French National Perinatal Survey Research Articles

Durée de séjour en maternité après un accouchement par voie basse en France

To study hospital length-of-stay (LOS) after childbirth and its determinants and to describe home care offered after discharge. We studied 10,302 women with vaginal delivery from the 2010 French National Perinatal Survey. Maternal, newborn, maternity unit characteristics and the region of birth were considered. Simple and polytomial regression analyses were used to study determinants of postpartum LOS. Maternity units that offered routinely home visits by midwives after discharge were described. Around 29,0% of women had a LOS ≤ 3 days, with significant variations between regions. LOS ≤ 3 days was more common among multiparas and women who bottle-fed their newborn. In the Greater Parisian Region, LOS ≤ 3 days ranged from 16,6% in private units <1000 del/year to 72,9% in teaching units ≥ 3000 del/y. Among women who had a LOS ≤ 3 days, only 19,7% were in a unit, which offered home visits routinely. LOS varies mainly according to the place of delivery. The trends towards short LOS are likely to continue due to economic pressures and home care services should be developed to ensure continuity of care for all mothers after discharge.

Preterm Birth and Congenital Heart Defects: A Population-based Study

Preterm birth (PTB) and congenital heart defect (CHD) are 2 major causes of mortality and disability of perinatal origin. There are limited data on the relation between CHD and PTB. Our objective was to use population-based data to estimate the risk of PTB in newborns with CHD and to study specific associations between categories of CHD and PTB. We used data from a population-based cohort study of CHD (EPIdémiologique sur le devenir des enfants porteurs de CARDiopathies congénitales study), including 2189 live births with CHD (excluding isolated atrial septal defects) born between 2005 and 2008. We categorized CHD by using an anatomic and clinical classification. Data from the French National Perinatal Survey of 2003 were used to compare PTB in the EPIdémiologique sur le devenir des enfants porteurs de CARDiopathies congénitales study to that of the general population. Of the newborns with CHD, 13.5% were preterm. The odds of PTB were twofold higher than for the general population (odds ratio 2.0, 95% confidence interval 1.6-2.5), essentially due to an increase in spontaneous PTB for newborns with CHD. The risk of PTB associated with CHD persisted after exclusion of chromosomal or other anomalies. There were significant variations in risk of PTB across the categories of CHD after adjustment for known risk factors of PTB and factors related to medical management of pregnancy and delivery. We found a higher risk of PTB in newborns with CHD, which was essentially due to spontaneous PTB. Risk of PTB varied for categories of CHD. Our finding may be helpful for generating hypotheses about the developmental links between CHD and PTB.

Obstetric Interventions for Low‐Risk Pregnant Women in France: Do Maternity Unit Characteristics Make a Difference?

In many countries the closure of small maternity units has raised concerns about how the concentration of low-risk pregnancies in large specialized units might affect the management of childbirth. We aimed to assess the role of maternity unit characteristics on obstetric intervention rates among low-risk women in France. Data on low-risk deliveries came from the 2010 French National Perinatal Survey of a representative sample of births (n = 9,530). The maternity unit characteristics studied were size, level of care, and private or public status; the interventions included induction of labor; cesarean section; operative vaginal delivery (forceps, spatulas or vacuum); and episiotomy. Multilevel logistic regression analyses were adjusted for maternal confounding factors, gestational age, and infant birthweight. The rates of induction, cesarean section, operative delivery, and episiotomy in this low-risk population were 23.9 percent, 10.1 percent, 15.2 percent, and 19.6 percent, respectively, and 52.0 percent of deliveries included at least one of them. Unit size was unrelated to any intervention except operative delivery (adjusted odds ratio [aOR] = 1.47 (95% CI, 1.10-1.96) for units with >3,000 deliveries per year vs units with <1,000). The rate of every intervention was higher in private units, and the aOR for any intervention was 1.82 (95% CI, 1.59-2.08). After adjustment for maternal characteristics and facility size and status, significant variations in the use of interventions remained between units, especially for episiotomies. Results for level of care were similar to those for unit size. The concentration of births in large maternity units in France is not associated with higher rates of interventions for low-risk births. The situation in private units could be explained by differences in the organization of care. Additional research should explore the differences in practices between maternity units with similar characteristics.

