Midwifery of darker times

 

The need to oppose those who argued for contraception or sterilisation dominated the thinking of leading Catholic obstetricians in Ireland of the 1940s and 1950s. In the mindset of the times, it was desirable that all married women should be facilitated and encouraged to reproduce repeatedly.

It was in this climate that doctors of the National Maternity Hospital (NMH) in Dublin tried to establish an operation known as symphysiotomy as an alternative to Caesarean sections. The doctors' motivation was clearly religious rather than medical, and the performance of this operation from the mid-1940s until 1965 drew horrified criticism from prominent British obstetricians, one of whom commented: "This is a midwifery of darker times. This is the murder of infants." Symphysiotomy was an operation which involved cutting through the fibro-cartilaginous junction of the two pubic bones to facilitate births in which the mother's pelvis was too narrow to permit a normal delivery, a problem termed "disproportion". Dr Moira Woods today more graphically describes it as an operation which permits the bony pelvis to "open like a hinge".

The procedure had a fearsome reputation in obstetrics, and its usage then in the West, as now, was confined to rare emergencies. But following a lead set by certain Latin-American doctors, Irish obstetricians sought to establish this operation as standard procedure for cases of mild to moderate disproportion, as an alternative to Caesarean section. Their reasons for this were that women subjected to repeated Caesarean sections might be tempted to use contraception, and that it was the custom in many countries to offer sterilisation to women after a third Caesarean section operation. Performance of symphysiotomy in a first pregnancy often resulted in a permanent widening of the pelvic region. Therefore, it was argued, no future Caesarean sections would be required by the patient, and neither they nor their doctors would be tempted to resort to contraception or sterilisation.

Trenchant criticism of the procedure came from a visiting speaker to the Royal Academy of Medicine in Ireland on Dublin's Kildare Street, Prof Chassar Moir of Oxford. "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 s mother's pelvis in the hope that subsequent brothers and sisters may thereby have (possibly) an easier entrance into this world?" he asked.

The doctors who wanted to perform sympysiotomies did not argue that repeated Caesarean sections were unsafe. Indeed, Dr Alex Spain, the major proponent of symphysiotomy, noted that he had performed a seventh Caesarean section on a patient without ill-effect, but went on to comment: "It will, however, be a long time before such a method of delivery will be easily accepted by the profession or by the community at large. The results will be contraception, the mutilating operation of sterilisation and marital difficulty."

The performance of symphysiotomy began cautiously under Dr Spain's mastership of the NMH. In 1944, four such operations were performed. By the end of his term as master in 1948, Spain had performed 43. In his final annual report for the hospital, he looked forward to a greater use of the procedure, adding: "That I have not employed it more frequently is due to the fact that it was an entirely new procedure to me and one that has to be faced against the weight of the entire English-speaking obstetrical world."

His successor lived up to expectation. The years of Dr Arthur Barry's mastership witnessed a dramatic increase in the number of symphysiotomy operations performed. By the end of his term of office, in 1955, Dr Barry noted that the hospital had performed 165 symphysiotomies in seven years. In addition, the Coombe hospital had also adopted the procedure.

Throughout this period, visiting obstetricians from Britain and doctors based at the Rotunda Hospital had queried the practice. Particular concern focused on the fate of the infants.

At a 1950 meeting of the Royal Academy of Medicine's obstetrics section, visiting speaker Prof T.N. Jeffcoate of the University of Liverpool pointed out that in many of the cases described the babies were already distressed by the time of the operation, and that Caesarean section would have offered certain and immediate relief to these. He noted that one baby was lost and several others were born in a state of severe asphyxia. He commented: "Bearing in mind the foetal risk, the account of the cases leave the reader horrified at the courage of the obstetrician."

Defence of the operation centred largely on the Catholic ethical position regarding contraception and abortion. Some figures were offered, to show that women who had had a previous symphysiotomy were able to have normal subsequent deliveries.

Prof Jeffcoate, however, pointed out that this was also true of a number of women upon whom Caesarean section had been performed previously. He considered the statistical data upon which the NMH was working to be too small to permit reliable conclusions, and called for more analysis of later births, both to those who had had symphysiotomies and those who had undergone Caesarean sections.

It was the following year that Prof Moir of Oxford voiced his criticism, focusing on three cases, two of which had resulted in the death of the child. One of these was openly admitted to have been done as a test, as it involved a case of gross disproportion. Symphysiotomy had only been promoted for cases of mild to moderate disproportion up to this point.

In the hospital report of this case, Dr Barry said: "It was decided to submit the operation of symphysiotomy to as severe a test as possible. The symphysis was therefore divided and, although the head seemed to enter, much remained above the brim. Twenty-four hours later the head had descended almost to the level of the spines, but despite good contractions there was no advance. Profound foetal distress developed and lower segment Caesarean section was performed immediately. The head was deeply impacted in the pelvis and great difficulty was experienced in extracting the baby, which could not be revived."

The same year, Dr O'Donel Browne, master of the Rotunda, said that the lower segment Caesarean section, if compared with an equally large number of symphysiotomy deliveries, would result in a lower foetal and maternal loss and damage rate.

Over the years, the NMH's annual reports described the application of the operation, and the foetal deaths and injuries which accompanied it. In his final report, Dr Barry said that, of the 165 symphysiotomies he had performed, he believed 12 infant losses were directly attributable to the operation. Elsewhere, he urged people to focus on the long-term benefits of the policy.

Another supporter of the operation, Dr Kevin Feeney of the Coombe, summarised this thinking when he said, in the Coombe Hospital annual report for 1953: "The real harvest of symphysiotomy is reaped in subsequent deliveries."

There was though, even then, another way of looking at things. Dr O'Donel Browne of the Rotunda, speaking in a broader context regarding first births, said: "Our duty as obstetricians is to get a 100 per cent result, for the child is not ours and it may well be that the mother may never have another pregnancy. You cannot forecast what is going to be the outcome on the next pregnancy, and you must counter your enthusiasm with humanitarianism." Coming from a Protestant doctor, this might be seen as an example of what later came to be termed a "contraceptive mentality".

By the early 1960s, with two of the major maternity hospitals of Dublin converted to symphysiotomy, its future in Irish obstetrics seemed secure. However, this did not prove to be the case.

During 1963, Dr Kieran O'Driscoll took over the mastership of the NMH. The following year, only five symphysiotomies were performed, the year after that, two. This was the result of Dr O'Driscoll's application of scientific research principles to the matter.

Disproportion was known to be difficult to diagnose accurately. Dr O'Driscoll noted that objective standards were required to estimate the real incidence of the condition. His study of 1,506 first births delivered in the NMH in 1966 provided this objective standard. Of these he noted that disproportion was diagnosed four times. None was considered suitable for symphysiotomy. He pointed out that if the hospital was merely failing to correctly diagnose the condition, then the incidence of cases involving damage to the infant's head, or rupture of the mother's uterus, should have risen. This did not happen. His conclusion was that disproportion was a rare complication in Ireland - "a mote in the eye of the obstetrician", as he put it in a contribution to a Royal Academy meeting in 1966.

This conclusion led to the rapid abandonment of symphysiotomy as an operation of choice in the NMH. The Coombe followed suit. If Dr O'Driscoll was correct, it would seem that, in their crusading enthusiasm, Irish doctors had drastically overestimated the numbers of women suffering from disproportion, and had performed large numbers of unnecessary operations, sometimes with tragic results.

Jacqueline Morrissey is an associate lecturer with the Open University. This research is work in progress for a PhD on the influence of Catholic ethics on Irish medicine