Acessibilidade / Reportar erro

Grief after fetal death: a voiceless mourning

Abstract

The Ministry of Health advises that death certificates should not be issued in cases of fetal death for a pregnancy of less than 20 weeks or fetus weighing less than 500 g or shorter than 25 cm in height; however, the legislation allows the issuance of the certificate in cases where the family wishes to bury the fetus. Given this context, abortion cases in which the certificate is issued are few. This article presents an integrative review that answers the question: would the death ceremonies, particularly the burial (made possible by the issuance of the death certificate), in case of fetal death under 20 weeks of gestational age help in the parents’ mourning process? The literature consulted presented favorable information for the issuance of the death certificate and enabled a medical, legal and anthropological discussion of the theme.

Keywords:
Miscarriage; Grief; Fetal death

Resumo

O Ministério da Saúde orienta que a declaração de óbito não seja emitida em casos de óbito fetal com gestação inferior a 20 semanas ou feto com peso inferior a 500 g ou estatura menor que 25 cm, acrescentando que a legislação permite a emissão da declaração em casos em que a família deseje fazer o sepultamento do feto. Nesse contexto, são poucos os casos de aborto em que a declaração é feita. Este artigo realizou revisão integrativa que responde à pergunta: os rituais de fechamento, particularmente o sepultamento (possibilitado pela emissão da declaração de óbito) em caso de morte fetal inferior a 20 semanas de idade gestacional, ajudariam no processo de luto dos pais? A literatura consultada trouxe informações favoráveis à emissão da declaração de óbito e possibilitou discussão médica, jurídica e antropológica do tema.

Palavras-chave:
Aborto espontâneo; Pesar; Morte fetal

Resumen

El Ministerio de Salud brasileño recomienda que no se debe emitir el certificado de defunción en los casos de muerte fetal de menos de 20 semanas de gestación, feto con peso inferior a 500 g o estatura inferior a 25 cm, pero agrega que se puede permitirlo cuando la familia opta por el entierro del feto. En este contexto, el certificado se emite en pocos casos de aborto. Este artículo realizó una revisión integradora a partir de la pregunta: ¿Ayudarían en el proceso de duelo de los padres los rituales de inhumación, sobre todo el entierro (habilitado mediante la emisión de un certificado de defunción) en caso de muerte fetal con menos de 20 semanas de edad gestacional? La literatura consultada aportó con informaciones favorables a la emisión del certificado de defunción y permitió fomentar la discusión médica, jurídica y antropológica del tema.

Palabras clave:
Aborto espontáneo; Pesar; Muerte fetal

Is there a place where death LIVES? Ah, it lives in farewells, in rituals of closure, when finality is legitimized. But life remains in the place of forever, in the place where memories are kept, in a space of affects11 Pallottino E, Rezende C. Prefácio. In: Lupi C, Camargo F, Lupi L, Couri R, organizadoras. Histórias de amor na perda gestacional e neonatal. [local desconhecido]: Bookstart; 2015. p. 100..

The arrangements to dispose of a fetal body in the event of demise vary worldwide. However, according to Laurenti and Jorge 22 Laurenti R, Jorge MHPM. O atestado de óbito: aspectos médicos, estatísticos, éticos e jurídicos [Internet]. São Paulo: Conselho Regional de Medicina do Estado de São Paulo; 2015 [acesso 15 jul 2020]. Disponível: https://bit.ly/3ehvVM1
https://bit.ly/3ehvVM1...
, several countries, Brazil included, have based their disposal procedures on the 10th Revision of the International Classification of Diseases (ICD-10) of the World Health Organization (WHO). In Brazil, issuance of a death certificate (DC) and consequent burial (or cremation) are mandatory in cases of fetal death at or over 20 weeks of gestation and/or fetus weighing over 500 g and/or measuring over 25 cm long.

