Supporting roots: report

Part 1: Short Evidence Review on Support for Birth Parents

Ariane Critchley

Three Key Principles for Practice

1. The Case for Support

Research has demonstrated that for birth parents, losing a child or children through child welfare processes has significant impact in both the short and the long term. In terms of physical and mental health, and in terms of social deprivation and stigma, the effects can be long-lasting. Studies have shown that complicated grief and loss are common experiences, and birth parents must renegotiate their identities in complex ways. The consequences if these needs go unmet can be extreme, with links to mental health difficulties for mothers, physical and mental health difficulties for mothers and fathers, and to suicide attempts and completions for mothers demonstrated by research. In recent decades, the numbers of families affected by separation from a child or children has increased in the UK, due to an increased child protection response to difficulties in families. This is particularly so for infants and very young children. Therefore, there is an increased need for effective support that addresses the needs of affected families, in addition to work that seeks to support family preservation.

2. Birth Fathers, Birth Mothers and Birth Families

Whilst much research and writing has been dedicated to the experiences and needs of birth mothers in recent years, services that target only birth mothers will address only part of the issue. Studies have shown the extent to which many ‘recurrent’ proceedings in England involved couples or families. Birth fathers are deeply affected by the loss of a child and children to ‘care’ and are also likely to have further children, yet their needs have often been overlooked. A need for services which address the experiences and issues for fathers is clearly indicated by research evidence, and services which acknowledge and work sensitively with the gendered nature of societal expectations of men and women as parents are required.

3. Indications for Best Practice

Research evidence points to a need for services that are multi-disciplinary, one- stop, collaborative, and co-located in order to address the complex needs of birth parents. All services and practitioners working with birth parents will need to engage with questions of reproductive justice in ensuring access to supportive reproductive healthcare and contraceptive services. The ethical questions around requiring long-lasting reversible contraceptive use as a condition of support must be considered in practice and a view taken by service managers and staff about what is most helpful and defensible in their setting. Practitioners are challenged in many ways by working to meet the needs of birth parents and family members and require regular supervision and good collaborative working arrangements that support their work. Birth parents participating in and contributing to research have made it clear that a non-judgemental approach that recognises their status as parents is required from practitioners. The significant barriers to trust that are created by the experience of losing a child to ‘care’ must be acknowledged, and perseverance, person-centred support, and a therapeutic approach are key ingredients of effective support. Evaluations of targeted services across the UK have shown that support is valued and can be well utilised by birth family members when made available locally.

Introduction

This Scottish Government commissioned evidence review is intended for use by practitioners, managers, and service providers who are developing the support available to birth parents in their area or agency. The review aims to offer a broad overview of research findings. It provides a guide for what to consider, and where you might find out more, in order to offer a service or set of supports that meet the needs of birth parents. The evidence is presented thematically, to help with navigation. However, these themes are interlinked and thinking about how the needs of birth parents may be met holistically is important. This review was provided as the first stage of reporting from a Scottish Government funded project designed to better understand the services available for birth families across Scotland who have been separated from a child or children through child welfare processes. Further reporting which links the literature reviewed here to the views of birth parents (part 2) and examples of the services that have been developed in Scotland followed (part 3), along with recommendations for practice and policy.

Methods

A systematic approach was taken to searching the literature; however, this is not a systematic literature review, and no claim is made towards providing a full and accurate review of the evidence. Rather, this necessarily partial and selective picture is focused on the major pieces of research published in English, that have been completed in this field between January 2012 and February 2021, with some more recent papers added to the final sample, due to relevance. The initial brief for the review was focused on birth mothers and ‘recurrence’ or ‘repeat removals’ and this is reflected in the search terms selected. This review of the literature is based on a literature search completed on 19th February 2021. The following Medline (EBSCO) search strategy was adopted:

The aim was to include all papers which related to the experience of early removal, particularly for mothers. The search included all study designs, reported in English.

The sources included the following databases and search functions in order to identify grey literature in addition to peer-reviewed academic articles:

Medline, CINAHL, PsycInfo, ASSIA, Sociological Abstracts, Social Science Abstracts, Google Scholar, Google, LibrarySearch (Edinburgh Napier).

