Termination of Pregnancy As Emergency Obstetric Care
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FEATURE Termination of pregnancy as emergency obstetric care: the interpretation of Catholic health policy and the consequences for pregnant women An analysis of the death of Savita Halappanavar in Ireland and similar cases Marge Berer Editor, Reproductive Health Matters. Correspondence: [email protected] “There is only one way to be sure a woman’s life is at risk, that is, after she dies.” (Christian Fiala, 2012) In 1987, the year the first Safe Motherhood government has been forced to consider the Initiative was launched by the World Health effects of her death for the law, health policy and Organization, there were more than half a million the Constitution of Ireland. maternal deaths annually. The women who were Savita’s death became iconic for a number of dying were often anonymous and their deaths reasons. First, preventing maternal deaths has never recorded or studied. They were mainly from been a global priority since 1987 when the first poor and often rural backgrounds in developing World Health Organization Safe Motherhood countries, such as India. A study in India pub - Initiative was launched. Since 2000, reducing lished in 1999 comparing 100 maternal deaths in maternal deaths by 75% by 2014 has been the a Rajasthan hospital in 1983–85 to 100 in main target of Millennium Development Goal 1994–96 found that: “Most of the women who died No.5, and since 2010 it has been one of five main in hospital in 1994–96 would have died at home in goals of the UN Secretary-General Ban Ki-Moon’s the earlier decade.”1 What had changed was that Global Strategy on Women’s and Children’s they had reached a hospital and were therefore Health.3 Hence, maternal deaths have started to no longer anonymous, but they were still over - be a news item globally, with journals like whelmingly women living in poverty with little or Reproductive Health Matters carrying studies and no access to skilled pregnancy and delivery care. the media in many countries where deaths Contrast this with the death of Savita Halap - remain frequent, reporting successes and failures panavar on 28 October 2012, a dentist from a to reduce deaths, and individual stories regularly. privileged background in India, who miscarried Secondly, holding governments accountable for 17 weeks into a very wanted pregnancy and died their failure to provide the required services, both in the maternity ward of a hospital in Ireland, a antenatal and delivery care and emergency ob - country with a very low maternal death ratio.2* stet ric care, to prevent avoidable maternal deaths Savita’s death was anything but anonymous; her name and photograph circled the globe within days of her death and sparked street demon - * The most recent figure published by WHO is thought by strations and protests, not only across Ireland but experts in Ireland to be too low, as data are incomplete by also in many other parts of Europe and in India. WHO measures. Ireland is in the process of shifting to using Six weeks later, articles and blogs about her death the UK system of determining the maternal death ratio; continued to be published in many countries, figures are due in 2013. For 2009-2011 data see: demands by her husband for a maternal death Maternal Death Enquiry MDE Ireland: audit were headline news and the Irish http://www.mdeireland.com/index.html. Early online publication: www.rhmjournal.org.uk 1 M Berer. Reproductive Health Matters 2013 has become the subject of public protests by account not just the individual death but also the women’s rights advocates, of court cases, inclu - constitutional and human rights obliga tions of ding in India, and of hearings by human rights the central government of India.5 bodies, par ticu larly CEDAW, examining individual Some communities where women are at high cases and making policy recommendations to risk because of the lack of routine and emergency governments.4 obstetric care are also beginning to protest against What was different about Savita’s death, how - maternal deaths. One such event took place in ever, was the fact that it was also about whether Uganda where, in May 2011, hundreds of con - and when to terminate a pregnancy when it is not cerned citizens and health professionals stormed viable and the woman’s health and life are at risk, the Constitutional Court in Kampala, Uganda, and how that intersected in Savita’s case with protesting the deaths of women in childbirth, in individual health professionals’ interpretation of support of a coalition of activists who took out a Catholic health policy and the law on abortion in landmark lawsuit against the government over Ireland. two women who bled to death giving birth As a committee of the Irish Parliament unattended in hospital.6 considers proposals to offer limited legal abortion Another example from India comes from in Ireland, this paper explores how these issues Barwani district, Madhya Pradesh, India, where came together around Savita’s death, the there were local protests against 27 maternal interpretation of Catholic health policy and the deaths in the period from April to November consequences for pregnant women. 