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You Can’t Have it Both Ways: The Interpretation of Catholic Health Policy and the Consequences for Pregnant Women

12:46 pm in Uncategorized by RH Reality Check

Written by Marge Berer for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

Republished with permission from Reproductive Health Matters.

“There is only one way to be sure a woman’s life is at risk, that is, after she dies.” — Christian Fiala, 2012

 

A view of Galway Hospital and parking lot

Savita Halappanavar died at Galway University Hospital.

In 1987, the year the first Safe Motherhood Initiative was launched by the World Health Organization (WHO), there were more than half a million maternal deaths annually. The women who were dying were often anonymous and their deaths never recorded or studied. They were mainly from poor and often rural backgrounds in developing countries, such as India. A study in India published in 1999 comparing 100 maternal deaths in a Rajasthan hospital in 1983-85 to 100 in 1994-96 found that: “Most of the women who died in hospital in 1994-96 would have died at home in the earlier decade.”1 What had changed was that they had reached a hospital and were therefore no longer anonymous, but they were still overwhelmingly women living in poverty with little or no access to skilled pregnancy and delivery care. 

Contrast this with the death of Savita Halappanavar on 28 October 2012, a dentist from a privileged background in India, who miscarried 17 weeks into a very wanted pregnancy and died in the maternity ward of a hospital in Ireland, a country with a very low maternal death ratio.2 Savita’s death was anything but anonymous; her name and photograph circled the globe within days of her death and sparked street demonstrations and protests, not only across Ireland but also in many other parts of Europe and in India. Six weeks later, articles and blogs about her death continued to be published in many countries, demands by her husband for a maternal death audit were headline news, and the Irish government has been forced to consider the effects of her death for the law, health policy and the Constitution of Ireland. 

Savita’s death became iconic for a number of reasons. First, preventing maternal deaths has been a global priority since 1987 when the first WHO Safe Motherhood Initiative was launched. Since 2000, reducing maternal deaths by 75 percent by 2014 has been the main target of Millennium Development Goal No.5, and since 2010 it has been one of five main goals of the UN Secretary-General Ban Ki-Moon’s Global Strategy on Women’s and Children’s Health. Hence, maternal deaths have started to be a news item globally, with journals like Reproductive Health Matters carrying studies and the media in many countries where deaths remain frequent, reporting successes and failures to reduce deaths, and individual stories regularly.

Secondly, holding governments accountable for their failure to provide the required services, both antenatal and delivery care and emergency obstetric care, to prevent avoidable maternal deaths has become the subject of public protests by women’s rights advocates, of court cases, including in India, and of hearings by human rights bodies, particularly CEDAW, examining individual cases and making policy recommendations to governments.3

What was different about Savita’s death, however, was the fact that it was also about whether and when to terminate a pregnancy when it is not viable and the woman’s health and life are at risk, and how that intersected in Savita’s case with individual health professionals’ interpretation of Catholic health policy and the law on abortion in Ireland. 

As a committee of the Irish Parliament considers proposals to offer limited legal abortion in Ireland, this paper explores how these issues came together around Savita’s death, the interpretation of Catholic health policy and the consequences for pregnant women.

Preventing maternal deaths as global policy

Maternal deaths, especially in countries where they remain frequent, are getting more and more media coverage. The Millennium Development Goals have made countries with continuing high maternal mortality ratios4 conscious of their shortcomings, and civil society organizations are beginning to pursue justice and even compensation in individual cases. 

In India, for example, a petition for legal redress was filed in the Delhi High Court in the case of Shanti Devi, who died in childbirth in January 2010 after two high-risk pregnancies in which she received delayed and insufficient care. 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 was delayed until she required intensive care which, when she finally received it, was inadequate. With her health still very precarious, she became pregnant again six months later, went into labor prematurely at seven months, delivered the baby at home without a skilled birth attendant or any medical assistance, and within an hour after delivery, began hemorrhaging and died. This case ensured that the Court took into account not just the individual death but also the constitutional and human rights obligations of the central government of India.5

Some communities where women are at high risk because of the lack of routine and emergency obstetric care are also beginning to protest against maternal deaths. One such event took place in Uganda where, in May 2011, hundreds of concerned citizens and health professionals stormed the Constitutional Court in Kampala, Uganda, protesting the deaths of women in childbirth, in support of a coalition of activists who took out a landmark lawsuit against the government over two women who bled to death giving birth unattended in hospital.6

