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Would an abortion have saved Savita Halappanavar?

by Frank Schnittger Tue Nov 20th, 2012 at 05:49:09 PM EST

The death of Savita Halappanavar has provoked world-wide condemnation of the Irish health service and the social and legal infrastructure which underpins it. There have been allegations of Roman Catholic dogma determining the medical treatments  available to non-Catholics in Irish hospitals; allegations of racism; and allegations of a patriarchal medical system and culture that would rather have a woman suffer in acute pain rather than give her appropriate treatment and relief.

Some or all of these allegations may turn out to be true. Some have certainly been true in many other instances in the past, as the outpouring of personal reminiscences by Irish women which have appeared in print and in the media over the past few days testify.  The mass protests at her death seen in Ireland and abroad indicate that a very raw nerve has been touched.

But there is also an altogether more innocent explanation of what happened in this particular instance of which we should be aware before we jump to conclusions and condemn all involved. I have spoken to medical personnel with some knowledge of the hospital and staff in question (but with no direct knowledge of this particular case) who rule out the likelihood of racism and point to the possibility of a very different scenario:


Firstly, despite many health service cutbacks, Ireland still has one of the best maternity services in the world with very low mortality rates for both mothers and their babies. When Savita Halappanavar apparently presented at Galway University Hospital with acute back pain, a ruptured membrane, and a dilated cervix, she had the classic symptoms of an impending miscarriage. At 17 weeks the foetus would not have been viable. She was, apparently, advised and accepted that this was the unavoidable outcome.

Standard medical practice under those circumstances would have been to allow the miscarriage to proceed naturally as any surgical intervention (such as an abortion) has its own risks of mishap or infection. The question which arises here however is why her complaints of acute pain weren't, apparently, adequately medicated. It might also have been possible to accelerate the process by inducing an earlier delivery.

Why was this not done? The suspicion has to be either that her condition was not adjudged to have been critical in any way, or that there were "theological" or legal concerns that the "substantial risk to the life of the mother" standard for allowing the induction of a live but unviable foetus had not been met. We do not yet know which was the case, although her husband's statement that they were told that "this is a Catholic Country" indicates that it was probably the latter.

She developed septicemia and subsequently died of an e.coli infection. It is important to note that an earlier miscarriage, induced birth or abortion would not necessarily have reduced her risk of becoming infected. The bacterium is apparently unfortunately very commonly found in Irish hospitals, and she may even have been better off and safer at home - always provided that her pain and general condition was being carefully monitored and managed. Certainly, the foetus itself is unlikely to have been the source of infection for as long as it was alive.

So it is as yet unclear whether an abortion would have had any material benefit in terms of reducing Savita Halappanavar's risk of infection and subsequent death. Had an abortion been performed before infection had set in, it is possible the risk of infection would have been reduced. If she was already infected by the time she presented at the hospital, it is possible an abortion would have had no material benefit. However that would also raise the question as to whether her infection was diagnosed and treated quickly and aggressively enough.

These issues can ultimately only be resolved by a minute examination of the medical records and interviews with the staff involved by the inquiry team. That is not to say, however, that the Savita Halappanavar case does not highlight a number of very troubling issues for the health of women who suffer complications during pregnancy in Ireland.

Irish women report many instances of being forced to carry unviable or naturally aborted foetuses to spontaneous abortion or even to term - a situation that many describe as traumatic. The lack of ethical guidelines clearly disposes doctors to take the road of least intervention and legal risk. Some may vaguely suggest that the women might consider traveling to England for treatments they are not in a position to provide. That option, is, of course, only realistic for women of means. Some report the additional trauma of having to travel to England without adequate support and whilst feeling unwell. Others report the utter inappropriateness of receiving the ashes of their unborn child in the post some time after their termination.

What happens, for instance, if a mother discovers she is pregnant and has cancer at more or less the same time, and needs urgent chemo and radiotherapy to improve her 5 year survival chances? The hormonal changes associated with pregnancy may even accelerate the development of cancer. However, because her condition isn't immediately life threatening she will be refused an abortion in Ireland. Some doctors may be reluctant to proceed with aggressive Chemo and Radiotherapy because of the damage it may do to the unborn child and some mothers may delay treatment until the child is born. Other doctors may suggest she travel to England and get a termination so that aggressive cancer treatment can proceed. But should a mother be expected to accept a much less than optimal medical treatment which materially effects her life expectancy if she cannot afford or does not wish to travel to England?

The bottom line is that whilst Ireland generally has a good maternity service with good outcomes for both mothers and children, when complications arise, doctors can differ, doctor's hands are sometimes tied, and the full range of medically indicated procedures are not available because some, led by the Catholic Church, believe they have a greater right to determine what the mother should do in that case than the mother herself.

Meanwhile the Government's response to the crisis is in real trouble. Following objections from Savita Halappanavar's husband, the Government has asked the  members of the Inquiry team who are also members of staff of Galway University Hospital to stand down from the inquiry to improve it's standing as an independent inquiry. However Praveen Halappanavar has also insisted that the inquiry be a full public sworn inquiry with powers to compel witnesses and subpoena evidence and has stated he will withhold his permission for any inquiry to access his wife's medical records unless it meets that standard. Without those records, any inquiry would be almost pointless, so the Government may, ultimately have to concede on that point as well.

The problem is that - going on past experience in Ireland - such lawyer led inquiries cost hundreds of millions and take several years to produce a report. We need a much more immediate response to this crisis. Another problem - for the Government - is that it has emerged that the chairman of the inquiry, Prof Sir Sabaratnam Arulkumaran, is also the author of an article in the International Journal of Gynecology and Obstetrics in 2009 on safer childbirth and "reproductive rights" in which advocated for much wider availability of abortion in countries with restrictive abortion regimes. Naturally the "pro-life" movement is up in arms about his suitability for the appointment.

Sinn Fein is moving a motion in Parliament tomorrow to force the Government to act to provide a legislative basis for doctors to perform an abortion where there is a "substantive risk" to the life of the mother - in line with a 20 year old ruling of the Supreme Court on the constitution. The Pro-life movement is accusing the pro-choice activists and the media of exploiting Savita Halappanavar's death for their own purposes and the Government is urging caution in the light of the complexity of the issues which need to be dealt with. The risk is that this issue may yet be kicked into the long grass and not dealt with for another 20 years.

