We are a group of educators, midwives, midwifery students, families, birth activists, artists, and lawyers who have been directly impacted by maternal deaths in Ireland and who have deep concerns about our maternity services and the lack of reproductive justice for women. From 2014, the Elephant Collective began to shape art work for a series of exhibitions to commemorate the women who had lost their lives in Irish maternity services. We had already worked alongside the then TD
Clare Daly to gain an inquest for the Nigerian woman Bimbo Onanuga who died in the Rotunda Hospital in 2010. Now we sought to work with Clare Daly on gaining a law which would make mandatory inquests for all maternal deaths in Ireland.
In 2013 alone, families of four women who had died in our maternity services had fought for cases to be brought to the courts, three inquests and a High Court case. All four young, healthy women were
of black minority ethnic (BME) status: two Indian, one Malaysian, and one Nigerian.
At first as a private member’s bill introduced by Deputy Daly, and then as a government bill introduced by Frances FitzGerald when she was Minister for Justice, the Coroners (Amendment) 2019 Act was passed in full and enacted at the beginning of 2020. By then, the Elephant Collective had shown its exhibition fifteen times across Ireland, endeavouring to raise support for mandatory inquests and for vastly improved maternity services.
Between 2007 and 2021, thirteen inquests on maternal deaths have been held. There have been thirteen verdicts of medical misadventure, twelve from coroners’ courts and one contested verdict
settled by the High Court.
This is a staggering indictment of Ireland’s maternity services. Each inquest has given detailed insights into how the services are failing women and their families with tragic consequences.
Worse still, this burden of injury and death has been borne disproportionately by women of colour.
Of these 13 maternal death inquests, six women who died have been women of colour. All thirteen of these deaths were AVOIDABLE maternal deaths. This repeats a pattern which holds true across Europe and in the UK: pregnant women of colour are especially vulnerable.
The next two maternal death inquests here in Ireland also entail lives lost by two women of colour, Geraldine Yankeu from the Cameroon and Tatenda Mukwata from Zimbabwe. Their inquests will tilt
the numbers still further to eight of fifteen inquests.
Clare Daly MEP is hosting an Elephant Collective exhibition of our Picking Up the Threads Quilt with squares knitted by hundreds of people across Ireland and abroad along with portraits of the women
who have lost their lives in Brussels in the European Parliament at 6pm on the 24th January to draw attention to this matter: as indicated by our statistics and by data from elsewhere in Europe, women
of colour are especially at risk of dying.
There is a pressing need for strong policy and legal responses to this in Ireland and straight across the EU countries.
Here in Ireland, there continues to be a pattern of keeping reviews done by the hospital groups and the HSE out of the public eye during inquests. At the conclusion of Sally Rowlette’s inquest in
December 2014, the noted health policy analyst Dr Sara Burke, wrote in the national press:
‘The HSE’s only investigation into the death of Sally Rowlette did not identify the failures in the care she received.’
We urgently need the ethic of truth-telling to be at the core of all coronial proceedings to enable our maternity services to be truly safer.
Open disclosure at all levels of the administrative healthcare system and the judicial system is imperative to secure safer reproductive health care for all women.

In childbirth, women are uniquely reliant on best quality services. We, the public, have to make this happen. That is one message we want to send to back to Ireland from the Brussels event: that our coroners need to make full use of Section 24 of the Coroners (Amendment) 2019 Act and compel hospital groups and the HSE to release their reports in full to the coroners during inquests so that all is in full view of families and the public.
The second message will be to other EU countries:

• To pass legislation similar to ours for mandatory inquests for maternal deaths
• And to strengthen the care in their maternity services to reduce numbers of maternal deaths
  It is an absolute certainty that the migration of women from Poor World countries, displaced by war and unendurable social conditions will not diminish. They need far better maternity services, services which do not cost them their lives.
  Which is why mandatory inquests and full disclosure during the inquests are crucial interventions.
  Ayaz Hassan whose beautiful wife Nayyab Tariq died in Mayo University Hospital in March, 2020 (Nayyab’s inquest was held in September 2021 in Swinford and concluded with a verdict of medical misadventure) will speak in Brussels, as will Sean Rowlette. Sean, whose wife Sally died in Sligo Hospital in 2013, befriended Ayaz after his wife’s death and attended the Nayyab’s inquest in support of him. Clare Daly MEP, Frances FitzGerald MEP, Robert Biedroń, MEP chair of FEMM in the European Parliament, and Dr Jo Murphy-Lawless will also be speaking briefly.
  Dr Jo Murphy-Lawless, Joint Coordinator of the Elephant Collective, Research Fellow, Centre for
  Health Evaluation, University of Galway