Another example from India comes from Barwani district, Madhya Pradesh, India, where there were local protests against 27 maternal deaths in the period from April to November 2010. In January 2011, an NGO fact-finding team found an absence of antenatal care despite high levels of anemia, absence of skilled birth attendants, failure to carry out emergency obstetric care in obvious cases of need, and referrals that never resulted in treatment.7

Events like these are making the governments concerned highly sensitive to criticism. As an upper middle-class woman, Savita Halappanavar would have been highly unlikely to die in India from the appalling treatment experienced by Shanti Devi or the tribal women in Barwani. Yet, ironically, the Indian government was among the first to criticism those in Ireland who failed to prevent Savita from dying. For example, India’s ambassador to Ireland said that Mrs Halappanavar may be alive if she had been treated in India.

Emergency obstetric care, termination of non-viable pregnancies and Savita’s death

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Abortion in Ireland: The Injustice and Day-to-Day Terror Faced by Countless Women

11:38 am in Uncategorized by RH Reality Check

Written by Sarah Fisher for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

See all our coverage of the tragic case of Savita Halappanavar here.

Ireland's abortion policies cause widespread misery.

As an organisation that hears first-hand from the women who bear the burden of Ireland’s archaic abortion laws, the tragic death of Savita Halappanavar was shocking and sickening.

And yet not as surprising as you’d think.

Given that abortion laws in Ireland are among the strictest in the world, a tragedy of this kind wasn’t so much a matter of if, but when. The circumstances in which Savita died are truly abhorrent. Admitted to hospital experiencing a miscarriage at 17 weeks, despite being told that the fetus “wasn’t viable” she was made to suffer for days, left begging for an abortion that she was refused as long as there was a foetal heart beat.

Haunted by the harrowing details of Savita’s death we’re left to wonder how many more women in Ireland may have lost their lives as a result of being denied a life-saving abortion.

If Savita’s family hadn’t bravely made the decision to go public, would her senseless death have come to light? Have the lives of more women been sacrificed because a fetus was deemed more important? Even when it was known that the fetus would not survive? When, technically in Ireland an abortion is permitted if there is a “real and substantial risk to the life of the mother?” These are questions that we cannot ignore and questions that demand answers.

Savita’s death is the worst illustration of what happens when abortion is highly restricted, and the worst way for the ‘pro-life’ lobby to be proved wrong. How often do we hear that abortion is never necessary to save the life of a woman? A protester at a vigil for Savita hit the nail on the head with a placard stating ‘Pro-Life beliefs killed Savita Halappanavar — Ireland needs abortion rights.’  So did Kartha Pollit in her compelling reflection on the case When ‘Pro-Life’ kills.

But what has been absent from the mainstream media coverage of Savita’s death has been the mass, day-in day-out misery and discrimination experienced by women as a result of the near-total ban on abortion in Ireland.

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Savita Had a Heartbeat, Too

1:20 pm in Uncategorized by RH Reality Check

Written by Shivana Jorawar for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

See all our coverage of the tragic case of Savita Halappanavar here.
For days now, I’ve been putting myself in Savita Halappanavar’s shoes.

I’m expecting. Seventeen weeks in, piercing pain sends me to the hospital. For three days, I’m miscarrying. There’s no hope for my child and my own health is fading. For three days, I’m in physical agony and doctors refuse my pleas to terminate the pregnancy to save my life. The child won’t survive, but there is a “heartbeat” and doctors fear terminating will violate my country’s laws. The unthinkable happens.

The tragedy that ended Savita’s life put a human face on the abortion issue. People are demonstrating in droves and even the Indian government is pressuring Ireland to change its laws. One demonstrator held a placard reading, “Savita had a heartbeat, too.”

For many of us, the disregard for women’s human rights in the name of religion just became personal. When I see Savita’s face, I can’t help thinking that she looks like me and, like me, was educated and could afford health care — but she still suffered this indefensible fate. Everyone knew the child could not survive, but that Savita could with proper care.

What does it say about a society when it leaves a woman to die in the name of “life?”

