Tag: Action on X

11 Consultants disagree with expert Boylan on Savita Halappanavar case

Last week I received an awful lot of flack on Twitter and in other places, for my writing on the case of Savita Halapannavar. The main criticisms seemed to be that being neither Irish nor a qualified medic, I had no right or authority upon which to pass comment.

Every single medical fact I commented upon was not made without reference to highly experienced qualified doctors and midwives, all of whom were in disagreement with Dr Boylan, whose testimony that a termination would almost certainly have saved Savita’s life, was widely quoted by the pro-abort activists as being proof that the law needed to change, as it was, in his opinion, responsible for her death.

The reason that this case has needed to be scrutinised in intricate detail, is because it was so quickly seized upon by those championing abortion in Ireland, as being definitive proof that lack of abortion was leading to unnecessary deaths. What I am more than qualified to state, is that abortion devastates lives and causes infinite pain and hurt to many women, (and men) as well as ending the lives of their babies. By all accounts Savita was a lively caring, compassionate woman. The last thing she would have wanted was for more pregnant women to be vulnerable as a result of her death.

I have just received a copy of the following press release from John McGuirk which I have replicated in full.

Ends

Dear Sir:

The recent inquest on Ms Savita Halappanavar has raised important issues about hospital infection in obstetrics. Much of the public attention appears to have been directed at the expert opinion of Dr Peter Boylan who suggested that Irish law prevented necessary treatment to save Ms Halappanavar’s life. We would suggest that that this is a personal view, not an expert one.

Furthermore, it is impossible for Dr. Boylan, or for any doctor, to predict with certainty the clinical course and outcome in the case of Savita Halappanavar where sepsis arose from the virulent and multi drug-resistant organism, E.coli ESBL.

What we can say with certainty is that where ruptured membranes are accompanied by any clinical or bio-chemical marker of infection, Irish obstetricians understand that they can intervene with early delivery of the baby if necessary. Unfortunately, the inquest shows that in Galway University Hospital the diagnosis of chorioamnionitis was delayed and relevant information was not noted and acted upon.

The facts as produced at the inquest show this tragic case to be primarily about the management of sepsis, and Dr Boylan’s opinion on the effect of Irish law did not appear to be shared by the Coroner, or the jury, of the Inquest.

Obstetric sepsis is unfortunately on the increase and is now the leading cause of maternal death reported in the UK Confidential Enquiry into Maternal Deaths. Additionally there are many well-documented fatalities from sepsis in women following termination of pregnancy. To concentrate on the legal position regarding abortion in the light of such a case as that in Galway does not assist our services to pregnant women.

It is clear that maternal mortality in developed countries is rising, in the USA, Canada, Britain, Denmark, Netherlands and other European countries. The last Confidential Enquiry in Britain (which now includes Ireland) recommended a “return to basics” and stated that many maternal deaths are related to failure to observe simple clinical signs such as fever, headache and changes in pulse rate and blood pressure. Many of the failings highlighted in Galway have been described before in these and other reports.

The additional problem of multi-resistant organisms causing infection, largely as a result of antibiotic use and abuse, is a serious cause of concern and may lead to higher death rates in all areas of medicine.

Ireland’s maternal health record is one of the best in the world in terms of our low rate of maternal death (including Galway hospital). The case in Galway was one of the worst cases of sepsis ever experienced in that hospital, and the diagnosis of ESBL septicaemia was almost unprecedented amongst Irish maternity units.

It is important that all obstetrical units in Ireland reflect on the findings of the events in Galway and learn how to improve care for pregnant women. To reduce it to a polemical argument about abortion may lead to more – not fewer – deaths in the future.

Yours sincerely,

Dr. John Monaghan, DCH FRCPI FRCOG Consultant Obstetrician/Gynecologist

Dr. Cyril Thornton, MB BCh MRCOG Consultant Obstetrician/Gynecologist

Dr. Eamon Mc Guinness, MB BCh MRCOG Consultant Obstetrician/Gynecologist

Dr. Trevor Hayes, MB BCh FRCS MRCOG Consultant Obstetrician/Gynecologist

Dr. Chris King, MB DCH MRCOG Consultant Obstetrician/Gynecologist

Dr. Eileen Reilly, MB ChB MRCOG Consultant Obstetrician/Gynecologist

Prof John Bonnar, MD FRCPI FRCOG Professor Emeritus Obstetrics & Gynaecology

Prof Eamon O’Dwyer, MB MAO LLB FRCPI FRCOG Professor Emeritus Obstetrics & Gynaecology

Prof Stephen Cusack, MB BCh FRCSI Consultant in Emergency Medicine

Dr. Rory Page, MB BCh FFA RCSI Consultant Anaesthetist

Dr. James Clair, MB BCh PhD FRCPath Consultant Microbiologist

Irish lessons

I know we should no longer be surprised when it comes to politicians displaying a capacity to lie to and deceive the general public, but the behaviour of two Irish Labour TDs, Aodhan O’Riordain and Anne Ferris really takes the cake.

Today’s Irish Sunday Independent (colloquially known as the Sindo) has run an exclusive splash, revealing that last June, four months before the death of Savita Halappanavar, these two politicians were caught on tape, explicitly outlining their intentions to use the X Case, (where suicide is deemed to be a life-threatening condition and thus a reason to abort) as a ‘starting point’ to introduce liberal abortion laws into the country.

Regardless of whether one takes a pro-life or pro-choice stance, this disingenuous approach is to be condemned. Politicians are elected on the basis that they represent those who vote for them. Aodhan O’Riordian stated that the X Case was a ‘starting point’, however if he were to be asked that question on the radio, his approach would be to lie about it, denying that it was a starting point and stating that ‘it is what it is’.

