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BackgroundEnvironmental health promotion interventions may reduce endocrine disruptor (ED) exposure. PREVED (PREgnancy, preVention, Endocrine Disruptors) project was developed to improve knowledge, to enhance risk perception and to change exposure behavior. Our objective was to present the phases of PREVED project using the RE-AIM method.MethodsPREVED intervention consisted of 3 workshops during pregnancy. Reach, adoption, and implementation phases were assessed with qualitative studies. Efficacy study consisted of a three-arm randomized controlled trial (RCT) on 268 pregnant women: i) control group (leaflet) ii) intervention group in neutral location iii) intervention group in contextualized location. The main outcome was the percentage evolution of participants who reported consuming canned food. Secondary outcomes were evolution of psycho-social scores, evolution of ED presence in urine and ED presence in colostrum. ResultsThe intervention adoption was centered on upper-privileged women, but implementation assessment showed that key features (highly practical intervention) seemed to be carried out and had initiated some behavior changes. A total of 268 pregnant women participated in the intervention and 230 on randomized controlled trial (control group: 86 and intervention groups: 172). We found no significant differences in consumption of canned food and in percentage of women having a decrease of bisphenol A or parabens in urine, but we found significant increase in the evolution of risk perception score and overall psychosocial score in intervention groups (respectively: +15.73 control versus +21.03 intervention, p=0.003 and +12.39 versus +16.20, p=0.02). We found a significant difference in percentage of women with butylparaben detection between control group and intervention groups (13% versus 3%, p=0.03). ConclusionPREVED intervention is the first intervention research dedicated to perinatal environmental health education in France. By sharing know-how/experience in a positive non-alarmist approach, it improved risk perception, which is a key to behavior change aiming to reduce perinatal ED exposure. Including women in precarious situations stay a major issue.Trial registration number: Retrospectively registered on 31 July 2017 (when the first participant was enrolled in this non-drug intervention, ClinicalTrials.gov was centered in therapeutic trials): NCT03233984 - URL: https://clinicaltrials.gov/ct2/show/NCT03233984

Introduction: Determinants of weight gain after bariatric surgery have not been sufficiently studied from the patients' perspective. Objective: The present qualitative study aims to identify these ...

Chlorinated derivatives of bisphenol A (ClxBPA) are endocrine disruptors that have seldom been studied. The aim was to assess the determinants of ClxBPA presence and bisphenol A (BPA) concentration in colostrum fluid. Pregnant women participating in the EDDS cohort study (France, 2011–2014) received two visits at home during their pregnancies, the objectives being to inform ourselves on their sociodemographic characteristics and consumption habits and to collect their urine samples. A colostrum sample was collected at delivery. All samples were analyzed using solid-phase extraction coupled with ultra-high-performance liquid chromatography isotope dilution tandem mass spectrometry method. Among 100 pregnant women, 32% had at least one ClxBPA detected in their colostrum fluid, 19% monochlorobisphenol-A, 23% dichlorobisphenol-A, 16% trichlorobisphenol-A and 2% tetrachlorobisphenol-A. After adjustment for sociodemographic factors, sample collection between 24 and 48 h after delivery was associated with lower ClxBPA presence in colostrum (OR = 0.06, 95%CI (0.01, 0.66) compared to colostrum collected during the first 24 h. BPA was detected in 60 colostrum fluids (61%) with mean concentrations of 2.1 ± 6.9 ng/mL. After adjustment, BPA was higher among women currently smoking during the third trimester (β = 1.20 95%CI (0.30, 2.09)) and lower when the sample was collected between 24 and 48 h after delivery (β = -0.72 95%CI (-1.43, -0.02)) compared to colostrum collection during the first 24 h after delivery. Sociodemographic factors, water exposure and food consumption were not associated with presence of ClxBPA in colostrum and concentration of BPA. Confirmation of these results with further powerful studies are needed, particularly those on kinetic investigation of ClxBPA excretion in colostrum would be interesting to improve storage condition’s knowledge.