If the fetal death does not fit these parameters, the Brazilian Ministry of Health (MS) and the Federal Council of Medicine (CFM) advise against the issuance of the death certificate. However, in practice, according to Brazilian legislation, there is no impediment to burial and issuance of the certificate depends on the parents’ wish 33 Brasil. Ministério da Saúde. A declaração de óbito: documento necessário e importante [Internet]. 3ª ed. Brasília: Ministério da Saúde; 2009 [acesso 15 jul 2020]. Disponível: https://bit.ly/3KGL4CW
https://bit.ly/3KGL4CW...
. If they do not express any desire in this regard, the body will be sent to incineration.

Medicine is currently undergoing a very positive period of appreciation of doctor-patient communication skills. However, mothers who experience fetal loss commonly report little appreciation of their pain and do not feel supported by society in general, including healthcare providers and even family members 44 Shakespeare C, Merriel A, Bakhbakhi D, Baneszova R, Barnard K, Lynch M et al. Parents’ and healthcare professionals’ experiences of care after stillbirth in low-and middle-income countries: a systematic review and meta-summary. BJOG [Internet]. 2019 [acesso 10 fev 2020];126(1):12-21. DOI: 10.1111/1471-0528.15430
https://doi.org/10.1111/1471-0528.15430...
.

Adequate guidance and listening to these women by healthcare providers can identify those for whom closure rituals and/or the possibility of keeping watch over their child’s body and burying it are an important way of grieving, with positive therapeutic consequences 55 Rådestad I, Steineck G, Nordin C, Sjögren B. Psychic and social consequences of women in relation to memories of a stillborn child: a pilot study. Gynecol Obstet Invest [Internet]. 1996 [acesso 10 fev 2020]; 41(3):194-8. DOI: 10.1159/000292267
https://doi.org/10.1159/000292267...
,66 Muza JC, Sousa EN, Arrais AR, Iaconelli V. Quando a morte visita a maternidade: atenção psicológica durante a perda perinatal. Psicol Teor Prat [Internet]. 2013 [acesso 15 fev 2020];15(3):34-48. Disponível: https://bit.ly/3cJB3Ze
https://bit.ly/3cJB3Ze...
. And if maternal grief is undervalued, paternal grief is simply ignored by academia and medicine 77 McCreight BS. A grief ignored: narratives of pregnancy loss from a male perspective. Sociol Health Illn [Internet]. 2004 [acesso 2 fev 2020];26(3):326-50. DOI: 10.1111/j.1467-9566.2004.00393.x
https://doi.org/10.1111/j.1467-9566.2004...
.

Iaconelli observes that (…) the ritual with the corpse; its cleaning, clothing, watching over, cremation, all of that is absolutely anachronistic when considered objectively. Nonetheless, we do not dispense with this prolongation of the existence of the other as a way of grieving their loss. In perinatal bereavement [in which the author includes bereavement related to fetal demise and stillbirth] the desire of the parents to perform ritualistic procedures that are part of other kinds of loss due to death is not always heeded and, when carried out, invariably create some embarrassment. These differences in treatment reveal an impossibility of attributing to the death of a baby (pre- or post-term) the status of the death of a child88 Iaconelli V. Luto insólito, desmentido e trauma: clínica psicanalítica com mães de bebês. Rev Latinoam Psicopatol Fundam [Internet]. 2007 [acesso 15 fev 2020];10(4):614-23. DOI: 10.1590/S1415-47142007000400004
https://doi.org/10.1590/S1415-4714200700...
.

In view of the above, the following question arose: might closure rituals, especially burial (enabled by the issuance of a DC) in case of fetal demise under 20 weeks of gestation, help in the parents’ grieving process? The objective of this work is to investigate this effect based on the literature.

