Certification

For some parents, the sadness of pregnancy loss before 24 weeks is increased by the fact that there is no documentation that acknowledges the loss of their baby.  We recommend that NHS trusts create and offer some form of certification for parents who would like this.

Background

The law in England and Wales, Scotland and Northern Ireland requires that the birth of a baby born dead from 24 weeks gestation should be registered as a stillbirth.  A baby delivered either before or after 24 weeks gestation who shows signs of life but subsequently dies within 28 days is registered as a neonatal death.  Registration is with the local Register Office in that country.

But many parents who lose a baby before 24 weeks of pregnancy would also welcome some form of certification.  It is a marker of their loss and can bring some comfort at a difficult time.

In their Good Practice Guide Registration of stillbirths and certification for pregnancy loss before 24 weeks of gestation, published in 2005, the Royal College of Obstetricians and Gynaecologists notes:

NHS trusts are encouraged to develop a system of hospital-based commemorative certification for fetuses that are not classified as stillbirths. This would provide women or couples with a certificate recording their pregnancy loss before 24 weeks of gestation.

However, not all women or couples will want this certificate following a pregnancy loss.

Recommendation

The Miscarriage Association recommends that all women who experience pregnancy loss before 24 weeks gestation are offered some form of certification, while recognising that some will not want to take it.  Some parents might feel that it is inappropriate, or that it adds to their distress, or induces feelings of guilt.

It should be noted that this document would have no legal force, nor could its provision be enforced, either on any hospital or indeed on any patient.  It would, however, offer an opportunity to increase the quality of care given to women who lose a baby before the legally recognised age of viability.

Notes on creating certificates

Background
There is no legal requirement to provide any form of certification for pregnancies lost before 24 weeks gestation: the legally recognised age of viability. But many parents who have a miscarriage, ectopic or molar pregnancy – and some parents who have a termination of pregnancy – may welcome some form of certification. It is a marker of their loss and can bring some comfort at a difficult time.

We suggest that it is good practice to offer the opportunity for such a marker, while recognising that some parents will not want to take it. Some might feel that it is inappropriate, or adding to their distress or inducing feelings of guilt.

Creating a certificate
There are several things to consider when designing a certificate – or indeed certificates: you may need more than one.

Consultation
In all cases, we’d recommend that you involve patients or patient groups to get a cross-section of opinion from people for whom this might be significant. It might be very useful to share ideas with colleagues in your place of work and/or elsewhere. Use the ideas and feedback to guide the design process – and be aware that you are likely to get differing opinions and will need to find a compromise.

Wording
Language is important, especially at a time of heightened sensitivity. Expressions or phrases that some people find comforting, such as Born Sleeping, may jar with others.  We have some examples here.

It might be wise to avoid references to specific religions or beliefs. Parents can always request something more specific from a minister of their own faith and/or the hospital chaplain.

You might want to consider having different wording for different circumstances, such as gestational age or perhaps the cause of the loss (miscarriage, ectopic pregnancy, termination).

firget-me-notDesign
We recommend that any document be produced on good quality notepaper or card, or in the form of a notelet. If it bears the hospital, Trust or surgery name, address and logo, that can add a sense of formality.

You might want to think about the use of images. As with wording, something that seems absolutely right for one person can be completely wrong for another. It may be best to use a flower image – perhaps bluebells or forget-me-nots or viola tricolor, also known as Heartsease.  We have some examples here.

Do feel free to consult with us at the Miscarriage Association if you would like external feedback.