Fact-check: arguments around health and access to abortion

While reading the submission made by Doctors for Life to the Citizens’ Assembly, I found myself becoming curious about some of the statements made. There are no footnotes and no detailed citations of research papers in this submission, so I was working on the few references given and what I can find myself.

Nevertheless, I think that these legal and medical examples of statements for which I can’t find a reference are worth examining in some detail, as they are perennial contentions in the debate around the Eighth Amendment. I am, of course, as a non-expert on the medical side of this, open to evidence-based correction; my commentary is on facts and statistics, and I am attributing no ill intent to the authors.

To that end, the following is informed by my own background in Irish and human rights law, and the research I  conducted into the statements I found puzzling. Block quotes are directly from the submission. Any mistakes in analysis are, clearly, my own – I am not a doctor and I have never been one. I am a legal researcher, a bit of a data-hound, and excessively nerdy. Be warned: the following contains a lot of referencing.

The “Eighth Amendment” refers to Article 40, 3 of the Irish Constitution, which reads as follows:

The provision in question is Article 40.3.3 of the Constitution.

The 8th Amendment is part of this world-leading care and provides an excellent framework for other countries to copy in their constitution,

Ireland is the only country in the world with a Constitutional provision on abortion. It has been in existence for 34 years. It has not been copied into the Constitutions of other countries. It is also not an excellent framework for anything: it is an inexact, unclear, blunt instrument of a law which took nearly a decade to be examined before our Constitutional Court and took three decades to be elaborated on via legislation. There is a difference between law that accords with one’s morality, and good law.

Ireland, out of 171 countries surveyed, is consistently ranked by the WHO (World Health Organisation) in the top five countries for women’s safety in pregnancy,. This has been the case for the past 25 years.

The Confidential Maternal Death Enquiry survey of Ireland published December 2016 (the most recent figures I can find) puts Ireland’s maternal death rate at 9.8/100,000 (deaths/”maternities”). This is higher, but not by a statistically significant margin, than the UK rate of 8.54/100,000. These figures, and further breakdown of the data, are available in accessible form here. These are both low rates, certainly, but the point is that data gathered and studied under the same conditions (CMDE is originally a UK study) shows no statistically significant difference in maternal mortality rates between a jurisdiction where abortion is almost entirely restricted, and one where it is not.

The Lancet’s Global Burden of Disease findings from 2015 put Ireland (using different measurement methods) at 4.7 maternal deaths/100,000 live births. This is higher than the Western Europe overall figure of 7.2/100,000, but comparable to other Western European figures for Austria (4.2), Denmark (4.2), Finland (3.8), Italy (4.2), and Sweden (4.4). I apologise for the need for academic access to that journal article.

The World Health Organisation figures from 2015 put Ireland’s maternal mortality ratio at 8/100,000 live births. This is globally very low (the source for those ‘Ireland leads the world’ claims – the comparison is to the whole world, not just other developed, wealthy countries) but again, congruent with other Western European rates and worse than some. Link is open-access, table you want is Annex 7 on page 51. The Association for Improvements in the Maternity Services, Ireland – which, full disclosure, is a pro-choice group, so I’m not leaning on them for evidence – adds more context on this figure here. In general: yes, Ireland is a safe country in which to be pregnant and give birth, but so is the rest of Western Europe, and it is far more likely that the commonality in all those cases lies in infrastructure and wealth, as opposed to a particular benefit due to the Eighth Amendment.

The World Bank points out that Ireland’s rate of 8/100,000 in 2015 (post-PLDPA) has actually fallen from 1990’s rate of 11/100,000. I don’t believe that the PLDPA has caused this, but it’s an interesting counterpoint to the argument that legalising abortion automatically correlates to increasing negative outcomes for pregnancy.

Constitutional democracy is based on the equal and inherent value of every human life and the equality of all before the law. Abortion denies the inherent dignity and worth of the unborn child and treats that child as someone who is unequal before the law.

Constitutional democracy is a system of government in which the citizens have input, via the electoral process, into the representatives and/or policies which will govern the jurisdiction, given a foundational set of legal principles. A referendum is an excellent example of constitutional democracy in action.

A foetus is unequal before the law because human rights, including a right to life, inhere in born persons. The Supreme Court of Ireland in Attorney General v X in 1992 stated that: “The right of the girl here is a right to a life in being; the right of the unborn is to a life contingent; contingent on survival in the womb until successful delivery.” (Paragraph 140). Even under the Eighth Amendment, a foetus is not considered the same as a child which is currently living.

once the principle is conceded that some human lives can be directly ended, what is to stop the targeting of other children?