Display:
The Pro-life movement is accusing the pro-choice activists and the media of exploiting Savita Halappanavar's death for their own purposes

I think it's fair to pose the question of what Savita would have wanted. Judging from her own requests, and husband's actions, it seems pretty likely that she would have been happy for her death to be exploited to push for law changes.

It is rightly acknowledged that people of faith have no monopoly of virtue - Queen Elizabeth II

by eurogreen on Wed Nov 21st, 2012 at 04:13:58 AM EST
I don't know about that, but it seems to me her husband (and the wider public) would be less outraged if she had died of complications from surgery than dying after being denied it.

I distribute. You re-distribute. He gives your hard-earned money to lazy scroungers. -- JakeS
by Migeru (migeru at eurotrib dot com) on Wed Nov 21st, 2012 at 07:27:51 AM EST
[ Parent ]
See my comment below.

It is rightly acknowledged that people of faith have no monopoly of virtue - Queen Elizabeth II
by eurogreen on Wed Nov 21st, 2012 at 07:44:02 AM EST
[ Parent ]
Would be interesting to know how common it is.
Of course the law needs to be "clarified" in any case.


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sapere aude
by Number 6 on Wed Nov 21st, 2012 at 04:47:20 AM EST
Apparently death form Septicemia during  pregnancy is extremely rare in Ireland but i haven't seen stats.

Index of Frank's Diaries
by Frank Schnittger (mail Frankschnittger at hot male dotty communists) on Wed Nov 21st, 2012 at 06:14:33 AM EST
[ Parent ]
European Tribune - Would an abortion have saved Savita Halappanavar?
She developed septicemia and subsequently died of an e.coli infection.

IANAD, but:

  1. It seems (by this account) she picked up an e.coli infection because of inadequate asepsis.

  2. Septicemia would then have set in in a second phase.

This suggests inadequate monitoring from the start. Any sign of infection should have been observed and treated appropriately, independently of the abortion question.

It sounds to me as if it was a case of "women have to suffer", and she was left to get on with it. A prompt abortion might indeed have saved her, but in a hospital with backward notions of women and suffering, inadequate asepsis and monitoring, it might not.

by afew (afew(a in a circle)eurotrib_dot_com) on Wed Nov 21st, 2012 at 09:00:06 AM EST
[ Parent ]
But "this account" assumes the infection was iatrogenic and did not originate with the foetus. If the latter, abortion was a medical necessity.

That she was left to get on with it, and was not adequately monitored, seem imo to be true in either case.

by afew (afew(a in a circle)eurotrib_dot_com) on Wed Nov 21st, 2012 at 09:07:29 AM EST
[ Parent ]
The main thing I as a non-medic can glean from online material on sepsis is "needs monitoring from the start and can be hard to detect."

I think the original diary said they did various tests at some point. May have been too late.

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sapere aude

by Number 6 on Wed Nov 21st, 2012 at 09:45:02 AM EST
[ Parent ]
A patient doesn't go straight to a state of sepsis/septicemia. If there was a primary infection with e.coli, there'd have been a rise in temperature which should have been observed and acted on.

Once septicemia has taken hold and the whole organism is involved, stopping it can be extremely hard or impossible, as I know from two deaths close to me.

by afew (afew(a in a circle)eurotrib_dot_com) on Wed Nov 21st, 2012 at 10:15:46 AM EST
[ Parent ]
if they can indeed ever be established, the appearance of what happened is very important.

After all, the average client of a hospital is not in a position to judge the adequacy of medical procedures.

But the known facts of the case are consistent with the interpretation that the woman was denied proper care as a result of the application of religious doctrine. And that is intolerable, and needs to be fixed.

Among other things, it is intolerable for the image of hospitals in Ireland, and for the confidence of patients.

It is rightly acknowledged that people of faith have no monopoly of virtue - Queen Elizabeth II

by eurogreen on Wed Nov 21st, 2012 at 07:10:26 AM EST
The medical facts include that
  1. there was no chance that delaying the abortion would have save the foetus;
  2. there is a chance that the dying foetus contributed to the septicaemia;
  3. there is a chance that surgical removal of the dying foetus could lead to life-threatening complications including septicaemia;

To me it seems that 2 overwhelms 3, but that must be because I'm a heathen.

I distribute. You re-distribute. He gives your hard-earned money to lazy scroungers. -- JakeS
by Migeru (migeru at eurotrib dot com) on Wed Nov 21st, 2012 at 07:25:09 AM EST
[ Parent ]
The (non-specialist) medical advice I received was that it is most unlikely that the foetus would have contributed to the Septicemia whilst it was still alive, but that point has been rebutted on Daily Kos (I don't seem to be able to link to specific comment there - but the comment trail isn't that long). My medical advice is in agreement with your points 1. and 3.

Index of Frank's Diaries
by Frank Schnittger (mail Frankschnittger at hot male dotty communists) on Wed Nov 21st, 2012 at 08:02:23 AM EST
[ Parent ]
On 2: does prolonging the miscarriage process contribute to the septicaemia by weakening the woman's immune system?

I distribute. You re-distribute. He gives your hard-earned money to lazy scroungers. -- JakeS
by Migeru (migeru at eurotrib dot com) on Wed Nov 21st, 2012 at 08:20:03 AM EST
[ Parent ]
I will try and get more advice on this, but we should be carefully about considering miscarriage as a disease. It is a natural process which kicks in in a significant % of pregnancies and I'm not sure it has any direct impact or taxing effect on the immune system. However the apparent fact that Savita was left in extreme discomfort and pain for several days hardly did her general health and resilience any favours. Her dilated cervix and ruptured membrane should have been the most obvious and immediate indicators of a risk of septicemia, especially in a hospital environment.