A positive association between Bisphenol A (BPA) exposure and coronary heart disease has been shown, but not in patients with type 2 diabetes (T2D). During the treatment of drinking water, chlorination leads to the formation of chlorinated derivatives of Bisphenol A (ClxBPA), that have higher estrogenic activity than BPA. No evidence exists for a relationship between exposure to ClxBPA and myocardial infarction in patients with T2D. The objective of this study was to evaluate the relationship between exposure to BPA, ClxBPA and the occurrence of myocardial infarction (MI) in patients with T2D. Two nested case-control studies in two independent European cohorts were performed. Each case with incident MI during follow-up was matched to one control on age, sex, and personal cardiovascular history in the same cohort. Association between baseline urine concentrations of BPA and of ClxBPA and incident MI was determined. Exposure to BPA was 31% in the ESTHER cohort and 18% in the SURDIAGENE cohort. In a meta-analysis of the two studies, occurrence of MI was significantly associated with urine BPA detection: adjusted OR = 1.97 (1.05-3.70), p = 0.04. Exposure to ClxBPA significantly differed in the SURDIAGENE and ESTHER studies: 24% and 8%, respectively (p = 0.0003). It was very strongly associated with MI in the SURDIAGENE cohort with an adjusted odds ratio (OR) of 14.15 (2.77-72.40) but this association was not replicated in the ESTHER study: adjusted OR: 0.17 (0.02-1.23). Whether these results may be explained by different water chlorination processes in France and Germany, resulting in different ClxBPA exposure levels, requires further investigation.

Background The suspected or actual effects on health of Endocrine Disrupting Chemicals (EDC) and their ubiquitous presence in everyday life justify the implementation of health promotion interventions. These interventions should ideally apply during critical windows like pregnancy. Perinatal environmental health education interventions may help to reduce EDC exposure during pregnancy. Methods/Design PREVED (Pregnancy, PreVention, Endocrine Disruptors) is an open-label randomized controlled trial assessing the impact of environmental health education intervention on EDC exposure during pregnancy. Inclusion, consent and randomization take place during the first trimester. The participants are randomly allocated into three groups: i) control group (information leaflet on EDCs), ii) intervention group in neutral location (information leaflet and workshops in a meeting room) and iii) intervention group in contextualized location (information leaflet and workshops in a real apartment). Workshops are organized between the second and third trimesters of pregnancy. Main outcome is the percentage of participants who reported consuming manufactured/industrial food. Secondary outcomes are: i) psycho-social dimensions ii) EDC concentrations in urine iii) EDC concentration in colostrum and iv) percentage of participants who reported consuming paraben-free personal care products. Discussion PREVED is a ground-breaking intervention research project dedicated to perinatal environmental health education that aims to identify pollutant sources in daily life and to offer accessible and realistic alternative solutions, by promoting the sharing of know-how and experience in a positive and non-alarmist approach. Trial registration number ClinicalTrials.gov: NCT03233984 (current status: ongoing). Retrospectively registered on 31 July 2017 (https://clinicaltrials.gov/ct2/show/NCT03233984) because when the first participant was enrolled in this non-drug intervention, ClinicalTrials.gov was centred in therapeutic trials. World Health Organization Trial Registration Data Set: Additional file 1

UNSTRUCTURED To combat the COVID-19 pandemic, many European countries have developed a public health strategy involving the use of digital contact tracing (DCT) applications to improve timely tracking and contact tracing of COVID-19 cases. France’s independent COVID-19 Control and Society Connection Council (CCL) was established by law in May 2020 to issue advice and recommendations on the national epidemic digital systems. In this paper, we present the recommendations by the CCL, with the objective to increase the uptake and utility of French DCT applications. As the country's most vulnerable population has been subjected to greater virus exposure, a stronger impact of the lockdown, and less access to preventive and health care services, the CCL is particularly aware of health inequalities. The French DCT app TousAntiCovid had been downloaded by 13.6 million users (ie, 20% of the French population) in March 2021. To promote the use of DCT apps, the CCL has recommended that communication about the app’s individual and collective objectives be increased. The CCL has also recommended the introduction of clear, simple, accessible, incentivizing, noncoercive information within the digital tools. In addition, the CCL has recommended improving public health policies to address the needs of the underprivileged. The CCL calls for promoting population empowerment with the use of digital tools, improving public health culture for decision-makers dealing with health determinants, taking social considerations into account, and incorporating community participation.

