Symphysiotomy. Probably not a word you’ve heard before – and if you have, I’m sorry? Symphysiotomy is an obstetric procedure in which a person’s pubic symphysis cartilage is cut to widen the pelvis for childbirth. Yes. Gross. I know. For most of the 19th century, symphysiotomy was a new solution to difficult births, and, to some doctors, preferable to Caesarean section, and certainly to the gruesome craniotomy. By the 1930s, though, in countries where childbirth had been medicalized, the symphysiotomy was phased out in favor of the safer C section – except Ireland. While surgical solutions to difficult childbirths increased in American and European obstetrics throughout the twentieth-century generally, it was only in Ireland that the use of symphysiotomy increased. Why, for the love of God, WHY, you ask? Let’s dig in.

Written and Researched by Averill Earls, PhD

Recorded by Averill Earls and Elizabeth Garner Masarik, PhD

Transcript for Obstetric Violence: Childbirth and Symphysiotomy in Catholic Ireland

Ave: Real talk: this is probably gonna be one of those “not safe for work or the car with kids” episodes. That might be a given for a series about birth (which I will remind you was a listener request) – so it’s probably no surprise to anyone that childbirth is a messy, bloody, shitty, “beautiful” physiological process, but that doesn’t mean your six year old or co-worker want to hear about it. Especially if you’re listening during lunch. Especially if your co-worker IS your six year old. So consider yourself warned, and also since this is already going to be a gross episode, I’m not going to bleep our fucks or shits after this intro, because this shit is fucking gross and you’re already down the rabbit hole, my friends. Making this episode EXPLICIT babbbyyyyy. Enjoy.

Ave: Symphysiotomy. Probably not a word you’ve heard before – and if you have, I’m sorry? Symphysiotomy is an obstetric procedure in which a person’s pubic symphysis cartilage is cut to widen the pelvis for childbirth. Yes. Gross. I know. For most of the 19th century, symphysiotomy was a new solution to difficult births, and, to some doctors, preferable to Caesarean section, and certainly to the gruesome craniotomy. By the 1930s, though, in countries where childbirth had been medicalized, the symphysiotomy was phased out in favor of the safer C section – except Ireland. While surgical solutions to difficult childbirths increased in American and European obstetrics throughout the twentieth-century generally, it was only in Ireland that the use of symphysiotomy increased. Why, for the love of God, WHY, you ask? Let’s dig in. (jkjk)

I’m Averill Earls

I’m Elizabeth Garner Masarik

And we are your historians for this episode of Dig

Elizabeth: Hey you! Yes, you! Thank you for listening to this podcast. And to our amazing Patreon supporters — Lauren, Edward, Denise, Maddie, Maggie, Danielle, Lisa, Agnes, Iris, Maria, Colin, Susan, Peggy, and Jessica — thank YOU for choosing us to patronize. We are nothing without you. Listener, if you’re not yet a patron of the show, it’s easy! Check us out at patreon.com/digpodcast to learn more

Ave: Three years after she married, Dolores got pregnant. It was a welcome enough pregnancy, and like thousands of Irish women just like her, she relied on the medical model of childbirth when it was time. “It was 1961. I suggested going to the Rotunda [the Protestant hospital in Dublin] myself … I was a public patient. One Friday morning, I got pains … My husband came in to hospital with me. I was in an ordinary bed for two days, nothing was happening. Saturday and Sunday, I had the odd pain, no more, they weren’t strong. I was due the next day, then they got anxious. On Sunday night, they told me I’d be going down the next morning, they brought me for a shower. On Monday, they brought me down to the labour ward, then they brought me to the operating theatre, I thought I was going to have the baby. I was put out, I nearly suffocated with what they gave me, it was sickening. When I woke up, I asked the nurse, is the baby alright. You didn’t have it yet, the nurse said, you’ve had your pelvis broken. Shocked, I was. The baby will be born soon, she said.”[1]

postoperative treatment of episiomotmy. black and white image on woman in a sling
Patient in a symphysiotomy hammock after surgery, 1907: Wikipedia Commons

Elizabeth: Dolores was one of hundreds, possibly thousands, of Irish survivors of symphysiotomy and pubiotomies. This procedure, regularly described as “barbaric,” was a staple of Irish obstetrics in the twentieth century. As suggested by Dolores’ testimony, the choice to employ symphysiotomy was rarely one made by laboring women. Instead, Catholic doctors in Ireland elected to perform the surgeries to “aid” in the vaginal birth of infants, often without consulting the patients. Scholars Cara Delay and Beth Sundstrom argue that Irish doctor’s use of symphysiotomy in the twentieth century constituted obstetric violence, or what C.H. Vacaflour defines as “the violence exercised by health personnel on the body and reproductive processes of pregnant women, as expressed through dehumanizing treatment, medicalization abuse, and the conversion of natural processes of reproduction into pathological ones.”[2]

Ave: Feminist scholars have long argued that the medicalization of childbirth has had an overall negative impact on reproduction and maternal health, with medical personnel divesting pregnant people of their agency and authority in the birthing process.[3] In the case of symphysiotomy in Ireland from mid-century to the 1990s, the increased “authority” of doctors coupled with the oppressive Catholic hierarchy’s intervention in healthcare created a perfect storm in which a unknown (but significant) number of Irish women had their pubic symphysis sliced without their knowledge or consent.

