I welcome Members. We will now have statements on symphysiotomy for the next two hours. I call on the Minister to make his statement under Standing Order 45.
Symphysiotomy: Statements
I am pleased to have the opportunity to address the House this morning and to have the opportunity to discuss the outcome of the symphysiotomy ex gratia payment scheme and the report of Judge Maureen Harding Clark, assessor to the scheme. It is fair to say we have all been touched by the stories of the women who underwent symphysiotomy and the Government’s aim was to take as humane and dignified an approach as possible to help bring closure to as many of the women as possible. The scheme has helped to bring that closure to a large number of women and I welcome that. However, I will address a number of issues raised in the House on 1 December 2016, including the terms of reference for the scheme, the issue of consent by women undergoing a symphysiotomy, the level of proof required to seek awards under the scheme and the right to appeal. I will do so during the course of this speech, as well as setting out the background to the establishment of the scheme.
Following examination of two earlier independent reports commissioned by my Department, it was agreed by the Government in July 2014 to establish an ex gratia scheme for women who underwent a surgical symphysiotomy. The surgical symphysiotomy payment scheme was established in November 2014 following engagement by the then Minister for Health with the three patient advocacy groups that support women who underwent the procedure. It is an important point for the House to note in our discussions today that two of those advocacy groups welcomed the Government-approved scheme. One of those groups has stated its clients were happy to have been vindicated and to have had their suffering acknowledged. This support group also indicated that they had positive feedback concerning the scheme from the women and their families, and it stressed the importance of providing redress for the women, given the older age group to which many of the women belong. This group has indicated that it supported in excess of 250 of the women in 2015. One advocacy group rejected the scheme and continued to advocate for court settlements for the women. The scheme provided an alternative, non-adversarial and person-centred option for women, many of whom were elderly and did not wish to pursue their cases through the courts.
As Deputies are aware, the first independent report commissioned by my Department was undertaken by Professor Oonagh Walsh. Professor Walsh is a renowned medico-social historian with a special interest in female medical history. Professor Walsh outlined the history of symphysiotomy in Ireland and recommended that an ex gratia scheme be established. Importantly, Professor Walsh’s research also included a national public consultation process with the women themselves and with other interested bodies. The Walsh report noted that symphysiotomy was an exceptional and rare intervention in obstetric practice in Ireland. The procedure was used in mild to moderate disproportion and in obstructed labour. It occurred in less than 0.05% of deliveries between 1940 and 1985. The report estimates that approximately 1,500 symphysiotomy procedures were undertaken in Irish hospitals and that there were approximately 350 women still living who underwent the procedure. The second report was prepared by Judge Yvonne Murphy, who was commissioned by the Government in 2013 to undertake a further independent review on the legal aspects of symphysiotomy in Ireland. Judge Murphy advised the Government on the merits and costs of proceeding with an ex gratia scheme relative to taking no action and allowing the court process to proceed. Once again, Judge Murphy recommended that an ex gratia scheme be established.
Regarding the issue of consent, based on the evidence available to the Department of Health, it appears that in a number of cases the procedure was carried out without a woman's knowledge or consent.
However, this was not the case in all hospitals. It would also appear that the lapse of time, the demise of the clinicians involved and the paucity of records may have made it difficult to establish whether reasonable efforts to obtain consent were made. Hospital records in some instances showed that it was an elective procedure. The data on symphysiotomies in Our Lady of Lourdes Hospital in Drogheda include a high number of elective procedures, which would have been carried out with patient consent. A total of 20% of respondents to Professor Walsh during her research were private patients.
Until the 1960s, it was common for many women in the Dublin area in particular to only present for a hospital delivery once complications had set in. Professor Walsh alluded to cases where patients had been in labour for extraordinarily long periods before admission to hospital. A labour period of 50 hours was high but not exceptional in those early years. Judge Yvonne Murphy found that a court was not likely to hold that it was necessary to have obtained an informed consent in unexpected lifesaving emergency situations of obstructed delivery during labour.
Judge Harding Clark provided a comprehensive report and we now have available a thorough overview of the historical and medical context of symphysiotomy in the country. The report included several appendices containing information gleaned by Judge Harding Clark and her team during the operation of the scheme. Appendix I includes information on radiological imaging used in the assessment of symphysiotomy, entitled Symphysiotomy & Pubiotomy Review - an Imaging Perspective. Two further appendices contain historical documentation relevant to symphysiotomy in Ireland. Appendix II contains extracts from the Transactions of the Royal Academy of Medicine in Ireland between 1943 and 1967. Appendix III contains extracts from the annual clinical reports of four major maternity hospitals: the National Maternity Hospital, Holles Street; the Rotunda; the Coombe Women and Infants University Hospital; and Our Lady of Lourdes Hospital, Drogheda. It also contains medical papers published between 1940 and 1960. Contrary to some reports in the media, the information provided in appendix II and appendix III shows that symphysiotomy was not a secret procedure at the time. In fact, it was debated and discussed in many medical papers by eminent physicians.
The total cost of the symphysiotomy payment scheme was a little under €34 million and payments of €50,000, €100,000 or €150,000 were made to 399 women who met the criteria for awards. All of the women have received their respective payments, totalling €29.85 million. The majority of claimants were aged over 75 years and payments were made to women between the ages of 51 and 96 years. Many women took legal advice and the scheme provided for payment of their legal costs. The total legal costs were a little under €2.1 million. A breakdown of amounts paid to the solicitors involved is available in appendix V of Judge Harding Clark's report. A little under €1.25 million was expended on administrative costs. These included rent, telephone, fees and salaries, office equipment and supplies, utilities and broadband.
The scheme was designed to be simple, straightforward and non-adversarial. It was designed to offer to women an alternative to pursuing their cases through the courts if they so wished. The women were not expected to give oral testimonies, unlike in a court setting. Although the scheme was non-adversarial, the provisions took into account that women may have wished to consult a solicitor and take legal advice and assistance in submitting applications to the scheme. In the interests of accountability, the scheme required each applicant to prove that she had a surgical symphysiotomy or pubiotomy to be considered for the assessment of an award. The level of proof required to qualify for an award was clearly set out in the terms of the scheme. It is important to note that the proof required was, rightly, considerably lower than the burden of proof that would have been required by a court. Judge Harding Clark worked with each woman or her legal representative to locate medical records. When she considered it necessary, Judge Harding Clark met some of the women in different parts of the country. Where claims could not be reconciled with established facts, women were examined by relevant medical experts. Judge Harding Clark encouraged women who believed they had undergone a symphysiotomy to apply to the scheme, advising them that they did not give up their right to pursue their cases through the courts. It was only on accepting an award under the scheme that a woman had to discontinue her legal proceedings. The vast majority of women opted to do so.
The scheme was administered to the highest standards in line with its terms of reference. The scheme had an independent website to provide advice, assistance and information to interested persons as the scheme progressed. Applicants and their family members could contact the office of the scheme by telephone. Where an applicant was too infirm to apply herself, applications were accepted by proxy on her behalf. All awards were transferred electronically to the applicant's account. Importantly, at the end of the scheme, all applications and supporting documents were returned to the applicants or were confidentially shredded in line with the wishes of each applicant. The scheme did not hold any original medical records.
In order to undertake her role under her terms of reference in an informed manner, Judge Harding Clark drew on the professional expertise of certain medical specialists. These clinicians specialised in the areas of obstetrics, radiology, orthopaedic surgery, pelvic injury and urology. They advised on the scheme throughout the process. This ensured an effective, fair and well-informed method of assessment of the applicants by means of a comprehensive clinical case review in line with best practice, whenever this was required. Many hundreds of hours were spent examining the medical records of applicants. Each application received individual and careful assessment. Medical evidence was sought to explain delivery records. When claims could not be reconciled with established facts, the applicant was examined by relevant clinical experts. Some applicants were examined by several experts.
When all efforts failed to obtain records, the scheme moved to seeking secondary proof of symphysiotomy by evidence of a scar and radiology evidence. In 12 especially difficult applications, Judge Harding Clark held a discussion conference between her medical team and the medical expert representing the women. Consensus was reached based on the medical facts in each case. Out of almost 600 applicants, 185 women were unable to establish that they had a surgical symphysiotomy. The report states that all of these applicants were assisted by members of the team in trying to establish their claims. The resources relating to the scheme were applied in rigorous investigations before a claim was declared ineligible for the scheme. On reading Judge Harding Clark's report, I get a real sense that the team and the judge worked with each applicant to try to establish facts, obtain records and ensure that an applicant to the scheme had every support and opportunity to have records and medical evidence presented.