Active tobacco exposure during pregnancy is a known determinant of fetal growth. Nitrates and atrazine metabolites in drinking water may affect fetal growth as a mixture of endocrine disruptors (ED). We aimed to determine whether EDC have an additional effect on fetal growth compared to active tobacco exposure. A historic cohort study was carried out with a sample stratified with regard to the maternity unit, drinking water exposure, and year of birth. The women included were living in Deux-Sèvres, had given birth between 2005 and 2010 in three selected maternity units, and ultrasound data were available in their obstetrical records. Mixed linear models were used to analyze fetal weight evolution from the second trimester to the time of birth according to drinking water exposure to EDC mixture and active tobacco exposure. We included 558 mother-neonate couples, of whom 9% were exposed to high doses of the mixture and 21% to active tobacco smoking. There was no difference in fetal weight evolution according to drinking water mixture exposure (0.97 g, 95% CI [−3.01, 4.94]). We could not show a supplementary effect of mixture exposure in drinking-water on fetal growth as compared to active tobacco exposure. Further research is needed, using more precise methods to estimate EDC exposure.

Background Active tobacco exposure during pregnancy is known to be an important determinant of fetal growth. Nitrates and atrazine metabolites in drinking water may affect fetal growth as a mixture of endocrine disruptors (ED). Our aim was to determine whether ED have an additional effect on fetal growth compared to the known and observed effect of active tobacco exposure during pregnancy. Methods A historic cohort study was carried out with a sample stratified with regard to maternity ward, drinking water exposure and year of birth. The women included were living in Deux-Sèvres, had given birth between 2005 and 2010 in three selected maternity wards, and ultrasound data from pregnancy were available in their obstetrical records. Mixed linear models were used to analyze fetal weight evolution from second trimester of pregnancy to time of birth according to drinking water exposure to atrazine metabolite and nitrate mixture and active tobacco exposure. Results We included 558 mother-neonate couples, of whom 8.5% were exposed to high doses of mixture and 20.5% to active tobacco smoking. There was no significant difference in fetal weight evolution according to drinking water mixture exposure (0.97 g; 95% CI [-3.01;4.94]) and when comparing nested models with and without drinking water mixture exposure, the likelihood ratio (LR) test was not significant (LR khi²=6.6, p=0.252). Conclusion We could not show a supplementary effect of mixture exposure on fetal growth as compared to active tobacco exposure. Further research is needed, using more precise methods to estimate ED exposure.

Background: Despite mediatization, only half of pregnant women are informed about endocrine disruptors (EDs). We wished to inquire about appropriate environmental health education procedures during pregnancy: Who, when, and how? Methods: The question stems from a comprehensive population health intervention research project. It includes qualitative studies aimed at constructing an educational program in environmental health and an accompanying assessment tool. The validation of a customized questionnaire (PREVED© for Pregnancy Prevention Endocrine Disruptors) about the knowledge, attitudes, and practices (KAP) of pregnant women regarding exposure to EDs was carried out in a quantitative study. Results: Health education by a prenatal professional with communication skills should take place as early as possible, during the preconception period or early pregnancy, as part of individual consultation or group workshops. In order to customize the discourse and to develop women’s empowerment, concomitant presentation of the risks by the products used in each room and of previous solutions is recommended. Conclusion: Appropriate health education procedures on EDs should be done at every contact but taking the KAP of pregnant women into account first. We propose all educational actions should be accompanied by questioning of the KAP of pregnant women; for example, with questions from the PREVED© questionnaire.

Introduction: As environmental health knowledge of population is associated with social economic status, the objective of this study was to determine environmental health knowledge, attitudes, and practices of French prenatal professionals working with a socially underprivileged population. Material and methods: A focus group with eleven prenatal professionals working with socially underprivileged population was carried out in France in 2015. Content analysis of verbatim explanation was conducted with choice-of-subject categories carried out according to the triangulation principle, and topic trees were generated and applied. Results: The professionals have non-specialized experimental knowledge of emergent risks and were essentially preoccupied by infectious biological risks. In practice, however, they became increasingly cognizant of emergent risks. Their educational practices take cultural context into account but educational tools with imagination and affectivity have to be developed in order to reach socially underprivileged population. Discussion: Professionals are often sensitized to the field of environmental health in their apprehension of polluted biological environments, which they associate with social contexts and behavioral factors. In this study, we recommend adapted training programs and updated professional guidelines in view of reducing prenatal emergent risk exposures and social inequalities of health.