After applying the inclusion criteria and filtering for relevance, 141 papers were identified. As suggested above, only articles published from 2012 onwards were included in the final results. This start date was chosen as it marked a major shift in the literature, beginning with Cox’s (2012) ‘call for action’ around the significant issue of ‘recurrent care proceedings’ or ‘the repeat removals problem’, and continuing with Broadhurst and Mason’s initial work in this area (Mason and Broadhurst, 2012). There has been a large amount published about the needs of birth family members in the UK and more widely since then, particularly around birth mothers. These papers effectively define the problem, and as practitioners and managers, the issues described are likely to be familiar to you. Commissioned evaluations of targeted services have added to the evidence base by providing findings, particularly on what birth mothers find helpful in terms of support. Disagreement exists about some important details, such as whether a pregnancy free period is essential for birth mothers to undertake therapeutic work around losing the care of a child, and over the best timing of support. However, there is a large amount of consensus about the kinds of approaches that can meet the needs of birth parents who are living without a child or children and about what good reparative support looks like.

Of the 141 papers, 13 papers were removed from the sample as these were not sufficiently relevant to the topic. A further 8 relevant papers were added to the final sample; these were published in 2021, while work was ongoing on this project. A thematic analysis of the content of the 136 papers included in the final sample was undertaken, which arrived at the themes presented below. As already stated, this cannot capture the full detail of the findings of the studies, or of the lives of the birth parents who contributed to the research studies. Many of the papers are freely available open access, or can be requested from their authors, providing avenues for following up on areas of specific interest for your setting. A very helpful book has also been published on the topic, edited by Alder (2019), and entitled Supporting birth parents whose children have been adopted which provides suggestions for practice which are broadly applicable.

Limitations

As indicated above, the initial search strategy for this review was targeted towards the issue of ‘recurrence’ and early separation of children from their birth family. This has also been a major motivation around the research and practice literature over the past two decades. Clearly, birth families include fathers, and many other relatives, but their experiences and needs are not as thoroughly covered in the literature, or in this review. Further, although there has been policy, practice, and public concern around increasing numbers of infant removals in recent decades, this experience will not be common to all birth families. Therefore, caution is needed in terms of the results of this review. In practice, approaches which seek to understand and respond to individual circumstances, histories and support needs are indicated. Papers and research focused on assessing risk to infants during pregnancy and on the pathways of babies and young children in out of home contexts have also been largely excluded from this review. This is in order to focus on the experiences, needs and views of birth parents.

Findings

1. ‘Calls to Action’ and Defining the Problem

Since Cox’s (2012) call to action around the ‘marginalised mothers’ coming to the attention of Family Courts in England, a number of papers have sought to define the issues for practice. Broadhurst and Mason wrote about ‘maternal outcasts’ (2013); women who have had multiple children removed through care proceedings and whose needs for reparative and therapeutic support have gone unmet. Broadhurst and Mason went on to call for a family justice response to the ‘collateral consequences’ (2017) of care proceedings that are designed to protect individual children but have long-ranging consequences for families, including welfare disqualifications and legal stigmatisation for birth mothers. These consequences leave women in an extremely vulnerable position post-removal, often with very limited support. Healy (2020) advocates a critical policy agenda that better recognises the circumstances of ‘vulnerable’ birth families, drawing on Boudieu’s concept of ‘misrecognition’. Many birth parents who are encountered by services may have had their children removed within this context of increased numbers of removals through difficult legal processes. The experiences of birth families of the somewhat different legal processes in Scotland are less well understood, and this ongoing project aims to provide data on this experience. Some families met in practice may have lost a child or children through care proceedings that are longer ago, and the intergenerational harms that characterise birth mothers’ lives have been emphasised by Richardson and Brammer (2020). Their qualitative interviews with nine mothers in England highlight the challenges that the women had endured since their own early childhoods, which contributed to their loss of their own children through care proceedings. These findings echo those of Mason et al. (2020), who emphasise the very difficult social histories of the 72 women who participated in qualitative interviews in relation to their experiences of recurrent care proceedings in England. Many of the women had suffered from significant adversities and poor care within their own childhoods, with ongoing impact on their capacity to trust and work with professionals.

