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Background: The main aim of this study was to determine: (1) whether early medical abortion at home is a reliable and safe method when provided by physicians in their private practice outside abortion facilities, and (2) whether early medical abortions at home supervised by general practitioners (GPs) in their private practice have the same efficacy rate and the same safety as those supervised by gynecologists in their private practice., Study Design: The data are drawn from a prospective survey of 15,447 in-home medical abortions up to 49 days after the last menstrual period (LMP), provided within the Ile-de-France abortion network between privately practicing physicians and hospitals (REVHO: Réseau entre la ville et l'hôpital pour l'orthogénie), from 2005 to 2008., Results: Approximately 150 privately practicing physicians participate in the REVHO network, and over half of them are general practitioners. Three physicians, called the main providers, performed over half the medical abortions. The overall efficacy rate was 97.43% (96.48 % for the gynecologists, 96.44% for the general practitioners, and 98.31 % for the three main providers). The rate was higher when abortion completion was determined by a decline in serum human chorionic gonadotropin rather than ultrasound., Conclusion: Early medical abortion at home supervised by gynecologists and GPs practicing in their private offices is a reliable and safe method. Promoting networks such as REVHO increases local accessibility to this type of abortion in France., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objectives: Test the hypothesis of an underestimation of infant homicides in mortality statistics in France; identify its causes; examine data from the judicial system and their contribution in correcting this underestimation., Methods: A retrospective, cross-sectional study was carried out in 26 courts in three regions of France of cases of infant deaths submitted to the courts, 1996-2000, with follow-up of their files until case closing (1996-2008). For each case, cause of death established by the courts was compared with ICD cause of death as coded in official mortality statistics., Results: We examined 247 cases. Shortcomings in investigations were noted (autopsies: 75% of cases; fundus examination: 11%; diagnosis of sudden infant death syndrome [SIDS] without autopsy: 41%). Eighty deaths were considered homicides by the courts. Homicide rates in the court study are 2-3.6 times higher than those in mortality statistics. Nearly 1/3 of "accidental" deaths and 1/4 of deaths from unknown cause in mortality statistics are homicides. Mechanisms of underascertainment are: physicians' inappropriate death certification and underreporting of suspicious cases; inadequate investigation of cases; incomplete communication of final medical and forensic results to the mortality statistics department., Conclusions: In a country where neither transportation of the body to a hospital nor autopsy is obligatory, judicial data can make an important contribution to correcting mortality statistics., Practice Implications: This study led to the first French protocol for investigating sudden unexpected deaths in infancy (SUDI). The protocol includes a physician "training" section focused on understanding the symptomatology and risk factors of violence, as well as the quality of death certification., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

This article presents a study of the identity of persons with motor impairments with regard to the community of disabled persons. The authors used the Tetrafigap survey on the long-term outcome of Tetraplegic Spinal-cord-injured (TSCI) persons, in France, to study the sense of belonging to the community of disabled persons among 1356 TSCI persons in relation to factors of social participation (both sociological and disability-related) and subjective factors (subjective well-being, social perception of disability, perceived disability). The results show that 44% of TSCI persons felt that disabled persons do not constitute a community (the "no-community" group). Of those who recognised the existence of such a community, 34% said they belonged to it (the "in-community" group) and 22% declared they did not (the "out-community" group). People in the "no-community" group tended to be more socially integrated, whilst those in the "in-community" group tended to have greater social and clinical difficulties. The "out-community" group was more diverse, being made up of both autonomous persons and dependent persons suffering from complications. Factors related to the sense of community belonging were identified using bivariate analysis and multiple logistic regression. Subjective well-being appeared to be independent of any sense of community belonging. However, the authors found a gender difference: women in the "in-community" group described themselves as having a poorer level of well-being than women in the other two groups. The results are discussed in terms of two views on the social treatment of disabilities: universalism and assimilation vs. particularism and positive identity and the growth of the disability movement., (Copyright 2002 Elsevier Science Ltd.)

