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A history of symphysiotomy: the impact of Catholic ethics on Irish medicine

Extracts from a recent article by Jacqueline Morrissey published in History Ireland.

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AFTER CARRYING OUT years of research into the impact of Catholic ethics on Irish medical practice between 1922 and 1992, Jacqueline Morrissey wrote about symphysiotomies in the Irish Times in September 1999.

Thirteen years on, the reasons why the procedure – which involves the mother’s pelvis being broken during labour – was carried out on hundreds of pregnant women between 1944 and 1982.

Morrissey has looked at the background, questioning if Ireland’s Catholic ethos was the driving force behind the decisions taken by doctors at the National Maternity Hospital. Here are a selection of extracts from her piece ‘The murder of infants? Symphysiotomy in Ireland, 1944-66, republished with the kind permission of History Ireland.

“Symphysiotomy and why it had declined elsewhere: Symphysiotomy involved cutting the cartilage joining the two parts of the pelvis. It had largely been abandoned in the 20th century owing to its perceived dangers; CS was preferred. The after effects ofsymphysiotomy included bladder injuries and impaired locomotion. By the 1940s, surgical advances and the advent of antibiotics had made lower-section CS the operation of choice in the developed world for cases of disproportion and obstructed birth.”

The NMH was Ireland’s leading Catholic-identified maternity hospital. NMH doctors were motivated by the perceived need to avoid the practice, common among non-Catholic doctors in Britain and elsewhere, of recommending sterilisation to women after a third Caesarean section (CS). The resurrection of symphysiotomy was controversial; one British obstetrician, Chassar Moir, speaking at a Royal Academy of Medicine in Ireland meeting in 1951, called it the ‘murder of infants’. Despite the evidence of a high infant mortality rate and other problems, the NMH experiment lasted until 1966.

“Symphysiotomy was thought to permanently enlarge the pelvis, and therefore, when carried out in a first pregnancy, it might remove the necessity for a woman with ‘disproportion’ to face repeated CS in future pregnancies. This was a particular problem for Catholic doctors. Contraception was practised in most developed countries, making repeat problem pregnancies less common, and non-Catholic doctors advised sterilisation after three CS. Irish Catholic doctors were unable or unwilling to do this. They were aware of criticism by colleagues who believed that Catholic religious structures disadvantaged patients. ”

Dr Alex Spain, master of the NMH from 1942 to 1948, pioneered symphysiotomy as the operation of choice for mild to moderate disproportion in replacement of CS. His stated motivation was not based on concerns about the medical undesirability of repeated CS. In a defence of CS, particularly the relatively new ‘lower-segment’ variety, he argued that no arbitrary limits should be placed on its performance, nothing that he had himself performed a seventh such operation on a woman without ill effects. His concern was that such a method of delivery would not easily be accepted by the medical profession or the public, and that this would lead to the use of contraception or voluntary sterilisation.

“In 1951 Chassar Moir emphatically opposed the NMH use of symphysiotomy, arguing that women recovered better and faster from CS. He too, focused on the perceived higher infant mortality rate, asking: ‘Is it then your policy to sacrifice the firstborn baby, and to use its dead or dying body as nothing more than a battering ram to stretch its mother’s pelvis.’”

Between 1944 and 1966, the NMH performed 319 symphysiotomies for disproportion. Between 1950 and 1965 the Coombe performed 202. Kieran O’Driscoll became master of the NMH in 1963; instances of symphysiotomy at the NMH declined sharply thereafter and ceased in 1966. The Coombe followed a similar pattern. O’Driscoll, who had previously voiced reservations about symphysiotomy, declared himself against it, as practised in the NMH….Reflecting changing Irish sexual mores, O’Driscoll introduced family planning talks and instruction in ‘natural’ methods of contraception, despite strong opposition from Drs Barry and de Valera.

“While symphysiotomy as an operation of choice for disproportion was abandoned in the NMH and Coombe, no final, disinterested assessment of it was ever produced. The NMH and the Coombe were teaching hospitals, their students dispersed elsewhere once trained. This, and the inconclusive manner in which symphysiotomy was dropped in Dublin, may partly explain its continued use in some Irish hospitals until as late as 1982.”

Conclusion: Irish doctors were strongly motivated to seek an alternative to CS in disproportion cases. The Irish state gave legislative force to Catholic teachings on reproductive matters. Catholicism was the religion of the majority and had institutional power. The conservatism of Irish doctors regarding contraception was, however, increasingly out of line with the trend in Ireland, and with mainstream developments within the Catholic Church.

“Irish doctors’ acceptance of an increased foetal death toll in those pregnancies for which they performed symphysiotomy in order to avoid CS in hypothetical future pregnancies was ethically dubious.

The impact of the NMH’s experiment reverberated throughout the Irish hospital system until 1982. Many Irish women are still living with the consequences.

Read more in History Ireland>

Interview: ‘I didn’t know if my baby was dead or alive for two days’

More: Symphysiotomy survivors gather to recount stories of torture>

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