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PERINATAL POLICY

Mediocre health results, greater mobilisation required

Thematic public report

Summary

May 2024

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Summary

Perinatal as a concept encompasses situations relating to birth, and has wider or

narrower meanings depending on the definition used. In this report, it is defined as the period

from the end of the first trimester of pregnancy until the infant is one year old.

The end of pregnancy and the first few months after giving birth are a delicate period for

infant development. Many factors determine the child's physical and psychological well-being

and emotional and cognitive development. Their effects can be immediate, but they can also

be manifest throughout an individual's life and have considerable consequences for healthcare

costs. This period also presents specific challenges for women's health in particular and

parenting support in general, involving issues of prevention, care and follow-up.

While the resources ear

marked for perinatal policy are increasing (€9.3 billion in

2021,

up 9 % on 2016) and the birth rate is falling (-5.3 % over the same period), the mediocre health

results observed call into question the efficiency of the allocated resources.

Summary of

expenditure on perinatal policy (€bn)

Source: CNAM (National Sickness Insurance Fund), mapping of pathologies

and Sickness Insurance expenditure (all schemes combined) and ATIH

(Technical Agency for Information on Hospital Care)

The main perinatal health indicators - stillbirths, neonatal mortality and maternal

mortality - highlight France's mediocre performance compared with other European countries.

Perinatal health has moreover deteriorated in recent times

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The main perinatal health indicators

Source: Court of Accounts

The rate of stillbirths in France rate, meaning the ratio of the number of stillborn babies

to the total number of births, has been among the highest in Europe for the past twenty years

(3.8

% for the period from 2015 to 2020). Furthermore, France is one of the only countries

where it has not improved since 2000.

Average stillbirth rate per 1,000 live births in Europe between 2015 and 2019

Note: stillbirths excluding therapeutic terminations, following 24 weeks of

amenorrhoea.

Source: Court of Accounts based on Euro-Peristat data 2015-2020

For neonatal mortality, meaning infant deaths occurring during the first month of life,

France ranks 22

nd

out of 34 European countries, with a rate of 2.7 %. The trajectory has been

unfavourable since 2012, after improving between 2001 and 2011. If the French neonatal

mortality rate had been identical to that of leading European countries, almost 40 % of the

deaths recorded in France between 2015 and 2017 could have been avoided,

i.e. 2,079 children.

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Trends in neonatal mortality in France between 2001 and 2021

Scope: live births in France, excluding Mayotte department, up to 2013; all of

France from 2014 onwards.

Source: Insee French National Statistics Office, register of births, marriages and

deaths, June 2023

Lastly, maternal deaths are a rare occurrence, with an average of 90 recorded each year.

The rate of deaths during pregnancy and up to the 42

nd

day after birth, an international

reference indicator, is 8.5 per 100,000 live births in France. This is comparable to the average

for European countries. Nevertheless, 60 % of maternal deaths are considered to be

potentially avoidable. In two-thirds of cases, they occurred after non-optimal care, due in

particular to malfunctions in the care system and perinatal care pathways.

Against this backdrop, the evaluation in this report addressed the following four

questions:

1.

Are the factors that explain France's mediocre results in terms of perinatal health clearly

identified, and do they provide sufficient guidance for prevention and healthcare during

pregnancy, childbirth and the first-year post-partum?

2.

To what extent have changes in the way care is organised helped to improve the safety

and quality of care and thus reduce perinatal mortality, maternal mortality and severe

maternal morbidity in the long term?

3.

How have primary and secondary prevention measures for risks that could affect the

health of mothers and children and the development of children effectively reduced

cases of serious morbidity and mortality at birth and during the first year of life?

4.

How can supporting parents, before or after childbirth, help to prevent psychological

suffering, in particular post-partum depression, and problems in the relationship

between parents and children, in addition to violence towards children and child abuse?