Trends in perinatal health in France from 1995 to 2010. Results from the French National Perinatal Surveys

To study trends in the main indicators of health, medical practices and risk factors in France. We collected data from samples of all births in France during one week in 1995 (n=13318), 1998 (n=13718), 2003 (n=14737) and 2010 (n=14903) and have compared them. Between 1995 and 2010, maternal age and body mass index increased steadily, but tobacco use decreased. In 2010, 39.4% of pregnant women had a visit with a midwife in a maternity unit, versus 26.6% in 2003. Deliveries occurred in large public hospitals more and more frequently. The increase in caesarean sections was no longer significant between 2003 and 2010. In general, medical decisions during pregnancy and delivery were closer to professional recommendations in 2010 than in earlier years. Live births before 37 weeks increased steadily from 5.4% in 1995 to 6.6% in 2010, but the proportion of birth weights below 2500g or the 10th percentile stopped increasing after 2003. Routine national perinatal surveys highlight major trends in maternal characteristics, obstetric practices, organisation of services, and perinatal health.

Preterm Birth (PTB) and Congenital Heart Defects (CHD): A Population-Based Study

Background and aims: PTB and CHD are the two main causes of mortality, morbidity and disability of perinatal origin. There are little population-based data on the relation between CHD and PTB. The objective of this study was to estimate the prevalence of prematurity in newborns with CHD and to study specific associations between subcategories of CHD and PTB.Methods: We used data from the EPICARD study, a population-based cohort study of CHD in France, including 2349 livebirths with CHD. We used an anatomic and clinical classification of CHD based on the International Paediatric and Congenital Cardiac Code to categorise CHD into ten groups. Data on PTB from the French National Perinatal Survey were used to compare PTB in EPICARD to that of the general population.Results: 15% (95%CI, 13.6-16.5) of the newborns with CHD were PTB and the odds of PTB was more than two fold higher than for general population (OR 2.3 95%CI, 1.8-2.8). The higher risk of PTB, and particulary very PTB (< 32 weeks), associated with CHD persisted after exclusion of cases associated with chromosomal anomalies and/or non-cardiac defects and adjustement for maternal age, sociodemographic characteristics and diabetes. There were wide variations in PTB across the ten groups examined.Conclusion: In this population-based study, the risk of PTB and particulary very PTB was substancially higher for newborn with CHD. Risk of PTB varied highly for subcategories of CHD and the specific associations oberved may be helpful for generating hypotheses about the developemental links between CHD and PTB.

Discordant time trends in maternal body size and offspring birthweight of term deliveries in France between 1972 and 2003: data from the French National Perinatal Surveys

We investigated time trends in maternal weight before and during pregnancy and in infant birthweight in France, from 1972 to 2003, using data on singleton live term births from the representative National Perinatal Surveys of 1972, 1981, 1995, 1998 and 2003 (n=8,664, 4,494, 11,445, 12,006, 12,692, respectively). Mothers were interviewed a few days after delivery and data on delivery and the newborn were extracted from hospital records. Maternal prepregnancy weight, height, body mass index and pregnancy weight gain all increased from 1972 to 2003; however, birthweight did not show a parallel trend. After taking gestational age, maternal age, parity, country of origin, newborn gender and maternal smoking during pregnancy into account, mean birthweight increased between 1972 and 1995 but decreased thereafter and, consistently, there was an increase in small-for-gestational age (SGA) and a decrease in large-for-gestational age newborns. Further adjustment for induced delivery, an indicator of obstetric practice, did not change the results. A similar variation has been observed very recently in the US and in Germany. Further research is needed to identify the factors responsible for these discordant changes and especially the factors responsible for the recent increase in SGA since this has been shown to be associated with poorer health in later life.