Elizabeth: Symphysiotomies, even when done well, can still lead to a lifetime of pain: incontinence, vaginal fistulas, and joint problems. For over five decades, doctors in Ireland performed symphysiotomies and pubiotomies without the consent or knowledge of their patients. You can probably imagine the degree of awfulness… but we’ll explain anyway.

Ave: The first successful symphysiotomy was recorded in Paris in 1777.[4] According to Delay, symphysiotomies never reached a point of being widespread in the European or American obstetric communities because of the long term health problems they caused. Even in the 20th century, when surgical solutions to difficult births have become perhaps overused, symphysiotomies were generally not the go-to procedure. Marissa is doing a whole episode on C sections in history, so we won’t get too deep into that, but of the surgical solutions for difficult births, C sections have been around the longest, and in most of the world, they are the primary mode of surgical extraction. Before modern sterilization techniques, however, all surgical options that involved creating incisions into patients were dangerous, leaving patients susceptible to sepsis and infection.

Elizabeth: For most of the 18th and into the 19th centuries, surgical solutions were not common, and often the last resort. When asked to intervene, physicians preferred craniotomy – in which the fetus’ cranium would be pierced, contents scrambled and removed, skull crushed, and body extracted. Most physicians in the 18th and 19th century saw this as a necessary if unfortunate procedure to save the mother, even when the fetus was living at the time of the failed birth. An infant that was unable to pass through vaginally naturally would die in utero anyway, and then kill the mother. As Marissa will undoubtedly discuss in her episode, historically the C section was used to extract fetuses from already deceased mothers. That kind of reputation left husbands and wives resistant to consenting to any kind of surgical intervention in a birthing room.

Ave: According to Judith Walzer Leavitt and Nadia Fillippini, throughout the early modern period and into the 19th century, physicians in the US and Europe tended to understand the fetus as part of the woman’s body until she successfully birthed it and it survived on its own. It was more important to save the life of the woman, or “sacrifice the fruit for the tree.” She was already a contributing member of society, probably already had children at home to care for or would be able to try again.[5]  But this was not a universally accepted premise. As one might expect, there were a range of perspectives on the issue. Some opposed craniotomies entirely, preferring to put the mother at risk with a C section or symphysiotomy if it meant the chance for a live birth. The ethical considerations were debated widely and hotly, well into the 20th century. When surgical interventions were made safer, however, more and more physicians leaned toward making the choice that might preserve both mother and child.

Elizabeth: But at the same time that these surgical interventions were being perfected, husbands, wives, midwives, and the various other women who’d attend a birth had a lot more say in what happened during a birth. In Europe and the US, almost all births took place in women’s homes well until the 1920s, where they were the primary decision-makers. According to Judith Walzer Leavitt, physicians were one of many people present at a birth, and usually not even required at a birth; if present, they would not intervene unless specifically asked to do so.[6] They were not the “authority” in the room, but one of a collective of knowledgeable individuals who might offer advice. That power balance wouldn’t shift in any significant ways until the late 19/early 20th centuries. In Europe, the 18th century professionalization of midwifery, and the rise of “man-midwives” gradually shifted obstetric authority from women in their homes to doctors in their hospitals.[7]

Ave: In continental Europe, the 18th century was a key turning point in the medicalization of childbirth. Though women maintained control over the realm of pregnancy and the birthing room well into the 19th century, starting in the 18th century European states began intervening and regulating medicine and public health works more closely. As historian Nadia Filippini has shown, with the Enlightenment and scientific revolution of the 17th centuries, 18th century states were increasingly concerned about public health and the body politic. Addressing abysmal maternal and infant mortality rates, the governments in most European countries established formal midwifery schools to try and regulate and standardize midwifery practices. According to Filippini,  In Italy, between 1757 and 1779, 13 midwifery schools were opened, and similar institutions were created in Germany, the Netherlands, Switzerland and Spain in the 1770s. Spain was one of the later states to establish a school, with one in Barcelona in 1795.[8]