2. Targeted Reproductive Healthcare

In working with birth parents who have had a child or children removed, the issue of access to contraceptive advice and healthcare is relevant. Broadhurst et al. (2015), questioned whether the enhancement of reproductive healthcare for women to avoid ‘recurrence’ was justified. There has been much debate since then about the use of long-acting reversible contraceptives (LARC) as a condition of receiving support for birth mothers. This is a condition of the intensive, time-limited Pause services commissioned by a number of local authorities, which have been very positively evaluated (Boddy and Wheeler, 2020; Bowyer et al., 2020; McCracken et al., 2017). However, there are ethical questions around whether this conditional approach enhances or works against reproductive justice for women. Particularly as the women are likely to have very limited support routes following the loss of a child to care. Other services for birth mothers have offered support with access to reproductive healthcare but have not made the support offered conditional on LARC uptake (Cox et al., 2015; Welch et al., 2015). Cox et al. (2017) provide some helpful comment on how advice and support with contraception may be sufficient in addressing recurrence, without making support conditional for women. It is not possible for this review to do more than highlight this key ethical

question. For practitioners, managers, and commissioners, it is important to engage with this and to make informed decisions about how access to reproductive healthcare will be supported for women, for men, and for couples, who are motivated to avoid the experience of further removal of children from their care. Service providers and practitioners may wish to carefully consider the evidence in deciding on the best approach.

3. The Scale and Nature of the Problem: ‘Born into Care’

An extensive body of research has demonstrated increases in the numbers of infant removals in England (Broadhurst et al., 2018; Pearson et al., 2020), Wales (Alrouh et al., 2019; 2020), and Scotland (Raab et al., 2020), in the context of a distinct orientation towards child protection as a response to difficulties in families across the UK nations reported in the decade between 2004/5 and 2013/14 (Bunting et al., 2018). Bilson and Bywaters (2020) have argued that this points to a ‘failed state’ within which family preservation is not supported. In Canada, Wall- Wieler et al. (2018) have modelled predictors of mothers having a first child removed at birth, and report that the strongest associations are with the mother having herself been in ‘care’, substance abuse, schizophrenia, developmental disability, and a lack of any prenatal care in the pregnancy. In the UK, the health vulnerabilities of mothers (Griffiths et al., 2020) and birth parents (Johnson et al., 2021) whose infants have been subject to care proceedings have been highlighted. As the authors of these studies suggest, these are factors which can be mitigated by community services, healthcare, and support for families. However, this arguably does indicate the extent to which the problem of increased removals points to wider structural issues, and particularly the gaps in community-based supports that might provide early help and refer parents on for more targeted treatment. For practitioners and managers, a need for collaboration with healthcare partners, including substance abuse treatment and support facilities, and mental health services in the local area, as well as specialist perinatal mental health services (Lever Taylor et al., 2019) is strongly indicated by the well-established evidence base on the complex needs of birth parents.

4. Substance Abuse

Substance abuse can be a key factor in children being removed from their families of origin (Boyd, 2019; Canfield et al., 2017; McElhinney et al., 2019), although there appears to be some variation in how maternal substance abuse informs professional assessments of infant safety (Rebbe et al., 2019; Tsantefski et al., 2014). It has been suggested that combining substance abuse treatment with good support in the perinatal period could allow more babies to remain in the care of their birth mothers (Grant et al., 2014; O’Connor et al., 2020). As Harwin et al. (2016) report, ongoing support around issues of mental health and domestic abuse is often necessary. A non-judgemental approach has been described as crucial by women seeking support and treatment in the perinatal period (Harvey et al., 2015). Shaw et al. (2014), reporting on the Family Drug and Alcohol Court in England, also emphasise the importance of the working relationship between professionals and families. As Taplin and Mattick (2015) suggest, motherhood can be a motivating factor in terms of treatment for substance abuse, with women seeking to retain care of their children, or to protect them from the harm of living with substance abuse. However, working with a multitude of services can be challenging for women (McGrory et al., 2020) and a collaborative professional

approach that addresses the complex needs of women using substances that may be harmful to them and their unborn baby in pregnancy is recommended. Rutman et al. (2020) offer a multi-methods evaluation of a community-based programme which has been successful in offering a ‘one-stop’ site that aims to meet the complex needs of women and their babies both before and after the birth, where substance abuse is a significant risk factor. This programme was offered in multiple sites in Canada and appears to have had positive impact through a co-located multi-disciplinary model.

Post-removal, substance abuse may begin or worsen as a means of coping with the pain of living apart from a child. Honey et al. (2019) found that mothers used drugs or alcohol to numb their pain. Although providing temporary relief, the women interviewed acknowledged that their strategy was ‘inconsistent with mother’s long- term well-being and goals’ (2019: 173). Therefore, whether working in a reparative way with birth mothers following the loss of a child through care proceedings and/ or seeking to provide a preventative service, collaborative working with healthcare colleagues to secure treatment and support for substance abuse problems can be essential.