“It is a starting point. Once you get that . . . then you can move . . . and of course if I’m on the radio and somebody says to me, ‘It’s a starting point for abortion on demand’, I’m gonna say, ‘No, of course it isn’t – it is what it is.'”

Anne Ferris said

We will legislate certainly for what the European Court has told us to and then we can go further than that . . . we get the first part done and then we will go on to the next bit… I would say then next term it will happen.”

The transcript of the conversation also shows Ferris promising to drink a bottle of champagne after this measure is passed. This matters, not simply because of the subject matter, but also because it is a case of blaring political hypocrisy, whereby elected politicians are once again making monkeys of the electorate, lying about their stated intent and who will no doubt later agonise over the general public’s disillusionment with politicians and voter apathy.

Lying is never acceptable, but one’s intentions with regards to abortion, (or reproductive rights if you’re on the other side of the debate) is far too important an issue to lie about to the public. The attitude on display here is nothing short of contemptuous.

When it comes to thinking about the X Case and whether abortion ought to be a remedy for those who may be suicidal, it’s worth remembering that in the case of a person who may be suicidal, this is almost always due to a perfect storm of contributing factors, of which a setback such as a crisis pregnancy provides the tipping point. People who are suicidal or who suffer from severe mental health issues are deemed to be (albeit temporarily) incapable of informed consent in law, wills and other legal contracts are deemed to be invalid, so why, all of a sudden is a threatened suicide deemed to be a valid reason to abort one’s unborn child?

There is no evidence to suggest that abortion is an effective therapy for a psychiatric problem, which needs to be solved by psychiatric means, but there is an substantial body of research suggesting that abortion has a negative impact upon mental health. Suicidal tendencies in themselves should not be confused with a medically life-threatening condition. Whilst suicide is of course life threatening, the desire to end one’s life, is not indicative that a person will necessarily follow through on their thoughts, though they do of course, require urgent help. Abortion circumnavigates the issue, confirms the woman in her despair and is not indicative of the most compassionate and caring approach. What if the woman caught up in the vortex of depression, aborts her baby and later bitterly regrets her decision, realising that her fears about her pregnancy or ability to mother her child were unfounded?

David Fergusson, a pro-choice doctor, who believes that abortion should be available on social or economic grounds, has published a peer-reviewed study in this month’s Australian and New Zealand Journal of Psychiatry, in which he reviewed the research to ascertain whether or not there were any mental health benefits to abortion. His findings were clear, as Breda O’Brien, is at pains to point out in the Irish Times:

“at the present time there is no credible scientific evidence demonstrating that abortion has mental health benefits.

The evidence will

“resurrect politically uncomfortable and socially divisive debates”. “However, it is our view that the growing evidence suggesting that abortion does not have therapeutic benefits cannot be ignored indefinitely, and it is unacceptable for clinicians to authorise large numbers of abortions on grounds for which there is, currently, no scientific evidence.”

With blatant disregard for scientific evidence as well as the views of the Irish electorate as a whole, a sizeable majority of whom wish to keep Ireland’s current laws protecting the unborn, the Irish Labour party are wishing to push and impose their ideological agenda on an unwilling public. It’s also interesting to note that 66% of voters are concerned about the EU’s potential to intervene in Irish pro-life laws.

As things currently stand, the Irish Supreme Court would be unable to accept any laws or proposals that go further than legislation on the X case, this being against the Eighth Amendment of the Constitution which reads as follows:

The State acknowledges the right to life of the unborn and, with due regard to the equal right to life of the mother, guarantees in its laws to respect, and, as far as practicable, by its laws to defend and vindicate that right.

Any legislation beyond X (and that’s accepting that suicidal people should be able to kill their unborn children to make them feel better) would require a repeal of the Eighth Amendment and a rejection of personhood.

All of which could spell trouble for Ireland’s coalition government led by Enda Kenny, leader of Fine Gael, with Labour’s Eamon Gilmore occupying the Deputy Prime Minister position. Fine Gael explicitly promised voters in 2011 that they would not legislate for abortion and over 40,000 voters have signed a pledge never again to vote for the party if they introduce abortion measures. Worryingly for Enda Kenny, John Bruton, a former Fine Gael leader and Taoiseach is one of those also publicly opposing the coalition’s abortion proposals as are several members of the Fine Gael party. What is telling is that if Ms Ferris is to be believed, the tail is very much wagging the dog, when it comes to Ireland’s coalition government, with Eamon Gilmour, apparently ordering Enda Kenny to whip Fine Gael TDs into line on the issue of abortion. Extraordinary stuff, it’s a bit like Nick Clegg trying to tell David Cameron to whip Tory MPs into line with Lib Dem thinking.

This weekend in the UK has seen the forty-fifth anniversary of the passing of the 1967 Abortion Act, which was sold to the British public on the grounds of compassion and helping women from dying in desperate circumstances. We now see over 200,000 abortions a year, more than 1 in 4 pregnancies are aborted and the numbers of those aborting under grounds F or G (to save the life of the pregnant women or to prevent grave permanent injury) are, in the words of the Department of Health, ‘exceptionally rare’. Grounds A and B that pertain to the risk of death or permanent injury of the pregnant woman account for a tenth of 1% of all abortions.

And yet, Ireland’s politicians perpetuate the myth that this is a necessary piece of legislation in order to further their own totalitarian ideology when it comes to the rights of the unborn. It’s a baffling state of affairs and one in which pro-lifers must do their best to support Ireland, whether that be via prayers or practical action. Ireland is a model of maternal care. It is the gold standard and a torch bearer for Western democracies everywhere. Ireland’s pro-life movement is cohesive, cross-party and pan-theistic, able to mobile huge numbers of people onto the streets to vocalise their support for the unborn. There are many lessons there for the UK, but equally Ireland must look to the UK as an example of how not to do things.

