Prenatal death and burials: what the law provides

by Claudia Ravaldi
Giovanni Presutti

Giovanni Presutti

The CiaoLapo Onlus association developed this exemplary document for hospitals and clinics in 2008 with the hope of shedding light on the laws governing burial in the event of abortion and stillbirth and to be able to facilitate the correct passage of information between institutions. persons in charge and those entitled (the woman, the couple, their representatives). What you are reading is the update to the Italian situation in October 2017.

Laws, regulations and regulations in force in Italy for the burial of embryos, fetuses and stillbirths

The topics addressed in the text are:

  1. Why a document on prenatal burials
  2. The Italian law in the case of early and late abortion
  3. Italian law in the event of stillbirth
  4. The procedure for requesting burial under 28 weeks
  5. The regulation of the Lombardy region
  6. The regulation of the Marche region
  7. Conclusions

1. Why a document on prenatal burials.

The numbers of prenatal death: a widespread and much ignored phenomenon.

The statistics carried out in Western countries tell us that one in 5/6 pregnancies is interrupted along its course, for “natural” causes, often scarcely foreseeable and unfortunately not avoidable.

This number in Italy is around 150,000 cases per year .

Almost all of these prenatal losses occur within the first trimester of pregnancy.

A much lower number in the second quarter (about 8,000), and an even lower number in the third quarter (about 2000).

To these data must be added the approximately 4000 cases of termination of pregnancy due to pathology , which are affected by the burial procedures covered by this document.

Why underline these numbers?

Because one in six pregnancies means about 150,000 women every year.

The Italian numbers show us that in a hospital emergency room, in a birth point or in a clinic it is not at all rare to meet a woman who has a spontaneous abortion in progress, whether early or late, or who has planned an interruption of pregnancy due to illness or having suffered a stillbirth.

Meeting these women is possible and far from rare in the normal work routine for anyone who works in an obstetrics and gynecology ward.

Knowing the laws in force and knowing how to provide the correct information is very important for the purpose of correct assistance , according to the latest international guidelines , including those of Sands UK, del NHS English and the regulations of the Australian government , to name but a few. Lancet 2016 includes correct information for parents affected by stillbirth (stillbirth in many countries is defined as such starting from the 22 week of gestational age) among the bases of care . Including information on burial or cremation procedures.

In Italy, perinatal loss occurs in 15-18% of pregnancies. Being prepared and knowing the possible procedures to be explained to the woman and the couple is part of good practice and is part of the duties of the healthcare professional. In the other countries, as we have seen, specific and detailed care protocols are already in place which take into account all the aspects (medical, bureaucratic-administrative, psychological) that a woman / couple affected by prenatal loss has to face.

Where the assistance protocols are present and correctly applied, the return in terms of user satisfaction is very high.

We cannot say the same when the procedures are limited to the medical aspects, and the clients receive no information regarding the bureaucratic and administrative aspects or the psychological implications of the loss.

This document aims to spread the knowledge of the regulations in force in Italy and the specific ones in force in some regions, and to clarify the psychological, anthropological and psychosocial rationale for which these regulations become important for the purposes of mourning.

Before starting, we remind readers that mourning is independent of religious belief, because mourning draws on a very marked psychological, anthropological and psychosocial dimension.

We also remember that CiaoLapo is apolitical, non-partisan and non-denominational and that over the years it has welcomed parents with all existing types of creed, atheist parents, agnostic parents, converted parents, parents of all political colors, and of all currents of thought .

Working with very different people but all united by the loss of a child during pregnancy or after birth, for any medical reason, has allowed us to start a healthy, calm and in-depth comparison between rites, beliefs and needs expressed by couples.

Most of our couples (since 2006 there have been about 800 couples we have followed, and over 3,000 women) affected by bereavement below the 28 week of pregnancy over the years have expressed regret that they have not received precise information on the burial. . Many received conflicting information, depending on the operators they asked. Many have been told half-truths or outright lies (the most frequent is “the burial is provided by the hospital”). Some parents, once they discovered the laws in force and the blatant violation of these laws, started a complex and painful legal dispute with the hospital where the birth took place. Some parents still live today with regret and embarrassment the choice made years ago, made on the basis of little information, in a moment of intense shock, and after having received self-styled reassurance on the best outcome of mourning in the absence of burial and funeral rite (it is true the exact opposite )

In our country, the burial of the stillborn is unfortunately colored by sad ideological connotations , politicians and religious , which inflame souls and shift the focus away from the mourning of the parents (and their right to choose, according to the law ) to sterile polemics, of which we have had to reluctantly occupy ourselves by wasting a lot of energy, but sometimes getting a glimmer of awareness. Just a glimpse, judging from the fact that even today, 2017, many operators of the departments of gynecology and obstetrics do not know the details of the law, they do not know the process that the body of the fetus embryo follows in case of burial or disposal, does not they know how to provide precise indications to precise requests from parents (the most banal request is: “but what cemetery are you taking him to?”).

