A fetus is a baby from the 9th week to the end of the 23rd week of pregnancy. In the past, fetal remains were cremated in hospital incinerators. Environmental legislation forced many of these incinerators to close in the 1990’s. Contractors were then used to collect and incinerate clinical waste offsite. Because of the sensitivity of fetal remains, these were often handled separately to all other clinical waste. However, all ash was then sent to landfill. Apocryphally, neither the firms nor their staff liked this process, not being used to handling human remains.
I was convinced that all human remains should be handled in such a way that, retrospectively, was beyond reproach. But I was never able to speak to women who had gone through such an experience. Even if I had, would their view at a young age be the same 40 or more years later? What is also evident is that in the past fetal remains were seen as just a pregnancy loss. That changed when ultrasound scans, as early as 12 weeks, showed the heartbeat. It became the loss of a baby rather than of a pregnancy.
In 1995, the Institute of Cemetery and Crematorium Management (ICCM) researched what happened to fetal remains. About 40,000 fetal remains were then cremated and about 100,000 were unaccounted for. The ICCM concern was that a decent and humane process should not utilise a ‘waste’ incineration process. However, by 2020, abortions had risen to 210,850 and we have little information on what happened to all those fetal remains.
Then and now, there are significant problems in creating a standard. Firstly, the government will not classify fetal remains as human remains because medical tissue is removed from the remains for research. As clinical waste this is not an issue, but as human remains it is. A second issue is that the NHS possibly fears being made responsible for any funeral costs that might arise. The ICCM was conscious of this, that high numbers of individual arrangements would be expensive. Consequently, they supported a ‘shared’ funeral arrangement.
The shared concept meant placing a number of fetal remains into one container. As such, remains can weigh a few grammes and the number placed in a container could be very high. However, an arbitrary figure of 30 was agreed. That figure was a major problem for cremationists because all cremations under the ‘Code of Cremation Practice’ had to be ‘individual’. Consequently, a cremation process was not agreed but ‘shared’ burial arrangements were feasible. At Carlisle Bereavement Services, where I managed, we interred ‘shared’ remains in a grave on ‘The Babies Memorial Garden’.
The Royal College of Nursing & Midwifery, the Stillbirth & Neonatal Death Society (SANDS) and the Federation of British Cremation Authorities (FBCA) were involved in these consultations with the ICCM. Over time, shared cremation was accepted at most crematoria. Whatever, all fetal remains were handled purely on a case number. No details whatsoever of the woman would move outside the hospital or clinic. That meant that, provided the woman knew her case number, she could, retrospectively, find the burial or cremation details and location.
In 2015, SANDS issued a statement that still applies. This included: The options for disposing of fetal remains and tissue following pregnancy loss are outlined by the HTA (Human Tissue Authority) and include individual or shared burial or cremation or sensitive incineration. Sensitive incineration is when any remains after pregnancy loss are packaged, stored and incinerated separately from other clinical waste. The HTA specifies that “Incineration should only occur where the woman makes this choice, or does not want to be involved in the decision, or does not express an opinion within the stated timescale, and the hospital considers this to be the most appropriate method of disposal. As there is variation in the feelings and experiences of bereaved parents, SANDS’ view is that parents should be always be given the choice of cremation, burial or making their own arrangements following a pregnancy loss prior to 24 weeks. However, sensitive incineration should remain an option”.
This suggests that my view about clinical waste incineration is wrong. However, I would immediately challenge ‘sensitive incineration’. Yes, the remains go into the incinerator separately, but the ashes still go to landfill. How does any hospital consider that to be ‘an appropriate method of disposal?’ Does the woman understand what happens to the ashes? I very much doubt that. Even if the woman does understand then cremation does not counteract her wishes. Assuming she wants nothing to do with the decision, then cremation ensures the ashes go into a Garden of Remembrance. If, at any time, she changes her mind then the ashes can at least be located, and the spot visited.
In 2012, the Scottish Government issued a directive which stated: Chief Executives of NHS Boards should note that disposal of any pregnancy losses by way of incineration or clinical waste is no longer considered acceptable.
I cannot analyze what is now happening to fetal remains in England & Wales. Women seem to have choices, but hospitals still appear free to decide what is appropriate. I still believe a minimum standard should be set along the lines of the Scottish decision. Their hospitals will hold records for at least 30 years showing where the remains were sent for cremation or burial. At the very least, the remains are treated sensitively, and nobody will ever look back and see them referred to as clinical waste.