Impact of maternity unit closures on access to obstetrical care: The French experience between 1998 and 2003

As in many other countries, the number of maternity units has diminished substantially in France, raising concerns about the reduced accessibility of obstetric services. We describe here the impact of closures on distance and mean travel time between pregnant women's homes and maternity units. We used data from the 1998 and 2003 French National Perinatal Surveys and from vital registries to measure indicators of accessibility: straight-line distance to the nearest maternity unit, number of units within a 15-km radius and reported travel time to the unit for delivery. We analyzed these measures for all births, births in rural versus urban areas and according to regional rates of maternity closures. From 1998 to 2003, 20% of maternity units closed (reducing the number from 759 to 621) with regional variations in the rate of closure from 0.0% to 36.0%. Mean distance to the nearest maternity unit increased (6.6–7.2 km, p < 0.001). The proportion of women living more than 30 km from a maternity ward was low; but rose from 1.4% to 1.8%. The number of maternity units with a 15-km radius of the place of residence fell (median, 3 to 2). Differences were more marked in rural areas and in regions highly affected by closures. However, reported travel time did not increase and even declined slightly for women from urban areas and in regions moderately affected by the closures. As such, the closures do not appear to have had a negative impact on the geographic accessibility of maternity units. Pregnant women were faced with a reduction in the number of maternity units near their homes and our results suggest that they more often chose their maternity units based on proximity. A full assessment of the impact of closures on accessibility to obstetric services would require information on how these changes affected available choices for care during pregnancy and delivery.

Differential trends in breastfeeding according to maternal and hospital characteristics: results from the French National Perinatal Surveys

Differential trends in breastfeeding according to maternal and hospital characteristics: results from the French National Perinatal Surveys

Gene–environment interaction is now hype

A number of genes have been identified leading to attention deficit and hyperactivity disorders (ADHD). Nearly 80% of ADHD seems to be heritable, according to the interesting review by Stephen Faraone et al. in this issue. Some of these genes encode for dopamine and serotonin transporters and receptors. However, many of these genes are not expressed in the phenotype, if not triggered by environmental factors. Nicotine and alcohol are two such factors that also interact with the dopaminergic and serotoninergic system. Another environmental factor that has been much discussed is extensive television viewing. Whereas there are at least 10 studies indicating a relationship between maternal smoking and ADHD, there are only a couple of studies suggesting that TV-viewing can increase ADHD. Environmental factors can interact with genes by epigenetic mechanisms, that is methylation or desmethylation of the genome. This mechanism may also be of great importance to explain the increase of childhood obesity. Children of obese parents, particularly if they are also suffering of Type 2 diabetes, are at increased risk of becoming obese. Environmental factors more common in poor families increase the risk. Prevention must start in the first year and not later than the third year according to Karina Huus et al. in this issue. Oestrogen is the most known female hormone we know and assumed to be of less interest for men until they get their prostate cancer. However, oestrogen is very important also for young males. In 1994, a man was diagnosed with an inactivating oestrogen receptor alpha. This patient had a bone age of only 14 years at the chronological age of 28 years. He was still growing and suffered from osteoporosis. Read more about oestrogen receptors and linear bone growth in this issue in a review by Andrei Chagin and Lars Sävendahl. Why has France still one of the lowest breastfeeding rates in Europe? Is it due to that the French promote culture more than nature? See the report from the French National Perinatal Survey by Mercedes Bonet et al. in this issue. Treatment of childhood cancer is one of the best success stories of modern paediatrics. However, the quality of life after curing cancer is not always optimal. Reinfjell et al. report that some of these children develop neurocognitive sequelae. See also Commentary by Krister Boman. British Medical Journal (BMJ) has a poll whether a boycott of Israeli academic institutions should be considered. It is disgraceful even to arrange a poll like this. Michael Baum (BMJ 2007;335:125) is strongly against a boycott and believes ‘passionately that we can all do our bit for peace by building bridges between British, Israeli and Palestinian academics and physicians’. His brother, the late David Baum former president of the Royal College of Paediatrics and Child Health did that by establishing a sick children's clinic in Gaza. This is a much more constructive approach than a boycott. If BMJ or Archives of Disease in Childhood, which is published by the BMJ group, start to reject papers from Israel after a ‘yes’ vote for boycott, Israeli paediatricians are welcome to submit their articles to Acta Paediatrica.

