Policy paper

Government response to the independent Pregnancy Loss Review: care and support when baby loss occurs before 24 weeks' gestation

Published 22 July 2023

Applies to England

Ministerial foreword

Pregnancy, for most people, is meant to be one of the most wonderful times in their lives. While most pregnancies have a happy outcome, for some families their dreams and hopes of new beginnings are cruelly cut short. Pregnancy loss before 24 weeks’ gestation is a common outcome, but too often it is not spoken about.

Every year in the UK, an estimated 250,000 pregnancies end through miscarriage, making it the most common complication of pregnancy experienced by an estimated 1 in 5 women. There are also around 11,000 hospital admissions each year for losses due to ectopic pregnancies, 19,000 admissions for molar pregnancies and, in 2021, around 3,300 women made the difficult decision to terminate a much-wanted pregnancy for medical reasons.

Pre-24-week pregnancy loss can be extremely isolating and significantly impact the emotional and psychological wellbeing of women and their families.

The Pregnancy Loss Review was commissioned to consider options aimed at improving care and support for parents who experience a pre-24-week pregnancy loss.

I would like to thank the women and families who engaged with this review. It is so important that the voices of those who have suffered a loss are heard. Your willingness to share your experiences will support the improvement in pre-24-week pregnancy loss care. I would also like to thank the many nurses, midwives, doctors and researchers who shared the challenges they face in providing high-quality care during and after early and mid-pregnancy loss, and their advice on how improvements in care can be made.

I am grateful to the review leads, Zoe Clark-Coates and Samantha Collinge, for their tireless work throughout the course of this review. They have, throughout their careers, supported thousands of women and families through their experiences of pregnancy loss.

Taken together, their 73 recommendations set out a comprehensive plan for changes in the NHS and wider society to minimise the trauma that pregnancy loss can bring. It is important that the healthcare system reflects on:

• the review’s findings
• what good, compassionate care looks like
• where gaps lie in service provision for those who suffer pregnancy loss

I would like to thank Tim Loughton MP, whose Civil Partnerships, Marriages and Deaths (Registration etc) Act placed a requirement on the government to consider this important issue. I am also grateful to the pregnancy and baby loss charities for the work they do to support families and clinicians, and for the research they support, and to the All Party Parliamentary Group for Baby Loss for their commitment to this cause.

I read with dismay and sadness about the lack of compassion shown to those who had suffered pre-24-week pregnancy loss and how, in some instances, families were not provided the emotional support they so desperately needed. We must do more to support those who lose their babies in early or mid-pregnancy.

Some of the changes recommended by the review will require major system modifications and substantial new funding. We will work collaboratively with the NHS, our other system partners, and with women and their partners to co-produce future developments that improve the experience of care for women and their partners, and provide value for money, and also make the case for new funding in future Spending Reviews where necessary.

In the meantime, women and their families should not continue to suffer unnecessarily. This response sets out how we will prioritise the recommendations that we can act on urgently while working on medium and long-term system reform.

Maria Caulfield, Women’s Minister (Government Equalities Office), Parliamentary Under-Secretary of State for Mental Health and Women’s Health Strategy

Introduction

This is the government’s formal response to the independent Pregnancy Loss Review: care and support when baby loss occurs before 24 weeks’ gestation.

The government welcomes the review, its insights and recommendations. Improving the outcomes and experiences of care for mothers and babies, and ensuring that grieving families have access to the support they need is a priority for this government.

The review was commissioned by and reported to the Department of Health and Social Care (DHSC) in England. The review fulfils the requirement set out in the Civil Partnerships, Marriages and Deaths (Registration etc) Act 2019, which required the Secretary of State for Health and Social Care:

to make arrangements for the preparation and publication of a report on whether and, if so, how the law ought to be changed to require or permit the registration of pregnancy losses that cannot be registered as stillbirths under the Births and Deaths Registration Act 1953.

The review’s terms of reference were published in March 2018. The purpose of the review was to consider:

• the impact on families of the current threshold of 24 weeks’ gestation before being able, formally, to register a miscarriage if they so wish
• whether it would, on balance, be beneficial to look at legislative options to amend existing primary legislation to allow parents to register a miscarriage if they so wish
• options to improve NHS gynaecology and maternity care practice for parents who experience a miscarriage and other causes of baby loss

The review was published on 22 July 2023. Following extensive engagement with healthcare providers, bereaved families, charities, academics and numerous local and national organisations, the review leads set out their findings and recommendations, which cover the following areas:

• education, training and information
• service provision
• early pregnancy assessment units (EPAUs)
• gynaecology services
• clinical care quality
• bereavement care and support
• primary and secondary care chaplaincy
• patient records, IT and data
• the workplace

The voices of bereaved women and men have been strongly reflected throughout the review’s report. Importantly, the review leads noted that, despite many families being affected by pre-24-week pregnancy loss, comparatively little policy attention has been directed towards improving their experience and outcomes throughout the early stages of pregnancy, which cuts across different services and clinical specialties such as primary care, gynaecology and emergency care.