Les perturbateurs endocriniens (PE) ont ete definis par l’Agence de Protection et de l’environnement des Etats Unis comme substance exogene qui alterent les fonctions du systeme endocrinien et induisent des effets nefastes sur la sante d’un organisme intact. Le Bisphenol A (BPA) est un PE qui interfere avec la synthese, metabolisme, transport, affinite des hormones naturelles. L’utilisation du BPA est tellement repandue dans l’environnement qu’il provoque de nombreux effets secondaires (cancers, anomalies du developpement, reprotoxicite, …). Le BPA est ubiquitaire, il est retrouve dans les sols, l’air et l’eau. Lors du traitement de l’eau du robinet, la derniere etape consiste a traiter avec du chlore afin d’eliminer des bacteries, cependant cette chloration mene egalement a la formation de derives chlores du BPA (ClxBPA). De plus la presence d’ions bromures dans l’eau, conduit a la formation de derives bromes du BPA (BrxBPA). Nous presenterons la synthese de ces composes ClxBPA, BrxBPA qui servent de temoins analytiques dans l’analyse d’echantillons biologiques humains ou afin d’evaluer leur toxicite. Une cohorte de femmes enceintes a permis de recueillir leur eau de boisson, des fluides biologiques (urine, colostrum) dont les analyses LC/MS-MS et GC/MS-MS seront detaillees sur leurs teneurs en derives halogenes du BPA. Enfin, les derives ClxBPA, BrxBPA ont ete evalues in vitro sur le recepteur Follitropine (FSHR). Ces composes ne sont pas cytotoxiques (test MTT), ils demontrent un effet allosterique negatif en presence de l’hormone FSH. Ces derives sont consideres comme des perturbateurs endocriniens et susceptibles d’avoir des effets reprotoxiques.

Introduction :Le diagnostic du diabète chez l’enfant impacte la qualité de vie (Qvie) des parents. Pour accompagner l’enfant et son entourage, les programmes d’éducation thérapeutique du patient (ETP) peuvent mobiliser plusieurs disciplines, dont l’art-thérapie.Objectif :Déterminer l’impact de l’art-thérapie sur la Qvie des aidants d’enfants diabétiques.Méthodes :Un essai contrôlé randomisé multicentrique, avec séances d’art-thérapie en binôme (animateur et observateur), a été réalisé avec une analyse mixte, quantitative sur l’évolution du score de Qvie « PedsQL Family Impact Module », et qualitative sur l’analyse des commentaires rapportés par un observateur.Résultats :In fine, 15 aidants non exposés et 17 exposés ont participé. Nous n’avons pas retrouvé de différence significative entre l’évolution moyenne des scores de Qvie des deux groupes (p = 0,2). Toutefois, les art-thérapeutes ont rapporté l’amélioration progressive des compétences de communication des aidants, l’acquisition du lâcher-prise et l’occultation ponctuelle du diabète.Discussion :Cette étude a permis d’identifier quatre leviers méthodologiques portant sur : (a) l’inclusion ; (b) la gestion des données ; (c) le choix des outils et des délais d’évaluation ; (d) le cadre thérapeutique.Conclusion :L’organisation des séances d’art-thérapie dans la nouvelle plateforme salutogénique de promotion de la santéVie La Santéfacilitera l’implémentation de l’étude Educ’Art-Ped2.

Background: The relationship between preterm birth (PTB) and endocrine disruptor exposure in drinking-water has only occasionally been studied. The objective of this work was to investigate the relation between exposure to atrazine metabolites, or atrazine/nitrate mixtures, in drinking-water during pregnancy and prevalence of PTB neonates, while taking neighborhood deprivation into account. Method: A historic cohort study in Deux-Sèvres, France, between 2005 and 2010 with a multiple imputation model for data of exposure to atrazine metabolites and a logistic regression were carried out. Results: We included 13,654 mother/neonate pairs living in 279 different census districts. The prevalence of PTB was 4%. Average atrazine metabolite concentration was 0.019 ± 0.009 (0.014–0.080) µg/L and 39% of mothers lived in less deprived areas. The individual data were associated with risk of PTB. The risk of PTB when exposed to highest concentration of atrazine metabolite adjusted for confounders, was ORa 1.625 95% CI [0.975; 2.710]. Taking, or not, neighborhood deprivation into account did not change the result. Exposure to atrazine/nitrate mixtures remained non-significant. Conclusions: Even if we took neighborhood deprivation into account, we could not show a significant relationship between exposure to atrazine metabolites, or mixtures, in drinking-water during the second trimester of pregnancy and PTB.