A total of 23 women experienced a spontaneous symphysiotomy during birth. While this condition is not particularly common, it is well recognised. These women did not quality for an award under the terms of the scheme because they did not have a surgical symphysiotomy.
Pubiotomy is a distinctly different procedure to symphysiotomy. It was also included in the scope of the scheme at the request of the support groups. Pubiotomy was frequently claimed by applicants but was established in only one case. Significant disability was established in that case.
It should also be noted that medical services, including medical cards, are facilitated for the women by HSE-nominated symphysiotomy liaison officers based throughout the country, regardless of whether a women has availed of the scheme.
In July 2014 one of the advocacy groups made representations to the UN Human Rights Committee concerning symphysiotomy. Ireland takes its membership of international organisations seriously. The country is absolutely committed to human rights. This is why we always engage with these processes in a meaningful way through providing information and updates, responding to recommendations and attending reviews held by these organisations. This gives us an opportunity to set out the Government position on Human Rights. Shortly, we will provide more details about the scheme to the Convention on the Elimination of All Forms of Discrimination Against Women. While the Government notes the comments made by the UN on symphysiotomy, it believes that the provision of the ex gratia scheme and the ongoing provision of medical services by the HSE represent a comprehensive response to this issue.
My Department has received the report that one of the support groups, Survivors of Symphysiotomy, has submitted to the UN Committee on the Elimination of Discrimination against Women, which has symphysiotomy on the agenda for its meeting on 15 February. There are serious inaccuracies in this report that cannot go without comment. The opening paragraphs refer to women having their pelvises broken during childbirth. A symphysiotomy does not involve breaking the pelvis. The procedure involves cutting the fibrous cartilage of the pubic joint. The report to the UN claims that no independent or thorough investigation has been carried out in Ireland into the practice of symphysiotomy. The contrary is the case, and I have already set out the background to the thorough work which has been done on the matter, most recently by Judge Harding Clark, but by others before her as well.
I urge anyone who wishes to get a fair and balanced view on the issue of symphysiotomy to read Judge Harding Clark's report. She was unfettered by Government in completing her work. She could have simply administered a payment scheme, and she would have been able to do so and fulfil the terms of reference. However, she chose to use her judicial skills and experience and that of her clinical team to examine all aspects of the issue and to review the evidence collected in the two years of her work. The report states that my Department has refused to supply information concerning the research conducted by Professor Leo Lawler, consultant radiologist at the Mater Misericordiae University Hospital, visiting consultant at the Rotunda Hospital and a member of Judge Harding Clark's clinical advisory team.
This is not correct. My Department was not involved in this study and therefore it has no further details other than the documents we have supplied in response to a recent freedom of information request.
It is important to emphasise the importance which we place on patient safety and quality in our modern maternity services. Ensuring that quality of patient care is at the heart of our health services and that we keep our patients at the centre of the provision of our services is key. We must continually learn and work to make our services safer. One year ago, my Department published Ireland’s first national maternity strategy in a concrete demonstration of a new, enhanced and long overdue focus on maternity care at both policy and service delivery level. Just before Christmas, I launched the new HIQA national maternity standards. Taken together, these initiatives provide a roadmap for how we can continue to improve maternity and neonatal care in the years ahead to promote and assure safe, standardised and high-quality care. In addition, I am pleased to note that all maternity services are now reporting monthly maternity patient safety statements and are participating in national data collections, including the Irish maternity indicator system.
More broadly, my Department remains fully committed to progressing a programme of major patient safety reforms. These measures are focused on legislation, the establishment of a national patient advocacy service, the introduction of a patient safety surveillance system, extending the clinical effectiveness agenda, commencing a national patient experience survey and setting up a national advisory council for patient safety. In December, I launched our new national patient safety office, which will be the driver behind many of these reforms. Within the programme of legislation we intend to progress the licensing of our public and private hospitals, the health information and patient safety Bill and provisions for open disclosure.
In conclusion, the brief given to Judge Clark in November 2014 was not an easy one. At that time, the advice to the Department of Health was that many women would face an uphill struggle in proving their claims in the courts and we did not want women to have to face that uphill struggle. Each woman would face an uncertain outcome, as each case would be adjudicated by the courts on its individual merits. We now know that this is the truth. For example, in one of the small number of cases that have gone through the courts, the judge in that case found that even though the woman had a symphysiotomy 12 days before her baby was born in 1963, this procedure was “not a practice without justification” at that time. This ex gratia scheme was to avoid the adversarial courts-based system. Judge Clark's independent report is a thorough body of work and I hope the implementation of this scheme has helped to bring closure to many women.
We now have one hour and 43 minutes left in this debate. I have 16 speakers offering. Due to the serious nature of this debate on symphysiotomy, I want every speaker on the list to be able to contribute. I will be strict on the times. Deputy Billy Kelleher is next and is sharing five minutes of his time with Deputy Smyth.
I might be even briefer if I can be.
Thank you.
I welcome the fact that the House and the Government established an ex gratia payment scheme. We said at the outset that an adversarial court procedure in the context of individuals having to go to court to vindicate their rights was something that we had grave concerns about. As alluded to by the Minister, the fact that every individual case would be taken on its merits and individually assessed by a court, with awards granted or not, would have been unfair to many of the survivors of symphysiotomy.
Reading the report, there is no doubt that some of the language could be seen to be abrasive if one looks at it in the context of where some of the survivors are coming from. It is hard-hitting. When one goes through the whole report, it does sit a little bit uncomfortably at times. Of course, the reality is that some women did not experience symphysiotomies in their time but we should also be conscious that they may have had very difficult labours and that it was many years ago. There were very few supports and services available to women who had forceps deliveries and extended labours of sometimes up to 50 hours, which would not have been uncommon at that time. There were very few supports available to those women after birth. That is an issue that is acknowledged in the assessments of Judge Yvonne Murphy and Judge Maureen Clark of people who went through very difficult experiences.
As has been said in this Chamber, there is no doubt that symphysiotomy was quite a barbaric practice and was continuing long after it was no longer seen to be a conventional medical intervention across the western world. It continued for a longer period of time in Ireland than elsewhere. It must be acknowledged that for whatever reasons, some obstetricians continued the practice when it was no longer deemed to be a recognised intervention for a complicated delivery. That is certainly something of which we must be conscious. We failed to bring forward supports both for these women and in the context of the wider maternity services, which left a lot to be desired for many years. There was no proper oversight. Peer assessment and peer review of obstetricians, practices and outcomes were not what they are today. Leaping forward in time to our modern maternity services, there needs to be a consistent underpinning of standards in the delivery of care, as well as for professional clinicians, peer assessment, peer review and in the oversight of HIQA, which is critically important.
Some people are still very unhappy with this report. Let us be clear about that. Survivors of symphysiotomy have issued a very hard-hitting statement. We have to acknowledge equally that many women are satisfied that it was an opportunity for their rights to be vindicated and for compensation to be paid. The payments themselves range from €50,000 to €150,000. It had been anticipated that in the region of 350 women would apply for the scheme, but, in fact, 590 applied. Around 400 women, I think it was 403, were awarded some form of redress in compensation.
Judge Clark encouraged women who believed they had had a symphysiotomy to apply to the scheme, advising them that they did not give up their right to pursue their case and vindicate their right through the courts. I believe that is critically important. There were concerns that if people entered the scheme, they would lose their right and entitlement to vindicate themselves in a court of law. Of course, as the Minister pointed out at the end of his speech, there was a case in which a person did go to court. A symphysiotomy had been carried out but no compensation was offered and her right was not vindicated. It does put into perspective the risk for women who were damaged by symphysiotomy in going to court and having their case individually assessed. We said at the very outset of the scheme and the establishment of same that its purpose was for people to have their rights vindicated, for compensation and redress to be given and for the money to go to the victims as opposed to their legal representatives in very expensive court cases.
