‘This Deliberate and Systematic Practice’: How Doctors’ Religious Beliefs Impelled Ireland’s Forced Symphysiotomies

Symphysiotomy is an eighteenth-century birth operation that involves severing one of the three pelvic joints, the symphysis pubis, which fuses the two pubic bones to the front, thereby unhinging the woman’s pelvis.

Conclusions of UN Human Rights Committee in 2014

In 2014, the UN Human Rights Committee (HRC) concluded that this operation had been performed from 1944-1987 on 1,500 women in Ireland without their informed consent. The HRC called for ‘a prompt, independent and thorough investigation into cases of symphysiotomy’ and prosecution and punishment of ‘the perpetrators, including medical personnel’.

Ireland’s response

Ireland has repeatedly refused to accept that the doctors who performed these operations are perpetrators who should now be punished. In 2022, in preparation for its follow up examination under the Covenant of Civil and Political Rights, Ireland effectively informed the HRC that the courts had never found the surgery to be unjustified. This claim is inaccurate and untrue. In one of the only two symphysiotomy cases to have gone to full trial, Kearney v McQuillan, Ireland’s highest court found the performance of symphysiotomy in the aftermath of Caesarean section to be ‘deeply and fundamentally flawed’. It is difficult to believe that the State could have been unaware of this landmark decision.

The State appeared to set itself even further on a collision course with the HRC during its examination in Geneva last year, when the Committee was led to believe that these surgeries were mainly performed in a life-threatening emergency, therefore patient consent could not be obtained. This novel suggestion is without foundation. (In its fifth periodic report to the HRC responding to the Committee’s 2014 concluding observations, Ireland did not contest (CCPR/C/IRL/5) its conclusion that 1,500 symphysiotomies had been carried out in the absence of informed consent.) Hospital clinical reports, such as those of the International Missionary Training Hospital (IMTH), a private Catholic hospital under the control of a Catholic Archdiocese, attest to the fact that these operations were performed there as a matter of hospital policy. Symphysiotomy’s chief promoter, Dr Arthur Barry, then master of the National Maternity Hospital (NMH) (another private institution under the control of a Catholic Archdiocese), assured his colleagues that: ‘[i]t is easy to know when to do the operation [of symphysiotomy]: do it when [Caesarean] section would otherwise have been employed, but be even more generous in your application. Interfere early’. The vast majority of these operations were conducted during labour, because doctors relied on the downward pressure of the foetal head to further open the woman’s severed symphysis to ensure vaginal birth. Young, healthy women were selected for the surgery where there was a suspicion of cephalo-pelvic disproportion, a broad term that referenced a misfit between the baby’s head and the mother’s pelvis (through which the head must pass in vaginal birth). At the IMTH, symphysiotomy - not Caesarean section - was carried out routinely when attempts to deliver the baby by forceps or vacuum had failed. The pelvis severing procedure was also done systematically for difficult presentations, such as breech and brow.

Trespass and battery

Although patient consent was legally required at the time to any ‘elective’ or non-emergency surgery, the practice of symphysiotomy was coercive. Dr Barry’s view was that patient consent was unnecessary. Responding to a suggestion by a visiting professor that, if the patient understood she would still be in labour after the operation, she would not choose symphysiotomy over Caesarean section, the NMH master asserted: ‘surely it will be a sad day for obstetrics when we allow the patient to direct us as to the line of treatment which is best for the case’. Women have consistently reported that their informed consent to symphysiotomy was not elicited. This was accepted, in effect, in Kearney, where the operation was performed on an unconscious girl without her prior knowledge, as the Supreme Court accepted; and in Farrell v Ryan, where the surgery was also carried out on an unconscious woman without her prior knowledge, as the domestic courts found. A similar view was adopted by the ECtHR in 2020 in three symphysiotomy lead cases in LF v Ireland, WM v Ireland and KO’S v Ireland, although the Court was less clear cut in it view.

Failure to investigate

Ireland has repeatedly claimed that three independent inquiries have been undertaken, which it suggested preceded the three government commissioned reports on the issue: Professor Oonagh Walsh, Report on Symphysiotomy in Ireland: 1944-1984 (2014); Judge Yvonne Murphy, Independent Review of Issues relating to Symphysiotomy (2014); and Judge Maureen Harding Clark, The Surgical Symphysiotomy Ex Gratia Payment Scheme Report (2016). The State’s claim that there have been three independent investigations is deeply misleading. No effective investigation has been conducted into Ireland’s practice of forced symphysiotomies with the capacity to establish either individual violations or even the facts in general.

