James Reilly (Dublin North, Fine Gael)

At the outset I wish to explain to the House precisely what symphysiotomy is and to give some context about its use as a medical procedure and specifically its use in Ireland. Symphysiotomy is a medical procedure that was used primarily before the advent of safe caesarean sections. The procedure was carried out in Ireland from approximately 1920 until the early 1980s. It was gradually replaced by caesarean section as the preferred method of delivery in childbirth where required. It is clear that the procedure continued to be used in Ireland for some time after it had been all but discontinued in other developed countries. In this regard within Ireland it continued to be used for a longer period, most notably in Our Lady of Lourdes Hospital, Drogheda.

I am conscious of the distress that symphysiotomy has caused to a number of women and recognise the pain that this issue has caused to those affected by it. The Government is committed to dealing with it sensitively, so that if at all possible, closure can be brought to those affected by it. This practice has resulted in long-term distress and pain, problems with urinary continence, problems with bowel function and difficulty walking to perform day to day duties within the home. It has had a serious effect on a number of women who have had the procedure performed.

My first priority is to make sure that the health needs of those who have had a symphysiotomy are met quickly and effectively. With this in mind, I am committed to ensuring that the greatest possible supports and services are made available to women who continue to suffer effects of having undergone this procedure. The women concerned continue to receive attention and care through a number of services which have been put in place including the provision of medical cards to all who requested them; the nomination of a liaison officer for a patients' group comprised of women who underwent a symphysiotomy procedure; the availability of independent clinical advice for former patients; the organisation of individual pathways of care and the arrangement of appropriate follow-up for women, including medical assessment, gynaecological assessment, orthopaedic assessment, counselling, physiotherapy, reflexology, home help, acupuncture, osteopathy and fast

tracked hospital appointments; the refund of medical expenses related to symphysiotomy in respect of medication and private treatments; the establishment of a triple assessment service for patients at Cappagh Hospital, Dublin, in January 2005; and a support group facilitated by a counsellor which was set up in 2004 in Dundalk and Drogheda for women living in the north-east region.

The provision of these necessary support services for women is monitored and overseen by the Health Service Executive which is committed to being proactive in seeking out and offering help to women who underwent a symphysiotomy and who may wish to avail of the services offered by the HSE.

It has been suggested that some 1,500 symphysiotomies took place during the period 1944 to 1992, giving a rate of approximately six symphysiotomies per 10,000 births. While there was a large variation, even in the hospital with the highest rates, the maximum rate appears to have been six per 1,000 births in one year. Thus, it was a rare intervention in comparison with caesarean section, for example, which rose steadily in the same period from three per 100 births in the early 1940s to now over 20 per 100 births. This is not in any way to minimise any serious effects and suffering it had on the women concerned, but it does indicate the procedure was quite rarely carried out in Ireland overall.

We need to act on the basis of the best evidence that is available on this issue, as in all aspects of our health services. To this end the Chief Medical Officer of the Department of Health commissioned an independent research report last year into the practice of symphysiotomy in Ireland. The aim of the report is to provide an accurate picture of the extent of use of symphysiotomy in Ireland, and an examination of the Irish practice relative to other countries. It is to include an assessment of the circumstances in which the procedure was carried out, what protocols or guidance existed at the time to guide professional practice and details of when the practice changed and why.

The specific terms of reference the researcher has been given are to document the rates of symphysiotomy and maternal mortality in Ireland from 1940 to date, by reference to available data, including annual and other reports; and to assess symphysiotomy rates against maternal mortality rates over the period. The researcher has also been asked to critically appraise international reviews of symphysiotomy practice and associated rates in a number of comparable countries in the world and in Ireland, to review any guidelines and protocols that applied in Ireland on symphysiotomy over the time period and to write a report based on the findings of the analysis providing an accurate picture of the extent of use of symphysiotomy in Ireland and an examination of the Irish experience relative to other countries. The academic researcher concerned was formally appointed on 1 June 2011.

