[The profile of neonaticide mothers in legal expertise]. / Le portrait des mères néonaticides dans les expertises judiciaires.

INTRODUCTION: Neonaticide is the term used to refer to the killing of newborn infants within the first 24 hours of life. A recent study conducted by Inserm Unit 750 found a frequency of 2.1 cases of neonaticide for 100,000 births in France. The persistence of these crimes raises serious issues, and scientists have attempted to explain this by the profile of neonaticidal mothers: young, or even teenage, single, primiparous, and socially deprived. The present study sought to question this profile, and to suggest a new profile for neonaticidal mothers. DATA AND METHODS: This retrospective study over the years 1996-2000 comprised 32 cases of neonaticide perpetrated in three French regions. Seventeen solved cases of these 32 cases generated 54 documents by expert consultants, mainly psychiatric and psychological expertise, studied and analysed here using Modalisa software for quantitative analyses and Nvivo software for qualitative data. RESULTS: No single socio-demographic profile was observed. The mothers were in contrasting situations at the time of the event. There were few psychotic profiles. The other psychopathological disturbances detected were very often related to the event. The most surprising feature in the expert reports describing the neonaticidal mothers was the existence of what we have termed "descriptive absent-factors". These mothers had not experienced major trauma in childhood such as the death of persons close or foster care. They were not living in an environment of family violence. They did not exhibit addictive or self-harm behaviour. Their parents before them had similar profiles, except three cases of alcoholism. Their parentage, and that of the infants, was not an issue. The most widely described personality features were immaturity, dependency on others, withdrawal, inhibition, emptiness, lack of affectivity, non-expressiveness, and devaluation of self-image. The very impoverished relational environment of these mothers also appears in the expertise data. Their affective and relational foundations were insecure. DISCUSSION: The "classic" profile of the neonaticidal mother as being young, single, and primiparous is not confirmed in this study. Recent American and European studies reach similar conclusions. More than half of these mothers already had other children; more than half were living with a partner. Nor did these mothers have an evident psychopathological profile, and even less so a psychopathic profile. This study suggests a "psycho-relational" profile for the neonaticidal mother: immature, affectively dependent, expressing herself very little, and experiencing considerable affective isolation. CONCLUSION: These neonaticidal mothers did not present any specific socio-demographic or evident psychopathological profile. The study nevertheless enabled definition of a "psycho-relational" profile.

Unintended injuries in children: the French situation.

The French situation with respect to mortality from unintentional injuries in children is far from satisfactory. International comparison is made difficult by statistical bias, but although excess injury mortality is decreasing in France, rates are higher than in most advanced European countries. Many regulations have been enacted during the past 30 years to reduce the economic and social burden of injuries, but political will is insufficient to establish a consolidated national program and enforcement of existing legislation is inadequate. Evaluation of preventive and educational programs is less than optimal; many attempts have not met basic methodologic requirements. The situation is improving, partly because of growing social concern. New regulations are in preparation, but solution of this major public health problem also demands behavioral change, which is much more difficult to effect than other measures. Greater commitment to research, proper evaluation of sound programs, and enforcement of existing law doubtless would reduce the excess morbidity and mortality resulting from unintended injuries to children.

Sports-related injuries in children. A study of their characteristics, frequency, and severity, with comparison to other types of accidental injuries.

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.

[Evaluation of the application of laws or regulations]. / Evaluation de l'application d'une loi ou d'une réglementation.

In the field of safety, accidents and injuries, laws and regulations can either ensure a passive protection of persons, or need their active participation. In the latter situation, beside the use of health indicators (rates of fatalities, accidents, injuries), the evaluation will also focus on changes of behaviour. In the case of mandatory restraint devices for young children, the evaluation of the laws indicates their effectiveness, but also: 1) methodological issues in interpretation of the results (reliability of the sources of information, choice of relevant denominators for the calculation of rates ...); 2) families low compliance, due to problems of acceptability of the laws and regulations, and to personal factors (demographic, socio-economic, cultural, and mainly psychological).

[An epidemiologic study of health care seeking behavior of children under 5 years of age by sex in developing countries]. / Etude épidémiologique du recours aux soins selon le sexe chez les enfants de moins de 5 ans en pays en développement.

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.

[Etiological study of low fertility in eastern Gaboon. I. Scheme and first findings (author's transl)]. / Enquête sur l'étiologie de l'hypofécondité au Gabon oriental: I. Protocole et premiers résultats.

