Key message seven: Seeing pregnancy as an opportunity for change

I don't think any of us are in any doubt of the significance of pregnancy for a woman is a time of great physical and emotional change, but it's also psychological change, and a woman's representation of herself can shift dramatically. Whilst we often associate pregnancy with anxiety and worry, it's also a time for hope. New start, new relationships. And it's this opportunity that we really hope that social work can work with, with the mother really helping her to develop her maternal identity, to think about her unborn child as a separate being from herself to mentally as that baby and its needs.

And it's working with that reflective functioning that provides a real opportunity for change, as we will hear in the clips below. There are tools available to help social workers to build a mother's reflective, functioning and tools to help her mentally with her unborn baby.

Those conversations are essential as part of that ongoing work to bring about support, help and change during pregnancy. So whilst practical preparation for parenthood is obviously important, this emotional preparation is arguably more important and should form part of that help and support.

This work around raising parents reflective, functioning and helping them to mentally their unborn baby should form part of that dynamic assessment described earlier. And as we'll hear from Jane Barlow, there are tools that can help us to assess reflective functioning.

In this video, I'm going to talk about the importance of the mother's relationship with her unborn baby, the ways in which we now think about and, uh, assess this relationship and the importance of working during the, uh, pre-birth period, uh, with women about whom there are concerns in terms of the risk of harm to their baby either before or after, uh, they're born. 

We know now that the mother's relationship with her unborn baby is very important because it appears to be, uh, strongly associated with the mother's ability to parent sensitively after the baby is born and thereby with the baby, um, being securely attached at 12 months of age. So, for example, uh, research has shown that some of the types of relationship with the baby pre-birth that I'm going to talk about in this video, uh, can actually be associated with parenting once the baby's born, that is hostile, frightening and intrusive, and thereby with infants having, um, a disorganised attachment. 

So the mother's relationship with her unborn baby has, um, a number of components that are interrelated. Uh, the first component is how she feels emotionally, uh, about her baby. Uh, something that may of course depend on whether the baby was planned or unplanned, wanted or unwanted. 

So a pregnant woman who planned the pregnancy might feel very, uh, protective and loving towards her unborn baby, whereas a pregnant woman, uh, with an unwanted pregnancy may have feelings of, um, hostility or even just prefer not to think about him or her at all. 

The second component of the relationship is the mother's ability to think about her unborn baby, which is known as the mother's representations of her capacity or her capacity for reflective functioning.  

The mother's mental representations of the baby refer to conscious and unconscious mental images, both of her baby and herself as a mother. Uh, we know that during pregnancy, women reorganise their representations of themselves, their relationships with their own mother and the baby. And, uh, this can be, um, assessed using a tool called the Working Model of the Child Interview. Based on this interview, women who are described as balanced, for example, can provide very richly detailed, coherent stories about their experiences of their pregnancies and their positive and negative thoughts and feelings about their foetuses. Women who are, are described as disengaged, however, appear to be uninterested in the foetus or the unborn baby, or their relationship with it, and demonstrate very few thoughts about the baby's future traits and behaviours or themselves as mothers and women who are described as distorted, um, tend to express, um, uh, unrelated or intrusive thoughts about their own experience as children often viewing their unborn baby primarily, um, as an extension of themselves or, uh, or their partners. 

Women who are experiencing domestic violence or who are substance dependent, um, have significantly more negative representations of their infants and themselves as, uh, mothers. Reflective functioning refers to our capacity to think about and understand other people's behaviours in terms of their internal states, um, such as their intentions and, uh, their beliefs. Uh, and it's now thought that an inability to understand other people's minds in this way is a central part of the pathology of, for example, personality disorders and a reduced ability for reflective functioning may also, uh, re be present in, uh, parents who have, uh, been abused as children themselves. 

Parents who can think about their baby's behaviour in terms of what the baby might need or want have been found to provide, uh, more sensitive parenting. So, just to give you an example, a mother who can think about why her baby is crying, um, in terms of the baby communicating their distress in relation to, uh, something such as hunger or tiredness or fear or loneliness. Uh, the, this group of women are able to respond more sensitively to their baby, uh, than a parent who can't think about or understand their baby's behaviours in this way, and, um, are such more, much more likely to feel that the baby, um, is crying, uh, intentionally, uh, or, or to do it to, uh, persecute the parent or attack them. 