Since the end of the 1970's, excess mortality among girls, from the end of the neonatal period until the age of 4 years, has been observed in some South Asian countries. Explanatory hypotheses for this situation have in fact noted differences by sex in food allocation and in care during illness. In some North African and sub-Saharan countries in Africa, mortality data suggest the same type of phenomenon, but less reliable statistics and a lack of data analysis by sex on use of health services does not really allow clarification of the problem. The objective of this study was to analyse health seeking behaviour by sex and to identify explanatory factors for any differences found. A cross sectional study of 1560 consultations of under-5 children was carried out in 6 university and regional hospitals in 3 African countries: Algeria (the zones of Aïn Taya and Tigzirt); Togo (the zones of Lomé, Atakpamé and Kara) and the Congo (Brazzaville). Results confirm the existence of discrimination against girls. In ways which vary according to zones, and in comparison to boys, observations of girls show: under-representation among outpatients (29% in Tigzirt, 40% in Kara), especially when they have many siblings, of which some are sisters; longer duration of the development of symptoms before first resort (leading to increased severity of symptoms); less investment in health care; detrimental feeding practices. Higher SES of the father plays a favourable role, especially for girls, and children of both sexes benefit when the mother has a good educational level. The large regional differences demonstrate the complex interaction among explanatory factors: rurality, problems of access to the hospital, low economic level, low social status of women. This research opens the way so that, in Africa, research will no longer be carried out on health seeking behaviour and utilisation of health services without examining separately the situation of boys and girls, and analysing the possible causes of any differences.

Epidemiological and anthropological studies were carried out in Togo on health seeking behavior for under 5 children to determine causes of dysfunctions in health services. This article reports on the main findings of the anthropological study. Anthropological literature on health seeking behavior has identified labeling and associated explanatory models of illness as important factors for making choices in the use of health services. This study, carried out among 100 families in Togo on health seeking behavior for under-five children, found little difference in the signs and symptoms of illness recalled and the health resources used. Different causal explanations similarly showed little variation in signs and symptoms of illness. The only causal explanation for illness which appeared to correspond to place of recourse was related to social causes, where traditional practitioners were more often consulted. Families explained choices more on the basis of the accessibility and quality of health services (geographical and financial accessibility, reception by health personnel, organization of services, drug availability) than on the basis of the particular signs and symptoms of the illness. Improving the organization and functioning of health services should contribute more to appropriate use of the modern health care sector than interventions targeting user populations, since the latter appear to be aware of the advantages of modern medicine, but find financial, social and organizational features of services unsatisfactory.

The functioning and efficacy of pediatric emergency services are currently being questioned in many Northern countries, as well as in the South, for example in North Africa. Reference is often made to unjustified medical emergencies in the face of an influx of patients with benign problems who come from socially disadvantaged families. In the university and regional hospitals in three regions in Togo, we compared three categories of under-5 patients: children sent to "day-time" emergency services after triage done by health personnel; those sent to the "ordinary consultation"; and children brought after hours by their family (without referral by a health professional in 92% of cases) and seen in the "after-hours" emergency service. Serious tropical pathology (cerebral malaria, malaria, sickle cell disease) is mainly seen in emergency consultations, in which high hospitalization rates are noted (83% during the day, 67% at night) and a lethality of 3.4%. One cannot therefore use terms such as "false emergencies", "felt" and "medically unjustified" and the pediatric supervisor for the research considered that recourse to after-hours emergency services was justified in 75% of cases. Families using night services have higher educational levels than those sent to day emergency services, the mother's educational level being the main factor associated with certain characteristics of health seeking behavior (duration of symptoms prior to arrival at hospital, recourse to modern medical drugs). There is often a long delay before recourse to hospital: only 45% of children seen after hours and half of those who died came the 1st or 2nd day of the illness. Self-medication at home is usual but recourse to tradi-practitioners appears rare (4%). Several solutions can be envisaged and should be linked: strengthening of the first level of care, technical improvements in emergency services, training of tradi-practitioners in the recognition and referral of emergency cases, improvement of reception practices at the hospital level, prophylactic and preventive measures for tropical diseases.