These revelations could be a crucial pivot in Ireland’s battle for life. What an own goal for Irish Labour and those advocating for Action on X.

Savita verdict – medical misadventure

SavitaPicVigil_large

Before going any further, we should all remember Savita’s husband Parveen Halappanavar in our thoughts and prayers. Today, the date that the inquest returned its verdict of medical misadventure following the death of his wife, they should have been celebrating their fifth wedding anniversary together with their newborn baby girl due to be be named Prasa. May they rest in peace.

There are already many disingenuous headlines in the press, stating that the inquest has ruled medical mismanagement, following the denial of an abortion to Savita, as if the two events are linked.

First of all, Savita was not denied an abortion, rather a termination of pregnancy. Though it may seem semantic, this is an important distinction. Though medically they both refer to the same end result, the term abortion is widely understood in the context of a woman who does not wish to have a baby. With women such as Savita, a termination of pregnancy is the more correct phrase, because the pregnancy and baby were accepted and welcomed. Savita wished for her pregnancy to be terminated swiftly when it became clear that she was miscarrying. She didn’t want to abort her unborn child, she wanted her miscarriage to be brought to a quick conclusion.

Savita’s request for her pregnancy to be terminated must be seen in the context of her miscarriage. The explanation given at the inquest, that this was not carried out because of the law, is an unsatisfactory one. The implication being that though there was a good medical reason to terminate the pregnancy, the law disallowed this.

Dr Katherine Astbury testified that on the Monday and the Tuesday, Savita did not appear to be unwell, though she was emotionally distressed. In these circumstances, Dr Astbury is quite correct, Irish law would not allow for a termination to take place, because there appeared to be no risk to Savita’s life. This is actually fairly reasonable. Poor prognosis for the foetus would not allow for a termination, because Ireland rightly places equal value on all life, born and unborn alike. That someone has a poor prognosis is not grounds to kill them. Patients who are given a diagnosis of a terminal or incurable disease are not then killed because the outlook looks bleak and neither are the elderly, much as people might agitate for euthanasia. Whilst there is life, there is always hope and when we take into account the fact that Savita’s pregnancy was a wanted one, so long as a life is not deemed to be at risk, then it is not morally acceptable to kill an unborn baby on the grounds that he or she is as likely going to die soon anyway.

The request to terminate the pregnancy from Savita, should not have determined what was in her best medical interests. All other things being equal, normal medical protocols dictate a conservative management (i.e. wait and see) approach. On a personal note, I can well imagine her distress and her physical pain. I was readmitted into hospital a week after my eldest child was born, suffering from retained infected placenta. When I apologised to the registrar in A&E for crying because I was in so much pain, his response was ‘madam, you have a uterine infection, it is going to hurt a lot’. In my case, despite my entreaties, they didn’t take me in for surgery for 4 days (it was Easter bank holiday weekend) preferring instead to administer IV antibiotics to cure the infection first and to see if the product would pass. Nine years on, I can still remember the pain vividly, but at least I was given the correct antibiotic treatment, though my desire to have a D&C and be back home was ignored. I can’t begin to imagine what Savita went through, especially when she had the ultrasound and could hear the heartbeat of her baby, whom she knew was shortly to die. It must have been awful for her and her husband, let’s not forget that.

But this question of abortion or termination is nonetheless the source of much misinformation. Speaking at the inquest Dr Astbury stated that had she known about Savita’s blood results on Monday or Tuesday, then she would have taken a different decision and terminated Savita’s pregnancy forthwith. Which begs the obvious question, why didn’t she? We know from the inquest that the blood test results taken from Savita at 6.33pm on the Sunday evening were immediately processed and were available on the hospital’s computer system at 6.37pm. They were not accessed until 5.24pm the next day, by an unidentified member of staff and Dr Astbury herself did not look at them until 11.24pm on the Wednesday morning, by which time Savita’s condition had severely deteriorated.

It is this delay that proved fatal for Savita. If a termination had been required, then Irish law allowed for this, the medical guidelines state that delivery of an unviable foetus may be expedited where there is real and substantial risk to the life of the woman. Sepsis would count as such a risk. Savita’s bloodcount was 16.9 (normal range 4.3 – 10.8) which should have rang alarm bells. She was definitely exhibiting signs of an infection which merited urgent further investigation which would have thrown up the presence of E.Coli. Real and substantial risk, are often confused with immediate. A woman does not have be in her death throes or dying for a real and substantial risk to be identified, simply that if a termination is not performed, there is a real and substantial risk that she will die.

With hindsight, this perhaps was the case with Savita, as she was at risk of chorioamnionitis (inflammation of the foetal membranes), once the membranes had broken on Sunday. Once this has happened there is a 30 – 40% risk of infection, which is why she was prescribed general oral antibiotics on the Monday evening. Had Dr Astbury thought Savita was at risk of this, or was exhibiting signs, then why were no further diagnostic tests peformed, in this case an amniocentesis would have confirmed whether or not chorioamnionitis was present. Regular monitoring to identify trends in the white blood cells count is also crucial.

What has confused the issue further is that Dr Peter Boylan, a doctor with a publicly stated position opposing abortion restrictions, testified as an expert witness stating that had Savita been allowed a termination earlier, it would have saved her life. It’s very difficult to know that with any certainty without recourse to a time machine. In any event the post mortem showed that it was the E.Coli bacteria that led to septic shock. The baby was not poisoning Savita’s bloodstream, though chorioamnionitis if diagnosed, requires delivery. If the baby had died then the placenta needed to be removed in order to halt the rapid of spread of infection spread via its dead blood cells. Bacterial chorio-amnionitis is exceedingly rare.