Differential trends in breastfeeding according to maternal and hospital characteristics: results from the French National Perinatal Surveys

To assess breastfeeding trends in hospital, between 1998 and 2003, according to several characteristics of mothers and maternity units. Two representative national samples of births, comprising 13,600 live births in 1998 and 14,580 in 2003 were used. Data were collected during hospital stay. All newborns fed entirely or partly on breast milk were considered 'breastfed'. Univariate and multivariate analyses were used to compare the results for the 2 years. Breastfeeding increased in all groups, but this increase varied slightly according to maternal age and the size of the maternity unit. For example, high rates of breastfeeding tended to be concentrated in large maternity units (> or = 1500 deliveries per year) in 1998, but were also found in middle-size units (1000-1499 deliveries per year) in 2003. In 2003, women were more likely to breastfeed if they were at least 25 years old, primiparous, non-French or from a highly qualified occupational group, or if they gave birth in a university hospital or in a maternity unit with more than 1000 deliveries per year. Despite recent efforts to increase the breastfeeding rate, clear social disparities persist and further efforts are required, targeting particular groups of mothers less likely to breastfeed.

Postpartum Maternal Mortality and Cesarean Delivery

A continuous rise in the rate of cesarean delivery has been reported in many countries during the past decades. This trend has prompted the emergence of a controversial debate on the risks and benefits associated with cesarean delivery. Our objective was to provide a valid estimate of the risk of postpartum maternal death directly associated with cesarean as compared with vaginal delivery. A population-based case-control study was designed, with subjects selected from recent nationwide surveys in France. To control for indication bias, maternal deaths due to antenatal morbidities were excluded. For the 5-year study period 1996-2000, 65 cases were included. The control group was selected from the 1998 French National Perinatal Survey and included 10,244 women. Multivariable logistic regression analysis was used to adjust for confounders. After adjustment for potential confounders, the risk of postpartum death was 3.6 times higher after cesarean than after vaginal delivery (odds ratio 3.64 95% confidence interval 2.15-6.19). Both prepartum and intrapartum cesarean delivery were associated with a significantly increased risk. Cesarean delivery was associated with a significantly increased risk of maternal death from complications of anesthesia, puerperal infection, and venous thromboembolism. The risk of death from postpartum hemorrhage did not differ significantly between vaginal and cesarean deliveries. Cesarean delivery is associated with an increased risk of postpartum maternal death. Knowledge of the causes of death associated with this excess risk informs contemporary discussion about cesarean delivery on request and should inform preventive strategies.

Smoking during pregnancy and preterm birth according to obstetric history: French national perinatal surveys

