Saturday, 11 March 2017

Symphysiotomy report begets more questions

Article I published in the Irish Examiner newspaper: 

Symphysiotomy report begets more questions

Judge Maureen Harding Clark’s findings downplay physical toll of procedure and fail to recognise women’s right to consent in childbirth, says Prof Linda Connolly
Picture: PA
SYMPHYSIOTOMIES were carried out on 1,500 women in Ireland up to the 1980s, long after it was discontinued in other jurisdictions.
The controversial procedure cut the cartilage of a pregnant woman’s pelvic bone (breaking the bone in extreme cases) to widen the birth canal.
Three hundred and ninety-nine women have received €50,000, €100,000, or €150,000 sums under the symphysiotomy grant payment scheme, which paid out €34m.
The women’s medical records were checked by experts and a judge awarded the payments to those who could prove they had undergone the procedure. Of the 590 applications, 185 women were unable to establish their claim, as per the terms of the scheme. The majority of women who applied were over 75 years of age. The oldest was 96.
Until last week, it was presumed that Irish women subjected to symphysiotomies, often without their consent or knowledge of what was to be done to them, were left with long-term medical difficulties, including incontinence and chronic pain.
In 2014, the UN Human Rights Committee said the perpetrators of symphysiotomy should be prosecuted. Ireland’s compliance with the International Covenant on Civil and Political Rights was monitored. However, the findings of the report, by Judge Maureen Harding Clark, published last week, paint a radically different view. The report suggests:
  • Symphysiotomy was (still is) a normal obstetric medicine. It is not an example of what childbirth experts in other research domains call ‘obstetric violence’ or a fundamental human rights violation. Literature supporting the case for this procedure was cited;
  • Doctors performed symphysiotomies in the best interests of the women giving birth. That contraceptives were not freely available because of Catholicism explains why a symphysiotomy might have been chosen over a caesarean section;
  • Some women who applied to the scheme had false memory about symphysiotomy in childbirth. They didn’t have a symphysiotomy, just had a traumatic birth;
  • Some women who did not have a symphysiotomy applied to the scheme with the strong encouragement of sons/daughters/family members and/or with the help of GPs and third parties;
  • Survivor groups and media sensationalised the long-term impact of the procedure (few women suffered life-long disability and the vast majority recovered);
  • Many applicants saw the word “episiotomy” on their medical records and equated it with “symphysiotomy”. They confused symphysiotomy with the after-effects of other childbirth procedures, based on what they were reading and hearing in the media. Extreme pain, incontinence, difficulty walking, etc, are not uncommon after childbirth;
  • Medical experts commenting on potential medical injustices in their own hospitals are unquestionably right in the assessment in the report. (And no international or independent experts were necessary). Medical records only noted clinical reasons for symphysiotomies. No notes citing any religious reasons are evident;
  • Oonagh Walsh’s “scholarly report” on symphysiotomy has been ignored by sections of the media, “who appear to prefer the more lurid and unfounded accounts projected by some activists and bloggers”.
  • Money is the ultimate mode of restorative justice. The women who had symphysiotomies (but who obviously recovered quickly) have been rewarded and are happy.
A large number of issues arising from this report need to be carefully addressed. Oonagh Walsh’s report, for instance, is widely cited in academic writing (by legal scholars, women’s historians, and social scientists). It is hardly ignored.
Some of the absences/silences in the report, as well as underlying assumptions, are as notable as some of the astonishing claims in it.
The term “obstetric violence” has caused division in medical, legal, and social science scholarship — ranging from positions that advocate the superiority of midwife-led care over modern obstetrics to those who uphold the principles of modern medicine as a necessary form of power over women’s own agency and choice, in the best interests of safe childbirth.
International human rights instruments contain guidelines on safe child birth. The Harding Clarke report reflects a view that women give birth because men help them and intervene to save their lives.
The report is informed by a group of male medical experts, with little attention to perspectives in childbirth studies that empower pregnant women and which prioritise women’s experience.
International literature on active versus hyper-managed childbirth, and on obstetric violence, is not referenced. Huge swaths of international research, in the field of obstetric law and women’s human rights, have also been ignored.
The reality that all medical procedures (historical or contemporary) always take place within a rights framework, and not purely within a rational, clinical ‘expert’ framework, is unexplored.
Even if women had symphysiotomies at a time when women had little or no power or say in childbirth does not negate basic rights. The full range of historical interpretations of symphysiotomy is far more complex than the report suggests.
The report emphasises evidence of symphysiotomy inscribed on the women’s bodies, and in their medical files, more than it does the question of consent.
THE prevailing cultural view of pregnancy and birth stems from a patriarchal attitude that women must be submissive and passive, and let the experts who know better do the work.
To presume that medical maternity care is an infallible authority over women, or to maintain that a live baby and/or live mother is the singular benchmark for birth, is misguided.
A woman has a right to informed consent or refusal. Moreover, she should not expect to end up in severe pain after childbirth. Whether or not the women in this report were able to ride a bike after any invasive procedure, or go on to have another child within a year, is separate from the fundamental principle of informed consent in childbirth.
Some researchers suggest that performing a procedure on a woman without her informed consent, or by coercing her to give consent, can be physical abuse.
Women have reported being held down, screaming, while birth procedures were performed on them. Doctors in the 1940s to the 1980s might have presumed they were doing the right thing for women, but there are alternative interpretations.
The report does not name the obstetricians who performed symphysiotomies, nor does it examine their rate of symphysiotomy, relative to other doctors.
Based on the evidence submitted to the scheme, is it apparent that some doctors were more likely to perform symphysiotomies? If so, why? Should the obstetricians who performed the symphysiotomies approved by the scheme not be named, in the interests of transparency and further historical research?
The Harding Clark report raises as many questions about the history of childbirth as it answers. Until it is accepted that women historically were purely vessels in childbirth changes, they will remain powerless in the face of ongoing childbirth questions and experts will remain powerful.
Compensation will now be paid out to the women whose reproductive histories and bodily parts were retrospectively judged for this scheme, but fundamental questions remain.
The €34m in compensation is a clear admittance of wrongdoing on the part of the State, despite what the report intimates about ‘victims,’ bloggers, misguided applications and advocacy groups.
This story is far from over and it remains yet another example of Irish women’s bodies on trial.
  • Prof Linda Connolly is a sociologist. She is the director of the Social Sciences Institute at Maynooth University and has authored a number of books and articles on Irish women’s social and political rights

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