The etiological study conducted in 1975 in Haut-Ogooué and Ogooué-Lolo included 1,548 patients male and female. In the 21 investigated areas the patients were asked questions and examined by a medical team which took swabs so that bacterial, parastic, immunological and genetical assays could be carried out. The object of this article is to review the feasibility of such a local inquiry and state the first findings. Abnormalities of the epididymis are more commonly verified in non-fertile men. Microfilaremia is related to the presence of hydroceles and epididymis lesions. It shows more often in men with less than 3 children. The authors do not refer to any of physiopathology to explain these findings which need to be ascertained in further inquiries.

[Etiological study of low fertility in eastern Gaboon. II. Results according to the geographical distribution and the ethnic group (author's transl)]. / Enquête sur l'étiologie de l'hypofécondité au Gabon oriental: II Résultats en fonction du lieu d'habitat et de l'ethnie.

An epidemiological study was conducted in Haut-Ogooué and Ogooué-Lolo, and included 875 men and 673 women. The purpose of this article is to precise the geographical distribution of the factors related to low fertility, and to verify the stability of the etiological relations according to the region, the place of residence and the ethny. Among men, hydroceles and epididym lesions are more frequent in Ogooué-Lolo, in small villages, and in forest areas. Microfilariae Loa-loa and D. perstans has the same distribution. In both regions and what ever the type of residence (town or village), the epididym lesions are more frequent in non fertile men, microfilariae is linked with genital lesions and is more seldom found in men who are the fathers of more than two children. Among women, leukorrheas, pelvic pains, and adnexal masses are related to low fertility, what ever the place of residence is.

[Risk-taking behavior and accidents in adolescence in developed countries]. / Comportement de prise de risque et accidents à l'adolescence dans les pays développés.

Injuries due to accidents are the primary cause of fatalities among adolescents. Between the ages of 10 and 19, mortality caused by accidents augments significantly, and there is an excess of male mortality, increasing with age. This mortality has remained virtually unchanged over the past 25 years, except for a small narrowing of rate differences by sex. Traffic accidents, particularly those involving motorcycles, are the leading cause of accident fatalities. Though not easily assessed, morbidity due to accidents is probably very high, especially among males. Sports accidents are the most frequent. Adolescents appear to be particularly exposed to some risks, but also tend to be careless about safety. Risk-taking is a source of rewards: pleasure, self-affirmation, sense of independence; but it is described by some authors as self-destructiveness, death from accidents reflecting suicidal tendencies. Paradoxical results of prevention have been observed in this age group.

[An epidemiological study of health care seeking behavior of children under 5 years of age in Algeria: what lessons for improving the health care system?]. / Etude épidémiologique du recours aux soins curatifs des enfants de moins de 5 ans en Algérie: quelles leçons pour le système de santé?

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.

[An epidemiological study of consultations of children under 5 years of age in Brazzaville (Congo)]. / Etude épidémiologique des consultations d'enfants de moins de 5 ans à Brazzaville (Congo).

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).

[Etiological study of low fertility in eastern Gaboon. III. Filarial endemicity (Loa loa, D. perstans). Prevalence of microfilariae in hydroceles (author's transl)]. / Enquête sur l'étiologie de l'hypofécondité au Gabon oriental: III. Endémie filarienne (Loa loa, D. perstans). Fréquence des microfilaires dans les hydrocéles.

During an inquiry performed in Gaboon the prevalence of hydroceles had led to puncture systematically every vaginal flow. 68 fluids were so collected at the end of the inquiry. Subsequently the statistical analysis of the results in men seems to suggest a correlation between microfilaremia (Loa loa and D. perstans) and the prevalence of hydroceles. Microfilariae were found in 77% according to the following distribution: Loa loa seldom diagnosed in this kind of flow were detected in 10%; D. perstans although never reported so far in hydrocele fluids appeared to be present in 62%. O. volvulus more currently referred to in hydrocele liquids were scarcely traced.

[Registration of children's accidents in health care and prevention facilities of a health sector]. / Enregistrement des accidents de l'enfant dans les structures de soins et de prévention d'un secteur sanitaire.

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.

[An epidemiological study of health care seeking behavior by children under the age of 5 years at hospital emergency services in Togo]. / Etude épidémiologique du recours aux consultations hospitalières d'urgence chez les enfants de moins de 5 ans au Togo.