So thinking about the unborn baby in terms of what they might be like, for example, or the things that the parent feels the baby likes or dislikes, is an important part of the mother's relationship with her unborn baby. So given the importance of RF in terms of the parents' feelings about, and their interactions with their newborn baby, the birth period is a key opportunity to both assess a pregnant, pre-pregnant woman's capacity for reflective functioning and also to work with her to support change. And this is particularly the case, uh, in terms of practitioners working with pregnant women who have a history of significant adversity in their own childhood, and who as a consequence may be experiencing significant current adversity, um, including mental health problems, substance dependence, and, uh, domestic abuse in addition to wider problems such as poverty and homelessness.  

Assessing the mother's capacity for reflective functioning enables social workers to make a more accurate assessment of the risk in terms of the woman's ability to prioritise the needs of her baby and thereby to keep him or her safe. A number of tools have been developed to enable practitioners to do this. So the parent development interview is an example of an excellent clinician administered tool that can be used to assess parental reflective functioning in pregnancy as part of a pre-birth assessment process. Or there are also, uh, a number of simple self-complete tools that can be used promoting the mother's capacity for reflective functioning, and also her ability to regulate her emotions should be key parts of all therapeutic, working with, uh, using a relationship based approach with pregnant women, uh, particularly those about whom there are concerns for the safety and wellbeing of the baby.  

The primary way that we have used the pregnancy interview in research is to look at reflective functioning, is to look at how much the mother in pregnancy is able to think about her own thoughts and feelings to understand some of the ways that she's experiencing the pregnancy. And she's beginning to have an idea that her baby is gonna have a mind and gonna have thoughts and feelings, and actually already, um, you know, is a, is a, uh, being in its own right. Um, uh, that she can... and, you know, there are things that mothers begin to observe, obviously during the latter stages of pregnancy where they can actually, um, begin to talk of some characteristics, you know, very active. Um, sometimes they'll say things like "wilful", which is a projection, but at any rate, they really begin to have pretty coherent, um, representations of the baby by the third trimester. 

One of the most important things to think about is what kind of attachment relationship is possible. You know, what is this parent's capacity for providing a secure base, for keeping the baby safe, for providing a loving environment? 

So what capacities does the parent have for, you know, creating a positive, loving connection with the baby for keeping them safe and supporting their exploration? And this, you can begin to imagine when you hear the, um, pregnancy interview. When you talk to parents about, um, the unborn child in this first and second trimesters, it hasn't necessarily really become real to them. It comes... becomes, of course now with ultrasound so early, it can become real earlier on, but it doesn't really become real until the sixth or seventh month of pregnancy. Before then, it's... can still remain somewhat of an abstraction. But then at that point, it's really real. You know, your body has changed so much. You can feel things, you can... you know, it's just everything is, is manifestly different. That is, denial can, um, doesn't work anymore.

Um, so that makes the last, you know, trimester pregnancy and part of the second trimester, particularly critical times to establish a therapeutic relationship because by then, they kind of know that it's really happening. Um, and I, you know, I could talk for a long time about, um, the relative absence, um, of interventions during pregnancy. It's a very tough time to intervene because most parents don't think they need help during pregnancy because it's a normal developmental phase. And of course it is, and it also doesn't last very long. So you don't have all that much time to accomplish things. And yet we now know even more, much more than when we originally created this instrument that so much happens in the first, in the three trimesters at a brain level, at, you know, just basic, um, parts of the child's, um, brain becoming activated. You know, the social parts of the brain, the, um, relational parts of the brain, even at a very basic level, start getting activated during pregnancy. 

So it's really such an important time if you're able to use the PI [Pregnancy Interview] to identify areas of risk. It can really pave the way both towards pre-natal interventions as well as post-natal interventions. And there is a tonne of literature linking what's going on in pregnancy to outcomes after birth - being, uh, able to sort of predict the quality of the mother-child interaction, to be able to predict the, uh, the, um, quality of the attachment, and so and so on.

So, um, the pregnancy interview, it takes, uh, it explores a parent's emotional experience of pregnancy and the representation and development of the attachment to the baby. 

So it's got several dimensions. One is the emotional experience of pregnancy, which, um, women welcome the opportunity to talk about. Fathers welcome the opportunity to talk about. Um, how prepared they are for the baby, how they're getting prepared for the baby. How, whether or not they feel connected to the child. And this is obviously very important. You know, some parents feel they have a relationship with the child already, they have nicknames for the child. It's a very... this is what I was talking about before with representations. It's a really well elaborated, um.... well, really set of fantasies that give the parent, um, hopefully a great deal of pleasure. Obviously in some contexts it gives, uh, the parents a great deal of anxiety or can make them very angry, et cetera. But there is already an elaborated, you know, kind of relationship with the child where there should be. And sometimes there's not. And that's concerning too. 