Where is the respect for women’s lives? This irony pervades the politics surrounding women’s health in my own country, the United States. Right-wing calls for abortion bans not only keep women from living full lives of our choosing, but often fail to include exceptions for our health or death. Most of those backing these so-called “pro-life” measures are also the ones blocking efforts to provide equal pay, health care, and safety net programs women and children rely on. It seems their concern for life ends when a baby is born.

And, if this can happen to someone like Savita, a doctor herself, what about more vulnerable women? As U.S. conservatives rush to eliminate the right to choose, it is poor women, disproportionately of color, who are seeing that right fade most quickly. It is these women who often cannot afford abortions, or do not have the time and know-how to see a provider during their first trimester. Twenty-week bans and funding cuts are not only sexist, but covertly racist and classist, too.

As I plan my own future and explore whether parenthood is right for me, I am thankful I live in a place where abortion is legal and safe, and that I can afford the right to choose. I am thankful that women have always been resilient in my country, and that we have a long history of fighting for and winning reproductive rights.

With strength and courage, women in the United States have come a long way. But our journey is not complete. Too many women are still left out and too many lawmakers threaten to send us back to a time when Savita’s story could happen here. That’s why I work to not only preserve the rights I have, but to expand them for all women — because we all have a heartbeat, too.

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Women’s Lives Matter: It’s Time to Hold Governments Accountable for Safe Abortion Care

12:49 pm in Uncategorized by RH Reality Check

Written by Patty Skuster for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.
See all our coverage of the tragic case of Savita Halappanavar here.

The news of Savita Halappanavar’s tragic death after being denied an abortion has been heard around the world by now. Protesters have gathered in her honor, vigils will continue to be held and, perhaps, the end of her life will be a wake-up call. Women’s lives matter and laws should protect them — not cost them their lives.

In Ireland, abortion is against the law in most cases. But Savita should have received a legal abortion; under the constitution abortion is allowed when a woman’s life is in imminent danger. And Savita’s husband reports that doctors told them an abortion wasn’t an option, despite her repeated requests and severely declining health, because Ireland “is a Catholic country.” What that meant for Savita was that the health-care providers at Galway University Hospital made decisions based on their values (as dictated by the Catholic Church) and disregarded the value of her life.

The lack of implementation of the abortion law in Ireland is very similar to so many countries where Ipas works. In most countries, abortion is permitted for one or more reasons. Human rights authorities — including at the United Nations and ICPD–agree that governments must take steps to make legal abortion available. In fact, in 2010, the European Court on Human Rights ruled that Ireland must implement its abortion law. But when governments don’t fulfill their obligations to protect women’s reproductive rights, women can’t access safe abortion services and die as a result. Just like Savita.

We have to hold governments accountable. Laws must be clear on abortion and guidance and training need to follow. And make no mistake, these laws and policies must include regulation of providers’ refusal of service — to ensure that a woman can receive an abortion from a willing colleague through referrals or some other mechanism. And never should a woman’s life hang in the balance because of someone else’s moral objection to abortion.

Savita isn’t alone. There are so many women whose deaths are never reported or don’t have access to hospitals and die because they can’t get safe abortion care. Why? Because the laws are not implemented, people are unwilling or untrained to provide service, and abortion stigma permeates legal systems, health systems, communities and even families. For years, Ireland has failed to enact mechanisms for legal abortion because of political and social sensitivities. Without clarity about what’s permitted and what isn’t under the law, doctors and other health-care workers tend, as they did in Savita’s case, tragically, to play it really safe — for them, that is, not for the women who are affected.

At Ipas we have worked throughout the world to help governments clarify and implement abortion laws. We partner with health-care providers, civil society organizations, and health ministries to pass guidelines that enable access to legal abortion. We support the training of health-care providers and partner with community organizations and the legal sector to promote an understanding of local abortion laws.

Let’s not forget; a woman is dead after doctors refused to terminate an already unviable — yet wanted — pregnancy for a woman in incredible pain. Her husband is left to question the decisions made by these doctors — and to grapple with her death, which could likely have been prevented.

Photo by infomatique under Creative Commons license.

Silence and Denial Don’t Work: Ireland, Malta, the European Union and the Lessons of Savita’s Death

1:49 pm in Uncategorized by RH Reality Check

Written by Johanna Westeson for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

See all our coverage of the tragic case of Savita Halappanavar here.