Judge Clark's report contains very hard-hitting language in many aspects, but she does refer to the issue of some people making applications based on evidence presented by others who were successful in their claims in court and things like that. A huge number of women suffered appallingly at the hands of the maternity services in Ireland in a previous time. It would be shameful and distasteful, to say the very least, if a small number of people were using the misery and the trauma that was visited on those women to try to seek redress. Even if there was only one or two, it would be shameful. The last thing we need to do is undermine the traumatic stories that people told us. Listening to the evidence was utterly traumatic, to be truthful. We met them in the AV room and listened to some of those affected. It was exceptionally difficult just to listen to their stories of what they endured. Let us be honest, the vast majority of them were vindicated in the context of their applications to the ex gratia payment scheme. We have to put that in context. It would be remiss of me to not accept the fact that there may have been a very small minority who used the tragic circumstances of symphysiotomy and the scheme itself to try to seek redress for themselves for ulterior motives.
The UN Human Rights Committee recommended that "the State party should initiate a prompt, independent and thorough investigation into cases of symphysiotomy, prosecute and punish the perpetrators, including medical personnel, and provide an effective remedy to the survivors of symphysiotomy for the damage sustained, including fair and adequate compensation and rehabilitation, on an individualized basis".
In that context we have done some of it. Whether or not the Dáil or Government would consider the prosecution and punishment of perpetrators, that would not necessarily be a role for us as legislators, but we must continue to ensure rehabilitation for the individuals. The fair and adequate compensation that was awarded through the ex gratia payment has been accepted by a lot of the survivors of symphysiotomy, but we still have a substantial group that feels dissatisfied with the report in its entirety, and not only the ex gratia payment. They are also dissatisfied with the recommendations made in the report prior to that by Judge Yvonne Murphy. It is a difficult issue to address to try to ensure everyone feels they could embrace this particular scheme, and that is regrettable. I sincerely hope we do not end up with people going to the courts continually with some of them finding that they will not get redress or compensation there. That is something we did not want to happen but it looks like it will happen now, unfortunately, for some people who did not embrace the scheme in that context.
We must be mindful of the language that was used in the report. While it was hard hitting and direct, in some areas one could say it was abrasive. Ms Justice Maureen Harding Clark used her judicial experience, of which there is no doubt, but it was very direct. I want to put on the record that we must be very mindful that there were a huge number of women who were badly damaged at the hands of the health services at the time and we should never lose sight of that. We can sometimes get caught up in what was said in the report with regard to the 185 women who did not qualify for the scheme, but that does not mean that many of those 185 women did not endure some form of traumatic experience at the hands of the health services in the context of difficult labours, forceps deliveries and almost no supports after the births of the kind that would be offered nowadays. We must also acknowledge the fact of postnatal depression, an area of which people are now very conscious. Back then, however, it was not even discussed. Many women are still damaged that have not received redress through this scheme.
Fianna Fáil hopes that the publication of Ms Justice Maureen Harding Clark’s report, The Surgical Symphysiotomy Ex Gratia Payment Scheme, will bring some closure to the women who were so badly affected. We believe the scheme was a genuine attempt to try to bring a resolution to this matter. Many of the findings of the report made for very distressing reading. The practice of symphysiotomy had stopped in other countries for many years but, unfortunately, continued for some time later in Ireland. The procedure has caused debilitating physical, psychological and emotional side effects for many women who have had decades of medical problems as a result. It is to be hoped they will be able to access the treatment and supports they so badly need. Unfortunately, four of the women passed away before the report was published. Thankfully, symphysiotomy is no longer an accepted practice in obstetrics and it is crucial that the medical professions have learnt lessons from the past.
In 2014, the UN Human Rights Committee recommended that, “The State party should initiate a prompt, independent and thorough investigation into cases of symphysiotomy, prosecute and punish the perpetrators, including medical personnel, and provide an effective remedy to the survivors of symphysiotomy for the damage sustained, including fair and adequate compensation and rehabilitation, on an individualized basis.” Ms Justice Maureen Harding Clark’s report on the surgical symphysiotomy ex gratia payment scheme was published in November. The scheme was aimed at women who underwent a surgical symphysiotomy in the State between 1940 and 1990. It had been anticipated that in the region of 350 women would apply to the scheme, but in fact 590 applications were received. Ms Justice Harding Clark encouraged women who believed they had had a symphysiotomy to apply to the scheme, advising them that they did not give up their right to pursue their case through the courts. I would like now to read an extract from the report:
All objective evidence received or obtained was carefully considered and any doubt was applied in an applicant’s favour. If an applicant identified a specific disability, her subsequent delivery records and her GP records were examined for evidence of any treatment or investigation capable of supporting the fact of that disability. The applicant’s personal statement was reviewed and considered in the totality of the evidence. That is not to say that all statements and reports were accepted uncritically.
I must confess to a feeling of sadness for those applicants who somehow believed that they were victims who had survived a symphysiotomy only to learn that they were mistaken and that their recollections were based on error. Elderly women should not have to face such emotional turmoil. I have no doubt that some of them spent good money presenting their claims, which cannot be recouped. Those who have been active in representing themselves as victims to the media must now retrace their lives and this, understandably, must be upsetting.
I will start with a quote: "For the public at large, the purposes of the Scheme were fulfilled by an objective but compassionate assessment ... It is hoped that the findings will quell the hurt and anger of the elderly women who have undergone the procedure and that this subject will now be laid to rest." With these words Judge Maureen Harding Clark concluded her chapter 1 overview before addressing the costs of the scheme and recording her thanks to those who assisted her over the two years of her role as judicial assessor over the surgical symphysiotomy payment scheme. Harding Clark seeks to assure the public at large that she conducted her role with objectivity and compassion. There is scant evidence of this claim in the pages of her report and there is none at all in their harrowing accounts of their experiences of the process and their reaction to Harding Clark's "insulting and wounding commentary", by several of the survivors.
Judge Harding Clark's brief was, I understood, to preside over the assessment of claims of those who were subjected to surgical symphysiotomy, to determine the legitimacy of claims made as best the women's testimony and available records would allow, to evaluate the extent of discomfort or disability arising from the procedure and to award the applicant accordingly in line with the three categories of payment prescribed from the outset of the scheme. I was not aware that Judge Harding Clark had been commissioned to provide a history of symphysiotomy or pubiotomy, but she has. I was not aware that Judge Harding Clark had been commissioned to evaluate the long-term effects of symphysiotomy on those who were subjected to the procedure, but she has.
Judge Harding Clark describes the payment scheme she was commissioned to oversee as "an ex gratia, non-adverserial scheme". She goes on to state that "once symphysiotomy...was established, a compassionate and generous view would be applied to the assessment of each claim". It is possible that some who applied under the terms of the scheme would view Judge Harding Clark's disposition towards them as compassionate and generous but not all of them would, nor near all by any means. The tone of Judge Harding Clark's report shows little empathy with the claimant women. Many of them, we know from their testimonies before us in the Houses of the Oireachtas and elsewhere, have lived a life of reduced capacity, discomfort and the presence of embarrassing side effects.
Judge Harding Clark acknowledges that 142 of the 183 women who were awarded the higher payments were assessed as having suffered "significant disability", yet she goes on to state in the subsequent page that "The majority of applicants who underwent symphysiotomy made a good recovery". That must surely be a comfort for the cadre of obstetricians who have defended their and their colleagues' actions in years past.
How far in the past, however? A footnote on page 18 speculates it is possible that one or two symphysiotomy procedures were carried out in 2003-04 at the Lourdes Hospital in Drogheda. Members take note. That is in 21st century Ireland. What I find most galling of all is that Judge Harding Clark, who did not interview all of the claimant women, has declared, based on her so-called findings, and with an eye of deference towards the consultant representative body and the reputations of its members, past and present, that the evidence before her "did not confirm that symphysiotomy inevitably leads to lifelong pain or disability or [that] those symphysiotomy patients aged in a manner which was different to those of non-symphysiotomy women." I assure Judge Harding Clark that there was a difference. It was there in the lives lived and in the daily reality of those women for a lifetime.
I wish to place on record what Judge Harding Clark did not hear and did not seek to hear, namely, the story, in part, of a woman whose documentation alone secured her a payment under the scheme but who, like so many others, was not heard. I will refer to her as "Rose", which is not her real name. Rose was taken into an empty ward at midnight. They strapped up her legs and began sawing her pelvis under a local anaesthetic, while a doctor leaned across her to block out her view. She remembers the terror as she felt the sensation of the sawing and there was an eerie silence among the six to eight people in the room, only broken by one of the students asking something about the severity of the operation. At no time did anyone explain what they were doing, either before or after. Rose was expecting the child to be born but was told the child would not be born now, leaving her thinking the worst. They then gave her an injection to put her to sleep. When she began to wake some hours later, they were holding a mask across her mouth which put her out again. When she came around, she was no longer pregnant but there was no baby to be seen. Although her husband and sister tried to assure her that the baby had been born, such was her condition, the hospital did not bring the baby to her for two days. Therefore, as well as her physical pain, she suffered the mental anguish of fearing the worst for those two days. She also had a B. coli infection from the symphysiotomy.
