A “fork in the road” of life for the trailblazing Australian obstetrician and gynaecologist Caroline de Costa was the top of Grafton Street in Dublin, back in March 1967.
She had arrived in the city, on the recommendation of a Trinity College arts student she had met in Jerusalem, to try to resume the medical studies she had started in her native Sydney before taking a break to travel. But, having been told at Trinity that no exceptions could be made for missing the cut-off time to be interviewed for a place there, it was suggested she try the medical school at “Catholic” UCD, then on Earlsfort Terrace, or possibly the Royal College of Surgeons in Ireland (RCSI). She walked to the other end of Grafton Street, where she had the choice of veering left to find UCD, hidden from sight on the other side of St Stephen’s Green, or bearing right to the RCSI that was already in view. She chose the latter.
Fifty-five years later, talking over a cup of coffee in Dún Laoghaire, she reflects on how momentous that decision was. Life would have been very different for this pioneering obstetrician and long-time campaigner for women’s rights in reproductive health, who married a fellow RCSI student, if she had turned left instead of right.
Coming from secular Australia and a family that she describes as “Protestant areligious”, she had no idea of the “all-encompassing” power the Catholic Church had over women’s bodies in Ireland at the time. That “eye-opening” discovery was to come later.
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She was accepted into the RCSI, which she found to be an “autonomous republic of many nations”. There was an initial hiccup of being sent home on day one in October 1967 to swap her trousers for a “decent skirt”. But, as she recounts in her new book, The Women’s Doc – True stories from my five decades delivering babies and making history (Allen & Unwin), that dress code for women students soon changed, after the arrival of the mini skirt.
The following year she was relieved there was no question of her having to leave the college when she became a single mother. “This might be Ireland but these are not Victorian times,” she was told on disclosing her pregnancy.
Yet, with the father of her baby living in London and having “little interest in me [and I in him]”, she writes, there were practical and financial worries. Not that she ever considered giving her son, Jerome, up for adoption, as so many other single pregnant women were pressurised into doing then. “I was in a very small minority of women who could keep their child,” she acknowledges. “I had an advantage that my family was not going to be horrified; [they were] quite supportive from afar – I had a brother who was here for a while – and I wasn’t Catholic.”
As she was doing some freelance journalism to help fund her studies, she did go to a Catholic agency for “fallen women” while pregnant, purely for the purpose of research. After being given a pseudonym of “Mary Mulcahy” to “protect” her family, she heard from a nun about how placement in a mother and baby home would work, which gave her insight into the plight of other unmarried mothers and enough material for an English magazine article.
With almost a detached curiosity at the time about what it was going to be like to see through a pregnancy and give birth, she says: “I had no doubts but I was also very naive. I didn’t know anything about what could go wrong.” She does now. Inevitably it is the more challenging births she attended as a clinician that lodged in her memory and are the most interesting in the retelling. (Reading the series of anecdotes in this memoir, I couldn’t help but feel relieved that my childbearing years are successfully and safely behind me.)
In the late 1960s and early 1970s, when contraception in Ireland was illegal and an oft-denounced “sin”, de Costa played a part in helping women to avoid unwanted pregnancies by regularly smuggling in intrauterine devices (IUDs) from the UK. Her own obstetrician, Dr Rory O’Hanlon, had enlisted her help. He wanted to provide them for patients but risked deregistration if caught by customs, whereas as a student she was likely just to have the items confiscated.
She was also on the famous “contraceptive train” of 1971, when members of the Irish Women’s Liberation Movement made a very public journey to Belfast to buy condoms and bring them back to Dublin. There’s a photograph in the book to prove it – of her and two-year-old Jerome – “helping customs officers with their inquiries” on their return to Connolly station.
It amuses her that, 44 years later, the Rough Magic Theatre Company staged a musical about that trip. She travelled from Australia to attend the premiere of The Train in Limerick in 2015 and was gratified to see it attract young people’s interest in a time so different from theirs.
She has other history-making credits on her CV, not least being the first woman in Australia to become a professor of obstetrics and gynaecology, at James Cook University in Cairns. In 2006, she and a colleague in Queensland became the first doctors in Australia to be authorised to import and prescribe the medical abortion drug Mifepristone, also known as RU-486.
De Costa’s choice of medical specialisation was significantly influenced by a breech birth she witnessed as a student in 1972 at Dublin’s Coombe hospital. She was in awe at the skill of Dr Jim who safely delivered the baby girl buttocks first that day. “When I saw this breech I thought would I ever be able to do this? It was a very important moment,” she says. “It really turned me on to how exciting this could be.”
By the time she had completed her medical studies at the RCSI, she had married a Sri Lankan classmate and had had her second child with him. The new graduates went to Papua New Guinea, then still an Australian colony, for their intern year. There she discovered that, as a married woman, she would receive only half the salary her husband did for doing the same work at Port Moresby General Hospital.
She encountered gender discrimination again after deciding to specialise in obstetrics and gynaecology. On seeking a junior registrar’s job in New South Wales, a professor told her that “we never train women in Sydney”. This local male stranglehold on the most female-centric possible area of medicine came as a complete surprise to her. When her husband also failed to get a surgical registrar post, almost certainly on the grounds of ethnicity in his case, they returned to Dublin to progress their careers. She worked in both the Rotunda and as assistant master in the Coombe, where she never felt at a disadvantage as a woman. “I was incredibly well supported.” While junior doctors in Australian talked of bullying and sexual harassment, “I never experienced anything like that here”.
It’s hard to get the balance between women understanding that things can go wrong, that there may need to be a change of plan, and saying the majority of women will have a vaginal birth and a healthy baby
What she likes about obstetrics is that “it is very interesting clinically. It also has a very big social component,” she says. You’re aiming to produce not only a mother and child who are as healthy as possible, but who are also going back to an environment as good as it can be, “and that is just as important”.
