A tale of two countries: women’s reproductive rights in Ireland and the USBMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2471 (Published 07 June 2018) Cite this as: BMJ 2018;361:k2471
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In their editorial, Professors Shaw and Norman contrast the evolution of reproductive rights in Ireland and the United States. While until recently, the latter nation’s laws permitted abortion in far broader scope than that of Ireland, this dynamic has shifted as of May 25th, 2018 where the citizens of Ireland voted in a nationwide referendum on whether to maintain or repeal the Republic’s Eighth Constitutional Amendment. Initially voted in 35 years ago via referendum, the Eighth Amendment effectively outlawed abortion, save in rare and exceptional cases of mortal maternal danger, and made Ireland one of the most restrictive states on maternal abortion rights in the European Union. This may now be changed as of May 26th, when poll results demonstrated a large two-thirds majority vote supporting the repeal of the constitution’s current ban. 
Ireland now joins the rest of Europe, save Malta and a handful of microstates, in legalizing abortion in some form beyond the medical necessity to prevent maternal death.  Access to safe abortions is a critical component of the World Health Organization’s (WHO) overall focus on women’s reproductive rights and is closely tied to maternal health and child mortality. It is currently captured under the Sustainable Development Goal of universal access to sexual and reproductive health (target 3.7) and was previously informally addressed by the Millennium Development Goal 5 to improve maternal health.  A large WHO-sponsored study published in The Lancet in 2017 characterizing the global state of abortion between 2010 and 2014 found that a startling 45% of abortions undertaken worldwide (25 million each year) were performed in unsafe conditions, with 4.7 to 13.2% of maternal deaths per year attributable to unsafe abortions.  A country’s abortion laws were found to have a strong correlation with the volume of unsafe abortions, the proportion being significantly higher in countries with highly restrictive abortion laws than in those where abortion is legal on a broader basis. [2,4]
Irish leaders of government were quick to note the changing societal landscape ushered in by the vote as results of the poll released overnight demonstrated heavy support for repeal by a near two-to-one ratio of voters. The Irish Taoiseach, Leo Varadkhar, was quoted as declaring that Ireland has seen the culmination of a “quiet revolution”,  a historic phrase well known to French-Canadians who initially minted the expression “révolution tranquille” to describe the rapid and wide-reaching societal changes that took hold in Québec during the latter half of the 20th century. In the run-up to the May 25th poll, Irish citizens held debates, town halls, information sessions, and door-to-door campaigns to engage citizen discussion and animate voter turnout.  Irish expatriates were heavily encouraged to fly home from around the world to participate; as votes must be cast in person, the referendum was billed as a “once-in-a-generation” opportunity  and both sides of the debate lobbied them to return, trending the #HomeToVote hashtag on Twitter in the run up to the opening of polls.  Many universities in the United Kingdom funded the return travel home for their Irish students while other, non-student, Irish citizens found ready travel support via the help of crowdfunding websites. 
The national activism and the grassroots efforts employed to evoke durable systemic change are notable as they are, in the most part, the result of the Irish citizenry’s steadfast motivation. Although initially outlawing abortion in 1983, such activism and cultural debate in the Republic of Ireland has seen the introduction of a progressive liberalization of women’s rights starting just two years later when the Republic legalized contraception in 1985, followed by divorce in 1995, and same-sex marriage in 2015.  Citizen-led activism preceding popular vote referendums and plebiscites has become the standard method for formalizing societal discussions of important health and reproductive rights issues in most high-income nations. Beyond Ireland, this type of debate recently formed the cornerstone of Australia’s postal survey on same-sex marriage in 2016 which led to the subsequent Marriage Amendment Act 2017 legalising same-sex unions and the 2011 referendum in Zurich where voters overwhelmingly decided to conserve the legality of assisted suicide in Switzerland. [9,10] In the face of a stable democracy, with little to no governmental corruption, such a form of consistent, stoic, activism punctuated by periods of large-scale national discourse has shown itself to be highly effective in producing and maintaining enduring societal change, potentially becoming the dominant model of contemporary activism we see today.
Similar to Ireland over the past year, the United States now faces the prospect of a political shift in the laws surrounding its domestic abortion laws. With the introduction of potential Title X reform – referred to colloquially as “the domestic gag rule” – a new threat may arise to the provision of federal funding to family planning services offering pregnancy counselling services providing information pertaining to abortion. Independent, but in parallel to the introduction of this potential legal reform, the announcement of Justice Anthony Kennedy’s planned retirement from the Supreme Court of the United States and of Judge Brett Kavanaugh’s nomination as his potential replacement has sparked renewed public debate in the United States regarding the durability of the core provisions enacted by the Court’s landmark 1973 decision in Roe v. Wade.  With the looming July 31st, 2018 deadline for the public comment period on the proposed Title X reforms as well as the beginning of senate confirmations hearings planned for fall 2018 on Judge Kavanaugh’s nomination, global attention on the evolution of abortion rights now shifts back from Ireland to the United States, where public activism may once again play a necessary and fundamental role in shaping the evolution of women’s reproductive rights for decades to come.
