Abortion and in utero death: the WHO document for respectful care

On March 13, 2019, the World Health Organization released this long-awaited document on abortion, in utero death, and respectful care.

Here is the Italian translation of the original document with some comments, in italics, relating to the situation in Italy.

Losing a baby during pregnancy through miscarriage or stillbirth is still taboo around the world, associated with stigma and shame.

Many women still do not receive appropriate and respectful care when their baby dies during pregnancy or at the time of delivery.

The stories collected by the WHO, coming from various parts of the world, in fact underline numerous criticalities.

Spontaneous abortion is the most common cause of death for a baby during pregnancy.

Estimates vary from country to country, although March of Dimes , an organization working for maternal and child health, indicates that abortion has a rate of between 10% and 15% of all women who have become pregnant and they know they are waiting.

Prenatal death is defined in different ways around the world, but broadly when a baby dies before 28 weeks of pregnancy this event is classified as abortion, and when a baby dies from 28 weeks onwards this event is classified as death in uterus.

In Italy, stillbirth is classified as such starting from the 180th day of pregnancy, corresponding to the 25th week of gestation plus five days.

This definition, which is anatomo-clinical type, has nothing to do with the psychological aspects of loss and with the grief perceived by the mother and the couple.

Grieving has a subjective dimension and one that cannot be “measured” in gestational weeks.

Bereavement that occurs during pregnancy and in the year after delivery occurs in the perinatal period, so it can be called perinatal bereavement.

Each year, 2.6 million babies are born dead and many of these events are avoidable. Unfortunately, in utero abortions and deaths are not systematically recorded, even in developed countries, including Italy: this suggests that the numbers may be higher.

Around the world, women have access to different types of health services; in many countries hospitals and clinics often offer underpowered services due to structural and staff shortages.

Although the experience of loss can be very varied, as it is subjective, in different parts of the world, stigma, shame and guilt emerge as common themes for most women.

As many stories show, taken by WHO, ISA and in the Lancet 2011 and Lancet 2016 monographic series on stillbirth, and as reported by hundreds of Italian women, women who lose their babies are strongly conditioned by their surroundings to remain silent with respect to their grief, either because abortion and in utero death are so common that they do not deserve too much attention, or because they are deemed “inevitable.”

Jessica Zucker, clinical psychologist and writer, USA

“As a clinical psychologist I have specialized in mental and reproductive health and have worked on this topic for more than ten years. Since experiencing an abortion myself at sixteen weeks, I have been able to experience the anguish and how intricate the path is. of bereavement my patients have told me about for years. After my loss, I promoted research showing that a large majority of women report feelings of shame, guilt and self-blame after prenatal loss. “

The price women pay for this silence and general indifference is very high.

Many women who lose a baby during pregnancy can develop mental disorders that last for months or years, even after a pregnancy finally ended with the birth of a healthy baby.

The cultural aspects and social attitudes towards those who lose a child in pregnancy can be extremely different in different countries of the world. In Sub-Saharan Africa, a common belief is that the child may be born dead due to witchcraft or evil spirits.

In our country there is still a tendency to attribute this tragic event to some “lightness” committed by the mother, to some error committed by doctors, or more simply, to “destiny”.

Even today, even in our culture, it is very rare to meet people who adopt a respectful, open, open minded and educated approach to these events. Unfortunately, fatalism is still widespread even among health professionals, who urge mothers to “get over it” and avoid in-depth diagnostic tests, even when required by current laws (read, for completeness, this 2014 Ministry of Health document and what is written in the Official Gazette)

The result of these fatalistic generalizations is that parents feel alone, misunderstood and abandoned in the face of their losses, without the necessary medical and psychological references.

Larai, 44, pharmacist, Nigeria

“Dealing with my abortion was traumatic. The medical staff has further magnified my bereavement, despite the fact that I am a doctor myself. The other relevant aspect is the cultural approach. In many traditional African cultures, people think you can lose a child to witchcraft. Here prenatal loss is surrounded by stigma because many people believe that there is something wrong with women who have multiple losses, for example that they have been promiscuous, and are therefore punished by God. “

People, especially the most famous ones, use social media to share their experiences, as happened to Kimberly Van Der Beek and her husband, actor James Van Der Beek, best known for his role in the American television series Dawson’s Creek. . The couple recently shared a very touching post on Instagram , where they openly talked about the suffering linked to poliabortivity and their path to face it better.

The words of the legendary Dawson are a great gift for couples and especially for fathers who are confronted with the pain they experience on their skin and on that of their companions, with all the facets that pain assumes.

I would like to share a passage in particular with you: “Do not judge your pain, do not try to rationalize it. Let it flow in the various waves, as it arrives, offer it the right space”. There are no grief instructions, no one-size-fits-all recipes or strategies for stopping the waves. The real strategy is to let them arrive by learning to swim and rest in between waves. Thanks Dawson!

There are many reasons why an abortion occurs, including these abnormalities of the baby at the level of embryonic or fetal development, maternal age, infections, some of which are preventable, such as malaria and syphilis: some causes are still mysterious and remain unexplained. .

