ObjectivesTo describe experiences including interviews with bereaved women in a clinical audit.DesignThe data come from an audit of all stillbirths and neonatal deaths at ≥22 weeks of gestation in ...Seine-Saint-Denis, a disadvantaged French district in 2014. We included bereaved women using a questionnaire that also contained open-ended questions administered in an interview format by a midwife-investigator several weeks after the death. The study included a referral protocol for bereaved women with unmet needs revealed during the interviews. A psychological support for the three midwife-investigators was set-up, in the form of a support group.SettingThe 11 maternity hospitals in the district.Participants218 women (227 deaths).AnalysesData come from medical records, maternal interviews, the reviews of the audit’s expert panel and written narratives of their experiences provided by the midwife-investigators. Quantitative data were analysed statistically, and qualitative data thematically.ResultsOne-third (75) of the women agreed to an interview, but acceptance ranged from 6% to 60% by maternity unit. Characteristics of respondents and non-respondents were similar. Members of the audit’s expert panel reported that 41% of the interviews contained new information relevant to their assessment. Of the women interviewed, 35% were referred to a medical professional, psychologist or social worker. Midwife-investigators’ experiences illustrated the benefits of a support group with three main themes identified: improving their interactions with bereaved women as well as medical teams and protecting their psychological well-being.ConclusionThese results showed that including interviews with bereaved women in audit designs was feasible and provided valuable information on women’s care and social circumstances that were not available in medical records. They also highlight the importance of implementing referral protocols for the bereaved women, used in over one-third of cases, as well as providing support for study investigators.
While studies have long shown the beneficial health effects of physical activity during pregnancy, such recommendations have been rarely analyzed in terms of how practitioners adapt such health ...messages to patients’ social profiles. The present study sought to apprehend the logics underlying practitioner (non)recommendations of physical activity and exercise during pregnancy, and how these were associated with social distinctions made between patients. Semi-directive interviews were conducted with 20 midwives and 17 gynaecologists and obstetricians in south-eastern France. Based on thematic analyses, the results show how recommendations draw from both medical and social knowledge, mobilizing social representations regarding physical activity, (non)normative bodies and othered social categories of class, ethnicity or obesity. The othering processes reiterate gendered social hierarchies as well as moral orders surrounding normative bodies and health-enhancing behaviours. The findings demonstrate how social hierarchies and beliefs intertwine with public health discourses about the body and health-enhancing practices, suggesting directions for reducing their impact in contexts of medicine and health.
Among hypertensive disorders of pregnancy (HDP), eclampsia is a rare but serious event, often considered avoidable. Detailed assessment of the adequacy of care for the women who have eclampsia can ...help identify opportunities for improvement and for prevention of the associated adverse maternal and neonatal outcomes.
1/ To estimate the incidence and describe the characteristics of women with eclampsia and to compare them with those of women with non-eclamptic hypertensive disorders of pregnancy (HDP)-related severe maternal morbidity (SMM) and of control women without SMM 2/ To analyse the quality of management in women who had eclampsia, at various stages of their care pathway.
It was a planned ancillary analysis of the EPIMOMS population-based study, conducted in six French regions in 2012-2013. Among the 182,309 maternities of the source population, all women with eclampsia (n = 51), with non-eclamptic HDP-related SMM (n = 351) and a 2% representative sample of women without SMM (n = 3,651) were included. Main outcome was the quality of care for eclampsia assessed by an independent expert panel at three different stages of management: antenatal care, care for pre-eclampsia and care for eclampsia.
The eclampsia incidence was 2.8 per 10,000 (95%CI 2.0-4.0). Antenatal care was considered completely inadequate or substandard in 39% of women, as was pre-eclampsia care in 76%. Care for eclampsia was judged completely inadequate or substandard in 50% (21/42), mainly due to inadequate use of magnesium sulphate.
The high proportion of inadequate quality of care underlines the need for an evidence-based standardisation of care for HDP.
Most indicators proposed for assessing quality of care in obstetrics are process indicators and do not directly measure health effects, and cannot always be identified from routinely available ...databases. Our objective was to propose a set of indicators to assess the quality of hospital obstetric care from maternal morbidity outcomes identifiable in permanent hospital discharge databases.
Various maternal morbidity outcomes potentially reflecting quality of obstetric care were first selected from a systematic literature review. Then a three-round Delphi consensus survey was conducted online from 11/2016 through 02/2017 among a French panel of 37 expert obstetricians, anesthetists-critical-care specialists, midwives, quality-of-care researchers, and user representatives. For a given maternal outcome, several definitions could be proposed and the indicator (i.e. corresponding rate) could be applied to all women or restricted to specific subgroup(s).
