Review shows maternal deaths under-reported
[Posted: Fri 23/11/2012 by Niall Hunter, Editor www.irishhealth.com]
Ireland’s maternal mortality rate is twice as high as has been previously reported, new figures show.
The first report from the recently-established Maternal Death Enquiry – MDE Ireland system shows that our maternal death rate is 8 per 100,000 births, compared with 4 per 100,000 reported by the Central Statistics Office (CSO).
The MDE Ireland report, which uses wider criteria for defining maternal death than that used by the CSO, found that in the years 2009 to 2011 inclusive, 25 mothers who attended maternity hospitals with their pregnancies died.
The Irish report adopted the more comprehensive British classification system for determining maternal death, and collated detailed data on mortality from hospitals. It classified two of the deaths in the period as being due to suicide.
In the wake of the death of Savita Halappanavar, assurances have been made by health authorities and the medical profession that Ireland has one of the lowest maternal death rates in the world. However, the new report shows that while our maternal death rate is still relatively low by international standards, it is higher than has been previously reported in official statistics.
According to the report, seen by irishhealth.com, six of the 25 deaths were classified as direct maternal deaths, 13 as indirect maternal deaths, while the remaining six were attributed to ‘coincidental cause’. Forty per cent of the deaths recorded were in women not born in Ireland.
It says of the 25 deaths MDE Ireland recorded between 2009 and 2011 inclusive, among the six direct maternal deaths, three were due to pulmonary embolism, one from amniotic fluid embolism, one due to uterine rupture and one due to multi-organ failure secondary to the HELLP syndrome, a life-threatening pregnancy complication related to pre-eclampsia.
The report says of the 13 indirect maternal deaths recorded during the period, five were due to heart disease, two due to suicide, two were due to swine flu, two due to epilepsy, one due to serious lung disease and one due to an oesophageal bleed.
Of the six ‘coincidental’ deaths, two were due to metastatic cancer, one due to a road traffic accident, one due to lymphoma and two due to substance abuse.
The MDE Ireland system, set up in 2009 and run by leading medical and midwifery experts, is linked to the Confidential Maternal Death Inquiry system for England and Wales. This system is regarded as the ‘gold standard’ for confidential maternal death inquiry.
MDE Ireland classifies maternal deaths under the criteria of:
* ‘Maternal’ deaths of women while pregnant or within 42 days of the end of pregnancy, from any cause related to or aggravated by the pregnancy.
* ‘Direct’ deaths resulting from obstetric complications of pregnancy, from ‘interventions, omissions, incorrect treatment or from a chain of events resulting from any of the above’.
* ‘Indirect’ deaths resulting from a previous existing disease, or a disease developing during pregnancy and which was not due to obstetric causes, but where the disease was aggravated by the physical effects of the pregnancy.
* ‘Coincidental’ maternal deaths, from unrelated causes which happen to occur in pregnancy or the during or just after childbirth.
* ‘Late’ deaths occurring between 42 days and one year after abortion, miscarriage or delivery that are the result of direct or indirect maternal causes.
Figures used by the CSO for maternal deaths rely on the cause of death as recorded on the coroner’s death certificate alone, which experts believe limits the definition of a maternal death and has led to under-reporting of the true rate.
The most recent CSO figures recorded only one maternal death in 2010 and three in 2009.
The MDE Ireland report says its aim is to investigate why some women die during or shortly after pregnancy, and to learn how such tragedies can be avoided in the future.
The new figures mean our maternal mortality rate is on the same level as that of France, it is still less than that of the UK and the US, but is higher than that of Sweden and Norway.
Referring to the significant number of maternal deaths in Ireland among women born outside the country, the report says the issue of how these women engage with our maternity services needs to be dealt with, and highlighted the importance of the availability of interpretive services.
A particular concern, the report says, is the issue of engagement with maternity services by non-national patients getting alternative medical advice from outside the country.
The MDE Ireland report says there was reluctance in some hospitals to share maternal death data due to concerns over data protection, potential litigation and anticipated review of cases by other agencies.
It says pregnant women with pre-existing medical and mental health disorders should have risk assessment on booking into a maternity hospital, and they should be afforded high priority when referred for assessment by doctors in other medical disciplines.
The report recommends that a question on pregnancy status at time of death, similar to that on the medical death cert, should be included on the coroner’s death cert.
Sean Kenny, Labour TD for Dublin North East.
Lisa Powell writes;
I re-e-mailed my TDs re: legislation this morning, this was one response:
You might be aware that Labour TDs including myself, did not support Clare Daly’s billon the X case last night. As your TD, I want to explain why I voted No.
In order to succeed in getting legislation for the X case, I, as a legislator, have to work with the reality of the political games that are being played in order to get X case legislation passed into law.
