estimates annual global obstructed labour related maternal mortality at 50,000 [15]. On top of that, prolonged labours frequently cause life long handicaps to mother and child. According to the United Nations Population Fund (UNFPA) there are 2 million women living with a vesico-vaginal fistula caused by obstructed labour (http:// www.endfistula.com/fast_facts.htm). The woman in obstructed labour should not be abandoned in her plight. Symphysiotomy is a potential solution in selected cases of obstructed labour with mild to moderate cephalopelvic dispro- portion [12,16–18]. A review of 5,000 symphysiotomies performed during the twentieth century concluded that: ‘‘If valid conclusions can be drawn from one hundred years of retrospective studies, there is considerable evidence to support a reinstatement of symphysiotomy in the obstetric arsenal, for the benefit of women in obstructed labour and their offspring’’ [16]. A theoretical model shows that under basic circumstances only a few symphysiotomies are needed to prevent one maternal death [19]. Still, symphysi- otomies are rarely performed systematically, with notable exceptions [17,20]. In contrast, Onah demonstrated a dislike for CS among pregnant Nigerian women [21], and a preference for symphysiotomy above CS, if given the choice [22]. In view of the ongoing controversy we found reasons to contribute to the discussion with a rare long term case control follow up study. At the same time we evaluate for the first time symphyseal width after symphysiotomy and after normal vaginal delivery with ultrasound technique, and knowledge, attitudes and practice related to symphysiotomy among doctors and midwives in Zimbabwe. Methods The present paper builds on two follow-up studies post symphysiotomy performed in Bulawayo, Zimbabwe in1994 and 1996 and one study in 1998 on knowledge, attitudes and practice among doctors and midwives at three levels of the health system in Zimbabwe; the academic hospital in Harare (Harare Central Hospital), two central hospitals in Bulawayo (United Bulawayo Hospital and Mpilo Central Hospital) and a convenience sample of seven district hospitals (Beitbridge, Lupane, Esigodini, Gwanda, Hwange, Victoria Falls and Kariba). Follow-up post symphysiotomy, studies in 1994 and 1996 Permission to conduct the interviews and ultrasound examina- tions, including ethical clearance, was obtained from the medical superintendents at United Bulawayo Hospitals (UBH) and Mpilo Hospital. All women were informed about the research project (in English or a local language) when seen by the first author (HLE) together with a local interpreter or an ultrasound technician. Since these follow-up studies were conducted among a partly illiterate population the women gave explicit verbal consent to involvement. Nobody refused. The interpreter or the ultrasound technician bore witness to the oral consent process. In 1994, 18 women who had undergone a symphysiotomy previously (S group) and 29 women with previous CS (CS group) were interviewed. The second author (DAAV) had made a serious effort to record basic data and the addresses of all the women who had a symphysiotomy in the UBH and the referring Matabeleland South Province district hospitals during 1990–1994. Also women who had a symphysiotomy performed even earlier and who were seen incidentally at the antenatal clinic or in labour were added to the list. Altogether 61 women were registered. Symphysiotomies had mostly been performed by consultants in UBH, and by experienced district doctors who considered symphysiotomy to be the best option in each of the cases. Symphysiotomy in Zimbabwe The CS group consisted of women having undergone caesarean delivery for a probable pelvic outlet obstruction. They were recorded in the register as having had a CS after a failed vacuum extraction. It was not possible to find enough time-matched failed vacuum extractions followed by CS in the registers of the UBH, therefore we included the delivery records of the other tertiary hospital in Bulawayo, Mpilo Hospital, which caters to similar women. Seventy women were selected in this way and we tried to match the time since the index delivery as much as possible. Serious efforts were made to visit women in both groups. Fourteen women in the S group and 24 women in the CS group were found at home. Letters written in local languages and English, promising a check up and expressing commitment to pay travelling costs and compensation (for themselves and necessary accompanying person), were sent to the remainder. After this, four and five women, respectively, appeared. The first author (HLE) prepared the interview in cooperation with DAAV. HLE conducted all the interviews and took notes, assisted by a single interpreter speaking fluent English, and the local languages. The interview was divided in four sections. Firstly, the baseline data (age, parity before and after index intervention, and years since index intervention) were confirmed and registered. Secondly, the woman was asked about the child’s condition when born and subjectively experienced perioperative complications (pain, fistu- lae, laceration, hemorrhage or infection). Thirdly, she was questioned about specific current complaints (pain when walking, dancing, jumping or carrying, painful scar, dyspareunia, infertility, and incontinence), and finally, the women were asked about any subsequent pregnancies and deliveries. In 1996, 19 women who had undergone a symphysiotomy previously (S group) and 92 women with only previous normal vaginal deliveries (NVD group) were interviewed and the symphyseal joints were examined by ultrasound at UBH. Ethical clearance for this study was also given in advance by The National Committees for Research Ethics in Norway. The register of women who had undergone symphysiotomy in the area around Bulawayo had in the mean time expanded to 70. Letters were written, inviting them to UBH for a checkup. Nineteen women appeared representing the S group, three of whom had also been interviewed in 1994. Two of these 19 women were pregnant (both 8 months). Eleven women lived in and around Bulawayo, four lived 20–100 kilometres outside the city, and four lived over 100 kilometres away. At the Department of Obstetrics and Gynaecology in UBH, 92 women with previous normal vaginal deliveries, referred for ultrasonography for different reasons, were during one month consecutively invited to have their symphyseal width recorded. Further inclusion criteria were parity 1–8, having delivered exclusively vaginally, age between 15 and 45 years, and no orthopaedic disorders. All the selected women were informed about the study, and all of them accepted to participate. Thirty- four of the women included were pregnant. Baseline data for both groups were registered and women in the S group were interviewed by HLE using the same semi-structured interview as in 1994. There was always an ultrasound technician present who spoke the local languages and English. Afterwards, women in both groups were sonographically examined by HLE with a Philips Sterling 1993 model, utilizing 5 mega Hertz convex sector probe to measure the internal symphyseal gap. Bjo¨ rklund et al had concluded in 1996 [23] that estimating the width of the symphysis pubis by ultrasonography offers at least the same precision as radiography. The image of the symphysis is seen as two curved lines representing the anterior surfaces of the pubic PLoS ONE | www.plosone.org 2 October 2008 | Volume 3 | Issue 10 | e3317