5. Young Mothers and ‘Care Leavers’

Hajski’s (2020) doctoral work on young mothers in the United States context highlighted the increased risk of separation from their infants through child welfare involvement. This risk appears even greater for looked after young people and care leavers who have a baby (Roberts, 2017). Based on qualitative interviews with eight young parents in Wales, discussing 31 pregnancies, Roberts reports that 75% of the sample of care-experienced parents ‘had experienced the permanent removal of at least one child’ (2017: 1280). Participants in Roberts’ study discussed intense feelings of failure having wanted to be good parents to their own children. Based on their research with 15 care experienced young women in a mother and baby setting in the Netherlands, Van Vugt and Versteegh (2020) show how the ambiguous loss of their own parents affected their participants’ transition to becoming mothers themselves. The authors suggest that rather than superficially teaching ‘parenting’, young people require more psychodynamic support during this significant time in their lives that acknowledges the ambiguous loss they have suffered of their own birth families. Sensitivity to the needs of young people who have been or remain in the care of the local authority and are having their own children is therefore important. Both in terms of addressing their specific needs in this transition and in order to decrease the risk of separation from their infant in the near or more distant future. Within the Scottish policy context, the ‘corporate parenting’ responsibilities of local authorities and communities require that tailored support be provided for young people (The Promise, 2020), with young care experienced parents having recognised needs for enhanced support.

6. Fathers

Until recently, the published literature on ‘recurrence’ and infant removals was largely focused on birth mothers, despite the distinctive needs of birth fathers having long been recognised (Clapton, 2003; Clapton and Hoggan, 2012). This gap has begun to be addressed in recent years. Work on linked data sets, which is connected to the Born into Care programme of work, has shown the nuance

around ‘recurrent’ families in the UK (Bedston et al., 2019), with a majority of fathers who experience repeat care proceedings in England doing so as part of a ‘recurrent family or couple’. This suggests that for many families, initiatives that seek to address the needs of birth mothers are only addressing part of the issues that lead to further child welfare involvement, with the needs of men in danger of being overlooked and side-lined (Philip et al., 2018).

Fathers are less likely to be represented through professional advocacy in pre- proceedings in England (Holt et al., 2013) or to be fully involved in these processes (Masson and Dickens, 2015). Writing in the Scottish legal context, Critchley (2021) found that in pre-birth child protection assessment, men were not always involved in key processes and fathers’ own vulnerabilities were poorly acknowledged by practitioners. These findings are supported by Philip et al.’s (2020; 2021) larger scale research with fathers in England. Leading the authors to call for far greater support for birth fathers, not to the diminishment of services for mothers, but alongside and in addition to these. Philip et al. describe their recommendations for practice as follows.

We suggest that there can be a more gender-sensitive approach to understanding and responding to recurrence, and indeed to working with fathers more generally. Our position, and central to such an approach, is a commitment to gender equity in relation to parenting roles and responsibilities. Supporting fathers and mothers cannot be seen as a zero-sum game, where service development for one necessarily diminishes or sits in opposition with the other. In relation to recurrence, we are arguing for the development of services that hold men equally accountable for the safe care of children and avoid positioning women as disproportionately responsible for children’s welfare. Such services are urgently needed and require sustainable resourcing, not least in terms of time (Philip et al. 2020: 13).

Therefore, the needs and strategies of couples (Critchley, 2019), fathers, and families (Philip et al., 2020; 2021) who may face and experience the removal of one or multiple children need to be better recognised and addressed. This work should build on and learn from the support that has been offered to birth mothers, but also consider the distinctive needs of men as fathers, and the gendered nature of societal expectations of fathers and mothers.

7. Listening to Birth Mothers and Birth Fathers

As Bengtsson and Karmsteen (2020) demonstrate in their paper on parental co-operation in foster care in Denmark, both fathers and mothers ‘seek recognition of their parenthood especially their love for their children’ (2020: abstract) from professionals. Services and practitioners seeking to engage with birth parents must therefore recognise birth mothers (Boddy and Wheeler, 2020; Morgan et al., 2019) and fathers as parents, regardless of their legal relationship to their children. Honey et al. (2018) describe how post-removal mothering is experienced by mothers as deeply constrained. Their interviews with eight mothers post-removal provide a picture of how unnatural it can feel for the women to have the limits of their maternal role dictated to them by professionals. Memarnia’s (2014) work also engages with the renegotiation of identity that mothers must undertake when separated from their children through child welfare intervention. Based on Memarnia’s (2014) in- depth interviews with seven birth mothers, Memarnia et al. (2015) describe the complexities around how women define themselves over time when permanently separated from their children, and how ‘letterbox contact’ affects this process. They suggest that for some women, there is a felt responsibility to improve themselves, or to find a new identity.

