The death of a 31-year-old woman who was denied an abortion during a life-threatening miscarriage has prompted calls for clarity in Ireland's abortion laws.
Savita Halappanavar was 17 weeks pregnant when she arrived at University Hospital Galway in Ireland, complaining of back pain, her husband, Praveen Halappanavar, told the Irish Times. Doctors told Halappanavar she was miscarrying, but they reportedly refused to terminate the pregnancy as long as there was a fetal heartbeat, because, they said, Ireland was a "Catholic country."
Halappanavar's death provoked protests outside the Irish Parliament, where Deputy Prime Minister Eamon Gilmore said Thursday the government would act "to bring legal clarity to this issue as quickly as possible."
"The discussion must be a reasoned, reasonable, dignified one, and it must be focused on what it is we need to bring legal clarity to sets of circumstances that have been outstanding for a long period and that are very real," he said, according to the Irish Times.
Abortion is illegal in Ireland unless continuing a pregnancy would endanger a woman's life. But Gilmore said certain circumstances cloud the interpretation of the law.
"Essentially, they center on what happens in a set of circumstances where a woman's life is at risk and medical professionals may not be entirely clear on where the lines of their responsibilities and duties lie," he said, as reported in the Irish Times.
Even as medically necessary abortions remain a contentious topic on this side of the Atlantic, doctors in the United States said Halappanavar's death was preventable.
"I don't do abortions, I'll tell you right now. ... But I'd have to tell the mother, 'Your baby doesn't have a chance and to save your life, I have to do this,'" said Dr. John Coppes, the medical director at Austin Medical Center-Mayo Health System in Minnesota.
In the United States, a Supreme Court decision, Roe v. Wade, made abortion safe and legal in 1973, but the abortion debate has continued to find its way into political discussions, with Republican presidential candidate Mitt Romney declaring himself a "pro-life president" in October after telling an Iowa newspaper he would not legislate on abortion if he won.
During a debate last month, Rep. Joe Walsh, R-Ill., said medical advances have eliminated the need to perform abortions to save ailing mothers' lives. He quickly backtracked on the statements.
At the Galway University Hospital, Halappanavar's fetal heartbeat stopped nearly three days after she arrived on Oct. 21. Doctors evacuated Halappanavar's uterus, but she died of septicemia, or blood poisoning, on Oct. 28, according the Irish Times, which cited the autopsy report.
The Galway Roscommon University Hospitals Group confirmed that Halappanavar was a pregnant patient who died in its care. It released a statement extending its sympathies to Halappanavar's husband, explaining that it would be reviewing the "unexpected death" as per the national incident management policy of Ireland's public health care provider, Health Service Executive, or HSE.
"The process of incident review seeks to ascertain the facts relating to the incident, draw conclusions and make recommendations in relation to any steps that may need to be taken to prevent a similar incident occurring again," HSE said in a statement, adding that it would seek an external obstetrician to join its team of investigators.
Coppes, who has never met Halappanavar, said that when a woman's water, or amniotic sac, breaks during early pregnancy, she is at risk for infection because the barrier between the baby and the outside world is broken. The fetus's environment is also no longer sterile, putting it at risk for "horrible malformations."
Coppes said the fact that Halappanavar's husband reported she was ill and vomiting suggested a serious infection had set in, and it's possible that it spread to her blood, resulting in the septicemia that killed her. When asked how long it takes for an infection in the uterus to spread to the blood, Coppes said it can vary.
"Let's put it this way, the clock starts ticking when the membrane ruptures," he said. "It can be pretty fast. That's why you don't sit and watch."
When an infection occurs in a pregnant woman's uterus, Dr. Kimberly Gecsi, an obstetrician at University Hospitals in Cleveland, said the only way to treat it is to terminate the pregnancy.
"Antibiotics are part of the process, but once an infection develops inside the uterus, antibiotics alone aren't going to treat the infection," Gecsi said. "The infection will continue until the products of pregnancy are removed, either by natural procedure or with surgical procedure."
Although Gecsi can comment only on what she's read, she said it seemed as though Halappanavar had an infection, given the agony her husband described.
Halappanavar's husband told the Irish Times the couple had repeatedly asked doctors to end the pregnancy, and were refused even though his wife's cervix was fully dilated and her amniotic fluid was leaking. The night after the fetal heartbeat stopped and doctors cleared the uterus, he got a call from the hospital.
"They said they were shifting her to intensive care," Praveen Halappanavar told the Irish Times. "Her heart and pulse were low, her temperature was high. She was sedated and critical but stable. She stayed stable on Friday, but by 7 p.m. on Saturday they said her heart, kidneys and liver weren't functioning. She was critically ill. That night, we lost her."
Dr. Bryna Harwood, a gynecologist at the University of Illinois in Chicago, said Halappanavar's story was more nuanced than it appeared on the surface. Although the ruptured amniotic sac could have led to an infection that caused the septicemia, it was impossible to know from published details whether Halappanavar's infection was related to her pregnancy, she said.
The septicemia also could have come from a kidney infection or an appendicitis, both of which can be harder to detect in pregnancy, can be exacerbated by immune system changes in pregnancy and can cause pregnancy complications. They would also cause the back pain Halappanavar's husband described.
"You treat based on the source of the infection," Harwood said, adding that if the infection's source is the uterus, terminating the pregnancy can be part of the solution.
Gesci said there wasn't much doctors could do for the fetus at 17 weeks old, because fetuses are not considered viable until 24 weeks, meaning they cannot survive outside the womb. Gesci added that steroids and antibiotics haven't been proved to benefit fetuses younger than 24 weeks old, either.
Gesci said many women miscarry and have their water break early in the United States, but she wanted pregnant women to know that they shouldn't fear that what happened to Halappanavar would happen to them.
"This is something that can happen, and it's terribly unfortunate what happened to this woman, but in most cases, this is not something we see happen," Gesci said. "We do have ways to treat this to avoid a woman becoming severely ill or losing her life."