“I’ll never forget the pain I went through. I was screaming and being restrained..."

“I just remember being brought into a [operating] theatre... packed with people. I wasn’t told what was happening. I was given a local anaesthetic. Then, two nurses put my hands behind my head, and two doctors pulled my legs apart...I’ll never forget the pain I went through. I was screaming and being restrained. I couldn’t see much except for them sawing. It was excruciating pain...”

"...the last thing I remember was my feet being pulled up into the stirrups and I don't remember anything after that until I was being wheeled out of the labour ward... I was lying flat on a board for about 5 weeks. I couldn't move. They actually split my pelvis bone...

"They showed me the saw… they showed me where they were going to open the pelvic bone. They didn’t explain—they said: “You are going to have your baby now.” It was such agony, a terrible severe pain.”

Three elderly Irish women describe their babies' births several decades ago. Stuck in obstructed labor or with a history of difficult births behind them, they might have expected to be delivered by cesarean section. Instead, a different fate awaited them.

 
Some women recall screaming in agony as they were forcibly restrained, while others only remember having their legs put into the stirrups and waking up later unable to move. "Something" had clearly been done to these young mothers, but no name was ever given for the mysterious procedure by either the doctors or attending nurses; one woman remembers no information about her operation other than a cryptic remark from one of the nuns on the labor ward, that she would "pay for it in her old age." In most cases it was decades later that these women finally learned the truth; they had been subjected to an utterly obscure obstetric procedure called symphysiotomy—a procedure most obstetricians in developed countries have never even seen, let along performed, but which was performed on more than a thousand Irish women around the middle of the 20th century due to the influence of the Irish Catholic Church.

The anatomical problem
Symphysiotomy is an operation in which the obstetrician partially severs the symphysis pubis--the cartilage holding the pelvis together. This partially unhinges the pelvis, which not only allows a baby to pass through if labor is obstructed, but is believed by some authorities to permanently enlarge the size of the pelvic outlet, thus—it is hoped—allowing future babies to be born more easily.

Birth is inherently problematic among humans, because we have narrow pelvises (all the better for walking upright with) and large heads housing enormous brains (all the better for doing crossword puzzles with). We somehow have to get a large-brained offspring through a small pelvic outlet. It’s not the greatest arrangement, and sometimes the head just won’t fit.

Cesarean section was known from ancient times, but because it almost guaranteed death for the mother, doctors and midwives generally shunned it in favor of the crude yet lifesaving (for the mother) technique of craniotomy—crushing the head of a dead or dying baby and removing its body piecemeal. It wasn’t until the 18th century that someone decided to experiment with the idea of getting a head through a pelvis by sawing through and enlarging the pelvis rather than crushing the head. Having first been tried out on animals and human corpses, the operation was first tried on a living woman—who had dwarfism and rickets— in 1777, allowing her to give birth to a live child for the first time; unfortunately, it also caused her to have walking problems and leak urine from a fistula for the rest of her life.

Over the centuries, symphysiotomy had several temporary vogues in various parts of the world as obstetricians tried it out for size... but were discouraged by the injuries caused to mothers and the high death rates among babies. Moreover, by the early 20th century cesarean section had become reasonably safe; it appeared that the problem of obstructed labor had been solved.

But symphysiotomy was to have one last outbreak before shrinking back into its rightful place in the “obscure, rarely performed techniques” sections of obstetrics textbooks, and as something done in remote areas where safe cesareans are not possible. That outbreak centered on a small country in north-western Europe: Ireland.

An unholy alliance
The problem was that cesarean section limited family size. The rule “once a cesarean, always a cesarean” still held, and it was well known that with repeated surgeries the risks to mother and baby multiplied as quickly as the scar tissue; most obstetricians set an upper limit of three or four.

This created a dilemma, since in Catholic Ireland, all contraception, abortion and sterilization were illegal. Religious-minded obstetricians of the time thus had a very strong incentive to pursue alternatives to cesareans; women who realized the peril they faced from repeated cesareans might be led into “temptation”—that is, seeking birth control. Developing an alternative to cesareans would also enhance the reputation of Irish obstetricians—always sensitive to criticism from outsiders that they were held back by their Catholic faith.

