Guest post: Savita and medicine.

I’m absolutely delighted to welcome Seonaid to guest post at the Tea Cosy- although I do, of course, wish it were in better circumstances. -Aoife

So, my international internet buddy Aoife posts a Thing about her reaction to hearing about the horrific way Savita Halappanavar died. And I cry, because like her, on October 21st-27th I was doing inconsequential things while a woman in a place in life not totally unlike mine lost a baby she wanted, and unnecessarily suffered and died. And I cry, because Ireland still has laws that outlaw all terminations of pregnancy, even cases of rape, incest, or where the mother’s life is in danger. And because the penalties are so great that no doctor would take the chance that perhaps the fact that the pregnancy was already terminating itself left room for an interpretation that the correct treatment might actually be legal.

Now I get self-centered and I cry some more because this is the type of thing that can’t happen here, where I live, in the United States, where people like Savita, and me, and any other person who menstruates, have fought for and won the right NOT to die like this. But also where the party that approximately half the population supports has just adopted similar ‘values’ as part of its official party platform. Where “repeal Roe v. Wade” and “support a woman’s right to choose” are opposing sides of a coin that is very prominent in any race for any elected position in the nation. Where we are saddened, but no longer surprised, when religious fundamentalists murder doctors who provide abortions.

And then an internet comment storm starts, with (astoundingly to this American so jaded by Republican/Democrat balkanization) hardly anyone screaming names like ‘demon’ and ‘murderer’. The most heated that side of it gets is actually very mild, to my ears, simply stating that the laws don’t need to be different to have saved Savita, that the right medical treatment was quite legal, and that it was criminal negligence on the part of the doctors that Savita had not been treated to stop her miscarriage.

Ah. Stop her miscarriage. And that’s where the commenter loses the ‘open to rational opposing opinions’ part of my brain that until then was willing to engage. Because as it happens, I know something about pregnancy, labor, pre-term labor, miscarriage, vaginal birth, and surgical birth. In the US, we deal with a different kind of suppression of reproductive choice: the right to give birth where and how you see fit. To give birth in a hospital and resist the immense pressure to let the staff ‘manage’ your labor is virtually unheard of (homebirth and midwives are a thing here, but are thought of as very ‘fringy’ and I was not aware at the time of my daughter’s birth that it was an option to be taken seriously).

And then I have an epiphany, the edges and vague form of which have occurred to me before but never in such clear, tangible form, that these two of my deepest-held causes (the right to choose NOT to give birth, and the right to choose HOW to give birth) are even more linked than parallel sentence construction and the obvious fact of the word ‘birth’. Because really, it’s all part and parcel of the same old disconnect: that self-proclaimed ‘pro-lifers’ are not pro-life in the slightest. They’re pro-birth. And yeah, that’s been said before, but it’s really not that my two causes are similar, related issues, it’s that they’re THE SAME ISSUE YOU GUYS. ‘Pro-life’ really means ‘pro-fetus-exiting-your-body-in-a-way-we-find-acceptable’.

Granted, that’s in the US, where we have much less access to birthing options even where they are technically available, so the parallels may be more obvious here. I’m not going to argue Irish law. I’m not going to talk about X, or A, B, and C. My own nation’s constitution and laws are difficult enough to understand, especially when you then get into how they interact with the 50 individual states’ constitutions and laws. Me arguing Irish constitutional law, Irish court rulings, ECHR rulings, etc. is pretentious at best and at worst leaves me looking like a nincompoop (as I proved to some small extent on Aoife’s facebook wall the other day).

But I know from medical interventions in birth. I know from pregnancy terminology. And what those people who are insisting that Savita should have been ‘treated for her miscarriage’ don’t understand is that preterm labor and miscarriage are not the same thing. Specifically, miscarriage is when pre-term labor has reached the point of no return. Miscarriage specifically means there is no treatment that will stop the fetus from exiting the womb one way or another. And Savita was diagnosed as having a miscarriage. So ‘scuse me while I get to the meat of this post: the technical details (pardon my American spelling of medical terms).

