Was Savita's death a bleak window into a post-Roe future or a false story used by access advocates?
The official investigation stated, "the team is satisfied that concerns about the law, whether clear or not, impacted on the exercise of clinical professional judgement.”
Backstory: Savita Halappanavar died in the hospital after spontaneous abortion, a miscarriage, in an Irish hospital. The circumstances of her death were contested in the media.
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While subpar care contributed to her death, the official investigation found the law was a “key causal factor” in Savita’s death. The lead investigator stressed that even after Savita’s condition had become grave: “They were worried that if they did a termination they might be accused of performing an illegal act by not complying with the Eighth Amendment. So I think it’s important to recognise that.”
Dr. Katherine Astbury, who cared for Savita, acknowledged feeling “constrained by Irish law.”
The inquest showed the care provider was concerned about whether the threat to Savita’s life was grave enough and consulted more than one other provider about it. Savita’s widower has consistently testified to requesting termination multiple times.
Another doctor, Dr. Hadeel Jawad, who testified at the inquest, recalled Savita’s doctor saying, “We can't do the termination of pregnancy when the fetal heart is positive because this would be illegal.”
The investigation found counseling is provided after miscarriage occurs rather than when an inevitable miscarriage has been diagnosed, which may further suggest the inability to recognize the reality due to legislation.
Sepsis was a contributing factor, but the lead investigator refuted the claim it explained her death.
The official investigation by Irish Health Services
That infection and eventual sepsis contributed to Savita’s death are not disputed by anti-abortion groups, her family, the care providers, or any of the investigations, so we will not spend time outlining that aspect. Savita had an infection that had likely caused her to miscarry, and it contributed to her death. It was one of three “Key Causal Factors” identified by the investigation.
In the report, Irish Health Services1 specifically states that “Legislative factors affecting medical considerations” contributed to Savita’s death, as depicted in the graphic from the report and the quote below.
“The investigation team is satisfied that concerns about the law, whether clear or not, impacted on the exercise of clinical professional judgement.”
The document continues:
“The records and interviews confirmed that - from the time of her admission, up to the morning of the 24th of October - the management plan for the patient was to “await events” and to monitor the fetal heart in case an accelerated delivery might be possible once the fetal heart stopped. The interviewees stated to the investigation team that this was because of their interpretation of the law related to pregnancy termination.”
The official investigation found that a key factor in her death had been that she was not offered all management options (Irish Health Services, 2013). The following are listed as a “Key Causal Factor” in Savita’s death:
“Failure to offer all management options to a patient experiencing an inevitable miscarriage of an early second-trimester pregnancy where the risk to the mother increased with time from the time that membranes were ruptured.”
Witness testimony and the trial
Savita’s widower
Savita’s husband testified that he asked doctors to expedite the loss by carrying out an abortion, which would have dramatically improved her odds of survival, according to the investigation and inquest (Gwen Malone Stenography Services, 2013; Irish Health Service, 2013; Taggart, 2013). His testimony has stayed consistent over time.
Care providers and investigators
Dr. Katherine Astbury, who cared for Savita, acknowledged feeling “constrained by Irish law,” which does not permit a termination even in cases where medical doctors find a condition incompatible with life (Taggart & Smith-Spark, 2013).
In the inquest, multiple people involved in her case stated they felt termination was needed prior to the cessation of fetal heart activity (Gwen Malone Stenography Services, 2013).
The lead investigator of her case, a medical doctor, refuted the claim that Savita died of sepsis, and his account affirms Savita’s widower’s testimony (Aodha, 2018).
“Dr. Arulkumaran has also clarified claims around Savita’s death, saying that the Eighth Amendment was a major factor. He refuted claims that sepsis was the only cause of her death, as has been claimed by some during the course of the referendum debate.He said that although “she showed signs of sepsis that were not well-recorded”, he said that the healthcare team that were looking after her were “really going for the foetal heart all the time, even when she had a heart rate of more than 160bpm, high temperature they didn’t think of terminating”.“The next morning, they were listening to the baby’s heart. They were worried that if they did a termination they might be accused of performing an illegal act by not complying with the Eighth Amendment. So I think it’s important to recognise that.”
Reporting from the time stated:
“In his evidence, a leading obstetrician said Halappanavar’s life could have been saved had a termination been carried out a day or two before her miscarriage. However, Dr. Peter Boylan admitted it would not have been practical under Irish law, which states there has to be a real and substantial risk to the mother’s life” (Taggart & Smith-Spark, 2013).
