A Pathway of Care for Vulnerable Families (0-3)

Guidance to support the implementation of Getting it right for every child through continous assessment and a continuum of support.

4. Guidance on approaches from the antenatal period to age 3

This section of the guidance presents the enhanced universal pathway from the antenatal phase to age 3, with suggestions for possible interactions at each core contact to support women, children and families where there is a concern about
the child's well-being.

It should be emphasised that these are not the only points where service providers will meet with the child or family, and local pathways should reflect flexible contact points in addition to these core contacts.

4.1 Guidance on approaches within the antenatal period to enhance the universal pathway

This is about equipping and supporting professionals to think about the kinds of issues that are important to women, children and families throughout their universal journey. The guidance presents prompts that will enable professionals to identify where women, children or families are at higher risk of poor outcomes. Professional judgement should then be used to decide how any needs can be met, working with the family and engaging other professionals as appropriate.

The antenatal period is a critical time to engage with women and their families to identify additional needs and to support them to achieve the best possible outcomes for their child and family.

Pregnant women with complex social factors may need additional support. Examples of high-risk groups are: 27

  • women misusing substances (drugs and/or alcohol)
  • women experiencing domestic abuse
  • women under 20 years old
  • women who are recent migrants, asylum seekers or refugees, or who have difficulty reading or speaking English.

Using the GIRFEC National Practice Model (see Figure 1) and placing the child at the centre of the assessment allows practitioners to consider their role in working with and supporting the family, whether through observation, practical support or involving other agencies as appropriate. The model focuses on key elements during the journey through consideration of the eight well-being indicators:

  • safe
  • healthy
  • achieving
  • nurtured
  • active
  • respected
  • responsible
  • included.

As Scottish Woman-Held Maternity Record ( SWHMR) is the national record for assessment used in maternity services, examples of strengths and needs have been mapped against the well-being indicators to show how the GIRFEC approach is reflected in the record.

Note that the examples are just that - examples that have been provided to support professionals to think about the kinds of issues they may want to address. Professionals and teams will also have to consider a wider range of issues, depending on individual needs.

4.1.2 Examples of questions to raise within SWHMR




  • Mother/family has stable relationships
  • Mother/family has good support network
  • Mother/family has suitable housing
  • Recognition and understanding of risks to the child
  • No concerns regarding previous children
  • Abuse or neglect of previous children
  • Previous children removed/on child protection register
  • Poor impulse control
  • Mother/family experienced abuse in childhood
  • Domestic violence
  • Drug or alcohol misuse
  • Homeless and/or poor housing

Examples of questions to raise within SWHMR

When is your baby due?

  • How sure are you of this date?

Is this a planned pregnancy? Be respectful of the decision the woman has made in ensuring the progression of a safe and healthy pregnancy.

Your previous pregnancy

  • Is your current pregnancy with a new partner?

Consider the safety and well-being of other siblings as this may impact on the unborn baby. Are you aware of any child protection concerns?




  • Mother keeps antenatal appointments
  • Mother develops and sustains good working relationship with professionals
  • Good self-care skills
  • Expresses an awareness of the unborn baby's needs and a desire for the baby
  • Ability to prioritise the baby's needs
  • Mother/family has good support network
  • Drug/alcohol misuse
  • Domestic violence
  • Mental ill health
  • History of postnatal depression
  • Poor engagement with professionals
  • Learning disability
  • Very young parent/immature
  • Stressful relationships
  • Limited support
  • Unwanted/concealed pregnancy

Examples of questions to raise within SWHMR

Mother's health

The woman can make a significant difference to the unborn baby's/child's health by giving them the best start in life through, for instance, having adequate nourishment, sleep and physical activity.

Other health-related questions

  • Do you go to the dentist regularly?

Consider referring the women to a dentist as part of the "Childsmile" programme if appropriate.

  • How many units of alcohol a week are you drinking now?

Consider the impact of all substance misuse on the unborn baby, as well as the health and safety of the woman.

  • Current smokers: cigarettes smoked per day

Consider the targets to reduce smoking and the programmes of local support available.

