The woman at the centre of a controversial case involving rape, suicidality and a termination of pregnancy has had a traumatic first five months in Ireland.
When she came to this country, she said, she thought she could “forget suffering”. Within days of arriving here, at the end of March, she had a medical examination. At this appointment, she said, a nurse employed by the HSE told her that her constant nausea was “probably because of the pregnancy”. The woman reacted with horror. “I told them this was very difficult to bear . . . I felt it would be a reminder of what happened in my country.” At some stage in the two months before she arrived, she said, she had been raped by a man, or men, who also played a part in murdering people close to her.
She told her story to The Irish Times, in a coffee shop, on Monday morning. She appeared thin and very fragile, and she looked about four years younger than she is. She has no English and spoke in her own language about what has happened to her over the past four months.
At several points she had to be asked to repeat herself, as she is so softly spoken. But despite getting upset several times, and being offered the opportunity to stop, she told her story in full. She had asked, through a friend, to speak with a journalist.
She said she was referred to the Irish Family Planning Association (IFPA), which confirmed her pregnancy and told her she was eight weeks and four days pregnant. This was within the time frame to have an abortion, if she had been able to access one. Although she was extremely distressed about the pregnancy, she does not seem to have been suicidal at this point.
Limited rights
As she had no right to an abortion in the State, she would have to travel to obtain one. But her right to leave the State was limited. She would have to get visas from both the Republic and the UK. She would have to fill in application forms and gather a letter from the IFPA, an appointment letter from an abortion clinic, and passport photographs, as well as more than €150 for the visas. The process could take months.
As the weeks progressed she grew more anxious. By about 15 or 16 weeks, at a counselling session towards the end of May, she expressed suicidal thoughts so seriously that an IFPA counsellor contacted the HSE, to express serious concern for her welfare. She said that later that day she tried to take her life but was interrupted.
She was now eligible for assessment by a panel of three experts for a possible abortion to save her life under the provisions of the Protection of Life During Pregnancy Act. But she did not return to the IFPA, and the association reasonably believed she had come into the care of HSE psychiatric services. The next contact the IFPA had with her case was when the counsellor got a call from her hospital psychiatrist, eight weeks later.
In the intervening period, it appears, she was receiving no support. Fearful that her only family member in the State would find out that she was pregnant, she moved from her accommodation sometime in June. She appears to have been overwhelmed with despair at this stage.
In early July, through a family member in her home country, she contacted a man from her country who got information about her rights and told her to go to a GP. She was now 24 weeks pregnant.
She did as advised and was referred the same day to the hospital psychiatrist, who kept her in overnight. The following day she was seen by a gynaecologist. A scan was done. She said she was not told for a number of days of the results: that she was more than 24 weeks pregnant and, she was told, too far progressed for an abortion.
She began what appears to be the first of two hunger strikes during her more than three weeks in hospital. The first, which lasted four days, ended when she was told she would get an abortion. Some days later she was told the pregnancy would be delivered by Caesarean section.
“They said the pregnancy was too far. It was going to have to be a Caesarean section. They said wherever you go in the world, the United States, anywhere, at this point it has to be a Caesarean. I didn’t know. I was suffering through it all.”
The HSE moved at this point to get a High Court order to hydrate her.
She did not want a C-section but felt by this stage that she had no choice. She had the operation on August 6th, when she was just about 26 weeks pregnant. She had been in hospital for more than two weeks, during which time the infant’s prospects of survival outside the womb increased dramatically.
She was discharged seven days later. The premature baby remains in hospital, while its mother receives ongoing psychiatric treatment in the community.
Complex ethical issues
The Protection of Life During Pregnancy Act was introduced to address cases such this young woman’s. Clearly, however, she did not benefit from it when she was should have: at 16 weeks. And complex ethical and legal issues arise about treatment she received when she did come within its ambit, at 24 weeks.
The IFPA and other organisations have called for clear protocols on referring suicidal women into the care of an HSE psychiatrist. Only a GP can refer to a psychiatrist, but this assumes a woman in crisis has a GP. This crucial gap must be bridged. Draft Department of Health guidelines on implementing the new legislation do not address it.
