The CLASS (CiaoLapo Stillbirth Support) checklist is a tool designed to assess the extent to which care for stillbirths and perinatal loss aligns with key national and international recommendations on perinatal bereavement. It systematically compiles and organizes the recommendations from various guidelines into six areas:
- respect for the child and the parents,
- information and communication,
- decisions related to childbirth,
- the hospital stay,
- the formation of memories and
- support in the weeks following the loss.
This page provides useful information for anyone interested in learning about and using the checklist: a summary of its scientific validation, instructions on how to apply it and calculate the score, links to reference resources, and downloads of the checklist in Italian and English.
Validation Results
The checklist was validated in the CLASS cross-sectional study, part of the OPALE (Observatory on Perinatal Health) project, conducted by the CiaoLapo Foundation in collaboration with the PeaRL laboratory at the University of Florence and published in the journal Birth. The validation study included 261 women who had experienced a pregnancy loss after the 20th week of pregnancy within the previous ten years. The checklist, consisting of 60 items grouped into the six areas mentioned, was used as a measure of adherence to guidelines, correlating the quality of care received with psychological well-being, which was assessed using the Perinatal Grief Scale and the NSESSS (post-traumatic stress symptoms).
A linear relationship emerged between adherence to recommendations and better psychological outcomes: the more closely care aligned with the guidelines, the lower the intensity of grief and the post-traumatic symptoms reported by the women. In the multivariate analysis, care that met at least 40 of the 60 items on the checklist was independently associated with greater satisfaction with the care received (OR 2.0), a higher perception of having received respectful care (OR 3.6), lower levels of grief (OR 0.08), and a reduction in post-traumatic symptoms (OR 0.21). The study also revealed overall low and inconsistent adherence across Italy, with differences among various regions of the country.
This is the first study to document, through clinical outcomes, a direct and proportional relationship between adherence to guidelines on perinatal bereavement care and the psychological well-being of parents: a finding that underscores the importance of these recommendations in clinical practice and the usefulness of the checklist as a tool for assessing and improving the quality of care.
A more detailed presentation of the results is available in the dedicated article on the Foundation’s website: CLASS CiaoLapo: Adherence to Guidelines, Grief, and PTSD. The full scientific article is published as open access in *Birth* (doi.org/10.1111/birt.70087).
How to Use the Checklist and How to Calculate the Score
Each item on the checklist can be evaluated in two ways.
- The first is a dichotomous assessment—present or absent (1/0)—which simply indicates whether (in the parent’s opinion) a particular practice was offered or not.
- The second is a continuous assessment, in which parents are asked to rate, on a scale of 0 to 100, how satisfied they were with each item.
This last method (currently used at CiaoLapo for post-validation studies) allows for the creation of a continuous score and provides a more nuanced description of the level of adherence. Based on these continuous scores, a satisfaction threshold can be defined—that is, the value above which the item is considered satisfied. The threshold is not an absolute value and may vary depending on the social, organizational, and cultural contexts in which the checklist is applied.
Currently, the CiaoLapo Foundation uses a percentage-based grading system and considers an item to have been passed if it scores higher than 75%.
Download the checklist
The checklist is available in Italian and English. The files are in PDF format and may be downloaded and used freely, provided the source is cited.
Resources and Guidelines
The CLASS checklist summarizes the guidelines from various national and international recommendations on perinatal bereavement care. Useful resources for further reading include:
- Italian recommendations from SIGO, AOGOI, and AGUI, Management of In Utero Fetal Death (IUFD). Caring for Stillbirths (Confalonieri Ragonese Foundation, No. 17, 2023).
- PSANZ Clinical Practice Guideline for Care Related to Stillbirth and Neonatal Death (Perinatal Society of Australia and New Zealand, Stillbirth CRE).
- SOGC Guideline No. 394 — Stillbirth Investigation (Society of Obstetricians and Gynecologists of Canada).
- HSE National Standards for Bereavement Care Following Pregnancy Loss and Perinatal Death (Health Service Executive, Ireland).
- Sands Stillbirth Bereavement Care Pathway (United Kingdom).
Work in Progress
The validation study published in *Birth* is a first step. Further work is currently underway to refine the tool, conduct a more in-depth analysis of individual areas, and better define the scoring criteria and satisfaction thresholds across different care settings. This page will be updated as new results or new versions of the checklist become available.
How to Cite
Ravaldi C, Roper F, Mosconi L, Vannacci A. Adherence to Stillbirth Guidelines and Women’s Psychological Well-Being: The CLASS (CiaoLApo Stillbirth Support) Cross-Sectional Study. Birth. 2026. https://doi.org/10.1111/birt.70087