What we do know though, is that in 40 years there have been 5 cases of septic abortions, no patients have died and Savita’s case was very rare. Every year in Ireland there are sadly 14,000 miscarriages, many of them carrying an infection risk, and no maternal deaths on record where the obstetrician felt that the law was inhibiting them. Dr Sam Coulter Smith, master of the Rotunda Hospital in Dublin, says that he has terminated a pregnancy in four instances where women had been diagnosed with sepsis and in all of them the baby did not survive. It’s difficult to see then, how Irish law can be said to be putting women at risk.

The failure of Dr Astbury to discuss abortion outside of legal terms is what has proved troubling in this case. A surgical abortion would have carried with it real risks of further infection which could have proved fatal, and had Savita been given the drug misoprostel to induce delivery, this would not necessarily have made delivery any swifter or negated the need for surgical intervention. Faced with a fully dilated cervix and ruptured membranes, the medics could thought that delivery was imminent and there was therefore no need for further medical intervention at this point. They were therefore wholly wrong not to discuss this in medical terms with Savita and her her husband. Anyone would be cross if their request for a certain type of medical treatment was refused purely on legal grounds.

What is important is that today’s inquest ruled that there was medical mismanagement in the death of Savita Halappanavar. The jury had the option to deliver an a narrative verdict which would not have attributed a cause. Despite the verdict which implies failures in medical care, the judge, Dr McLoughlin, has thrown further confusion into the mix by stating the verdict did not mean that deficiencies or systems failures in University Hospital Galway contributed to Ms Halappanavar’s death; these were just findings in relation to the management of her care.

That seems to imply that there was nothing wrong with the general systems in place at University Hospital Galway, simply that the management of Savita’s individual care was unsatisfactory as we can see. One cannot help but wonder whether or not this is about offloading any legal liability that the hospital may incur in terms of compensation that might be due? After all, it was a galloping sepsis that killed Savita, stemming from the E.coli, ESBL bacteria that entered her bloodstream from the urinary tract and one that is antibiotic resistant. No-one can say with any certainty whether, even had the care been perfect, she would have survived this. Perhaps that is what the coroner is trying to convey, medical misadventure was a factor in relation to her care, but not necessarily in her death. It’s no wonder Parveen is still in the dark.

What urgently needs to be addressed is the factors behind the poor care. Did the law really make Dr Astbury too afraid to check blood results, which needed further analysis or carry out further diagnostic tests? Was the law behind the lack of regular observations, the lack of communication and the failure to realise that paracetamol administered as a painkiller could mask other symptoms? Did the law cause staff to forget that infection requires a low burden of proof? Or was it the effects of austerity measures on an already overstretched hospital struggling with lack of resources? What caused the glaring omissions and can any law be expected to cover every single permutation that might arise in the management of pregnancy or childbirth, or is this simply that medical guidelines need to be more precise and explicit?

Here is the list of the coroner’s recommendations which the jury all unanimously and strongly endorsed

* The Medical Council should say exactly when a doctor can intervene to save the life of a mother, which will remove doubt or fear from the doctor and also reassure the public;

* Blood samples are properly followed up;

* Protocol in the management of sepsis and guidelines introduced for all medical personal;

* Proper communication between staff with dedicated handover set aside on change of shift;

* Protocol for dealing with sepsis to be written by microbiology departments;

* Modified early warning score charts to be adopted by all staff;

* Early and effective communication with patients and their relatives when they are being cared for in hospital to ensure treatment plan is understood;

* Medical notes and nursing notes to be kept separately;

* No additions or amendments to be made to the medical notes of the dead person who is the subject of an inquiry.

Savita’s request for a termination to have been accepted and acted upon, simply by dint of her wishes. would have required Ireland to have legislation which is much more liberal than even that in the UK, which in practice, allows abortion on demand.
It’s no wonder that the clamours for a repeal of the Eight Amendment of the Irish Constitution, (which defends the right to life of the unborn) have already started. None of which addresses the reasons behind the catastrophic failures in care.
Savita’s treatment timeline can be accessed here.

Postscript

One thing that should be emphasised is how rare it is to have a miscarriage at 17 weeks. 0.5% of single pregnancies in women with no history of recurrent miscarriages end in spontaneous second trimester foetal loss. Sepsis is still thankfully rare. Whilst it should be on the radar as a possibility, most maternity staff will not be panicking about the possibility of sepsis when a pregnant woman presents with a UTI. In the incidence of a UTI, blood samples are tested and antibiotics administered. A normal reaction to a UTI would not be to terminate the pregnancy as a precautionary measure. UTIs are serious if left untreated but no medical protocols would consider them as a real and substantial risk to life. Even with a suspected UTI there was no reason (in the absence of blood results) for medical staff to believe that Savita was dying.

I would be seriously concerned if any medic proposed termination of pregnancy as being necessary as a precautionary measure, unless it was in the most serious and grave of circumstances. Nowhere in NICE guidelines is termination mentioned as a treatment for a bacterial infection. Savita’s death should not prompt pregnant women diagnosed with a UTI to seek abortion and neither should they worry about contracting sepsis. One thing that should be remembered is the importance of scrupulous personal hygiene in terms of preventing the spread of bacteria such as E.coli.

Savita, Sepsis and Statistics

Much crucial detail from the inquest into the tragic death of Savita Halappanavar is emerging in the media, which is being seized upon and manipulated by opponents of Ireland’s pro-life laws as well as those with an anti-Catholic or militant secular agenda.

