Table 3. The width of symphysis pubis after S and after NVD. S n 17 2 Average mm 9,2 13,9 Range mm 2,0–20,4 12,8–15,0 Not pregnant Pregnant doi:10.1371/journal.pone.0003317.t003 vagina. The women were not asked about possible psychosocial complications arising from this. Width of symphysis pubis and subsequent deliveries. Table 3 shows the width of the symphysis pubis in women post symphysiotomy and in women with only previous normal vaginal deliveries. The average symphyseal width after symphysiotomy was 9.2 mm. Among women with previous normal vaginal deliveries the average distance was 4.7 mm (p,0.01). The outcome of subsequent deliveries after CS and after symphysiotomy is presented in table 4. Knowledge, attitudes and practice among doctors and midwives, study in 1998 Eighty doctors and midwives were invited to participate in this study, and all accepted. The interviews in the urban settings comprised 34 doctors and 26 midwives, and in the rural settings 7 doctors and 13 midwives. Thus a total of 41 doctors and 39 midwives were interviewed. Of the doctors in the urban settings, 10 were obstetricians and 24 junior doctors. In the district hospitals, all the 7 doctors interviewed were non-specialist. Of the midwives in the urban settings, 13 were clinical instructors, 10 qualified midwives and 3 student midwives. In the rural settings, 4 were clinical instructors, 7 were qualified midwives and 2 were student midwives. Seventy-nine of the 80 participants knew about symphysiotomy, and 76 could describe the technique, including 16 of the 17 midwife instructors. One junior doctor was not aware of the intervention. One of the ten obstetricians had occasionally performed a symphysiotomy the other nine did not practice the intervention, but indicated that they would be able to carry it out. Among the 24 junior doctors in the urban settings, six wanted to learn the skill. One of the seven district doctors thought he could do a symphysiotomy if need be, another two wanted to learn the procedure. Table 5 shows the responses of the doctors to a series of statements on symphysiotomy, comparing the opinions of obstetricians and junior doctors working in the large cities with those of district doctors. The latter have more positive attitudes to symphysiotomy. Table 6 compares the responses of doctors and midwives in the Total number of women No of women with subsequent delivery Total number of deliveries Normal vaginal deliveries Caesarean section doi:10.1371/journal.pone.0003317.t004 CS n 29 8 10 6 4 % 27,6 60 40 S n 34 16 22 19 3 % 47,1 86,4 13,6 Symphysiotomy in Zimbabwe NVD n 58 34 Average mm 4,7 5,8 Range mm 1,9–7,8 2,9–9,7 P ,0,01 ,0,01 urban and rural settings, respectively, to the same series of statements as those of Table 5. All the rural midwives (n = 13) regarded symphysiotomy as a lifesaving operation appropriate for remote areas, and 23 of the 39 midwives (59%) thought that the procedure should be taught to midwives. One third of the doctors and two thirds of the midwives thought that symphysiotomy should be performed, if only for teaching purposes, in central hospitals. Eight of the ten obstetricians stated that their opinions on symphysiotomy were based on what they were taught to believe in medical school or during specialist training, and that they had not been influenced by papers on symphysiotomy they had read later in their careers. Three of the ten obstetricians thought that randomised controlled trials of symphysiotomies were needed, whereas the other seven saw no need for further research into a procedure they regarded as outdated. Ninety percent of the junior doctors indicated that their opinion on symphysiotomy was based on what they were taught in medical school. One of the 39 midwives was aware of scientific studies on symphysiotomy, the rest had never heard of any such studies. Fifty-one percent of the doctors spontaneously commented that symphysiotomy had been Table 5. Affirmative answers on statements about symphysiotomy among obstetricians and junior doctors in three hospitals in the two largest cities of Zimbabwe; Harare and Bulawayo, and among district doctors at seven district hospitals. Urban Junior Obstetricians doctors Rural District doctors n = 10 (%) n = 24 (%) n = 7 (%) Symphysiotomy is a harmful operation is obsolete and second-class can be lifesaving Symphysiotomy has negligible maternal mortality high maternal morbidity uneventful subsequent deliveries Symphysiotomy should be performed in central hospitals taught to district doctors taught to midwives 6 (60) 8 (80) 3 (30) 8 (80) 8 (80) 7 (70) 2 (20) 2 (20) 2 (20) *More remote areas than existing in Zimbabwe1998. doi:10.1371/journal.pone.0003317.t005 16 (67) 16 (67) 12 (50) 9 (37) 18 (75) 15 (63) 5 (21) 9 (37) 9 (37) 5 (21) 2 (28) 4 (57) 5 (71) 5 (71) 6 (86) 2 (28) 2 (28) 3 (43) 4 (57) 2 (28) Table 4. Outcome of subsequent deliveries after CS and S. is appropriate in very* remote areas 5 (50) PLoS ONE | www.plosone.org 4 October 2008 | Volume 3 | Issue 10 | e3317