The awareness of perinatal bereavement, the knowledge of the problem and all its forms, the prevention of complicated bereavement and the onset of mental pathologies also passes through correct information .

In Italy, even today, due to the media and thanks to politicians, journalists and even “insiders” who are not very competent in psychology and anthropology, obtaining correct information after a perinatal bereavement is very difficult. Especially when it comes to contact with the child and funeral rites.

So let’s try to clarify what the law says and what people can focus on when deciding what to do after a perinatal loss.

2. Legal provisions in case of abortion (early and late)

When a pregnancy is interrupted in the first trimester, the pregnant woman is followed with specific medical protocols that carefully establish how to proceed according to the course.

Most first trimester loss events begin with bleeding and spontaneous expulsion of the embryo or fetus. In some cases the pregnancy is interrupted but the embryo or fetus remains in the uterus. When diagnosing a presumed abortion, doctors can decide with the woman between several options: waiting, medical procedure, surgical procedure. When the measurements of the fetus reach those of the 14th week of gestational age, we usually proceed with the induction of the so-called “abortive” birth, after hospitalization. The “abortive” birth engages the physical and psychic energies of the woman, and of her partner, like a normal birth. Furthermore, for many women this is their first childbirth experience. The woman must be followed with particular care, to avoid future post-traumatic repercussions. This treatment includes the correct explanation of the possibility of proceeding with the burial / cremation of the child’s body.

After a diagnosis of early or late abortion, the medical objective is to favor the expulsion of all the “abortion material” which also includes the body of the embryo / fetus.

The body of the embryo-fetus is not without value and meaning for the woman . Not only, as some hypothesize, because it was seen during ultrasound scans, but also because, in a natural and physiological way, it was thought, imagined, idealized as such, even before becoming a “body”.

It is the baby’s body that develops in the uterus, and it is the baby’s body that is monitored during pregnancy, and whose vital signs are searched and recorded (the famous heartbeat of the first ultrasound). Finally, it is the child’s body that stops living. Believing that this ” child in the making” stops being thought of, or of having any meaning for the woman / couple once dead, is not what thousands of women and men in Italy and in the world experience. On the contrary. After the diagnosis, the child’s body is even more important: women want to understand what happened, they need an explanation, they need to be able to explain what happened. Far from being “forgotten”, it is on the child’s body that further investigations, examinations, and investigations are asked. (…)

The thought child is embodied in those millimeters of the body. When the child dies, it is that child in that body that dies. For many parents (not for all, for many), that body is important. To the point that, for some of them, it could be essential to proceed with a burial ritual. Required by law.

If the expulsion of the embryo / fetus takes place at the woman’s home, the woman is free to decide together with her partner what to do with the body of the embryo or fetus, without having to fill in any form. However, this form is required by law to obtain a burial in a municipal cemetery area.

If the expulsion of the embryo or fetus takes place in the hospital, spontaneously, following a curettage surgery, following an “abortive” birth, it is necessary to follow a specific procedure in accordance with the law.

The Italian mortuary police regulations, albeit with local variations, are based on DPR 10/09/1990 n. 285, which in art. 7 declares:

Article 7

  1. For stillbirths, without prejudice to the provisions of art. 74 of the Royal Decree of 9 July 1939, n. 1238, on the organization of the civil status, the provisions established by the previous articles are followed.
  2. For the burial of abortive products of presumed gestation age from 20 to 28 complete weeks and fetuses who are presumed to have reached 28 weeks of intrauterine age and who have not been declared stillborn to the registrar, transport and burial permits are issued by the local health unit .
  3. At the request of the parents , in the cemetery can also be collected with the same procedure products of conception of presumed age less than 20 weeks .
  1. In the cases provided for in paragraphs 2 and 3, relatives or those on their behalf are required to submit , within 24 hours of expulsion or extraction of the fetus, an application for burial to the local health unit accompanied by a medical certificate indicating the presumed gestational age and the weight of the fetus.

Comments

If the parents request it, after early or late abortion the burial of embryos and fetuses is possible even before 28 weeks of gestational age (for any reason or under any circumstances, including IVG), provided that the request is submitted within 24 hours from expulsion.

The law does not set any gestational age limit below which burial cannot be requested.

3. Legal provisions in the event of stillbirth (over 28 weeks of gestational age)

Stillbirths are defined as babies who are over 28 weeks of gestation at the time of delivery.

