are the midwives working in rural areas. They have to manage every day with poor medical facilities and limited resources, including transport. These midwives often see mothers and their babies in bad condition due to prolonged obstructed labour, and frequently have to handle the situation alone. Ten of 13 district midwives wanted to learn how to perform a symphysiotomy themselves, in agreement with an editorial in the British Journal of Obstetrics and Gynaecology of 2002: ‘‘Symphysiotomy is simple. ….It requires only local anaesthesia, a catheter, a scalpel and a pair of gloves. It can be performed safely and successfully by individuals who are not obstetricians’’ [31]. The technique utilized does not require special surgical skills, and experience indicates that symphysiotomy may be carried out by a well-trained midwife if training is provided by an experienced obstetrician [24,32]. On the other hand, the obstetricians are the most reluctant subgroup, 90% had never done a symphysiotomy, not even on a model like their colleagues in the United Kingdom have to do as part of their specialist training, to be able to handle emergency situations. The obstetricians are responsible for the education of new doctors and they will also influence the teaching of student midwives. Their lectures are of great importance because only a few of the participants in this study had access or paid attention to the scientific literature on symphysiotomy. The present situation in Zimbabwe (like in several other countries) demonstrates another important factor related to symphysiotomy. In the wake of the economical collapse, a previously well organised health service struggles to maintain References 1. Frank F (1910) U¨ ber den subkutanen Symphysenschnitt und die suprasymphy- sa¨re Entbindung. Monatschr Geburtshilfe Gyna¨k 22: 680–693. 2. Kupferberg H (1927) Zur Therapie Beim Engen Becken. Monatsschr Gyna¨k Geburtshilfe 76: 176–183. 3. Peytavin C (Paris 1931) De la symphysiotomie partielle sous-cutane´e. E´ tude critique de 45 observations de symphysiotomie suivant le proce´de´ de Zarate [dissertation]. 4. Barry AP (1952) Symphysiotomy or pubiotomy. Why? When? And how? Ir Med J 6: 49–73. 5. Dexeus S, Salarich N (1954) De la sinfisiotom´ıa complementaria de recurso o de emergencia en el curso de la extraccio´n fetal por las v´ıas naturals. Rev Esp Obstet Ginecol 13: 358–366. 6. Za´rate E (1931) Die Za´ratesch Technik der partiellen Symphyseotomie. Ihre Indikationen und ihr therapeutischer Wert bei patologischen Geburten nach Beobachtungen von 100 Fa¨llen. Arch Gyna¨kol 147: 759–767. 7. Ram´ırez Olivella J, Ortiz-Perez J (1935) Doce a n˜os de sinfisiotomia subcutanea. Arch Med Int 1: 254–273. 8. Peralta Ramos A (1948) La sinfisiotom´ıa en la era antibiotica. Obstet Ginec Lat- Amer 6: 3–12. 9. Seedat EK, Crichton D (1962) Symphysiotomy: technique, indications and limitations. Lancet i: 554. 10. Hartfield VJ (1973) A comparison of the early and late effects of subcutaneous symphysiotomy and of lower segment Caesarean section. J Obstet Gynaecol Br Commonw 80: 505–514. 11. Gebbie DAM (1982) Symphysiotomy. Clin Obstet Gynecol 9: 663–683. 12. van Roosmalen J (1987) Symphysiotomy as an alternative to cesarean section. Int J Gynaecol Obstet 25: 451–458. 13. Mola GDL (1995) Symphysiotomy or cesarean section after failed trail of assisted delivery. PNG Med J 38: 172–177. 14. Abouzahr C (1998) Prolonged and obstructed labour. In: Murray CJL, Lopez AD, eds. Health dimensions of Sex and reproduction. Geneva: WHO. pp 243–266. 15. WHO (1999) Reduction of maternal mortality. A joint WHO/UNFPA/ UNICEF/World Bank Statement. Geneva: WHO. 16. Bjo¨rklund K (2002) Minimally invasive surgery for obstructed labour: a review of symphysiotomy during the twentieth century (including 5000 cases]. BJOG 109: 236–248. 17. Sunday-Adeoye IM, Okonta P, Twomey D (2004) Symphysiotomy at the Mater Misericordiae Hospital Afikpo, Ebonyi State of Nigeria (1982–1999]: A review of 1013 cases. J Obst Gyn 24: 525–529. 18. van Roosmalen J (1990) Safe motherhood: Caesarean section or symphysiot- omy? Am J Obstet Gynecol 163: 1–4. 