Index of Frank's Diaries
by Frank Schnittger (mail Frankschnittger at hot male dotty communists) on Wed Nov 21st, 2012 at 08:34:33 AM EST
[ Parent ]
Miscarriage looks like significant physical trauma, involves pain, exhaustion, and the expulsion of a "foreign body".

E.coli infection is more likely to take hold in a weakened patient. We are exposed to pathogens more often than we fall ill from them.

So the question is not whether the E.coli came from the foetus, or whether it came form the hospital or was there before she was admitted. The question is whether allowing the natural miscarriage process to proceed for days rather than performing an abortion can tip the chances of falling to opportunistic infections.

In addition, am I mistaken that the abortion might have been performed by inducing delivery rather than by a caesarean? Does that not involve less risk of "surgical" complications?

I distribute. You re-distribute. He gives your hard-earned money to lazy scroungers. -- JakeS

by Migeru (migeru at eurotrib dot com) on Wed Nov 21st, 2012 at 08:41:24 AM EST
[ Parent ]
Frank Schnittger:
It is a natural process which kicks in in a significant % of pregnancies

IIRC, historically around 25%, mostly depending on how widespread syfilis is in the population. If this looks high it is mostly because a lot of these are in early stages and may not be noticed as a miscarriage.

A vote for PES is a vote for EPP! A vote for EPP is a vote for PES! Support the coalition, vote EPP-PES in 2009!

by A swedish kind of death on Wed Nov 21st, 2012 at 01:08:31 PM EST
[ Parent ]
Wasn't aware of the syfilis link.

Had heard as much as one third of pregnancies - early stages.

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sapere aude

by Number 6 on Thu Nov 22nd, 2012 at 04:36:05 AM EST
[ Parent ]
Phew - the commentary on this Diary at Daily Kos is pretty hostile. I've been called many things, but Concern Troll is not one of them. It seems anyone who considers the possibility that, in this particular case, the lack of availability of abortion on demand in Ireland may not have been the cause of death is a closet "right to life" zealot.

For the record, my position is that the women in question, in consultation with her family and doctor, has the ultimate right to make the decision as to what is best in what is almost always a traumatic circumstance. As Fran has noted from her own counseling experience it is a decision that is never made lightly.

But I also think we ought to be careful about over medicalising and over technologising the process of childbirth. I am a supporter of natural childbirth, in the home if possible, and being cognizant of the emotional and spiritual dimensions of creating life. Severe medical or surgical interventions should be a last resort unless aggressive medical management of a condition is clearly indicated by the research.

I suspect an abortion carried out as soon as possible after Savita presented to the hospital would have been the best strategy for enabling her survival, and that medical staff (for theological/legal reasons) did not take her requests for an abortion seriously enough. I further suspect they did not take the risk of septicemia seriously enough, early enough, which would be a straightforward medical failure. But we don't have enough evidence to come to any conclusions at this stage, and a rush to judgement which turns out to be wrong in this instance could do damage to the freedom of choice argument.

The best we can hope for in Ireland at the moment is that the Government takes prompt and decisive legislative action to ensure that theological/legal concerns do not intrude on the right of women to receive the best medical treatment possible in Ireland, and do not have to travel abroad for the privilege. Abortion on demand isn't going to happen in Ireland any time soon, and to criticize this diary for not just advocating that Savita should have been given an abortion on demand and be done with all the medical issues is not realistic in the current Irish political context. Let's at least make sure that women don't have to die for lack of the best, prompt and local medical treatment here in Ireland.

Index of Frank's Diaries

by Frank Schnittger (mail Frankschnittger at hot male dotty communists) on Wed Nov 21st, 2012 at 07:15:04 AM EST
Wow. Thanks for posting over there anyway.

A certain tendency in some parts to shut down people who

  • disagree even slightly with strongly held opinions
  • bring up alternative views
  • are of the wrong gender

(There seems to be an equal amount of comments criticising you for "anecdotal evidence" and not being a professional who worked on this specific case personally, and comments arguing based on other anecdotal evidence.)


-----
sapere aude
by Number 6 on Wed Nov 21st, 2012 at 08:13:12 AM EST
[ Parent ]
Most of the Diary isn't even about my personal views, but an attempt to analyse the medical facts currently in public evidence (which may or may not be ultimately confirmed by the inquiry). The reason I wrote the diary was because most of the commentary I have read doesn't even go into the medical details - but make large assumptions as to what must have occurred. The presumption, on the "right to life" side seems to be that the lack of availability of abortion is never a risk factor for the mother. Equally, however, the Daily Kos presumption seems to be that of course it was the lack of an abortion with killed her, duh!

I don't think we do her memory any favours by presuming facts not currently in evidence. The husband obviously feels she was very wronged, and the least he can expect is an impartial, independent review of what went wrong. Long term, I don't think the abortion on demand viewpoint does itself any favours if it turns out that the lack of an abortion was not the main contributory factor to her death.

Index of Frank's Diaries

by Frank Schnittger (mail Frankschnittger at hot male dotty communists) on Wed Nov 21st, 2012 at 08:26:56 AM EST
[ Parent ]
There was a comment from an MD on one of the Savita threads which basically said that not aborting was clearly medical malpractice, and the foetus was clearly the cause of the fatal septicemia.

So 'well, duh' would be entirely fair and accurate.

Certainly it's difficult to imagine any doctor without religious bias saying 'It's true you have a dead foetus inside you, but let's just leave it there and see if your condition improves, eh?'

It's true that Savita might have died anyway. But it's surely obvious that the odds of death would have been very greatly reduced to the point where it was very unlikely she would die - as opposed to the medical inaction which made it far more likely she would die.

So far as I can tell, medicine doesn't offer certainties.

But the reality is that any unbiased medical facility would have treated the situation as a medical emergency and aborted immediately, knowing this would tilt the balance of probability away from likely death to likely survival, and that this was a valuable and ethical thing to do.

by ThatBritGuy (thatbritguy (at) googlemail.com) on Wed Nov 21st, 2012 at 08:41:33 AM EST
[ Parent ]
The foetus wasn't dead and this is what delayed more aggressive/invasive treatment. All cases are different and I'm surprised an MD would comment so decisively without direct access to a lot more data than is currently in the public domain. Abortion is legal in Ireland if there is a "clear and substantial risk" to the life of the mother, so either the medical team didn't think that standard was being met, or the lack of legislation and legal certainty inhibited their response, or religious bias caused them not to act in the best interests of their patient.