In many developing countries, dissatisfaction with primary health care has been accompanied by inappropriate use of university teaching hospitals, frequently for benign health problems. This situation is often attributed to the user population who supposedly misunderstands the functioning of health systems. This article describes the health seeking process and outcome of consultations for under-five children in two geographic zones in Algeria (very different in their care networks, and in the socioeconomic and educational characteristics of their populations), using a representative sample of users of public and private health services. During 4 one-week periods in 1991, a cross-sectional study was carried out among families of children and the health personnel they consulted, in all the health structures in the 2 zones. A Franco-Algerian supervisory team prepared consensual definitions of both the seriousness and the urgency of the pathology, as well as of the appropriateness of the health care structure chosen for that condition. The analysis of 1560 consultations shows dysfunctions in the health seeking process: numerous "self-referrals" (94%); unjustified recourse to university hospitals in 29% of cases; important delays before consulting (> or = 1 week in 14% of cases); absence of the mother during the consultation; differences in the mode of recourse according to the child's sex (for equivalent seriousness and urgency, recourse is more frequent to the emergency room and university hospital for boys, but girls are more often hospitalized). Nonetheless, the Algerian supervisors of the research consider that the choice of the health care facility is appropriate in 91% of cases. At the service level, dysfunctions are equally frequent, especially the absence of the transfer of information on the child between different health care professionals. The primary preoccupation of parents is with accessibility (distance, cost), which leads to recommending the revitalizing of small first-line facilities, especially in rural areas, the more so because they are used and appreciated by families.

In most of the large cities in developing countries, geographic accessibility to health care is not a major problem. Thus, indifference to public services and a preference for home treatment, recourse to traditional medicine or to the private sector may be related to problems in the quality of services. A cross-sectional epidemiological study of hospital visits by under-5 children was carried out in health centres and hospital out-patient services in Brazzaville (Congo). Sampling in these health facilities was done using a systematic random sample with a proportion of 25%, during 4 periods chosen according to seasonal factors. An exhaustive investigation of the entire public sector serving children was done in the study. At the same time, the same data were gathered in a sample of private facilities (doctors' and nurses' offices, traditional healers, religious healing centres), chosen as a function of their permanence and the numbers of their clientele. This article analyses services offered during 2215 visits by children, who were under 1 year of age in more than 50% of cases. In the public sector, 75% of visits were to first-line health centres. Public services show marked dysfunctions: the complexity of internal referrals, clinical examinations which are inadequate in relation to symptoms, and poor communication (explanations as to cause of illness in less than 2% of cases, and on treatments in less than 50% of cases). Communication seems well developed among private physicians and traditional healers, the latter engaging in both preventive and curative activities. Communication during well-child visits and consultations at health centres is especially disappointing, in light of the very young age of the parents (1/4 are high-school or college students). There is a two-fold risk in this situation: flight towards non-conventional medicine on the one hand, and access to private medicine based on socio-economic status on the other. It thus appears necessary to standardise procedures and acts in first line public health services and to promote training of personnel in communication skills with families (training using social science perspectives and participative pedagogical techniques).

Unlabelled: The objectives of the study were to estimate the current level of breast-feeding at hospital discharge in France, and to identify maternal factors and characteristics of the pregnancy and delivery associated with breast-feeding., Data and Methods: The sample included all births during 1 week in France in 1995 (n = 12,179 babies). The data were collected during the postnatal stay in hospital. Factors associated with breast-feeding were identified, using bivariate analysis and multiple logistic regression. As the relations between the studied factors and breast-feeding differed between French women and women of foreign nationality, multivariate analysis was carried out separately in the two groups., Results: In 1995, 52% of babies were breastfed at hospital discharge, including 10% of babies partially breastfed. Breastfeeding was more common among women of foreign nationality than among French women, 76 vs 49%. In both groups, breastfeeding was more common among older women, women with a high level of education or a qualified occupation; breastfeeding was also more frequent among non smokers during pregnancy and among women who attended antenatal classes. On the contrary, among French women, induction of labour and delivery in a small hospital were associated with a low level of breastfeeding; among women of foreign nationality, a low level of breastfeeding was observed for unmarried women, women who had an induction or a caesarean section, and those who delivered in a private hospital., Conclusion: France was at the lowest level among Western countries for which national data on breastfeeding were available. Efforts to promote breastfeeding are needed, both towards sub-groups of pregnant women and towards health professionals. Maternity hospitals should provide support to breastfeeding mothers, and avoid practices which may affect breastfeeding.