There is substantial research evidence of the long-lasting harm, pain and grief endured by birth mothers separated from their children. Morriss (2018) describes how women are left unable to resolve their grief, since their children are alive and well, but out of reach. As Morriss also highlights, women are often materially harmed by the removal of their children, their welfare benefits and eligibility for social housing dramatically reduced at a time of extreme emotional distress. Through her qualitative interviews with 17 birth mothers, based on artefacts related to their motherhood and children, Geddes (2021) also found that women were suffering from deep ambiguous loss around the adoption of their children out of their care. Mothers were often left with anger at professionals about what had happened. Lewis and Brady (2018) report negative, but also some potentially positive impacts of child welfare and protection in the lives of the 12 birth mothers and two birth fathers interviewed by Lewis. Some of the birth parents interviewed had been supported to access services that they needed through social work involvement with their children, with therapeutic input being highly valued. This perspective is supported by Morgan et al. (2019) who discuss the positive benefits of person-centred counselling support to birth mothers. The authors, including Stevens who is a birth mother and activist, conclude that,

The findings of this study invite the provision of services for this client group that address the social and systemic nature of child removal, privilege the relational nature of recovery, empower birth mothers and create safe spaces for the processing of the emotional pain inherent in having your child taken away (Morgan et al., 2019: 151).

Honey et al. (2019) also found that birth mothers highly valued non-judgemental support that could address some of the mental health sequelae of living apart from their children. Mason et al. (2019) emphasise the role that midwives could play in meeting both the emotional and physical needs of mothers separated from their children in the immediate post-partum period, suggesting that continuity of midwifery care, and a compassionate approach, could be of significant benefit to women recovering from childbirth without full care of their infant. As Bell et al. (2016) suggest, based on their qualitative interviews with ten women in London, women often feel abandoned and alone after their children have been removed. A common theme in the literature. The impacts of this isolation, stigma and grief on mental and physical health can be overwhelming for mothers. In the Canadian context, Wall-Wieler et al. (2018b) have demonstrated an association between child removal and subsequent maternal suicide attempts and deaths by suicide. In summary, the mental health needs of birth mothers are very well recognised, evidenced consistently by research, and non-judgemental support to address these has been found to be helpful to women. Yet support services continue to be patchy and underfunded across not only the UK nations, but across European jurisdictions (Luhamaa et al., 2021).

Evaluations of targeted services in England (Bellew and Peeran, 2017) and Scotland (Welch et al., 2015) offering post-adoption reparative work with birth mothers have been generally positive. The Breaking the Cycle programme evaluated by Coram (Bellew and Peeran, 2017) was designed to run for two years and take a staged approach with women, building skills and confidence. Broader remit services designed to prevent recurrence in Suffolk, Positive Choices and M Power, were also positively evaluated by a team at the University of Essex (Cox et al., 2017) who emphasised the importance of genuine and empowering relationships between practitioners and women accessing these open-ended services.

Bowyer et al.’s (2020) evaluation of Pause in England also emphasised the need for long-term relationship-based practice in order to achieve change. The safety and stickability of the relationship with practitioners is a common theme. These evaluations provide a picture of holistic and flexible support, which can respond both to immediate crises in women’s lives and to their longer-term needs and vulnerabilities. Trust in practitioners is a factor that women emphasise when interviewed, and this trust being a significant precursor to working through past adversities and pain in their lives (Cox et al., 2020).

A fiscal argument is also present in evaluations of targeted interventions designed to prevent recurrence and infant removal (Bowyer et al., 2020, Cox et al., 2015; McCracken et al., 2017). In particular, cost benefit analysis has been used to consider the savings that the Pause programme can provide in terms of avoiding future infant removals. McCracken et al. suggest that the costs of delivering Pause to the cohort of 125 women over the seven pilot sites that their evaluation covered (2017: 6) were 'likely to be offset by savings to local authorities within two to three years’ (2017: 58). There is clearly an ethical imperative for intervening to prevent ‘recurrent care proceedings’, and the distress of this experience for families. However, an economic imperative is also described in the literature, based on the argument that investment is required to prevent the need for costly services at a later date. A compelling argument can be made in terms of the complex and intersecting needs of birth parents, which span a wide range of services, and which are at high risk of going unmet, without targeted interventions.