Index of Frank's Diaries
by Frank Schnittger (mail Frankschnittger at hot male dotty communists) on Wed Nov 21st, 2012 at 11:50:43 AM EST
[ Parent ]
Savita was admitted on Saturday, and everyone agrees she was obviously miscarrying. There was no possibility of a live birth at that point.

The foetus died on the Wednesday, which was an entirely predictable outcome.

So was the ensuing life-threatening septicaemia, and the shift to ICU.

Pretending there are grey areas around this is disingenuous.

by ThatBritGuy (thatbritguy (at) googlemail.com) on Wed Nov 21st, 2012 at 12:00:49 PM EST
[ Parent ]
There was no possibility of a live birth at that point.

Expect religionists to argue that as long as there was a heartbeat there was hope of a miracle.

I distribute. You re-distribute. He gives your hard-earned money to lazy scroungers. -- JakeS

by Migeru (migeru at eurotrib dot com) on Wed Nov 21st, 2012 at 12:05:00 PM EST
[ Parent ]
Nah - they will just argue that killing a dying man is still murder - so killing a dying foetus is still abortion...

Index of Frank's Diaries
by Frank Schnittger (mail Frankschnittger at hot male dotty communists) on Wed Nov 21st, 2012 at 12:53:48 PM EST
[ Parent ]
Next up: "the fetus had a yawn"... Fetal yawning: Cute, but what does it mean?.

I distribute. You re-distribute. He gives your hard-earned money to lazy scroungers. -- JakeS
by Migeru (migeru at eurotrib dot com) on Thu Nov 22nd, 2012 at 04:45:38 AM EST
[ Parent ]
The foetus wasn't dead

The foetus had a heartbeat but the prognosis was that it would not survive.

This is like keeping a braindead patent alive because it has a heartbeat.

I distribute. You re-distribute. He gives your hard-earned money to lazy scroungers. -- JakeS

by Migeru (migeru at eurotrib dot com) on Wed Nov 21st, 2012 at 12:04:20 PM EST
[ Parent ]
Yes - and once in a trillion years it may happen that the baby/patient recovers - probably because of inaccurate diagnosis in the first place. Euthanasia, abortion, contraception, whatever - its all a sin because it compromises the sacredness of life in their eyes. Never mind that their concern for the actually living generally leaves a lot to be desired...

Index of Frank's Diaries
by Frank Schnittger (mail Frankschnittger at hot male dotty communists) on Wed Nov 21st, 2012 at 12:58:28 PM EST
[ Parent ]
I'm with the Daily Kos people.

This is a concern troll diary by someone writing from a position of medical ignorance. There's a substantial literature about septicaemia and miscarriage in the third world.

And that person is you. And that is profoundly depressing to me, Frank.

by Metatone (metatone [a|t] gmail (dot) com) on Wed Nov 21st, 2012 at 12:55:35 PM EST
[ Parent ]
That's a bit harsh. Nobody here has access to the medical records, we are largely discussing events as reported by a media barely more medically knowledgeable than us.

Frank is trying to be fair while avoiding pre-judgement, preferring instead to try to determine if there are scenarios where the actions of the medical team might be seen as reasonable and justifiable. That seems a worthwhile activity to me, even if I personally think that the medical team bear considerable responsibility for the tragic result.

keep to the Fen Causeway

by Helen (lareinagal at yahoo dot co dot uk) on Wed Nov 21st, 2012 at 01:37:10 PM EST
[ Parent ]
That's a bit harsh. Nobody here has access to the medical records

What metatone is saying (though he can correct me if I'm putting words in his mouth) is that we're debating whether there's a causal link between miscarriage and septicaemia, which he claims is well documented in developing countries and we in the west must have forgotten about because we weren't born when out grandmothers were giving birth without access to antibiotics and, in some cases, electricity or medical facilities. And thus the "debate" on the "link" is concern trolling.

I distribute. You re-distribute. He gives your hard-earned money to lazy scroungers. -- JakeS

by Migeru (migeru at eurotrib dot com) on Wed Nov 21st, 2012 at 01:49:07 PM EST
[ Parent ]
Actually I didn't think the link between miscarriage and septicaemia was contentious; indeed from the newspaper articles I've read the "medical" opinion seems to be that the moment the cervix opens from the "waters" breaking is when the susceptibility to disease goes from low to high.

So, I thought Frank was trying to determine if there was a medical justification beyond religiously-inspired negligence for allowing a woman to face this risk for over three days

keep to the Fen Causeway

by Helen (lareinagal at yahoo dot co dot uk) on Wed Nov 21st, 2012 at 02:03:38 PM EST
[ Parent ]
Actually I didn't think the link between miscarriage and septicaemia was contentious

That what is the whole debate about?

I distribute. You re-distribute. He gives your hard-earned money to lazy scroungers. -- JakeS

by Migeru (migeru at eurotrib dot com) on Thu Nov 22nd, 2012 at 04:05:43 AM EST
[ Parent ]
How great is the risk of septicaemia, over a period of several days, in a woman whose waters have broken but has not yet miscarried?

I find it unlikely that accurate statistics exist for this risk, because it is such grave medical malpractice to allow such a situation to drag on for several days. Because, in particular, of the risk of septicaemia.

It is rightly acknowledged that people of faith have no monopoly of virtue - Queen Elizabeth II

by eurogreen on Thu Nov 22nd, 2012 at 04:47:41 AM EST
[ Parent ]
As I understand it, whatever about the third world, the incidence of septicemia in or subsequent to miscarriage is very low in Ireland, which is partly why our maternal and child mortality rates are so low. It may also be why the medical team felt the "real and substantial risk to the life of the mother" standard wasn't met - until she actually did develop septicemia by which time (AFAIK, but I don't have a precise timeline) the foetus was already dead, but also by which time an abortion/womb evacuation/hysterectomy or other surgical procedure might only have increased the risks to her life.