The investigation concluded that “Non-adherence to clinical guidelines related to the prompt and effective management of sepsis, severe sepsis, and septic shock when it was diagnosed” was a contributing factor, though this does not change or mitigate the fact that policy contributed to her death and that similar policies have contributed to deaths in other countries too (Bennhold & Pronczuk, 2022; Gera, 2021; McCammon & Hodges, 2022).
The lead investigator also clarified that even on the last day of her life, when sepsis was clear, records show they were preoccupied with the fetal heart rate. The investigation found that this is standard practice.
“The investigation team established that counselling is provided after miscarriage occurs rather than when an inevitable miscarriage has been diagnosed.”
This approach to care conflicts with the international standard of care, a standard to which the US may no longer ascribe depending where you live (Irish Health Service, 2013; McCammon & Hodges, 2022).
Policy recommendations from trial
Trial conclusions included a call for policy change from multiple parties. The coroner for the trial recommended changes to policy needed to remove “doubt and fear from the doctor and also reassure the public” (AP News, 2013).
On policy, the official investigation said (Irish Health Services, 2013):
“There is difficulty in interpretation of law in relation to ‘what constitutes a potential major hazard or threat to mother’s life.’ This needs clarification. The consultant clearly thought that the risk to the mother had not crossed the point where termination was allowable in Irish law on the morning ward round on the 24th.”
The report goes father than recognizing the law as causal in Savita’s death. It warns that it could kill others in the future:
“The lack of clear clinical guidelines and training is considered to have been a material contributory factor in this regard. Similar incidents with a similar clinical context could happen again in the absence of:→ Clarity as to the application of the law in a situation where it may be necessary for a doctor to consider, in the exercise of their clinical professional judgement, the termination of a pregnancy in the clinical welfare interest of their patient→ An absence of appropriate national clinical guidelines on the clinical management of inevitable miscarriage in the early second trimester including the management of prolonged rupture of membranes with infection” .
The vote to repeal
A vote to repeal came after the investigation, and an inquest found waiting for the fetal heart activity to cease had been a key factor in Savita’s death (Aodha, 2018; Gwen Malone Stenography Services, 2013; Irish Health Service, 2013; Yalgi, 2018). The inquest showed the care provider was concerned whether the threat to Savita’s life was grave enough.
Savita’s parents, widower, and the lead investigator in this case both urged the court to repeal it because, as Irish Health Services noted, nothing had changed that would prevent this from happening again (Aodha, 2018; Gwen Malone Stenography Services, 2013; Irish Health Service, 2013; Yalgi, 2018).
Her father expressed in a video published on Facebook his hope that this would not happen again:
“I hope that people in Ireland will remember the fate of our daughter Savita on the day of the referendum and vote yes so that what happened to us won’t happen to other families.”
Anti-abortion activists claim, without evidence, that pro-choice activists exploited Savita
Anti-abortion activists accuse the “pro-choice” movement of using Savita’s death to legalize abortion, saying she died from poor care (Irish Times editors, 2012). In 2012, immediately after Savita’s death, Niamh Uí Bhriain of the Life Institute denied that the death had anything to do with the ban on abortion in Ireland and said it was "very sad to see abortion campaigners rush to exploit this case” (Irish Times editors, 2012).
It’s unclear what justified Niamh Uí Bhriain’s claim, and there is the obvious question of bias given her position with “Life Institute” and lack of connection to Savita’s family. Uí Bhriain works as a Catholic policy lobbyist and has spread a false claim that — intentionally or not — advanced her favored policy before, falsely claiming that children raised by same-sex parents were more likely to abuse drugs (Irish Examiner editors, 2006).
Despite facing more stressors than opposite-sex couples, studies with transparent funding, peer-review, qualified researchers, and repeatable, replicable, and reproducible design do not find significant differences in outcomes of children (Bos et al., 2018; Power, 2017; What Does The Scholarly Research Say about the Well-Being of Children with Gay or Lesbian Parents?, 2013), and in some instances, children of same-sex parents performed better in school (Mazrekaj et al., 2020).
A 2022 study found (Mazrekaj et al., 2022):The findings obtained by coarsened exact matching suggest no significant disadvantages for children with same-sex parents compared to different-sex parents. We contextualize these findings in their wider cultural context, and recommend a renewed focus in future research away from deficit-driven comparisons.