Concepts and legislation

Brief theoretical background

It is important to point out some conceptual differences. Abortion is the expulsion or extraction of an embryo or fetus weighing less than 500 g (approximately 20 to 22 weeks of gestation), regardless of the presence or absence of vital signs. Fetal death is the death of the product of conception that occurs before its complete expulsion or extraction from the maternal body, regardless of the time of gestation. Death is confirmed when, following separation, the fetus does not breathe or show any other signs of life, such as heartbeat, umbilical cord pulsation or voluntary muscle movements 99 Brasil. Ministério da Saúde. Manual de vigilância do óbito infantil e fetal e do Comitê de Prevenção do Óbito Infantil e Fetal [Internet]. 2ª ed. Brasília: Ministério da Saúde; 2009 [acesso 29 jul 2022]. Disponível: https://bit.ly/3Cb6iFg
https://bit.ly/3Cb6iFg...
.

As of ICD-10, WHO considered the gestational age of 22 weeks (weight equivalent to 500 g) as the lower limit of the perinatal period. According to Laurenti and Jorge 22 Laurenti R, Jorge MHPM. O atestado de óbito: aspectos médicos, estatísticos, éticos e jurídicos [Internet]. São Paulo: Conselho Regional de Medicina do Estado de São Paulo; 2015 [acesso 15 jul 2020]. Disponível: https://bit.ly/3ehvVM1
https://bit.ly/3ehvVM1...
, this new ruling greatly influenced CFM’s decision-making that culminated in CFM Resolution 1,601/2000, which was amended by CFM Resolution 1,779/2005, according to which, in the event of fetal death, the mother’s attending physicians are obliged to issue a Death Certificate when the pregnancy lasts for 20 weeks or more or the fetus weighs 500 grams or more and/or measures 25 cm long or more1010 Conselho Federal de Medicina. Resolução nº 1.779, de 11 de novembro de 2005. Regulamenta a responsabilidade médica no fornecimento da Declaração de Óbito. Revoga a Resolução CFM n. 1601/2000. Diário Oficial da União [Internet]. Brasília, p. 121, 5 dez 2005 [acesso 15 fev 2020]. Seção 1. Disponível: https://bit.ly/3Q8FlH5
https://bit.ly/3Q8FlH5...
.

In addition, the Ministry of Health advises that the DC should be issued when the child is born alive and dies soon after birth, regardless of the gestational age, the newborn’s weight and how long the child lived33 Brasil. Ministério da Saúde. A declaração de óbito: documento necessário e importante [Internet]. 3ª ed. Brasília: Ministério da Saúde; 2009 [acesso 15 jul 2020]. Disponível: https://bit.ly/3KGL4CW
https://bit.ly/3KGL4CW...
. On the other hand, the DC should not be issued in the case of fetal death with gestational age under 20 weeks, or the fetus weighing under 500 grams or measuring under 25 centimeters long 33 Brasil. Ministério da Saúde. A declaração de óbito: documento necessário e importante [Internet]. 3ª ed. Brasília: Ministério da Saúde; 2009 [acesso 15 jul 2020]. Disponível: https://bit.ly/3KGL4CW
https://bit.ly/3KGL4CW...
. Lastly, the MH adds: according to the current legislation, in practice, issuance of a DC is optional in cases where the family wants provide a burial for the fetus33 Brasil. Ministério da Saúde. A declaração de óbito: documento necessário e importante [Internet]. 3ª ed. Brasília: Ministério da Saúde; 2009 [acesso 15 jul 2020]. Disponível: https://bit.ly/3KGL4CW
https://bit.ly/3KGL4CW...
.

The Brazilian National Health Surveillance Agency (Anvisa), through Resolution of the Collegiate Directorate (RDC) 222/2018, regulates healthcare waste. The following are classified as group A, subgroup A3: human anatomical parts (limbs); product of fecundation with no vital signs, weighing less than 500 grams or measuring less than 25 centimeters long or with gestational age under 20 weeks, which has no scientific or legal value and has not been requested by the patient or their family members1111 Agência Nacional de Vigilância Sanitária. Resolução da Diretoria Colegiada – RDC nº 222, de 28 de março de 2018. Regulamenta as Boas Práticas de Gerenciamento dos Resíduos de Serviços de Saúde e dá outras providências. Diário Oficial da União [Internet]. Brasília, nº 61, p. 76, 29 mar 2018 [acesso 15 fev 2020]. Seção 1. Disponível: https://bit.ly/3qafS5m
https://bit.ly/3qafS5m...
.

