Group-think in Irish maternity hospitals


SECOND OPINION:Was the practice of symphysiotomy in Ireland an example of ‘group-think’?

IRVING JANIS described the symptoms of ‘group-think’ as an unquestioning belief in the expertise of a particular group of people, closed-mindedness, and stereotyping anyone who opposes the group views as stupid, biased or ill-informed.

Was the practice of symphysiotomy in Ireland an example of ‘group-think’?

Group-think was, and still is, part of the culture in Irish maternity hospitals. The new draft report on Symphysiotomy in Ireland, 1944-1984 underlines this group-think culture. The report was compiled from printed sources only, including hospital records and a literature review.

The author, Dr Oonagh Walsh, argues that concentrating on printed sources is central to the production of “an independent report . . . free from influence from either proponents of the procedure or opponents of it”.

Unfortunately, whatever her intention, the report is heavily influenced by the opinions of obstetricians. The literature review is based almost exclusively on research articles from medical journals. Selection bias in collecting information is an example of group-think.

Where is the evidence from the women, their partners, sociologists, midwives, physiotherapists, psychologists and other professional or voluntary groups who have published reports?

Bodily Harm: Symphysiotomy and Pubiotomy in Ireland 1944-1992, written by Marie O’Connor, was not used as evidence of the effects of the procedure on women’s lives.

Walsh cites only medical research. In 1955 the master of the Coombe hospital published a study of 50 women who had undergone the procedure and this research is cited in the Walsh report in great detail whereas O’Connor’s is not, although Walsh concedes that “some women have suffered adverse effects”. The overall impression is that the effects were not that bad and not any worse than often happens after a normal birth.

The Walsh report maximises the expertise of obstetricians and minimises the risks associated with symphysiotomies by giving only the 1952 Rotunda hospital mortality figures in the short version of the report. In that year, of 201 Caesarean sections carried out in the hospital there were 34 foetal deaths, and with seven symphysiotomies there were no foetal deaths. This gives the impression that it was a very safe procedure and not used as a substitute for Caesarean section.

The figures for the National Maternity Hospital for the same year, and given in the full report, tell a different story. That year there were 28 symphysiotomies with five foetal deaths and 67 Caesarean sections also with five foetal deaths. In addition, maternal mortality figures for 2005, “the lowest in the world” are used to illustrate Ireland’s “wonderful” maternity services instead of the more recent 2009 figures which show Ireland is actually ranked 14th among 22 EU countries. Overestimating the quality of services is a sign of group-think.

The piece on malnutrition is the most insightful part of the report but is not reflected in the findings. Many working class Irish women were undernourished in those years and this affected their ability to give birth safely. The Walsh report gives the impression that obstetricians did the best they could in difficult circumstances and they are not criticised for using surgical procedures to address health inequalities. Symphysiotomy was not, and is never, the answer to deprivation. Rationalising bad practice is another sign of group-think.

The Walsh report does not even consider the fact that obstetricians might be the problem. Fooling ourselves that the birthing process is safer for women when doctors are in charge is the ultimate example of group-think.

The vast majority of women are able to give birth without surgical intervention so doctors are redundant except in about 10 to 15 per cent of cases. Obstetricians spent the 20th century inventing surgical and mechanical ways of interfering with a natural process to ensure they were not redundant.

The truth is that symphysiotomies were the product of a consultant controlled and highly interventionist childbirth culture which still exists in Ireland today. A midwife is all most women need and the HSE will save millions of euro by immediately implementing midwife-led services.

Dr Jacky Jones is a former regional manager of health promotion with the HSE