Photo by Kristina Tripkovic on Unsplash

One in four birth mothers who have a child taken into care in England will re-appear in care proceedings within seven years. Women in this situation have experienced structural disadvantage in multiple domains including socio-economic deprivation, histories of trauma and abuse, low educational attainment and lack of access to healthcare. Owing to the stigma of having a child removed, the phenomenon of ‘recurrent care proceedings’ (RCP) was unacknowledged until recently. Just over a decade ago, a scoping study led by Pam Cox for the Suffolk Family Justice Council was undertaken to determine the scale of local RCP. As a result, this ‘national problem with no name…and no data’ was identified and, together with other local studies, influenced a new field of national collaborative interdisciplinary research and practice.

A national RCP intervention, “Pause”, supported by the Department for Education, was initially rolled out in London in 2015 and later via 21 hubs in England and Wales. One key critique of Pause was that the original service model included a requirement that women wanting support from the service must accept Long Acting Reversible Contraception (LARC, i.e. coils, implants or injections). Some have questioned whether this contravenes a rights-based approach to sexual and reproductive health. Informed by the nuanced findings of the second independent evaluation in 2020, PAUSE undertook a consultation on the requirement for LARC. Currently, Pause no longer require clients to use LARC but clients are still required to “commit to a pause in pregnancy”.

Over the last decade, independent of Pause, locally developed RCP services have been established variously funded through NHS, social care or third sector. Many of these have not included contraception as a requirement for service access, although most do discuss contraception with women and support women to consider LARC.

Supporting these services, our interdisciplinary team of academics and professionals have drawn on sociological, psychological and theoretical research in trauma-informed, attachment, and relationship-based approaches to inform intervention models and help evaluate service outcomes. Our research has established that women supported within these services have very high levels of past trauma, including iatrogenic trauma from interactions with services and professionals. Service development recommendations emphasise that professionals working with these women need to acknowledge past trauma, formulate their behaviour in this context, and attempt to build positive trusting relationships to avoid further iatrogenic harm. Research also emphasises the need for services to enquire sensitively about past trauma, prioritise transparency in communications, develop collaborative relationships, adopt strengths-based approaches and work in partnership with survivors.

Ongoing funding for these local services sitting outside of Pause has been precarious because the women concerned have tended to be maligned and seen as ‘undeserving’ of further support or assumed to be ‘hard to reach’ or ‘unwilling to engage’. Keyworkers tend to be very conscious that their clients are in need of health and wellbeing services and have experienced structural inequalities and significant disadvantage, yet skeletal staff teams have limited resources and usually limited or no capacity for performing the bureaucratic practices needed to demonstrate value to commissioners such as service evaluation.

To support these services, our interdisciplinary team developed a tailored evaluation methodology through a “Change project” funded by Research in Practice (RiP; a partnership championing evidence informed practices in children’s services). The toolkit grew out of initial pilot evaluation work carried out for one of the first RCP services in England (Suffolk) which had been established in 2013 by the local authority with limited funding.  While evaluation methods risk reducing structural inequalities and complex individual histories into codes, spreadsheets and monetary values, the work has enabled reframing of perceptions of women in these situations, for example by documenting histories of trauma and disadvantage. The methodology systematically documented key features of clients’ backgrounds including socio-demographics, trauma histories and healthcare needs while also collecting psychometric measures of mental health and wellbeing.

At the same time, the work has been able to demonstrate cost benefits of the services arising from avoiding care proceedings and ongoing care costs and hence enable the services to retain funding. Through ongoing evaluations in Suffolk, Norfolk, Stockport, Merseyside, Croydon, Birmingham, Southend, Salford, Lambeth and Essex, themes have emerged around experiences of past and current trauma as well as the unique aspects of grief and bereavement associated with having a child removed. Using these findings, we also began to support developments to service models incorporating trauma-informed approaches and providing training for frontline social care staff on incorporating this approach into practice. A new intervention, the Hope Box Project intervention, is being developed and piloted to provide support for the complex grief reactions many mothers have following this type of child loss. What is ground breaking about this intervention is that it has been designed  by mothers who have been through care proceedings themselves and have direct experience of child loss, making it the first peer designed intervention in the field.

Our evaluations of independent (non-pause) RCP services have consistently highlighted two key themes. First is that the services, staffed by passionate and dedicated keyworkers working extremely hard to support their clients, generate a wide range of benefits for women and families as well as local authorities by avoiding many (if not all) children being taken into care. A critical aspect of this is that they do this without requiring women to take LARC, indeed some women do become pregnant and are enabled to keep their children, demonstrating that this is not a necessary criterion for success. Secondly, evaluations show that in spite of several successful outcomes, including cost savings, women seen in RCP services come with a high level of mental health need, and these needs remain very high even after engaging with the RCP service. Many RCP services now include a counselling service or some form of mental health and well-being support for women who accept psychological support. However, given the high levels of past trauma, it is not surprising that the severity of mental health symptoms among these women are very high and would normally merit longer-term treatment in secondary care. This level of intervention is still unavailable to these women indicating there is still a long way to go in establishing greater equality of access to adequate mental health support for women who have experienced some of the severest forms of structural inequality.

RCP is no longer a ‘national problem with no name and no data’. A community of practice has been established to support practitioners and services working in this area. Our work, always in collaboration with others, has helped to create space, evaluative learning and resource which have enabled highly innovative local responses to take root. These responses remain precarious and must be nurtured and protected if they are to survive short-term policy cycles. Fortunately, service design now includes room for lived experience participation, empowering mothers, reducing shame through increasing connectedness, and challenging some societal stigma around this long-maligned group of women.