This is why abortion-care is healthcare

The year is 2016. Angela (not her real name) is in the labour and delivery suite at Mater Dei Hospital. Her baby just died. She was one hour old. She suffocated to death because her lungs had not developed. Why? Because her heartbroken mother’s waters broke four weeks before, at 19 weeks of pregnancy. Unexpectedly. Once all the fluid drained out, the foetus had no liquid to swallow and pee out. Her lungs remained small and undeveloped so she couldn’t breathe well once she was born. The technical name for this is hypoplastic lungs, in case you want to look it up.

Can you imagine what it feels like to be Angela, and the many other women who have been in the same situation? Imagine being pregnant and knowing your baby will die. Imagine knowing that you have to wait several weeks until you spontaneously go into labour, or you are induced at 36 weeks. Imagine knowing that while you wait, you are susceptible to developing a severe infection, called chorioamnionitis. Imagine knowing you could die from that infection, and that nothing can be done, until you are literally a step away from death, all because the foetus that is inside you, who will die soon after birth, still has a heart beat.

Imagine the harm to your mental health, possibly your physical health and, indeed, your life, all because the doctors looking after you refused to give you all the options. They know that preterm premature rupture of membranes (PPROM) is a dangerous situation for both you and the foetus. They know there is a risk the foetus’ growth will slow down, as indeed it did in Angela’s case. They know that the chance of the foetus being born alive is very very small, and that the foetus, once delivered, will live only a short time and then die. And all the while, you are hoping that you don’t develop a life threatening infection.

Both in Malta and in most other countries, if the membranes rupture between 24 and 37 weeks, doctors will generally follow a watchful waiting approach by giving the woman antibiotics and steroids that help the foetus develop. After 37 weeks, the treatment is usually induction of labour.

But when the waters break before 24 weeks, which is before viability, the prognosis for the foetus is usually poor. Survival is extremely rare if the membranes rupture before 21 weeks. This is why abroad women are offered a choice of either watchful waiting or a termination of pregnancy (abortion).

However, because in Malta there are no exceptions to the blanket ban on abortion, a doctor who terminates a pregnancy before 24 weeks (and so, before a foetus can survive outside the womb), would be commiting a crime.

Although abortion is illegal in Malta, that should never stop a medical doctor from referring women who wish to end their pregnancy, for whatever reason, onwards to other countries where this is legally possible. Why did this not happen in Angela’s case? Because doctors in Malta are hampered by the law which states they cannot offer an abortion even when they know that the outcome is inevitable.

This is why doctors in Malta adopt a watchful waiting approach in pre-viable cases of premature rupture of membranes, even if the chances of survival for the foetus are almost non-existent.

To make matters even worse, continuing the pregnancy in these cases increases significantly the risk of infection (sepsis), which can be fatal to the pregnant woman, as happened not too long ago to Savita Halappanavar in Ireland. She asked to have an abortion because she did not want to continue with her risky pregnancy, but the request was declined because the foetus was still alive at the time.  Unfortunately, Savita developed an infection because of her complicated pregnancy and sadly passed away a few days later. This could have happened to Angela too!

Then there is the issue of so-called fatal foetal anomalies. There were 4555 births in 2016, and that same year there were nine foetal deaths from neural tube defects, anencephaly (which is a condition where the foetus’ skull does not develop so the brain is exposed and there is no chance of survival at all), or various types of congenital heart diseases. According to the Malta Congenital Anomalies Register between 1993 and 2016, there were some 170 foetal deaths due to severe congenital and/or chromosomal anomalies. For some reason, these data have not been updated since 2016. COVID struck Malta in early 2020, so goodness knows why the delay in reporting more recent foetal deaths. Perhaps our health department would rather we did not know quite how many of them there actually are every year.

Some of these deaths were preventable. For example, we know that taking folic acid before and during the first three months of pregnancy can reduce the risk of neural tube defects. Fortunately, most serious conditions are now detectable in pregnancy using sophisticated ultrasound. Sadly however, whatever the diagnosis, even if 100% fatal, the doctors looking after these women will not offer them the choice of travelling abroad to end the pregnancy, should they so wish.

I cannot understand the reluctance to mention the option of ending the pregnancy abroad. This is not against the law, provided it is carried out in a country where the procedure is itself legal. In my view, failing to offer this option is effectively a dereliction of the duty of care. Why not explain the options, explain why you cannot carry out abortions in Malta, but offer to provide all the information they would need to obtain an abortion abroad? It is actually as simple as giving these women the telephone number of the Abortion Support Network (+356 27780991) who will provide unbiased and non-judgemental advice on travelling for an abortion, as well as financial assistance towards the costs, if needed.

I respect the conscience of those who oppose abortion on moral grounds but I do not believe they have the right to deprive other women of this option.

So, if your foetus has been diagnosed with a fatal foetal anomaly or your membranes have ruptured before 24 weeks and you want to discuss your options, including the option of abortion, contact our Family Planning Advisory Service on 2778 0037 or www.fpas.mt for advice on what can be done and what risks are involved. We are here to help.