In today’s (justified) outrage over the medical neglect and death of Savita Halappanavar, there is a little talking point going around that the cause of Savita’s death was a separate issue from denial of abortion care. The question has become prevalent enough that Jodi Jacobson tackled it today at RHRC. An example of the idea is this tweet, which says:
septicemia seems to have been the killer of poor #savita not the baby or lack of termination. lack of treatment seems to be the issue
If development of septicemia is unrelated to pregnancy or premature/protracted conclusion thereof, this idea makes sense.
So, what was it that actually happened to Savita?
According to the Irish Times:
Speaking from Belgaum in the Karnataka region of southwest India, Mr Halappanavar said an internal examination was performed when she first presented.
“The doctor told us the cervix was fully dilated, amniotic fluid was leaking and unfortunately the baby wouldn’t survive.” The doctor, he says, said it should be over in a few hours. There followed three days, he says, of the foetal heartbeat being checked several times a day.
“Savita was really in agony. She was very upset, but she accepted she was losing the baby. When the consultant came on the ward rounds on Monday morning Savita asked if they could not save the baby could they induce to end the pregnancy. The consultant said, ‘As long as there is a foetal heartbeat we can’t do anything’.
“Again on Tuesday morning, the ward rounds and the same discussion. The consultant said it was the law, that this is a Catholic country. Savita [a Hindu] said: ‘I am neither Irish nor Catholic’ but they said there was nothing they could do.
“That evening she developed shakes and shivering and she was vomiting. She went to use the toilet and she collapsed. There were big alarms and a doctor took bloods and started her on antibiotics.
“The next morning I said she was so sick and asked again that they just end it, but they said they couldn’t.”
“Internal examination was performed” means that a doctor looked inside Savita’s vagina to check her cervix. This is how it was verified that the pregnancy was spontaneously terminating, but it is also a way that foreign bacteria can be introduced.
When the cervix is dilated and amniotic fluid is leaking, that means the body is especially vulnerable to infection via the uterus.
When they say “induce to end the pregnancy,” they mean induce uterine contractions to expel the fetus—since the body wasn’t doing a good job of moving the process along on its own—and allow the cervix to close. They’re not talking about dismembering the fetus in utero. They’re talking about hastening the expulsion of a fetus who already has no chance of live birth.
Michael Nugent explains the risk factors further:
Because her cervix remained fully open for this time, Savita was in prolonged danger of infection, comparable to having an untreated open head wound. Savita developed septicaemia, and she died on Sunday 28 October, a week after entering hospital.
By then doctors had removed the foetus, but only after its heartbeat had stopped. If they had removed the foetus when it was clear that it could not survive, Savita’s cervix would have closed earlier and she would have been less likely to develop the infection.
Right, so, she got infected because the fetus was still inside her for such a long time after the miscarriage began.
The final question, then, would be, what were the doctors supposed to do about it?
Dr. Jen Gunter takes us through the options for a second-trimester miscarriage in progress:
The standard of care with ruptured membranes (scenario A) is to offer termination or, if there is no evidence of infection and the pregnancy is desired, the option of observing for a few days to see if the leak seals over and more fluid accumulates. If no fluid accumulates and by some chance the pregnancy manages to go beyond 24 weeks (the vast majority of pregnancies with ruptured membranes delivery within a week), survival is unlikely given the lungs require amniotic fluid to develop. I have seen the rare case where a woman with no infection (and no fluid) elects conservative management in the hopes that might make it to at least 24 weeks in the pregnancy, however, I have never heard of a baby surviving in this scenario. Regardless, if at any point infection is suspected the treatment is antibiotics and delivery not antibiotics alone.
The standard of care with scenario B involves offering delivery or possibly a rescue cerclage (a stitch around the cervix to try to prevent further dilation and thus delivery) depending on the situation. Inducing delivery (or a D and E) is offered because a cervix that has dilated significantly often leads to labor or an infection as the membranes are now exposed to the vaginal flora. Many women do not want to wait for infection. A rescue cerclage is not without risks and is contraindicated with ruptured membranes or any sign of infection. Rescue cerclage is a very case by case intervention and well beyond the scope of this post. These decisions are difficult and the mark of good medical care is that all scenarios are discussed, all interventions that are technically possible offered, and then the patient makes an informed decision. All with the understanding that if infection develops, delivery is indicated.
As Ms. Halappanavar died of an infection, one that would have been brewing for several days if not longer, the fact that a termination was delayed for any reason is malpractice.
When Savita and her husband asked the doctors in Galway to induce delivery of her 17-week fetus, they knew what they were talking about.
The lack of termination WAS the lack of treatment that killed Savita. She didn’t die because they waited too long to give her antibiotics, she died because they waited too long to empty out her uterus.
To say that Savita died of septicemia, not because she was denied abortion care, is like saying it wasn’t the car crash that killed her, she just bled out from all those lacerations after flying through the windshield. To say abortions don’t cure E. coli infections is like saying contraception doesn’t cure post-partum hemorrhage.
Also, if you hear anyone telling you that “pro-life” Ireland is a safer place to be a pregnant woman than Great Britain, land of abortions, remember that Irish women have plenty of abortions. They have lots of safe, legal abortions performed by competent, qualified medical professionals…in England. If you want to see an example of a population with outstanding maternal health outcomes without taking advantage of legal abortion care, Ireland won’t be it.