  • Substances used

Is the well-being of the woman and unborn baby/child being compromised due to substance misuse? There is a need for skilled and sensitive enquiry to elicit information and to establish the additional support needed from other practitioner and partner agencies as appropriate.

  • Medication

Is the woman compliant with prescribed medication and getting any additional help with problems?




  • Mother demonstrates understanding of the developmental needs of a baby
  • Good early childhood experiences
  • Positive experience of professional relationships
  • Lack of awareness of baby's needs
  • Unrealistic expectations
  • Poor physical and/or mental health
  • Learning disability
  • Poor experience of professional relationships

Examples of questions to raise within SWHMR

Information for mother

The named person (midwife) will be establishing the relationship with the pregnant woman and should support understanding of the desired outcomes and their shared responsibility to work with practitioners to make this happen.

Plan of care for pregnancy

The plan for care should be documented following the assessment undertaken using the pregnancy record. The pathways for maternity care (green/amber/red) will support the identification of the Health Plan Indicator appropriate for the unborn baby/child and family as part of the continuum of support.

Postnatal record

  • Problems identified during pregnancy, labour/birth
  • Problems in the postnatal period/referrals, investigations or results pending

Transition from antenatal to early years care will require that the assessment and plan for the unborn baby needs to be refreshed by the named person when the baby is born.

  • Postnatal care

Transfer of the relationship-based care from, and to, a named person/lead professional as appropriate will need to be managed sensitively to achieve the best outcome for the child and family.

  • Feeling confident with the baby

The support a child and family needs to achieve the desired outcomes can be developed through the well-being indicators of safe, healthy, achieving, nurtured, active, respected, responsible and included.

Examples of questions to raise within SWHMRcontinued

  • Formula feeding the baby

Sensitivities around supporting informed decision-making to bottle feed may impact on the mother's bonding with the baby and create potential concerns regarding mental health issues and attachment as a result of feelings of failure/rejection. This will inform assessment and planning to support early intervention and prevention of problems.

  • Thinking about the pregnancy, labour and birth

Sensitive enquiry should be considered to elicit health and social care needs which may affect the woman's decision to have another pregnancy or come to terms with the current pregnancy.




  • Positive childhood experiences
  • Stable relationships developed and maintained
  • Mother shows maturity
  • Mother/family has good support network
  • Empathy and the ability to keep the unborn child in mind
  • Safe and secure family environment
  • Expectant mother happy about pregnancy
  • Conflict and hostility in the family environment
  • Very young parent/immature
  • Poor relationship history
  • Poor physical and/or mental health
  • Lack of social supports
  • Inability to focus on the needs of the unborn child

Examples of questions to raise within SWHMR

Questions or concerns

Consider the impact on the child's health and development as a result of:

  • living in a poor physical environment
  • family tensions
  • social and family networks.




  • Keeping active during pregnancy
  • Taking advantage of local activities
  • Prepared for the baby's arrival
  • Attending antenatal education classes
  • Social isolation
  • Physical or mental health problems that inhibit social activity
  • Inability to prepare for the baby's arrival

Examples of questions to raise within SWHMR

Breastfeeding the baby

  • Raise topic of breastfeeding.
  • Consider local community planning initiatives in relation to infant nutrition/healthy start food cooperatives and peer support groups to support ongoing breastfeeding.




  • Good self esteem
  • Positive relationships
  • Involved in decision-making
  • Makes positive choices
  • Poor self care
  • Poor self esteem
  • Poor relationship history
  • Domestic violence

Examples of questions to raise within SWHMR

Postnatal record

Mother's progress

Ensure that needs are systematically assessed universally for all children and, for a small proportion of children with additional needs, on a multi-agency and/or multidisciplinary basis.

Mother's health after the birth

Managing transitions from the woman and unborn baby being at the centre to the child and family being at the centre by ensuring that the woman does not feel excluded and remains central to the well-being of the child.




