cree (2009) highlighted the necessity for a joined-up approach, with close interagency liaison and midwives who were not afraid to challenge historical working practices and traditional boundaries. This study also identified that communication gaps needed to be bridged even between midwives working in different settings within their own profession. Bradbury-Jones et al's (2011) research highlighted problems such as delayed transfer or absence of records and poor communication between professionals, especially across differing geographic boundaries, resulting in poor interpersonal relationships between clients and professionals.
Organisational perspectives
Both Marchant et al (2001) and Long et al (2006) highlighted the need for improved standards and policies. Marchant et al (2001) found that protocols do not always exist in practice and more policy development based on research was required, for which there were no national guidelines. In addition, all units had an individual way of interpreting policy. This study relating to domestic violence found substantial variation around England and Wales in the implementation of DH policies between professional organisations. Just over half of all the maternity services had printed information associated with domestic violence on display but only half of these did so in places where they could be viewed in privacy. Only a small proportion of the hospitals routinely screened their clients. This study also identified conflicting policies such as partners being included in all aspects of maternity care when the domestic violence policy recommended that women should be seen alone. This study is over 10 years old and it would be useful for it to be replicated to see if improvements have been made.
Baird et al (2005) and Wood (2008) identified a need for increased support for individual practitioners working in the child protection field. Baird et al (2005) suggests that education and skill development needs to be supported a systematic approach to domestic violence teaching and teaching midwives how to ask appropriate questions about domestic violence when seeing women at ante natal clinics. Wood (2008) highlights the need for midwives to be supported as some areas of child protection work can be stressful and threatening. This suggests there is a need for development of support structures, supervision and training in recognising domestic abuse appropriate for health professionals. Bull (2008) suggests midwives can be supported by the use of comprehensive care packages. Bennett et al (2001) highlighted that managers need to assess the knowledge base, skills and wishes of their workforce, before implementing change.
Conclusions
This literature review supports the findings of the other three reviews in Table 3 demonstrating that there is a dearth of empirical evidence in the area of safeguarding. There were no papers identified that fitted the inclusion criteria for vulnerable client groups such as mental health, substance misuse, learning disability or teenagers. The only studies relating to a specific client-base were related to domestic violence, despite a vast amount of narrative papers in all of these areas.
Many of the studies appeared to demonstrate potential regional, interviewer or establishment bias and some had relatively low response rates. It is therefore difficult from this literature review to form any firm conclusions or to identify all the factors that may influence the effectiveness of midwives working in the area of child protection.
Nevertheless, the studies included spanned a 10 year period and ranged in settings from national to regional studies. Despite social, cultural and regional differences, similar themes emerged. Research needs to be undertaken into child protection for vulnerable groups, the development and use of evidence-based policies in child protection and the impact of improved education in child protection for midwives.
Despite clear national guidelines (DCFS, 2010) around interagency working and organisational responsibilities there seems to be a lack of evidence-based policies or national guidelines at both organisational or educational levels. The review also found little effective education and training in this area for both pre-registration and post-registration midwives, with widespread differences and approaches to teaching between higher educational institutions and Trusts.
There is a need for on-going professional development, both single and multiagency, in order to develop key skills in effective identification, reporting, management and communication when dealing with child protection cases. Managers need to not only ensure training is available but that all staff are able to access it. Hospital policy needs to be enforceable and not conflict with other existing policies. The skill base of the workforce needs to be assessed and support and supervision need to be provided. Improved education, management, interagency communication and support should lead to a clearer definition of the roles and responsibilities for the individual professional making them feel more confident and supported in this safeguarding role.