Elizabeth: Rather than improving the efficacy of midwives and thereby saving the lives of mothers and infants, these schools tended to hamstring the practitioners. Laws forbade midwives from using instruments like forceps, or providing oral medicines to dull birthing pains, and were required to call on (male) physicians or doctors to administer drugs or to deal with “difficult pregnancies” that might require surgical intervention.[9] The licensure requirements also ultimately usurped women’s authority in the realm of childbirth; most women couldn’t afford or weren’t permitted to spend months or years training in one of the midwifery schools. Many midwives continued practicing, unlicensed, and passing down their traditions through apprenticeships, as had been done before.[10] But others bent to the will of the state, if only to hold onto this female realm of power. It was necessary to obey the state in order to keep the power of childbirth out of the hands of men. As Teresa Ployant wrote in 1797, “They are already indifferently abandoning mothers in the hands of men in France and England and threatening the same in the rest of Europe. Let us then be quick to stem this fatal turn of events and through tireless study make the public realise that we are the ones that can bring childbirth to a happy outcome, and at the same time save women’s modesty.”[11]

Ave: As Ployant suggested,  the medicalization of childbirth in England rapidly outpaced that on the continent. Regulation, enforced through the trial and imprisonment of midwives, quickly relegated women to the periphery of childbirth in the UK. In the 17th and 18th centuries, English midwives – some of whom were literate, knowledgeable, and extensively trained in their fields – resisted this power shift, to no avail. Sarah Stone, a midwife who practiced in the mid-18th century, balked at the increasing number of medical interventions in childbirth. In her 1737 midwifery treatise she insisted that “more Women and Children have died by the hands of such professors, than by the greatest imbecility and ignorance of some Woman-Midwives who never went through or heard of a Course of Anatomy.”[12] According to historian Janette C. Allotey, “During the 154 years between the first publication of Sharp’s The Midwives Book and the writing of Stephen’s Domestic Midwife, men midwives gained increasing authority in the field of midwifery practice whereas traditional midwives continued to carry on practising. The midwife-authors believed that the incidence of severely obstructed labour was relatively rare, and that forceps and instruments were being used indiscriminately by men midwives who generally overstated the need for medical intervention.”[13]

The human pelvis

Elizabeth: As we already know, however, the use of forceps was just the beginning. By gradually chipping away at the authority of European midwives, governments and physicians (who were all men, of course) shifted reproduction from the home to the hospital. It was dangerous and challenging to perform interventionist surgeries of any kind in the homes of patients. This was a hard sell; particularly among the middle and upper classes, women preferred to receive treatment in their homes, surrounded by familiar faces and people to help care for them. Hospitals were for the poor and indigent. It took decades for the medical establishment to market itself as a welcoming environment for patients.

Ave: By 1920, when germ theory and improved sanitation meant that surgical interventions were more likely to result in the survival of both infant and mother, doctors were able to argue that a woman who might have a difficult birth should start her labor process in a hospital. Over time, the qualifications for what might be classified as a “difficult birth” expanded, and more and more women were pressured by the health care providers – generally physicians, as midwives were pushed out of the market by regulation – to give birth in hospitals. As of 2010, less than 1% of European births were at home.

Elizabeth: And in hospitals, doctors are the authorities.

Ave: Exactly. And that authority has, traditionally, been exercised with impunity. We needn’t focus on symphysiotomy to find examples of doctors who make decisions for patients based on what they, the physician, thinks is “best.” Consent was not an implicit or explicit component of medical care in the 19th or early 20th centuries.

Elizabeth: Among other marginalized groups who’ve been subjected to the whims of “professional” (male) medicine, women have been ignored, undermined, and refused the right to make choices for their own bodies in the US and Europe for well over a century. Without even touching the issues of family limitation, access to birth control, access to safe abortions, and those other hot-button issues, studies have shown that women struggle to get doctors to believe when they are in pain, or when something feels off in their bodies.

Ave: It’s a whole thing. And this can of course be said for Black people in the US, immigrants, prisoners – the list goes on and on. Medical experimentation, nonconsensual treatment, and all kinds of unethical behavior are not just historical realities of the medical profession — they were essential to the development of modern professional medicine.

Elizabeth: As giving birth shifted from the home to the hospital, surgical procedures were no longer decisions made with women, and with multiple parties weighing in. From the 1920s on, doctors made snap decisions, including “emergency” C sections, or in the Irish case, symphysiotomy, or occasionally pubiotomy.