Competing interests: No competing interests
Thanks Shyan for your response.
To be clear, the inquiry into Savita's death revealed that poor monitoring (of Savita), not adhering to clinical guidelines, and poor training regarding the management of sepsis were key causal factors of her death (1). You are absoutely right to warn against blame. It is all too easy to be critical with the benefit of hindsight. My intention was not to blame. Though it is clear that Savita’s doctors made mistakes, these are mistakes we must all learn from. However, I believe it would also be wrong to blame Irish law, or to let those who do so to push ahead unchallenged. To allow falsehood does not honour Savita’s memory.
In answer to your point on what you call the "fundamental issue" (2), I remain unconvinced that rejecting outright any discussion on the basis of a foetal heartbeat is the intention of current Irish law. However, the actions of Savita's consultant do highlight that clarification regarding the law is needed: as recommended by the report (1).
I too would not want anyone to take away lessons from misrepresentation of facts.
2. BMJ 2018;361:k2471
Competing interests: I am a practising Christian. I am passionate about truth. I do not blindly subscribe to the teachings or doctrine of any particular church or denomination. My personal beliefs are based upon 3 'pillars': the Bible, science and rational thought.
Misrepresentation of facts surrounding Savita Halappanavar's death: who is actually doing it? Not BMJ.
Although I have no active nor personal interest in the case of Savita Halappanavar (SH)*, I cannot let misleading allegations cloud the key issues surrounding her death.
* I choose to use her initials from here on for easier reading and do not intend any disrespect to her or her loved ones by doing this.
Dr David Jones seems to portray the circumstances of her premature death as simply a missed sepsis diagnosis and the team looking after her could have "instigated early sepsis treatment and performed a legal termination of pregnancy under the current Irish law", since abortion is "legal when the mother's life is at risk" (ref 1).
Using the very same reference material he used, I wished to point out the following facts:
1. The treating doctors and midwives suspected as early as within 6 hours of hospital admission that SH is likely to be experiencing pregnancy loss/miscarriage.
2. SH experienced spontaneous rupture of membranes (SROM) within 15 hours of admission and was informed 8 hours after SROM that it "was unlikely she would continue on to a time of fetal viability"
3. The attending Consultant 1 noted 56 hours after SROM "the patient and her husband were emotional and upset when told that a miscarriage was inevitable". The consultant stated that the patient and her husband enquired about the possibility of using medication to induce miscarriage as they indicated that they did not want a protracted waiting time when the outcome of miscarriage, was inevitable. This was their first (and last known documented) request for termination of pregnancy (TOP).
4. At this time Consultant 1 advised SH and her husband of Irish law in relation to this. At interview the consultant stated “Under Irish law, if there’s no evidence of risk to the life of the mother, our hands are tied so long as there’s a fetal heart”. The consultant stated that if risk to the mother was to increase a termination would have been possible, but that it would be based on actual risk and not a theoretical risk of infection “we can’t predict who is going to get an infection”.
5. Although empirical antibiotics was already started from 21 hours post SROM, there are sufficient clinical signs and observations for the team to actively look for infection at 54 hrs after SROM. There are assertions by the treating team that the patient and her husband were advised (around 56 hrs post SROM) that "if the source of infection could not be found, a termination of the pregnancy might have to be considered"; this discussion was undocumented.
6. Within 6 hours of this (alleged) discussion (62 hrs post SROM), SH's clinical condition rapidly deteriorated requiring intensive monitoring/ intervention, involvement of a Microbiologist and had a spontaneous delivery at 63 hrs post SROM. She was then transferred to HDU/ICU
7. SH died of cardiac arrest some 144 hrs after SROM, despite vigorous measures to treat her condition.
8. The investigation team (when interviewing all involved) did not actually have access to the post mortem results and therefore did not have information about the actual cause of death in this case. Hence, any investigating bias from the post mortem report is minimised.
As reflected in the report, the speed of unfolding events immediately preceding the rapid deteriorating condition of SH was both catastrophic and unexpected, with most of the measures implemented appropriately after the suspicion of sepsis is considered from 56 hrs post SROM. Despite this, the investigating team was highly critical of clinical culture of "await events" in this case.
The possibility of earlier diagnosis (and treatment) of sepsis is always perfect when events are considered in retrospect; any practicing clinician would acknowledge that it is difficult to define a threshold in which the prevailing diagnosis is certain to be sepsis to explain the patient's condition. Another coronial (and subsequently criminal) case involving the death of Jack Adcock illustrates the difficulties in diagnosing sepsis.
Even in retrospect, it would have been less certain when or if early change in antibiotic cover would have changed the ultimate outcome without early TOP.