19. Verkuyl DAA (2007) Think globally act locally: the case for symphysiotomy. Plos Med 4(3): e71 doi:10.1371/journal.pmed.0040071 www.plosmedicine.com. Symphysiotomy in Zimbabwe standards. Midwives and doctors emigrate. Transferring patients is often not possible because fuel is unobtainable. Women with a scar of previous CS(s) are in mortal danger when pregnant. Some of them could have been delivered in the past by a symphysiotomy, and that would have prevented the scar and made her pelvis somewhat larger. Conclusion The frequency and severity of long term complications post symphysiotomy do not differ from those after CS. The permanent increase of the width of the symphysis pubis, measured in this study, seems to facilitate subsequent vaginal deliveries. Therefore, the benefit of symphysiotomy in cases of mild to moderate cephalopelvic disproportion is positively correlated to the local risks of a CS (nearly always the alternative course of action), the number of deliveries expected in the future, and the chance that subsequent deliveries would not happen in a well equipped and staffed hospital. This study indicates that almost 50% of doctors and 85% of midwives working in a developing country agree with this statement. Author Contributions Conceived and designed the experiments: HLE SB. Performed the experiments: HLE DAAV. Analyzed the data: HLE DAAV KB SB. Contributed reagents/materials/analysis tools: HLE KB. Wrote the paper: HLE DAAV KB SB. 20. Ezegwui HU, Olomu OO, Twomey ED (2004) Symphysiotomy in a Nigerian hospital. Int J Gynaecol Obstet 85: 272–273. 21. Onah HE (2002) Formal education does not improve the acceptance of cesarean section among pregnant Nigerian women. Int J Gynecol Obstet 76: 321–323. 22. Onah HE, Ugona MC (2004) Preferences for cesarean section or symphysiot- omy for obstructed labor among Nigerian women. Int J Gynecol Obstet 84: 79–81. 23. Bjo¨rklund K, Bergstro¨m S, Lindgren PG, Ulmsten U (1996) Ultrasonographic measurment of the Symphysis pubis: A potential method of studying symphyseolysis in pregnancy. Gynecol Obstet Invest 42: 151–153. 24. van Eygen L, Rutgers RAK (2008) Caesarean section as preferred mode of delivery in term breech presentations is not a realistic option in rural Zimbabwe. Trop Doc 37: 1–4. 25. Wykes CB, Johnston TA, Paterson-Brown S, Johanson RB (2003) Symphysi- otomy: a lifesaving procedure. BJOG 110: 219–221. 26. Goodwin TM, Banks E, Millar L, Phelan J (1997) Catastrophic shoulder dystocia and emergency symphysiotomy. Am J Obstet Gynecol 177: 463–464. 27. Glaster E, Vial Y, Hohlfeld P (1999) Current aspects of symphysiotomy. Apropos of 1 case and review of the literature. J Gynecol Obstet Biol Reprod (Paris) 28: 519–28. 28. Spencer JAD (1987) Symphysiotomy for vaginal breech delivery: two case reports. Br J Obstet Gynaecol 94: 716–718. 29. Menticoglou SM (1990) Symphysiotomy for the trapped aftercoming parts of the breech: a review of the literature and a plea for its use. Aust NZJ Obstet Gynaecol 30: 1–9. 30. Hill K, Thomas K, AbouZahr C, Walker N, Say L, Inoue M, Suzuki E (2007) Estimates of maternal mortality worldwide between 1990 and 2005: an assessment of available data. Lancet 370: 1311–1319. 31. Editorial (2002) The rebirth of symphysiotomy. BJOG 109. 32. Mola M, Lamang M, McGoldrick IA (1981) A retrospective study of matched symphysiotomies and Caesarean sections at Port Moresby General Hospital. P.N.G. Med J 24: 103–112. 33. Pape GL (1999) 27 symphysiotomies. Trop Doct 29: 248–249. 34. Greisen G (1999) Three-year follow-up of 8 patients delivered by symphysiot- omy. Int J Gynaecol Obstet 23: 203–205. 35. Hartfield VJ (1975) Late effects of symphysiotomy. Trop Doct 5: 76–78. 36. Lasbrey AH (1963) The symptomatic sequelae of symphysiotomy. A follow up study of 100 patients subjected to symphysiotomy. S Afr Med J 37: 231–234. 37. Bird GC, Bal JS (1967) The vacuum extractor in association with symphysi- otomy at a provincial hospital in Kenya. E Afr Med J 43: 51–56. 38. Bergstro¨m S, Lublin H, Molin A (1994) Value of symphysiotomy in obstructed labour management and follow up of 31 cases. Gynecol Obstet Invest 38: 31–35. PLoS ONE | www.plosone.org 6 October 2008 | Volume 3 | Issue 10 | e3317