Women having repeated induced abortions have social and affective difficulties. Pregnancy results from ineffective or erratic contraceptive practices. One woman out of two expresses the desire for a pregnancy and/or child. During childhood they frequently experienced unsatisfactory relationships with their parents and within the family.

In 1987, 162,352 legal abortions have been recorded in France; 55% of them were performed before 9 weeks of amenorrhea. Abortions were performed earlier among married than among unmarried women, and the proportion of early abortions increased with the women's age. The method of abortion was: vacuum aspiration for 73% of women, curettage (associated to vacuum aspiration or not) for 21%; 65% had their abortion performed under general anaesthesia, and 19% under local anaesthesia. Since 1976, there has been an increasing proportion of vacuum aspirations, and of local anaesthesia. In the private sector, abortions were performed at an earlier gestational age, but curettage was more frequent than in the public sector, and general anaesthesia, quasi systematic. There were also wide regional variations. There results were consistent across years. Data are collected on the day of intervention; thus, they do not allow an exhaustive estimation of the rate of complications: in 30% of cases, the information was missing. For the cases for whom the information was available, the rate of immediate complications was 0.6%. In 1990, modification of the notification form should allow better monitoring of new techniques.

Improvements in combining obstetrics and neonatology led to a trend to intervene earlier in premature babies born before the 33rd week of gestational age. The enquiry that was carried out in 1985 in the Paris geographical region had as its objective to assess on the one part how many premature deliveries occurred between the 25th and 33rd week of amenorrhea and on the other hand what happened in the short term to the infants born from these pregnancies, i.e., their mortality; and for those who survived, their quality of life. The study was carried out on a representative sample of the deliveries in 1985 in the four departments of the Paris region--Paris and the three departments of the Petite Couronne--where half of all deliveries were assessed. The enquiry covered 53,430 deliveries for which the overall prematurity rate was 4.5%, and those deliveries that occurred before 33 weeks of gestational age constituted 1.0% (539 babies). Twenty children were lost for follow-up after a year. This was 4.9% of the live births and 6.3% of the live children who left the neonatology centres. At 2 years of age, the numbers that were not followed up were eventually 24, which was 5.8% of live births and 7.6% of those that left the centres of neonatology. The results show a very high rate of antepartum mortality but also of mortality during and after labour. Only 379 infants out of the 539 (70%) were transferred into special care baby units. By 1 year of age, the survivors were 57% of the total number of deliveries and 75% of the live births and 82% of those transferred to the special units. As far as concerned those that were live born, the survival rate at the age of 1 year varied considerably according to the duration of the pregnancy. The number of those that survived a pregnancy of less than 27 weeks was low (31%). It was, at 28 weeks, 53%. This is the age where births have to be registered. It reached 87% of the live births that occurred at 32 weeks. One has to point out that there is no statistically significant difference between 27 and 28 weeks of gestation. Whereas there is a significant difference (p less than 0.05) with those delivered at 29 weeks (75%). 80% of those 291 infants that were examined at 1 year of age were considered to be normal as far as psychomotor and sensorial behaviour was concerned.(ABSTRACT TRUNCATED AT 400 WORDS)

