Women Declining Antenatal Care or Midwifery Services

Objectives

To provide a clear, consistent, and sensitive approach for all maternity staff when a woman declines antenatal care or midwifery services, ensuring her autonomy is respected while fulfilling professional, safeguarding, and legal responsibilities.

Scope

This SOP applies to all midwives, obstetricians, and maternity support staff in both community and hospital settings. It covers care across the full maternity pathway—including antenatal, intrapartum, and postnatal care—for women who decline engagement at any stage.

Audience

Primary Target Audience

These individuals are directly responsible for implementing and responding to nonattendance protocols:

• Midwives(Community and Hospital-based)
• Obstetricians and Gynaecologists
• Maternity Support Workers
• Safeguarding Midwives/Leads
• Health Visitors
• GPs involved in maternity care

Secondary Target Audience

These roles support or oversee maternity care and may need awareness of the SOP for coordination or escalation:

• Safeguarding Teams(Adult and Child)
• Social Workers(especially in cases of concern)
• Clinical Governance Leads
• Service Managers and Team Leaders
• Reception and Admin Staff(who manage appointment systems and follow-up processes)
• Mental Health Practitioners(working with perinatal patients)

Tertiary Audience

These groups may not implement the SOP directly but benefit from understanding its implications:

• Patient Experience Teams
• Training and Education Coordinators
• IT/Systems Teams(if involved in flagging DNAs or alerts)
• Policy Makers and Commissioners(for service planning and evaluation)

Procedure

1. Initial Identification

• If a woman declines antenatal care at booking or at any point during pregnancy, document her decision clearly in her records.
• Ensure the woman’s decision is informed and voluntary. Offer information about the benefits of antenatal care and potential risks of non-engagement.

1A. Multidisciplinary Team (MDT) and Obstetric Involvement

• If a woman declines antenatal care and there are clinical, safeguarding, or service delivery concerns, an MDT discussion should be considered.
• MDT involvement may include:
  • Named midwife or team lead
  • Obstetric consultant or registrar
  • Safeguarding lead (if applicable)
  • Senior leadership or service manager
  • GP or health visitor (if appropriate)
• Obstetric input should be sought when:
  • There are known or suspected medical conditions that may affect pregnancy outcomes.
  • The woman presents in labour or with complications without prior antenatal care.
  • There is uncertainty about clinical management due to lack of antenatal history.
• MDT meetings should be documented, and outcomes shared with relevant professionals.

2. Sensitive Engagement

• Attempt to engage the woman through her preferred method of communication (phone, letter, text, or home visit).
• Use interpreters or advocates if there are language or communication barriers.
• Explore and address any barriers to engagement (e.g., transport, childcare, cultural beliefs, previous negative experiences).
• In cases where obstetric input may be beneficial, midwives should liaise with the obstetric team to determine appropriate clinical follow-up or contingency planning.

3. Information Provision

• Provide written and verbal information about:
  • The purpose and benefits of antenatal care.
  • How to access care if she changes her mind.
  • Emergency contact details and how to seek help if needed

( A template letter has been produced for use in these circumstances)

4. Risk Assessment

• Assess for any safeguarding concerns, including domestic abuse, substance misuse, mental health issues, or learning difficulties
• If there are safeguarding concerns, follow local safeguarding procedures and consider referral to social services.

5. Documentation

• Record all attempts to contact and engage the woman, including dates, times, and outcomes.
• Clearly document the woman’s decision to decline care and any information or advice given.
• If the woman later re-engages, update her records accordingly.

6. Multi-Agency Communication

• Inform the woman’s GP and health visitor of her decision to decline care.
• If appropriate, discuss the case at the multidisciplinary team (MDT) or safeguarding meeting.
• MDT discussions should not be limited to safeguarding concerns. They may also be convened to
  • Support staff managing complex or high-risk cases.
  • Ensure coordinated care planning across services.
  • Review escalation decisions and ensure consistency.

7. Ongoing Support

• Keep the case open and continue periodic attempts to engage, unless the woman explicitly requests no further contact.
• Ensure the woman knows she can access care at any time during her pregnancy.
• Staff should continue to offer support across all stages of care, including:
  • Antenatal: Re-engagement opportunities and risk assessment.
  • Intrapartum: Safe and respectful care during labour, even if no prior contact.
  • Postnatal: Follow-up and health visitor involvement, regardless of antenatal engagement.

8. Escalation

• If there are significant concerns for the welfare of the woman or unborn baby, escalate according to local safeguarding policies.

Key Points

• Respect the woman’s autonomy and right to decline care.
• Maintain a non-judgmental, supportive approach.
• Ensure all actions are clearly documented.
• Prioritise safeguarding and multi-agency working where appropriate.
• Ensure MDT and obstetric input are considered when clinically or operationally appropriate.
• Provide guidance and support across the entire maternity pathway.