  • Able to make positive choices in pregnancy
  • Keeps all appointments and is proactive in self care
  • Acknowledges concerns
  • Able to prioritise the well-being of the unborn child
  • Able to budget - good practical skills
  • Chaotic lifestyle
  • Unable to focus on, or prepare for, the baby
  • Poor antenatal care
  • Prioritising own and partner's wants above well-being of baby
  • History of offending

Examples of questions to raise within SWHMR

Mother's age

If the mother is a young woman, consider if she is actively playing a responsible part at home and in school. Is she a confident individual?

Postnatal care

Consider the transition from named person (midwife) to named person (public health nurse/health visitor). What aspects of well-being do you need to consider. How will the transfer of the relationship-based care to another practitioner impact on the woman? What process will you use if there are additional needs and a lead professional is responsible for coordinating the care?




  • Good support from family and/or friends
  • Makes use of community resources
  • Socially isolated family
  • Mother/family has poor social supports
  • Negative childhood experiences by mother/family
  • Housing and financial problems being experienced by the mother/family

Examples of questions to raise within SWHMR

Mother's partner/supporter for this pregnancy

Have all contact details for any health or social care agency the woman is in contact with been gathered? Sensitive enquiry to elicit wider health and social care needs.

Ethnic origin

Is the woman and her family accepted into the community without prejudice or tension and included in local supports and resources?

Referral needed

Consider if anyone else is involved with the care of the pregnant woman. Care and intervention may be required from other practitioners and agencies to determine the extent of the additional needs.

Additional needs identified here may require discussion with practitioners and partner agencies. An integrated assessment and core planning meeting may need to be called. Are you confident that you understand how this happens?

4.2 Guidance on approaches to enhancing the universal pathway in the immediate postnatal period up to age 3

The well-being of children and young people and their "well becoming" are at the heart of Getting it Right for Every Child. The eight indicators of well-being (safe, healthy, achieving, nurtured, active, respected, responsible and included) are the basic requirements for all children and young people to grow, develop and reach their full potential. Children and young people will progress differently depending on their circumstances, but every child and young person has the right to expect appropriate support from adults to allow them to develop as fully as possible across each of the well-being indicators.

Family circumstances may change over time. The additional needs that arose in the antenatal period will impact differently in the immediate postnatal period and beyond.

Families with additional needs may be able to manage their circumstances with little or no intervention from universal or specialist services. However, continuous assessment of need, at every contact, will enable the right level of support, in agreement with the family and other professionals, to be given at the earliest opportunity.

Examples of families at higher risk of poor outcomes include:

  • first-time young mothers
  • parents misusing substances
  • those experiencing domestic abuse
  • those with emotional or mental well-being issues
  • parent or child with disabilities.

4.3 Protective and risk factors 28

Protective factors are behaviours or characteristics for which there is research evidence that shows they make a difference in outcomes for children with complex or multiple needs. In addition to generic social and psychological indicators, there are specific risk and protective factors for particular outcomes.

4.3.1 Protective factors


  • authoritative parenting combined with warmth, with an affectionate bond of attachment being built between the child and the primary caregiver from infancy
  • parental involvement in learning
  • protective health behaviours, such as smoking cessation in pregnancy
  • breastfeeding
  • psychological resources, including self esteem.

The parent/carer may show evidence of understanding and appropriate action in some areas. These should be considered strengths and a measure of where to start building parental capacity, rather than focusing on areas that are not being met.

4.3.2 Risk factors


  • an underlying medical or developmental disorder and temperamental characteristics, some of which may be genetic
  • low birth weight and prematurity
  • obesity in parents (a child is at greater risk of becoming obese if one or both of the parents is obese)
  • poor attachment and cold, critical or inconsistent care (this can result in emotional and behavioural problems)
  • smoking in pregnancy (this has multiple short and long-term adverse effects on both the foetus and child, and can be a wider indicator of a pregnant woman's self esteem)
  • smoking by partners (this also has both a direct and indirect impact on children and is the most powerful influence on the mother's smoking habit).

Some of the indicators listed above are more difficult to identify than others. Health professionals need to be skilled at establishing a trusting relationship with families to enable them to build a holistic view.

