Rural 2 (29) 4 (57) 5 (71) 5 (71) 6 (86) 2 (29) 2 (29) 3 (43) 4 (57) 2 (29) 4 (31) 9 (69) 13 (100) 13 (100) 4 (31) 4 (31) 10 (77) 9 (69) 11 (85) 10 (77) Table 6. Affirmative answers on statements about symphysiotomy among doctors and midwives in three hospitals in the two largest cities of Zimbabwe (Harare and Bulawayo), and among doctors and midwives at seven district hospitals. Midwives Doctors Midwives n = 34 (%) n = 26 (%) n = 7 (%) n = 13 (%) Symphysiotomy is a harmful operation 22 (65) is obsolete and second-class 24 (71) can be lifesaving is appropriate in remote areas Symphysiotomy is associated with negligible maternal mortality high maternal morbidity uneventful subsequent deliveries Symphysiotomy should be performed in central hospitals taught to district doctors taught to midwives Urban Doctors 14 (41) 14 (41) 26 (76) 23 (68) 12 (35) 11 (32) 11 (32) 7 (21) 11 (42) 17 (65) 20 (77) 20 (77) 10 (38) 11 (42) 12 (46) 15 (58) 20 (77) 13 (50) Symphysiotomy in Zimbabwe pelvic disproportion, live foetus and longitudinal lie. The British Journal of Obstetrics and Gynaecology proclaimed, in an editorial (2002), the rebirth of symphysiotomy to reduce maternal and foetal mortality and morbidity [31]. According to the literature symphysiotomy is associated with immediate post-operative pain and discomfort [4,10,12,13,16– 18,32–38], and it is a painful procedure when insufficient local anaesthesia is given. All women will experience pain at the moment of delivery, and separating the different origins of pain in labour might be difficult, also because an episiotomy and mostly a vacuum extraction is part of the symphysiotomy procedure. The results from the present study and previous follow-up studies indicate that symphysiotomy confers an acceptable level of complaints in the long run [10,16,32,36,38]. Lasbrey assessed pain in the symphysis pubis, groin, hip, thigh, sacro-iliac joint and stress incontinence, mostly associated with physical activity, and found that these problems were small and did not interfere with day-to- day activities [36]. The prevalence of these symptoms at some time during the follow-up period or in a subsequent pregnancy was 58% in the symphysiotomy group and 60% in parous women with unassisted vaginal deliveries. Hartfield compared the outcomes of symphysiotomy and CS (for cephalopelvic disproportion) includ- ing a long-term follow-up study [10]. Prevalence figures of reported sub fertility (7%), stress incontinence (3%), and backache (25%) in the symphysiotomy group were similar to corresponding figures in the CS group. Infertility after symphysiotomy was not addressed in the present study, and the woman who reported incontinence was apparently subject to an incorrect judgement of the degree of cephalopelvic disproportion. Pain or tenderness over the symphysis pubis when walking long distances was observed in this study, but not reported nor mentioned as a parameter in previous follow-up studies [4,10,13,32–38]. Dyspareunia was registered in 17,2% (CS group) and 29,4% (S group) of the women in this study, unfortunately women with normal vaginal deliveries were not asked about this. Overall, prevalence of maternal complaints after symphysiotomy and CS do not differ much, though they are somewhat different in nature. The study performed in 1996 indicates that the width of symphysis pubis is permanently increased after a symphysiotomy, potentially facilitating future vaginal deliveries. Over three-quarters of the women with previous symphysiotomy that had a subsequent delivery had given birth vaginally without complications, in agreement with previous observations [3–5,20,25,27]. This is an important advan- tage for a young woman with a borderline pelvis and several pregnancies ahead, living in a rural area with a tradition to deliver at home far from a well equipped hospital. The studied S group, including almost 50% of the women recorded after a symphysiotomy, might be a biased sample. Maybe women with severe complications were kept away, or the other way around, women without complaints had little to gain from leaving home for 1–2 days. Health services were free and well organized at that time, so it is likely to believe that the network of clinics would have picked up a woman with severe handicap and referred her. All the women in the record were operated in Bulawayo or an adjacent mission hospital, and the registered addresses were in the same region. Both postal service and bus transport system were reliable in 1994 and 1996. Doctors and midwives, working in Zimbabwe in 1998, knew in theory what a symphysiotomy is, and the majority of the participants in this study considered the operation lifesaving and appropriate in remote areas. Knowledge, attitudes and practice may have changed with time, but the results from 1998 indicate that district doctors and midwives have a more positive attitude to symphysiotomy than colleagues working in the cities. Most positive doi:10.1371/journal.pone.0003317.t006 abandoned in Western countries, and considered this fact an argument against the use of the intervention in Zimbabwe. Discussion There are no reports of maternal mortality directly related to symphysiotomy from the antibiotic era [16]. There are still large regional differences in CS-related mortality. A study from the adjacent Matabeleland-South province of 1,128 CSs performed in 7 district hospitals 1998–2000 (covering a period when the health/ transport infrastructure was still good) revealed a CS-related mortality of 1.6% [24]. In circumstances where CSs are not very dangerous and where women have few children (hence few deliveries after a previous CS) the advantages of symphysiotomies are small and furthermore doctors cannot obtain or maintain the expertise needed [19], but symphysiotomies are still sometimes the best option even in this situation [25–29]. Verkuyl calculated that in breech presentations in district hospitals in sub-Saharan Africa a policy of replacing elective CS with trial of labour combined with a symphysiotomy if the foetal head became stuck, would, in nullipara, prevent one maternal death for two symphysiotomies performed [19]. Replacing emergency CS for failed vacuum extraction with a symphysiotomy was claimed in this paper to have a similar beneficial effect on maternal mortality [19]. Hill et al estimated 535,900 maternal deaths worldwide in 2005 [30], of which 50% were concentrated in sub-Saharan Africa and there was no significant reduction in maternal mortality ratios between 1990 and 2005 in this area. For all other countries with data there was a decrease in maternal mortality ratios of 2.5% per year in the same time period [30]. Symphysiotomy is an alternative management in cases of mild to moderate cephalo- PLoS ONE | www.plosone.org 5 October 2008 | Volume 3 | Issue 10 | e3317