Lead investigator and inquest refute the claim that the law played no role in Savita’s death
Returning to Savita, while it’s true the court case ruled her death a “medical misadventure,” it is incorrect that this alone explains her death.
The inquest, the official investigation, and the lead investigator on the case all concluded the law affected medical decision-making (Irish Health Services 2013; Aodha 2018). Additionally, Dr. Katherine Astbury acknowledged feeling “constrained by Irish law.”
The reported circumstances surrounding Savita’s death have remained unchanged since being reported in November 2012 (Gwen Malone Stenography Services, 2013; Holland, 2018; Holland & Cullen, 2012; Irish Health Service, 2013). Still, anti-abortion activists or media sometimes claim medical failures, which did take place, fully explain Savita’s death (Holland & Cullen, 2012; White, 2013). That is false, as detailed in earlier sections.
Savita’s widower and parents were also publicly outspoken about the situation, demanding legislative action, which conflicts with the idea that “pro-choice” activists exploited the situation (AP News, 2013; Taggart & Smith-Spark, 2013; Yalgi, 2018).
Claims echoed in the United States
In the US, the negative consequences of abortion laws in Texas led Texas Right to Life to argue in a blog post that “misinformation” from the media and abortion advocates is the real problem (Texas Right to Life, 2022).
The trouble with this account is that this implies the sources of “misinformation” are the most respected relevant organizations, including but not limited to those listed below (Brief of Amici Curiae American College of Obstetricians and Gynecologists, American Medical Association, American Academy of Family Physicians, American Academy of Nursing, American Academy of Pediatrics, American Association of Public Health Physicians, Et Al. In Support of Respondents, 2022).
American College Of Obstetricians And Gynecologists
American Medical Association
American Academy Of Family Physicians
American Academy Of Nursing
American Academy Of Pediatrics
American Association Of Public Health Physicians
Texas Right to Life failed to demonstrate that anything but fact led expert organizations to take this stance, nor do they demonstrate themselves to be a credible source.
The expert coalition expressly warns in the amicus brief that the ban “places clinicians in the untenable position of choosing between providing care consistent with their best medical judgment, scientific evidence, and the clinicians’ ethical obligations or risk losing their medical licenses.”
Relevant experts’ fears realized in Texas
The consensus, spelled out in a amicus brief 2 authored by the American College of Obstetricians and Gynecologists (“ACOG”), American Medical Association, (“AMA”), American Academy of Family Physicians, (“AAFP”), American Academy of Nursing (“AAN”),, American Academy of Pediatrics (“AAP”), American, Association of Public Health Physicians (“AAPHP”),, American College of Medical Genetics and Genomics, (“ACMG”), American College of Nurse-Midwives, (“ACNM”), American College of Osteopathic Obstetricians and Gynecologists (“ACOOG”), American College, of Physicians (“ACP”), American Gynecological and, Obstetrical Society (“AGOS”), American Medical, Women’s Association (“AMWA”), American Psychiatric Association (“APA”), American Society for Reproductive Medicine (“ASRM”), Association of Women’s, Health, Obstetric and Neonatal Nurses (“AWHONN”),, Council of University Chairs of Obstetrics and Gynecology (“CUCOG”), GLMA: Health Professionals Advancing LGBTQ Equality (“GLMA”), North American, Society for Pediatric and Adolescent Gynecology, (“NASPAG”), National Medical Association (“NMA”),, National Association of Nurse Practitioners in Women’s Health (“NPWH”), Society for Academic Specialists in General Obstetrics and Gynecology (“SASGOG”), Society of Family Planning (“SFP”), Society of, General Internal Medicine (“SGIM”), Society of Gynecologic Oncology (“SGO”), and Society of OB/GYN, Hospitalists (“SOGH”) is that the overturn of Roe V Wade will bring predictable, preventable harm and that exemptions will not stop dozens of potentially lethal situations (Brief of Amici Curiae American College of Obstetricians and Gynecologists, American Medical Association, American Academy of Family Physicians, American Academy of Nursing, American Academy of Pediatrics, American Association of Public Health Physicians, Et Al. In Support of Respondents, 2022), 2022).