The inference is clear – Catholic dogma is responsible for the death of a pregnant woman from sepsis, as evidenced, according to one tweeter, by the presence of a religious statue outside of Galway University College Hospital and the fact that many of the wards are named after saints. Something of a non-sequitur. Clearly the presence of religious symbolism, a reflection of Ireland’s cultural heritage, is indicative that patients can expect a substandard level of care, where medically unsafe and morally dubious dogma overrides the best clinical interests of the patients. Anyone attending St Thomas’s or Bart’s hospitals in London had better be on their guard!

Let’s start with the stats.

Here’s a table showing the maternal mortality ratio, the number of maternal deaths per 100,000 live births from the Guardian’s datablog, where ‘facts are sacred’.

Screen Shot 2013-04-10 at 22.52.28

So, the one of the highest rates of maternal mortality occurs in the US which rather disproves the claim that liberal abortion legislation is safer for women. Ireland, that country where women are deprived of abortion, has one of the lowest maternal death rates in the world, official stats show that on average 4,000 women in the Republic travel to the UK for an abortion every year, a figure that has been steadily decreasing from a high of 6,600 in 2001, so the blame for the UK’s relatively poor performance in the area of maternal health care, can hardly be explained away as being an Irish export. Pro-life Chile has the lowest maternal death rate in Latin America and Poland, another pro-life country also fares well.

Furthermore, more than 100 mothers have died in childbirth in London in the last five years, twice the rate of that of the rest of the country. Whilst we are all screaming about the first maternal death in 17 years at a hospital in Galway, where is the outrage about the lamentable situation in the UK, due to a desperate shortage of midwives? Surely anyone who identifies themselves as ‘pro-woman’ should be demanding to know how the government intends to remedy this increasing problem, aside from disincentivising those who may want more than two children?

Whilst on the subject of outrage, where were the candlelit vigils and expressions of anger over the death of Jessie-Maye Barlow, God rest her soul, the 19 year old mother of one, who died from septic shock following an abortion in September 2012, the inquest acknowledging that BPAS had not followed up on their aftercare and thus the fact that Jessie-Maye had failed to pass all the ‘products of conception’ was missed, leading to her death? Where were the protestations of anger that a beautiful young mother of one, with her entire life in front of her died as a direct result of medical negligence on behalf of an abortion clinic that was too busy to follow basic protocols regarding patient care?

Sepsis

Savita Halappanavar died from sepsis. According to the Royal College of Obstetricians and Gynaecologists, between 2003 and 2005 there were five maternal deaths in the UK of pregnant women from sepsis, with a baby under 24 weeks gestation. “Sadly, substandard care was identified in many of the cases, in particular lack of recognition of the signs of sepsis and a lack of guidelines on the investigation and management of genital tract sepsis. Between 2006 and 2008 sepsis rose to be the leading cause of direct maternal deaths in the UK, with deaths due to group A streptococcal infection (GAS) rising to 13 women. Severe sepsis with acute organ dysfunction has a mortality rate of 20 to 40%, which increases to 60% if septic shock develops. Studies in the non-pregnant population have found that the survival rates following sepsis are related to early recognition and initiation of treatment.”

In 2012 the RCOG published green top guidelines for treatment of sepsis in pregnancy. The guidelines state

The signs and symptoms of sepsis in pregnant women may be less distinctive than in the non- pregnant population and are not necessarily present in all cases; therefore, a high index of suspicion is necessary.

The diagnosis of sepsis must be confirmed by blood cultures and early swift administration of broad spectrum antibiotics are the key to the survival of the patient, alongside regular monitoring.

Crucially and unfortunately, this did not happen in the case of Savita, who was admitted into the hospital on the evening of Sunday 21st October. Blood tests that were taken that night, which were never followed up on, showed an elevated white blood cell count which would have been one of the key indicators that infection and indeed sepsis was present.

Whilst oral antibiotics appear to have been started on the Monday night, following the spontaneous rupture of membranes, an infection of the severity of Savita’s would have required intravenous administration. The consultant obstetrician has described the situation as a systems failure on multiple counts, not only were the blood results not followed up on, but also, the vital regular observations which may have alerted the staff to the presence of an infection sooner, were not carried out at regular intervals throughout the night, which is why the infection was only picked up in the early hours of the Wednesday morning, after Savita had taken a dramatic turn for the worse, a doctor who had come to check on her on the Tuesday evening, saw she was asleep and so left her. Once Savita’s membranes had ruptured (in the early hours of Monday morning) then she should have been checked every 4 hours for signs of infection.

The RCOG guidelines state that all staff should be aware of the signs and symptoms of potential sepsis and the rapid and potentially lethal course of the disease, which is often less distinctive in pregnant women. Therefore whilst one can reasonably assume that care was lacking, notably in the failure to follow up on the results of the blood tests, the narrative that University College Hospital Galway were knowingly refusing to treat a woman with a severe and life-threatening infection in order to prioritise the life of her baby, due to Catholic dogma reflected in the law, is an erroneous one. As the consultant testified, had they known about the sepsis or infection, they would have intervened much sooner, however Savita’s symptoms did not physically manifest until the early hours of Wednesday morning, over 48 hours since she was first admitted, whilst the signs may have been present, i.e. a slightly elevated temperature and raised pulse rate, this could also have been due to other factors, such as anxiety and it is only with hindsight and in the light of the missing bloodwork, that this can be identified as being the start of the infection.

Speaking to the inquest, Savita’s husband has reported that doctors seemed nonchalant on Tuesday, certainly there was no cause for concern, or reason to think that her life might be at stake.