On a point of information, she experienced unforeseen difficulties in accessing information sources and, as a result, submitted the report behind schedule in late January 2012. She informed the Department this was due primarily to the challenges associated with accessing historical data from a time when records on the procedure were not routinely kept. Subject to legal advice, I propose to make the draft report available for consultation and will further engage with the relevant patients' representative bodies concerned and through them the women who underwent symphysiotomy. My Department will also consult with the Institute of Obstetricians and Gynaecologists in Ireland. When these consultations have been completed satisfactorily, the draft report will then be finalised by the academic researcher, taking account of the consultative process and any legal considerations, and presented to me. Informed by the outcomes of the consultation process, I will then consider the final report thus produced by the researcher and decide on the steps required to address this situation.

Ireland is now one of the safest places to have a baby. We have one of the lowest maternal mortality rates and perinatal mortality rates in the world. Ireland is a now a very safe place to have a caesarean section and we should be proud of the fact that we are recognised internationally as leaders in the field of obstetrics. Recent legislation requires doctors to maintain and update their competence. These new requirements for doctors to maintain their professional competence are a significant step and a concrete assurance that medical practitioners are appropriately qualified and competent to practise safely. With the advent of new clinical programmes and directors, there is now much greater monitoring across each specialty.

The national clinical effectiveness guidelines published last year provide a framework for national endorsement of clinical guidelines and audit to optimise patient care. These guidelines will contribute to improving health outcomes, by reducing variation in practice, improving quality of clinical decisions, influencing health service policy and informing service users and the public about the service they should be receiving. These and many other developments ensure that the health system is striving to fulfil the vision of the Commission on Patient Safety and Quality Assurance - knowledgeable patients receiving safe and effective care from skilled professionals in appropriate environments with assessed outcomes. In other words it aims to empower patients more to know what is safe, to what they are entitled and what they should expect and to empower them to complain when that does not happen or they do not receive that care.

The new clinical programmes being developed and implemented in the HSE are one of the most important developments in this regards. These are currently led in the HSE by the directorate of clinical strategy and programmes which was established to improve and standardise patient care throughout the Health Service Executive by bringing together clinical disciplines and enabling them to share innovative solutions to deliver greater benefits to every user of HSE services. Very often we have excellence in practice in an area which can be translated to a different discipline. The interaction that now occurs between the clinical programmes is already yielding great benefit. The clinical programmes are a multidisciplinary initiative between the HSE and the various faculties and generally include patient representatives. Each programme is led by a clinician. The clinical programmes are a sea change in the way we provide health care in Ireland. This new approach utilises key proven drivers of success in improving disease management and is aimed at improving patient care.

The obstetrics and gynaecological clinical programme is led by Professor Michael Turner. The aim of the programme is to improve health care choices for women. Its initial work aims to implement key guidelines, establish local programme implementation groups to facilitate change, develop national models of maternity care, develop a standard approach to capturing and reporting audit and performance metrics, develop solutions and guidelines to reduce the number of multiple pregnancies requiring neonatal intensive care, develop workforce planning and training models and strategy and investigate the numbers of women attending for antenatal care in early pregnancy.

More generally, there has been considerable progress in the options of maternity care available to expectant mothers in Ireland. They now have a number of choices they can make in respect of the obstetric care they choose. Women may opt for a combined care package with their GP and the hospital, under the maternity and infant care scheme which provides a number of free GP and maternity hospital visits to all eligible expectant mothers. There are also a number of midwifery-led units nationally which offer the opportunity to expectant mothers to give birth in a uniquely designed birth room cared for by a team of experienced midwives. These units are located close to hospitals should an emergency arise that requires specialist intervention.

I commend developments in the south of the country, which I would like to see extended, where the maternity service is delivered entirely in the community, with GP and consultant visits being held in the local primary care centre. This is the practice in Mitchelstown, for example.

While these developments can bring further improvements to maternity services in the future, I am committed to addressing the issues that have arisen from the legacy of past practice in relation to symphysiotomy. The Government is also committed to dealing with this whole issue, with all the sensitivity which is undoubtedly required, to help do whatever can be done for those affected by it. I have outlined the supports that have been provided to the women affected and the progress in finalising the research report, but I am aware that much remains to be done. I know there is cross-party support for this group of women who have suffered as a consequence of this procedure. It is the role of the Government and of this House to support them in reaching closure on this matter and to ensure that they receive the service they require to help them recover and lead as normal a life as is possible.

I hope to bring this matter to a satisfactory conclusion as soon as possible and I firmly believe that the women who have had this procedure deserve nothing less.

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