Released from hospital, Rose had to move from her home in Dublin and live with her parents in another location because it took six months before she could walk properly and look after the baby on her own. The pain in her lower back and hips became part of her life, her daily reality for the rest of her life. She also had some problems with incontinency. She did not understand what had happened to her. She miscarried her next pregnancy and subsequent pregnancies had her in nervous dread of what she might have to face giving birth. It was only after Survivors of Symphysiotomy was set up that she realised she was not alone. She was able to talk to others who had also suppressed their horrific experiences for decades. Her son has written to me to state that while being able to talk about what happened has been somewhat therapeutic for Rose, what he has described as Judge Harding Clark's "one-sided report that attempts to whitewash over this shameful episode in Irish medical history has compounded the traumatic stress of these women, rather than seeking the truth, which might have gone some way to helping Rose and the other women come to terms with the consequences of their experiences".
This report is shameful. The character and integrity of the women has been placed in question. Judge Harding Clark's conduct of the scheme entrusted to her has been, in the view of many, both flawed and dismissive. Her treatment of the victims and - let there be no doubt about it - the paltry payments involved, in my opinion, as both a Deputy and as convenor of the Oireachtas support group for over a decade with colleagues in this Chamber, amount to a national disgrace.
Judge Harding Clark's report on the surgical symphysiotomy ex gratia payments scheme does not remedy an injustice, as the Minister claims, but in fact adds to the injustice faced by a group of women, women maimed without their consent by this State and its health services. After everything these women have been through, some suffering for over 60 years, they are effectively being re-traumatised. Let us be honest about it. The elderly women and their supporters believe they are being accused of dishonesty, of deceit and of making fraudulent claims. How unfair it is that these women, one of whom is in her 90s, are left feeling their reputations and honesty are called into question and that their years of suffering are belittled.
The judge asserts that a compassionate approach was adopted in assessing the claims of these women. Frankly, this is hard to credit. It is worth repeating that the barbaric and controversial procedure used on an estimated 1,500 women in Ireland up to the 1980s involved the cutting of the cartilage of a pregnant woman's pelvic bone and of breaking the bone itself in some extreme cases to widen the birth canal. The thought of it is horrific, not least for those of us who have had babies ourselves. Many subjected to the procedure were left with long-term medical difficulties, including incontinence and chronic pain.
The UN Human Rights Committee, the only independent body which examined the issue, described the practice of symphysiotomy as being cruel, inhuman or degrading treatment, amounting to torture. Judge Harding Clark's report takes a different view, arguing that this brutal procedure was non-injurious and medically appropriate. The consent of the patient, she further argues, was unnecessary and not required. The UN committee also recommended that the State should identify, prosecute and punish those who had carried out these procedures without the prior consent of the women involved. The recommendation was to identify, prosecute and punish but the State and the Government have chosen to ignore it.
This lack of accountability adds to the injustice inflicted on these women. As is so often the case in this State, the persistent, relentless campaign for recognition and justice by a determined group of people has forced the Government towards offering some form of redress in compensation for an historic injustice. Judge Harding Clark was appointed as an independent assessor. She processed and assessed applications from almost 600 women who had been subjected to symphysiotomy or pubiotomy. Judge Harding Clark examined hospital records and medical tests to verify the claims of these women. As the Minister announced, payments were offered as redress - €50,000 to those who could show they had had a symphysiotomy; €100,000 to those who could link that procedure to ongoing health consequences; €150,000 for pubiotomy; and so on. The Minister referred to the non-adversarial nature of this process. It was also, of course, ex gratia, which is the crucial point.
I could say so much more, but I want to finish on the following point. Women have suffered all their lives with the consequences of a symphysiotomy. It impacts on entire lives, on families and on physical and mental health. This report has not healed the old wounds. In fact, I would say it has opened up new ones.
Symphysiotomy is an issue which, unfortunately, has hugely impacted on my constituency. Many women in our community have been left with lifelong disability and it has been a life of trauma and upset for both the women and their families. Symphysiotomy procedures dropped off after the 1960s in most parts of the country in favour of caesarean sections, but not at Our Lady of Lourdes Hospital in Drogheda, where they were, unfortunately, carried out right into the 1980s.
I welcome the fact many women were offered compensation under the surgical symphysiotomy ex gratia payments scheme but this was not the scheme the survivors or their supporters wanted after they had endured a long, hard fight to get to this stage.
Liability was never admitted by the medical profession or others, and the survivors were not afforded the opportunity to give oral evidence, to tell their story or have their voices heard. While some women who underwent the procedure made a full recovery, many who had a symphysiotomy have suffered significant pain, illness and psychological damage as a result of the procedure. It is only right that this is recognised by the State and by Irish society.
It comes as a disappointment that the Harding Clark report and media coverage of it left a bad taste in some of the survivors' mouths. There was much focus on the women who did not receive payments under the scheme and the inference is that they were confused or deluded, or even that they were lying. This does a disservice to the women involved. As the inquiry only accepted written evidence, it was difficult to prove that a medical procedure had taken place 60 or 70 years ago. Doctors pass away, medical records are lost - even disposed of - and memories fade. Many women were not even told that they had undergone a symphysiotomy and they did not realise what was the cause of their symptoms or the agony that they went through until many years later. In the absence of medical records, the scheme employed radiological evidence and medical assessments. Survivors of symphysiotomy have stated that this type of evidence is not conclusive for a myriad of reasons, for instance, scars fade, the gap in the pelvis made by this procedure can heal itself. Women have endured a long history as second-class citizens but the Harding Clark report did not do justice to many of the survivors of symphysiotomy.
I thank the Deputy.
I commend all the women who were brave enough to take on this fight for justice and redress and all who came before the scheme. I hope they feel vindicated. I hope they feel the brutal procedure that was done on them has been recognised by the State as precisely that. I hope they feel at the end of the day they got some sort of justice for the pain that they went through for the rest of their lives.
Difficult and all as this discussion is, it is important that it is held. First, I again extend my sympathy to all of the women who were affected by this.
I have read the different reports, including the report of the socio-medical historian, Professor Oonagh Walsh, who goes into the history of it. This was in Ireland, where there was no legal access to contraception and where the question of the mother being subsequently perhaps able to deliver multiple babies successfully was a key element of socio-medical strategy. This was part of the background to what happened in maternity hospitals. Also, the great privacy attaching to pregnancy, which still pertains for instance in most of the developing world where there is very little discussion it is fairly secretive. Once a woman has a baby successfully delivered, very often what most people want is to forget as much as possible as quickly as possible. That pertains to this day. We have practices which in future years may be looked back upon where we have a lot of arrangements around very high numbers of caesarean sections, which are running close to 30%, without a huge amount of discussion. It is true that while for some women delivering a baby is not only a happy and joyful event, it can also be relatively speedy and less painful than it is for a certain proportion of women on the other end of the spectrum for whom, even today, delivery can be extraordinarily and exceptionally painful.
When I was part of the then Government that discussed this, I was of the view that the redress approach should not be the same as an inquiry, that it should be a redress scheme which would be set up and which would invite women who were affected to go through the procedure to seek to get their redress. Let me say why I take that position. I have just heard Members suggesting there should have been a more court-based adversarial process. I personally knew many affected by the different inquiries into children who were held in institutions, in some cases as adult women in Magdalen institutions for the greater parts of their lives. While some are robust in going through procedures and telling their stories, for others, who are both fragile and damaged, it is an incredibly difficult experience where not only must they share with whatever the procedure is but then they must explain to their families and children something which, like this procedure, they may never have explained previously. Setting up a process that would allow women to be compensated was certainly uppermost in my mind and the Labour Party's mind, given that we were coming off a long period. In 2003, as I recall, Deputy Michéal Martin was Minister for Health. The Deputy is a compassionate person but he did not do anything to address the stories that were coming forward then. That happened over a long period of time. It was put to one side. Really, it was not addressed until the various more detailed examinations were undertaken, starting with Professor Walsh's report, going on to the good report done by Judge Yvonne Murphy and then the redress scheme administered by Judge Harding Clark.