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Significant perinatal risks, marked by inequalities, which require better

monitoring

Major risks, some of which are becoming more prevalent

Obesity or excess weight in women prior to pregnancy are risk factors, as is inappropriate

weight gain during pregnancy, whether this is too much or too little. Despite positive

developments, addictive habits and the consumption of high-risk products such as drugs,

alcohol and tobacco remain at high levels, despite their toxicity for both mother and child.

The incidence of prematurity and low birth weight (less than 2,500 grams) has been

stable since 2016, after rising steadily over the previous decade. The rates of prematurity and

low birth weight stand at 7 % each, putting France at the median level in Europe.

The proportion of late pregnancies, after the age of 35, is increasing and now accounts

for almost a quarter of all births in France. They are associated with increased risks for both

mothers and children, as well as greater obstetric complications.

Complications during pregnancy and characteristics of childbirth by age of mother at

delivery (%)

Source: INSERM (French National Institute of Health and Medical Research) for the Court

of Accounts

Social and territorial inequalities in perinatal health

Perinatal health is characterised by major social and territorial inequalities. The vulnerability of

families and mothers, as measured by income, qualifications or access to social security cover,

is associated with greater maternal and infant morbidity and complications during pregnancy.

These inequalities are greater for mothers born abroad, whose social situation correlates with

greater morbidity and risk, while almost a quarter of births are to foreign mothers. Lastly, the

overseas territories face particular difficulties.

A deficient epidemiological monitoring system

In the absence of a unified perinatal information system, and despite the valuable

contribution of existing surveys conducted regularly, the epidemiological surveillance and

analysis system is unable to identify or rank the factors that explain perinatal health indicators,

and consequently to provide useful guidance for public action.

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The quality of perinatal health monitoring could be improved by setting up a more efficient

information system, a proper birth register able to produce more complete data. Provided it is

progressively expanded, the national health data system (SNDS) is probably the adequate tool

for achieving the objective of centralising data production, as required by European standards.

In this way, information on the birth of the child, taken from records in the register of births,

marriages and deaths, could be permanently matched with the SNDS to produce more robust

perinatal health indicators.

A policy that has failed to improve care safety and quality

A care supply that is ill-adapted to current perinatal issues

The organisation of care and the quality of care play a decisive role in preventing

perinatal health risks and harm, particularly during and following childbirth. However, the

current situation does not meet the requirements of optimal safety or efficiency in the

organisation of healthcare provision.

The regulations governing the organisation and technical operating conditions of

maternity units, which have remained unchanged for the last twenty-five years, do not seem

to have kept pace with changes in care provision or the restructuring of healthcare provision

over the last few decades.

The development of perinatal care provision is also insufficiently steered by the health

authorities, against a backdrop of severe pressure on medical and paramedical human

resources. Around twenty maternity units still do not meet the minimum threshold of 300 births

a year, set in 1998 to ensure the quality and safety of care. The fact that maternity units with

fewer than 1,000 births a year are finding it increasingly difficult to attract and retain qualified

staff also calls for a case-by-case analysis of the conditions under which they carry out their

work. As far as neonatal critical care is concerned, there are major disparities between regions,

prompting a reassessment of provision in certain regions. Finally, women with high-risk

pregnancies should always be monitored in facilities equipped to deal with possible

complications and those that could affect newborn babies.

These findings call for a review of the organisation of perinatal care, with the aim of

improving care safety and ensuring that resources are allocated more efficiently.

In order to consolidate the demographic balance in the perinatal professions, efforts must

be made to provide training for childbirth professionals, taking into account the actual location

and nature of practice of current professionals. This should include improving the

attractiveness of these professions in hospitals, and improved mother and child protection

services (PMI) and in towns and cities, particularly in the least well-equipped areas.

The "1,000 first days" strategy: renewed ambition, but too narrow in scope

Between 1970 and 2007, France adopted structured, mobilising perinatal plans. Public

policy today is based on a more generalised design. For example, the perinatal objectives of

the 2018-2022 National Health Strategy (SNS) have been adopted, sometimes redundantly,

in around ten separate thematic plans.

