Clinical NHS practices to dispose of pregnancy remains following an early-stage miscarriage (first trimester) appear at odds with some patient wishes and therefore are not conducive to inclusive care, a new study finds.
Researchers argue that when clinical settings only offer ceremonial options, such as burial or cremation, they make assumptions about patients' wishes.
Following a miscarriage, national guidance suggests three options for pregnancy remains should be offered: cremation, burial or incineration.
In reality, the options available to women differ between hospitals, with most NHS settings not offering sensitive incinerations.
Historically in the UK, pregnancy tissue was treated as clinical waste and was incinerated without consultation. However, following a series of scandals in the 1990s and 2000s and an accompanying shift in how we view pregnancy loss the practice was discontinued.
Over a 20-month period (April 2020-September 2022), Professor Susie Kilshaw (UCL Anthropology) carried out detailed observations of all elements of miscarriage care at one English NHS Foundation Trust. She conducted interviews with 37 women experiencing miscarriage, as well as with those involved in their care (38). The trust in question did not offer the disposal option of incineration.
Professor Kilshaw found that many women who experienced an early miscarriage within the trust had not considered what would happen to the pregnancy remains prior to the formal discussions with healthcare professionals. Some expressed relief or surprise when presented with disposal options*.
Many participants, however, expressed disbelief about the nature of the options available, suggesting they were inappropriate or overly ceremonial given the early stage of the pregnancy. Most of the participants thought the pregnancy remains would be managed as clinical waste and expressed surprise and, at times, disquiet that it was to be managed differently.
Some women highlighted the differences in experience between women who miscarry at home, compared to those in clinical settings.
Professor Kilshaw said: "All women experience miscarriage differently, and I saw this diversity of views in my interviews and observations. It seems reasonable that the processes in place to support women should be flexible enough to accommodate this diversity of perspectives.
""Central to the women's experiences was their notion, or lack of notion, of foetal personhood: whether the women understood her pregnancy as containing a 'baby' and/or whether she perceived the pregnancy remains as being akin to human remains.
"Many of the women I spoke were upset about the end of their pregnancies, but this sadness was often connected to their hopes for the future, disentangled from the biological material." **
In their interviews many of the women expressed discomfort with procedures that focused on commemorating loss or creating a permanent memorial. Some women explained how viewing the material as biological tissue helped them process the experience, but the disposal options available made this process more challenging***.
Professor Kilshaw said: "Options that treat the tissue as a baby or person, while certainly suitable for some, did not provide all the women I spoke to with an option in line with their wishes.
"Around one in five known pregnancies end in miscarriage, so it is important that clinical miscarriage care is fit for purpose. These findings show that more could be done to ensure disposal procedures meet women's needs and hospital practices should not imply value or attribute personhood to the pregnancy remains.
""Whilst I observed responsive, sympathetic and expert care of women experiencing miscarriage, the bureaucratic mechanisms seemed inflexible to their diverse experiences."
The researchers thank the host NHS trust for their support of this research and the participants for giving so generously of their time even when experiencing upset and distress.