Of the 49 experts invited to participate, 37 agreed. The response rate was 92% in the second round and 97% in the third. Finally, a set of 13 indicators was selected to assess the quality of hospital obstetric care: rates of uterine rupture, postpartum hemorrhage, transfusion incident, severe perineal lacerations, episiotomy, cesarean, cesarean under general anesthesia, post-cesarean site infection, anesthesia-related complications, postpartum pulmonary embolism, maternal readmission and maternal mortality. Six were considered in specific subgroups, with, for example, the postpartum hemorrhage rate assessed among all women and also among women at low risk of PPH.
This Delphi process enabled us to define consensually a set of indicators to assess the quality of hospital obstetrics care from routine hospital data, based on maternal morbidity outcomes. Considering 6 of them in specific subgroups of women is especially interesting. These indicators, identifiable through codes used in international classifications, will be useful to monitor quality of care over time and across settings.
La santé périnatale constitue un vaste champ d’études pluridisciplinaires et de nombreux travaux en anthropologie de la santé y sont consacrés. En France et aux États-Unis notamment, les mouvements ...féministes pour la santé des femmes des années 1970 ont questionné la mainmise du corps médical sur la santé reproductive (Boston Women’s Health Book Collective, 1973 ; Davis, 1983) et permis des avancées législatives sur les questions de contraception, d’accès à l’avortement et plus récemment sur ...
In this study, we aimed to describe the autopsy acceptance rate and to understand the factors associated with declining an autopsy after stillbirth in a disadvantaged French district with a high ...migrant population. Between 1992 and 2015, the costs of autopsies for fetal and neonatal deaths in this district were completely covered by the local council (Conseil Général) and there was therefore no financial burden associated with an autopsy for families or for hospitals. We used a mixed-method approach using data from medical records and interviews with women experiencing a stillbirth collected as part of a population-based audit in the district in 2014.
To examine disparities by maternal place of birth in the opportunity to make an informed choice about Down syndrome screening, in France, where the national guidelines recommend that physicians offer ...it to all pregnant women.
We used population-based data from the nationally representative French Perinatal Surveys in 2010 and 2016 (N=24,644 women) to analyze the opportunity for an informed choice for prenatal screening, measured by a composite indicator.
Among the 24 644 women in the study, 20 612 (83.6%) were born in France, 861 (3.5%) elsewhere in Europe, 1550 (6.3%) in North Africa, and 960 (3.9%) in sub-Saharan Africa. The probability of screening was lower for women born outside France. After adjustment for survey year, maternal age, parity, education level, and the maternity unit's level of perinatal care, women born outside France had the opportunity to make an informed choice less often than women born in France. This association remained essentially the same even after excluding women without adequate prenatal care.
Women born outside France, including those with adequate prenatal care, had less opportunity than women born in France to make an informed choice about prenatal screening for Down syndrome.
In many Western countries, higher rates of cesarean have been described among migrant women compared to natives of receiving countries. We aimed to estimate this difference comparing women ...originating from France and Sub-Saharan Africa (SSA), identify the clinical situations explaining most of this difference and assess whether maternal origin was independently associated with cesarean risk.
The PreCARE prospective multicenter cohort study was conducted in 2010-2012 in the north Paris area. Our sample was restricted to 1500 women originating from Sub-Saharan Africa and 2206 from France. Profiles of cesarean section by maternal origin were described by the Robson classification. Independent associations between maternal origin and 1) cesarean before labor versus trial of labor, then 2) intrapartum cesarean versus vaginal delivery were assessed by logistic regression models to adjust for other maternal and pregnancy characteristics.
Rates of cesarean for women originating from France and SSA were 17 and 31%. The Robson 5A category "unique uterine scar, single cephalic ≥37 weeks" was the main contributor to this difference. Within this category, SSA origin was associated with cesarean before labor after adjustment for medical risk factors (adjusted odds ratio aOR = 2.30 1.12-4.71) but no more significant when adjusting on social deprivation (aOR = 1.45 0.63-3.31). SSA origin was associated with cesarean during labor after adjustment for both medical and social factors (aOR = 2.95 1.35-6.44).
The wide difference in cesarean rates between SSA and French native women is mainly explained by the Robson 5A category. Within this group, medical factors alone do not explain the increased risk of cesarean in SSA women.
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