To study women's views on epidural analgesia, three groups of primiparous women were compared. In the first group (41 women), they were given epidural analgesia, after having asked for it during pregnancy. In the second group (79 women), epidural analgesia was given during labour although it had not been planned during pregnancy. The third group included 60 women who underwent labour and delivery using the preparation for childbirth technique alone. The data showed differences between the three groups from medical and social points of views. Women in the first group were of a higher social status than the others; they had been more often admitted to hospital during their pregnancy. Women of the second group more frequently explained that they had psychosocial problems during pregnancy. Furthermore, women who had planned an epidural explained that their choice was mainly due to anxiety. On the other hand the majority of women were rather hostile to this technique. Even though women pointed out the physical and psychological relief due to epidural analgesia, there was no obvious difference in maternal satisfaction between the three groups. Maternal satisfaction with the birth experience was related rather to the moment when the epidural analgesia had been decided on, before or during labour, to the attitude of the medical staff and to the hospital standards for labour and delivery. Advance planning of an epidural analgesia also appeared to be insufficient to keep control of the whole process of childbirth and particularly of its psychological meanings. The study showed that even with a perfect technique, epidural analgesia is not the only possible answer to women's anxiety.

In 1981-82, 5, 963 children's accidents were reported over a one-year period in 2 public and 11 private hospitals in a given public health district. The nature of treated accidents in the public hospitals differs from that in the private facilities. Reporting of cases reaches 75% in the public hospitals; only about 50% in the private hospitals. Characteristics of reported accidents differ from those unreported. While the quality of clinical data is satisfactory, the site of the accident is unknown in 14%, and the causal agent, in 35% of the cases. The estimation of incidence implies the extension of registrations to the private sector, source of 31% of reported cases, and where significant differences from the public sector were observed in the nature of the accidents. A permanent system requires use of a rolling sample and training of personnel. Systematic registration is a tool to measure incidence of accidents, but is not a suitable instrument for the surveillance of dangerous products and objects.

In 1981 to 1982, within a 1 year period, details were recorded of children aged 0 to 15 years and 3 months, who were treated for accidental injury in a French health care district; 789 sports-related accidents were registered, representing 11% of all accidents. Sports areas were the leading sites of accident among children over age 12. Out-of-school sports accidents were more frequent among boys, but boys and girls had similar injury rates in school physical education. Compared to home, school, and road accidents, sports accidents had the highest rate of upper limb injury. The fracture rate was 22% and the hospitalization rate 11%. In most cases children were injured without any participation of other players or sports equipment. Sports-related injuries were usually benign, but several hospital admissions for the same accident were required in 20% of the admitted children (significantly higher than in home, school, and road accidents), and the time elapsed between the accident and the end of the last stay in hospital was significantly greater than in other kinds of accidents. This might be explained by a higher rate of epiphyseal fractures (10%) and internal fixation (17%). Musculoskeletal sequelae were observed in 12% of inpatient children.

From 1981 to 1982, within a one year period, all medically treated childrens' accidents were recorded in the public and private medical facilities of a French health care district near Paris. Sports injuries represented 11% of all injuries, and in children aged 12 years and over, sports areas were the leading site of accidents (24%). Seven hundred thirty-eight sports injuries to children aged 6 years and over were analysed and compared to other types of accidental injuries (home, school and traffic accidents). The overall incidence of sports injuries was estimated to be 1.1% in children aged 6 to 14 years. Out-of-school sports accidents were more frequent among boys, but boys and girls had similar injury rates in school physical education. Most lesions were benign but the fracture rate was 22%. A majority of lesions were located on the upper limb. Most commonly, the mechanism of accident was a forward fall and children were injured without any participation of sports equipment. The hospitalization rate was 11%. Repeated hospital admissions and a long time elapsing between the accident and full recovery were significantly more often observed than in other types of accidents. This might be explained by a higher rate of epiphyseal fractures and internal fixations. Eighteen months after the accident, musculo-skeletal sequelae were observed in 12% of the inpatient children.

The article offers a detailed analysis of the characteristics of the supply and demand of prenatal diagnosis by amniocentesis in order to identify the major problems that must be faced in formulating a policy designed to diffuse the use of this technique. The data collected for the whole of France made it possible to evaluate exhaustively the increase in the number of prenatal diagnoses during the years 1972-1981; to determine the number and geographic distribution of the diagnostic centers; to identify the medical criteria justifying the examinations. A comprehensive survey covering all examinations performed in the Ile de France (Paris region) in 1979--which constituted 46.5% of all the prenatal diagnoses performed in France that year--made it possible to determine the predominant socioeconomic characteristics of the women who took this examination, revealing, particularly, the significant inequalities of access, with an underrepresentation of the least privileged socioprofessional categories. The confirmation of the influence of socioeconomic status on access to this medical innovation is further reinforced by the fact that usage rates vary widely according to place of residence; furthermore, it adds to the financial barriers implicit in any policy of having reimbursement of the examinations dependent upon Social Security conventions. A public health policy regulating the diffusion of this innovation must take into account the discriminatory aspects of the first phase of diffusion, as analyzed here.