The amici note the Supreme Court’s misapprehension where the science is concerned, saying, “Indeed, the Ban reflects a fundamental misunderstanding and misrepresentation of the science of fetal development.” They state that the argument put forth by Mississippi “attempts to manufacture a concern that medical consensus rejects as scientifically unfounded.”
The negative consequences detailed in the amicus brief came to life in an article titled “Abortion laws spark profound changes in other medical care” from the Associated Press (Tanner, 2022), one of the most reliable news agencies available in English:
“For physicians and patients alike, this is a frightening and fraught time, with new, unprecedented concerns about data privacy, access to contraception, and even when to begin lifesaving care,” said Dr. Jack Resneck, president of the American Medical Association.
Even in medical emergencies, doctors are sometimes declining immediate treatment. In the past week, an Ohio abortion clinic received calls from two women with ectopic pregnancies — when an embryo grows outside the uterus and can’t be saved — who said their doctors wouldn’t treat them. Ectopic pregnancies often become life-threatening emergencies and abortion clinics aren’t set up to treat them.
It’s just one example of “the horrible downstream effects of criminalizing abortion care,″ said Dr. Catherine Romanos, who works at the Dayton clinic.
With the fall of Roe v. Wade, “the art of medicine is lost and actually has been replaced by fear,” Munoz said.
Munoz said he faced an awful predicament with a recent patient who had started to miscarry and developed a dangerous womb infection. The fetus still had signs of a heartbeat, so an immediate abortion — the usual standard of care — would have been illegal under Texas law.
“We physically watched her get sicker and sicker and sicker” until the fetal heartbeat stopped the next day, “and then we could intervene,” he said. The patient developed complications, required surgery, lost multiple liters of blood and had to be put on a breathing machine “all because we were essentially 24 hours behind.’’
Yes, the overturning of Roe V Wade could lead to deaths from ectopic pregnancy. Here's how.
Hoaxlines’ explainer on some of the negative outcomes related to laws was published a couple of weeks ago and covers many of the disconnects that have happened in this discussion. The cases in this presentation do not include Savita.
References
Figures and images
Snippets of investigation and inquest
Citations
Aodha, G. N. (2018). Doctor who led inquiry into Savita Halappanavar’s death calls for Yes vote “for women”s health and rights’. The Journal. https://www.thejournal.ie/doctors-savita-halappanavar-4027207-May2018/
AP News. (2013, April 20). Irish Jury Finds Poor Care in Death of Woman Denied Abortion. The New York Times. https://www.nytimes.com/2013/04/20/world/europe/jury-cites-poor-medical-care-in-death-of-indian-woman-in-ireland.html
Bennhold, K., & Pronczuk, M. (2022, June 12). Poland Shows the Risks for Women When Abortion Is Banned. The New York Times. https://www.nytimes.com/2022/06/12/world/europe/poland-abortion-ban.html
Bos, H. M. W., Kuyper, L., & Gartrell, N. K. (2018). A Population-Based Comparison of Female and Male Same-Sex Parent and Different-Sex Parent Households. Family Process, 57(1), 148–164. https://doi.org/10.1111/famp.12278
Brief of Amici Curiae American College of Obstetricians and Gynecologists, American Medical Association, American Academy of Family Physicians, American Academy of Nursing, American Academy of Pediatrics, American Association of Public Health Physicians, Et Al. In Support of Respondents, 2022. (2022). Dobbs V Jackson: Brief of amici curiae of ACOG, AMA, AAFP, AAN, AAP, AAPHP, et al. in support of respondents. ACOG. https://www.acog.org/-/media/project/acog/acogorg/files/advocacy/amicus-briefs/2021/20210920-dobbs-v-jwho-amicus-brief.pdf?la=en&hash=717DFDD07A03B93A04490E66835BB8C5
Gera, V. (2021, November 2). Pregnant woman’s death puts spotlight on Polish abortion law. Associated Press. https://apnews.com/article/abortion-business-poland-reproductive-rights-warsaw-b341c34d236d51fdda36c2fc7a8aa88c