And then we ask them to imagine the future, which is a, um, again, an exercise in seeing, you know, it's kind of a projection. You know, how do they see all of this? What... it's like giving them a, a post-pregnancy Rorschach test or, um, asking them their fantasies. But they are very important in understanding what that's actually gonna look like.

So you wanna create a calm, contemplative environment. That is, what's key to that is being a good listener, being curious, warm and empathic. "I wanna know what's in your mind. I am curious about what you're thinking." Um, you know, which is very different from "Let me get through all these questions." It's really much more of a stance that really conveys "I'm interested in what's going on in your mind."

And don't hesitate to ask for clarification if you don't understand a parent's responses. I always say that "Tell me more" are the three most valuable words in the English language for clinicians. Um, it is, uh, so simple. It's such a simple way to get, get him or her to, um, tell you more. And it often really elaborates things. If the parent uses vague or general terms, and this is something that comes out of Mary Main's, uh, work on the attachment interview, um, is to really listen for the quality of language. And here's where it comes in again about, tell, tell me more. Like, "I'm fine." How, you know "What's the pregnancy been like for you?" "Oh, it's fine." That tells you absolutely nothing except that they're defending. Um, it may also be that they're not comfortable with you yet, that they don't know you yet. That you have to like, work a little bit harder to establish rapport, but you almost always want to probe, um, and push a parent a little bit when they give you vague or general terms. If they can't move beyond the vague or general, you don't keep going, you know, you don't badger them.

But, you know, oftentimes vague terms like "Oh, I'm, it's, it's better now." You know, those are often used as kind of conversation holders and they don't necessarily mean conversation stop. But when you get a conversation stop, you stop.

Now I wanna talk about two general kinds of responses that you get in the pregnancy. One, uh, well, well there's three actually. 

One, if you're lucky, is the person talks freely, is interested in the topic, welcomes your questions, has a lot to say, and is, um, you know, essentially, um, talkative but not too talkative. Um, and um really engaged in the interview.

There are some parents, however, who really doesn't wanna talk about it. And it's hard to say that these parents don't wanna talk about it, but they are not gonna talk about it with you. And oftentimes these are people who are more on the dismissing end in relation to attachment. Use a, you know, sort of downregulating strategy for regulating their effects. That is, they, they damp everything down, they shut off, they shut down. That's how they cope with complexity, with emotional complexity. That's how they keep themselves organised. Um, and sometimes when you speak to parents like that, the probes can help them a little bit. It can help them organise, it can help them open up.

But as I said just a few minutes ago, if you get a full stop, you stop. And because you, you don't wanna make them angry. Because often what will happen, you know, is parents, you know, um, teenagers say "No, I don't want to." You know "No, it's fine. I don't care. It's fine. It was, it was nothing." And you're like "What? It was nothing? Your pregnancy?" And you push. And what that, you know, you can imagine can lead to "No, I don't wanna talk about it," you know. So you really don't wanna push too much 'cause it's, um, these defenses of not talking have arisen for a reason. That is, we have to appreciate that an individual's defences are there for a reason. A reason that deserves our utmost respect. "I will try to get to know you, I will try to get you to open up a little bit, but I respect that you're shut down because that's the way you've survived," right?

And by the same token, parents who are incredibly talkative, you know, where the interview you feel could go on, and it has happened, you know, two, two and a half, three hours. What ends up happening in these situations, just as you gain nothing from pressuring a quiet person, you get nothing from letting a talkative person go on and on and on and on and on, because they're just saying the same thing typically over and over and over again. 

And so, um, there are some strategies both for getting people to open up and some strategies for getting people to, um, get onto the next question, which I'll talk about next.

So if they're talking on and on and on, um, beyond a point that's useful, and, and you'll know it because you'll get bored, you'll get restless, you'll get tired, you'll get annoyed. Try to, um, and often this can be very difficult 'cause they won't leave you an ounce of room. Say "Ok, I get a pretty good sense of that. Let's move on to the next question." 

Um, and you know, if you let a couple of answers go on and on and on, then you can feel perfectly fine about, you know, some of the answers cutting in, uh, sooner. Let them go some, but then, then cut it off.