The criminal law as it relates to murder, manslaughter, etc; the precepts of international law from the Geneva Conventions through the UN Conventions on Human Rights through the European Convention on Human Rights; the knowledge that there is no comparison between ending a pregnancy before the foetus can be in any way aware, and killing a child who can feel fear and distress.

Abortion is not a murder. If it must be termed as the ending of a life, it is an ending of that life contingent, the end of a potential to become. A foetus is not sentient. It can react to stimuli, in the same way as muscles involuntarily flinch or contract, but it does not have the neural capability to feel pain below the 24-week cutoff for most abortion regulation. There is also increasing evidence that the foetus remains in a sedated state at all points in the womb; it cannot feel fear, anger, or distress. (All of that via a Royal College of Obstetricians and Gynaecologists report from 2010.)

the termination of pregnancy for reasons of terminal illness or disability diagnosed in the infant prior to, or after, birth.

It is also important not to equate fatal foetal abnormality, a condition wherein a foetus has abnormal development to the point it where, to the best of medical knowledge, it will not reach term or will not be able to live after birth; terminal illness, a condition where a fatal condition is contracted or discovered in a living person; and disability, which is a condition which impairs but is not likely to be imminently fatal.

Peri-natal palliative care, for children with life limiting conditions…

This paragraph is cited as coming from “ACT 2009 (ACT- Association for children’s Palliative care: http://www.act.org.uk)”. Here are my findings on that citation:

  • firstly, ACT.org.uk is no longer a site – it redirects to togetherforshortlives.org.uk
  • the organisation in question is also called Together for Short Lives now, not ACT
  • at no point on the website does it give a definition for “peri-natal palliative care”, although it does give a definition for “palliative care”, which is the paragraph cited in the submission except without the word “peri-natal” at the start of it
  • TfSL do mention that palliative care can be provided from birth if needed
  • however, neither TfSL’s family resources nor professional resources talk about pregnancy or abortion (please point this out if I’m wrong here – I don’t have time to download all of them)

All of this would lead me to believe that TfSL make life better for families who decide to continue with a pregnancy following a foetal abnormality diagnosis of any level, but are not a group which is dedicated to trying to influence that decision and therefore do not lend weight to this argument.

This is the cornerstone of the argument around FFA and related diagnoses: if a family wants to continue the pregnancy, they should absolutely be allowed to and supported in every possible way in doing so. But if they do not, they should not be forced to. That’s it. The families of Terminations for Medical Reasons can speak to this more eloquently than I ever could.

For reference, in the UK, where a termination can be requested where there “a substantial risk that, if the child were born, it would suffer from such physical or mental abnormalities as to be seriously handicapped” – and which therefore goes further than a requirement of fatal abnormality diagnosis – the recommendations given by the RCOG include:

“5. All staff involved in the care of a woman or couple facing a possible termination of pregnancy must adopt a non-directive, non-judgemental and supportive approach (section 6).

6. It should not be assumed that, even in the presence of an obviously fatal fetal condition such as anencephaly, a woman will choose to have a termination. A decision to decline the offer of termination must be fully supported (section 6).”

We are repeatedly told that removing the 8th Amendment would have saved the life of Savita Halappanavar by enabling doctors to perform an abortion. This is not true.

The HIQA inquiry into the circumstances of Savita Happanaver’s death found that medical mismanagement of sepsis led to her death.

**Halappanavar.

The submission quotes from the HIQA report, which does indeed attribute her death to medical mismanagement of sepsis. It does not, however, quote the paragraph where part of this mismanagement is described:

“The Hospital had a guideline in place on the management of ‘Suspected sepsis and sepsis in obstetric care’. This guideline covered, throughout its stages of development, the clinical identification of sepsis. However, the guideline did not include an escalation/referral pathway to include clinical, legal and ethical guidance for staff at critical clinical points. The guideline also lacked information that enabled patient consultation and consent in respect of their treatment and associated interventions.” (emphasis mine)
Furthermore, no reference is made to the report into the incident commissioned and published by the HSE, and written by Sabaratnam Arulkumaran. Sir Arulkumaran is an obstetrician, a Professor Emeritus, a previous President of the British Medical Association and of the Royal College of Gynaecologists, and an expert in best practice in the area (and more accolades that Wikipedia catalogues but I don’t have space to).
His report states:
page 33:

“O&G Consultant 1 stated that the patient and her husband were emotional and upset when told that a miscarriage was inevitable. The consultant stated that the patient and her husband enquired about the possibility of using medication to induce miscarriage as they indicated that they did not want a protracted waiting time when the outcome of miscarriage, was inevitable. At interview, O&G Registrar doctor 2 stated that the plan was to check the fetal heart and that the patient had asked on the 23rd of October about termination.