The Walsh report was initiated in such a way that it lacked independence in the view of UN human rights bodies, such as the HRC. The Commissioner for Human Rights of the Council of Europe also found that this report could not be considered as independent, ‘an important shortcoming given that the two ensuing Reports relied heavily on its findings’. The report’s terms of reference were settled between the Institute of Obstetricians and Gynaecologists and the Department of Health, both implicated in forced symphysiotomies. The Institute (and its predecessor, the Royal College of Obstetricians and Gynaecologists) accredited hospitals that were sites of symphysiotomy for training and its membership includes doctors who performed these operations. The Department of Health took no measures to halt these operations. The Walsh terms conferred no substantive powers, such as compellability of witnesses, and confined the report to published sources, which excluded from its scope relevant hospital records and survivor testimony and precluded the comprehensive establishment of the facts. Taken together, these restrictions resulted in a narrow, private review, which consisted mainly of material on symphysiotomy written by practitioners who tended to be proponents of the surgery.

The report concluded in the absence of any worthwhile evidence that symphysiotomy was ‘used in the majority of cases’ as ‘clinically appropriate’, on women who had been in labour for a long time, a supposed emergency that ignored the fact that symphysiotomy was to be performed when a woman’s labour was well advanced, and that, done in preference to Caesarean section, these pelvis severing operations could not have been ‘emergency’, because women were still in labour after them. 

Walsh also asserted that consent to medical interventions was not a legal requirement in Ireland during the relevant period, except in relation to mental health. This claim does not reflect the legal position at the time. During the relevant period, to perform a symphysiotomy in the absence of informed consent constituted trespass and battery in domestic law, breached women’s constitutional rights and violated applicable international law.

The Murphy review is primarily a cost-benefit analysis, to which three quarters of the heavily redacted text is devoted. The object was to determine whether the State’s financial interest would be better served by establishing a redress scheme or by defending the 172 legal actions then before the courts. The report recommended a redress scheme that, inter alia, excluded the families of deceased survivors, an issue raised by the HRC in 2022.

Notwithstanding the fact that the Harding Clark report was expected to confine itself to the administration of the payment scheme, a considerable amount of text was devoted to subjective commentary and selected, edited extracts on symphysiotomy, generally from old medical debates and hospital clinical reports, all of which generally justified the practice. Such an approach cannot be considered an investigation, as the State has claimed.

An ulterior purpose

Patient safety did not impel the practice. Proponents of symphysiotomy judged Caesarean section (and multiple Caesarean sections) to be safe: ‘the modern lower segment [Caesarean] section is a sound and safe operation’. However, if a woman was delivered by Caesarean section, subsequent children were more likely to be Caesarean deliveries and good practice was often seen to limit the number of such surgeries to three. Symphysiotomy was a method of ensuring vaginal birth not only in the index delivery but in future births. The object was to separate a woman’s pubic bones to ensure a permanent widening of her pelvis through the formation of scar tissue at the site of the wound. Catholic obstetricians repeatedly presented symphysiotomy as the moral alternative to Caesarean section, which was seen as leading to practices prohibited in Church law. At a world congress of Catholic doctors in Dublin in 1954, Dr Barry promoted the operation explicitly on religious grounds:

‘It is unnecessary to stress to Catholic doctors that the practices of contraception, sterilisation and therapeutic abortion are contrary to the moral law. But what we must all guard against … is the unwarranted and unnecessary employment of Caesarean section … If you must cut something, cut the symphysis.’

Conclusions of UN Human Rights Committee in 2022

The HRC rejected Ireland’s claim that symphysiotomy was done mainly in an emergency. In 2022, citing articles 2, 6–7 and 14 of the Covenant, the Committee reiterated its concern at the State’s ‘failure’ to recognise ‘the nature of the motivation of this deliberate and systematic practice, which was carried out ‘without women’s prior knowledge or informed consent’. The Committee called for a ‘prompt, independent and thorough criminal investigation into the consequences’ of symphysiotomy, and prosecution and punishment of ‘the perpetrators’.

Ireland is the only country in the world to have practised this dangerous birth operation as a preferred alternative to Caesarean section.

Marie O’Connor, Chairperson of Survivors of Symphysiotomy, author and health correspondent with the national broadcaster.