Gwen Malone Stenography Services. (2013). Inquest Into The Death Of Ms. Savita Halappanavar Held Before The Coroner, Dr. Ciaran Macloughlin, On Wednesday, 10th April 2013 - Day 3. https://data.oireachtas.ie/ie/oireachtas/committee/dail/32/joint_committee_on_the_eighth_amendment_of_the_constitution/submissions/2017/2017-10-25_coroner-report-on-ms-savita-halappanavar-dr-peter-boylan-iog_en.pdf
Holland, K. (2018, May 28). How the death of Savita Halappanavar revolutionised Ireland. The Irish Times. https://www.irishtimes.com/news/social-affairs/how-the-death-of-savita-halappanavar-revolutionised-ireland-1.3510387
Holland, K., & Cullen, P. (2012, November 14). Woman “denied a termination” dies in hospital. The Irish Times. https://www.irishtimes.com/news/woman-denied-a-termination-dies-in-hospital-1.551412
Irish Examiner editors. (2006, April 28). “Mother and Child Campaign” opposes adoption by gay couples. Irish Examiner. https://web.archive.org/web/20210318225107/https://www.irishexaminer.com/news/arid-30256352.html
Irish Health Service. (2013). Investigation of Incident 50278 from time of patient’s self-referral to hospital on the 21st of October 2012 to the patient’s death on the 28th of October, 2012. https://www.hse.ie/eng/services/news/nimtreport50278.pdf
Irish Times editors. (2012, November 14). Independent expert to be appointed in Savita review. The Irish Times. https://www.irishtimes.com/news/independent-expert-to-be-appointed-in-savita-review-1.748721
Mazrekaj, D., De Witte, K., & Cabus, S. (2020). School Outcomes of Children Raised by Same-Sex Parents: Evidence from Administrative Panel Data. American Sociological Review, 85(5), 830–856. https://doi.org/10.1177/0003122420957249
Mazrekaj, D., Fischer, M. M., & Bos, H. M. W. (2022). Behavioral Outcomes of Children with Same-Sex Parents in The Netherlands. International Journal of Environmental Research and Public Health, 19(10). https://doi.org/10.3390/ijerph19105922
McCammon, S., & Hodges, L. (2022, February 28). Doctors’ worst fears about the Texas abortion law are coming true. NPR. https://www.npr.org/2022/02/28/1083536401/texas-abortion-law-6-months
Power, J. (2017, September 6). FactCheck: are children “better off” with a mother and father than with same-sex parents? The Conversation. http://theconversation.com/factcheck-are-children-better-off-with-a-mother-and-father-than-with-same-sex-parents-82313
Taggart, P. (2013, April 8). Husband testifies his wife died after abortion was denied in Ireland. CNN. https://www.cnn.com/2013/04/08/world/europe/ireland-abortion-controversy/index.html
Taggart, P., & Smith-Spark, L. (2013, April 19). Woman’s death in Ireland abortion case ruled “medical misadventure.” CNN. https://www.cnn.com/2013/04/19/world/europe/ireland-abortion-controversy-inquest/index.html
Texas Right to Life. (2022, July 17). Miscarriage Treatment is Not an Abortion in Texas. Texas Right to Life. https://archive.ph/4xEse
What does the scholarly research say about the well-being of children with gay or lesbian parents? (2013, July 10). What We Know Project, Cornell University. https://whatweknow.inequality.cornell.edu/topics/lgbt-equality/what-does-the-scholarly-research-say-about-the-wellbeing-of-children-with-gay-or-lesbian-parents/
White, V. (2013, October 31). Savita’s death is not about abortion — it is about medical negligence. Irishexaminer.com. https://www.irishexaminer.com/opinion/columnists/arid-20247993.html?fbclid=IwAR0SBWEOiyuoFK9N9gY-nEQwYbKfoavxN0mUjAKH0ZkuNBB8f0tH0GOYVU8
Yalgi, A. (2018). A message from Savita’s parents. Facebook. https://www.facebook.com/Together4yes/videos/2044305905892227/
Health and personal social services are delivered by the Health Service Executive (HSE) in Ireland. Health Service Executive may be unclear to readers and does not communicate the country of origin. For clarity, Hoaxlines will refer to this entity as “Irish Health Services” for the duration of this report.
Amicus Curiae
Amicus Curiae literally translated from Latin is "friend of the court." Plural is "amici curiae."
Generally, it is referencing a person or group who is not a party to an action, but has a strong interest in the matter. This person or group will petition the court for permission to submit a brief in the action intending to influence the court’s decision. Such briefs are called "amicus briefs."
LLI. amicus curiae. In: LII / Legal Information Institute [Internet]. 2022 [cited 17 Jul 2022]. Available: https://www.law.cornell.edu/wex/amicus_curiae