What is interesting about the scheme is that, initially, it was thought - this was following on two previous detailed expert reports - that approximately 350 women would apply. In fact, there were 950 applications. That is no one's fault. Inevitably, when a scheme is advertised those who feel they were affected as well as those who perhaps had been involved in different groups over a long period of time campaigning on it would, of course, go forward. It is also interesting how many awards were made. Liability was established in over 400 cases. That is a shocking figure. In that sense, the scheme dealt with and made awards to far more women than were even anticipated would come forward when it was set up at the outset.
There have been comments here about the fact that awards were classified in groups by amounts awarded but that is often done internationally where one is making a scheme easy to access. It is quite a sensible approach to take because it lessens the trauma for most of those concerned. We need to be honest about that. We have had so many cases in here of women who have been accused of sexual abuse who have been thrashed on social media because of what they have said, and we have discussed that here. I entirely disagree with the idea that these most private matters would be entirely in the public domain and before a court-type procedure because of the cases of those of whom I am aware who either chose or did not choose to go before court-type procedures on previous occasions.
Three-hundred and thirty-nine applications received awards, 166 of which were awarded €100,000. I am not saying that in any way compensates for what the women suffered but it is a significant sum. Some 15 assessments involved awards of €150,000 because those women suffered potentially significant disability which, as the House will be aware from the women's testimonies, affect their lives in profound ways.
What do we do as a consequence of learning this?
I suggest that we invite the authors of the various reports to make presentations to the Oireachtas health committee and to have a discussion with the members about the history, with due regard to the sensitivities of people who suffered in this way. That would be a valuable public exercise in terms of education.
We should consider this as well in today's context. About three weeks ago I sat with over 20 women in a hospital and rehabilitation centre in Dar es Salaam in Tanzania in east Africa, where I worked in the 1980s. I wish to speak particularly to all the women who are present, because this is very much a women's concern. In Africa and in most of the developing world, the follow-on and current day practices to which symphysiotomy relates is called fistula. This is where after a delivery, as a consequence of vaginal or rectal damage, a woman basically becomes incontinent in respect of urine and, in some dreadful cases, in respect of faeces as well. It is truly horrifying because in many countries and societies, women to whom that happens are ostracised and shunned as though they have done something wrong. We never had such a history in Ireland; we would never do that. When we are looking at the past through the prism of the present sometimes we do not sufficiently recall what Ireland was like and what the different forces of authority in Ireland were. In any event, we should point out here today that where parallel practices continue to be staple treatments for women who are being delivered of babies in the developing world, this country in its development programmes should help in trying to provide recovery for the women and girls affected.
Of the approximately 23 women I spoke to in Dar es Salaam, who had all had potentially life-saving operations to correct what had happened in a recent childbirth, about seven were teenagers. The youngest was around 15 years of age. As we in Ireland seek to address a dreadful wrong and what women here suffered in the past, we must also thank those women for telling us about it and for sharing what happened to them with later generations of women. The eldest of the women who received the awards was 91 years old while the youngest was 51. All of us would like to believe that the services in Ireland have moved on dramatically, but we should not forget that this type of dangerous event during pregnancy is still very prevalent in much of the developing world.
The other voices that are missing from the debate in Ireland are those of midwives. People who have watched the popular television programme "Call the Midwife", which is based on Jennifer Worth's memoir of being a midwife in the east end of London in the 1950s, will be aware that it was the development of the British National Health Service by Aneurin Bevan, the great Labour Party Minister, which brought an end to some of the terrible practices of that time, as outlined in the books and the television series.
I propose that the authors of these detailed reports be invited to appear before the committee. I am pleased that hundreds of women have received some redress. I hope it has helped them in their lives. It will not have cancelled out what happened to them but, hopefully, it will have given some comfort to them and their children. We should also be proud of the Irish development aid programme, which partly sponsors the hospital and facility I visited. Thousands of women's lives are being saved every year partly through the development money that Irish taxpayers contribute through their taxes. In that way they are bringing an end to parallel sufferings that, unfortunately, women are still undergoing. The tragedy, both then and now, is that when these things happen in a maternity case the baby is often lost as well. The woman is not only physically damaged but her capacity to have children is also severely damaged. Again, that is an enormous heartache for people. It was in the past and it is now.
The Harding Clark report is another injustice to the women who had symphysiotomies against their will. The report is unbalanced, flawed and not objective. It should not be accepted and promoted by the Government. The report was released before Christmas but we are only discussing it at the end of January because a number of Deputies intervened and demanded that it be discussed in the Dáil. In the meantime, some in the Catholic right, the media and the medical establishment have seized on the report and used it as an opportunity to cleanse what happened in the past and to pretend it was not so bad. The message being conveyed in the last month or so is that the women concerned were not believed then and will not be believed now. That is shocking and outrageous.
Judge Harding Clark's report came up with the concept of alternative facts before Donald Trump even thought about it. The Government, Fianna Fáil and the Labour Party should think very seriously before giving this report their imprimatur. The Irish State has an appalling record in dealing with women's health, women's bodies and women's lives. Fianna Fáil, Fine Gael and the Labour Party have all participated in Governments which took decisions to relegate women's health in general, to subcontract women's bodies to the church and its institutions and to challenge in the courts women who were making claims against the State for abuse and injury. Before they consider signing off on this report, they should recall the other chapters in a very bad saga. Those chapters include the Magdalen laundries and the mother and baby prisons - we should stop calling them homes because that gives them a cosy sounding name. There is the export of the abortion trail, where women with crisis pregnancies are shunned out of the country. The death of Savita Halappanavar is another chapter. Of course, let us not forget the glorious plot, with denial and fighting to the very end, against the anti-D women who were poisoned by a State institution. Key figures in this Government and Dáil who played a role in that shameful episode 20 years ago are potentially playing a role now in respect of symphysiotomy.
Let us be clear and frank about what is happening here. A process was commissioned by the Dáil that was supposed to be restorative for women damaged by medical professionals, church and State. Instead, a flawed report is being seized on by the same establishment and ardent Catholic commentators to give the impression that it was not that bad, that was how things were then and a woman's lot was hard everywhere. However, let nobody fool themselves. Ireland was not a normal European country then with its maternity practices, and nobody should fool themselves that it is a normal European country now with the eighth amendment and the continuation of utterly condescending patriarchal maternity practices. I can give two quick examples. The heads of the hospitals that look after women giving birth are still called "masters". Some of them are archbishops, such as the chairman of the board of the National Maternity Hospital as a result of an Act that Fianna Fáil, Fine Gael and the Labour Party have not bothered to repeal in 80 years.
Instead of restorative justice to damaged women, is what we are seeing in this case an attempt by the Government to spin this story out until the last of the ageing symphysiotomy women die? Frankly, that is how it appears. There is disdain in this report on the part of the judge towards the women.
She used language such as that they were "amenable to ... emotional contagion", subject to "acquired group memory" and "self convincing confabulation of personal history". The women were subjected to symphysiotomy because of patronising and patriarchal views of women. They did not give consent and were not informed about what was happening to them. It would seem they are being condescended to again in the 21st century by the judge. The tone of the report suggests the women were ignorant and it is claimed at one point that they were under the influence of campaigners, rather than that the women were well aware of what happened to them and the trauma it created afterwards, especially during subsequent pregnancies. At one point, Judge Harding Clark used the defence that the women were Roman Catholic themselves. It is incredible. Does the fact that 95% of the population is born Roman Catholic mean they should not be asked for consent to have their pelvic bones broken?
Symphysiotomy was a human rights violation. It disregarded the women's rights to bodily autonomy. Whether the doctors intended to harm people is irrelevant. The point is that they did. The tone of the report is what we see again and again in this country when it comes to women's health, namely, the idea of an acceptable standard of suffering. Judge Harding Clark is obsessed with whether it can be proven with "near certainty", a standard that is not even applied in personal injury law, that the woman endured lifelong suffering - not just any suffering; it has to be lifelong. As it was, 35% had to prove they suffered significant disabilities which lasted more than three years. A similar threshold of suffering was applied in the case of Savita Halappanavar, when doctors literally stood over her to measure whether her life, not just her health, was at risk. The issue is that the women did not consent to the procedure and were not informed of it. There are many flaws in the report, which I do not have time to deal with. They have been taken up by people such as Marie O'Connor, Máiréad Enright, Professor Linda Connolly and Dr. Jacqueline Morrissey.