One of the things that, uh, you, uh, clinicians often do when a person is presenting in a very chaotic way is they'll, they'll say "Oh, well I hear you saying is" or "What you're really talking about is" or they reframe their answers or put words in the person's mouth. That's therapy. This is not therapy. This is an exploration. So when they're chaotic, you're learning that they're chaotic. When they can't come up with words, you're learning, that they can't come up with words. So if, even if every instinct in your body is to act, uh, in the way that we all do as clinicians, which is to try to make sense of it, this is not the time to do it. You'll have a chance the next time you see them clinically, but this is not the time to try to figure it out for them. So focus on each parent's individual way of responding and don't try to change it. 

Why do we administer the PI in... when, when we're starting a parent-infant intervention? Because this is such an important vulnerable and meaningful time in the parents' life. This is when you can really build the relationship. And we've found, um, in our Minding the Baby programme that when, uh, we are not able to really connect with the moms in pregnancy, either because we recruit them too late, or they drop out and then come back when the baby is born, or because there's just too much going on, we actually don't, aren't able to accomplish as much after the baby is born as if we really get a relationship started, um, while the, while the woman is, is still pregnant. And while the, uh, father is still not a father yet. Um, but it's an opportunity to connect and build a relation... to relationship, to support parents. To learn about them, to learn about their important attachment relationships, which of course hugely predict what's gonna happen with the baby and how they're experiencing this momentous event. And as I'm gonna now detail somewhat more, um, it's gonna allow you to take a first look at the content, form and quality of the parent's psychological organisation. 

So I'm gonna, I'm gonna make four distinctions. The first is content. Um, for many years, clinicians only focused on content. What is the story they're telling? What is the content of their story? Meaning, um, what do they actually talk about? Um, so that is very important. And I think actually, um, some of us, uh, got too far away from content, but it's really important to say what's the emotional tone of the pregnancy narrative? Is it positive? Are they excited? Are they happy? Are they just... really can't seemto sum it up any positive stuff about it at all, and may actually be negative and say no?

I mean, mothers will say things like, um, you know, very distressed, vulnerable, traumatised mothers will say things like, well, “I thought about killing it, but...” and these things come through loud and clear in these pregnancy narratives. Some mothers, you can really, um, really experience their ambivalence, um, and their back and forth within the content about positive and negative and positive. 

But it's, you know, this is predictive of the relationship they're gonna have with the baby. We know that this is going to predict it. So you wanna be listening for the emotional tone of the pregnancy. What kinds of words does the parent use to describe the baby? I mean, there can be humorous, you know, kind of “Oh he’s a little dictator, I can tell you that.” Or, you know “She's gonna be running me ragged.” You know, those are important, and sometimes they're done with humour, and the humour is a natural way to prepare for this ginormous responsibility, but sometimes they're not kidding. You know, what kind of picture does the parent paint of life once the baby has arrived? 

 I, I always remember this, um, teenage mom in one of our samples, you know, who was living a very difficult life and was, you know, very disadvantaged, teenager with a in and out kind of partner. Um, and I think, trying to remember, but I think, you know, they had some major domestic violence issues between them. And when she was asked about her life post-pregnancy, she talked about "Well, we'll all, you know, be together and we'll take wonderful vacations together and we'll go to Disney World, and..."

Now granted, she needed that feeling to get through her pregnancy, but it really, along with many other things in her interview, indicated, you know, a level of disconnect between what her life was, what her partnership was, and what she was gonna be able to imagine afterwards. But these representations do forecast the quality of the parent-child relationship. 

Then the form of the pregnancy narrative. This really comes from, um, Mary Main's, uh, work on the adult attachment interview. What is essentially central to Main's approach to the adult attachment interview, which is looking at how the parent tells the story.

The most important criterion that Mary Main identified was narrative coherence. Can you follow the story? Does it make sense to you? You know, are you, can you like paint the arc of the story in your mind? Or are you struggling? Are you trying to say, when did that happen? And where did it go? Um, and the, the four things that we look for in a coherent narrative are quality. That it's, um, that it's concise, that it tells a story, that it tells it in a meaningful way. That it's not too long, it's not too short quantity, that it's relevant, that they don't bring in all kinds of sidebars and go off here and go off there. 

Um, and their manner. That is, the way in which they tell the story to another person. And these are all things that you can recognise and you can identify, and you can see in a parent's demeanour and the way they tell a story. Is the parent realistic? Idealising? "Oh, this baby's gonna be perfect. It's gonna be the happiest thing in my life." Or denigrating? Are they flat or animated? How defensive is the parent in telling the story? Are they blocking? You know, so that narrative just stops, you know? "Could you remind me of the question?" "Could you, um..." You know, "That's all I can remember. I can't remember anything. I'm fine." Do they vacillate, like "Oh, it's gonna be great, but I'm really, really terrified. It's gonna be great."