In 1980, within a 29 day-period, we studied all the hospitalizations of children in 14 departments of the "Assistance Publique" in Paris. The survey included 940 children and 978 hospitalizations. We compared French children with foreign children, living in France and born to 2 foreign parents. The rate of foreign children among the hospitalized children is abnormally high. This high rate is partly explained by social factors but remains high after adjustment of those factors. The 2 groups of children are not hospitalized for the same kind of diseases: French children are more frequently hospitalized for congenital malformations, foreign children for accidents and infections. Foreign children are hospitalized longer than French children for a same disease. The length of hospitalization is not connected with the father's type of work but rather with the occupation of the mother. The child's hospitalization is shorter when the mother has a professional occupation, and that influence of the mother's work is independent of the other factors.

An extensive study was undertaken in northern France from January 1st to May 31st 1978, concerning the transfer of neonates from maternity hospitals to specialized units. Analysis of 250 children whose birth weight was below 2,000 gm showed that several risk factors could be taken into account to reduce neonatal mortality in this area. Prematurity (22% children weighing less than 1,500 gm in those discharged alive, 54% in the dead), neonatal distress (36% versus 61% of resuscitation) hypothermia (7% versus 23% with temperature below 34 degrees 6 at the time of admission), the need for an other transfer (1% vs. 12%) seem to be features highly related with poor prognosis. This stresses the importance of the prevention of prematurity, of proper management of the babies in the maternity hospital, of the conditions of transport and of the choice of the neonatal unit.

Eight hundred fifty-four injuries to children under 2 years of age were analysed. Injuries were more frequent in the second year than in younger infants. No major male predominance was observed. Most injuries were related to home accidents and mainly to mechanical trauma. Burns and poisonings were less frequent but their percentage was higher during the second year. Most lesions were benign, except in case of fall from a height (window falls, falls from baby furniture). Medical cost was rather high due to a 17% rate of hospital admissions and a 4 days average length of stay. Two fatal cases were registered. Sequelae appeared to be rare. Child abuse was seldom suspected and reason for that remains unclear. The study of accidents mechanism leads to think that teaching young children the control of hazardous situations should play a large part in prevention.

Two national surveys of representative samples were held in France in 1972 and 1976. They revealed an increase in the frequency of breast-feeding in the neonatal period (from 36.6 to 45.5%). This increase was observed in almost all regions and population subgroups. Breast-feeding remains influenced by ethnic group (more frequent in immigrants), social level, the quality of prevention and the size of maternity-hospitals. Classification of French women in 6 groups by education and care received (number of beds in the maternity-hospital) shows that the frequencies of breast-feeding range from 65% (university-educated women giving birth in large maternity-hospitals) to 28.5% (women with primary or secondary education, giving birth in small maternity-hospitals).

Two national enquiries were carried out in France by INSERM in 1972 and in 1975-76 in order to review the efficiency of using medical discoveries and health programmes. The first was carried out on a representative sample of 11,254 deliveries and the second on a representative sample of 4,685 deliveries. The perinatal mortality rate and the prematurity rate have gone down quite definitely, while on the other hand the birth weight has stayed more or less identically the same and the number of small-for-dates babies has not become less and in fact there is a slight tendency for a rise in the number. Antenatal care has improved considerably for most women, without the idea of high risk factors having really become integrated. The number of maternity units with fewer than 15 beds has considerably dropped, especially in the private sector. Monitoring of labour and of the newborn has shown a certain progress. These changes exist in a family context which is evolving with more planned pregnancies and a slight improvement in the social and cultural conditions of parents.