The Minister for Health, Deputy Simon Harris, mentioned the 185 so-called false claims. He repeated that 185 people were unable to establish their claims. Midwives for Choice went through these cases and outlined the facts. Could the Minister please correct this? A total of 65 people withdrew their claims. We do not know why; there could be any number of reasons. Eight people engaged in the process initially but did not engage any further; 21 had inaccurate medical records; 12 were late applications given that the women were given only 20 days in which to make an application; and one person died. This means 78 people did not establish a claim, not 185. The Government is using the figure of 185 inaccurately.
The 78 women are not liars. The process had no oral testimonies. It was centred on written medical records and the judge even claimed that there was no evidence of a religious rather than obstetric reason for the claims. Again, I do not have time to go into it. However, I validate the work done by Survivors of Symphysiotomy Ireland and I hope they will fully answer this outrageous report, which tries to demean them and the women involved.
When I first read this report in The Irish Times, which was the first one to flag to the people that the tone of the report was very much to say there had been no whitewash, nothing was going on, people should move on, there was no problem and there was too much panic about something that was not really a problem, I immediately felt sick in my stomach. It reminded me greatly of the litany of offences that the women who suffered from the anti-D serum in the hepatitis C scandal went through for years at the hands of the State under the current Minister for Finance, Deputy Noonan.
We listened to the evidence of women who suffered from symphysiotomy although we could not hear the evidence of the many such women who are dead. Some of those who gave evidence to us at the time when the scandal was breaking have since died. I pay tribute to those women and their families who fought for truth and justice in this case and who, I am afraid, will have to continue to fight for truth and justice. The truth is not out and justice has not even been attempted in the Harding Clark report. It is a whitewash. It is utterly disgraceful and totally prejudiced against those women who suffered the violation of their bodies in this manner. I thank the academic Máiréad Enright, who has done brilliant work in highlighting how flawed the report is.
Of the 275 pages of the report, 133 are commentary from the judge while 142 are extracts from medical literature. She assessed applications from 600 women who believed they had been subjected to symphysiotomy, she oversaw searches of hospital records and medical texts and she allocated payments according to what she believed was just. The judge allocated €50,000 in some cases, or €100,000, to those whom she believed could link symphysiotomy to ongoing, lifelong health consequences. However, Máiréad Enright points out to us that the extensive defence of what is a uniquely Irish practice of non-emergency dealing with women in pregnancy is not an independent report and that survivors are entitled to more under international law. I entirely agree with her.
What is independent about a report that spends more than a whole chapter criticising and condemning women who mistakenly claimed they had had a symphysiotomy and spends less time examining why doctors carried out the practice? I argue the reasons for which they carried out the practice were rooted in the conservative, Roman Catholic nature of Irish society and not just the church itself but how it is linked to the operation of everything that happens with the State, crucially in the health service. Therefore, we find a very heavy concentration of the use of the procedure in somewhere like Our Lady of Lourdes Hospital, Drogheda, which was dominated by a Roman Catholic ethos, as Deputy Caoimhghín Ó Caoláin pointed out. It is clearly linked to the role the State plays in dealing with women. Deputy Ruth Coppinger has gone through how the State has dealt with women on many issues, from abortion to contraception.
In the 1970s and beyond, when the operations were being carried out, doctors probably thought, with their Catholic heads on, and with discussion with hospital management, that if a woman was in trouble during her pregnancy it was better to break her hipbone so she could easily have more children than to put her through a caesarean section, which would make it more difficult for her to have children. They probably thought what they wanted out of the country was for women to have more and more children, that childbirth was fundamental to what a woman was in Catholic Ireland in the 1970s. Symphysiotomy guaranteed that women could have more children, and that the process of reproduction, of women's bodies being used to reproduce more human beings, would not be interfered with.
This goes to the heart of what Máiréad Enright points out and which was ignored entirely by the report. The report, by its very nature, is flawed, given that it fails to deal with the direct consequence of the linkage between church and State, particularly in the health service and on the question of women's reproductive rights. We will not interview a doctor who will admit he or she thought a woman should have lots more babies and broke her hipbone to guarantee it would happen. However, this attitude would have been enshrined in the ethos of the hospitals and the management of maternity services at the time. One of the reasons it was enshrined in it was linked to the fact that women did not have access to contraception.
The judge referred to women who went on to say that although they suffered pain during sexual intercourse for up to a year afterwards, it did not stop them from having more babies. Hello. All it says is that they had sexual intercourse without contraception, during which they suffered pain, because at that time it was understood that it was their role in life to have more babies regardless. The fact that they had no access to contraception or abortion is crucially linked to how they were treated. There are many misinterpretations and opportunities in dealing with it.
We need a new report and a new study as well as a new attitude to the countless women who suffered physical and emotional pain. They also suffered, as was stated in many of the testimonies, from distress and powerlessness. Imagine one's body is being used for experimentation in a medical practice to ensure future generations will be procreated. C-section or surgery were not to be used. Instead, a procedure was used to ensure women could have more babies. This is what is at the heart of this and what has been missed. To add insult to injury, the judge said one person's case is worth €50,000, another’s, €10,000 but she hardly believes others suffered. The judge should be coming out with a report that utterly condemns the system of symphysiotomy, the hospitals that oversaw it, as well as the health service which continues to whitewash it and do these women down. Hats off to those women for fighting. It must be very difficult to do.
I call Deputy Mick Wallace, who is sharing time with Deputies Catherine Connolly, Maureen O'Sullivan and Joan Collins.
And Deputy Clare Daly.
She has her own slot of five minutes.
Chronic pain, incontinence, hip degeneration, organ prolapse and psychological trauma are some of the horrendous lifelong effects of symphysiotomy. They are also the effects which have been completely rubbished by the assessor of the Government's symphysiotomy redress scheme, Ms Justice Harding Clark. The exclusion of survivors’ oral evidence from the terms of reference of the scheme and a narrow focus on medical records going back 50 years as proof of disability make it near impossible for many to prove they are in fact victims. Hospitals are not required to keep medical records going back more than seven years. The burden of proof, therefore, lies unfairly and disproportionately with the victim. In cases where medical records are available, in many cases symphysiotomy was not recorded, even when it took place. MRI scans were also used in assessing victimhood but the report itself admitted that the use of modern radiology to measure disability occurring half a century ago is unsupported by any orthopaedic literature, yet it was used as a diagnostic tool.
While the UN Human Rights Committee classified symphysiotomy as torture, cruel, inhuman or degrading treatment and involuntary medical experimentation, Judge Harding Clark decided it was not that bad. According to her report, it was medically appropriate and patient consent was unnecessary. Not only does the State not believe many of the women who came forward as victims, but in classic victim-blaming mode, Judge Harding Clark actually accused many of them of making false statements for financial gain. The voices of the victims were trumped by accounts of doctors who engaged in the practice of symphysiotomy, many of whom were guided by their own religious convictions. It may seem unbelievable now that C-section was once seen as a form of birth control. However, we only have to look at the State’s ongoing violation of the human rights of women through its draconian stance on abortion to see religious nuts still call the shots as regards women's bodily integrity.
One would think after the Magdalen laundries, the death of children in mother and baby homes and the sex abuse scandals in the Catholic Church, the State might start to take responsibility for its many crimes against women. Yet this scheme strips victims of their constitutional rights, denies applicants their right to appeal and forces them to see their abusers as harmless. For anyone who actually read the survivors’ testimonies, the idea of describing the perpetrators as harmless is sickening. The report is an exercise in the protection of the medical hierarchy. It is a load of rubbish.
In his statement, the Minister urged us to read Ms Justice Harding Clark’s report, pointing out it was unfettered by the Government. He said she could have simply administered a payment scheme but she chose to use her judicial skills and experience, and that of her clinical team, to examine all aspects. That is shocking. She was given a job to do which was to administer a compensation scheme.