Much has been said about the tragic death of Savita Halappanavar in Galway, Ireland last month. Even before seeing the outcome of the official investigation we can conclude that her death was the result of a combination of factors: inhumane laws, lack of guidelines on how to apply the laws that do exist, fear of prosecution on behalf of doctors, medical incompetence, influences of the most conservative wing of the Catholic Church over hospitals, and — as pointed out recently by Jodi Jacobson — a general climate of misogyny, poisoning both the medical establishment and society at large.

Twenty years ago, the Irish Supreme Court established that abortion is legal when a pregnant woman’s life is in danger. More specifically, it ruled that termination of pregnancy is lawful “if it is established as a matter of probability that there is a real and substantial risk to the life, as distinct from the health, of the mother, which can only be avoided by a termination of the pregnancy.” Please note how restrictive these words are: “real and substantial risk” and “life, as distinct from the health.” With due respect for a court that took a courageous step forward in a country where the issue of abortion is and was taboo under any circumstance, it is remarkable how the ruling goes out of its way to make this exception to the abortion ban as narrow as possible. Anyhow, these are the parameters. It is the law of the land.

But nobody knows how this rule should be understood because there is no further guidance. No written law, no guidelines, no official interpretation. So doctors in Ireland, whether pro- or anti-choice, whether in Catholic hospitals or elsewhere, must navigate around this. It may be that in Savita Halappanavar’s case, the situation was crystal clear: her life was in danger, the situation was acute, an abortion would probably have saved her, and doctors refused her care because they favored the life of her unviable fetus over hers. It is even likely that this was the case. But in most situations, threats to the life and health of the pregnant woman cannot be so clearly distinguished. Usually, a threat to life is preceded by a threat to health. So is a doctor to wait until a critical health situation turns into a life-threatening situation? It appears that way. How does this correspond with medical ethics? It doesn’t. I do not envy ob/gyns in Ireland. I cannot imagine the agony that they, or many of them, must experience when a woman shows up with pregnancy-related complications. This is not to take away any of the responsibility from those doctors or the hospital that treated, or mistreated, Savita Halappanavar. It is only to shed light on the context in which they are operating.

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The Death of Savita Halappanavar: A Tragedy Leading to Long Overdue Change?

10:23 am in Uncategorized by RH Reality Check

About Ten Thousand People Attended A Rally In Dublin In Memory Of Savita Halappanavar

About Ten Thousand People Attended A Rally In Dublin In Memory Of Savita Halappanavar

Written by Carole Joffe for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

The tragic and unnecessary death of Savita Halappanavar — a 31-year old Indian woman who was denied a life-saving abortion in an Irish hospital — has sparked reactions across the globe. Thousands have marched in Dublin. Demonstrations have taken place in India and elsewhere. An international day of protest is called for November 21. Tense meetings between Indian and Irish government officials are taking place. The overriding question now is: what will be the legacy of this horrible event, beyond the unspeakable grief of Savita’s loved ones? After the demonstrations have stopped, will Irish hospitals — where abortion remains illegal but is permissible in life-threatening conditions — proceed differently in the future? Will the country finally move toward legalizing abortion?

This heartbreaking incident has led me to contemplate the long history of abortion struggles around the globe and under what circumstances, change takes place. It is not an exaggeration to say that throughout history millions of women have died and even more have been injured because of the lack of safe abortion. But only some of these tragedies capture the public’s attention and become catalysts for change.  And sometimes public attitudes are affected even when a woman’s death is not involved.

Consider the history of abortion in the United States. Two events that occurred in the 1960s were instrumental in moving much of the country toward an endorsement of legal abortion. The first, in 1962, involved Sherri Chessen Finkbine, a Phoenix woman pregnant with her fifth child, who learned that the Thalidomide pills she had been using as a sleep aid were strongly associated with severe birth defects. Her doctor was able to arrange a “therapeutic” (i.e. approved) abortion for her at a local hospital, but Finkbine, in an act of decency that would prove costly, went public with her story as she hoped to warn other women who were in her situation. Her interview with a journalist created a media sensation, and nervous hospital authorities cancelled her abortion. Ultimately Finkbine, unable to find an abortion anywhere in the United States, obtained one in Sweden, where she delivered a fetus with missing limbs. Doctors told her the fetus would have had no chance of survival. Finkbine’s story spread beyond Phoenix to become a national story, including a cover on Life magazine. This incident, particularly the unprecedented visibility of abortion on the cover of the leading news magazine of the 1960s, “had a galvanizing effect on public opinion,” in the words of the journalist Linda Greenhouse, a longtime observer of the trajectory of abortion rights in the United States.
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Irish Law, “Conscience Clauses,” and Needless Death: Three Questions About Savita Halappanavar’s Death