8. Practitioner Perspectives

It will be clear that the needs of birth family members who are separated from a child or children through child welfare processes are complex. The pain of losing care of a child in this way is known to be long-lasting. Families affected are likely to have endured a range of adversities, which have led to the involvement of child protection services in their lives. Removal of a child or children has further identifiable ‘collateral consequences’ (Broadhurst and Mason, 2017) for birth mothers, including welfare and housing issues. The loss, stigma, and grief for birth parents and for wider family can be intense. Therefore, as suggested in relation to birth parents’ views, collaborative multi-disciplinary practice approaches are indicated to begin to address the needs of birth family members. A number of studies have considered the views of practitioners engaged in this work and these are considered here. In addition to literature focusing on social work and legal aspects of this work, within health, several articles have been published on practice responses. In New South Wales (NSW), Australia, the impact of working in the area of infant removal and with birth mothers has been particularly well recognised and researched. Everitt et al. (2017) interviewed ten midwives with experience of 91 episodes of ‘assumption of care’ or infant removal. The authors describe the tensions for midwives in remaining woman-centred in their practice whilst also working collaboratively with child protection services in respect of infant safety and well-being. Also in NSW, Marsh et al. (2015) have also described the challenge to ethics and practice that assumption of care at birth represents for midwives.

Marsh et al.’s (2019) interviews with a range of relevant professionals and with women themselves provide evidence of the difficulties of infant removal for all involved. Marsh et al. (2019) recommend ways that legal, health and social work responses could better support the needs of infants and mothers, including the following suggestions:

1. Instead of the statutory process currently in place for maternity care a collaborative therapeutic justice process linked to a partnership built on strong interdisciplinary relationships.

2. Each woman who is at risk of her baby’s care being assumed by the state be automatically part of a continuity of care midwifery model where she is assigned her ‘own’ midwife (with the backup of a strong team) for the duration of the woman’s pregnancy, labour and birth and time following.

(Marsh et al., 2019: e10).

The need for social workers, community practitioners and health colleagues to work together with parents, families and communities has also been emphasised by Keddell et al. (2021a; 2021b) in their work on preventing baby removal in Aotearoa, New Zealand. Writing in the UK context, Hannah and Condon (2020) provide suggestions for practice for health visitors working with families at risk of ‘recurrence’. Whilst the needs of young, first-time parents have been prioritised by some successful initiatives, Macdonald et al. (2018) provide evidence from Northern Ireland that targeted support for older, non- first-time mothers and their babies can be effective when there is a risk of adverse outcomes. Finally, Enlander et al. (2021) have recently highlighted the role and ethical dilemmas for psychologists and psychiatrists. The authors call for wider societal changes that tackles problems of deprivation for families. Therefore, research with and comment on the role of practitioners has pointed to more collaborative, joined up, and preventative services. This perspective is supported by the extensive research of Broadhurst and colleagues at Lancaster into the lives of birth mothers (Broadhurst et al., 2017), and the more recent and related work with birth fathers (Philip et al., 2020). In order to address the needs of birth family members, practice responses that go beyond the scope of any one profession are required. The demands that the workplaces on professionals should also be acknowledged, and appropriate support and supervision provided for practitioners.

Conclusion

In summary, this review of the available evidence clearly indicates long-lasting and significant impacts for birth parents around the loss of a child or children through child welfare processes. There are risks to the physical and mental health of birth mothers in the immediate and longer term. Parents experience shame, stigma, grief, loss, and material hardship over time. There are compelling arguments for providing better processes, services, and supports for birth family members than currently exist in Scotland. Specific thought should be given to the needs of young care-experienced parents, around the links to substance abuse, and to ensuring access to supportive reproductive healthcare. Practice approaches that are non-judgemental, person- centred, multi-disciplinary, and that recognise birth parents as parents are clearly indicated by the research findings summarised within this review. Practitioners experience this area of work as ethically complex and demanding, and their need for appropriate support and supervision should be met within relevant services.