Book Review by Felicity Allen
Kitty Holland: Savita: the tragedy that shook a nation, Transworld Ireland, 2013 ISBN: 9781848271838 RRP: €14.99
Following the controversy generated by the tragic death of Savita Halappanavar and the subsequent change to the Irish constitution, Kitty Holland has told the story of Savita’s life within the background of her own distinctive culture. Savita and her family followed a form of Hinduism called Lingayat – founded on tolerance and the rejection of inequality between humans. The aim of followers of Lingayat is to attain dignity, honesty and meaning through the way they live their lives. Through the terrible details of her final days, it’s clear that both Savita and her husband Praveen strove to do just that.
The story interweaves the medical observations of Savita’s inexorable decline with the cultural and religious prohibitions of the Galway University Hospital as an institution within Irish Catholic society. Although it had been planned and wanted by the couple, there were early signs that the pregnancy was a difficult one; persistent backache and loss of fluid, probably due to an infection acquired in the community. When Savita first sought help from the Hospital, it was very clear that the pregnancy was in trouble and she initially met with considerable kindness: ‘Once the midwife put Savita on the bed she held her hand and said she was very sorry,’ says Praveen (p 15). Unfortunately Savita needed more than kindness: she needed a prompt intervention to terminate her failing 17 week pregnancy. Her medical records show that when she first entered the hospital she already had one clear sign of infection; tachycardia (rapid heart beat). Combined with a rupture of the membranes, that should have indicated to the staff the need for action. Had the Modified Early Obstetric Warning System (MEOWS) been used in this hospital, she would have been immediately flagged as a serious case, but unfortunately the inquest was to reveal that it was not in use. Over the next few days she and her husband repeatedly asked for a termination in vain and were famously told by midwife Anna Burke ‘It’s a Catholic thing. We don’t do it here’ (p 17). It’s to Holland’s credit that she resists the temptation to represent this comment as a flip justification and shows it for what it was: a well-meant effort from a kindly woman to explain what was happening to a patient from another country.
As the story of delay, incompetence, poor communication between staff, missing test results, uninterpreted blood counts and inadequate monitoring of vital signs (blood pressure, pulse and temperature) unfolds, it’s hard to avoid the suspicion that the hospital staff were hoping to be saved from the awful dilemma of choosing to save either the mother or the baby by the miraculous intervention of a spontaneous miscarriage. Unfortunately, foetuses compromised by infection are more likely to require active intervention to end the pregnancy without the death of the mother than are foetuses whose development is impaired. Once the staff realised that spontaneous miscarriage was not going to happen, it was too late to act effectively and both lives were lost where one might have been saved. Holland contextualises the Halapannavars’ suffering against a background of judicial rulings against both contraception and abortion during the 1980s, but especially the eighth amendment to the Irish Constitution (1983) which reads:
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.
This amendment simply ignores the situations, rare but very real, when a choice must be made between the two lives even today. Classic examples of these ‘one or the other’ choice points in a pregnancy include: an infection compromising the foetus and possibly entering the maternal bloodstream (as happened with Savita); pre-eclampsia – when rapidly rising blood pressure can kill the mother unless the foetus is delivered; and ectopic pregnancy – when the foetus is not growing in the normal place. Other possibilities include the need for treatments, such as cancer treatment, which would be highly dangerous for the foetus, while possibly life-saving for the mother. In all of these situations, waiting until the mother is in real danger of her life, makes it very likely that she will lose that life. For the next nine years after the eighth amendment was passed, hundreds – possibly thousands of Irish women who could afford to do so – went abroad for abortions. Many of these would have been on grounds other than a threat to the life of the mother. Although this Irish solution to an Irish problem is essentially an open secret, nothing is ever done about it and the fiction that there is no abortion in Irish society is maintained by the device of outsourcing it to the surrounding societies of England, France and even Spain. The eighth amendment was not publicly challenged until the notorious X case of 1992. In this case, a 14 year old girl, pregnant as a result of rape had already gone to England to have an abortion. Her family contacted the Gardaí and asked whether they should preserve some tissue as evidence in the rape case, prompting a demand that they return to Ireland and an attempt to force Ms X to have the baby. This failed when she became suicidal and was allowed to return to England and go through with the abortion. Twenty years later, this case remained highly controversial and no government had attempted to clarify the legislation on the relative rights of the mother and the foetus. As a result, the Galway University Hospital staff were left without any clear guidance to follow when Savita walked through their doors carrying a wanted but unviable foetus and a potentially deadly infection.
Following his wife’s death, Praveen gave interviews on RTE which sparked large rallies for and against abortion. Holland has researched the views of all sides of the polarised debate with care and represents them fairly. She acknowledges that much opposition to more liberal abortion laws in Ireland proceeds from a deep concern for the rights of the unborn. She does, however, raise a point which no other commentator has ever made: the issue of overseas influence on the Irish abortion debates. In these days of Email and Twitter, it’s possible to trace the origins of the messages. For example, the Pro-Life Campaign of November, 2012 had 70% of its followers based in America and only 10% in Ireland. Unfortunately, it was not possible to trace the funding sources in the same way, but this does make the reader wonder about the extent of foreign influences on the laws of a sovereign nation. Holland gives an extensive account of the findings of the longest inquest in the history of the State and shows the importance of Praveen’s calm and stoic presence during the woeful tale of his wife’s unnecessary death. Expert testimony was called and confirmed that only prompt action when Savita first presented for care would have saved her life. While there were certainly serious errors made in her medical treatment, the over-riding issue that killed her was the doctors’ unwillingness to terminate the pregnancy. Midwife Burke was summoned to account for her explanation about the influence of Catholicism, but Praveen and Savita’s family were very grateful both for her kindness at the time and her willingness to admit publicly that she had indeed said that. By contrast, some of the doctors flatly denied discussing the possibility of an abortion with the couple, although there were witnesses to these discussions. Praveen was to sum up the revelations of the inquest by saying ‘you lose your rights basically when you are pregnant here, I think’ (p 219). Following the inquest there was enormous pressure on the Dáil to prevent any repetition of the tragedy by clarifying the law. Holland describes the efforts of the anti-abortion lobby to prevent this, partly by spreading misleading accounts of how abortions are performed and partly by lobbying TDs so forcefully that many felt threatened and some did receive direct threats to their lives. Threatening to kill people or to attack their families seems a strange way to indicate a respect for human life, but several TDs reported receiving just such threats. The pressure on Taoiseach Enda Kenny was particularly intense and he reported:
I’m getting medals, scapulars, plastic foetuses, letters written in blood, telephone calls all over the system and it’s not confined to me. (p 251-2).
Ultimately the Protection of Life During Pregnancy Bill was passed by 127 votes to 31 on 12 July, 2013. While this does give some clarity to doctors in these desperate situations, it is by no means clear that it would have saved Savita’s life. A well written account of a highly contentious period in Irish history.