The real issue here is that the current Constitutional standard in Ireland ("real and substantial risk to the life of the mother") is too high, and ANY risk to the life or health of the mother should have been taken into account - in which case an immediate abortion on admission would have been a no brainer, as the foetus had no chance of survival in any case.

It would require a Constitutional Amendment, by popular referendum, to change that standard. I don't sense any appetite, amongst the political parties, to go through the very bitter and divisive "right to life" Constitutional referenda campaigns of the 1980's all over again. The RC Church and "Pro-life" campaigns would attempt to spin any attempt to lower the Constitutional Standard (to real and substantial risk to the  Life OR Health of the mother) as tantamount to abortion on demand and point to statistics in the UK where, apparently, the justification of risk to the mental health of the mother is utterly routine and used in the vast majority of abortions.

I'm not sure, in that context, whether such a referendum would pass and it would be very unlikely to do so unless at least some of the major political parties campaigned actively and energetically in favour. They show little inclination to do so, and so  in that context I doubt such a referendum would pass.

Losing such a referendum could throw the the ongoing liberalization of Irish society into reverse and it might be at least another generation before women's rights to their own health and bodies were placed on a firmer Constitutional footing.

The bottom line is that Savita may have died because her medical team were justifiably reluctant to intervene aggressively and early enough in the context of current Irish law. It may sound callous (and it is), but the "Right to Life" movement will probably argue that one life lost in rare and exceptional circumstances is a small price to pay in the context of the thousands of "lives of unborn babies" that would be lost if Ireland were to introduce what they call abortion on demand on the British model.

A more winnable proposition, in the short term, for the pro-choice movement might be to argue that where the death of a foetus is inevitable, an abortion should be permissible if it would reduce ANY risk to the life or health of the mother. The "pro-life movement" will undoubtedly argue that this is a form of euthanasia and that it is open to abuse by doctors exclusively concerned about the health of the mother and who might be over eager to declare a threatened miscarriage unavoidable or a fetus unviable, and thus a foetal death inevitable.

However doctors generally, and maternity services more particularly, still have a very high standing and reputation in Ireland. Any attempt by the "Pro-life movement" to impugn the integrity of the profession would not go down well, and such a proposal would probably pass in parliament. What is not clear to me is whether it would require a Constitutional amendment to be passed. Any attempt by the Dail to legislate to that effect would probably be challenged as unconstitutional by the "pro-life" movement, and depending on how the Supreme Court ruled, a referendum might be necessary.

It might only be a small step forward for women's rights in Ireland, but at least it sounds to me like a winnable campaign and it would probably have saved Savita's life.

Index of Frank's Diaries

by Frank Schnittger (mail Frankschnittger at hot male dotty communists) on Thu Nov 22nd, 2012 at 06:41:26 AM EST
[ Parent ]
Migeru:
we in the west must have forgotten about because we weren't born when out grandmothers were giving birth without access to antibiotics

giving birth != miscarriage

In fact why our "grandmothers" (Early Modern ancestresses) died of infection in or after childbirth (and they did, massively) was because the physicians of the time infected them with dirty hands -- until antiseptic precautions became understood and standard. Poor women who could afford neither physicians nor midwives were better off because they did not undergo the intervention of professionals who came hotfoot, bearing pathogens, from other births.

Frank's diary suggested an iatrogenic e.coli infection, which prompted my comments above. However, if this were not the case, a miscarriage is sufficiently dangerous of itself, and this was a long, fraught miscarriage that did not conclude (except in the death of the patient).

Refusing to consider an abortion and leaving this woman to suffer with either insufficient monitoring or a deliberate decision (or both) not to place her life before that of a condemned foetus's heartbeat (when did they diagnose septicemia and realize they would save neither the mother nor the foetus?) was an evident dereliction of medical duty.

by afew (afew(a in a circle)eurotrib_dot_com) on Wed Nov 21st, 2012 at 02:39:00 PM EST
[ Parent ]
afew:
Poor women who could afford neither physicians nor midwives were better off because they did not undergo the intervention of professionals who came hotfoot, bearing pathogens, from other births.

Midwives were better at physicians, that was in part how Semmelweis discovered the importance of washing hands. And physicians came not only from other births but also from things like autopsies.

Best was probably having a midwive coming to the home. That was the practise up here until the physicians monopolised childbirths through legislation.

A vote for PES is a vote for EPP! A vote for EPP is a vote for PES! Support the coalition, vote EPP-PES in 2009!

by A swedish kind of death on Thu Nov 22nd, 2012 at 04:01:42 AM EST
[ Parent ]
Yes, midwives were better because they intervened less than physicians, and may have had the advantage of traditional practices like hand-washing (though a ready supply of clean water in homes was problematic, in cities at least). Yet a poor woman who gave birth aided only by a family member or neighbour was probably "best off", because more isolated from causes of infection.
by afew (afew(a in a circle)eurotrib_dot_com) on Thu Nov 22nd, 2012 at 04:41:37 AM EST
[ Parent ]
Ignaz Semmelweis - Wikipedia, the free encyclopedia

Despite various publications of results where hand-washing reduced mortality to below 1%, Semmelweis's observations conflicted with the established scientific and medical opinions of the time and his ideas were rejected by the medical community. Some doctors were offended at the suggestion that they should wash their hands and Semmelweis could offer no acceptable scientific explanation for his findings. Semmelweis's practice earned widespread acceptance only years after his death, when Louis Pasteur confirmed the germ theory and Joseph Lister practiced and operated, using hygienic methods, with great success. In 1865, Semmelweis was committed to an asylum, where he died of septicemia at age 47.

we reserve usually for those who come to show us what should be obvious...

"We can all be prosperous but we can't all be rich." Ian Welsh

by melo (melometa4(at)gmail.com) on Thu Nov 22nd, 2012 at 06:06:26 AM EST
[ Parent ]
It is ironic he died of Septicemia when he spent his life trying to reduce its incidence. I wonder if the doctors treating him at the asylum didn't approve of his hand washing theories and succeeded in infecting him...