Symphysiotomy—along with a sister operation, “pubiotomy” in which the pubic bone itself (rather than the cartilage joint) was sawn through using a wire saw—was revived in 1944 by Dr. Alex Spain at the National Maternity Hospital (NHM) Hospital in Dublin, in an unholy alliance between obstetrics and conservative religious forces. Dr. Spain and fellow symphysiotomy proponent Dr. Arthur Barry published writings in both the medical literature and the ecclesiastical press of Ireland, expounding the virtues of a procedure that prevented cesarean section with its attendant problem of “encouraging the laity in the improper prevention of pregnancy or in seeking its termination.”

The operation “spread like a plague in Ireland” in the words of Marie O’Connor, author of a book on the subject. Between 1944 and the 1980s, symphysiotomies and pubiotomies were performed on an estimated 1,500 women in hospitals from Cork to Kilkenny, and were particularly widespread at the notorious Our Lady of Lourdes Hospital in Drogheda. The atmosphere surrounding the operations was clandestine; women were typically not informed of what was going to be done to them, let alone asked for their consent.

“A midwifery of darker times”

"I wasn't in labour but I thought it was for my [cesarean] section... I was physically restrained…  they had this circular saw. I was screaming, asking what they were doing. They said 'new procedure'… They told me they broke the pelvis bone and my hips were dislocated… only God and myself know the excruciating pain, violation and intimidation I felt."

Because the whole point was to avoid a cesarean, women were left to push “through the agony of an unhinged pelvis” for as long as it took—often hours and hours. About 10% of babies died—far more than with cesareans—while many more were brain-damaged. This was well known by Dr. Barry and Dr. Spain, by the way—but the “benefits” in terms of avoiding "contraception, the mutilating operation of sterilisation and marital difficulty" were thought to justify this. British obstetricians, meanwhile, had other views on their Irish counterparts’ experiments, with one being moved to say “This is a midwifery of darker times. This is the murder of infants,” while another asked “Is it then your policy to sacrifice the first-born baby to use its dead or dying body as nothing more than a battering ram to stretch its mother's pelvis in the hope that subsequent brothers and sisters may thereby (possibly) enjoy an easier entrance into the world?”

Women, meanwhile, were left with serious damage—incontinence, pelvic instability (leading to great difficulties with walking) and chronic pain—rendered more serious because the secrecy surrounding the procedures meant that women did not receive proper nursing care and were dispatched from hospitals without medical advice. Most had no idea what had been done to them until the symphysiotomy scandal started to come out in the 1990s, leading ultimately to the creation of Survivors of Symphysiotomy (SOS), a support and advocacy group which is currently campaigning for compensation for the surviving victims. Many survivors speak of marriages blighted by sexual dysfunction and chronic pain, of isolation and loneliness caused by disability, and of the psychological trauma caused by the operations—including, in many cases, the death or injury of their babies.

One particularly grotesque twist in the symphysiotomy story concerns the calculated use of the procedure on many women either before labor or when already delivered of their babies, for training purposes. The Lourdes Hospital was run by the Medical Missionaries of Mary which operated missionary hospitals in Africa, India and other places. In environments lacking electricity or proper facilities, the attractions of a low-cost procedure that could replace cesareans were obvious. Symphysiotomies performed on Irish women—without their knowledge or consent—were thus an invaluable teaching aid for Catholic missions.

“The obstetrician, like God, must look to the future…”
Symphysiotomy and pubiotomy in Ireland began to decline in the 1970s due to changes in Irish society and other factors. In developed counties, it is now performed only in extremely rare life-threatening cases where labor is too advanced for a cesarean. Yet some of the issues surrounding these procedures have resonance for our times, in particular, women’s right to control over their fertility, and the question of how to balance the safety of the baby being born now—in this birth—against the safety of future pregnancies—a dilemma that we have faced ever since safe cesarean section become a possibility.