Also according to Anvisa, subgroup A3 healthcare waste must be disposed of by burial, cremation, incineration or other method licensed by the competent environmental agency. (…) When sent to incineration, the waste must be packed in red bags and identified with the labelANATOMICAL PARTS1111 Agência Nacional de Vigilância Sanitária. Resolução da Diretoria Colegiada – RDC nº 222, de 28 de março de 2018. Regulamenta as Boas Práticas de Gerenciamento dos Resíduos de Serviços de Saúde e dá outras providências. Diário Oficial da União [Internet]. Brasília, nº 61, p. 76, 29 mar 2018 [acesso 15 fev 2020]. Seção 1. Disponível: https://bit.ly/3qafS5m
https://bit.ly/3qafS5m...
.

According to article 14 of the aforementioned resolution, bags used for Group A healthcare waste should be replaced when they reach the limit of 2/3 of their capacity or every 48 hours (…), regardless of volume, aiming at environmental comfort and the safety of users and professionals. (…) Bags containing easily putrefying Group A healthcare waste should be replaced every 24 hours at most, regardless of volume1111 Agência Nacional de Vigilância Sanitária. Resolução da Diretoria Colegiada – RDC nº 222, de 28 de março de 2018. Regulamenta as Boas Práticas de Gerenciamento dos Resíduos de Serviços de Saúde e dá outras providências. Diário Oficial da União [Internet]. Brasília, nº 61, p. 76, 29 mar 2018 [acesso 15 fev 2020]. Seção 1. Disponível: https://bit.ly/3qafS5m
https://bit.ly/3qafS5m...
.

Method

The study consists of an integrative review, following these steps: identification of the theme and formulation of the research question; definition of inclusion and exclusion criteria of articles; definition of the information to be extracted from the selected studies; evaluation and categorization of studies included in the integrative review; analysis and interpretation of results; and presentation of the review/synthesis of knowledge 1212 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto & Contexto Enferm [Internet]. 2008 [acesso 15 fev 2020]; 17(4):758-64. DOI: 10.1590/S0104-07072008000400018
https://doi.org/10.1590/S0104-0707200800...
.

The databases used for the search were Virtual Health Library (VHL) and PubMed, using Health Science Descriptors (DeCS), with the search strategy “miscarriage and grief.” The initial inclusion criteria for the publications were: research with humans, full text available for free in Portuguese or English, published in the last five years.

Based on those requirements, 37 articles were selected, of which 17 were excluded for being duplicates and 13 for not meeting the guiding question (three after reading the abstract and ten after reading the full article). Thus, the final sample was composed of seven articles capable of answering the research question.

Results and discussion

Charts 1 and 2 feature the analyses of the final sample.

Chart 1
Presentation of articles by authors, year of publication, setting and journal
Chart 2
Presentation of articles by objectives, type of study and results

Chart 2 shows that the objectives of all selected articles were not directly or exclusively related to the guiding question of this integrative review, which was answered through the information contained in the results, which were invariably broader in the papers. Only one study (14% of the sample) was carried out exclusively with men, two (28%) were undertaken with women only and the rest involved both genders, in couples or separately. Using the method described, no Brazilian study was found that answered the research question.

All the articles in the sample provided information favorable to the issuance of a death certificate for the fetus, even below 20 weeks of gestation, although it was not possible to identify the percentage of family members who would recognize themselves as having benefited from such issuance.

