Symphysiotomy in Zimbabwe; Postoperative Outcome, Width of the Symphysis Joint, and Knowledge, Attitudes and Practice among Doctors and Midwives Hege Langli Ersdal1*, Douwe A. A. Verkuyl2, Kenneth Bjo¨ rklund{1, Staffan Bergstro¨ m1 1 Division of International Health (IHCAR), Karolinska Institutet, Stockholm, Sweden, 2 Department of Obstetrics and Gynaecology, United Bulawayo Hospital, Bulawayo, Zimbabwe Abstract Background: Obstructed labour remains one of the leading causes of maternal and foetal death and morbidity in poorly resourced areas of the world, where the 24 hours availability of a caesarean section (CS) cannot be guaranteed, and the CS related mortality rate is still high. In these settings, reinstatement of symphysiotomy has been advocated. The objectives were, in1994; to study perioperative and long-term complications of symphysiotomy and compare them to those related to CS for similar indications, in 1996; to measure the symphyseal width after symphysiotomy and compare it to that after normal vaginal delivery, and, in 1998; to assess knowledge, attitudes and practice related to symphysiotomy among doctors and midwives in Zimbabwe. Methods and Findings: Thirty-four women who had undergone symphysiotomy and 29 women who had undergone a CS for obstructed labour were interviewed. The symphyseal widths of 19 women with a previous symphysiotomy were compared to that of 92 women with previous normal vaginal deliveries, using ultrasound technique. Forty-one doctors and 39 midwives, in three central hospitals and seven district hospitals in Zimbabwe, were interviewed about symphysiotomy. None of the 34 women reported serious soft tissue injuries or infections post symphysiotomy. Long-term complications after symphysiotomy do not differ notably from those after CS for similar indications. The intra-articular width of the symphysis pubis is increased after a symphysiotomy. Seventy-nine of the 80 interviewed health care workers knew about symphysiotomy. One obstetrician had performed symphysiotomies. Two-thirds of the participants considered symphysiotomy an obsolete and second-class operation, but lifesaving and appropriate in remote areas of Zimbabwe. Ten of 13 midwives in remote areas wanted to carry out symphysiotomies themselves. Conclusions: No severe complications due to symphysiotomy were revealed in this study. The results suggest that a modest permanent enlargement of the pelvis post symphysiotomy (together with the absence of a scarred uterus) may facilitate subsequent vaginal delivery. Doctors and midwives working in district hospitals have a more positive attitude to symphysiotomies than the colleagues in central hospitals. Obstetricians (who would have to do the teaching), working in the large urban hospitals almost exclude symphysiotomy as an alternative management in Zimbabwe. Citation: Ersdal HL, Verkuyl DAA, Bj o¨rklund K, Bergstro¨ m S (2008) Symphysiotomy in Zimbabwe; Postoperative Outcome, Width of the Symphysis Joint, and Knowledge, Attitudes and Practice among Doctors and Midwives. PLoS ONE 3(10): e3317. doi:10.1371/journal.pone.0003317 Editor: Landon Myer, University of Cape Town, South Africa Received May 9, 2008; Accepted September 12, 2008; Published October 10, 2008 Copyright: 2008 Ersdal et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: The work presented is partly financed by The Research Council of Norway (student scholarship for the first auther HLE). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript Competing Interests: The authors have declared that no competing interests exist. * E-mail: hege@ersdal.com { Deceased. Introduction Symphysiotomy was developed in Europe late in the 18th century as a means to save the lives of mother and child in obstructed labour. In the early days the separation of the bones was performed after exposing the symphysis. With the introduc- tion of aseptic techniques in the mid 19th century and the subcutaneous symphysiotomy by Frank [1], using local anaesthet- ics, the operation gained acceptance and became part of the obstetric arsenal in many parts of Europe [2–5]. The technique was further refined by Za´rate in Argentina [6], and symphysiot- omy was extensively practised in Latin America and Ireland up to the mid 20th century [4,7,8]. Seedat and Crichton in Durban, South Africa, further developed the technique [9] and symphy- siotomy came to be used in Africa for the ensuing decades [9–12]. Currently, outside Africa, symphysiotomies are still performed in Papua New Guinea [13]. Mechanical obstruction in the second stage complicates 1–2% of labours [14]. In developing countries this percentage might be higher because women often do not attain their (pelvic) growth potential due to stunting. The facilities and staffing level of non- private hospitals in developing countries make it often inevitable that CSs are associated with an appreciable mortality rate. In addition, there is no guarantee that a woman with a scar in the uterus can, or even would like to, reach in time a (still adequately staffed) hospital for the next delivery. The World Health Organization (WHO) PLoS ONE | www.plosone.org 1 October 2008 | Volume 3 | Issue 10 | e3317