In the event of stillbirth, registration is mandatory at the registry office, as required by art. 74 of the Royal Decree 09.07.1939 n. 1238 which quotes verbatim:

Art. 74

When the child is not alive at the time of the birth declaration, the declarant must make known whether the child was stillborn or died after birth, indicating in the latter case the cause of death. These circumstances must be proven by the declarant with the birth assistance certificate pursuant to art. 70, fourth paragraph, or with a medical certificate.

The civil status officer only forms the birth certificate, in the case of a stillborn child, and makes this appear on the sidelines of the act itself; he also forms that of death, in the case of a child who died after birth.

Comments:

The stillborn child is registered in the civil registry and has all the rights that belong to any other human being, regardless of whether his death occurred while he was still in the mother’s womb. He therefore also has the right to be buried.

4. How to apply for burial / cremation under 28 weeks of gestational age

Burial can be requested through the hospital by filling in the ASL forms containing the permits for transfer to the cemetery.

The request must be completed and submitted within 24 hours of the operation or birth (Article 7 paragraphs 3 and 4 of Presidential Decree 10.9.90 n. 285): many hospitals have specific forms for making the request; in the absence of pre-set forms, it is sufficient to apply on plain paper and in triplicate (the request can be completed by the woman or by a family member):

Example:

To the Health Department of the ASL n: …

The undersigned … …………………………………….. ( name and surname of the applicant), domiciled in ……………. in via ……………………. ……………………………………..(Street address)

asks that her child, to whom she wished to give the name of …………………………, be buried individually in accordance with the provisions of Law (DPR n.285 of 10.9.1990, art.7, paragraphs 3 and 4).
(date and signature)

Attachment: 1 medical certificate.
for receipt in the Department: …………. (date and signature)
for receipt from the Health Department: …………… (date and signature)

A) The first copy must be delivered to the Head of the Department; the second must be delivered to the Health Department of the Hospital; the third copy will be kept by the applicant and can serve as a receipt for the other two.

B) The medical certificate must be attached to the application, which will be issued by the Gynecologist who followed the pregnancy or who underwent the surgery and must report the presumed gestation age and the weight of the fetus.

For individual burials, we recommend that you go to the municipal burial office, in order to establish the methods you deem most appropriate (example: any religious ceremonies, transport to the cemetery, cremation, scattering of ashes, burial in a common grave, or in a family tomb etc)

On that occasion you can choose whether to entrust the transport to the Municipality or to a private funeral company.

Upon request, it is possible to present for viewing only the copy of the burial request with the appropriate proofs of receipt.

The burial space in the cemetery is generally fixed in the area provided for stillborn babies and products of conception (art. 50, Presidential Decree 285/90).

Please note: not all cemeteries have areas for the burial of embryos and fetuses. The hospital company should have a protocol including the indications about the local, municipal or provincial cemeteries where it is possible to carry out the burial / dispersion of the ashes.

Note 2: after the diagnostic investigation of the histological examination, a polluting chemical component, formalin, is present in the child’s body. By law, the burial of embryos after the diagnostic examination is only possible in cemeteries in accordance with the law for the protection of aquifers. If there is no suitable cemetery area near you it is advisable to look for a suitable one.

It is not true that if you do the histological examination you cannot bury it.

It is not true that one thing excludes the other.

Furthermore, in the event that a deceased relative is already present in your municipal cemetery, you can choose to burial the remains of the child in the same grave (in this case the costs are higher and vary from area to area).

5. The regulation of the Lombardy region

Art. 1

(Amendments to the regional regulation 9 November 2004, n.6 )

  1. In the regional regulation of 9 November 2004, n. 6 (Regulations on funeral and cemetery activities) the following changes are made:

[….]

  1. b) paragraph 1 of article 11 is replaced by the following:

“1. Authorization for the burial or interment of corpses and stillbirths is issued in accordance with current national legislation.”;

  1. c) after paragraph 1 of article 11 the following are added:

“1 bis. For abortive products of presumed gestational age from twenty to twenty-eight complete weeks and for fetuses presumably twenty-eight weeks of intrauterine age, as well as for products of conception presumed to be less than twenty weeks old, the health directorate informs the parents of the possibility to request burial.

1 ter. The ASL, informed by the health management by sending the burial request accompanied by the indication of the presumed age of the fetus or abortive product, issues the transport and burial permit directly to the municipality where the event occurred.

1 quater. In the absence of a burial request, provision is made in analogy with the provisions for recognizable anatomical parts. “;

Comments

The Lombardy Regional Regulations introduced the duty on the part of the hospital operator to inform parents of the possibility of requesting burial. This applies to any parent, whatever the gestational age of the baby. Furthermore, in the absence of a request for burial from the parent, the Lombardy Region will in any case provide for the burial of the fetus, as usually done with the “recognizable anatomical parts”.