Fetal loss is one of the most frustrating episodes in a woman’s life. It is hard to cope with, besides being a professional failure for the obstetrician 2020 Aquino MMA, Guedes AC, Mesquita MRS, Hernandez M, Cecatti JG. Conduta obstétrica no óbito fetal. Rev Bras Ginecol Obstet [Internet]. 1998 [acesso 9 dez 2021];20(3):145-9. DOI: 10.1590/S0100-72031998000300004
https://doi.org/10.1590/S0100-7203199800...
. Thus, this healthcare provider may have difficulty to communicate the bad news and, as a result, the patient may feel helpless due to the lack of medical information.

Issuing a DC and offering a burial for the fetus are often avoided for fear of negatively affecting the statistics of the healthcare facility (hospital or maternity) or of the actual physician with intrauterine fetal demise (IUFD) data. There is a difference in notifications: miscarriages do not enter statistics, whereas IUFD does. Issuing the DC to allow burial requires a notification of fetal demise.

Although, as previously mentioned, current legislation provides that, in practice, the issuance of the DC is optional for cases in which the family wants to carry out the burial of the product of conception33 Brasil. Ministério da Saúde. A declaração de óbito: documento necessário e importante [Internet]. 3ª ed. Brasília: Ministério da Saúde; 2009 [acesso 15 jul 2020]. Disponível: https://bit.ly/3KGL4CW
https://bit.ly/3KGL4CW...
, this results in data being recorded for the healthcare provider.

According to data from the Information Systems Department of the Unified Health System (DataSUS), in 2019 there were 2,803 fetal deaths under 500 g in weight and 2,055 fetal deaths under 22 weeks of gestation 2121 Brasil. Ministério da Saúde. Óbitos fetais: Brasil. DataSUS [Internet]. [s.d.] [acesso 9 dez 2021]. Disponível: https://bit.ly/3Q8oFiP
https://bit.ly/3Q8oFiP...
. This shows that the DC is issued in very few cases of miscarriage and that the burial of the fetus is hardly ever offered to the family as a possibility.

These data are from the Mortality Information System (SIM), managed by the Department of Health Situation Analysis of the Health Surveillance Department, together with the state and municipal health departments. These departments collect the DC from notaries and enter their information in SIM. Such data can then be sorted by location (such as hospitals and maternity hospitals) and entered in health service statistics. Many physicians may avoid offering fetus burial for fear that the data resulting from the issuance of the DC will have a negative impact on the service.

Discussion grounded in law and anthropology

Based on the results shown in Chart 2, it can be said that death and the relationship with people who pass away are part of human life. This is not linked to any specific religion or spirituality, but rather to human experience itself. It is not, however, a relevant fact only in the private sphere. Although the experience is in the personal sphere, there is an evident social transcendence, since the family is the nucleus of society.

Based on this premise, one may consider that the articles analyzed in this review meet this human dimension of a personal relationship with death. First, it is evident that this relationship cannot be privatized, that is, it cannot be viewed merely from the individual perspective of the people involved, but must have a social outlook and, to that end, political recognition. Thus, facts that have a public impact are usually imbued with solemnity and expressed with appropriate formality so that their social, political and legal importance is acknowledged.

Such relevance is indubitable in the case of fetal demise, for both the objective data, which contribute, for example, to analyzing birth rates and statistics on syndromes, and the subjective data, such as assessment of effective respect for dignity and human rights. Absence of public and legal recognition—manifested in the DC—denies the existence of a personal relationship, and even the fact that a person may suffer from the loss of a child during pregnancy. It is not a mere formality, but a social acknowledgement of something that exists and needs to be experienced.

Such acknowledgement enables parents, close people and society itself to take their farewell of loved ones through different ritualistic and symbolic forms of farewell, of mourning. Thus, it is possible to establish a much healthier relationship from the human point of view—considered in the integrity of the material and spiritual dimension—which makes it possible, once the grief of loss is overcome, to establish memories of the period of human relationships of the moments they experienced together. In addition, spirituality itself—regardless of the way it is lived—is reinforced in the actual experience of human relationships, whether during the life or after the demise of these loved ones.