In traditional societies, high infant mortality rates create a more philosophical attitude to child death, while also necessitating multiple pregnancies if a couple want to make sure they leave any living descendants behind them. And cesarean sections are highly risky. In such environments, techniques like symphysiotomy make a grisly sort of sense—sure, this baby might have a 10% risk of dying, but avoiding primary cesarean means the mother can give birth to many more babies. As discussed here, symphysiotomy remains part of the obstetrician’s box of tricks in parts of sub-Saharan Africa—not because symphysiotomy is good, but because it's better than letting the mother die or sectioning her in an insanitary environment where there is no guarantee she could make it to the hospital next time, and where large families are still considered essential.

As infant mortality rates have fallen, the average number of children a woman will give birth to has declined sharply; meanwhile, we have higher expectations of safety and are no longer content to regard dead babies as disposable or do-overs… and cesareans are safer than ever. Present-day trends in obstetrics reflect these patterns, with cesarean section replacing not only symphysiotomy but also vaginal breech delivery and (increasingly) forceps deliveries and vaginal birth after cesarean (VBAC).

But respecting women’s control over their bodies goes both ways, and there is a case for saying that when obstetric practice is based only on the desire to reduce all risk to the fetus to zero, it can become decidedly unfriendly to many women who actually choose to have larger families. VBAC, for example, involves a small but real risk to the unborn baby because of the possibility of the uterus rupturing, as was discussed recently on The Skeptical OB; but what about the risks (to futuer babies) of multiple surgical births? I am going to quote in full one particular poster (who had a prior cesarean) because I think what she said was so moving and so important:

“I have always wanted a large family, but stories like these scare the crap out of me. It's been extremely difficult for me to decide whether I should have a VBAC or 4-6 c-sections…. If there were some way to know that I'd end up being one of the women with 4-5 c-sections and minimal scar tissue I'd be all over it, but I know I could just as easily end up being like someone I know of who had so much scarring after two that her third birth was a classical c-section followed by a hysterectomy.

“I think I could ultimately accept just 3 kids, but I would always feel like someone was missing and long to love and hold them. It kind of bugs me that there are so many in VBAC threads that berate moms for even considering a VBAC over a RCS [repeat cesarean section] in order to protect the lives of future babies who might end up stillborn, etc., but if you want additional children you love and long for them every bit as much as you do your first… It's like people who tell infertile couples to just adopt and then are bewildered and even mad when they say it's just not the same even though logically it should be because they'll still end up with kids. I just don't think wanting to do what's safest for your family as a whole is a choice that deserves such much criticism and so little understanding.”

Childbirth politics generally takes the form of as a conflict between those who see birth as inherently hazardous and regard it as a medical matter, and those who see it as a basically functional process where interventions are seldom necessary. Symphysiotomy in Ireland is difficult because it doesn’t fit neatly into either “side.” You can read Ireland’s symphysiotomy scandal as “Obstetrics has a history of violating women’s bodies with interventions that are not evidence-based” or as “Thank God we have cesareans now! See, this is what happens when you prioritize vaginal delivery above all else.” I prefer to see it as a story of what happens when religious doctrine takes precedence over women’s rights to informed consent and control over their bodies. This is something we should bear in mind as we face the possibility of a US vice-president—a Catholic—who is completely opposed to abortion even in cases of rape and incest, and who has sponsored a bill that would outlaw some forms of birth control.

In many countries, it has become increasingly common for women who prefer cesarean and plan to have a small family to be permitted a prophylactic cesarean section without medical indication. I think this represents an extremely important moment in terms of respecting maternal choice. I also hope that there will be room on maternity wards for VBAC, forceps deliveries and even (carefully screened) vaginal breech deliveries, and that in the future, obstetricians will give women unbiased information on the risks of cesarean and vaginal deliveries, discuss women’s desired family size with them and take this into consideration when presenting information and options.

As the surviving symphysiotomy victims wait for justice, what a wonderful tribute it would be to see their struggle not as a victory for a certain “type” of birth, but as a moment for reflection on the importance of women being able to make informed decisions about their bodies and fertility—an issue which is as relevant in our times as it was all those years ago in Ireland.

More information:

Mutilating mothers in the name of God (video)