Fine Gael, Labour’s coalition partners would not support Clare Daly’s bill. I believe that Labour Ministers suggested to them that they should support it. But they did not wish to do so – they want to wait to debate the Expert Group Report which has been published recently. This is because Fine Gael and Labour agreed on the Expert Group process a year ago.
Fine Gael now want to see that through. It is clear on reading the Expert Group
report that the Expert Group believes legislation for the X case and regulations for doctors, is the way forward on this matter.
Fine Gael are a very conservative political party. They do not really want legislation. Labour will have to force them to support legislation.
It is very, very difficult getting them to move on this – but it is working previously, for example, Enda Kenny has said he will not be rushed. But earlier this week he said he would move swiftly.
The really conservative Fine Gael TDs and Ministers are now speaking out in the media about their opposition. They are doing that because they know that Labour is influencing Fine Gael and that they will have to support legislation. They are trying to re-assure their anti-choice voters.
All of that going on in Fine Gael is down to Labour Party TDs and Ministers pushing Fine Gael on this.
As part of that, if Labour, their coalition partner, were to antagonise Fine Gael by supporting Clare Daly’s Bill and breaking with the Expert Group route, Fine Gael will not trust Labour and then there never will be any legislation because Fine Gael will not support it.
I also would like you to consider the way in which Dáil seats are divided up in this Dáil. Each seat in the Dáil is worth one vote.
Labour have 37 seats in the Dáil.
Fine Gael have 74 seats in the Dáil.
Fianna Fáil have 19 seats.
Sinn Féin have 14 seats.
Independents have 20 seats.
ULA have 4 seats.
The Ceann Comhairle has one vote – this vote is cast only in the event
of a tie.
If Fine Gael seats (ie, votes) are left out of the equation, there are not enough TDs who will support legislating for the X case. A number of the FF and Independent TDs are very pro-life – some will vote against legislating and others will simply not show up to vote at all.
Just 27 votes supported Clare Daly’s Bill last night. Even if all the Labour TDs had supported it, it still would have failed to pass.
In other words, for X case legislation to be passed without question in the Dáil, Fine Gael AND Labour are needed to support X case legislation when it comes down to a vote on in the Dáil because they have the most seats, and therefore, the most votes.
Fine Gael control Dáil Éirean and Labour supporting legislation alone will not get that legislation voted through.
Fine Gael are required.Over the next couple of weeks, there will be a debate on the Expert Group report. After that, the Government will decide what steps to take. I
am confident that there will be legislation on the X case and that it will happen within the next two or three months.
Sean Kenny TD
28th November is the full moon and there will be a lunar eclipse, it will also be one month from when Savita Halappanavar died in hospital in Galway.
That same day a bill to legislate for the X Case is tabled to be debated and discussed. Claire Daly as part of the ULA is bringing the bill forward and it will do what is needed.
Unfortunately despite it being a good bill and legally sound it is most likely it will be voted down by the government parties.
Who will not want to legislate someone else’s bill, who want to drawn out the process and will stall and then grudgingly create their own bill months later.
The Labour party does want to legislate as soon as possible but they are tied in coalition with the very conservative Fine Gael and even if there was a free vote in the Dáil the bill can not pass with out Fine Gael votes to support it.
So they are playing party politics with women’s lives.
Women must be allowed to make informed decisions about crisis pregnancies
A few days before the 1983 referendum that gave us article 40.3.3 of the Constitution, a heartbroken man spoke out. Brendan Hodgers described the death of his wife Sheila in an Irish hospital.
She had cancer but was taken off all drugs and treatments when she became pregnant because they might harm or kill the foetus. Mr Hodgers said that with his wife screaming in agony, he asked for her to be given an abortion. He got no reply. After giving birth to a premature baby girl who died immediately, Sheila Hodgers died.
He revealed his personal tragedy in the hope that it would remind Irish people that sometimes a woman needs an abortion and that the amendment could cost women’s lives. In the same year, an Irish man was convicted of the rape of two girls aged 14 and 16, both of whom had given birth to babies.
The architects of the amendment swept aside all such sorrowful facts. Ireland was a Catholic country, they insisted. Feminists who said they wanted contraception, women’s refuges, rape crisis centres, support for single mothers and divorce, were out to destroy traditional Irish values. Abortion must be banned in all circumstances. Leading campaigner John Reilly warned that those who opposed the amendment were opportunists whose strategy would be to spread confusion by arguing for abortion in cases of rape, incest, alleged “life and death” situations, and in the case of foetal abnormality.
The counter-strategy was to convince the people that abortion was, in the words of Fine Gael TD Alice Glenn “a slaughter of the innocents”.
The Catholic bishop Joseph Cassidy said in the full confidence of his moral authority that the most dangerous place for a child to be in the world was in a woman’s womb.
The zealots didn’t get the wording they originally wanted. Women were to be given equal rights with the foetus. However, they were confident when the amendment was passed that Ireland was the safest place in the world to be unborn.