Ave: This is an on-going issue. I just finished teaching a Reproductive Ethics course for Albany Medical College, where we talk about patient rights, and provider rights and responsibilities, and how those rights/responsibilities clash in reproductive health. Obviously there are Catholic, Muslim, Anglican, Lutheran, Sikh, Buddhist, atheist, agnostic, Baptist doctors — and there are frequently doctors from backgrounds that prohibit things like birth control or abortion who, still today, make the choice to deny services related to family limitation to their patients. And as my students who are themselves in the medical field and find themselves leaning toward sympathizing with the medical professionals. Individual codes of ethics are necessarily informed by our socialization into spiritual/moral/ethical communities. We don’t want to say that Catholics who would refuse to perform abortions should not go into a medical career – that’d be discriminaotry – but we still want to challenge the notion that that same doctor has the right, on their own moral/ethical grounds, to deny a patient a procedure they have every legal right to. It’s a really tricky conversation. As Leavitt notes, physicians in the 19th century (like today) had a range of perspectives on the issues of things like craniotomy, C-sections, and symphysiotomy. Among Catholic doctors in particular, craniotomy was rejected. Doctors and religious hierarchy privileged the unborn and “innocent” (sinless) fetus over the mother. Leavitt describes two scenarios in which Catholic priests attempted to interfere with reproductive medical decisions. (We’re just going to read these straight from the original text, I apologize for the long block quotes):

Elizabeth: “In 1885 a pregnant Catholic woman, known to have a narrow pelvis, went into labor in the company of her husband, her clergyman, and her physician. The physician soon realized that a successful vaginal delivery was impossible. Before he could recommend any course of action, how- ever, the priest spoke in favor of a cesarean section and rejected the alternative of a craniotomy. The parturient and her husband strongly desired that a craniotomy should be performed (despite the inevitable mortality of the fetus) in order to save the woman’s life. The physician, Dr. Green of Dorchester, Massachusetts, himself uneasy with the alternatives, was reluctant to proceed given the divided opinion. He consulted with a colleague who specialized in abdominal surgery, and the noted surgeon, “for good [medical] reasons,” declined to operate, recommending also that a craniotomy be undertaken. Green finally performed a craniotomy, and the woman recovered. However, the physician felt uncomfortable with his participation in the destruction of a live fetus and said he “was not sure that he should proceed in like manner again under precisely similar circumstances.”

Ave: When in 1901 Dr. Joseph DeLee of Chicago faced a similar situation, the outcome for the parturient was quite different. He was called to attend a woman with a pelvis deformed by childhood rickets who had been in labor for sixty hours. He advised against a cesarean section because the duration of her labor at this point made the procedure a threat to her life. However, the priest in attendance insisted on a cesarean section, overruling the woman’s initial preference for a craniotomy. With priest and parturient ultimately in agreement, DeLee, feeling he had no other choice, performed the cesarean section. The woman subsequently died without rallying from the operation. DeLee concluded, “This case made a strong impression on my mind, for I am certain craniotomy would have saved the patient.”[14]

Elizabeth: In Protestant-dominated countries, with the secularization of society and of public services – like hospitals, schools, and other organizations that were traditionally run by  religious organizations – in the 18th and 19th centuries, the Catholic Church attempted to reassert its daily authority by issuing decrees and opinions on issues of state, medicine, and the like.

Ave: (You may be wondering – why the fuck was there a priest present at these births?? – but remember that up through the 19th century, births in homes were public affairs in the US and Europe. Husbands went around town and gathered up neighbors. The women would assist the midwife in the birth, and the husbands would smoke and drink and wait. A priest would likely be on hand in the event that the mother or infant died, and needed last rights. So in 1885 and 1901, even if those patients had submitted themselves to hospital births, it is likely that there would still be quite a few people present for the birth. Childbirth didn’t become the isolated, highly medicalized affair it is today until the 1940s/50s.)

Elizabeth: Consequently, the priests had opinions on how one should or should not proceed in the surgical solution to difficult births. Those opinions, shaped by official Catholic hierarchical statements about health care, and especially reproductive healthcare, were generally isolated interferences of individual priests, or maybe the occasional Catholic doctor who put their religious beliefs before the standardized best practices of the time. The cases that Leavitt describes in the US were not widespread, even if they were still undue influence by the priest. And by the 1920s and 30s, when C-sections were fairly safe, the surgical solutions to difficult births no longer revolved around questions of save one or the other – C sections in particular were safe enough so as to ensure the survival of both.  

Ave: But that’s not how we get to Dolores’ story. Because in Ireland, the priests weren’t just the decision makers in the birthing rooms – they dominated public life, even influenced state policy. From early in the 20th century, as synthetic methods of birth control became more widely available in Europe and the US, the Catholic Church took a hard and fast stance on unnatural forms of “contraception” – namely, that it did not serve God’s plan, and that to prevent procreation in any way was a terrible sin. The forms of birth control approved by the Catholic Church throughout the 20th century were either the rhythm method, in which women were supposed to track their menstrual cycle to figure out when they probably wouldn’t get pregnant, or “Natural Family Planning,” which is essentially the same thing but instead of guessing, women track the mucus membrane on their cervix. Not challenging at all.

