Three years ago, Nepal’s Supreme Court(SC) catapulted the nation to the forefront of the global women’s rights movement by unequivocally ruling that women have a constitutionally protected right to safe and affordable abortion services. The story behind that groundbreaking decision begins with Lakshmi Devi Dhikta. Lakshmi is an extremely poor woman from Dadeldhura who already had five children when she became pregnant for the sixth time. She and her husband knew having another child would be too hard on their family financially and on Lakshmi’s health — so they went to a government hospital to request an abortion. 

At the hospital, they were told to pay 1,130 rupees for the procedure, which they did not have. As a result, Lakshmi had no choice but to continue her unintended pregnancy

Read full article by MELISSA UPRETI here
 
 
THERE is broad agreement that the Dáil must provide a legislative framework for a woman’s right to an abortion when her life depends on it, yet division persists about the inclusion of suicide as a risk to life.

People on the anti-choice side of thedebate, citing the UK’s 1967 Abortion Act, say that inclusion of suicide in any legislation would open the floodgates to abortion-on-demand in this country. 

This claim is specious. Legislation here would have to comply with the constitutional position that an abortion can only be countenanced when there is "real and substantial risk" to the life of the woman. 

In contrast, the UK’s decades-old liberalisation of its laws provided for an abortion in circumstances where "the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman" or when "there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped". 

You don’t have to be a legal expert to appreciate that the Oireachtas is precluded, by the pre-eminent legal authority in this country — the Constitution — from enacting similar provisions here. 

Full article by Colette Browne here

 
 
The Irish Catholic Bishops have seen fit to clarify the church’s view on gynecology given Savita Halappanavar’s death from sepsis at 17 weeks in her pregnancy and the concern that evacuating her uterus was delayed because the fetus still had a heart beat. The full statement is here, but this is the excerpt I find most troubling:

- Whereas abortion is the direct and intentional destruction of an unborn baby and is gravely immoral in all circumstances, this is different from medical treatments which do not directly and intentionally seek to end the life of the unborn baby. Current law and medical guidelines in Ireland allow nurses and doctors in Irish hospitals to apply this vital distinction in practice while upholding the equal right to life of both a mother and her unborn baby.

I spent quite sometime trying to understand how one could possibly translate this statement into medical care. I’ve been a doctor for 22 years and an OB/GYN for 17 years and I admit that I am at a bit of a loss. My three interpretations are as follows.

  • Terminating a pregnancy is “gravely immoral in all circumstances.” All circumstances includes 17 weeks and ruptured membranes. Unless I misunderstand the meaning of “all,” then Irish Catholic Bishops also view ending a pregnancy at 17 weeks with ruptured membranes and sepsis, either by induction of labor or the surgical dilation and evaluation (D & E), to be “gravely immoral.” They must also view ending a pregnancy for a woman who previously had postpartum cardiomyopathy and a 50% risk of death in her pregnancy as “gravely immoral.” So if you have a medical condition that is rapidly deteriorating because of your pregnancy, too bad for you if you live in Ireland. Because the mother and unborn baby have equal rights to life, Irish law spares women the anguish of choosing their own life. Neither can be first, so both must die.

Full article by Dr Jen Gunter here
 
 
The Master of the National Maternity Hospital is a woman under pressure. When I arrive at the agreed time for an interview, I am told at the front desk of the antiquated building on Holles Street that there are others waiting ahead of me. The “others” sitting in the small entrance hall waiting for Dr Rhona Mahony include a significant one – the Minister for State at the Department of Health, Alex White.

When Dr Mahony arrives about 10 minutes later to greet White, an apologetic secretary says that she is not sure how long I’ll have to wait as the master also has to go down to theatre.

Being the head obstetrician at a hospital with 700 staff and where about 27 babies are born each day is an onerous responsibility. She wears the stress lightly, although with the country convulsed over the death of Savita Halappanavar and the issues arising from that, everybody working at the coalface of the maternity services must be particularly deeply affected.