Some general tips for avoiding abortion focus on the importance of healthy eating and regular exercise, abstaining from smoking, drugs and alcohol, limiting caffeine, controlling stress, and maintaining a healthy weight. (It is interesting to note that perceived stress is among the main causes of compulsive search for strategies to reduce stress, among which, alas, binge eating, smoking, alcohol. It is evident that we must work on anxiety and stress, because reducing those accordingly we also reduce abusive behaviors.) This emphasis on lifestyles, in the absence of specific causes, can lead women to feel guilty for causing the abortion.

Blaming increases stress and therefore enhances the use of compensatory strategies. The right amount of time should be invested in working with women and couples with a history of abortion or stillbirth in a manner that to create the right therapeutic alliance and encourage adherence to any more correct lifestyles, reducing stress instead of increasing it.

Lisa, 40, marketing manager, UK

“I have had four miscarriages. Every time that happens, a part of you dies. The most traumatic was the first. We were so happy for the baby to arrive. But when we went to the twelve week ultrasound we were told that I had an internal abortion, also called a silent abortion, which means that the baby had already died inside me for some time but my body had not shown any signs of this. event. I was devastated. I couldn’t even believe they were sending me home with my dead baby in my belly, and no indication of what to do. “

Just as it happens in other areas, such as mental health, there is still a tremendous taboo around prenatal bereavement, many women report that, regardless of their culture, their friends and family do not want to talk about their bereavement. This also happens for all the other griefs

Susan, 34, writer, USA

“I have been treated for infertility for nearly five years. When my path of medically assisted procreation began, I quickly learned that I had no idea what was going on: I was really physically and emotionally exhausted. Fortunately I got pregnant, my husband and I were really happy. Despite this, the baby stopped growing after seven weeks. So I stopped the hormones, and after another two weeks the abortion began. It lasted nineteen days. I didn’t immediately realize that abortion was a long process of pain and bleeding. May the reality of fertility and abortion be shrouded in shame and silence. “

Stillbirths occur in late pregnancy, 1 in 2 during labor, many are avoidable. About 98% of stillbirths occur in low- and middle-development countries. Better quality of care during pregnancy and childbirth can prevent half a million stillbirths worldwide. Even in high-development countries, including in Italy, substandard care is a significant risk factor for stillbirths.

There are effective ways to reduce the number of babies dying during pregnancy – improve access to antenatal care (in many countries around the world, women do not see a health worker until they are late in pregnancy), introduce access to continuity of care and introduce care in the area when possible.

Emilia, 36, shopkeeper, Colombia

“When I had a stillbirth at 32 weeks my baby already had a name. I ran into the clinic with really very high blood pressure. After the visit the doctor told me to rest and take some blood pressure lowering medications. week I had the same symptoms. The doctor immediately gave me an ultrasound and told me that the baby was showing no signs of life. If I had received more information from the beginning and had received more attention in difficult times, my baby would be been saved. “

How women are treated during pregnancy is closely linked to their sexual and reproductive rights; many women in the world still do not have this autonomy.

In many countries around the world, social pressure pushes women to get pregnant when they are not physically or psychologically ready. Even in 2019, 200 million women who wanted to avoid pregnancy were unable to access contraception. When they become pregnant, 30 million cannot give birth in healthy settings and about 45 million receive completely inadequate antenatal care: this puts mothers and babies at risk of complications and death.

Divya Samson Panabakam, 30, consultant, India

“I had my first miscarriage in 2013. As soon as I started bleeding I went to the hospital and they immediately sent me for an ultrasound, but the person in charge thought I was not married and therefore made me wait. I asked: even if I were not married, why do you treat someone who is losing a child like this? She just looked at me and replied: It’s not an emergency, only a woman over 60 could represent an emergency . “

Cultural practices such as female genital mutilation (FGM) and marriages with child brides are real attacks on the sexual and reproductive health of girls, and on the health of their children. Having babies too early can be dangerous for mothers and babies. Teenage mothers (10-19 years) are more at risk of having eclampsia and uterine infections than women between the ages of 20 and 24, which increases the risk of stillbirth. Babies born to mothers under the age of 20 are also more at risk of being underweight, premature, or having severe birth problems. All of these conditions increase the risk of death in utero.

Female genital mutilation increases the risk during labor, of bleeding, of severe lacerations, as well as the use of operative delivery. Babies born to mothers with FGM are at higher risk of needing resuscitation and have an increased risk of death during labor or after birth.

Putting women at the center of care is essential for a positive pregnancy and delivery experience. biomedical and physiological aspects of care must be integrated with social, cultural, emotional and psychological support.

Still too many women, even in our countries with high economic development, even in Italy, receive inadequate care after losing a child. The language used to talk about abortion and stillbirth can be very traumatic in itself, and words should be treated when speaking to women and couples who are dealing with a highly traumatic event.