The review leads concluded that, while it currently may not be possible to prevent many pre-24-week pregnancy losses from occurring, much more can be done to ensure that each grieving parent receives excellent care and compassionate support.

The review and its 73 recommendations make a strong case for major changes in service organisation and delivery to ensure that those experiencing a pre-24-week pregnancy loss are supported by well-trained clinicians throughout a clearly defined pathway of care in which their views and choices are respected.

This response sets out the immediate action the government is taking to prioritise the 20 recommendations that we can begin to implement in the short term, while continuing to work with our system partners on those that need more time to consider complex clinical questions and planning to progress.

We will provide updates within the next 2 years via written ministerial statements on the remaining recommendations.

The government’s response to the recommendations follows.

Immediate actions

This section sets out the immediate action the government is taking to prioritise the 20 recommendations that can be implemented in the short term.

Certificate of baby loss

Recommendation 61

In recognition of a life lost, the government must ensure that an official certificate is available to anyone who requests one after experiencing any loss pre-24 weeks’ gestation. The certificate must:

• be backdate-able with no cut-off point so people with a historic loss may also access this long-requested recognition
• be available to anyone regardless of the type of loss they have experienced. Parents must have the option to be able to supply evidence of the loss, but this should not be mandatory
• contain wording that is adaptable (including an option to add a baby’s name) as it is vital that parents are able to choose the language they prefer
• be available as a download or as a hard copy. The certificate needs to be accessible by all, not just by people with access to a computer
• be available to both parents

To ensure the certificates remain credible, the applicant should be required to provide identity verification.

The certificates will not be legal certificates, but will be official government-issued ones, and should look official, rather than just commemorative, as it is crucial to families that they have official recognition of their loss.

We will continue to partner with the government to design and deliver this as quickly as possible.

For many women and their families, it is important that early pregnancy losses are recognised and remembered. While parents whose babies are born without signs of life after the 24th week of pregnancy receive a certificate of registration of stillbirth, there is no formal process for parents to legally register a loss that occurs before the 24th week of gestation.

Some bereaved parents find this to be distressing, although other parents may find it equally distressing if they were required to legally register the loss when they did not wish to do so. For this reason, the Women’s Health Strategy, published in July 2022, included a commitment to introduce a voluntary baby loss certificate in England, as recommended by the review in an interim report to DHSC ministers.

Work has begun to develop and assess the ‘Certificate of Baby Loss’ service through which eligible parents will be able to apply for a certificate to recognise their pre-24-week pregnancy loss.

The purpose of issuing a certificate is to provide comfort and help parents validate their loss. The service will be voluntary for parents who have had a pregnancy loss at any gestation under 24 weeks. Medical verification of the loss will not be required so that parents who have experienced a historic loss (that occurred before the launch of the scheme) can apply.

The certificate will provide official recognition of the pre-24-week pregnancy loss, but it will not be a legal document. The certificate will not provide evidence of the parents’ identity, or entitlement to any statutory maternity or bereavement benefits. Bereaved parents will be able to apply online through GOV.UK and receive a paper certificate in the post. A telephone support service will be available for those not able to apply online.

In advance of a public launch, the certificate will be tested with 1,000 bereaved families, who will be able to advise on the application process and receive a Certificate of Baby Loss. Subject to this testing, this process will enable the rollout of a certificate during International Baby Loss Awareness Week (9 to 15 October) 2023.

Sensitive handling and storage of pregnancy loss remains

Recommendation 35

We must have an enforceable guideline or regulation (in line with the Human Tissue Authority guidance) surrounding the sensitive disposal of pre-24-week babies’ and baby loss remains, rather than guidance that is not always followed.

Recommendation 36

The NHS, in partnership with Zoe and Sam, should develop and deliver an appropriate and sensitive receptacle to collect baby loss remains when a person miscarries.

Recommendation 37

The NHS, in partnership with Zoe and Sam, should develop and deliver an appropriate, respectful container where baby loss remains may be stored following a miscarriage.

