Disposal of pregnancy remains
The full HTA guidance on the disposal of pregnancy remains is available to download as a PDF, it is recommended that you refer to both the guidance and these FAQs when drafting policies around the disposal of pregnancy remains.
The Miscarriage Association have developed a suite of learning resources for professionals, informed by women and their partners who have experienced miscarriage, ectopic pregnancy or molar pregnancy, and by health professionals who care for patients with pregnancy loss.
You can find these materials on their website here - http://www.miscarriageassociation.org.uk/for-health-professionals/learning/.
Pregnancy remains may be packaged individually in separate containers or collectively for disposal. If the practice adopted by providers is to package them collectively, they should ensure that the information they give to women about disposal options makes it clear that, unless they object, their pregnancy remains will be collected together with others in one receptacle for disposal separate from clinical waste. Some women may prefer that their pregnancy remains are packaged separately; if they make this known, their request should be respected and acted upon.
The current practice of collecting several pregnancy remains in one receptacle separate from clinical waste can be the default position, providing there are safeguards in place that ensure women know they have choices, that they are given the opportunity to make their choice and that their wishes are carried out.
The role of the HTA is to ensure that human tissue is used safely and ethically, and with proper consent. The HTA regulates, through licensing, the removal, storage and use of human tissue for scheduled purposes. Although the disposal of pregnancy remains, which are considered to be the mother’s tissue, is not within the scope of our regulatory remit, the HTA was asked by Professor Dame Sally Davies, Chief Medical Officer, with responsibility for developing guidance in this area and working with other organisations to monitor compliance.
The guidance applies in England, Wales and Northern Ireland to pregnancy loss or terminations of pregnancy that have not exceeded the 24th week of pregnancy, irrespective of cause or origin, where no signs of life have been detected following the loss, and whether or not fetal tissue can be identified.
- The guidance is complementary to, and should be read alongside the HTA’s code of practice on disposal and guidance on the sensitive disposal of fetal remains published by the Royal College of Nursing (PDF).
- Guidance is also available from the Stillbirth and Neonatal Death Charity, Sands.
- There is different guidance in Scotland (PDF).
Women define their pregnancy according to their own circumstances, values, understanding and beliefs. The HTA and professionals in the field consider that any attempt to categorise the pregnancy may result in health professionals viewing the pregnancy differently from the woman involved. Furthermore, if the mode of disposal were to be linked to types of pregnancy or pregnancy loss, some women may find themselves being denied certain choices. Acting in response to the needs and wishes of the women first and foremost helps avoid such problems.
Both cremation and incineration are processes used to destroy human body parts. Cremation is used as an alternative to burial and is often associated with a religious and/or spiritual ritual. Cremation takes place within a registered crematorium under the oversight of a Registrar, and the relatives of the deceased may be present. Incineration of human tissue as clinical waste is normal practice and is subject to separate regulation. Incineration does not usually have any associated ceremony.
Technically, cremation and Incineration are similar processes, both using burning to reduce part or whole deceased human bodies to basic chemical compounds in the form of ashes. Cremation is regulated in England and Wales by a permit issued by Local Authority Regulators and in Scotland by SEPA, as required by the Secretary of State’s Guidance for Crematoria PG5/2(12). These notes are aimed at providing a strong framework for consistent and transparent regulation of installations regulated under the statutory Local Air Pollution Prevention and Control (LAPPC) regime in England and Wales, Scotland and Northern Ireland. Incineration must take place in accordance with a permit granted under regulation 10 of the Pollution Prevention and Control (England and Wales) Regulations 2000.
Incineration of fetal tissue is not banned in Scotland, but is considered unacceptable in any circumstance. Incineration against the wishes of the woman is considered unacceptable in England, Wales and Northern Ireland. The HTA has developed its guidance to operate within the current legislative framework. In doing so, it has put the needs and wishes of the woman at the heart of the guidance, recognising that in some circumstances, incineration may be her preferred option.
The HTA has a statutory duty to carry out its functions having regard to the principles of best regulatory practice, including the need to be proportionate. At the time of writing the guidance, pregnancy remains under 24 weeks gestation are not subject to burial and cremation legislation and Burial and Cremation Authorities are under no obligation to provide a service to dispose of these remains. The HTA is mindful of the practical challenges associated with the disposal of pregnancy remains and does not consider it would be proportionate to remove the option of incineration in relation to the disposal of pregnancy remains where this is the woman’s choice or where, when leaving the decision to the hospital, the hospital considers this the most appropriate method of disposal.
Yes. Women undergo termination for many reasons and they should not be excluded from the range of options offered to women suffering pregnancy loss. Therefore, the guidance should be adopted by abortion clinics as well as hospitals.
