Table 1. Baseline data from the three groups; CS, S, and NVD. Symphysiotomy in Zimbabwe Maternal age Parity before index operation Interval since operation, years Total number of deliveries at follow up doi:10.1371/journal.pone.0003317.t001 bones, turning parallel into the symphyseal gap, where the width may be measured. Measuring the width may sometimes be difficult due to the shape of the gap. The opposing edges of the gap might be highly irregular and there is a widening mostly upwards, but also occasionally downwards. The measuring point was defined as the narrowest part of the symphyseal joint gap in the upper half of the symphysis. The women were in a supine position with extended hips while the measurements were taken. For statistic calculation Student’s t-test was used. Knowledge, attitudes and practice among doctors and midwives, study in 1998 The interviews were not announced beforehand. All relevant doctors and midwives present at the respective maternity units at the time of the visit were invited to participate, and everyone accepted. Permission to conduct the interviews, including ethical clearance, was obtained from the medical superintendents at each location. The first and second authors (HLE and DAAV) prepared the questions in cooperation with a local general practitioner in Bulawayo. The interview consisted of two parts. Firstly, the participant was asked about her/his practice and if he/she could describe the procedure. Secondly, the interview included a series of statements on symphysiotomy. The person interviewed was asked to react affirmative or negative to closed questions. HLE conducted all the interviews. In the data analysis the interview locations were divided into urban and rural, comparing the responses of specialists in obstetrics and gynaecology, junior doctors and district doctors and different categories of midwives. Results Follow-up post symphysiotomy, studies in 1994 and 1996 Baseline data. The baseline data from the three groups (S, CS, and NVD) are presented in Table 1. Twelve women in the S group had delivered before their symphysiotomy, five with a CS. Women in the NVD group had no abdominal deliveries, and their average parity when seen was 2.6. Reported perioperative complications after symphysio- tomy. There was one neonatal death during the hospital admission associated with a symphysiotomy among the 70 deliveries on record. None of the 34 interviewed women in the S group reported serious soft tissue injuries in the birth canal, e.g. laceration, fistulae, and hemorrhage, or post-operative infection. One woman delivered a baby in a district hospital, the neonatal death, with an undiagnosed hydrocephalus and experienced a too wide separation of the symphysis resulting in damage to the tissues PLoS ONE | www.plosone.org 3 October 2008 | Volume 3 | Issue 10 | e3317 CS 1994 n = 29 Average 26,8 1 2,9 2,3 Range 15–40 0–5 0–15 1–6 S 1994+1996 n = 34 Average 26,1 0,8 4 2,5 Range 18–42 0–6 0–15 1–8 NVD 1996 n = 92 Average 31,1 2,6 Range 19–45 1–8 supporting the urethra/bladder neck. She suffered from stress incontinence as soon as the urinary catheter had been removed. Thirteen (38%) of the women did not remember their symphy- siotomy delivery as being particularly painful. Current complaints. Table 2 shows a comparison of current complaints in the S and CS groups. The outcomes are very similar for the two interventions, except for scar pain (p,0.01). Eight women (23.5%) in the S group reported that they felt pain when walking; seven of them had tenderness or pain over the symphysis pubis only after walking 10–20 km. The woman who delivered a baby with hydrocephalus reported pain in the symphysis pubis and a feeling of instability in the pelvis when walking any distance. She was the only woman in the S group with urinary stress incontinence at follow up. She could presently cope with her incontinence if she remembered to void frequently. She managed her daily duties, but was not able to walk far from the village. None of the other women in the S group experienced instability in the symphysis pubis or the pelvic region. Half of the women in the CS group experienced pain in the scar. They also mentioned itching, pins and needles. Five women in the CS group reported pain deep in vagina during coitus, none of them having had this problem before the CS. Ten women in the S group reported some pain over the symphysis pubis with abduction of the legs during coitus, but none experienced pain in Table 2. Comparison of current complaints after CS and after S. Pain when walking* Pain when dancing Pain when jumping Pain when carrying Painful scar Dyspareunia Infertility Incontinence CS n = 29 % 13,8 6,9 6,9 6,9 51,7 17,2 6,9 6,9 S n = 34 % 23,5 2,9 8,8 8,8 2,9 0 2,9 29,4** P 0,33 0,52 0,78 0,84 0,41 0,12 0,47 ,0,01 *CS 4/4 pain when walking any distance. S 1/8 pain when walking any distance, 7/8 pain when walking long distance. **10/10 some pain over symphysis pubis when abduction of the legs. doi:10.1371/journal.pone.0003317.t002