Index of Frank's Diaries
by Frank Schnittger (mail Frankschnittger at hot male dotty communists) on Thu Nov 22nd, 2012 at 06:55:46 AM EST
[ Parent ]
On Daily Kos I have commented that an explanation is still possible which does not involve:
There have been allegations of Roman Catholic dogma determining the medical treatments  available to non-Catholics in Irish hospitals; allegations of racism; and allegations of a patriarchal medical system and culture that would rather have a woman suffer in acute pain rather than give her appropriate treatment and relief.

and that the medical team treating Savita may have taken the view that an abortion in this particular case would not reduce her risks of infection or that an abortion carried at least as many risks as benefits.  That raises two issues:

  1. Were the medical team correct in their assessment based on the available evidence -  e.g. no evidence of infection at that time, and the very low incidence of septicemia following miscarriage in Ireland? Doctors aren't infallible, mistakes happen,  and even very low risks materialize in a very few cases.  So the question here is a straightforward medical practice one - was she properly diagnosed, monitored and treated based on the available evidence, did the medical team make a good faith mistake, were they negligent in some way, or was this a case of medical malpractice requiring, at the very least, a disciplinary response if not a criminal prosecution. It is just about possible that this is one of the rare occasions where a patient dies even though proper medical protocols were adhered to. Unlikely, but still possible, in my view, depending on what the inquiry finds.

  2. But why then was she apparently told she couldn't have an abortion because "this is a Catholic country" and not that the team's medical judgement that an abortion carried as many risks as benefits? It is possible that she WAS told that an abortion carried as many risks as benefits and that the team was therefor not going to carry one out. It is possible that she then she decided that she wanted an abortion anyway, and that she was THEN told that abortion of demand is not possible because "this is a Catholic country".

My point is that we have only heard her husband's allegations, but have heard no testimony for the medical team themselves. We haven't even seen the medical records. So it is to prejudge the issue to make firm assertions at this stage.  The medical team, too, are entitled to a presumption of innocence until the facts are fully investigated. My concern is that a rush to judgement which turns out to be wrong could be damaging to the pro-choice movement. Hell, any rush to judgment in the absence of all the evidence being heard is damaging to the credibility of any community which claims to be reality based and which claims to respect due process.

Some here have accused me here of being a concern troll.  I am most certainly concerned that all the evidence is heard before judgement is made.  I consider the reputation of Daily Kos being at greater risk because of some of the prejudicial, ill-informed and intemperate commentary here.

Index of Frank's Diaries

by Frank Schnittger (mail Frankschnittger at hot male dotty communists) on Thu Nov 22nd, 2012 at 08:05:12 AM EST
[ Parent ]
I fear that the Kossacks on average does not care about the effects on the Irish abortion debate, but only the effects on the US abortion debate. And while in Ireland the eventual outcome of the inquiry will be important, Savita will be forgotten in a week or two in the US so they better get the most outrage out of it while it lasts.

A vote for PES is a vote for EPP! A vote for EPP is a vote for PES! Support the coalition, vote EPP-PES in 2009!
by A swedish kind of death on Thu Nov 22nd, 2012 at 08:30:54 AM EST
[ Parent ]
Unpleasantly similar to a creationism or second amendment debate ...


-----
sapere aude
by Number 6 on Thu Nov 22nd, 2012 at 10:49:13 AM EST
[ Parent ]
You are right about the screeching crowd over there, and I appreciate your raising arguments in advance, before the foetus firsters do so. Your argument hinges on the risk of an infection by the abortion, though. Even if I concede for argument's sake that this might be true for an operation, there is still prostaglandine. Where is the heightened infection risk for that? Your scenario is really far-fetched and makes me wonder if you aren't wrong too when you say this is not the best moment for a campaign to alter the law.
by Katrin on Thu Nov 22nd, 2012 at 08:41:04 AM EST
[ Parent ]
I said in the diary that:

European Tribune - Would an abortion have saved Savita Halappanavar?

It might also have been possible to accelerate the process by inducing an earlier delivery.

I don't know if this was considered, and if so why that option was rejected. Presumably her medical records will shed some light on this. Given that miscarriage is basically premature childbirth triggered if there is some malfunction - I'm not sure if it is known precisely why or how - but which is a naturally occurring end to many pregnancies, perhaps the medical team felt - at the time - there was no need to accelerate the process, or that it was proceeding normally and naturally and with no excessive risk to the mother.

I share your view that this is a somewhat far fetched scenario given that, reportedly, her membrane had ruptured, and that this posed a significant risk of infection. I do know that many successful child-births can take a long time and that induction is often used to accelerate the process, so the suspicion has to be that this was not done here because it was known the foetus was unviable and so that an induction at that time could be construed as an abortion.

However the Catholic Church has often used the somewhat Jesuitical distinction between a treatment intended directly to abort a foetus, and a treatment required by the mother and which has the "side-effect" of aborting the foetus, and so it seems to me the medical team where not "theologically" precluded from pursuing this option. However the failure of the Irish Parliament to legislate to provide greater clarity as to what is and is not legally allowed under the current Constitution may have contributed to uncertainty and procrastination on their part.  

Presumably the inquiry team will question them precisely on this point.

Index of Frank's Diaries

by Frank Schnittger (mail Frankschnittger at hot male dotty communists) on Thu Nov 22nd, 2012 at 09:15:53 AM EST
[ Parent ]
I share your view that this is a somewhat far fetched scenario given that, reportedly, her membrane had ruptured, and that this posed a significant risk of infection. I do know that many successful child-births can take a long time and that induction is often used to accelerate the process, so the suspicion has to be that this was not done here because it was known the foetus was unviable and so that an induction at that time could be construed as an abortion.
Well, I know wikipedia is not an authoritative source and all that, but...
Premature rupture of membranes (PROM) is a condition that occurs in pregnancy when there is rupture of the membranes (rupture of the amniotic sac and chorion) more than an hour before the onset of labor. PROM is prolonged when it occurs more than 18 hours before labor. PROM is preterm (PPROM) when it occurs before 37 weeks gestation. Risk factors for PROM can be a bacterial infection, smoking, or anatomic defect in the structure of the amniotic sac, uterus, or cervix. In some cases, the rupture can spontaneously heal, but in most cases of PROM, labor begins within 48 hours. When this occurs, it is necessary that the mother receives treatment to avoid possible infection in the newborn.