It should be noted that crematoria will not accept unidentifiable fetal remains as there is no record of the consent of the woman. For these remains, sensitive incineration is the only disposal option.
Where women choose to donate their fetal tissue for research, they should be informed as part of the consent process what the mode of disposal will be, where this is known, whether any options will be available in that regard and whether the woman will be able to change her mind at a later date. Where options are available, the woman’s wishes should be recorded in order that they can be acted upon when the time comes.
The guidance sets out that women should be given choices and that their wishes should be acted upon. Cremation and burial are the default methods of disposal. If hospitals have effective systems in place that involve consultation with the woman and minimise the use of incineration as a mode of disposal, these are in keeping with the spirit of the guidance. Note that crematoria are unlikely to accept remains that do not contain fetal tissue.
Although the guidance refers to pregnancy remains rather than fetal tissue, hospitals may make a distinction when disposing of remains in circumstances where the woman prefers to leave the decision to them. For example, they may consider the gestation of the pregnancy. Usual practice is for fetuses to be cremated or buried rather than incinerated.
Pregnancy remains at gestations not exceeding 24 weeks are not subject to the provisions of the Cremation Act or Regulations. Although it is at their discretion, most crematoria are prepared to cremate them (see question below relating to the use of consent forms). Guidance from the Institute of Cemetery and Crematorium Management gives helpful advice (PDF) on agreements hospitals should have with burial and/or cremation authorities and other issues such as the packaging of pregnancy remains in readiness for burial/cremation.
Yes. Where the hospital’s practice is to bury/cremate remains together, the woman should be informed of this when she chooses one of these options. It should be noted that not all Cremation Authorities will agree to carry out communal or shared cremations.
No, placentae can be disposed of as clinical waste in line with the hospital’s usual procedure.
Women may miscarry naturally or pass the pregnancy by medical induction outside of a clinical facility. The woman may choose to dispose of the pregnancy remains herself, and in such circumstances advice on how to manage this appropriately should be available from service providers such as termination services or early pregnancy units. Some women will need to retain the pregnancy remains for histological examination, or would prefer to have the remains disposed of by a clinical facility, and consideration should be given as to how this can be facilitated.
Paramedics should be aware of the guidance in the event that they are called to assist.
There is no legal bar to women taking their pregnancy remains home with them for disposal, although there are certain requirements that need to be met. The women should be advised to think carefully about what she will do with the remains and consider any associated restrictions which might exist, for example in relation to burial on a home property.
Yes. Provided that the person carrying out the burial owns the freehold or has the permission of the owner of the freehold, burial in a garden or other private land is not unlawful. More advice on the burial of pregnancy remains at home can be obtained from the ICCM.
The guidance sets out that the woman’s medical notes should record whether information was provided and what the woman’s decision was, and that a record should be kept of the date and location of the disposal. This is to ensure an audit trail for the disposed of remains, should the woman make enquiries at a later date. As the cremation or burial of pregnancy remains fall outside the scope of legislation in this area, there are no legal requirements in relation to consent and therefore the guidance does not specify that a consent form for the disposal is required. What is important is that sensitive discussion takes place, that a record of this happening is made, and that the date and location of the disposal are recorded, so that a record exists should a woman wish to trace the disposal of her pregnancy remains in the future.
Tissue samples from early pregnancy loss may be sent to Histopathology for examination to identify any unusual pathology and aid diagnosis. These can be considered part of the woman’s diagnostic record and do not need to be disposed of in line with this guidance.
Service providers that are involved with the disposal of pregnancy remains should self-assess and monitor their compliance with this guidance through regular audit of relevant policies, procedures and women’s medical records.
The CQC may consider compliance with this guidance as part of its ongoing monitoring and during inspection of registered providers of maternity and family planning services and termination of pregnancy services. The CQC makes judgements about these type of services in respect of whether they are safe, effective, caring, responsive and well led, and publishes its findings.
During inspection of HTA-licensed premises that are involved with the disposal of pregnancy remains, HTA will check the establishment’s compliance with the guidance and provide advice and guidance where shortfalls are identified.
Designated Individuals should contribute to the development of policies and procedures on the disposal of pregnancy remains, where they are handled on HTA licensed premises. However, the DI’s statutory responsibility to ensure that suitable practices are taking place under the licence does not extend to the activity of disposal of pregnancy remains that have not been removed, stored or used for a scheduled purpose.
The guidance does not apply to the disposal of embryos created in vitro (for fertility treatment or embryo research), which is regulated by the Human Fertilisation and Embryology Authority (HFEA). As set out in its Code of Practice the HFEA requires centres to take account of the special status of the human embryo when the development of an embryo is to be brought to an end. Terminating the development of embryos and disposing of the remaining material should be approached with appropriate sensitivity, having regard to the interests of the gamete providers and anyone for whose treatment the embryos were being kept.