La fibrillation atriale (FA) majore le risque d’accident vasculaire cerebral ischemique (AVC). De par l’interet demontre en prophylaxie, le traitement anti-vitamine K (AVK) est recommande pour un score CHADS 2 ≥ 2. Pourtant ce traitement reste sous-prescrit dans la population geriatrique. Notre etude avait pour objectif principal d’evaluer le taux de conformite aux recommandations CHADS 2 et pour objectif secondaire de determiner les variables du non suivi des recommandations pour un score CHADS 2 ≥ 2. Methode : etude retrospective, menee au sein du pole de geriatrie du CHU de Poitiers, des dossiers de patients > 75 ans hospitalises entre le 1 er juillet et le 31 decembre 2009 et atteints d’une FA. La description de la population comprenait : caracteristiques epidemiologiques, autonomie (score GIR), statut cognitif, notion de chute, recueil du traitement antithrombotique et calcul des scores de risque ischemique (CHADS 2) et hemorragique (HEMORR 2HAGES). Resultats : ainsi 161 sejours hospitaliers ont ete repertories. La moyenne d’âge des patients etait de 87,4 ± 5,4 ans. Le traitement de fond comportait un traitement antithrombotique dans 84 % des cas. Le taux de conformite aux recommandations CHADS 2 etait de 44 %. Les hospitalisations concernaient en majorite (143 sejours, 88,9 %) des patients avec score CHADS 2 ≥ 2. Le taux de non-conformite atteignait 60 % dans ce groupe avec 5 variables significatives : score MMS < 26 (OR : 3,17 [IC95% : 1,23-8,17]), score hemorragique eleve (2,88 [1,28–6,47]), existence d’une demence (2,46 [1,01–5,95]), score GIR ≤ 4 (2,43 [1,23–4,84]) et antecedent de chute (2,42 [1,13–5,17]). Les variables analysees n’expliquaient cependant que 19 % de la non-conformite et l’analyse multivariee ne permettait pas d’isoler de variable significative. Discussion : notre etude montre 56 % de non suivi des recommandations CHADS 2, plus particulierement chez les patients a risque ischemique eleve (score ≥ 2). Les recommandations apparaissent moins suivies chez les patients les plus vulnerables, sans pour autant identifier une variable independante. De par les nouvelles recommandations CHA 2DS 2-VASc, il est important que la prescription des antithrombotiques dans la FA soit bien argumentee dans les dossiers avec evaluation de la balance benefice-risque.

Objectif Les parabenes sont des conservateurs utilises dans les medicaments et l’alimentation, mais ils sont principalement retrouves dans les cosmetiques et produits de soins corporels. Les femmes, y compris les femmes enceintes, peuvent donc y etre particulierement exposees. De par leur capacite a se lier aux recepteurs œstrogeniques, les parabenes sont suspectes d’etre des perturbateurs endocriniens (PE), et la grossesse constitue alors une periode de vulnerabilite face a ces molecules. L’objectif de ce travail est de presenter les mesures d’exposition aux 4 principaux parabenes a partir des concentrations urinaires mesurees au sein d’une cohorte perinatale de 164 femmes. Description Dans le cadre de la cohorte prospective de femmes enceintes Endocrine Disruptors Deux-Sevres (EDDS), dont le recrutement a ete mene de 2011 a 2014 dans les Deux-Sevres, des prelevements d’urines ont ete effectues au deuxieme et troisieme trimestre de la grossesse en vue de rechercher et de quantifier des PE, dont le methyl-, l’ethyl, le propyl- et le butyl-parabene. Methodes Les urines recueillies ont ete stockees a −20 °C jusqu’a leur analyse. La methode utilisee a ete validee selon les guides de validation de bioanalyse (EMA). Elle consiste en une extraction liquide/liquide simple, suivie d’une analyse par UHPLC-MS/MS en mode MRM (Xevo TQ-S). La limite de detection a ete definie comme correspondant a trois fois l’ecart-type de l’aire obtenue lors de l’analyse de cinq blancs. La limite de quantification (LOQ) etait de 0,025 ng/mL pour les 4 parabenes. Resultats Les urines de 152 femmes pour lesquelles les deux prelevements ont pu etre recueillis ont ete analysees. La valeur 0 a ete attribuee en cas de non detection et LOQ/√2 en cas de non quantification. Les concentrations moyennes retrouvees sont presentees dans le Tableau 1 . Les taux de detection et de quantification des 4 parabenes sont presentes dans le Tableau 2 . Conclusion Les 4 parabenes ont ete retrouves dans la majorite des urines du deuxieme et du troisieme trimestre de la grossesse. Les concentrations moyennes en methyl-parabene sont largement superieures a celles des 3 autres cumulees (de 12 a 33 fois plus). Le methyl-parabene est le plus frequemment retrouve, ce qui est en accord avec son utilisation tres repandue dans les produits de soins corporels. Ces observations confirment l’importance d’informer les femmes enceintes ou desireuses d’avoir des enfants sur ces perturbateurs endocriniens, leurs sources d’exposition et les moyens de les eviter.