O&G Consultant 1 stated that the patient and her husband were advised of Irish law in relation to this. At interview the consultant stated “Under Irish law, if there’s no evidence of risk to the life of the mother, our hands are tied so long as there’s a fetal heart”. The consultant stated that if risk to the mother was to increase a termination would have been possible, but that it would be based on actual risk and not a theoretical risk of infection “we can’t predict who is going to get an infection”.”
page 44, more than 24 hours later, patient already in septic shock:
“While it has not been documented in the clinical record, the patient’s consultant obstetrician/gynaecologist stated that (s)he discussed the management of the patient with another consultant obstetrician/gynaecologist (B) at a time between 13.00 hrs and 15.00 hrs. The patient’s consultant stated explaining to their colleague that the patient was very unwell, appeared septic and regardless of fetal heart, would the other consultant sign off (as a second consultant opinion) on the delivery and (s)he said they would. The patient’s consultant stated that if there was a fetal heart (s)he would get their consultant colleague (B) to put a note in the chart. The second consultant (B) confirmed to the investigation team at interview that (s)he agreed with the assessment of the patient’s consultant.”
page 69, on the causal factors of Savita’s death:

“Key Causal Factor 2:

Failure to offer all management options to a patient experiencing inevitable miscarriage of an early second trimester pregnancy where the risk to the mother increased with time from the time that membranes were ruptured…

This investigation is concerned with establishing in so far as is practicable the clinical circumstances in which a patient in hospital died in a tragic and untimely manner. The investigation team is satisifed that concerns about the law, whether clear or not, impacted on the exercise of clinical professional judgement.”

page 71:
“Fetal demise is certain in an inevitable miscarriage at 17 weeks where there is spontaneous rupture of the membranes and infection in the uterus. The risks to the mother can be reduced by expediting delivery… International best practice includes expediting delivery in this clinical situation of an inevitable miscarriage at 17 week with prolonged rupture of the membranes and infection in the uterus because of the risk to the mother if the pregnancy is allowed to continue…
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 investigation team emphasises that, in the legal context related to termination in Ireland, there is a need for increased vigilance in clinical assessment of the patient in relation to the risk of infection, especially, infection in the uterus as failure to offer termination of pregnancy directly increases these risks.”
page 73:

“The interpretation of the law related to lawful termination in Ireland, and particularly 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…”
page 74:

“Recommendation [to the HSE] 4b.

There is an immediate and urgent requirement for a clear statement of the legal context in which clinical professional judgement can be exercised in the best medical welfare interests of patients. There is a parallel immediate requirement for clear and precise national clinical guidelines to meaningfully assist the clinical professionals who have the responsibility, often in circumstance of rapid deterioration or emergency, as to how to exercise their clinical professional judgement in a particular case.
We recommend that the clinical professional community, health and social care regulators, and the Oireachtas consider the law including any necessary constitutional change and related administrative, legal and clinical guidelines in relation to the management of inevitable miscarriage in the early second trimester of a pregnancy…”
It is impossible to separate the clinical mismanagement from the chilling effect that the illegality of abortion procedures had on the doctors in question.
Onward to suicidal ideation in pregnancy and the psychological effects of abortion:
reference
(screengrab of original, highlight mine – but parentheses not)
Good question. The only places I’m seeing it cited are:
– anti-choice organisations’ websites
– Doctors for Life Ireland’s website
– some news outlets, but without referencing
The news outlets also tell me that the survey was sent to 302 psychiatrists, of whom 127 responded, and that it emanated from a doctor who is on record as being against abortion. I can’t find a write-up of the methodology, questions, responses, or review procedures in medical publications – does anyone know where it was published?

