Kathleen Lynch (Cork North Central, Labour)

I thank those Senators who called for this debate which deals with a subject that is not only emotive but very pertinent and which needs to be dealt with. I will start by explaining precisely what symphysiotomy is, to give some context about its use as a medical procedure and specifically its use in Ireland. Symphysiotomy is a medical procedure that was primarily used before the advent of safe caesarean sections. The procedure was carried out in Ireland from about 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 the procedure continued to be used in Ireland for some time after it had been all but discontinued in other developed countries, most notably in Our Lady of Lourdes Hospital in Drogheda.

The Minister, Deputy Reilly, and I are conscious of the distress symphysiotomy has caused to a number of women and recognise the pain this issue has caused to those affected by it. The Government is committed to dealing with it sensitively, so that if at all possible this issue can be brought to an appropriate and fair conclusion for all the women affected by it. Our first priority is to ensure the health needs of those who have had a symphysiotomy are met quickly and effectively. With this in mind we are committed to ensuring the greatest possible supports and services are made available to women who continue to suffer the 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. These include 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, gynaecology assessment, orthopaedic assessment, counselling, physiotherapy, reflexology, home help, acupuncture, osteopathy and fast-tracked hospital appointments. Also included is the refund of medical expenses related to symphysiotomy in respect of medication and private treatments. A triple assessment service was established for patients at Cappagh Hospital in Dublin in January 2005, and support groups, facilitated by a counsellor, were established in 2004 in Dundalk and Drogheda for women living in north-east region. A national lead officer for symphysiotomy was nominated. In addition, five designated regional liaison officers are in place across the regions of the HSE. 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.

A figure of 1,500 symphysiotomies has been suggested for 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 more than 20 per 100 births now. This is not in any way to minimise any serious effects and suffering it had on the women concerned, but it indicates 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 last year commissioned an independent research report 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 researcher was given the specific terms of reference to: document the rates of symphysiotomy and maternal mortality in Ireland from 1940 to date by reference to available data, including annual reports and other reports; assess symphysiotomy rates against maternal mortality rates over the period; critically appraise international reviews of symphysiotomy practice and associated rates in a number of comparable countries in the world and in Ireland; review any guidelines and protocols on symphysiotomy that applied in Ireland over the time period; and 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. The researcher experienced unforeseen difficulties in accessing information sources and, as a result, submitted the report behind schedule in late January 2012. The researcher informed the Department that this was due primarily to the challenges with accessing historical data from a time when records on the procedure were not routinely kept. In line with best practice, the Minister, Deputy Reilly, has initiated a peer review process of the draft report and he proposes to make the report available for consultation with relevant individuals and bodies this month. Following the consultation process and taking into account the outcome of the peer review, the report will be finalised and published. The Minister will then consider the final report and decide on the next 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 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 concrete assurance that medical practitioners are appropriately qualified and competent to practise safely.

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 are ensuring that the health system is striving to fulfil the vision of the commission on patient safety and quality assurance of what has been termed "knowledgeable patients receiving safe and effective care from skilled professionals in appropriate environments with assessed outcomes".

The new clinical programmes being developed and implemented in the HSE represent one of the most important developments in this regard. These are currently led by the HSE 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. 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 gynaecology clinical programme is led by Professor Michael Turner. The aim of the obstetrics and gynaecology 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.

While these developments can bring further improvements to maternity services in the future the Minister, Deputy Reilly, and I are committed to addressing the issues that have arisen from the legacy of past practice regarding symphysiotomy. The Government is also committed to dealing with this issue, with all the sensitivity which is undoubtedly required, do whatever can be done to help bring this issue to appropriate finality as far as is possible 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. We hope to bring this matter to a satisfactory conclusion as soon as possible - the women who have had this procedure deserve nothing less.