That is why it is essential to strengthen a support network to help with the experience of loss. Thus, one expects a disposition towards giving a new meaning to the grieving process, attributing dignity to suffering and helping overcome it. To this end, there is no legal obstacle that prevents the creation of memory through the formalization of death, since, based on the principle of legality as established in Article 5, II, of the Federal Constitution, no one will be obliged to do or refrain from doing anything other than by virtue of law2222 Brasil. Constituição da República Federativa do Brasil de 1988. Diário Oficial da União [Internet]. Brasília, p. 1, 5 out 1988 [acesso 1 set 2022]. Seção 1. Disponível: https://bit.ly/3P525Z8
https://bit.ly/3P525Z8...
.

There is a natural right to bury and keep watch over the dead, as well as the ethical and legal recognition of the human nature of the fetus. Indeed, the Pact of San José (or the American Convention on Human Rights, introduced in Brazilian legislation by Decree 678/1992) 2323 Brasil. Decreto nº 678, de 6 de novembro de 1992. Promulga a Convenção Americana sobre Direitos Humanos (Pacto de São José da Costa Rica), de 22 de novembro de 1969. Diário Oficial da União [Internet]. Brasília, p. 15562, 9 nov 1992 [acesso 9 dez 2021]. Seção 1. Disponível: https://bit.ly/3Q6zdz3
https://bit.ly/3Q6zdz3...
provides, in Article 4(1), the right to respect for life, which is protected by law and, in general, from conception.

Hence is the human nature of the fetus recognized, as well as the right to have its life and dignity respected. Likewise, the need to support the family is acknowledged, especially as its awareness of the legal system and medical deontology is insufficient.

Lastly, it is necessary to understand that the social recognition offered by the DC, which enables rites and symbols of a funeral farewell, does not grant the state the right to determine how this should be experienced. It will always be a deeply personal reality, marked by the parents’ beliefs and decisions, which cannot be disregarded in the decisions of which rituals and symbolic forms should be used in this farewell. This emphasizes the relevance of the solemn acts to celebrate the existence of the child, making it possible to remember them in the intimacy of each family, which, being the nucleus of society, extends this celebration to society as a whole.

Final considerations

Some parents who have experienced fetal death, even before 20 weeks of gestation, recognize in the issuance of the DC important effects on their grieving process, including before society. Supporting and identifying these parents are made possible by the communication skills of the physician. It is very important to discuss whether potential professional concerns about healthcare service statistics stemming from the issuance of fetal death certificates negatively influence the legitimate need to support these parents in coping with grief.