“Cervical incompetence” “Blind egg”, “Fetino”, “He choked with the cord”, “Abortive material” are just some of the words that parents consider inappropriate and poorly cared for at the time of diagnosis, hospitalization or follow-up. up. For further information on the communication strategies to be used in these cases, you can read La morte peasing

Andrea, 28, fashion designer, Colombia

“When I was 12 weeks pregnant, I went for my scheduled ultrasound. The doctor told me something was wrong without specifying what it was. The next day I woke up and noticed that the bed was stained with blood. I did not receive any information about why I had an abortion. The nurses were very cold and insensitive, and acted as if it was just routine for them. Of all the staff at the hospital, the only one who showed any humanity was the doctor, who later reassured me that I could look for another pregnancy.”

Depending on the hospital rules, children’s bodies can be treated as hospital waste and incinerated. In our country , the laws in force for almost forty years offer ALL women the possibility of choosing burial / cremation, at any gestational age. No hospital can refuse to release the child’s body or prevent the family from providing the burial.

Sometimes, when a woman finds out that her baby has died, she is asked to wait for some time before giving birth, even weeks. Although there are no urgent reasons to rush the procedures, this waiting can often be very stressful for the woman and her partner.

In Italy, to date (May 2019) there is no univocal procedure respected by all birth points and the management of abortion, especially that of the first quarter is strongly linked to company choices (drug abortion, surgical abortion, waiting).

Even in high-development countries, many women deliver their dead baby in obstetrics wards, surrounded by women with healthy babies.

Not all hospitals are up-to-date or provide integrated services. This is the reality of overburdened health services in many countries.

However, improving sensitivity when relating to bereaved couples and removing the taboo and stigma around prenatal death COST NOTHING.

This request is also present in many stories of mothers.

Becky, 38, primary school teacher, Viet Nam / UK

“My husband and I were over the moon when I became pregnant with twins, and it was devastating to lose one of them-her name is Isla-at 34 weeks. I was terrified of losing the other one too, and I insisted on staying in the hospital. The next day I delivered our babies by C-section. After all, the hospital was very supportive, we were given a single room, and we had time to spend with Isla. Despite this, however, some of the doctors showed a total lack of sensitivity, and one even asked me why I was crying and told me to be strong.”

Healthcare professionals can show sensitivity and empathy, recognize how parents feel, provide clear information and understand that parents may need specific support, both in managing their loss and in thinking about a possible future pregnancy.

Providing support based on respect for human rights that is socioculturally adequate, respectful and dignified is a necessary requirement for caring for mothers and babies as much as clinical skills

Sarah, 40, civil servant, Australia

“In utero death is so common in Australia when it happens to you or someone you know. It’s immediately everywhere. In utero death affects 2,000 families in Australia every year. The number of in utero deaths has remained the same for the last 20 years, and for indigenous women it is even twice as high. Before it happened to me and I became that 1 in 6 I never thought that a baby could die in utero. It is never talked about. The doctor had told me about my increased risk of cord prolapse due to polyhydramnios, but no one told me that I also had an increased risk of death in utero.”

Key messages on supporting women and couples affected by abortion and stillbirth

It can be difficult to know what to say when someone loses a baby in pregnancy, but sensitivity and empathy can offer support and allow people to find a space to talk about how they are feeling.

Rather than saying, “Everything happens for a reason, it had to be this way,” try saying something like, “I am very sorry. I can only imagine how painful it is.”

Rather than saying “At least you know you can get pregnant”, just try listening. You might just ask, “How are you feeling?” “What can I do?”

Rather than saying “At least you already have another healthy baby” maybe it is better to say “I am deeply sorry for your loss.”

The experience of losing a baby in pregnancy can be experienced differently from a cultural and anthropological point of view in various parts of the world, but stigma, shame and guilt emerge as a common theme for many women.

Many women who lose a baby in pregnancy can develop a mental disorder that lasts for months or years, even after other healthy babies arrive.

To improve mental health outcomes it is necessary to offer support from the moment of diagnosis of abortion and stillbirth. It makes no sense to adopt the policy of “closing the barn when the oxen have run away” and only then waiting to treat women who, after years, fall ill with depression, anxiety or any other pathology. Tertiary prevention should not be considered as an effective prevention strategy, as this aspect is now well known in the academic world and in the most important patient associations.

We know how to save the lives of many children who die in utero, by improving access to antenatal care (in many countries around the world, women do not see a health worker until they are late in pregnancy), by introducing continuity of obstetric care and assistance in the area when possible.

Every year 2.6 million children are born dead: many of these deaths are preventable. Integrated treatment of infections in pregnancy, cardiac monitoring of the baby and assistance to labor if they were an integral part of the care for all mothers could save 1.3 million babies who will be born dead.

We need to end this unacceptable stigma around prenatal death and the shame women feel after the loss of a baby.

“Pregnancy must be a positive experience for mothers and babies – when this is not possible, women deserve all our respect, empathy and support” N. Simelela.

Original article from the World Health Organization.

For further information on more appropriate assistance to couples affected by perinatal bereavement in Italy, you can read this notebook on your tablet, or purchase a solidarity hard copy.