Armagh, St Patrick’s Cathedral (Church of Ireland), Photo by John Armagh

Elizabeth: For the first half of the 20th century, chemical and latex forms of birth control were illegal, and policed pretty heavily by governments in the US and Europe – check out my episode on Comstock for my on the US situation. But because of the advocacy and protest work of groups in the 1920s and 30s, like the American National Birth Control League, the available forms of birth control like the cervical cap were legalized and made available, at first through prescriptions to married couples, and later widely. By the 1960s there were effective and reliable chemical forms of birth control as well. In all cases, the US and European states resisted. Giving women such precise control over their own bodies was undoubtedly frightening to the men in power.

Ave: But while most European states, including the Soviet Union, granted women some level of control over their reproduction, Ireland stayed firmly in control of the bodies of their women. Ireland gained its independence from the United Kingdom in 1922. The independence movement, notably, included women who fought on the front lines of the war for independence, and a handful of women were elected into the first Dail (Irish parliament). But their investment in greater Irish nationalist goals ultimately subsumed whatever feminist intentions they had when getting involved in the fight. In the first few years of independence, the Irish police drove sex workers underground, harassing street walkers extrajudiciously until they dared not ply their wares openly. As Maria Luddy noted, well into the 1990s Irish citizens insisted that there was no prostitution in Ireland – that it had left with the British deoccupation in 1922.

Elizabeth: Unmarried women who got pregnant were sequestered away in Mother and Baby homes – usually run by Catholic women religious – and if they didn’t have any male support network to speak for them, their babies were seized and adopted out, often to American families. All kinds of women and teen girls – those suspected of having had premarital sexual contact, or those deemed too “unruly” or “problematic” – were held captive in the Magdalene laundries, forced to work for free for the Sisters of Mercy who ran those institutions, belittled, beaten, and reminded again and again of their worthlessness. Some escaped; too many did not.

Ave: The new Irish state passed censorship laws to rival those of Anthony Comstock. It wasn’t just newspaper advertisements and the sale of birth control that was forbidden – any and all books, movies, poems, music, and art that even hinted at ways that women might practice family limitation were banned by the Evil Literature Committee. The leadership of the Catholic Church in Ireland had their hands in all major decisions, and the majority of hospitals and schools continued to be run by the Church. With few exceptions, Irish women were at the mercy of the Catholic Church – and its practices were far from merciful.

Elizabeth: Even when the C-section was deemed safe, it was general knowledge in the medical community that after three C-sections, it was best practice to sterilize a woman to prevent future pregnancies. In Ireland, where any kind of contraception was either illegal or forboden — even when medically necessary — Irish doctors elected to employ symphysiotomies instead of C-sections with alarming regularity. They did so with the same non-consensuality that doctors in the Americas and the rest of Europe did C-sections — which also have a long history of being performed unnecessarily and without patient consent. Generally, however, C sections were preferred because of their relatively short recovery time, and the minimal long-term damage to the recipient. Symphysiotomies, on the other hand, allowed women to keep having babies endlessly – and with an average of seven children per woman in the period 1944-1992, that is exactly what Irish Catholic doctors achieved with their practices.

Ave: The experiences that survivors of symphysiotomy and pubiotomies described ranged from masochistic doctors who performed the procedures out of cruelty to naive first-time mothers who signed waivers without being informed what they were agreeing to. Some were injected with local anesthetic or given gas to knock them out; some were lucid through the procedure. According to a survivor known as Cora, the nurses told her, “Don’t worry because you’re going to have a Caesarean, they said. It’s a little cut, but it won’t be noticeable, because it’s on the bikini line. They said Dr Sheehan will do you …The nurse held my hand and told me there was nothing to worry about. They got me to sign a piece of paper and one of them held my hand up while I was doing it. He [Dr Sheehan] comes in with a black case. In his hand there was a needle like one you would use for a cow, with a plunger, full of white stuff, and he put that into my leg, near the top, on the inside. You’ll be alright now, he said, it’s to stop the pain, so you won’t feel it….I seen him go and take out a proper hacksaw, like a wood saw, the same thing as for wood, a half-circle with a straight blade and a handle. It was out of this world, the torture. The blood shot up to the ceiling, up onto his glasses, all over the nurses. I’ll get you in the next world, I thought. Then he goes to the table, and gets something like a solder iron and puts it on me, and stopped the bleeding. It was death. I knew I was being killed, there was blood coming out of me.”

Elizabeth: The feeling of being powerless, of having decisions made for them, is universal among the survivors of symphysiotomy who testified in the Human Rights court case against Ireland. “Vera” describes being “tied up, [having] no control.” Kathleen recalls “They didn’t tell me what they were doing.” But Hannah put it most clearly: “I’d no idea what a symphysiotomy was.”