Recommendation 39

EPAUs and A&Es should ensure that cold storage facilities (such as a dedicated refrigerator) are available to receive and store baby remains or pregnancy tissue 24/7, so that people aren’t asked to store them in their home refrigerators.

Women going through a pregnancy loss or termination of pregnancy before 24 weeks of gestation are faced with the question of how to handle the pregnancy remains or fetal tissue. Every parent facing this question will have their own personal beliefs and views.

The role of clinicians supporting parents is to:

• provide them with the information they need
• support them in their decisions
• treat pregnancy remains of any gestation with respect

It should never be acceptable that fetal remains are treated like waste products and parents should never be asked to store fetal remains in their own refrigerators until their local gynaecology or laboratory testing services are open.

Guidelines and regulation of the sensitive disposal of pre-24-week babies and baby loss remains

The Human Tissue Authority (HTA) published Guidance on the sensitive handling of pregnancy remains in 2015 at the request of the Chief Medical Officer at the time.

The disposal of pregnancy remains, which are considered to be the mother’s tissue, is not, however, within the scope of the HTA’s regulatory remit. Service providers such as NHS trusts that are involved with the disposal of pregnancy remains should self-assess and monitor their compliance with this guidance through regular audit of relevant policies, procedures and women’s medical records.

At present, the Care Quality Commission (CQC) may consider compliance with this guidance as part of its ongoing monitoring and during inspection of registered providers of NHS trust maternity and gynaecology services, as well as NHS and private termination of pregnancy services. CQC makes judgements about these type of services in respect of whether they are safe, effective, caring, responsive and well led, and publishes its findings.

A regulatory route for CQC to enforce the appropriate handling of clinical waste exists through the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Regulation 15(1)(a) includes the provision that:

Domestic, clinical and hazardous waste and materials must be managed in line with current legislation and guidance.

CQC cannot prosecute an individual for a breach of Regulation 15 or any of its parts, but it can take direct regulatory action by issuing a ‘notice of changes’.

In cases of termination of pregnancy, Regulation 20 of the Care Quality Commission (Registration) Regulations 2009 requires the registered person to:

prepare and implement appropriate procedures to ensure foetal tissue is treated with respect.

CQC can directly prosecute for a breach of this regulation.

The Royal College of Nursing has produced guidance to help all healthcare professionals to have in place sound systems and processes to ensure the safe and appropriate disposal of pregnancy remains where the pregnancy has ended before the 24th week of gestation.

CQC has committed to ministers that its inspections of maternity and gynaecology services (including EPAUs) and all termination of pregnancy services will continue to include both of the following:

• a formal assessment of whether bereaved families are informed of all of their available options, in line with HTA guidelines, and supported to make a choice that is right for them
• taking a record of whether the trust provides bereavement support, including support with funeral, burial or sensitive disposal of fetal remains, in the case of early pregnancy loss

In response to the Pregnancy Loss Review and to ensure remains of pregnancies lost before 24 weeks’ gestation are disposed of sensitively, we will lead a review of the Guidance on the sensitive handling of pregnancy remains and ask the HTA to make any necessary updates that are within its remit by March 2024.

Receptacles for the sensitive storage of pregnancy loss remains

Early pregnancy losses may occur in a clinical setting such as a hospital emergency department or an EPAU. If a first-trimester miscarriage is expected, some women will choose to go through the loss at home.

While being at home may be a comfort for some women experiencing loss, ministers are clear it is not acceptable for women to be asked to collect and store remains in household receptacles. Also, women going through a miscarriage in hospital should not have fetal remains stored or transported in receptacles normally associated with waste products, such as bed pans or kidney dishes.

To ensure this is not the case, we will work at pace to develop and create a bespoke receptacle to allow fetal remains to be collected and stored with due dignity. We will convene a working group comprising parents, clinicians, design experts and others to co-produce product specifications for the sensitive collection and storage of pregnancy loss remains. Scoping work will begin immediately and the group will hold its first meeting in September 2023 with the objective to finalise product specifications by February 2024.

Cold storage facilities

Women choosing to be at home during their loss should not be expected to store pregnancy remains in their domestic refrigerators, unless this is their wish.

At certain times, such as evenings or weekends, a woman’s local EPAU might be closed. NHS England (NHSE) will undertake scoping work to understand the provision of cold storage facilities across EPAUs and A&E departments. This work will include:

• assessment and identification of any gaps in provision of cold storage and clinical resources
• the potential funding required to address the gaps

NHSE will also consult on clear pathways on accessing this cold storage, recognising that there are sensitivities around not only the remains but a need for a compassionate approach to the women and their families.