How: unfortunately this law that seemed excellent is applied unevenly from municipality to municipality. Not all areas designated for embryos and fetuses are adequately structured. Sometimes, unfortunately, parents do not obtain the requested information, because the procedure is not yet adequately structured. Not all companies have updated care protocols and procedures. It is important to always ask for the administrative procedure envisaged by the structure and its traceability. Even if it is difficult and painful to ask.

6. The regulation of the Marche region

(Published in the Official Bulletin of the Marche Region on November 26, 2015)

The real virtuous novelty of the last two years

Regional regulation 16 November 2015 , n. 7 concerning: Amendment to the regional regulation 9 February 2009, n. 3. “Funeral and cemetery activities pursuant to article 11 of the regional law 1 February 2005, n. 3.

The President of the Regional Council Upon consistent resolution of the Council – regional legislative assembly n. 12 of session no. 10 of 10 November 2015; Having regard to paragraph 3 of article 35 of the Statute of the Region; issues the following regulation: Amendment to the regional regulation 9 February 2009, n. 3 “Funeral and cemetery activities pursuant to article 11 of regional law no. 3 Art. 1 (Inclusion of article 7 bis in regional regulation no. 3 of 9 February 2009) 1. After article 7 of the regional regulation no. 3 (Funeral and cemetery activities pursuant to article 11 of the regional law 1 February 2005, n.3) the following is inserted:

Art. 7 bis (Authorization for the burial and entombment of fetuses and abortion products)

  1. The ASUR, the hospitals indicated in article 2, paragraph 1, letter b), of the regional law of 20 June 2003, n. 13 (Reorganization of the Regional Health Service) and accredited private health structures prepare information brochures on the possibility of requesting , within the limits and in the manner provided for by state and regional legislation, the burial of the fetus or the abortive product and on the provisions applied in the absence of such a request.

The brochure, together with the request for formal consent, is delivered to parents, relatives or to whom they represent, upon admission to the health facility. 2. For burial in the cemetery it is not compulsory to indicate on any gravestone the surname of one or both parents but it is also possible to use a fantasy name which, in the relevant section of the cemetery register, will correspond to the actual membership of the product of conception. “. Art. 2 (Transitional provision) 1. Within sixty days from the date of entry into force of this regulation, the ASUR, the hospitals indicated in Article 2, paragraph 1, letter b), of Regional Law 13/2003 and the health facilities accredited private companies govern the information procedures indicated in paragraph 1 of article 7 bis of rr 3/2009, as introduced by this regulation. This regulation is published in the Official Bulletin of the Region. Anyone responsible is obliged to observe it and have it observed as a regulation of the Marche Region .

Ancona, November 16, 2015 THE PRESIDENT Luca Ceriscioli

Comments

The Marche Region for the first time declares the importance of correct written information that can explain to parents the existence of this possibility, a possibility that in the acute moment of diagnosis and hospitalization can be difficult to contemplate.

7. Conclusions

Italian law protects women and couples affected by perinatal bereavement even at the beginning of pregnancy and provides for ALL the possibility to proceed with the burial of the child’s body at any gestational age, both privately (fully paid by the taxpayer) and in the cemetery areas designed to accommodate embryos and fetuses (not quite properly called fields of angels). A similar procedure is envisaged for the cremation and dispersion / conservation of the ashes.

Messes:

There is no uniform ministerial information for the whole Italian territory and for all birth points; each hospital company can decide how to set up communication with the woman / couple. It can also decide, as we often see, not to set up any communication and decide by default, ignoring the laws in force.

The ideological battles right / left north / center / south lay-Catholics and vice versa make it impossible to address the subject with the sober competence of other countries, with all that follows in terms of assistance and sequelae on the well-being of women and couples (change name to a child, the name assigned by his parents, with a fancy name is not a neutral act).

In fact, they hinder correct information for women / couples, who we remember only have 24 hours to apply for burial, or to choose not to have burial.

Again it is not important what women and couples choose. It is very important that they know their rights and can make the best possible choice for them, whatever that is.

In a truly civilized and truly avant-garde country, respect for all laws should be guaranteed, as well as respect for all women in a service.

Downplaying perinatal bereavement and denying the right to burial of our embryos or fetuses does not offer any advantage to women who choose to terminate their pregnancy. And viceversa. I wrote about it here , some time ago, in full.

I await the day on which all the users of our Italian national health service will be able to receive, as happens in other countries, the most correct, comprehensive and most appropriate information for their specific case of perinatal bereavement.

While we wait for that day, learning what the law says and what we can do as citizens but also as healthcare professionals is very important.

For any further information, for clarifications or positive or negative updates of the various local realities, you can write to [email protected] or to our regional volunteers:

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Thanks for the attention,

Claudia

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