The relation between smoking and preterm delivery is not totally known. Our aim was to determine whether smoking during pregnancy was associated with preterm birth among women at different risk according to their obstetric history. The study was based on data from the 1998 French national perinatal survey. Of the 13073 singleton live births, 4.7% were preterm; 15% of the pregnant women were moderate (one to nine cigarettes per day) and 10% heavy smokers (at least 10 cigarettes per day). Smoking heavily was related to preterm birth (crude odds ratio [OR] = 1.35, 95% confidence interval [95% CI]: [1.04, 1.74]). Multivariable logistic regression showed a relation between smoking and preterm birth among multiparae without previous adverse pregnancy outcomes; the associated adjusted ORs (AORs) were 1.25 [95% CI 0.83, 1.87] among moderate smokers and 1.46 [95% CI 0.98, 2.20] among heavy smokers. The corresponding AORs were 0.69 [95% CI 0.46, 1.05]) and 0.96 [95% CI 0.59, 1.56] for primiparae and 1.11 [95% CI 0.63, 1.93] and 0.50 [95% CI 0.25, 0.98] for multiparae with previous adverse pregnancy outcomes. Our study showed a relation between heavy smoking during pregnancy and preterm birth mostly for women with low obstetric risk.

Impact of induced abortions on subsequent pregnancy outcome: the 1995 French national perinatal survey.

To study the impact of previous induced abortions on preterm delivery, small for gestational age and low birthweight in subsequent pregnancies. Survey of a national sample of births in France in 1995. All public and private maternity hospitals in France. 12,432 women who had a singleton live birth during one week. Data were collected during the women's postpartum stay in hospital, partly obtained by interview and partly abstracted from hospital medical records. Rates of preterm delivery, small for gestational age and low birthweight were compared according to existence and number of previous induced abortions. Maternal age, parity, history of previous adverse pregnancy outcome, maternal weight before pregnancy, marital status, educational level, maternal employment status during pregnancy, nationality, smoking during the third trimester of pregnancy and antenatal care were controlled for using multiple logistic regression and polytomous logistic regression. Twelve percent of women reported one previous induced abortion, and 3% two or more. Previous induced abortion was associated with an increased risk of preterm birth (OR 1.4; 95% CI 1.1-1.8); the risk of preterm delivery increased with the number of previous induced abortions (OR 1.3; 95% CI 1.0-1.7 for one previous abortion and OR 1.9; 95% CI 1.2-2.8 for two or more). The relationship was the same for very preterm and moderately preterm deliveries and for spontaneous and indicated preterm deliveries. After controlling for potential confounders, the association between previous induced abortions and small for gestational age and low birthweight infants was no longer significant. This study suggests that a history of induced abortion increases the risk of preterm delivery, particularly for women who have had repeated abortions. The respective role of the surgical and medical techniques used for induced abortions needs to be explored.

Impact of induced abortions on subsequent pregnancy outcome: the 1995 French national perinatal survey

Objective To study the impact of previous induced abortions on preterm delivery, small for gestational age and low birthweight in subsequent pregnancies. Design Survey of a national sample of births in France in 1995. Setting All public and private maternity hospitals in France. Population 12,432 women who had a singleton live birth during one week. Methods Data were collected during the women's postpartum stay in hospital, partly obtained by interview and partly abstracted from hospital medical records. Rates of preterm delivery, small for gestational age and low birthweight were compared according to existence and number of previous induced abortions. Maternal age, parity, history of previous adverse pregnancy outcome, maternal weight before pregnancy, marital status, educational level, maternal employment status during pregnancy, nationality, smoking during the third trimester of pregnancy and antenatal care were controlled for using multiple logistic regression and polytomous logistic regression. Results Twelve percent of women reported one previous induced abortion, and 3% two or more. Previous induced abortion was associated with an increased risk of preterm birth (OR 1.4; 95% CI 1.1–1.8); the risk of preterm delivery increased with the number of previous induced abortions (OR 1.3; 95% CI 1.0–1.7 for one previous abortion and OR 1.9; 95% CI 1.2–2.8 for two or more). The relationship was the same for very preterm and moderately preterm deliveries and for spontaneous and indicated preterm deliveries. After controlling for potential confounders, the association between previous induced abortions and small for gestational age and low birthweight infants was no longer significant. Conclusion This study suggests that a history of induced abortion increases the risk of preterm delivery, particularly for women who have had repeated abortions. The respective role of the surgical and medical techniques used for induced abortions needs to be explored.