A new ambition has been established since 2021 through the "first 1,000 days" strategy,

understood as the period from the beginning of pregnancy to the child's second birthday. The

plan includes structural measures such as support for the widespread use of early prenatal

and postnatal sessions, reinforcing medical, psychological and social teams in maternity

wards, and experimenting with personalised perinatal pathways, in addition to more incidental

measures. A great deal of space is given over to experimentation, the sometimes ephemeral

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nature of which can lead to the players involved running out of steam, with the risk of losing

sight of the long-term objectives.

This new, more preventive approach reflects a welcome commitment to understanding

the psychological risks associated with perinatal care and the developmental risks for newborn

babies, and to combating social and health inequalities. However, it does not take sufficient

account of the quality and safety of perinatal care, which is one of the reasons for our country's

poor performance. Overseas, despite significant mobilisation, the strategy is not adapted to

the particular economic vulnerabilities of these territories, nor to their specific geographical or

socio-cultural characteristics.

More effective governance could result from a multi-year strategic plan specifically

focused on perinatal care, covering the issues identified in the "first 1,000 days" project and

those relating to care quality and safety alike, w

hich are not taken sufficiently into account at

the current time. In this context, specific levers for action in the overseas territories would need

to be identified, as well as the provision of financial support commensurate with local health

and social issues. To ensure the governance of this strategy and enhance its visibility, it would

be appropriate to reinstate the National Commission on Birth and Child Health, review its

membership and extend its scope to include maternal health.

Perinatal care coordination resources require optimisation

Given the diversity and complexity of the pathways taken by pregnant women, mothers

and their newborn babies depending on the medical risk they are at or their vulnerability, a key

issue is the coordination of healthcare professionals working in towns, hospitals and mother

and child protection centres (PMI).

It would be useful to clarify the respective roles, scopes and responsibilities of the

structures involved in this coordination (coordination support systems, territorial health

professional communities, etc.) and the players offering personalised support to patients

(personalised perinatal pathway, named midwife).

Insufficient preventive measures

Prevention must be stepped up in order to achieve a lasting reduction in risk factors

during the perinatal period and to improve the health of women and children. There have been

some positive developments, such as an increase in the number of rare diseases screened for

in newborns.

However, shortcomings persist. Despite their appropriateness, the screening or

vaccination campaigns run by health authorities have a limited impact. Furthermore, they do

not effectively reach the most at-risk groups, particularly women in disadvantaged situations

or those suffering from a combination of particular illnesses, either in France or overseas.

To be more effective, the public authorities need to focus on the risk factors for mothers,

and do more to disseminate health recommendations to health professionals and families. We

need to take greater account of mothers' individual situations, based on their backgrounds and

known risk factors. Greater use of early prenatal and postnatal sessions, which are still

underused, could contribute to this.

More support for parents

The recent "first 1,000 days" strategy aims to prevent the psychological and

developmental risks associated with the perinatal period. However, the inadequate scope of

some of the core measures of this strategy, shortcomings in the provision of perinatal and

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social psychiatric care, and the plethora of parental support measures and structures, limit the

prevention and treatment of psychological distress and issues in the parent-child relationship.

In this context, it would seem preferable to postpone the current dismantling of the "Prado

maternity" home support service set up by the health insurance scheme.

It has proved its effectiveness and should be maintained until other ways of coordinating

perinatal care pathways have demonstrated equal appropriateness.

Lastly, parenting support schemes (networks for listening to, supporting and

accompanying parents - REAAP - and child-parent drop-in centres - LAEP) should be made

more uniform and easier to understand, so that efforts can be concentrated on the most

effective schemes and better coordination is achieved between the social players and health

professionals working in this field.

The Court's seven recommendations are designed to identify ways forward in response

to the issues raised by each of the four evaluation questions.