Referências

  • 1
    Pallottino E, Rezende C. Prefácio. In: Lupi C, Camargo F, Lupi L, Couri R, organizadoras. Histórias de amor na perda gestacional e neonatal. [local desconhecido]: Bookstart; 2015. p. 100.
  • 2
    Laurenti R, Jorge MHPM. O atestado de óbito: aspectos médicos, estatísticos, éticos e jurídicos [Internet]. São Paulo: Conselho Regional de Medicina do Estado de São Paulo; 2015 [acesso 15 jul 2020]. Disponível: https://bit.ly/3ehvVM1
    » https://bit.ly/3ehvVM1
  • 3
    Brasil. Ministério da Saúde. A declaração de óbito: documento necessário e importante [Internet]. 3ª ed. Brasília: Ministério da Saúde; 2009 [acesso 15 jul 2020]. Disponível: https://bit.ly/3KGL4CW
    » https://bit.ly/3KGL4CW
  • 4
    Shakespeare C, Merriel A, Bakhbakhi D, Baneszova R, Barnard K, Lynch M et al Parents’ and healthcare professionals’ experiences of care after stillbirth in low-and middle-income countries: a systematic review and meta-summary. BJOG [Internet]. 2019 [acesso 10 fev 2020];126(1):12-21. DOI: 10.1111/1471-0528.15430
    » https://doi.org/10.1111/1471-0528.15430
  • 5
    Rådestad I, Steineck G, Nordin C, Sjögren B. Psychic and social consequences of women in relation to memories of a stillborn child: a pilot study. Gynecol Obstet Invest [Internet]. 1996 [acesso 10 fev 2020]; 41(3):194-8. DOI: 10.1159/000292267
    » https://doi.org/10.1159/000292267
  • 6
    Muza JC, Sousa EN, Arrais AR, Iaconelli V. Quando a morte visita a maternidade: atenção psicológica durante a perda perinatal. Psicol Teor Prat [Internet]. 2013 [acesso 15 fev 2020];15(3):34-48. Disponível: https://bit.ly/3cJB3Ze
    » https://bit.ly/3cJB3Ze
  • 7
    McCreight BS. A grief ignored: narratives of pregnancy loss from a male perspective. Sociol Health Illn [Internet]. 2004 [acesso 2 fev 2020];26(3):326-50. DOI: 10.1111/j.1467-9566.2004.00393.x
    » https://doi.org/10.1111/j.1467-9566.2004.00393.x
  • 8
    Iaconelli V. Luto insólito, desmentido e trauma: clínica psicanalítica com mães de bebês. Rev Latinoam Psicopatol Fundam [Internet]. 2007 [acesso 15 fev 2020];10(4):614-23. DOI: 10.1590/S1415-47142007000400004
    » https://doi.org/10.1590/S1415-47142007000400004
  • 9
    Brasil. Ministério da Saúde. Manual de vigilância do óbito infantil e fetal e do Comitê de Prevenção do Óbito Infantil e Fetal [Internet]. 2ª ed. Brasília: Ministério da Saúde; 2009 [acesso 29 jul 2022]. Disponível: https://bit.ly/3Cb6iFg
    » https://bit.ly/3Cb6iFg
  • 10
    Conselho Federal de Medicina. Resolução nº 1.779, de 11 de novembro de 2005. Regulamenta a responsabilidade médica no fornecimento da Declaração de Óbito. Revoga a Resolução CFM n. 1601/2000. Diário Oficial da União [Internet]. Brasília, p. 121, 5 dez 2005 [acesso 15 fev 2020]. Seção 1. Disponível: https://bit.ly/3Q8FlH5
    » https://bit.ly/3Q8FlH5
  • 11
    Agência Nacional de Vigilância Sanitária. Resolução da Diretoria Colegiada – RDC nº 222, de 28 de março de 2018. Regulamenta as Boas Práticas de Gerenciamento dos Resíduos de Serviços de Saúde e dá outras providências. Diário Oficial da União [Internet]. Brasília, nº 61, p. 76, 29 mar 2018 [acesso 15 fev 2020]. Seção 1. Disponível: https://bit.ly/3qafS5m
    » https://bit.ly/3qafS5m
  • 12
    Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto & Contexto Enferm [Internet]. 2008 [acesso 15 fev 2020]; 17(4):758-64. DOI: 10.1590/S0104-07072008000400018
    » https://doi.org/10.1590/S0104-07072008000400018
  • 13