...

Maternal _risk factors for a premature rupture of membranes include chorioamnionitis or sepsis. ...

...

... Current obstetrical management includes an induction of labor at approximately 12 hours if it has not already begun though many physicians believe it to be safe to induce labor immediately, and consideration of Group B Streptococcal prophylaxis at 18 hours.

...

Infection

  • Maternal: If chorioamnionitis [inflammation of the amniotic sac] is present at the time of PPROM, antibiotic therapy is usually given to avoid sepsis, and delivery is indicated. If chorioamnionitis is not present, prompt antibiotic therapy can significantly delay delivery, giving the fetus crucial additional time to mature. In preterm premature rupture of membranes (PPROM), antibiotic therapy should be given to decrease the risk of sepsis. Ampicillin or erythromycin should be administered for 7 days
  • Fetal: If the GBS status of the mother is not known, Penicillin or other antibiotics may be administered for prophylaxis against vertical transmission of Group B streptococcal infection.


I distribute. You re-distribute. He gives your hard-earned money to lazy scroungers. -- JakeS
by Migeru (migeru at eurotrib dot com) on Thu Nov 22nd, 2012 at 09:47:39 AM EST
[ Parent ]
Frank Schnittger:
we ... have heard no testimony for the medical team themselves. We haven't even seen the medical records.

How then can we even ask (but you do) this question:

Frank Schnittger:

Were the medical team correct in their assessment based on the available evidence

What assessment? What evidence?

Frank Schnittger:

no evidence of infection at that time

At what time? This took place over several days. Evidence of infection should have been constantly watched for during that time.

Frank Schnittger:

the very low incidence of septicemia following miscarriage in Ireland

What kind of miscarriage? This one wasn't over quickly, three days went by in which the risk of sepsis was constantly rising. This case called for careful monitoring and attentive reassessment more than once a day. It evidently didn't get it -- I see no reason to doubt the husband's testimony that it was only when his wife collapsed on the third evening that it was realized she needed antibiotics.

Of your three sets of allegations, religious bias and racism will be hard to determine, it will be one person's word against another's. But "a patriarchal medical system and culture that would rather have a woman suffer in acute pain rather than give her appropriate treatment and relief" seems to me clearly established.

by afew (afew(a in a circle)eurotrib_dot_com) on Thu Nov 22nd, 2012 at 09:15:59 AM EST
[ Parent ]
afew:
Frank Schnittger:
we ... have heard no testimony for the medical team themselves. We haven't even seen the medical records.

How then can we even ask (but you do) this question:

Frank Schnittger:

Were the medical team correct in their assessment based on the available evidence

What assessment? What evidence?

Frank Schnittger:

no evidence of infection at that time

At what time? This took place over several days. Evidence of infection should have been constantly watched for during that time.

I am not referring to the public evidence available to us now, but to the evidence available to the medical team at the time, and which will now, presumably, be minutely examined by the inquiry team.

What I am saying is that we are not currently in a position to draw definitive conclusions from the publicly available evidence, but that is precisely what the inquiry team should be doing based on a minute investigation of the currently private medical records and interviews with all the parties involved.

Index of Frank's Diaries

by Frank Schnittger (mail Frankschnittger at hot male dotty communists) on Thu Nov 22nd, 2012 at 09:27:03 AM EST
[ Parent ]
Then I suppose there's no point in discussing this further, it's up to the "inquiry team" (that we may trust with pretty much as much trust as we usually bestow on inquiry teams).
by afew (afew(a in a circle)eurotrib_dot_com) on Thu Nov 22nd, 2012 at 09:41:34 AM EST
[ Parent ]
The Hospital has apparently released Savita's medical records to her husband, so they may well end up in the public domain shortly. His lawyer's first reaction is to note they make no reference to Savita's requests for an abortion. So their completeness and accuracy is immediately open to question.

The Chairman of the inquiry team is a senior professional with a very high international reputation. Given that he has advocated for wider availability of abortion in countries where it is currently very restricted seems to indicate he is at least not a "pro-life" nut job like those medics who recently passed the Dublin Declaration.

The other members of the inquiry team are all Irish medical professionals/administrators/advocates who probably have no great desire to throw their colleagues in Galway under a bus. However the reputation of the profession is at stake, so I doubt they would cover up clear medical malpractice. They may, however, be tempted to pass responsibility onto the politicians who have failed to provide a clear legal framework so that professionals know where they stand and what treatment options are available to them under what circumstances.

I suspect their remit is only to examine the circumstances of Savita's death. They will probably not make specific recommendations for legislative, much less Constitutional changes. So there will be lots of wriggle room and  controversy as to what legal changes are required even if the Inquiry finds legislative changes are required.

Indeed the original Inquiry - in addition to having it's three Galway Hospital based members removed - now seems to be downgraded to the status of a "Clinical Review" and with Health Information and Quality Authority being asked to initiate a Statutory Inquiry. Perhaps this will satisfy Savita's husband demand for an independent public inquiry.

HSE asks Hiqa to carry out Savita Halappanavar inquiry - The Irish Times - Thu, Nov 22, 2012

The Health Service Executive has asked the State's health watchdog Hiqa to initiate a statutory inquiry into the death of Savita Halappanavar.

Separately, Praveen Halappanavar's solicitor Gerard O'Donnell has said there is no record in Ms Halappanavar's medical file of her requests for a termination while she was being treated in University Hospital Galway.

The director general designate of the HSE Tony O'Brien said even if Ms Halappanavar's family decided not to co-operate with the executive's inquiry, the review "must be brought to a conclusion".

"There was 'no way' the inquiry could be stopped as it would be "criminally negligent" not to proceed, he said.

Mr Halappanavar's decision not to participate in the inquiry "does not absolve the HSE of an obligation to ensure that the inquiry proceeds" he said. The HSE inquiry would provide it with a clinical information that may be of "immediate value" in the hospital,he said.