In fact the evidence is very much to the contrary: there is abundant evidence that abortion is harmful to the mothers mental health

Royal College of Obstetricians and Gynaecologists, The Care of Women Requesting Induced Abortion: Evidence-Based Clinical Guideline Number 7, 2011, page 45:

“RECOMMENDATION 5.13

Women with an unintended pregnancy should be informed that the evidence suggests that they are no more or less likely to suffer adverse psychological sequelae whether they have an abortion or continue with the pregnancy and have the baby.
RECOMMENDATION 5.14
Women with an unintended pregnancy and a past history of mental health problems should be advised that they may experience further problems whether they choose to have an abortion or to continue with the pregnancy.
The great majority of women who have abortions do not experience adverse psychological
sequelae. Two recent systematic reviews addressed the relationship between unintended pregnancy, abortion or childbirth and mental health; both concluded that abortion of an unintended pregnancy was no more likely to be associated with poor mental health outcomes than if the pregnancy continued…
A good-quality population-based cohort study, published in 2010, linked information from a number of Danish registries to explore rates of first-time psychiatric contact (inpatient admission or outpatient visit) for any type of mental disorder within the 12 months after the abortion or childbirth compared with the 9-month period preceding the event…
The relative risk of a psychiatric contact did not differ significantly after abortion compared with before abortion (P= 0.19) but did increase after childbirth compared with before childbirth (P < 0.001). The authors concluded that there is no evidence of an increased risk of mental disorders after a first-trimester induced abortion.
A systematic review on the mental health impact of induced abortion was undertaken in 2010 by the National Collaborating Centre for Mental Health in the UK… The review concluded that whether a woman with an unintended pregnancy opts for an abortion or continues the pregnancy, the mental health outcomes will be the same. For women who have a prior history of mental health problems, there is a higher likelihood of mental health problems following both abortion and birth.”
I also found this PubMed article reviewing studies around abortion and mental health risk, which found that the higher the quality of the design and implementation of a study, the less likely it was to find a link between abortion and suicide. You’ll need academic access, which I have, but the data are there.
Edit, 05/03: after reading the notes to the Doctors for Choice paper given at the Citizens’ Assembly, I find a 2015 paper by Gissler et al (the authors of “the Finnish studies” cited in the submission) which refutes the anti-choice use of their work. Paper is here and show that the increased risk of suicide after abortion is not statistically significant, as increased risk of other violent death such as homicide appear to show that there are common contextual causes for increased risk of suicide, and increased need to access abortion.
Really big content warning for rape in the next bit.

It is understandable to think that terminating the pregnancy, or having an abortion, would help to lessen suffering. However, abortion does not reverse the pregnancy, it kills the child…

To repeal the 8th amendment to facilitate those women who become pregnant as a result of a criminal act, such as rape or incest, to undergo an abortion would lead to abortion on demand, as has happened in numerous countries. One of the main reasons [a rape ground exception] leads to abortion on demand is because by the time the abortion takes place it is impossible to prove that a criminal act has taken place. The abortion in every case would have taken place before any criminal charges are upheld.

The length of time it takes to secure a rape conviction is not an argument against abortion. It’s an argument against a legal system that continues to victimise people who have already suffered a violation.I am finding it hard to formulate search queries which have any chance of answering this, so for a placeholder, let’s have some questions of my own:

Why should a survivor of rape be forced to give birth? Why should they suffer more than they already have?

Which countries have decided to forego abortion regulation following an experiment with entering a rape ground onto the books?

Did you know that the United Nations Committee on the Elimination of Discrimination Against Women called forcing a raped, pregnant 13-year-old to stay pregnant until she gave birth – she miscarried – before giving her medical treatment, a violation of her fundamental human rights?

Did you know that, committed in the context of war, rape and forced impregnation are crimes against humanity, and proscribed by the Statute of the International Criminal Court?

Irish women should be afforded the best of medical care and given treatments that benefit them in the long run. It is wrong to abandon them to a social ideology of “whatever you want, you can get “. Treatment should be based on sound medical evidence.

Yes, they should. There’s a reason I’ve been quoting doctors and professors and researchers all through this. The sound medical evidence is that abortion does not carry risks to psychological health. It’s that Savita died in part because her doctors were too worried about being scrutinised under the Offences Against the Person Act 1861 to perform a termination before she spontaneously miscarried when sepsis had set in. It’s that Ireland’s maternal mortality statistics are no more exceptional than those of most comparable, developed, Western European countries.

It’s that, in short, looking at unbiased clinical sources and best practice standards from across the world, I cannot find evidence against abortion.

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