SH and her husband asked "about the possibility of using medication to induce labour as they indicated that they did not want a protracted waiting time when the outcome was going to be an inevitable miscarriage" AFTER they were told the pregnancy was unlikely to be viable; this suggestion were summarily rejected on the basis that "under Irish law, if there’s no evidence of risk to the life of the mother, our hands are tied so long as there’s a fetal heart" (the consultant's own words) without regard of distress to the mother nor the clinical picture in which the fetus was unlikely to survive.
Even after the referendum, the Irish "government draft legislation indicates that abortion will be available without limitation until 12 weeks’ gestation and after that only with some indication of serious threat to the woman’s health or in cases of fetal anomaly" (ref 3); this would not necessarily alter the outcome of SH's case but is intended to encourage more open dialogue and consideration without resorting to blanket excuses and disincentive measures effectively stonewalling.
To suggest the matter is essentially a delayed diagnosis of sepsis causing SH's death is misleading and mispresents the fundamental issue whereby any discussion of TOP (when obvious that to proceed and persevere with the pregnancy is futile), is rejected outright on the basis of a fetal heart beat without regard for maternal mental and physical wellbeing.
It might be alright for clinicians unwilling to address the moral dilemma of TOP to hide behind the law and passively "await events"; in this case a young woman's life is lost though this medical misadventure dictated by misdirected ideas.
I would not want anyone to take that lesson away from her death through misrepresentation of facts.
We "await events" no more on this matter.
Competing interests: No competing interests
I'm horrified at the way Savita Halappanavar's death has been spun by the media and even parts of the medical profession to push for liberalising Irish abortion law.
Despite triggering >2 SIRs criteria and having a potential source of infection (prolonged rupture of membanes with inevitable miscarriage), sepsis wasn't considered as a diagnosis by Savita's team. Hence, a sepsis 6 was not completed, no lactate checked, and the patient was only commenced on oral antibiotics. When Savita became pyrexial, paracetamol was repeatedly given for her pyrexial episodes and sepsis continued to be overlooked as a diagnosis. In fact, though the patient continued to show signs of sepsis/septic shock, it was 22 hours before this was recognised by her doctors.
Savita's story is one of missed sepsis. This is acknowledged by the report you reference in your article (1). If Savita's team had recognised this, they could have instigated early sepsis treatment and performed a legal termination of pregnancy under the current Irish law. Abortion is not illegal in Ireland despite what the media have led the public to believe. It is in fact legal when the mother's life is at risk, and Savita's life was at risk. The law did not have to change to save Savita's life. This is wrong.
I'm appalled at the lack of knowledge regarding this fact, and the failure of the BMJ to report this is worrying. It makes one wonder if there is inherent bias in the BMJ, as well as the BMA, and numerous other medical bodies/organisations. Maybe we should stop pointing the finger at Ireland, and examine our own consciences.
Competing interests: I am a practicing Christian. I am passionate about truth. I do not blindly subscribe to the teachings or doctrine or any particular church or denomination. My personal beliefs are based upon 3 'pillars': the Bible, science and rational thought.
The article states "Added to this were over 160 000 women known to have left the country to obtain abortions safely in the UK because abortion was prohibited in Ireland". Surely this should read 'in Great Britain' (not 'in the UK') as abortion is also highly restricted (verging on prohibited) in Northern Ireland.
Competing interests: No competing interests
Abortion won't go away and settle into the canon of medical "pathology" or standard "management." It will always keep people awake, energized and driven as this editorial shows. The great human outcries of past centuries were also forever alive in people's hearts and minds. The voices of the oppressed can never be silenced and the truth will out. The liberation from slavery in USA. The many fights for freedom in suppressed countries worldwide. The "hidden" genocides and ethnic cleansings all spoke out. Many were redressed.
People are human and eventually the voice of suffering and oppression breaks through and human beings hear the voice and respond by liberating the oppressed and comforting the suffering - because it resonates with their spirit and humanity. This is the evidence and experience of humanity. This is also why abortion speaks out. The voices of millions of human beings not allowed to take a breath of fresh air will not be silenced. These are the generations of English men and women and Irish men and women who never got a chance. The editorial in this week's BMJ makes no reference to the innocent party in the drama - the innocent oppressed and ultimately suffering unborn baby.
Abortion is not a right or a procedure or solely a woman's issue. It involves two others. The father and the innocent victim. It makes absolutely no sense to say an unborn gains human rights by the act of birth. Pre- natal and perinatal and genetic and epigenetic studies clearly show that what grows in a woman's womb is a vulnerable developing fragile human being. A truthful editorial on the origins of human beings, like any credible comprehensive assessment, must include all the actors. In this case - baby, mother and father. Some champion is needed to fly the flag of unborn human rights and represent the just most fundamental right which is to get a free and fair chance at life.
Competing interests: No competing interests