2010. In January 2011, an NGO fact-finding team found an absence of antenatal care despite high levels of anaemia, absence of skilled birth Preventing maternal deaths as global attendants, failure to carry out emergency obste - policy tric care in obvious cases of need, and referrals Maternal deaths, especially in countries where that never resulted in treatment.7 they remain frequent, are getting more and more Events like these are making the governments media coverage. The Millennium Development concerned highly sensitive to criticism. As an Goals have made countries with continuing high upper middle-class woman, Savita Halappanavar maternal mortality ratios* conscious of their would have been highly unlikely to die in India shortcomings, and civil society organisations are from the appalling treatment experienced by beginning to pur sue justice and even com pen - Shanti Devi or the tribal women in Barwani. Yet, sation in individual cases. ironically, the Indian government was among the In India, for example, a petition for legal first to criticise those in Ireland who failed to redress was filed in the Delhi High Court in the prevent Savita from dying. For example, India’s case of Shanti Devi, who died in childbirth in ambassador to Ireland said on Friday that Mrs January 2010 after two high risk pregnancies in Halappanavar may be alive if she had been which she received delayed and insufficient care. treated in India.8 With the first of these two pregnancies, she fell down the stairs and afterwards could no longer feel the baby moving. Induction of the pregnancy Emergency obstetric care, termination of was delayed until she required intensive care non-viable pregnancies and Savita’s death which, when she finally received it, was inade - Whether the details of the maternal death audit in quate. With her health still very precarious, she Savita’s case will be made public, as Savita’s became pregnant again six months later, went husband demanded in the weeks following her into labour prematurely at seven months, death, is uncertain at this writing. It is widely delivered the baby at home without a skilled birth accepted by the medical profession that maternal attendant or any medical assistance, and within death audits must remain confidential in order to an hour after delivery, began haemor rhaging and have the desired outcome – open examination of died. This case ensured that the Court took into the causes of death and the actions that need to be taken to prevent such a death in future, if such a death is indeed preventable. This is the basis on * India’s is 200 deaths per 100,000 live births compared to which the UK Confidential Enquiries into Maternal only 6 per 100,000 live births in Ireland in 2010.2 Deaths have been conducted every three years 2 M Berer. Reproductive Health Matters 2013 and reported,* and the process followed for these required an emergency obstetric response. Termi - enquiries has been a model for other countries. nation of pregnancy to save a woman’s life is legal There is an assumption in these cases that the in Ireland under the Offences against the Person individual health professionals involved acted in Act 1861, and indeed in all but five countries in good faith, and the point is therefore to ensure the world. Termination to save the woman’s life that any mistakes made are avoided in future, not should be understood to mean to prevent a to punish people for making them. This is quite pregnancy from becoming life-threatening before different from addressing medical malpractice. it is already life-threatening. One would have Savita’s husband may or may not have under - thought that includes termination to complete an stood why such audits are confidential when he inevitable miscarriage and to end an unviable demanded that the enquiry into her death be pregnancy, both of which could easily become carried out in public, but his demand, according septic, as well as termination when the woman to the newspapers, was because he believed the has or develops a life-threatening illness while doctors involved may have been covering up pregnant. However, there is nothing in writing information, at least in terms of what they were that specifies what “termination of pregnancy willing to say to him and his solicitor. to save a woman’s life” actually means, nor when In Savita’s case, and in others summarised it applies. below that are similar, the question of whether or This was made even more complicated in not the deliberate decision not to terminate the Ireland since a 1983 Constitutional amendment, pregnancy does constitute malpractice is highly whose aim was to prevent termination of preg - relevant.