Review
The perinatal autopsy: Pertinent issues in multicultural Western Europe

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Abstract

Western Europe is in a demographic transition with increasing multicultural societies. Health professionals have to understand the background, religious and cultural aspects of parents to counsel them regarding an autopsy in the event of a perinatal loss. Autopsy rates have declined over the past decades, the major limiting factor being the granting of permission for an autopsy, possibly because of adverse publicity or reluctance of doctors to obtain consent. Autopsy has proved its value in revealing unsuspected findings. The public can be convinced of this utility by means of good information notwithstanding their religious or cultural background.

Introduction

Western Europe is in a demographic transition with migration and reproductive health choices influencing its population make up. Internal European migration and, particularly, an external migration into Europe from the Muslim world and from Asia and Africa have brought a multicultural diversity. Reproductive health and lifestyle choices have generally resulted in small family size in Europe in recent decades. Urbanisation has resulted in fracturing of the traditional nuclear family support and has contributed to the trend to smaller families. This demographic transition has meant that when there is a perinatal loss, health professionals have to understand the changed cultural aspects to counsel parents regarding an autopsy. Furthermore, health professionals have to counsel the parents against a background of recent adverse publicity about the autopsy that has also influenced the public perception of its usefulness.

One of the limiting factors for the autopsy is the granting of permission by a doctor who is insecure about the inquiries and procedures of the autopsy in relation to parental background or religion and who is not always convinced of its value [1], [2]. The purpose of this paper is to provide all necessary information for health professionals who counsel parents for a perinatal autopsy. In the following sections, we will discuss the reasons for declining autopsy rates, the quality of autopsies, the role of autopsy in the subgroups of perinatal mortality, the procedures of autopsy and its alternatives, the issue of organ retention and the religious and cultural proscriptions to the autopsy.

Section snippets

Perinatal autopsy rates and the quality of the autopsy

Perinatal autopsy rates were stable in comparison to the (low) adult autopsy rate until the 1990s [3]. However, a drop in the perinatal autopsy rate was found over the past decades [4]. The major rate-limiting factor is the granting of permission from the parents to a postmortem examination [5], [6]. Adverse publicity could have contributed to this decrease. It can also be due to the reluctance of some doctors to ask permission for the autopsy because of personal reasons or due to the

Why perform a perinatal autopsy?

The primary reason for performing a perinatal autopsy is to ascertain the cause of death or, in the case of (therapeutic) terminations, to confirm the indications for the termination [14]. A review of contemporary studies on the value of perinatal autopsy showed that the autopsy could reveal a previously undiscovered diagnosis, a change in the diagnosis or additional information in 22–76% of cases [7]. The cause of death is important for counseling the parents and family about recurrence risks

The use of autopsy in different subgroups of perinatal mortality

Different definitions for subgroups of perinatal mortality have been used over time and between countries [19], [20]. The autopsy has proved to be useful in these separate groups. Generally, perinatal losses can be divided in three subgroups.

The first group consists of (therapeutic) terminations. This group would comprise mainly fetuses terminated for anomalies, but may also comprise terminations for maternal reasons in case of illness or for psychosocial reasons. Antenatal ultrasound diagnoses

How to perform the autopsy, what are the alternatives?

The autopsy in general involves an incision into the body. The autopsy should consists of a thorough macroscopic examination of the body and the internal organs. Tissue samples can be taken for microscopy, but no more tissue than necessary for establishing the diagnosis. In certain cases, additional laboratory tests for virology, bacteriology, cytogenetics and molecular studies are desirable [14].

Some parents may not give permission for a complete autopsy. They may, however, permit a limited

Tissue and organ retention

The “organ retention” controversy in the wake of tissue retained following paediatric autopsy in United Kingdom has had a profound effect on the granting of consent for autopsy [6]. Parents are likely to ask and wish to know their choices with regard to this topic and may find it useful to discuss this directly with the pathologist. Practices may differ between institutions but, in general, portions of tissue are taken to be fixed before trimming for histopathological processing.

A contentious

Religion and autopsy in multicultural societies

In the Netherlands in 2005, approximately 10% of the inhabitants were migrants and the percentage of immigrants is still increasing in the Dutch population. The religious distribution in 2002–2003 in the Netherlands is—Roman Catholic: 31%, protestant: 21%, Islam: 5%, other (Buddhist, Jewish, Hindu): 3% and non-religious: 40% [33]. In Germany, approximately 9% of the inhabitants are migrants. The German religious distribution is—Roman Catholic: 32%, protestants: 32%, Islam: 4%, other (Buddhist,

Conclusions

The perinatal autopsy is an integral part of perinatal care and management in cases of perinatal mortality. Contemporary studies have demonstrated the value of the perinatal autopsy in revealing unsuspected findings [4], [7], [16], [18]. Convincing the public of this utility by means of good information has already been demonstrated to reverse falling neonatal autopsy rates [22]. This process can be further enhanced by understanding possible religious or cultural sensitivities to the autopsy as

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