In 1992, they were appalled when the Supreme Court ruled that a suicidal 14-year-old girl, pregnant as a result of rape, had a constitutional right to an abortion in Ireland. This followed huge demonstrations of solidarity for the child by the Irish public, with candlelit marches, impassioned debates, and, most potent of all, the brave and sometimes devastated voices of women and children telling their own secret abortion stories to journalists.
The late John McGahern believed pregnancy was a private matter and felt “nothing but shame” upon being asked to vote in the subsequent referendum to give or withhold from women the right to travel or obtain information about abortion. The whole sorry situation was the fault of cowardly politicians who had failed to legislate, he wrote.
Praveen Halapannavar has described the death in agony of his pregnant wife Savita. He said that when, knowing she was miscarrying, she asked for an abortion, she was refused and told that she was in a Catholic country. The foetus died and was delivered, and later Savita died. They should, her grieving husband said, have saved “the bigger life”. The couple could have had other babies.
Anti-abortionists – and let us call them this, for they are no more pro-life than the rest of us – have accused pro-choice activists of being opportunists over this case. There is no problem with our laws or our Constitution, they insist.
But Mr Halapannavar, through his friends, went to the Galway Pro-Choice group and decided with its support to reveal the story of his tragedy because, like Brendan Hodgers 30 years ago, he wanted to let the Irish people know that our prohibition on abortion can cost the lives of women.
Article 40.3.3 has been a disaster. It has led to misery and it has failed to stop women from wanting, needing and in many cases getting abortions.
Ten women a day leave Ireland for terminations, and others go online and order abortion drugs. Proposed restrictions through further amendments were rejected in 1992 and 2002. Opinion polls show steadily increasing support for liberalising abortion law.
Successive governments have claimed legislating for article 40.3.3 is too complicated. This one must give us the chance to remove it and legislate in a way that trusts women to make informed decisions about crisis pregnancies.
Doctors should never be distracted in clinical emergencies by worries about the distinction between life and health, intentional and unintentional outcomes.
This is not a Catholic country. It is not opportunistic to talk about rape and incest and life and death situations and foetal abnormality in relation to abortion. It is the real experience of women.
Who, instinctively and lovingly, does not understand and support what Praveen Halapannavar said about “the bigger life”?
Reporter Oonagh Murphy reported on the excerpts of the report from the Expert group set up to review the X Case ruling.
It seems that the expert group reports back that the options are to put in place guidelines, legislation or regulations.
Guidelines, which can be put in place quickly can be easily amended but they would have no legal force behind them and would not meet the recommendations of the EU court of human rights.
Legislation would meet the recommendations of the EU courts of human rights, but it will mean time spent drawing them up, time spent debating for it to be passed. Legislation will take more time and has a lack of flexibility in the future as medical advances are made.
Regulations in conjunction with legislation may offer flexibility but will have to be backed with legislation which will allow the regulations to be changed as needed.
It was also reported that the X Case only deals with the risk to the life of the woman rather then the risk to health and as a result cases like those of Savita may not be covered by anything which the government put in place.
Tuesday the 27th of November has been given for the publication of the report.
Those who opposed the 8th amendment were accused of being pro abortion and running a campaign for abortion when they were questioning the flawed nature of the 8th amendment.
The 8th Amendment introduced the following clause into Article 40.3 of the Constitution:
3° The State acknowledges the right to life of the unborn and, with due regard to the equal right to life of the mother, guarantees in its laws to respect, and, as far as practicable, by its laws to defend and vindicate that right.
For Release: Galway Pro Choice Were Approached by Savita’s Friends
As was made clear by Sarah McCarthy of Galway Pro Choice on last night’s Prime Time programme on RTE, Galway Pro Choice were approached by the friends of Savita Praveen Halapannavar on 3rd November 2012. They came to us before going public with her story. Their only wish was to try to make sure that what
happened to Savita would never happen to another woman again in Ireland.
After an initial phone call on 3rd November from a friend of Savita and Praveen’s, Savita’s friends sent Galway Pro Choice an email containing more details of the case. A meeting between Galway Pro Choice and approximately ten of Savita’s friends then took place, during which they explained the facts of the case as they saw them. They believed that a termination may have saved Savita’s life. They requested the assistance of Galway Pro Choice in deciding how to proceed.
Galway Pro Choice presented Savita’s friends with a number of options, including the option of not releasing the story at all. The option of releasing the story anonymously, without a name or place being mentioned, was also discussed. However, Savita’s friends and her husband Praveen felt that going fully public with the tragic story of Savita’s death was what they wanted to do in order to bring home to the public how Ireland’s abortion laws can place pregnant women in danger. A phone call between Galway Pro Choice and Savita’s husband Praveen, in India, also occurred, in which Praveen reiterated his desire to go public with the story.