I have read the report and, given my previous life in law, I am absolutely shocked at its tone and the fact the judge went completely outside her terms of reference. “Abuse” is a strong word, but the language in the report is one of abuse, pointing out to women that they are not believed when the majority who came forward showed they had a symphysiotomy. Of those who could not, the figure is fewer than the judge claimed. It was in fact 58. The fact she repeatedly used a substantial section of the report to say these women lacked credibility - perhaps not in that language but that is what she inferred - is shocking. Not only that, these women were subject to outside influence of a nature which overwhelmed them. She did not focus on the fact that of the 590 applicants who came forward, the majority had the operation and suffered.
Interestingly - the judge does not dwell on it - symphysiotomy was an unnecessary procedure in the UK. The report actually stated “in the major public hospitals in Liverpool, Leeds, Manchester, Glasgow … where significant communities of Irish Catholics lived”, there was no necessity for symphysiotomy. That in itself deserved three chapters as to how that could possibly have happened and what led to it.
The Minister should take his own recommendation and read the report
Symphysiotomy was a most inhumane, degrading and brutal procedure carried out on women without their full knowledge of what was involved, without their permission, and, in some cases, they did not even know what was going on. It led to horrific health problems for these women with intense suffering and discomfort that affected their lives and their relationships. In the previous Dáil, we had the opportunity to meet some of the women affected to hear exactly what had happened to them and the effects on their lives afterwards. We debated it here and had Leaders’ Questions on the matter.
Survivors of symphysiotomy have serious and genuine concerns, despite what the Minister said. What will happen to those concerns? There are concerns about the content of the report and how little actually concerns the subject matter with so much skirting around the central issue. There are also concerns about the requirement for the contemporaneous medical records, records which are not readily available; the exclusion of oral evidence; that the terms of reference did not comply with the recommendations made by the UN Human Rights Committee; that none of the perpetrators were held to account and there was no admission of wrongdoing; that the report did not respect the integrity and credibility of all applicants; that the burden of proof required went beyond that required by courts, which the Minister disputed in his speech; the finding that some leading symphysiotomy survivors who had one did not; that the infant mortality rate was not considered by the judge; and that the radiological review used applicants’ health data without their knowledge or consent.
These are serious concerns which have been brought to the attention of the House and the Minister. What will happen to these concerns? Will they be just let slide? It is doing a complete and utter injustice to those women who have these concerns. I hope the Minister will address these in his reply.
The publication and media coverage of Ms Justice Harding Clark’s report into the surgical symphysiotomy ex gratia payment scheme raises fundamental questions about how citizens who pursue justice in cases of historical abuse are treated by the organs of the State. The terms of reference called for the assessor to report to the Minister on the activities and the expenditure of the scheme. I believe Ms Justice Harding Clark overstepped the mark in this case. It was highly inappropriate for her to comment on ongoing litigation because some cases are going through the courts.
The report on the scheme, overseen by Ms Justice Harding Clark, can only be read as a defence of the uniquely Irish practice of non-emergency symphysiotomy, as it served to diminish survivors’ claims that the non-emergency substitution of symphysiotomy for caesarean section, without consent as practised in Ireland, violated many women's human rights. This was taken up by the United Nations Human Rights Committee, which found that symphysiotomy, as practised in Ireland, constituted torture, cruel, inhumane and degrading treatment where patient consent was never sought. The report has caused tremendous anger and upset among women who successfully applied for the scheme and those whose applications were unsuccessful.
I believe it is an attempt to undermine the women by concentrating on unsuccessful applicants and brushing over the fact that 70% of applicants applied successfully to the scheme. The scheme's burden of proof made it difficult, if not impossible, for some women to prove their cases. It demanded absolute certainty. For women who were unsuccessful applicants and had no right to appeal, the report has just added insult to injury. It is hostile in its tone and attempts to smear the survivors and discredit them rather than own up to a bad and damaging policy and a poorly administrated redress scheme which not all people supported when it was set up.
I will finish by reading out an e-mail that was sent to me before Christmas, for the debate we were supposed to have in December, from a young woman whose mother-in-law was subjected to symphysiotomy. The latter is quoted in the e-mail as stating:
It is with a feeling of hurt and sadness I have read Judge Clarke's and the Irish Times view of the end of the symphysiotomy scheme. It was to be an non-adversarial scheme, and on the advice of my solicitor and because of my age (79) it would be easier for me to apply for the scheme (even though I had all my documentation of proof). I was prepared to go to court. Now as a group we are all being maligned as cheats and liars. Such a pity that [Mr.] Varadkar told us how straightforward this non-adversarial scheme was going to be. I remember the words he used. In future, schemes like this will remember our treatment as an example of trusting a minister and his appointee.
It goes on, but I will leave it at that. The report has affected these women very badly and should be withdrawn.
Buíochas - I thank the Deputy for her co-operation. I call Deputy Daly.
What should have been a routine assessment of the activities and expenditure of the scheme was used by Ms Justice Harding Clark to turn it into a vitriolic assault on the victims of this barbaric procedure. It is abhorrent and shameful and should be withdrawn. The Justice in her remarks went way beyond her remit and made accusations without evidence. The report was flawed in its objectivity, full of conjecture and raises serious concerns about the scheme in its entirety. Let us be clear: there would never have been a scheme if the women and their advocates had not campaigned for years to demand justice and accountability for what happened to them. When it was put in place, the scheme was roundly warned about by Members on this side of the House as being inadequate in the manner in which it was structured. Other Deputies have made these points. It was an abysmal scheme. The kinds of awards that were covered by it, for a lifetime of pain and hardship, were minuscule. Obviously, I am glad the women received something, but Ms Justice Harding Clark got more in a year than these women did for a lifetime of suffering. Other Deputies have made the points about the 20 days within which to apply, the methodology for the burden of proof being flawed and the reliance on documentary evidence. The scheme allowed for oral evidence; Ms Justice Harding Clark chose not to use this. The scheme allowed for awards to be made without the admission of liability. This amounted to an expression of regret without responsibility. It is just not on.
The report by Midwives for Choice is an excellent critique of the Harding Clark report. It points out that the Harding Clark report is characterised by a reticence to present actual figures, using vague generalisations instead of key findings, as though keeping the reader in the dark, and that such an absence of transparency and proximity to objective scientific standards at any level means that they do not recognise any contribution to the body of knowledge on symphysiotomy. Midwives for Choice is correct. That the Minister sought to claim in his introductory remarks that this narrative added to our understanding of symphysiotomy clearly demonstrates to me that he has not read the report because the data and methodology for establishing symphysiotomy and any resulting disability were completely inappropriate and unscientific. I challenge the Minister to read the report. In fairness, Midwives for Choice makes the point about the challenges faced by the judge in the absence of objective evidence due to inconsistencies across medical records, birth registers, annual clinical reports and so on. However, it also makes the point that irrespective of these challenges, there was an onus on the judge to do justice to the best of her ability to the women who had put their faith in her, and that the failure to acknowledge the limitations of the scheme's methodology in favour of branding honest and responsible elderly women as false claimants and setting an arbitrary diagnostic bar in full knowledge of the impossibility of women whose symphysis pubis had reapproximated over time reaching it is far from the justice to which these women are entitled.
These actions are irresponsible, and the media coverage was irresponsible and hurtful. The 800-page report devotes just 82 pages to the scheme. The rest consists of the judge's bizarre opinions - and this is not for the first time. She wrote to some of the complainants - and language is important - telling the women to "treat themselves" and commiserating about their "unhappy experiences". She wrote to me and Deputy Wallace in terms which to me were like the ravings of a lunatic. They certainly were not the words of a competent, independent assessor. It was bizarre language, and this bizarre language, the inference and her own ideology seep through the report. It is a defence and a whitewashing of the State's involvement in barbaric practices which have been condemned by international human rights organisations. It utterly should be withdrawn. This issue will not rest. The questions asked by Deputy O'Sullivan about the scientific critique of the report must be answered by the Minister and the Department.
I thank Deputy Daly for ending right on time. Before I call Deputy Harty, I wish to say "fáilte" to the students from St. Nathy's College in Ballaghaderreen, definitely County Roscommon, not Mayo. They are very welcome. I hope they have a good time today. I call Deputy Michael Harty.
I do not think I will take 15 minutes, so Deputy Eamon Ryan will have a free run for the end of the debate.