1:36 pm in Uncategorized by RH Reality Check

Written by Editor-in-Chief Jodi Jacobson for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

See all our coverage of the tragic case of Savita Halappanavar here.

An Irish flag hangs against a blue sky

Could the tragic death of an Irish woman happen in the United States?

Last night, we reported on the unnecessary and tragic death of Savita Halappanavar, who entered an Irish hospital undergoing what turned out to be a miscarriage of a wanted pregnancy at 17 weeks, and was denied a life-saving abortion because, as she and her husband were told, Ireland is “a Catholic country.” Translation? Even a non-viable fetus, perhaps already dead but in any case absolutely certain not to survive, is more important than a woman’s life.

Numerous questions have arisen in the wake of this case.

One: Why did this happen? Doesn’t Ireland, a country with otherwise draconian abortion laws, allow abortion to save the life of the mother?

Two: Was there any doubt an abortion was necessary to save Savita’s life?

Three: Can this happen in the United States?

I’ll take these in turn.

The reason this happened is at once very simple and highly complex. It starts with Irish abortion law, and ends with the imposition of a misogynistic ideology on a woman literally begging for mercy from pain and for her own life as she pleaded with her doctors numerous times to perform an abortion on a fetus it was clear would not live.

Current Irish law on abortion is somewhat murky. The country’s laws, like those of most others, have shifted dramatically over the past two centuries, until in the mid-fifties abortion was made illegal in virtually all circumstances. The legal landscape changed again over 20 years ago when the Irish Supreme Court decided that women had a constitutional right to an abortion where there was “real and substantial risk” to the life of the mother. The Supreme Court decision came in response to the case of “X,” who, as a February 2012 article in the New York Times pointed out, was a 14-year-old girl prevented from leaving the country to have an abortion after she became pregnant from rape. After that decision, according to a Human Rights Watch (HRW) report:

 abortion [in Ireland remained] legally restricted in almost all circumstances, with potential penalties of penal servitude for life for both patients and service providers, except where the pregnant woman’s life is in danger.

In its 1992 decision, the Irish Supreme Court also required the government to clarify the conditions under which a legal abortion might take place.

Nonetheless, as we reported in December 2011, Human Rights Watch found that 20 years later:

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We Are All Savita Halappanavar: Catholic Hospital in Ireland Denies Woman Life-Saving Abortion

3:27 pm in Uncategorized by RH Reality Check

Written by Editor-in-Chief Jodi Jacobson for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

See our further analysis of this case.

Galway University Hospital, the scene of the crime.

Last month, a woman was admitted to a hospital in Galway, Ireland. She was 17 weeks pregnant with a wanted child. She was experiencing severe back pain. She was found to be miscarrying the pregnancy.

Within days, she was dead.

Why? Because she ended up in a Catholic hospital, governed by an ethic that even a non-viable fetus doomed to die is more important than a living, breathing 31-year-old woman.

It really is that simple.

IrishTimes.com reports that Savita Halappanavar, a dentist, arrived at the hospital on October 21st. According to the story:

Her husband, Praveen Halappanavar (34), an engineer at Boston Scientific in Galway, says she asked several times over a three-day period that the pregnancy be terminated. He says that, having been told she was miscarrying, and after one day in severe pain, Ms Halappanavar asked for a medical termination.

This was refused, he says, because the fetal heartbeat was still present and they were told, “this is a Catholic country.”

Indeed.

So, the story continues, “She spent a further 2½ days “in agony” until the fetal heartbeat stopped.

According to IrishTimes.com, Mr Halappanavar, speaking from Belgaum in the state of Karnataka, India, said an internal examination was performed when she first presented.

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