Ave: The short term effects were long hospital stays, immense pain, infection, and slow healing. Aileen said, “Over a month my friend said I was in hospital, but I don’t remember.”[15] Describing her recovery period after receiving an unexpected pubiotomy -which is like a symphysiotomy, but instead of snipping the pubis cartilage, doctors break the pelvis bone to widen the birth canal –  Kathleen discussed what life was like after she got: “[At home], the wound was discharging; there was a terrible smell. I dosed it with Dettol. There was no nurse [to look after me]. I remember, it was the winter, the pain in my back [was so bad], it would be fine thing to be dead, I thought. The doctor came in, turned the key in the [front] door like they did then. My God, my love, I’m so sorry, he said, you’ve suffered so much. It didn’t work out for us, things didn’t go right for you, it never crossed my mind that that would be done to you. Take little strolls, little ones….I took a stroll down town, but I couldn’t keep going, I got locked in, I couldn’t move, it was the soreness of the bones. A woman on the other side of the road asked me to come over and have a cup of tea, but I couldn’t cross the road. They thought I was going to die, I was so white. There was no binding of the pelvis, no, I was shuffling for six months. Once, I went up the stairs, but I couldn’t keep going, and I couldn’t come down, I was jammed in the middle, frozen to death. My husband came home to find me shaking.”[16]

Elizabeth: The long-term effects of symphysiotomies and pubiotomies took an immense toll on their survivors. Nuala “had pain for nine years.”[17] Aileen remembered “I wasn’t even walking by the time I had my second, in ’64. I’ll never forget the pain of trying to conceive.”[18] And true to form, even though they continued to suffer from the long-term effects of the surgeries, many women had no idea what had happened to them until many years later. When Cora sought help from her GP as a much older adult, “I was telling my doctor and she wouldn’t believe me, she thought I was a clinical nuisance. Until you bring me the medical records, she said… Is it very painful, my son asked. For me it was, I said, I had to have a Caesarean section, I was cut with a saw. But you don’t do it with a saw, he said… Then he found it … It all came together, we got the records and brought them to the doctor. She shook hands with me, she knows I am in pain now, she sent me for counseling.”[19]

Ave: In all the cases of symphysiotomies and the rarer pubiotomies, women like “Kathleen” and “Dolores,” (whose names were anonymized by the group Survivors of Symphysiotomy-Ireland for the report they put together for the Human Rights Court) described their lack of control, agency, and choice in the implementation of the procedure. The Catholic ethos saturated the reproductive health field in Ireland for the majority of the 20th century. And of course, this needn’t have been the case. There were no laws that prohibited C-sections in Ireland. Every symphysiotomy was a choice that a doctor made in order to perpetuate a woman’s potential fertility – to ensure that, no matter what she wanted for her body and reproductivity, she could get pregnant if she had sex.

Elizabeth: As we’ve discussed previously on this show, Ireland’s independence movement was, by 1919, deeply entwined with Catholicism. Catholicism became an ethnic marker of difference between the Irish and their English overlords, but it was more than that; the Irish Catholic ethos of sexual purity and morality were written into the very fabric – and Constitution – of the independent Irish state. The 1937 constitution explicitly laid out an Irish woman’s place: in the home, as a mother. With the virgin mother as the model Irish citizen – and all the horrible ironies laden therein – there was an assumption that “good” Irish women would marry and just have babies until their bodies stopped being able to have babies. When one Dr. De Valera met with “Hannah,” he told her “I normally do a Caesarean section, De Valera said, but because you are such a good a Catholic, I’ll do a symphysiotomy, you’re a Catholic family, you’d be expected to have at least ten – if you have a Caesarean, you can only have three. And, as a Catholic, you need to go through the pains of childbirth – if you had a Caesarean, you wouldn’t. The baby is as big as yourself – why do small women marry big men? I’ll have to stretch your hips and straighten your pelvis.”[20]

Averill: Obviously this is absurd – but also representative of how women were treated, what was expected of them, and how the cycle of childbirth was used to keep them complacent, owned, and powerless in Irish society. And, as Delay and Sundstrom argue, this is why we must consider the Irish reproductive health “care” system as characterized by obstetric violence – from the inception of the Irish Free State until very, very recently – it was only in 2017 that Ireland voted by referendum to decriminalize abortion, and in 2018 the Health Act made abortion legal within 12 weeks of conception. Before that, women – immigrant women in particular – died because Catholic doctors and hospitals refused to provide abortion services. Despite being codified in the Irish Constitution, it turns out that Irish mothers were not as valued as one might think.