 

Abortion to treat Sepsis – a red herring

Savita’s sepsis stemmed from an antibiotic resistant strain of E-coli, an issue that is in itself concerning. Pathology has indicated that the infection most likely originated in her urinary tract and tallies with the backache that she complained of, prior to admission to hospital. Aborting the baby would not have cured Savita of her infection and indeed in these situations, surgery is to be avoided if at all possible, as it runs the very real risk of spreading the infection further and causing death.

Whilst the hospital had failed to spot the infection, they had noted that an inevitable miscarriage was taking place. Savita, understandably, was very distressed, and wished for her ordeal to be over, as opposed to the interminable wait for nature to take its course and allegedly requested an abortion on the Tuesday morning, following the ultrasound to determine the baby’s progress.

Upon admission to hospital on the Sunday night, it was noted that no cervix could be felt, hence Savita was fully dilated and hence the premature delivery of the baby was imminent, which would mean that the baby would not survive. Later on, her membranes ruptured, meaning that the protective sac of fluid surrounding the baby completely drained, a situation which would likely result in the death of the baby and spontaneous natural delivery.

This is where the confusion sets in, which is being exploited to the max by the abortion lobby. Firstly, that Savita was fully dilated, was as a direct result of the infection which was in her urinary tract. The unborn baby was in a sterile sac of waters and therefore not the cause of the infection. The dilated cervix did not cause her infection either. An open or dilated cervix will not cause an infection, as any woman who has ever had more than one baby, or indeed a smear test will testify. Once you have had a baby, the cervix never fully closes. When I was pregnant with my eldest child, I was dilated by 2cm for a good week before I delivered. An open cervix does not make one more ripe for infection.

The infection risk is posed when the membranes or waters have ruptured, normally hospitals will be wanting a woman to deliver within 48 hours of this occurring in order to minimise risk of infection to the newborn baby. Clearly in Savita’s case this would not have applied, but if her waters broke on the Sunday night, it was not unreasonable for no action to have been taken on the Tuesday, the medics obviously thought that delivery or natural miscarriage would take place swiftly and that conservative management was the safest option in the circumstances.

Whilst Savita may have requested a termination, this may well not have been in her best medical interests.

The unborn baby was not the cause of the sepsis and so there was no good reason to terminate it as Savita’s life did not seem to be at risk. Dr. Hema Divakar, President-elect of the Federation of Obstetric and Gynaecological Societies of India speaking to the Hindu Times said:

“Delay or refusal to terminate the pregnancy does not in itself seem to be the cause of death. Even if the law permitted it, it is not as if her life would have been saved because of termination. Severe septicaemia with disseminated intravascular coagulation (DIC), a life-threatening bleeding disorder which is a complication of sepsis, major organ damage and loss of the mother’s blood due to severe infection, is the cause of death in Savita’s case. This is what seems to have happened and this is a sequence which cannot be reversed just by terminating the pregnancy.”

Catholicism and the law

It seems to me that there is something of a cop-out or buck passing exercise going on here. Dr Katherine Astbury, the doctor in charge of Savita’s care, told the inquest that in Ireland it is not legal to terminate a foetus on the grounds of poor prognosis for the foetus, but also admitted that she did not once clarify the legal situation with her colleagues or think to do so.

The law in Ireland does not prevent a termination from being carried out, if the life of the mother is at risk and as Dr Astbury testified, had she known the severity of the situation she would have intervened earlier, although from what we know now, an abortion could well have made the situation a lot worse. It seems obvious, that Dr Astbury perhaps sought to take shelter in the law as opposed to exercise her own moral and clinical judgement. No law can be formulated that will cover all the possible permutations and complications that might arise from real-life pregnancy management and so doctors can’t ever be entirely freed from having to make theraputic and ethical decisions. Whilst doctors might have to work within the law, they also need to exercise clinical judgement which will invariably and inevitably involve ethics.

The law in Ireland is clear, section 21:4 of the Medical Council Guide for Registered Practitioners says this:

“In current obstetrical practice, rare complications can arise where therapeutic intervention (including termination of a pregnancy) is required at a stage when, due to extreme immaturity of the baby, there may be little or no hope of the baby surviving. In these exceptional circumstances, it may be necessary to intervene to terminate the pregnancy to protect the life of the mother, while making every effort to preserve the life of the baby.”

So there was no legal reason why the pregnancy could not have been terminated were Savita’s life deemed to be at risk. One has to wonder why Dr Astbury couched her response to Savita’s request in purely legal terms? This was not simply about what the law proscribed, but medically speaking, conservative management of delivery is the safest approach, in the absence of any other pressing clinical factors. Theatre was obviously felt to be unnecessary at this stage, the cervix had dilated, the membranes had ruptured, delivery could not be far off, there was still a foetal heartbeat, the prognosis for the baby was poor, but there was no pressing need to abort medically, as well as legally. Why were the medical reasons not explained to her – that it was presented purely in legal terms seems to be a total failure of communication and gave the Halappanavar’s the impression that best clinical practice was being hampered by the law. The only people qualified to judge on whether or not an abortion should be performed were the doctors, not the lawyers and if any conflict had been perceived, why was this not instantaneously taken up with the hospital’s legal team, who would have been well versed in the ethics.

The Irish Catholic Bishops, responding to the case, said this:

The Catholic Church has never taught that the life of a child in the womb should be preferred to that of a mother. By virtue of their common humanity, a mother and her unborn baby are both sacred with an equal right to life.

– Where a seriously ill pregnant woman needs medical treatment which may put the life of her baby at risk, such treatments are ethically permissible provided every effort has been made to save the life of both the mother and her baby.