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.

[Health care seeking behavior of children in Togo]. / Le recours aux soins des enfants au Togo.

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.

[Use of health facilities by children from 0 to 5 years in Togo. Results of an epidemiological study carried out at a RHC (Atakpamé)]. / Utilisation des structures de soins par les enfants de 0 à 5 ans au Togo. Résultats d'une enquête épidémiologique menée dans un CHR (Atakpamé).

Through a prospective survey coordinated by the CIE of Paris, and carried at a semi-urban regional hospital (Atakpame), the authors studied the use of health structures by inpatient and outpatient consulting children. Questionnaires were filled for the 112 children of the study. Results were as follows: There is a maladjustment between recruitment at the regional hospital and its real mission (emergency cases and special health care). Thus only 13.3% of children were seen for an emergency, and 4.5% admitted for special health case. In the majority of cases (69.4%), the health state of patients was not alarming. Improper channelling of the patients is responsible for this condition. 79.4% of children consult directly at the hospital without prior consultation at the "peripheral" health centers. The regional health center thus finds itself overburdened, whereby long waiting periods before consultation (> 300 mn for certain patients), and delay in the management of referred patients.

[Mental disorders in children: the value of epidemiology]. / Connaissance de la pathologie mentale de l'enfant: l'apport de l'épidémiologie.

Epidemiological research on the mental health of children is not well developed in France, as demonstrated by the very small number of publications on the subject, especially in French. The purpose of this article is to show the contribution of epidemiology to an understanding of childhood mental illness. We emphasize descriptive epidemiology (currently the most developed component), but discuss analytic and evaluative epidemiology as well. We have thus considered methodological issues related to the advantages and limitations of techniques employed, using concrete examples from international publications. For example, an extensive review of the literature reveals considerable disparity in figures on the prevalence of psychiatric disorders, chiefly because of problems of variation in definitions used and in the places and techniques of data collection (especially screening tools and diagnostic classifications). Only studies carried out in representative samples of the general population allow reliable evaluation of frequency, but these are particularly difficult and costly. The same may be said for follow-up studies, in particular those on birth cohorts, whose principle importance is that they enable the identification of predictive factors for mental disorders, starting from earliest childhood. Entire areas are currently in need of development, such as the genetic epidemiology in mental illness, clinical trials, or the evaluation of programs. Epidemiology enables the evaluation of service needs, the identification of 'risk groups' and a scientific approach to explanatory factors. In a country such as France where nearly all children are in the school system from the age of 3 years on, schools should become a place for early detection, which assumes a considerable increase in the means available and an innovative policy in the training of health personnel, especially in the area of mental health.

[Epidemiological study of sequelae of injuries in adolescents]. / Etude épidémiologique des séquelles d'accidents à l'adolescence.

BACKGROUND: In all industrialized countries, injuries constitute the primary public health problem during adolescence; study of long-term outcome of injuries to adolescents remains poor. POPULATION AND METHODS: A longitudinal epidemiological study performed on 8,140 students in 17 secondary schools in Paris and the Department of the Côte-d'Or followed the development over one year of 777 adolescents who had injuries in 1990. All injuries, both within and outside school, were included if they fulfilled the following criteria: school absence or excused from vocational training exceeding or equal to 2 days, or excused from physical education classes for at least 14 days. RESULTS: One year after the injury, 13% of the adolescents were still bothered by their injury, especially those who were older and the girls. Among described impairments, musculo-skeletal problems (88% of cases) were the major difficulty. These impairments were primarily in the lower limbs (53%). Unaesthetic scars were found in 17% of cases, and a psychological impact was found in 16.5% of the adolescents. The presence of sequelae was related to the type of initial lesion (present in 24% of head injuries and in 16% of cases affecting the lower limbs). The most serious difficulties were caused by dislocations, serious sprains and fractures. One year after the injury, sequelae were serious in 10% of those adolescents still experiencing problems; they had some impact on the daily life of the adolescents in 36% of cases, that is, 5% of all adolescents experiencing an injury. These sequelae were responsible for a high level of consumption of medical services. CONCLUSIONS: Although observed sequelae were relatively minor, the high frequency of injuries during adolescence, as well as their high economic costs, justify the most appropriate care available for victims of injuries, even those which appear benign. In addition, longitudinal studies should be prepared using adapted tools (scales for the evaluation of the gravity of injury sequelae).