In order to give "further reassurance" to her family and the public, Mr O'Brien said he told the Hiqa chief executive  he will request that Hiqa initiate its own statutory inquiry. This could take place before the HSE inquiry concluded, he said.

It was not "either or" as to a public review and the HSE clinical inquiry, he told RTÉ Radio's News at One.  There will also be a coroner's process under way shortly which has "many attributes of a public inquiry," he said.

Mr O'Donnell said he had studied the medical records given to the family closely and had written to the HSE about them on Monday.

Mr O'Donnell's main concern was that there was no request documented in the Savita Halappanavar's medical records that she or her husband had repeatedly sought a termination.

"There's absolutely no entry by the medical team of this in the medical records," he told RTÉ.

In response Mr O'Brien said any information that Mr Halappanavar had that would "speak to any inconsistencies between what's in the record and his personal knowledge would be of great value to the review team".

He also that the HSE was not as "aware as it should have been of the wider context that was emerging" and was focused on the "clinical aspects" in its inquiry.

Asked about the inclusion of three Galway clinicians in the original review team, he said Minister for Health Dr James Reilly was not aware of the total composition before it was announced because that was a matter for the HSE.

Once the HSE heard the concerns of the family it took steps to have the Galway clinicians stand down, he said.

Earlier today, Minister for Social Protection Joan Burton welcomed President Michael D Higgins's intervention in the controversy over the inquiry into the death of Savita Halappanavar.

Ms Burton said she had read and heard the comments made by the President and believed they were considerate, thoughtful, reflectful and humane, she added.

President Michael D Higgins yesterday intervened in the continuing row over the inquiry into the death of Ms Halappanavar, saying it must meet the needs of her family as well as those of the State.



Index of Frank's Diaries
by Frank Schnittger (mail Frankschnittger at hot male dotty communists) on Thu Nov 22nd, 2012 at 10:15:06 AM EST
[ Parent ]
Frank Schnittger:
They may, however, be tempted to pass responsibility onto the politicians who have failed to provide a clear legal framework so that professionals know where they stand and what treatment options are available to them under what circumstances.

Yes, and that produces pressure for legislation. I assume that one needn't alter that constitution of yours in order to define "substantial risk to the life of the mother".

by Katrin on Thu Nov 22nd, 2012 at 10:32:18 AM EST
[ Parent ]
No - the purpose of legislation is to define the constitution in more detail. A new can be challenged as "unconstitutional", and then the Supreme court had the final word on whether it is or not.

Index of Frank's Diaries
by Frank Schnittger (mail Frankschnittger at hot male dotty communists) on Thu Nov 22nd, 2012 at 10:44:41 AM EST
[ Parent ]
"A tragic case but also unique and unlikely to occur again. No change necessary."


-----
sapere aude
by Number 6 on Thu Nov 22nd, 2012 at 11:20:55 AM EST
[ Parent ]
As I understand, the patient was in hospital for 3 days (at least, I'm not sure of the actual timescale as reports have varied) with a dying foetus and with her waters broken.

Once the waters break, the chance of infection apparently skyrocket. At that point, the responsible medical response to preserve the life of the mother would have been abortion. To do nothing was to play russian roulette with her life. And, thanks to the hospital's gambling, Savita lost.

keep to the Fen Causeway

by Helen (lareinagal at yahoo dot co dot uk) on Wed Nov 21st, 2012 at 08:31:09 AM EST
It apparently depends on the timeline. An abortion after infection has set in would do nothing for her and might increase the risk. An abortion before any indications of infection could have reduced the risk - and, I agree with you, I think that is most likely what happened here because I don't see any reports of her presenting with a high temperature, for instance, on admission.

Index of Frank's Diaries
by Frank Schnittger (mail Frankschnittger at hot male dotty communists) on Wed Nov 21st, 2012 at 08:39:51 AM EST
[ Parent ]
There are many different methods of abortion, and I would be surprised if all of them would have increased her risk.

It seems undisputed that the hospital didn't cite medical reasons when they refused the abortion. They didn't say it would have increased her risk or something. They cited ideological/legal reasons. The Catholic country stuff.

Obviously the staff thought their risk of being prosecuted (or of having to answer nasty questions) was higher if they carried out an abortion. It is important to make sure that this is shifted, and that the staff becomes aware that refusing an abortion is an equally (at least) high risk, if there aren't compelling reasons for this refusal, which should be documented.

by Katrin on Wed Nov 21st, 2012 at 09:00:29 AM EST
[ Parent ]
I got a robocall from a calling claiming to give an objective description (a pro-life one) of the current legal position in Ireland regarding the right to life of the mother, and asking me to press:

  1. If I thought the current legal position was fine
  2. If legal changes were required, and
  3. if I supported "Abortion on demand" as in the UK.

When I pressed 3  it just went into a continuous loop.

Automated anti-abortion line shut down - The Irish Times - Thu, Nov 22, 2012

The service provider that has been sending anti-abortion automated calls to households across Ireland has been shut down after it was identified by the Office of the Data Protection Commissioner.

Since the calls began yesterday, the Office of the Data Protection Commissioner has received more than 30 official complaints related to the automated calls. A spokeswoman for the office said that it was marked as a priority case.

"We would consider 30 complaints to be a very large number, so it was made a priority," she said. "We can ensure that no more calls will be made from this number, but the may change to another."

The spokeswoman could not name who was behind the automated calls as it is still under investigation.

The calls were made from a Dublin number and claimed to be from a professor emeritus of obstetrics and gynaecology at NUI Galway. The automated caller said that Irish doctors do not put the life of a mother at risk, even if it means the unborn child's death.

The call references a recent case where a pregnant woman died in Ireland, but did not directly mention the case of Savita Halappanavar.

Before the number was shut down, the Office of the Data Protection Commissioner advised people not to engage in the call.



Index of Frank's Diaries
by Frank Schnittger (mail Frankschnittger at hot male dotty communists) on Thu Nov 22nd, 2012 at 01:14:47 PM EST


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