Any required investment to address gaps in provision of cold storage and implementation of pathways will be subject to future Spending Reviews, and further work to address the gaps will form part of the medium to long-term actions.

Care for sporadic and recurrent miscarriage

Recommendation 43

Working with the Royal Colleges, NHSE should develop standardised primary and secondary care clinical guidelines for pre-24-week baby loss, and the Royal College of Obstetricians and Gynaecologists (RCOG) should revise its Green-top Guidelines so that local service providers and commissioners can update their local guidelines and service provision. The guidance should include the following:

• following the first loss, if individuals experience a pre-24-week baby loss and request an appointment with their GP practice, a person-centred consultation should be offered to them. If appropriate or requested by the individual, during this appointment, the individual’s baby loss experience and future pregnancies should be discussed. Information about the impact on mental health and trauma that may ensue following a baby loss should be provided, and individuals should be advised that they can self-refer to NHS talking therapies. Clinicians should actively encourage this self-referral if they feel it would benefit the individual
• following 2 losses, an appointment should be made for blood tests, including full blood count and thyroid function and other necessary investigations. Depending on the results of these tests, along with any other pre-existing or chronic physical or mental health conditions, referrals should be made to the relevant specialism
• following a third baby loss, a consultant-led appointment should be offered at a specialist recurrent miscarriage centre, where possible, so additional tests, including genetic testing, scanning, screening and treatment, may be offered
• the standardised primary and secondary care clinical guidelines should include flexibility to accommodate and prioritise differing factors such as advanced maternal age, infertility, recurrent loss and other medical conditions

We agree with the recommendations that pregnancy loss needs to include plans for ongoing care after every loss.

We welcome RCOG’s update of its Green-top Guideline No. 17 on Recurrent Miscarriage published on 19 June 2023. The guideline does not cover detailed care for women with fewer than 3 miscarriages (that is sporadic miscarriages), but it does encourage clinicians to use their clinical discretion to recommend extensive evaluation after 2 first-trimester miscarriages if there is a suspicion that they are of a pathological rather than sporadic nature.

To further inform decision-making, the Tommy’s Miscarriage Centre at Birmingham Women and Children’s Hospital is launching a 3-month pilot that will assess the effectiveness of a graded model of sporadic or recurrent miscarriage care. The pilot will ensure that women receive testing and advice following a first, second or third miscarriage, and will measure its success on the number of identified medical conditions through the additional tests that will take place. We will evaluate the outcomes and impacts on women’s miscarriage care of the Tommy’s project at the end of this year, including value for money.

We recognise that implementing a service that would offer testing and investigation for women who experience 1 or 2 miscarriages as standard care will require significant investment – notably, recruitment and training of specialist staff. The offer of a consultant-led appointment at a specialist recurrent miscarriage centre following a third baby loss also requires further consideration.

The investment needed will be considered alongside the results of the Tommy’s Miscarriage Centre pilot and will inform our decision on seeking the required funding in a future Spending Review. We envisage that further work to implement the graded model of care more widely will take place in the medium to long term.

Bereavement

Recommendation 57

NHSE must increase capital investment to ensure adequate facilities are provided for bereaved parents. Bereavement suites, counselling rooms and private spaces should be available to all families regardless of the baby’s gestational age. Women and their partners should not be expected to receive unexpected bad news, discuss treatment options or grieve in public spaces. Funding should be allocated for this.

All parents experiencing a loss should be provided with safe and compassionate bereavement support that is responsive to their needs and choices. While we recognise that many units are working towards these standards, this standard of bereavement care provision needs to be consistent nationally.

The National Bereavement Care Pathway (NBCP) for Pregnancy and Baby Loss was launched with DHSC funding in 2017. Based on 9 standards, the NBCP provides a dedicated evidence-based care pathway with guidance for professionals delivering bereavement care to parents and families.

Ensuring parent voice is at the heart of its development, Sands has led on the development and implementation of the NBCP. As of 1 July 2023, 119 NHS trusts in England with maternity services (93%) have voluntarily committed to adopting the 9 NBCP standards. Sands is in regular contact with and has offered support to the final 7% of trusts (9 in total) yet to adopt the NBCP.

Sands supports those trusts who are committed to implementing the NBCP by:

• facilitating a community of best practice
• running regular workshops and training sessions
• creating resources
• hosting regular support meetings

It recently developed an implementation toolkit to support trusts adopting the NBCP.