4.4 What questions to ask

Within the National Practice Model, the "My World Triangle" questions should prompt users about key areas to focus on, following identification of a need. Probing questions on areas that impact on "How I grow and develop" and that relate to "What I need from people who look after me" and "My wider world" are found within the GIRFEC guidance. 29

Table 2 provides examples of families who may need additional support. The list is not exhaustive, but can be used as a guide to considering what the population-level needs might be within your local area. 30

Table 2. Universal pathway (enhanced) - birth up to age 3

Example of family need*

Evidence of strength/asset in 31 relation to (or knowledge of):

Birth to around 10 days

  • First-time parents
  • Mother recovering from a difficult delivery
  • New babies up to eight weeks
  • All children in neonatal unit until completion of SOGS assessment
  • Breastfeeding mothers depending on need
  • Pram and cot safety
  • Sleeping pattern, bed sharing, position, temperature
  • Feeding preparation safety
  • SIDS (sudden infant death syndrome)
  • Animal safety
  • Carer's routine/lifestyle

Around 10-28 days (handover from midwife to public health nurse/health visitor)

  • Families new to area
  • Children whose main carer is isolated, unsupported partner
  • Previous history of child bereavement
  • Serious illness of parent/child
  • Children isolated from services due to geography, resources or parenting capacity
  • Children recently removed from child protection register
  • Skin care - bathed and nappy changed regularly
  • Smoke-free home
  • Parent/carer expresses love and emotional warmth towards the baby
  • Parent/carer seeks appropriate help and advice if experiencing difficulties managing baby
  • Parent/carer calm and consistent when dealing with baby's distress

From handover - 6 months

  • Parents with complex needs
  • Significant life events, such as bereavement or homelessness
  • Children with disabilities, including communication disorders
  • Children with complex care needs, chronic ill health or terminal illness
  • Chronology frequent no access
  • Baby is calm and comfortable with parent/carer
  • Siblings show obvious love and affection towards the baby
  • Physical needs of baby attended to by parent/carer
  • Appropriate play (singing, talking, reading, floor play etc.)
  • Parent/carer may attend local groups
  • Taken out to visit family/friends/shops/local community
  • A limited number of safe adults deliver intimate care
  • Feeding appropriate for age and stage
  • Appropriate sleeping pattern

6 months to 1 year

  • Children with emotional, behavioural, developmental or mental health issues
  • Families with literacy issues
  • Children whose development may be affected by a succession of carers
  • Specific behavioural problems such as sleep difficulties
  • Children in families where there is poor hygiene
  • Children subject to supervision requirement
  • Chronology indicating high mobility
  • Chronology failed health appointments
  • Appropriate home safety precautions
  • Infant is normally well
  • Developmental milestones reached
  • Appropriate use of language and tone of voice (by parent/carer)
  • Taking cues and responding appropriately
  • Support from family and friends
  • Gross motor skills age appropriate
  • Vision and fine motor skills age appropriate
  • Development of secure attachment
  • Child understands simple commands

1 year to 3 years

  • Obesity and/or other weight issues (with parent/carer and/or child)
  • Children experiencing a crisis likely to result in a breakdown of care arrangements
  • Parents who self refer for additional support
  • Looked after and looked after and accommodated children
  • Young carers in the family unit
  • Children involved in contact/residence disputes
  • Failure to thrive/developmental delay
  • Children on child protection register
  • Parent/carer ensures child has plenty of opportunity and encouragement to develop motor skills
  • Appropriate modelling of behaviour
  • Child expects to be liked by parents/carers
  • Child is outgoing, smiles and "talks" - responds appropriately to parents/carers
  • Child's sense of self begins to develop
  • Child explores their environment with parent/carer in close proximity
  • Child has a range of safe toys to play with
  • Accidental injuries appropriately dealt with by parent/carer
  • Parent/carer responds appropriately to any symptoms of illness
  • Infant has age-appropriate diet

* Examples of HPI additional categories from a number of NHS Boards

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