Elizabeth: Interestingly, though they are no longer the mainstay of Irish surgical solutions to obstructed labor, symphysiotomies have not disappeared. Doctors in countries with lower GDPs and less access to resources – including medical supplies – have turned to symphysiotomies as hopeful solutions to high infant and maternal mortality rates.[21] Public health experts argue that in resource-poor regions, symphysiotomies can be literally life-saving – as they were in the 19th century, before the standardization of C sections. Most recommend that women undergo the operation early, because when allowed to heal adequately, the symphysiotomy (and pubiotomy) permanently alter the birth canal, and can allow people to give birth in more traditional settings – at home or in birth clinics. The reduction in a likelihood of an obstructed labor improves the chances of mother and infant survival significantly. For example, in the last 10 years, Nigerian reproductive health advocates have proposed a revival of the symphysiotomy. Since 98% of maternal deaths occur in countries that are resource-poor, it seems like a reasonable solution.

Ave: Of course, in a setting where a symphysiotomy is an informed choice made by a pregnant person, that’s an entirely different horse. The instances that Cara Delay uncovered in her research, and the testimonies collected by the group Survivors of Symphysiotomy – Ireland for their various lawsuits against the Irish state, are obviously describing coercive, non-consensual procedures, which left lasting psychological and physiological damage on the survivors.

Elizabeth: For some survivors, there’ve been some settlements made with the Irish government. Without proof of surgery – and conveniently, many of these women’s symphysiotomies weren’t recorded in hospital records, despite the clear post-op scars and scar tissue – claimants can receive up to €50,000, but are forced to waive their right to pursue legal action in court. For those who had proof of the non-consensual surgery, they’ve received up to 450,000 euros in hospital damages. The SOS-Ireland group continues to advocate on behalf of those subjected unwillingly and unknowingly to these procedures. Money, of course, won’t erase the decades of pain, the trauma, and the scars; but like the many scandals instigated by Irish Catholicism, they’re being aired out in the 21st century, and changing the country, its reproductive health services, and its people for the better. 

Ave: So I’ve never had a baby before, nor will I – which most of you probably already know, LOL – so I could have gone my whole life happily not knowing about symphysiotomies. But in 2016, Cara Delay wrote an essay for Nursing Clio, where I’m the layout editor, about symphysiotomies in Ireland – her original essay for NC, and then the longer academic essay that she published last year, are the main secondary sources for this episode. As I read it to prep it for image curation, it was like a car wreck… horrible, and all I wanted to do was look away, but I couldn’t. So disturbing. Actually, if I remember correctly, she wrote the essay for us because our Sarah, who was also an editor at NC then (she’s Executive Editor now, go girl!) came across the term in one of Cara’s other NC essays, and asked her to write an entire post of symphysiotomies. Cara obliged, and it’s been haunting my nightmares ever since. Of course, as a scholar of gender and sexuality in Ireland, I am not at all surprised. The Catholic-nationalist ethos and its iron-fist ruling of sex, sexuality, women’s bodies, etcetera, is what I’ve been researching and writing about for the last decade. But just when you think things couldn’t have been worse… ugh. Have you ever heard of symphysiotomies before?

Elizabeth: That’s it! Thanks for listening. Be sure to follow us on Facebook and Twitter @dig_history. If you’re looking to bedazzle yourself in some epic Dig swag, visit our Tee Public store! Find the link to our Swag store, as well as transcripts and bibliographies for all of our episodes, at digpodcast.org


Notes

[1] Appendix to the SOS Report to the European Union International Court of Human Rights. Report submitted 14 June 2014, accessed on 25 May 2021, p39.

[2] C. H. Vacaflor, “Obstetric violence: A new framework for identifying challenges to maternal

healthcare in Argentina,” Reproductive Health Matters, 47, 6573 (2016) 1.

[3] Sonya Charles, “Disempowered Women? The Midwifery Model and Medical Intervention,” in Sarah LaChance Adams and Caroline R Lundquist, Coming to Life: Philosophies of Pregnancy, Childbirth, and Mothering, (New York: Fordham University Press, 2013) 215.

[4] Cara Delay and Beth Sundstrom, “The Legacy Of Symphysiotomy In Ireland: A Reproductive Justice Approach To Obstetric Violence,” Reproduction, Health, and Medicine: Advances in Medical Sociology, Volume 20, 197-218 (2020) 206.

[5] Judith Walzer Leavitt, “The Growth of Medical Authority: Technology and Morals in Turn-of-the-Century Obstetrics,” Medical Anthropology Quarterly , Sep., 1987, New Series, Vol. 1, No. 3, Obstetrics in the United States: Woman, Physician, and Society (Sep., 1987), 230-255; 243; and Nadia Filippini, Pregnancy, Delivery, Childbirth: A Gender and Cultural History from Antiquity to the Test Tube in Europe (Taylor & Francis Group, 2020) 95.

[6] Leavitt, “The Growth of Medical Authority,” 231.

[7] Filippini, Pregnancy, Delivery, Childbirth.

[8] Filippini, Pregnancy, Delivery, Childbirth, 168.

[9] Filippini, Pregnancy, Delivery, Childbirth, 168.

[10] Filippini, Pregnancy, Delivery, Childbirth, 170.