It’s clear the clinical work she found most satisfying in this regard was in remote regions of Queensland and among the large indigenous population there. “I didn’t enjoy private practice,” she admits. She had always hoped to be able to combine academic work and research in Cairns with clinical practice in a public hospital but that wasn’t possible, so she ended up seeing private patients.
Since she started out, there have been big improvements in both mortality and morbidity of mothers and infants but childbirth is still a risky business. No expectant parent should be too complacent, she suggests. “It’s hard to get the balance between women understanding that things can go wrong, that there may need to be a change of plan, and saying the majority of women will have a vaginal birth and a healthy baby.” Her advice is “to embark on this with an open mind”.
She’s not a fan of homebirth, at least not unless there is a very good system supporting it, as things can go pear-shaped so quickly. “You need to have proper back-up and good antenatal care. It needs to be completely ‘normal’ to start with and you need to have a definite plan of when you will opt out of the home birth and move to the hospital.”
Criticism about the medicalisation of birth, with the risk of one intervention leading to another, is “perfectly valid”, she acknowledges. However, she points not only to the reduction of mortality but also that there are some increased risk factors now among women giving birth.
They are having babies later – in Ireland the average age of first-time mothers is almost 32. They’re also heavier, which means they are more likely to have diabetes and hypertension. They are also more likely to have needed medical assistance to conceive. “If you are going to do something complex like IVF, you are going to be much more anxious about the pregnancy when you achieve it and, therefore, much more likely to accept intervention, or even ask for it.”
Within obstetrics, “increasingly there is a view that the baby is going to come out easily vaginally or through an abdominal incision. There is no place for difficult forceps,” she argues. “If an obstetrician starts off doing a forceps or vacuum [delivery] and it is not going well in the first two or three contractions, you need to stop and take an alternative route.”
Many more women are choosing to have a planned Caesarean section “and, certainly in private practice in Australia, they are likely to get it”, she says. “Basically, it is a safe procedure for a first or even a second pregnancy.”
Does she back a woman’s right to an elective Caesarean? “I think so. It’s not something I would have done myself, but quite a lot of women doctors do and they are pretty well informed. If you are going to try for a vaginal birth, you still have a reasonably high chance of ending up with an emergency Caesarean, which is riskier. That needs to be factored into it as well.”
It’s time, she believes, to stop talking about “normal birth”. With medicine now able to compensate for some of the shortcomings when it’s left entirely to nature, we have many kinds of birth and we should embrace them all, she says. “It’s not like studying for an exam. You can read as much as you like about it but you can’t control what nature is going to do to you. It is not a competition.”
No woman should have guilt that she has “failed” in her birth plan if intervention is required, she says, but rather “enormous joy and the feeling that you have accomplished something absolutely amazing, because you have”.
De Costa herself has given birth seven times. She thought her family was complete at five children, but, after Jerome died in a car crash when he was aged 17 and she was 39, she made a conscious decision to have another child, with the full support of her husband.
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It necessitated the reversing of her tubal ligation but that “worked immediately”. She was 41 when she had the first of their two later children and then 44 when she had her youngest daughter, who is now 30. De Costa and her husband, referred to only as “A” in the book, have since divorced.
“I did prenatal testing because I don’t think I would have coped with an abnormality,” she says. While the rapid evolution of non-invasive prenatal testing has been one of the big changes, she singles out ultrasound as “the most amazing development” during her career. Before that, it was “pretty much guess work from the outside”.
Ultrasound is getting more and more sophisticated, and she predicts there will be a time when parents will be able to “get a printout of exactly what your baby is going to look like when it is as big as a grain of rice, just by genome sequencing and turning it into a kind of picture.
“There will be more and more of the expectation that you can demand a perfect child – designer babies.” It makes her uneasy that technological advancements can happen without any proper discussion on how they are going to be used. Ireland today is “completely transformed” from her student days and, as it turned out, abortion was legalised here before New South Wales became the final Australian state to introduce it in 2019. The Catholic Church still has an impact on some reproductive health services over there, she says.
“We have got big maternity hospitals in Brisbane, Sydney and Melbourne, run by the Catholic Church, where there is public money, [but] no contraception, no sterilisation and no termination of pregnancy, none.
“There is still the hypocrisy of the doctors having to say ‘sorry, you have got this severe [foetal] abnormality but we can’t do an abortion here.” Women have to be directed to another hospital on the other side of the river “which is something very familiar to me from my training years”, she remarks.
De Costa is “totally glad” that a chance meeting brought her to Ireland. Her grandfather, who died 12 years before she was born, was Irish but she doesn’t think her father, a physicist, grew up with any sense of Irishness. “But when I came here, I just loved it. I started to feel Irish.”
When her father visited Dublin during her first term at the RCSI, he went to look for his father’s birth certificate. He came back with a copy, having been told that, with an Irish father, he was entitled to Irish citizenship, which, in turn, she was too.
“I have been Irish ever since. I have dual citizenship,” she says. Living in Cairns but with friends here dating back to the 1960s, she is a frequent visitor, usually finding some conference to attend “to make it tax deductible”.
This time she’s combining seeing friends with a publicity tour for what is her 15th book. Previous publications have included medical text books and several crime novels in recent years. An avid reader of the genre as she waited around in maternity hospitals for patients to labour to the point of delivery, she decided to write some herself.
It was part of her “retirement plan”, she says, for leaving a field of medicine that has become increasingly female since she entered it. And Prof Caroline de Costa, now a grandmother of three, has been one of the role models for that in Australia, due in no small part to her Irish medical education.