At 24 weeks the woman was suicidal, and she was admitted to hospital immediately when she saw a psychiatrist. But her pregnancy continued for more than two weeks. Based on the information from the woman herself, there appears to have been a change of plan during these days, between an abortion and the surgery.
The balancing act required of the clinicians, between protecting the rights of the woman on the one hand and the unborn child on the other, must have been excruciating. They may have felt, with an eye to the legislation and ethical concerns, that an abortion at 24 weeks could be illegal, given that the foetus was on the cusp of viability.
The legislation is new and the guidelines remain unpublished. The HSE has begun a “fact-finding” exercise to report exactly what happened in this case. It said that “learnings” will be acted on. But must “learnings” come only after tragic cases such as this one?
Anatomy of a decision - Fiona Gartland on how the woman’s pregnancy progressed and how it could have been handled
Young woman’s account
February
The woman at the centre of the case is raped in her home country.
Eight weeks
She arrives in Ireland when she is eight weeks pregnant. Four days later she sees a public-health nurse – who tells her that she is pregnant. She is distressed and tells the nurse the pregnancy is "very difficult to bear".
She is referred to the Irish Family Planning Association (IFPA). She asks for an abortion and is given information about travelling to England for one. She is told it could take six weeks for the documents to be arranged. She attends hospital for a scan, which confirms gestation. She has a series of meetings through April and May with the IFPA.
15-16 weeks
At 15 or 16 weeks she is told that an abortion in England will cost ¤1,500 and that the association cannot help her financially. She tells staff she would rather die than continue with the pregnancy. It is her last meeting with an IFPA counsellor. The counsellor contacts the Health Service Executive to express extreme concern for her welfare. Later that day she attempts suicide, but is interrupted.
21 weeks
The woman moves from her accommodation when she is 21 weeks pregnant in the hope that she will get more help at a new location. She makes contact with a friend who helps her.
23 weeks
When she is 23 weeks pregnant a friend contacts a colleague for advice. He is told that she needs to see a GP and a psychiatrist to access a termination under the Protection of Life During Pregnancy Act.
24 weeks
At 24 weeks she sees a GP, who refers her to a hospital psychiatrist. The psychiatrist keeps her in overnight. She is referred to a gynaecologist at another
hospital.
25 weeks
Twenty-five weeks into her pregnancy she is assessed by a panel of experts. The two psychiatrists deem her suicidal and the obstetrician deems it too late for an abortion. She goes on hunger and thirst strike.
The HSE asks a court for a care order, so it can hydrate the woman.
About 26 weeks
The HSE returns to court on August 5th with a plan for her treatment, including a Caesarean section.
The woman agrees to have the section.
The baby is delivered shortly afterwards, at 25 weeks and six days, and is taken to intensive care.
One week later
The woman is discharged from hospital a week later and receives psychiatric care in the community. The baby remains in an incubator and is in the care of
the State.
Draft Department of Health guidelines
The draft guidelines come from a version of the Guidance Document for Health Professionals seen by The Irish Times. Prepared by the Department of Health in collaboration with a committee of medical and legal experts, it will offer guidance for health professionals when providing care for pregnant women with life-threatening conditions. It has not yet been published.
"If a health professional is of the opinion that the life of a pregnant woman might be at risk and he or she does not feel qualified to treat her, he or she would be expected to make urgent referral to an appropriate medical practitioner for further assessment."
"Women may also present to crisis pregnancy services, public health nurses, counsellors, social workers . . . Such services can refer her] to her GP or advise [her] to present at an emergency department."
"If a GP considers a pregnant woman's life to be at real and substantial risk from suicide, he or she should refer her urgently to the local consultant psychiatrist or a consultant obstetrician in an appropriate institution."
Decisions to certify as appropriate for termination "or otherwise should be reached expeditiously and communicated to the woman".
"In cases where the woman's condition does not satisfy the test criteria, one of the psychiatrists or the obstetrician shall inform the woman of their decision . . . The psychiatrist or obstetrician must inform the woman in writing of her right to apply for a formal medical review."
"If the unborn has reached viability and the woman's life is in danger, the best course of action may be deemed to be an early induction or Caesarean section . . . This medical procedure would not fall under the Act as it is not a medical procedure during which or as a result of which an unborn life is ended."
"Once delivered the medical staff should ensure the necessary care for the neonate in accordance with clinical guidelines and best practice."