The Clark report

A dozen or so years ago a group of people in Ireland got the idea that between the 1940’s and 80’s Irish obstetricians had systematically abused young women by inflicting an outdated and cruel operation on them; dividing the ligaments joining the pubic bones to enlarge the pelvis and facilitate birth. The claim was that although doctors knew symphysiotomy was agonisingly painful and had a high rate of life-altering complications, they did it in preference to Caesarean section as a form of punishment for women pregnant out of wedlock. As a result of their Catholic religious zeal, hundreds, maybe thousands, of women suffered terrible lifelong injuries. Click here for the main pressure group’s website.

A few women went to court for civil redress, but with little success; there was little objective evidence of serious injury. Nevertheless a campaign for “no fault” compensation gained momentum, and at least four enquires were set up. Two ran into the sand under partisan criticism, but two others (available here) suggested there might be a problem and, in view of the difficulties of pursuing negligence claims so long after the event, recommended a state redress scheme overseen by a high court judge, Maureen Harding Clark.

Her report (click here) (alternative here the-surgical-symphysiotomy-ex-gratia-payment-scheme-report) was released on 19 October. She confirmed that symphysiotomy was indeed used more often in Ireland than other similar developed countries; the rationale being unavailability of contraception and the risks of repeat Caesareans for women with large families. The prohibition on contraception was driven by Catholic teaching, but Clark found little evidence that the symphysiotomy itself was done for religious reasons or to punish single mothers. Rather she unearthed some evidence to the contrary; the doctors used the procedure sparingly, and were driven by a desire to avoid the morbidity and mortality associated with Caesarean section in that era.

“While evidence of religious motivation […] is found in the 1949 NMH [national Maternity Hospital] Annual Clinical Report and in a study by A P Barry, Master of the NMH, it was absent from any other report although the issue of large families and no contraception was commonly raised during the annual discussions known as the Transactions Meetings. There appeared to be a high degree of support for Catholic teaching on contraception among those present and contributing to discussion.” (para 32)

Perhaps now is rather late to second guess motivation. Obstetricians like me* will be more interested in learning what complications actually occurred, particularly in the long term.  This is not straightforward because Judge Clark’s primary interest was not in causation; her criterion for making an award was any contemporaneous documentation of any injury or symptom which could plausibly ever be an effect of symphysiotomy. But let me try. Of 589 alleged cases submitted for review, at most 404 had actually undergone symphysiotomy.

“It is highly probable that several applicants received awards in error. In 3 extremely troublesome cases, notwithstanding very extensive investigations, even with the assistance of specialists, I was simply unable to exclude the possibility that the applicants had undergone a symphysiotomy procedure. In those cases, the birth records were either incomplete or unavailable and medical evidence was unsatisfactory. I formed the view that it was better to err in making an award to an elderly applicant convinced of the truth of her claim than to be wrong and refuse an award to a deserving applicant. In approximately 6 other cases, earlier reliance on scar and in one case, radiology evidence led me into error. I take responsibility for my errors. In 2 cases where reliance was placed on medical opinion, records which were not available at the time of assessment subsequently became available from stored archives. They confirmed earlier suspicions that no symphysiotomy procedure had been performed.”

The true number of cases is therefore likely to be 393 (404-11). About 100 of these agreed that they had suffered no injury beyond the immediate pain of the procedure, and were given “compensation” of £50K. This left about 300 women who claimed to have long term injury. Of these, Clark eventually judged that 142/404 (35%) had suffered something; excessive separation of the pubic bones, pubic pain, pelvic instability, incontinence, psychological/psychosexual difficulties or sacroiliac pain. On the face of it a high rate, but this assumes all documented problems which could plausibly be an effect of symphysiotomy, were caused by it. In the real world pubic bones separate spontaneously during birth, separation is often asymptomatic, and other symptoms are common anyway, particularly after forceps, which many women had also undergone. Clark, realising this, writes:

“No general pattern of immediate or developmental injury was seen. The evidence did not confirm that symphysiotomy inevitably leads to lifelong pain or disability or those symphysiotomy patients aged in a manner which was different to those of non-symphysiotomy women. The majority of applicants who underwent symphysiotomy made a good recovery and went on to have normal pregnancies and deliveries and to lead a full life. Most applicants had at least 4 normal deliveries after the symphysiotomy. A small number of applicants suffered from pelvic pain and a slightly larger group [24 cases] from urinary issues. Whether the conditions were associated with prolonged labour, the use of forceps, parity or the symphysiotomy procedure or a combination of all three was not possible at this remove to determine. It was noted that many symphysiotomy procedures were carried out after a ‘failed forceps’.” para 22

Here is judge Clark describing her process for evaluating if incontinence had resulted.