Which is why the conjecture over potential situations coming from all sides is unhelpful. Catholic teaching is very clear. Mother and baby have an equal right to life, whilst a baby must never be directly killed in order to save the life of a mother (and I cannot envisage a single situation where that would be necessary), a mother may receive treatment such as in the case of an ectopic pregnancy or a cancer diagnosis, which may put the life of her unborn baby at risk, or may end a baby’s life as an indirect consequence.

‘This is a Catholic country’

This was the comment made by Ann Maria Burke, a midwife manager, in response to a conversation with Savita, who stated that in India, a Hindu country, an abortion would be possible. Now is not the place to discuss India’s abortion record, especially when it comes to baby girls or how that reflects Hinduism, which treats all life as sacred, but as Ms Burke now admits, the remark was regrettable and had nothing to do with medical care. The remark perhaps smacks of racism, or was made in the context of a general conversation pertaining to religious and cultural attitudes, but tellingly the midwife was not directing the care of Mrs Halpannavar, nor was she dictating hospital policy. She was trying to explain the reason behind Ireland’s pro-life laws, which whilst they might stem from and be in accordance with Ireland’s Catholic history, do not indicate that Ireland is currently a country that is governed by those in accordance with the Catholic Church, quite the opposite Enda Kenny the current Taoiseach is doing all that he can to put distance between himself and the Vatican. Moreover Catholic moral theology would not sanction the delivery of a non viable baby as a direct cure for a pregnant woman, and is therefore slightly at odds with the letter of Irish law.

Conclusion

Had the initial blood tests been followed up on, and 4 hourly observations undertaken, then perhaps the tragedy may not have unfolded in the way that it did. What seems clear is that the infection was present upon admittance to hospital and that it is unlikely that an abortion would have cured the infection and potentially could have hastened Savita’s death. The unborn baby could not have been the source of the infection and by the time that the infection was noted, things had already progressed too far. The infection was obviously incredibly aggressive and Savita’s condition deteriorated so rapidly on Wednesday 24 October, that the decision as to whether or not to abort became moot. According to the inquest, septic shock was diagnosed at 1.20pm, two hours later, Savita’s already dead baby was delivered in theatre, so the conservative approach would have been the correct one, nature had taken its course swiftly, within the normal 48 hour window.

There is no indication that the hospital was ignoring the plight or symptoms of a critically ill woman with sepsis in order to rigorously follow the letter of the law regarding her unborn baby, when the law already allowed for an abortion to take place in these circumstances. Until the early hours of Wednesday morning, there was no obvious manifestation of infection, to those caring for her. It was only then that seriousness of the situation became glaringly apparent.

The issues here are about an awareness of sepsis. That is what Parveen Halappanavar, Savita’s husband should be angry about. This is the issue that he should fight for in his wife’s memory, as well as suing the hospital for their negligence in following up on her blood tests. Understandably he wanted his wife’s distress to be alleviated by an abortion, a procedure that may well not have been in her best interests either physically or emotionally. That the hospital could only explain this in legal terms is as great a dereliction of care and duty as it was not to have chased her blood results or carried out her observations.

Ireland’s abortion laws may change as a result, unborn babies will die and no action will be taken to address the urgent problem of sepsis diagnoses, nor indeed the worrying spread of ESBL bacteria that killed Savita. Abortion won’t cure sepsis or aid its diagnosis. It may however mean that more women and babies are exposed to the deadly bacteria. Savita’s memory deserves better.

Proceeding with caution

Some pro-lifers are uncomfortable with my previous post and I can understand why. The facts are not yet known and yet the abortion lobby have turned Savita Halapannavar into a pro-choice martyr, stating conjecture as certainties.

I am well aware that pro-life needs to keep its powder dry and not engage in more rumour mongering. however I think Ruari’s post raises some questions. I disagree with his statement that those who fail to find evidence of a conspiracy aren’t looking hard enough. Most often there is no evidence of a conspiracy because no such conspiracy exists. I doubt there is a conspiracy in this case, but I do believe there is much opportunism and a great deal more confusion and misreporting.

The issues of note are the concerning rise in reported cases of ESBL and as has been widely reported, the fact that pro-choice groups were privvy to the case before it hit the media and seemed to be gearing up to take swift co-ordinated action to dovetail with the widespread coverage. I also agree that the timing is interesting, coming shortly after Ireland’s first abortion clinic opened and obscured the revelations emerging from an investigation that revealed that the Irish FPA was giving dangerous advice to women seeking abortion.

That medics are frightened for their jobs is unsurprising given the media frenzy. I think it’s proper to ensure that any investigations are wholly impartial. It is unfortunate that Savita’s husband Praveen refuses to meet with the HSE, he obviously feels very strongly that her life could have been saved by premature delivery; this case looks set to run and run.

We do need to wait for answers and not jump to conclusions, but at the same time questions need to be asked and predominant narratives challenged whilst remembering there is a widower grieving the loss of his wife and baby.

None of this should however, let India off the hook re its appalling gendercide or dictate the terms of the inquiry.

Hard Cases

Warning: this post contains discussion that could upset those who have experienced stillbirth or late-term abortion.

There was a lot of publicity in Ireland this week surrounding the Private Member’s Bill to provide limited access to abortion in the Republic, following a 1992 Supreme Court ruling that makes abortion legal in circumstances where there is a substantial risk to the life of the mother. The bill was defeated by 111 votes to 20, reflecting the views of the Irish population, 89% voting against the legalisation of abortion in an online poll held on behalf of the Irish Labour party. The Republic of Ireland, incidentally boasts one of the lowest maternal mortality rates in the world.