Galway Pro Choice then put Praveen and his friends in touch with the Irish Times. We explicitly made clear to Praveen and his friends that if they were uncomfortable in any way, at any stage, with any of our activities they should just say so and we would immediately do what they wished. We have informed them in advance of all of our planned activities so far, and they have been supportive of all of them. Savita’s friends were present at the candlelit vigil we held on Saturday in Galway, and expressed their amazement that anyone could say that we were ‘taking advantage of’ or ‘hijacking’ the tragedy of Savita’s death.
Now that these facts have been made clear, any and all implications by anti-choice campaigners or politicians to the effect that Pro-Choice groups are taking advantage of this tragedy should stop. If they do not, they must be interpreted as deliberately misleading statements. As well as being false, they are offensive and potentially upsetting to Savita’s family and friends.
Galway Pro Choice would also like to make the following points:
– We must legislate on the X Case immediately; Government statements that it will take months to get legal clarity are unacceptable.
– Minister for Health James Reilly must instigate a fully independent public inquiry now.
– The Expert Group Report should be released to the public immediately.
– The only way to safeguard the health of pregnant women in Ireland is to guarantee access to free, safe, and legal abortion for all women.
We will be holding a public meeting this Thursday, 22nd November, at 7:30pm in the Harbour Hotel in Galway on the urgent need to legislate for the X Case. Speakers include Clare Daly ULA TD; Mary Smith, a retired midwife and pro-choice activist, and Ailbhe Smyth, former Head of Women’s Studies at University College Dublin, and women’s rights activist. Sarah McCarthy of Galway Pro-Choice will chair the meeting.
On Saturday, December 1st we will be hosting a national demonstration in Galway on the need to immediately legislate for the X Case. The demonstration will assemble at the Spanish Arch at 2pm.
For more information email us at firstname.lastname@example.org or call 0860621503 or 0877060715.
Yes Pro Choice groups did know about Savita’s death before the newspapers were published and they respected the family’s requests.
Herself and no one from her offices responded to my initial email send on the 2nd of November, but responded to the one I send yesterday.
Fri, 16 Nov 2012 13:17:28
I wish to acknowledge and thank you for your recent email in relation to the tragic and dreadful story of Savita Halappanavar, the 31-year-old dentist who died from septicaemia in NUIG after being refused a termination when miscarrying.
First and foremost, this is a human tragedy, and all sympathies should be extended to her husband Praveen and her family who are now grieving.
Investigations are being carried out the by hospital’s risk review group and the HSE’s National Incident Management Team as well as by the coroner in Galway. In other words, we don’t know the full circumstances of the case, and we should resist the temptation to get drawn into coming to conclusions in absence of all the facts.
That does not mean that we can or should avoid considering this case in the context of the X Case and of the report of the Expert Group that was established by the Government.
This issue has been with us now for 20 years and this is the first Government that has decided that were are going to deal with it. We put place a process, an Expert Group chaired by Judge Ryan to address all of the issues, to make recommendations to us. That Expert Group looked for an extension on the period of time they needed to consider the issues. It is a complex and sensitive area. They have now completed their work, submitted their report to Minister for Health and will be presented to Cabinet once the Minister has considered its contents. Whether the Expert Group recommends legislation or regulation, we will not ignore it. Legal clarity is required on this issue.
The Programme for Government negotiated by both Labour and Fine Gael on forming government contains the following commitment:
“We acknowledge the recent ruling of the European Court of Human Rights subsequent to the established ruling of the Irish Supreme Court on the X-case. We will establish an expert group to address this issue, drawing on appropriate medical and legal expertise with a view to making recommendations to Government on how this matter should be properly addressed.”
Tackling the issues around the X Case is a complex matter and while Deputy Daly’s Private Members Bill was welcome in facilitating debate, it was not without flaws.
There were number of concerns around the detail and drafting of the Bill that lacked clarity and that could have caused confusion. The Bill was therefore not appropriate as a basis for addressing the many complexities in this area.
Joan Burton TD
Minister for Social Protection
Recieved on the 15/11/2012 16:00
First of all thank you very much for your email. I fully support the need for the legislation on the X case and have done so for some time.
Last April legislation was presented to the Dail to bring in this law which I voted For. I believe this is twenty years overdue.
As recently as November 14th I raised the matter directly with Enda Kenny at the order of business in the Dail.
Here is a link to a statement I released yesterday following the tragic death of Savita which is a tragedy which should never have happened – http://www.patricknulty.ie/?p=1532
I also requested that the issue be debated in the Dail yesterday which forced the Minister for Health to come in and explain himself.
I believe that it is a disgrace that 20 years on this matter has not been addressed and is it is a fundamental issue of equality for women. I will do everything in my power to campaign for change on this crucial issue.
Patrick Nulty TD