“I first determined that the test for finding incontinence constituting significant disability would be evidence of any mention of any degree of incontinence or urinary tract infections on the available notes relating to the symphysiotomy birth and the next pregnancy. The cases were so few that the threshold was lowered again to any mention of incontinence or multiple urinary tract infections in GP records in the first decade following the symphysiotomy birth. Even when the threshold was set at the low level of any possible temporal association with symphysiotomy, little was found to match complaints in the majority of cases.”(para 179)

In only five of the 24 cases of urinary incontinence associated with symphysiotomy was there a close temporal or other relationship such that causation was likely.

“[These five] had suffered bladder / urethral damage or fistula at the time of symphysiotomy. The injury was identified within hours of the symphysiotomy and repaired at the first opportunity. All five applicants were thereafter predisposed to urinary tract infections and in one case, continuing incontinence.” (para 24).

Here is Judge Clark on unstable pelvis/ arthropathy etc.

“The appearance of the pubic symphysis was abnormal in 80 cases with variable degrees of other musculo-skeletal conditions. 12 applicants demonstrated what were described as grossly
abnormal findings. The abnormal radiological findings included continuing diastasis (separation of the bones of the symphysis) of 15mm or more and included a small number of cases of severe sclerosis, fluid in the joint, large osteophytes, capsular hypertrophy, vertical misalignment or the presence of bone fragments. Sometimes the wide diastasis was associated with sacroiliac joint arthropathy but in several instances, the sacroiliac joints were normal. There were very few cases of pelvic instability, that is, evidence of movement in the joint. For the purposes of the Scheme, if the appearance of the joint was abnormal, this was always taken as evidence of either inflammation or movement at the joint occurring in the immediate aftermath of the symphysiotomy procedure. There were very few cases of hip degeneration at an inappropriate age and no documented cases of difficulty with walking after about 3 months.” (para 23).

To summarise, 404 (or 393) symphysiotomy procedures resulted in five cases of urinary tract damage, one of whom was left with incontinence, and, despite 80 women ending up with radiological signs of pelvic damage, no documented cases of difficulty with walking after about 3 months. Until the campaign drew their attention to the “harms” of symphysiotomy, the women who had undergone it had gone on to have more children, to have backache, sexual difficulties and troublesome periods at pretty much the same rate as their sisters. Nevertheless:

“On countless occasions, it seemed that once the symphysiotomy procedure was identified (usually in 2003/2004), new complaints previously absent from the records spanning decades were made and every health ailment was attributed to symphysiotomy.” (para 112)

Lawyers and psychiatrists dealing with other types of alleged historical abuse will be interested in the 185 women who had not undergone symphysiotomy. Experimental psychology has shown that false memory is real – if you see what I mean – but no-one knows how common it is in real life. Here is Justice Clark:

“Almost a third of applicants did not undergo symphysiotomy. This is a very significant number. Even if applications made on behalf of those who simply did not know whether they underwent symphysiotomy or where  family members thought their mother might have undergone such a procedure are excluded, the number (185 in total) still begs some examination and scrutiny. How could these don’t knows and so many other women wrongly believe that they had undergone this procedure with its highly publicised adverse effects?” (para 220)

“It is very possible that advertising by some legal firms to encourage women who “may” have undergone symphysiotomy to bring claims resulted in many of the unfounded applications. The applications may have been submitted simply in order to comply with the application time period before the necessary supporting medical records were obtained. While there may have been a vexatious element to their applications, many of these applications were withdrawn once their records were examined. In others, misunderstanding between episiotomy and symphysiotomy was evident.” (para 224)

“The publicity surrounding the activism for the Government to set up a compensation scheme for symphysiotomy victims was quite intense. There can hardly be a person in Ireland who has not been exposed to reports of the procedure described as butchery akin to Nazi medical experimentation;, aggravated sexual assault; a form of female genital mutilation causing life long disability, chronic pain, mental suffering and family breakdown and much more. These reports have been so persistent and frequent that they have created something akin to a knee jerk reaction to the word symphysiotomy. It is viewed as a procedure synonymous with barbarism and pain; but not just barbaric and painful but unnecessary and unwarranted, creating a legacy of countless victims whose lives were permanently ruined. […] Some of those […] women who did not undergo symphysiotomy have been prominent, vocal and long time activists as victims of symphysiotomy. (para 225)

“After much thought, I concluded that it is very probable that the combination of a traumatic birth experience and exposure to other women’s stories has created a self convincing confabulation of personal history. Another inference is that the possibility of financial payment has influenced suggestible women and their family members into self-serving adoption and embracing of the experiences described by others or in the media and created psychosomatic conditions.” (para 226)

Obstetricians and lawyers will be studying this report for some time.

Jim Thornton

*Disclosure. Over a four year period in rural Kenya in the early 1980s I performed a couple of symphysiotomy operations. My hospital had good facilities for Caesarean, albeit under ether anaesthesia, so the need was small.  A colleague in a less well-staffed hospital nearby, where Caesarean was often impossible, performed the operation more regularly and taught me.