Full article by Sheila Wayman here
 
 
TIMELINE: This is the story of one woman’s death in an Irish hospital, based on the account given by her husband and friends

Savita Halappanavar was admitted to Galway University Hospital with back pain. She was 17 weeks pregnant. Seven days later she was dead. The hospital has said it cannot comment on individual cases and in relation to Ms Halappanavar, it must await the outcome of official investigations.

October 20th 

It’s a Saturday night, and Savita Halappanavar (31) and her husband Praveen (34) are holding a small get-together at their home in the Roscam area of Galway. It’s both a farewell dinner for her parents who are returning to India soon and an opportunity to announce to friends they are expecting a baby. Savita is 17 weeks pregnant. “Savita was very excited, very happy,” recalls Praveen. “All our close friends came to congratulate us.”

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THE husband of Savita Halappanavar has repeated his insistence that he will not meet the chairman of an inquiry into his wife’s death following a miscarriage.

Praveen Halappanavar said in an interview to be broadcast tonight on RTE's Prime Time that he would not co-operate with an HSE-run inquiry.

"We are just not confident in the whole family about the HSE leading this investigation," he said.

"These people are salaried by the HSE. They pay them. We think that there would be some kind of bias during the investigation.

"We are requesting a public inquiry basically funded by the Irish Government."

 
 
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While a full analysis of the tragic case of Savita Halappanavar’s death from sepsis at 17 weeks in her pregnancy is not possible without access to her medical records, there is a key piece of information provided by her husband that supports his claim that a termination was not allowed or was delayed because of the law. It is the fact that the medical staff were checking fetal heart tones. Not just once a day as is sometimes done during a previable induction so the mother knows which day her baby died, but several times a da.

Fetal heart tones are not checked with any medical purpose in mind until viability (around 23-24 weeks). The presence of fetal heart tones was irrelevant because survival of a baby at 17 weeks with ruptured membranes and/or advanced cervical dilation is impossible. Ms. Halappanavar was not 22 weeks pregnant where there might be a 3% chance of survival (depending on weight, sex of the baby, gestational age, whether it is a singleton or a multiple gestation etc). At 17 weeks with ruptured membranes, regardless of cervical dilation, this pregnancy could only end in with a fetal demise. In a study from 2006, when membranes ruptured at 21 weeks or less the outcome was “dismal.” In fact, in this study there were no survivors when membranes ruptured between 18 and 19 weeks. Whether a fetus has cardiac activity at 17 weeks with ruptured membranes and a dilated cervix is simply not part of the medical decision making tree.

Then of course there is the matter of infection. When membranes rupture at 17 weeks the risk of infection just walking in the hospital door is 30-40% and, according to the American College of Obstetrics and Gynecology (ACOG), “At any gestational age, a patient with evidence of an intrauterine infection….is best cared for by an expeditious delivery.” By her husband’s account, she had abdominal pain on or shortly after arrival, a potential sign of infection. On the Tuesday, two days after she was admitted, he reports that she was shaking and complaining of chills. In this scenario those symptoms can only mean infection. And when a woman with a previable fetus has an intrauterine infection the treatment is not antibiotics and watch the fetus, it’s antibiotics and expeditious delivery.

I’m told that while Irish law technically allows abortion to save the life of the mother, many practitioners fear recrimination and exactly whenthe life of the mother is “at risk” is a murky question. I can easily argue that Savita’s life was at risk the moment her membranes ruptured at 17 weeks. However, does Irish law mean a different kind of risk? And if so, how would doctors judge that risk to be present? Ruptured membranes and fever? Shaking chills? Bacteria in the amniotic fluid? Positive blood cultures? Sepsis? Cardiovascular collapse? How sick must a pregnant woman be in Ireland be for a doctor to state that her life is at risk?

Whether the delay in Ms. Halappanavar’s care was fear of criminal repercussions or personal dogma, both of these scenarios are permitted to exist because of laws that trounce evidence based medicine. Her husband’s claim that Irish law played a role rings true because the team was checking for fetal heart tones when the only vital signs that mattered were Savita’s.