Comment & Analysis

When what isn’t said is more important than what is
False caricatures around care in pregnancy contribute nothing to a reasonable debate, writes David Mullins

David Mullins

Dr Rhona Mahony is Master of Dublin’s National Maternity Hospital at Holles Street. She is a vocal critic of the Eighth Amendment to the Irish Constitution which protects the right to life of unborn children. She has spoken frequently about how the amendment affects her work and the work of other medics dealing with pregnancy.

In an interview with Pat Kenny on Newstalk, Mr Kenny asked Dr Mahony to elaborate on how the Eighth Amendment impacts on her life and the lives of her staff in the hospital. Almost immediately, Dr Mahony went on to cite as an example the case of a pregnant mother presenting at 14 weeks with ruptured membranes, where the waters around the child have broken.

“Now,” she said, “the chances of that baby being born well are tiny and very slim, but there is a significant risk that she (the mother) will develop chorioamnionitis…now…we are charged with waiting until she develops that infection before we can do anything. We are making that decision to deliver her in the context of a custodial sentence of 14 years,” Dr Mahony said.

Analysis

There are several issues here that require further analysis. As a clinician working within the Health Service Executive (HSE), Dr Mahony will be aware of the guidance document that was issued in 2013 by the Institute of Obstetricians and Gynaecologists and the HSE Directorate of Strategy and Clinical Care, Preterm Prelabour Rupture of Membranes (PPROM) which was revised in 2015.

The provisions of that guidance document seem at odds with Dr Mahony’s stark claim that “we are charged with waiting until she develops that infection before we can do anything”.

Indeed, the document specifically alerts clinicians to the fact that women with PPROM are at increased risk of infection and that if there is any clinical evidence of chorioamnionitis or maternal sepsis, a septic work-up should be obtained and broad-spectrum intravenous antibiotics commenced immediately.

This is very far from the image conjured up by Dr Mahony of the Eighth Amendment forcing clinicians to sit on their hands until the mother becomes unwell.

The document also acknowledges those studies that have demonstrated benefits in conservative management for gestations of less than 34 weeks, while also acknowledging that the management of pregnancies complicated by PPROM between 34 and 37 weeks continues to be a contentious issue.

We may well ask why Dr Mahony didn’t mention the crucial, positive role of antibiotics in a post-membrane rupture scenario, and instead the impression was that only a termination of pregnancy would suffice. Perhaps if Dr Mahony had been given time or if she had been pressed to elaborate she might have referred us to the 2010 analysis of Preterm Pre-labour Rupture of Membranes by the Royal College of Obstetricians and Gynaecologists.

That analysis published the outcomes of 22 trials involving over 6,000 women with PPROM before 37 weeks of gestation. This study demonstrated:

1. Use of antibiotics following PPROM is associated with a statistically significant reduction in chorioamnionitis;

2. Neonatal infection was also significantly reduced in the babies whose mothers received antibiotics;

3. There was also a significant reduction in the number of babies with an abnormal cerebral ultrasound scan prior to discharge from hospital;

4. There was no significant reduction in perinatal mortality, although there was a trend for reduction in the treatment group.

Dr Mahony might well reply that she specifically gave the example of the mother presenting at 14 weeks with a ruptured membrane and that positive outcomes are more pertinent to later gestational ages.

Yet, a 2009 review in the European Journal of Obstetrics & Gynaecology and Reproductive Biology clearly refers to a study of 53 mothers presenting with PPROM between 14–28 weeks with perinatal survival rates: as follows:

  • 14–19 weeks: 40%
  • 20–25 weeks: 92%
  • 26–28 weeks: 100%

It also shows that perinatal survival of second-trimester PPROM was better than previously thought.

In light of this information, and in the presence of clear HSE health care protocols in both scenarios of pre- and post-diagnosis of PPROM, we are left to ask why Dr Mahony did not refer to this research and once again left the impression that the Eighth Amendment as a barrier to the application of appropriate healthcare.

It is also not correct for Dr Mahony to make the claim that clinicians are making the decision in the context of a custodial sentence of 14 years. Let us return again to the guidance document that was issued in 2013 and revised in 2015 by the Institute of Obstetricians and Gynaecologists and the HSE Directorate of Strategy and Clinical Care.

Number seven in the list of 14 key recommendations contained in that document clearly states that “women with clinical signs of chorioamnionitis should be commenced on broad-spectrum intravenous antibiotics and delivery should be undertaken”.

Is Dr Mahony therefore claiming that the Institute of Obstetricians and Gynaecologists and the HSE directorate deliberately recommended that doctors place themselves in a position where a custodial sentence is likely? Or is it more likely that they were aware when drafting it that nothing – either legally or constitutionally – prevents doctors from responding appropriately when there is a threat of chorioamnionitis developing and even if the action adversely impacts the child?

There are serious questions to be asked about why Dr Mahony framed the issue in the manner in which she did and just why the Eighth Amendment was targeted by her as some kind of ominous shadow threatening the liberty of doctors and the lives of women when there is plenty of evidence to suggest that this is far from being the case.

 

David Mullins is a bioethics commentator who did his postgraduate work on Catholic bioethics at the Pontifical University, Maynooth.