Preterm labor has three possible outcomes:

  1. Preterm labor can be treatable, that is, it can sometimes be stopped or slowed long enough to let the fetus grow to a more viable stage. Treatments, whether medical or surgical (progesterone or cerclage) are focused on preventing the water from breaking, preventing dilation of the cervix, because if these things occur, the fetus will be expelled from the uterus.
    In nearly all cases, treatment only delays expulsion of the fetus for a few days, but this may be long enough, if the fetus is of sufficient gestational age at the time preterm labor begins,  to administer certain drugs to the mother that will accelerate development of the fetus’ lungs and brain to increase viability.
  2. Whether treatable or not, preterm labor can end in a premature birth, where the fetus is born alive. The fetus may only live briefly, depending on how far along the pregnancy has progressed and what caused the preterm labor.
    Fetuses from 16 weeks on might have a heartbeat for a few minutes after birth.
    Long-term survival has never been reported for less than 21 weeks and 5 days.
    At 24 weeks gestational age, there is about a 50% chance the infant will survive long-term.
    At 26 weeks gestational age, there is about a 50% chance the infant will survive long-term without moderate or major neurological disability.
  3. Preterm labor can end in miscarriage. Up to 24 weeks, even if the fetus is born alive, the outcome is termed a miscarriage if it then dies shortly afterward. Untreatable preterm labor at 17 weeks can only end in miscarriage.

Miscarriage is also referred to medically as spontaneous abortion, that is, a pregnancy that ends naturally before the embryo or fetus is capable of surviving outside the womb. One of the stages of a miscarriage is called ‘inevitable miscarriage’. This means that the cervix is dilated but the fetus is not yet expelled.

Preterm labor is what Savita experienced before the point where her cervix was fully dilated and her water had broken. Inevitable miscarriage is what Savita presented with at the hospital, and what she was forced to experience for three days because her fetus would certainly die outside her uterus.

Her cervix was fully dilated, her water had broken, and her uterus was contracting. THERE WAS NO TREATMENT, LAWFUL OR OTHERWISE, that could stop the fetus from exiting her womb one way or another, and at 17 weeks of pregnancy there was no chance of its survival. What could have saved her life was medical induction of stronger contractions to make her uterus expel the fetus faster, once the diagnosis of miscarriage was confirmed, so her body could do what bodies do after any birth: contract the uterus down to near its pre-pregnancy size and close the cervix.

Let me paint a very different picture for you. If Savita had been 26 weeks along, the fetus would have had a 50% chance of survival without neurological disability.  After 12 hours of labor, the doctors would have become very concerned about stress on the unborn fetus. Well before 24 hours had passed, they would very probably have insisted on inducing stronger labor (the treatment she requested three times) or performing an emergency cesarean, because the fetus would have a greater chance of survival in neonatal intensive care than going through the physical stress of a prolonged labor.

And again, another, still different picture. If she had been 37 weeks along, they would have exerted extreme pressure on Savita, whether she wanted it or not, to let them induce stronger contractions or perform a cesarean once her water had been broken for 24 hours, because they would have perceived both her and the fetus to be at increased risk for septicemia. SEPTICEMIA. They would have done just about anything they thought would work to manipulate her into agreeing, in some cases even lying about her baby’s well-being. They would have done this even though it is actually repeated cervical checks that increase the risk of septicemia, and if they keep their hands out of laboring people’s vaginas, the risk does not increase.

In other words, if the fetus stood a chance of surviving the birth, they would have insisted on doing exactly what Savita asked them at least three times to do. But because Savita was only 17 weeks along; because this baby she wanted could not survive but had not yet died inside her; because the law on abortion in her adopted country is at best so ambiguous that no doctor could be sure they would not go to prison for life if they treated her appropriately, and at worst outright values the life of a fetus who is absolutely going to be born, and die within minutes of being born, over that of a mother begging repeatedly for her life to be saved… because of these things, she was forced to wait three days for her baby to die inside her. She was forced to wait, with her cervix open to infection and a uterus that was not able to contract sufficiently to expel a non-viable fetus and get on with the business of healing. She was forced to wait, because doctors were unable, on penalty of life in prison, to save her life.

I can’t think of a way to wrap this up neatly. It’s not a story of disgust and outrage, with a tidy resolution at the end. Because at the end of this story, Savita dies. This is real-life disgust and outrage, and real life is rarely story-shaped.


Guest post: Savita and medicine.