In March 2023, NHSE published its 3-year delivery plan for maternity and neonatal services. The plan includes a commitment to undertake a compliance survey of the estates, inclusive of early pregnancy, starting by spring 2024.

NHSE will also commission a review of the Health Building Note 09-02: Maternity care facilities to give best practice guidance on the design and planning of new healthcare buildings and the adaptation or extension of existing facilities, including access to appropriate facilities for women and families who suffer bereavement at any stage of pregnancy. This will help to determine the level of investment needed for the development of sensitive bereavement facilities in the medium to long term.

NHS employees

Recommendation 69

The NHS should be a leading example in offering excellent bereavement support and leave to staff who experience pre-24-week baby loss.

We recommend that up to 10 days of paid leave for the person who is pregnant and 5 days for the partner should be provided for any pre-24-week baby loss. A ‘fitness for work’ statement from a GP should not be required unless additional time off is required.

This paid time off should not be used for ‘sickness trigger’ purposes.

In addition, NHS employees (both the person experiencing the loss and their partner) should be offered paid time off for appointments linked to pregnancy or baby loss, and flexible working arrangements, where possible.

Recommendation 70

Each trust should offer reasonable bereavement leave and remove any restrictions limiting bereavement leave to 3 days a year.

Recommendation 71

Trusts should not group bereavement, sickness and parental leave in the same category.

Recommendation 72

The NHS must put adequate mental health support in place for all NHS staff.

Many employers have a maternity policy or guidance in place to support their employees who are struggling to cope (for physical or mental health reasons) following a miscarriage. It is clear, however, that this is not universal.

There are statutory provisions already in place to support an employee following loss of a pregnancy as follows:

• employees who are not able to work can claim up to 7 days of Statutory Sick Pay without providing any documentary evidence to their employer. After this, they must seek a medical ‘fit note’ to continue to receive Statutory Sick Pay
• a woman is automatically protected against disadvantage in the workplace that arises because of her pregnancy, any illness related to her pregnancy or absence because of that illness – this includes any illness caused by miscarriage. This protection extends for 2 weeks after the end of the pregnancy.  After that, the general law on sex discrimination continues to offer some protection
• under the right to request flexible working, all employees with 26 weeks’ continuous service can make a statutory request to change the hours, timing or location of their work. Having a flexible working arrangement can help individuals to balance their work and home lives when faced with a traumatic life event such as baby loss

This statutory provision is a floor, not a ceiling, and the government strongly encourages employers to go further to actively promote a workplace where women and their partners are comfortable to take the time that they need following pregnancy loss.

The NHS will consider the recommendations in scoping what, if any, additional policy requirements can be taken at a national level to support NHS employees, and provide managers and colleagues with advice on how to support people affected.

Staff should be supported with kindness, compassion and understanding, and feel able to reach out to someone they trust to ensure that their mental and emotional health needs are adequately met. We recognise everybody is different and individuals may also need temporary work adjustments or other levels of support.

Education, training and information

Recommendation 2

NHSE should commission the development of a poster on ‘what to do if you have pain or bleeding during pregnancy’ to be made available to GP practices, sexual health clinics, pharmacies and women’s health hubs.

The poster should include a QR code to link to more information and should have space for contact details for local services.

Recommendation 3

NHSE should work with NHS trusts and their Maternity Voices Partnerships to review the quality and accessibility of information regarding pre-24-week baby loss, including:

• what information should be given at the first antenatal visit
• what to do and how to access services if there is pain and bleeding in early pregnancy

This information should include a list of local services and the care they can expect to receive, as well as emergency contact numbers and medical guidance on managing symptoms. People should know what to expect in advance.

This information must be available in all languages and in easy read and digital formats.

Recommendation 6

Information leaflets, bereavement support books and bereavement resources should be available to bereaved parents to take home in all primary and secondary healthcare settings, following a pre-24-week baby loss.

Leaflets must be available in all languages and in easy read and digital format.

We recognise it is important that mothers, partners and anyone supporting them should have access to the correct information about the signs of pregnancy loss and how and when to seek emergency care, and easy access to local information on who to contact if they have concerns.

Translating all information materials into all languages would incur a substantive cost that would divert money from frontline services. Translation into some languages will be required based on local needs with production managed nationally.

We will collaborate with NHSE and other stakeholders to identify and review best practice examples of existing information resources, and look at how they may be adapted and made available for use in other areas.