Are they denying having any feelings at all about the pregnancy? Are they avoiding? And the other, one of the things that Mary Main pointed out were language disfluencies, which, um, are these things, you know, which they're blocking, vacillating, denying, or avoiding, but they're also things like, um, there's a shift in time. You know, that a mother might be talking about time one, and suddenly she'll be talking about something that happened 20 years ago, and you don't know how she got there. And she seems to not be aware that she's lost track of time, literally. 

So, um, and, and Mary Main talks about that contradictions - very common in narratives. Vagueness - vagueness, that you just can't penetrate. You just can't get the person to tell you what they mean. And that's a defence. And again, these are to be honoured and understood. And the degree to which a parent is incoherent or defensive tells you something important about their openness to the complexities of parenthood. How ready do they seem for parenthood? Do they see themselves as a parent? Now, obviously, you don't really see yourself as a parent for even a while after the baby is born. You're so sort of, especially if it's your first, you're pretty shocked.

Um, but it's this capacity that, um, Bowlby talked about and that the circle of security intervention has really beautifully emphasised is whether a parent can begin to see themselves as a secure base. As a stronger, kinder, wiser, and now they also say bigger caregiver. That is, do, do they see, you know, Bowlby talked about the infant seeking care from the parent, um, and the reciprocal instinct, if you will, in the parent to provide protection and comfort for the baby. Do they see themselves as a protector? Are they aware? Are they at some level aware that the baby's gonna need safety and comfort?You know, that is, if you think about, um, Bowlby called it the caregiving system. But he talked about how the parent begins to see themself again as a... as engaging in this reciprocal system to the attachment system of providing care and of providing, um, a safe place. Um, are we beginning to see that happening? And you would want to see that happening. 

And do they feel emotionally connected to the foetus? Really just the kind of nicknames they pick. We ask a mother, you know, "Do you feel you have a relationship with the baby now?" And some will say "Yes, and I sing to the baby. I talk to the baby, I call 'em noodles." And some will say "Not really." You know? "Yeah, sort of" you know. And those are, again, very significant, especially if they're getting close to delivery. Um, and then of course there's reflective functioning, um, uh, which as I said, is how we've primarily, um, uh, use the interview. 

But how well is a parent able to identify their own, especially during pregnancy and others, namely their partner, their parents, I mean, for teenage parents, clearly the relationship with their own parents is still very alive and probably has, you know, been affected by this, uh, pregnancy. 

How well are they able to recognise that their feelings affects.... their feelings and thoughts affect behaviour? You know, the key thing in reflective functioning is “I understand that my feeling makes me behave in a certain way. I understand that my mother was very unhappy about my being pregnant, that she had bigger dreams for me, and she rejected me and kicked me out of the house because she was so disappointed.” That mother is in a lot better shape than if she just said "I don't know. I hate my mother. My mother's a terrible person." Even as painful as that realisation is, at least she has that capacity to recognise that a person's feelings make them behave. It gives you a whole different relationship to other human beings when you understand that they have interior lives. 

How much does the parent appreciate that the infant will have feelings and thoughts? You know, that this is going to be a sentient, emotional person with whom you have a relationship. Do they have an appreciation that the child will have a mental life, right? This is when the parent begins to think about the child as a person. And this sets the stage for a secure relationship. Because if you don't see the child as a person with thoughts and feelings of their own, you're gonna spend a lot of the time in your relationship to them, getting them to be who they you need them to be, rather than who they are going to be. And this is a, you know, again, really a critical stage.

And, you know, the more at risk you are, um, the more you know adverse childhood experiences you've had, the more toxic stress you're struggling with. And, you know, I know that, you know, you all, um, see a variety of different, um, patients with a variety of different, um, histories and, uh, cultural and social contexts. But, um, the more you're struggling, the harder it is to really let the baby be, um, an individual. Even as you are approaching birth, when of course you feel profoundly merged with this, um, creature that's inside of you. You know, I mean, they're part of you. You don't feel that they're in you, you know? And yet for some mothers, this... they can embrace the complexity of "Yes, the baby is in me, but the baby is separate, and the baby is not me, but the baby is me." And this is the kind of complex thinking that Winnicott talked about. But you know, that, um, that we're both together and profoundly independent. And that's a reality, you know, from the point of delivery onward. 