Whilst it goes without saying that I support the decision of the Dåil, this particular story certainly gave pause for thought and should prove challenging to even the most committed of pro-lifers. Here are four women, not seeking to campaign for abortion on demand, they stress that their stories are not typical of debate, but that they discovered that their unborn children had anomalies incompatible with life and thus felt forced to compelled to seek abortion outside of the republic. They further state that they do not see this issue as a party-political issue but one of human rights. Their stories are compelling, tragic and heart-breaking. They aborted much-wanted pregnancies because they could not withstand the trauma of having to endure another 20 weeks of pregnancy only to have the baby die in utero, shortly after birth, or alternatively go through gruelling courses of medical intervention and surgery with a small chance of success.

It would take a heart of stone not to weep with these women and grieve both for them and their children.

“Having to walk around Birmingham for five hours when you’ve just ended your baby’s life, you’ve had an anaesthetic and are bleeding and cramping . . . I believe in a loving, caring, understanding God and that I won’t be damned for what I did . . . I want to say to people who would judge us – Where is your compassion? Where is love in all this?,” she says, her voice cracking.

For these women, their grief was compounded by their need to travel. No-one should judge women who find themselves in these situations, even though we may objectively be able to disagree with their decision.

This story had an added dimension for me, coming shortly a week after my own 20 week anomaly scan. I know how nerve wracking these scans are and precisely the types of anomaly that are being looked for. The first time I had such a scan was in a London teaching hospital, the baby was in perfect health and in an excellent position, so I was asked if I would allow some students to come in and have a try, whilst the scan was repeated with detailed explanations and precise definitions of what could be seen and what sonographers should be looking out for. In one of my pregnancies, the 20 week scan was delayed due to a problem having been detected in the preceding patient, the couple eventually emerging in floods of tears.

I always opt for the 20 week scan on the grounds that it is better to be prepared for what may follow and in order that, if necessary, any neonatal teams can be on hand, but many are not prepared for the eventuality that their baby may be seriously ill or die. Despite the fact that I could never abort my unborn child for any reason, had I discovered that this baby would be seriously ill and/or die, I would have found it almost impossible to cope in my current situation. I do not blossom in pregnancy, far from it, this one has been the worst yet, for a multitude of reasons and I am having moments of severe self-doubt when I really don’t know whether or not I will be able to cope. I cannot begin to imagine what it must be like to have to endure 20 weeks of getting bigger and bigger, feeling more and more uncomfortable with all the aches and pains of late pregnancy, feeling your baby kick and move, knowing that you are going to have to go through the ordeal of birth (and yes, it is an an ordeal for many) only to have your baby die. I don’t know how I’d manage to keep going, to explain it to my 8 year old, to explain it to the toddler and then go through the grief and heartbreak.

I would undoubtedly do it, but it would take a lot of strength and courage and therefore no-one can sit in judgement upon those who have taken different decisions. My faith would give me the resources to do it, as would my husband, but no doubt I would be under a lot of pressure, social, medical and environmental to take a different decision. What I think would give me hope is knowing that when my baby died, it would be in its mothers arms, it would hopefully die peacefully surrounded by love and comfort. Unbearable though it would be, I would rather give my child that chance of life, no matter how small and know and feel the comfort of its mother rather than the pain and torture of the abortionist’s instruments. The much-derided Rick Santorum movingly describes how when their son Gabriel was born prematurely, he lived for two hours and for those two hours the baby knew nothing but love. As a mother, I can see no greater act of love or sacrifice; as Christian I can see parallels of Christ. For me there would be no other choice.

Should I deny this “choice” to others? Hard cases make bad law. Were these women wrong, should they be condemned? Whilst I cannot condone their actions, to issue an outright condemnation displays a total lack of empathy and compassion. It is quite one thing talking about the principles and ethics involved, quite another when you consider that there are real humans, real lives and real emotions involved. The problem is with passing laws for these types of situations is that it sends the signal that it is perfectly acceptable to kill an unborn baby because it may be born severely disabled and/or die. It is not surprising that many disabled people are feeling increasingly uncomfortable living in today’s society that seeks to reject unborn children who are less than perfect.

Even where a baby has a definite incompatibility with life outside of the womb, this seems to give licence to the medical profession to put pressure upon the expectant mother. It’s a very utilitarian attitude – the baby will die anyway, much kinder (and cheaper) now, for all concerned. But is it? The mother still has to live with the grief, but coupled with guilt and defensiveness. Many women will find the experience of giving birth to their child and holding and soothing them helps them to heal and reconcile with their grief.

Society and the medical profession must exercise more compassion and less judgement to enable women to make this decision rather than hasten them to the abortionists. Pro-lifers must equally respect the horrendous circumstances that these women face and offer the appropriate sensitivity. Furthermore, instead of talking the sheer ethics of the matter, we must not neglect the reasons why mothers decide that they would not be able to cope with a disabled baby? It’s one thing saying that disabled babies must not be aborted, it’s quite another voting for any government that takes measures to make life for the sick and disabled infinitely more difficult and services either non-existent or difficult to access. Put simply we must place ourselves in the shoes of the expectant mother, as well as the mother of the child with severe disabilities.

As for having to walk around Birmingham for 5 hours after you’ve ended your baby’s life, bleeding and cramping, or having to travel back home to Ireland in order to deliver a dead infant, there can be no words sufficient for the horror. Where was the love, duty, concern and compassion shown by the abortion clinics on these occasions? How can any establishment that professes to care about women’s welfare, kick a woman out of a clinic who is post-anaesthetic, groggy and bleeding to walk strange streets for 5 hours. I know where my anger would be directed.