    Cesare N, Oladeji O, Ferryman K, Wijaya D, Hendricks-Muñoz KD, Ward A, Nsoesie EO. Discussions of miscarriage and preterm births on Twitter. Paediatr Perinat Epidemiol [Internet]. 2020 [acesso 12 out 2021];34(5):544-52. DOI: 10.1111/ppe.12622
    » https://doi.org/10.1111/ppe.12622
  • 14
    Smith LK, Dickens J, Bender Atik R, Bevan C, Fisher J, Hinton L. Parents’ experiences of care following the loss of a baby at the margins between miscarriage, stillbirth and neonatal death: a UK qualitative study. BJOG [Internet]. 2020 [acesso 25 out 2021];127(7):868-74. DOI: 10.1111/1471-0528.16113
    » https://doi.org/10.1111/1471-0528.16113
  • 15
    Obst KL, Due C, Oxlad M, Middleton P. Men’s grief following pregnancy loss and neonatal loss: a systematic review and emerging theoretical model. BMC Pregnancy Childbirth [Internet]. 2020 [acesso 25 out 2021];20(1):11. DOI: 10.1186/s12884-019-2677-9
    » https://doi.org/10.1186/s12884-019-2677-9
  • 16
    Miller EJ, Temple-Smith MJ, Bilardi JE. ‘There was just no-one there to acknowledge that it happened to me as well’: a qualitative study of male partner’s experience of miscarriage. PLoS One [Internet]. 2019 [acesso 25 out 2021];14(5):e0217395. DOI: 10.1371/journal.pone.0217395
    » https://doi.org/10.1371/journal.pone.0217395
  • 17
    Bellhouse C, Temple-Smith MJ, Bilardi JE. “It’s just one of those things people don’t seem to talk about…” women’s experiences of social support following miscarriage: a qualitative study. BMC Womens Health [Internet]. 2018 [acesso 14 abr 2021];18(1):176. DOI: 10.1186/s12905-018-0672-3
    » https://doi.org/10.1186/s12905-018-0672-3
  • 18
    Cassidy PR. Care quality following intrauterine death in Spanish hospitals: results from an online survey. BMC Pregnancy Childbirth [Internet]. 2018 [acesso 15 abr 2021];18(1):22. DOI: 10.1186/s12884-017-1630-z
    » https://doi.org/10.1186/s12884-017-1630-z
  • 19
    Meaney S, Corcoran P, Spillane N, O’Donoghue K. Experience of miscarriage: an interpretative phenomenological analysis. BMJ Open [Internet]. 2017 [acesso 25 out 2021];7(3):e011382. DOI: 10.1136/bmjopen-2016-011382
    » https://doi.org/10.1136/bmjopen-2016-011382
  • 20
    Aquino MMA, Guedes AC, Mesquita MRS, Hernandez M, Cecatti JG. Conduta obstétrica no óbito fetal. Rev Bras Ginecol Obstet [Internet]. 1998 [acesso 9 dez 2021];20(3):145-9. DOI: 10.1590/S0100-72031998000300004
    » https://doi.org/10.1590/S0100-72031998000300004
  • 21
    Brasil. Ministério da Saúde. Óbitos fetais: Brasil. DataSUS [Internet]. [s.d.] [acesso 9 dez 2021]. Disponível: https://bit.ly/3Q8oFiP
    » https://bit.ly/3Q8oFiP
  • 22
    Brasil. Constituição da República Federativa do Brasil de 1988. Diário Oficial da União [Internet]. Brasília, p. 1, 5 out 1988 [acesso 1 set 2022]. Seção 1. Disponível: https://bit.ly/3P525Z8
    » https://bit.ly/3P525Z8
  • 23
    Brasil. Decreto nº 678, de 6 de novembro de 1992. Promulga a Convenção Americana sobre Direitos Humanos (Pacto de São José da Costa Rica), de 22 de novembro de 1969. Diário Oficial da União [Internet]. Brasília, p. 15562, 9 nov 1992 [acesso 9 dez 2021]. Seção 1. Disponível: https://bit.ly/3Q6zdz3
    » https://bit.ly/3Q6zdz3

Publication Dates

  • Publication in this collection
    28 Nov 2022
  • Date of issue
    Jul-Sep 2022

History

  • Received
    15 Dec 2021
  • Reviewed
    10 Aug 2022
  • Accepted
    15 Aug 2022
Conselho Federal de Medicina SGAS 915, lote 72, CEP 70390-150, Tel.: (55 61) 3445-5932, Fax: (55 61) 3346-7384 - Brasília - DF - Brazil
E-mail: bioetica@portalmedico.org.br