The Maureen Harding Clark report on surgical symphysiotomy remains a very unsatisfactory report for many women. It covered a period of 50 years from 1940 to 1990 and was set up on the assumptions that symphysiotomy led to lifelong disability and was impelled by Catholic teaching on contraception and that Irish doctors were alone in the English-speaking world in using the procedure. However, the report found that the procedure for many women was non-injurious in the long term and medically appropriate and that patient consent was not necessary. These findings could not have been upheld if oral evidence had been taken. This also calls into question medical ethics. It is completely unacceptable that procedures would be carried out on anybody, even in 1940 to 1990, without obtaining consent or explaining the procedure.
The process of the procedure was very invasive and barbaric and was not a first option in allowing women to deliver their children. It certainly was not an option when caesarean section was freely available at the time. It was carried out because women were deemed to have pelvic disproportion, which is a small pelvis. This was a very difficult diagnosis to make up to the 1990s, certainly in the 1940s and 1950s. The procedure was carried out very often on first-time mothers who were not given a trial of labour and who could have had a caesarean section if their labour was not progressing. To use symphysiotomy in this regard was therefore completely unacceptable. Many procedures were carried out as an alternative to caesarean section, not because the women could not deliver the child.
The issue of consent is very important. Many women availing of this scheme did not know what procedure had been carried out. They were unaware that they had had symphysiotomies. This may have led to difficulty regarding the Maureen Harding Clark hearings. A total of 107 of the applicants were between 85 and 96 years of age at the time of application. These women could be forgiven for memory lapse and their ability to sustain a claim. Who would falsely claim redress for a procedure he or she did not experience?
The report relied on medical records, if they were available, going back many decades. Medical records going back 40 or 50 years were quite often not available, whether the survivors' GP records or their hospital records. They were subjected to an examination for evidence of a surgical scar, but this would not be absolute evidence of whether they had a symphysiotomy.
The scar was small and could have faded in time. It also relied on radiological evidence of the symphysis pubis gap being large, which would have been the case in many of those who would have had a symphysiotomy, but that may have healed over time and would not be absolute evidence that they did not have a symphysiotomy. Written evidence was taken but often discounted and no oral evidence was taken. The scheme applied an almost criminal standard of proof, beyond reasonable doubt, as opposed to the civil standard of proof, which would be on the balance of probability. Lack of consent or explanation of what had been performed was one of the inhibiting factors in this report and symphysiotomies were carried out before and during labour and even after a woman had had a caesarean section, to, in my view mistakenly, aid their next delivery. Of the 590 women who applied for inclusion in the scheme, 185 were excluded as they did not meet these criteria even though failing to meet them did not mean they had not undergone the procedure. Many were left to deliver their babies through a now traumatised, unstable pelvis adding to their labour and their pain. Thankfully, this procedure is no longer carried out in modern medical obstetrics. This report has many deficiencies. A major one was the failure to take oral evidence. If oral evidence had been taken, women could have outlined the mobility difficulties they had after the procedure, the pelvic instability they endured for many years, the urinary incontinence, the damage to their pelvic floor and the chronic pain they endured. Many lived a life of misery. The integrity of the 185 who did not meet these criteria has been called into question.
The procedure was not necessary and it led to poorer outcomes for baby and mother, when taking into account the availability of caesarean section. This is a crucial point. Infant mortality increased over and above what would have been available through caesarean section by having a symphysiotomy. It was a procedure that could damage the baby as well as the mother. The procedure was carried out in Ireland almost exclusively in hospitals which had a very strong Roman Catholic ethos in respect of fertility, contraception and particularly tubal ligation. This report has not brought closure to many people who went through this process, particularly the 185 who did not meet the criteria. They were assaulted, the procedure was unnecessary and their integrity has been called into question which is to be regretted.
It is important to stand with and support those women, particularly those who have not got any ex gratia payments. For them this problem continues. We have not given what we should have given, an upfront apology, a recognition that what went on was wrong and recompense for the huge damage, loss and pain that occurred over their lives. I listened to the Minister for Education and Skills, Deputy Bruton, ask how we could have done that if Judge Harding Clark did not deliver that for those women. While we did not want to go into an adversarial, inquisitorial system, was it not possible to listen to those women in a humane way rather than merely stating they did not have the records? That would have been an appropriate response to what had gone on. I regret that we are not getting that today but we are getting a similar defence of the system that was indefensible. That is a terrible missed opportunity and that is why this debate today is important.
The way our medical system deals with births remains an issue today. Let us hope the new national maternity strategy published last year will lead to a genuine change and shift in the system. The statistics show we have not learned the lessons we would have learned had we stepped back, apologised and said our approach is wrong. The doctors and consultants say the statistics show we have the safest and best system but we could refer to other statistics. The level of inductions in birth in Irish hospitals at 31% is approximately three times what the World Health Organization, WHO, recommends. That has real consequences today for mothers and babies. I have seen oxytocin used as part of this active management of labour. Symphysiotomy was also part of that system. The Minister for Health said certain labours went on for 50 hours. We have created a managed system which tells a woman that if her chart is not going the right way within 12 hours, the doctors will intervene and apply oxytocin which has real medical consequences for the child, particularly some in crisis pregnancies, and mother. This is done, as I have seen, without really consulting, preparing or offering choices to the woman. It is the same interventionist approach in which doctor knows best and one should not listen to the mother that still happens today.
According to the statistics from the National Maternity Hospital approximately 27% of women have an episiotomy. That has real consequences. Our level of caesarean births is high at 30% and in some hospitals it is as high as 38%. In some instances that is no doubt the right medical procedure. We have to stand up for our doctors because there are certain acute cases where they provide lifesaving, important interventions but that level of intervention has knock-on consequences, making the average mother's recovery period at least two or three times what it would be with an alternative approach. Today, 60,000 women are suffering the consequences of that excessively interventionist, medicalised, doctor-knows-best approach. It is against all the recommendations of the WHO and other international scientific best practice. We say we are the best in the world but the statistics say otherwise. Our approach fits women into the consultant's or active management timetable, rather than trusting and working with them to make their deliveries the best they could be.
Breastfeeding is connected to this and is a cultural problem within our medicalised interventionist system. Why are our levels of breastfeeding the worst in the world? Only 6% of mothers here breastfeed after six months. I do not want to send them on a guilt trip and far be it from me as a man to talk about it but we cannot ignore the statistics. We spend only €100,000 a year on supporting breastfeeding but we spend €15 million a year on the acute infections in infants which could be addressed by higher levels of breastfeeding because it is the healthiest alternative. All the evidence is clear on how we raise our babies but we do not do it because we are still stuck in this consultant-led system.
Today we should be celebrating the work of Máiréad Enright and Dr. Jacqueline Morrissey and the Association for Improvements in the Maternity Services, AIMS, who have done a fantastic job, as well as the women themselves but it should not be up to those women to fight their case. It should have been for the State to acknowledge the facts, admit we were wrong and to listen but not in an adversarial way. Had the doctors really listened to Savita Halappanavar, her tragic case might not have happened. Our Lady of Lourdes Hospital was mentioned several times. Michael Neary should have listened to the midwife who was having her baby there and screamed at him not to do a hysterectomy. She was not listened to. We should be listening to those women today. We should be responding, as Deputy Bruton said, not in an adversarial or inquisitorial way but a listening way and responding accordingly to admit we need to change. More than anything else that comes out of this debate let us respect, honour and apologise to those women. Let us give them due recompense.
More than anything else, we should use this opportunity to admit that the delivery of medical services in the obstetric health system is still not right and is still not mother-centred in nature. We have chased after midwives who have tried to provide alternatives such as home births, which should be available. We have hounded them out. I have seen it personally. They have been demonised and hounded out. I understand that just 5% of deliveries are led by midwives, even though such deliveries are just as safe as doctor-led deliveries. I am speaking from personal experience when I say that this completely different cultural and medical approach is fit for purpose in many pregnancies. It should be commonplace. To my mind, we should have a completely midwife-led system. I appreciate that in cases of acute medical emergency, consultants and others have to be brought in to save the lives of babies and mothers. We have allowed doctors to control the system. I am afraid they need to learn the lesson that they are not gods. We need to have a system that is led by midwives and mothers. We need to apply the lessons of the symphysiotomy experience to all mothers today.
I thank Deputy Eamon Ryan for bringing the statements on symphysiotomy to a conclusion. Tá na ráitis maidir le simfiseatóime críochnaithe. I thank the Minister and all the other Deputies who participated in this morning's quite emotional debate.
Sitting suspended at 11.55 a.m. and resumed at 12 noon.