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

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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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.

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

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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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.

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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Written by Sandy Eisenberg Sasso, and posted on RHRealityCheck.org – News, commentary and community for reproductive health and justice.

This article was originally published by the IndyStar.com.

In commemoration of the 100th anniversary of International Women’s Day, congregations across the country are designating the weekend of March 4-6 as Rachel Sabbath. In the Bible, Rachel is the matriarch who dies in childbirth.

The purpose of this day is to raise awareness of the crisis in reproductive health services and care around the world. Rachel Sabbath supports the United Nations goal of improving maternal health by doubling current global investments in family planning, reproductive and health services to women around the world. The effort could save $1.5 billion in long-term medical costs and it would save the lives of 400,000 women and 1.6 million infants each year.

Women in developing countries are at greatest risk. In Niger, the risk of women dying from pregnancy-related complications is one in seven, the highest in the world. The lowest-risk country is Ireland. Despite our exemplary medical care, 40 nations have a lower risk of maternal death than the United States.

So it is both shocking and appalling that in America, federal legislation is being proposed that would eliminate Title X funding, which covers family planning and preventive reproductive medical care. Federal and state legislation also is targeting Planned Parenthood funding.

What’s behind these efforts? … Read more

Written by Kelly Castagnaro for RHRealityCheck.org – News, commentary and community for reproductive health and justice.

This article is part of a series by RH Reality Check in collaboration with EngenderHealth, Guttmacher Institute, the International Women’s Health Coalition, the Fistula Foundation, the United Nations Population Fund (UNFPA), and the Campaign to End Fistula.  All articles in this series can be found at this link.

The series is being published during a time of renewed efforts by advocates and the public health community to increase U.S. international support for efforts to address obstetric fistula, a wholly preventable but debilitating and sometimes deadly condition caused most immediately by prolonged labor and too early or too frequent childbearing, but generally rooted in lack of access to health care and discrimination against women.  Fistula affects the lives of individual women, their children and families, and also grossly undermines women’s economic productivity and participation in society. The global public health community has called for comprehensive strategies both to prevent new cases and treat existing cases of fistula.  Congresswoman Carolyn Maloney (D-NY) will soon introduce legislation intended to support a comprehensive U.S. approach to fistula as part of a broader commitment to reducing maternal mortality and morbidity worldwide.

It has been said that in an unequal world, women are the most unequal among equals.  Obstetric fistula—a condition driven by a range of inequities in access to basic health services, nutrition, education and other basic elements— is a living example of this statement.

Obstetric fistula is a tear or hole in the birth canal through to the urinary tract and/or rectum and caused by obstructed labor; left untreated, women become incontinent and may uncontrollably leak urine and feces.  With more than two million women living with obstetric fistula and between 50,000 to 100,000 new cases each year, we must do more collectively to prevent and treat this condition.

This requires a focus on the human rights dimensions of public health problems. 

Whether by choice, persuasion or coercion, many girls in the developing world have had sex before their 15th birthdays, often without adequate information or protection from unintended pregnancy or sexually transmitted infections (STIs), including HIV. For example, an estimated 60 million women between the ages of 20 and 24 in developing countries were married before 18.  The Population Council estimates that this number will increase by 100 million over the next decade if current trends continue.

For girls, sexual initiation is more likely to occur in the context of sexual violence and forced marriage, both of which place them at high risk of pregnancy, and STIs, including  HIV.  In Ethiopia, for example, nearly 70 percent of young married girls are forced to have sex before they have begun to menstruate. Because their bodies are not fully developed and ready to bear children, these young girls are at high risk for injury and death during pregnancy and childbirth. In fact, complications from pregnancy and childbirth are the leading causes of death among girls between the ages of 15 and19 in the developing world.

Read more

Written by Cristina Finch for RHRealityCheck.org – News, commentary and community for reproductive health and justice.

This article is part of a series published by RH Reality Check in partnership with the Center for Reproductive Rights. It is also published in recognition of International Human Rights Day, December 10th, 2010.

Amnesty International released a report last spring entitled Deadly Delivery concerning the maternal health care crisis in the United States including how this crisis disproportionately affects marginalized communities.  This report is part of a series of reports that we are issuing as part of our Dignity campaign which is focused on fighting poverty with human rights.  The statistics are shocking; every 90 seconds a woman dies from pregnancy related causes.  Although the vast majority of these deaths are in the developing world, it is also an issue in the United States which spends more on health care than any other country in the world. On November 2, I presented Amnesty International’s findings during a panel discussion at the UN.

The Universal Declaration of Human Rights says, “Every human being has the right to health, including healthcare.” Unfortunately, the human right to health care, particularly maternal health care, is not being met in the US. The problem is especially severe in marginalized communities such as women of color. Since the vast majority of maternal deaths in the United States are preventable, maternal mortality is a human rights issue. Mahmoud Fathalla, past president of the International Federation of Obstetricians and Gynecologists, once said, “Women are not dying of diseases we can’t treat. [...] They are dying because societies have yet to make the decision that their lives are worth saving.”

Two to three women die each day in the US because of pregnancy-related causes. A further 34,000 more women experience “near misses” each year. Women in the US are more likely to die of complications resulting from pregnancy or childbirth than women in 49 other countries, including South Korea, Kuwait, and Bulgaria. In fact, according to recently released UN numbers, the maternal mortality rate nearly doubled between 1990 and 2008.

There are shocking inequities in maternal health in the US. Women of color, low-income women, Indigenous women, immigrant women and women with limited English proficiency all face additional risks. Read more