Um, the pregnancy interview is generally a non-threatening and positive experience. It activates the attachment and caregiving representations, for better or worse, there is such a powerful, you can't keep it down. You know, you'll have wild dreams, you'll have unexplained, um, bursts of emotion because you're trying to keep it damped down, but it won't work. And one of the things that I really like to get people to pay attention to when they're giving the pregnancy interview is the balance between how activated and aroused they are and how able they are to reflect and regulate, be emotionally authentic and remain organised. That is, are they really struggling with just regulating themselves, telling the story in an open way, being emotionally real and organised? Or how much are they shutting down or getting overwhelmed? And what you see with some parents is they're in a state of flight, you know, they don't wanna talk about it. They wanna keep it out of their consciousness. They don't wanna think about it. They're super regulated. They do everything they can to keep you out. 

And on the, uh, right hand side of the slide, people who are dysregulated, overwhelmed, you know, flooding you with feelings. And both of these states indicate that, um, they're in a defensive stance, flight or fight. And when things really get bad, they collapse into freezing. And what you are trying to do, usually in an intervention, is get a parent out of those states of fight flight or freezing into a more open, coherent, regulated state that you're gonna try to engage with them, with. But, um, that can be very challenging. That can be, um, difficult, especially when you're fighting literally against somebody who's hyper-regulated or dysregulated. And, you know, we all know how challenging it can be to work with somebody who's super chaotic and overwhelmed and can't stop. Not only can't stop talking, but can't stop over-reacting. And, you know, being emotional and people who are, you know, really flat and you can't engage them. 

At the end of the pregnancy interview, parents are asked to name the three wishes they have for the child. You can return to these throughout your time with the parent. We keep using the three wishes because oftentimes they can help a parent remember. "After the baby is born, this is what I wanted for the baby, and these are the things that I can do that will help the baby and help me make... create the situation for the baby that is gonna bring about what I want." It anchors the parents and reminds them what they want for the child. They may change over time, their wishes for the child, um, but what they wish for when they're pregnant. Is it always an important reminder of going of, you know, is what you're doing actually bringing about what you want for your child? 

Remember that the pregnancy interview is a clinical tool to help you understand the parent and forge a meaningful connection. It can be used to help you anticipate areas of potential parent child difficulty, um, when it can be used in research and coded in a... while it can be used in research and can be coded, it is not a screening instrument and should not be used as such. It should not be used to predict outcomes or used as a basis for determining risk status. It should always be used as part of a series of assessments and evaluations. 

Watch this film with Dr Peter Fonagy, Professor of Psychoanalysis and Developmental Science at University College London, to find out more about mentalisation.

Use the Pregnancy Interview, developed by Dr Arietta Slade. This resource can support practitioners to think about issues of reflective functioning in work with parents, rather than as a clinical tool which requires training and validisation of the tool.

Insua-Summerhays, B., Knowles Bevis, B., & Barlow, P. J. (2024). What tools should be used to identify women in need of additional support in pregnancy?. Journal of Reproductive and Infant Psychology, 42(2), 234-268. https://doi.org/10.1080/02646838.2022.2103525 

Slade, A., Grienenberger, J., Bernbach, E., Levy, D., & Locker, A. (2005). Maternal reflective functioning, attachment, and the transmission gap: A preliminary study. Attachment & Human Development, 7(3), 283-298. https://doi.org/10.1080/14616730500245880 

• Barlow, J., Dawe, S., Coe, C., & Harnett, P. (2016). An evidence-based, pre-birth assessment pathway for vulnerable pregnant women. The British Journal of Social Work, 46(4), 960-973. 
• Brown, R., & Ward, H. (2014). ‘Cumulative jeopardy: How professional responses to evidence of abuse and neglect further jeopardise children’s life chances by being out of kilter with timeframes for early childhood development’, Children and Youth Services Review, 47, pp. 260–267.  
• Lushey, C. J., Barlow, J., Rayns, G., & Ward, H. (2018) ‘Assessing Parental Capacity when there are Concerns about an Unborn Child: Pre-Birth Assessment Guidance and Practice in England’, Child Abuse Review, 27(2), pp. 97–107.  
• Powell, C., Bedi, S., Nath, S., Potts, L., Trevillion, K., & Howard, L. (2022). Mothers’ experiences of acute perinatal mental health services in England and Wales: a qualitative analysis. Journal of Reproductive and Infant Psychology, 40(2), 155-167.