EPAUs

Recommendation 11

NHSE should develop guidance for commissioners of 111 and ambulance services that sets out how to work with trusts to contract appointments with EPAUs so that patients with pre-24-week complications can be sent directly to an EPAU, where appropriate.

This practice already happens in some areas but not everywhere.

Recommendation 17

NHSE must ensure that a Directory of Services (DoS) is created in each region, which is locally owned and regularly updated, to ensure that any patient calling 111 or using 111 online is correctly directed to appropriate clinical care.

The DoS should reflect EPAU availability to ensure that women experiencing baby loss are accurately directed to the most appropriate service.

Where services do not currently exist, these should be commissioned and funding allocated.

EPAUs provide specialised clinical services for women with suspected complications during early pregnancy, including clinical assessments, ultrasound and laboratory investigations, management planning, counselling and support. EPAUs shorten the time needed to reach a diagnosis and reduce the number of hospital admissions for women with suspected early pregnancy complications.

As noted in the review, when pre-24-week complications take place, primary and secondary care services in most areas are working well to put in place dedicated appointments with EPAUs so that, where there are concerns, pregnant women can be sent directly for specialist care. These types of arrangements, however, are not implemented nationally.

In partnership with NHSE, we will review best practice examples and look at how to roll them out nationally. Work will be undertaken to look at how commissioners of 111 and ambulance services can work with trusts to contract block appointments with EPAUs so that patients with complications before 24 weeks’ gestation can be sent directly to an EPAU when appropriate.

A Directory of Services is already in place, which is nationally owned and locally managed with regular updates. NHSE has committed to undertake a review of the DoS within each area to ensure EPAUs are reflected correctly, ensuring that women experiencing baby loss are accurately directed to the most appropriate service.

Research

Recommendation 15

The National Institute for Health and Care Research (NIHR) should commission additional research into EPAU working practices, accessibility, outcomes for women, and cost-effectiveness (including prospects for new community EPAUs), drawing on the Variations in the organisation of and outcomes from Early Pregnancy Assessment Units: the VESPA mixed-methods study and other studies.

Recommendation 27

We recommend that further research, evaluation and piloting is required to develop screening tools and pathways for women and their partners suffering with mental health illness as a result of baby loss.

Studies have demonstrated the link between baby loss and post-traumatic stress disorder (PTSD) and depression, which in some cases has resulted in suicide.

Recommendation 33

NIHR should commission research into pain management for pre-24-week baby loss as our research has shown that patients are often left without suitable or sufficient pain relief.

Recommendation 54

NIHR should commission additional research into why there is an increased risk of pre-24-week baby loss in women from black, Asian and ethnic minority backgrounds and people from socio-economically deprived areas, and what may be done to minimise these risks.

We recognise that research is needed to inform system reforms. We will duly consider each of these proposed recommendations with a view to commissioning research, through NIHR, into:

• the organisation, function and health economics of EPAUs
• mental health screening for those affected by pre-24-week baby loss
• pain management during and following early baby loss
• the disparities in outcomes and experiences of care for women from different ethnic and socio-economic backgrounds

Medium and long-term actions

The report makes the case for major changes in service organisation and delivery to ensure that those experiencing a first or second-trimester pregnancy loss are supported throughout a clearly defined pathway of care.

Our response has so far set out in detail what actions the government intends to take immediately to progress recommendations in relation to:

• baby loss certificates
• the sensitive handling and storage of baby loss remains
• recurrent miscarriage
• bereavement care
• NHS employees
• education, training and information
• EPAUs

It is important that we, together with our healthcare system partners, carefully consider the remaining recommendations to ensure they are taken forward in a manner that appropriately addresses the gaps that the review has identified in service provision for those who suffer pregnancy loss. During the next 12 months, we will convene a series of workshops, roundtables and stakeholder meetings to develop and cost the system changes needed.

The review highlights that pregnancy loss care pathways and services need to link smoothly with the maternity care pathway, and gynaecology and fertility pathways. In too many places, these links simply do not exist.

To ensure that links are made between primary care, maternity, gynaecology and emergency services, and that the pathways of care between services are clear to women and their partners, we will establish a Pregnancy Loss Ministerial Oversight Group chaired by Maria Caulfield, Women’s Minister (Government Equalities Office) and Parliamentary Under-Secretary of State for Mental Health and Women’s Health Strategy.

Collaborative working across clinical specialties and with women and their partners will be required to consider how the recommendations can be delivered effectively and provide best value for money.

We will continue to update on our work, including on the remaining medium and long-term recommendations, via written ministerial statements.