[11] Ployant [1797] 1803: 6, qtd. in Filippini, Pregnancy, Delivery, Childbirth, 171.

[12] Janette C. Allotey, “English midwives’ responses to the medicalisation of childbirth (1671–1795),” Midwifery, Volume 27, Issue 4, (August 2011) 532-538; 533.

[13] Allotey, “English midwives’ responses to the medicalisation of childbirth,” 536.

[14] Leavitt, “The Growth of Medical Authority,” 231.

[15] Appendix, 45.

[16] Appendix, 39.

[17] Appendix, 47.

[18] Appendix, 43.

[19] Appendix, 44.

[20] Appendix, 47.

[21] A Wilson, EG Truchanowicz, D Elmoghazy, C MacArthur, and A Coomarasamy, “Symphysiotomy for obstructed labour: a systematic review and meta‐analysis,” BJOG : an international journal of obstetrics and gynaecology, Vol.123 (9), (2016-08) 1453-1461.

Bibliography

Appendix to the SOS Report to the European Union International Court of Human Rights. Report submitted 14 June 2014, accessed on 25 May 2021, available at https://tbinternet.ohchr.org/_layouts/15/treatybodyexternal/Download.aspx?symbolno=INT%2fCCPR%2fCSS%2fIRL%2f17504&Lang=en

SOS Report to the European Union International Court of Human Rights. 26 July 2017, accessed on 25 May 2021, available at https://tbinternet.ohchr.org/Treaties/CAT/Shared%20Documents/IRL/INT_CAT_CSS_IRL_27972_E.pdf

SOS Submission to the United Nations Special Rapporteur on Violence Against Women, May 2019, accessed on 25 May 2021, available at https://www.ohchr.org/Documents/Issues/Women/SR/ReproductiveHealthCare/SurvivorsSymphysiotomy.pdf

Janette C.Allotey, “English midwives’ responses to the medicalisation of childbirth (1671–1795),” Midwifery, Volume 27, Issue 4, (August 2011) 532-538.

Kate Antosik-Parsons, “A Body is a Body: The Embodied Politics of Women’s Sexual and Reproductive Rights in Contemporary Irish Art and Culture,” Reproductive Justice and Sexual Rights : Transnational Perspectives. (Taylor & Francis Group, 2019).

Kenneth Björklund, “Minimally invasive surgery for obstructed labour: a review of symphysiotomy during the twentieth century (including 5000 cases),” BJOG: an International Journal of Obstetrics and Gynaecology, Vol. 109, (March 2002) 236–248.

Sonya Charles, “Disempowered Women? The Midwifery Model and Medical Intervention,” in Sarah LaChance Adams and Caroline R Lundquist, Coming to Life: Philosophies of Pregnancy, Childbirth, and Mothering, (New York: Fordham University Press, 2013)

Cara Delay, “The Torture Began”: Symphysiotomy and Obstetric Violence in Modern Ireland, Nursing Clio, May 31, 2016

Cara Delay and Beth Sundstrom, “The Legacy Of Symphysiotomy In Ireland: A Reproductive Justice Approach To Obstetric Violence,” Reproduction, Health, and Medicine: Advances in Medical Sociology, Volume 20, 197-218 (2020).

Nadia Filippini, Pregnancy, Delivery, Childbirth : A Gender and Cultural History from Antiquity to the Test Tube in Europe (Taylor & Francis Group, 2020).

Dan Aurel Nica, Horatiu Alexandru Moisa, Aurel Mohan, and Alexandru Vlad Ciurea, “Leonardo Gigli and the Gigli SawGigli Redivivus,” World Neurosurgery 135 (March 2020) 35-37.

Marie O’Connor, Bodily Harm Report: Symphysiotomy and Pubiotomy in Ireland, 1944-1992, (2011) 

Ludwik Schroeter, “A Plea for Hospital Delivery of Our Maternity Patients,” Buffalo Medical Journal (1910).

C. H. Vacaflor, “Obstetric violence: A new framework for identifying challenges to maternal healthcare in Argentina,” Reproductive Health Matters, 47, 6573 (2016)

Judith Walzer Leavitt, “The Growth of Medical Authority: Technology and Morals in Turn-of-the-Century Obstetrics,” Medical Anthropology Quarterly , Sep., 1987, New Series, Vol. 1, No. 3, Obstetrics in the United States: Woman, Physician, and Society (Sep., 1987), 230-255.

Adrian Wilson, Ritual and Conflict: the Social Relations of Childbirth in Early Modern England, (Taylor & Francis Group, 2013).

Adrian Wilson, The Making of Man-Midwifery: Childbirth in England, 1660-1770 (Harvard University Press, 1995).

Newspaper articles:

Olivia Kearney awarded 450,000 euros in hospital damages,” BBC (26 March 2012)


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