Group B streptococcus (GBS) neonatal infection can be prevented by screening pregnant women for GBS colonization from the 34th to the 38th week of gestation, as has been recommended in France since 2001. We assessed guideline adherence among midwives and obstetricians.From 2006 to 2008, new and mandatory GBS data were added to the obstetric database. We merged the latter with a bacteriological database and a paediatric database and defined process indicators for pregnant women who delivered from the 37th week of gestation in the hospital of Poitiers and for neonates hospitalized for a GBS infection from 2006 to 2008.We abstracted 5997 pregnant women (1942 in 2006, 1975 in 2007 and 2080 in 2008) and 84 neonates (17 in 2006, 32 in 2007 and 35 in 2008). GBS pregnancy colonization prevalence was 15%, 13% and 18% respectively. Availability of GBS screening status was stable (96%, P = 0.15). The rate of GBS screening during pregnancy increased significantly (86% to 90%, P = 0.002). Percentage of correct-term screening increased significantly (89% to 96%, P0.001). Percentage of women who received intra-partum antibiotic prophylaxis decreased significantly (84% to 70%, P = 0.001). Percentage of women who received correct intra-partum antibiotic prophylaxis was stable (75%, P = 0.65). Percentage of neonates whose mother had been correctly screened but negative was 77%, 67% and 68% respectively (P = 0.61).Our mandatory database entailed guideline adherence over a short lapse of time and resulted in a significant increase of the screening rate at the correct term. However, circumstances where neonates are infected still remain. Screening test performance needs to be re-evaluated.

Environmental health is a discipline that studies the influence of environmental factors on the health of individuals. According to the emergence of salutogenesis, these factors, considered as determinants of health, constitute the justification for promoting health in its environmental dimension, a vision supported by current scientific knowledge. At the same time, the work established around the concept of 1000 days of development, that is to say the period from a child’s conception up to two years of age, has highlighted the need to act during this period of great vulnerability on the development of health capital of the newborn. The concept of 1000 days appears to be the solution to the increase in chronic diseases to reduce costs on public finances. In light of this double consideration, this thesis presents an educational path for environmental health for pregnant women in Nouvelle-Aquitaine, France. After an inventory of knowledge, the thesis details the setting up of a pilot project within the Angoulême maternity hospital, in connection with a whole set of institutional actors., La santé environnementale est une discipline qui étudie l’influence des facteurs environnementaux sur la santé des individus. Avec l’émergence de la salutogénèse, ces facteurs, considérés comme des déterminants de santé, constituent la justification pour faire la promotion de la santé dans sa dimension environnementale, vision confortée par les connaissances scientifiques actuelles en la matière. Dans le même temps, les travaux autour du concept des 1000 jours, période allant de la conception aux deux ans d’un enfant, ont mis en lumière la nécessité d’agir pendant cette période de grande vulnérabilité sur le développement du capital santé de l’être en devenir. Le concept des 1000 jours apparaît comme la solution face à l’augmentation des maladies chroniques dans un contexte d’opportunités de réduction des coûts sur les finances publiques. Au regard de cette double considération, la présente thèse présente un parcours d’éducation pour la santé environnementale pour les femmes enceintes en Nouvelle-Aquitaine. Après un état des lieux des connaissances, la thèse détaille la mise en place d’un projet pilote au sein de la maternité d’Angoulême, en lien avec tout un ensemble d’acteurs institutionnels.