Information Matters. Experience Matters.

• Ask your care team for a summary of disposition options available in the hospital and state where birth is intended. This information may be available at your birthing institution or via prenatal care providers. Be prepared to answer questions like, "What was the timing of death in gestation?" Providers may ask questions of this nature to discern what options will be specifically available for a given patient. This information will also help discern how birth/death certificates may be handled.

• Request time for memory-making (holding, bathing, naming, photographing) before transport or processing of remains if desired/able, as most hospitals permit this unless constrained by pathology deadlines. Some hospitals have cooling cots that allow families to spend extra time with babies lost later in gestation and postpartum. 

• Understand deadlines and storage limits. Hospitals often have policies about how long they can store remains before disposition or must move them to a pathology lab.

• Ask for contact names (i.e., bereavement coordinator, hospital chaplain, legal or risk office) who can assist you in navigating regulations or advocacy in your jurisdiction.

U.S. Context: 

In the U.S., states differ on whether they mandate burial or cremation of fetal remains (some do, many do not) and on what gestational thresholds (e.g., ≥ 20 weeks, or ≥ 350 g) trigger certain reporting or disposition rules.

• Some states classify fetal remains (especially early ones) as medical waste unless a parent requests a different disposition, while others require hospitals or clinics to offer burial or cremation options.

• For example, Texas law requires that embryonic or fetal remains not be treated as pathological waste and allows (or mandates) interment, cremation, or steam disinfection plus interment. 

• U.S. hospitals increasingly adopt principles of “respectful disposition” (sometimes called “sensitive disposal”) to centralize family choice, clear communication, and flexibility within legal constraints.

International Context:

• In many countries, no legal requirement exists for burial or cremation of early pregnancy loss, and hospitals may treat fetal remains as clinical waste unless the family requests otherwise (e.g. in the UK for losses before 24 weeks). 

• In UK and NHS practice, policies often use the term “sensitive disposal”: fetal remains are collected separately from other waste and either cremated or interred; hospitals often offer parents choice of private service, shared service, or letting the trust arrange disposition.

• In England, hospitals may have policies that allow individual incineration or cremation with a unique tag number, organized through their clinical waste contractor with tracking.

• In settings where regulatory oversight is limited or where cultural norms vary, actual practice often reflects hospital norms and institutional culture more than strict law. Ethnographic research highlights how“clinical practices produce foetal personhood” and how women may feel their wishes are marginalized when institutional disposal is rigid.

• In some countries, cultural or religious practices may dictate very different norms for handling pregnancy loss; hospitals in those regions often adopt flexible or hybrid policies to accommodate cultural respect.

It is important to note that laws and protocols often change and may limit or expand what memorialization and remain disposal options are feasible.

Below are categories of how fetal remains might be handled. Some will be routine in certain jurisdictions; others may be optional or unavailable depending on local law.

Hospital communal or shared burial/cremation

The hospital (or health system) periodically arranges respectful collective burial or cremation of fetal remains (often without individual return of ashes).

Common in many systems (e.g., in the US and UK many hospitals use “sensitive disposal” policies for losses < 24 weeks).

Individual cremation or burial via funeral services

Families may engage a funeral director or mortuary to cremate or bury remains, with option of returning ashes, pending the fetal loss occurs after ~24 weeks gestation, at which point there is a sufficient amount of bone matter for cremation in most locations.

Requires that local law and hospital policy permit transfer and that relevant permits (burial, cremation, transit) be obtained. Death certificate will most likely be issued.

Home burial or natural burial

In locations where laws permit, remains may be interred on private property, woodland burial, or in a meaningful personal location

Many jurisdictions have strict environmental, zoning, or health restrictions. Some require advanced approval.

Hospital respectful disposition (default)

If no private arrangement is made, hospitals may perform a “respectful disposition” per policy (e.g., cremation or incineration, as part of or separate from other medical waste)

If a hospital treats early fetal remains as general medical waste, families may need to request special handling or appeal policy. Policies vary by hospital, state, and nation. 

Release to family

In some settings, fetal remains may be released to the family (enclosed in a container) for private arrangement.

This depends heavily on hospital policy, law, and whether pathology or autopsy has occurred.

Note: In some jurisdictions, remains that have undergone fixation (e.g., in formalin for pathology) may no longer be acceptable for burial in certain forms because of chemical safety rules.

Whether or not remains are accessible or used in burial/cremation, there are many meaningful ways to remember:

• Naming the lost multiple(s) 

• Spiritual or cultural rituals

• Ceremonies (bedside, chapel, cemetery, scattering if law permits in desired jurisdiction)

• Memory garden, trees, plaques, stones

• Memory boxes, keepsake items (e.g., those offered by the Skye High Foundation, Footprints, and others)

• Online memorial pages, events, or journaling (such at those offered by Footprints, RTZ Hope, Chasing the Rainbows, and others)

• Anniversary rituals on birthdays, due dates, death dates, etc. (lighting candles, letters)

Institutions should encourage families to consider planning these even when remains disposition may be managed by others.

• Affirm the legitimacy of grief and identity disruption. Even when a twin death occurs very early, the surviving baby is part of a multiple and that relationship (however brief) may have meaning—emotional as well as biological—for both families and surviving children. 

• Know VTS status may not be obvious. As most VTS cases occur in the first trimester of pregnancy, understand that the VTS status of an early twin/triplet loss may not be at the forefront of a patient's medical profile by the time they arrive at their respective birthing institutions, where they may or may not require advanced neonatal care.

• Policy transparency is crucial. Hospitals should publish or provide written policies on fetal remains disposition, including how to request alternate options.

• Informed consent and clear communication: Families should be told of options ahead of time, including timelines, costs, and whether remains may or may not be available for private arrangement. OBGYNs, midwives, NICU & L&D nurses, bereavement coordinators, chaplains, social workers, and other relevant personnel should understand what the birthing institution can provide.

• Coordination with pathology: If diagnostic testing is needed, it may limit the kind of disposition possible (e.g., remains must stay in lab or be fixed).

• Containerization and safety: If remains are released, protocols must ensure leak-proof containers, biohazard bags, opaque wrapping, refrigeration if needed, and liability waivers.

• Cost & funding: Some hospitals or jurisdictions subsidize shared disposition; private services can be expensive, and cost may limit choices that may be offered to families. 

• Cultural and religious sensitivity: Some families may want immediate burial, rapid cremation, or specific ritual timing—these should be anticipated and accommodated where feasible.

• Flexibility and advocacy: Families (or advocates) may need to request exceptions or deviations from default institutional policies, especially in jurisdictions with less clear law.

• Highlight follow-up vigilance. Clinicians caring for surviving multiples should be aware that those children might benefit from enhanced developmental, psychosocial, and mental health monitoring over time.

• Encourage integration of multiple-loss awareness in bereavement support. Support services (counseling, peer groups) should explicitly acknowledge twin loss as a distinct grief experience, not simply subsumed under “loss of child.”

• Promote research and registry efforts. Collecting data on surviving multiples (i.e., growth, neurodevelopment, mental health) after twin loss can help generate evidence for best practices in monitoring and intervention.