• The midwife should access the patient’s Badgernet record, communicate with the GP/PAU, check Trackcare appointments to ascertain that this is an ongoing pregnancy and she is not receiving care elsewhere.
• Check to see if there are any difference/possible discrepancies in contact demographics.
• If it is confirmed that the woman has an ongoing pregnancy then an appointment should be provided or the earliest available clinic date and arranged with the woman, checking up to date demographics.
• Midwife should document non-attendance on ‘Did not Attend’ note on Badgernet record and record actions taken.
• Risk assess based on known gestation and known vulnerabilities, late booking is known to be associated with poorer outcomes for mothers and babies. (ISD Scotland, )
• Consideration should be given as to the need for a Child Protection Referral.

First non-attendance

• The midwife should access the patient’s Badgernet record, check that the woman is not a current inpatient or receiving care elsewhere.
• Attempt to contact the woman and agree the first available clinic date to rearrange if it is required.
• Document the woman’s non-attendance within the ‘Did not Attend’ note on Badgernet record, stating reason for non-attendance if known, and additional notes re actions taken.
• Copies of any reappointment letters posted should be scanned onto Badgernet record as proof of same.
• Consideration should be given as to the need for a Child Protection Referral.

Second non-attendance

• Discuss with additional professionals/agencies involved in the woman’s care. Ask if they are aware of any difficulties with regards to the woman being unable to attend antenatal clinic, as they may be able to provide further information.
• Re-appoint the woman for the earliest available appointment.
• Document the woman’s non-attendance within the ‘Did not Attend’ note on Badgernet record, stating the reason for non-attendance if known and additional notes re actions taken.
• Copies of any re-appointment letters should be scanned into Badgernet record as proof of same.
• Consideration should be given as to the need for a Child Protection Referral.

Third non-attendance

• It will be necessary at this stage for the Midwife to make a home visit to ascertain the reason(s) for non-attendance at antenatal appointments. A joint visit should be considered, dependant on the individual situation and potential risk.  Consideration should be given to link with any other key workers involved in the woman’s care to attend as second person at this visit which may help the woman engage.  Please refer to lone working policy for more information on safety around community visits.
• Inform Health Visitor/GP (enquire about compliance with any previous children).
• If direct contact is made, discuss with woman actions that would be considered if no improvement in attendance/engagement with Maternity Services, e.g. contacting Social Services.
• The woman should be re-appointed for the earliest available Clinic.
• Document the woman’s non-attendance within the ‘Did not Attend’ note on Badgernet record, stating the reason for non-attendance if known and additional notes re home visit findings/actions taken.
• Re-appointment letter should be hand delivered. Copies of any letters should be scanned into Badgernet Record.
• Inform and discuss with Senior Charge Midwife/Clinical Manager for guidance and actions to be taken.
• Inform Consultant Obstetrician with details of non-attendance and take any relevant guidance with regards to repeated DNA’s.
• Consideration should be given as to the need for a Child Protection Referral.

Fourth non-attendance

• Midwife should consider discussing concerns around persistent defaulting at the local Pre-Birth Oversight Group meeting. Midwife should also contact Social Work Department and determine if Social Work have any pertinent information or involvement with the family.
• A further home visit is required to ascertain the woman’s physical and emotional wellbeing, explore barriers to attendance and offer assistance to the woman to attend Antenatal Clinic.
• Midwife should discuss necessary arrangements for maintaining engagement, e.g. further home visits or antenatal care at a suitable location. Consider if a referral is required to an additional service, e.g. FNP, Perinatal Mental Health for additional support.
• Information from Social Work, in addition to observations from visits/discussions with woman, should inform ongoing risk and needs assessment, e.g. consider Request for Assistance or Notification of Concern if appropriate. Document in Badgernet ‘Social Plan’ and scan any referrals to Maternity record.
• If regular engagement is not established, Midwife should notify Nurse Consultant, Public Protection and agree further actions to be taken.
• Document continued non-attendance within the ‘Did not Attend’ note on Badgernet record and plan.
• Consideration should be given as to the need for a Child Protection Referral.

A standard letter is available for the purpose of informing women of any re-appointments.  (Appendix 1).

A letter also presents the opportunity of stressing to women the importance of regular Antenatal care.

• Community Midwife should inform Senior Charge Midwife, Senior Midwife PAU and Clinical Manager and Obstetric Clinical Director.
• Offer appointments/home visits for discussion of options of care.
• Midwife to provide woman with a copy of the NICE Antenatal Care Guidelines (2008, updated in 2021).
• If the woman is clear that she understands the benefits of receiving antenatal care and the risks of declining care but still choses to decline this, she has a right to do so.
• Seek support from Senior Midwifery Team/Consultant Obstetrician.
• Involve appropriate support agencies – particularly where there may be safeguarding concerns or mental capacity concerns.
• Complete legal safeguarding form for information only (unless specific welfare concerns).
• Ensure the woman is aware she can seek care at any point should she change her mind and has contact details to do so.
• Document all discussions and plans made on Badgernet.

A woman may make an informed decision not to engage for antenatal or intrapartum care and this term is often described as ‘Free Birthing’.  It is legal in the UK to give birth without assistance ‘You do not have to accept any medical or Midwifery care or treatment during childbirth.  No one can make you accept care unless you do not have the mental capacity to make decisions for yourself, and this is very rare.’ (Birthrights, 2024).  Midwives should attempt to engage families and ensure discussions around care provision are evidenced based.  However, health professionals should respect, support and document a person’s right to accept or refuse care and treatment.  (NMC The Code, 2018).  Senior midwives should be informed if any woman is planning to have an unassisted birth and submit a referral to the Head of Midwifery for further consultation around patient’s choices.

Consideration should however be given to the possibility of coercion or pressure being placed on the woman to have an unassisted birth (RCM, 2020).

Please ensure staff are aware of seeking support from the Public Protection Team for concerns in relation to Child Protection, Adult Support and Protection and/or gender based violence:  01896 752111

Letter to patient who has not attended Antenatal Clinic Appointment

 *Please print on NHS Borders Headed notepaper*

Date:    XXXXXXX

Patient Address

Dear XXXXXX

Sorry you were unable to attend your appointment as arranged on XXXXXX.  This is your XXXXX missed appointment.

We hope you are well.  It is important for the health and wellbeing of both yourself and your baby that you attend all your antenatal appointments.  Therefore, I would like to offer you a further appointment for XXXXX at XXXXX.

If you find this unsuitable, please inform me by telephoning XXXXX and I will make alternative/suitable arrangements to meet with you.

I look forward to hearing from you.

Yours sincerely,

Signature

Print Name

Community Midwife