Study on the use practices and knowledges of French practitioners about the use of intra-uterine devices in early post-partum contraception in France.

OBJECTIVES: Intra-Uterine Device (IUD) insertion is possible in early postpartum. Although this contraception method is recognized and used in lots of country, it seems infrequent and poorly known in France. Our study aims to assess the barriers to the application of this method in France. METHODS: A questionnaire was sent to obstetricians-gynaecologist professionals and midwives in France, through the affiliation to CNGOF (French National College of Obstetricians and Gynecologists) and to CNSF (French National College of Midwives). Questions were focused on the practices and knowledge about the insertion of IUD in early postpartum. RESULTS: four hundred eight practitioners responded. Amongst them, 63% knew about the possibility to use IUDs after a vaginal delivery and 31% knew it could be inserted during cesarean section. Ten percent of them used this method. Most of these practitioners (80% of them) would like to discuss the insertion of an IUD in early postpartum with their patients and 71% would like to perform the insertion themselves after training. Besides, this study shows that contraception is rarely addressed by physicians during the follow-up of pregnancies. Less than 15% of respondents report discussing the topic systematically with the patient during the pregnancy follow during pregnancy follow. CONCLUSION: insertion of IUDs in early postpartum is uncommon in France. The main limitation seems to be a lack of knowledge, but practitioners seem to be interested in this practice. Training courses could be created in order to rase up the adoption of this practice.

[Screening and healthcare for pregnant women with psycho-social vulnerability : A French national study]. / Dépistage et parcours de soins en cas de vulnérabilités psycho-sociales maternelles : une enquête nationale française.

INTRODUCTION: Psycho-social vulnerabilities are a medical risk factor for both fetus and mother. Association between socioeconomic status and prenatal follow-up has been well established and inadequate follow-up is associated with higher morbidity and mortality in women in unfavorable situations. OBJECTIVE: The objective is to identify screening strategies and to describe existing systems for pregnant women in psycho-social vulnerability in French maternity hospitals. MATERIAL AND METHODES: This is a national survey conducted by questionnaire in all French maternities. RESULTS: Screening by means of targeted questions is carried out by 96.7% of maternity units. Early prenatal interviews are offered systematically by 64% of maternity units and access to them is still difficult for women in vulnerable situations. In order to organize care pathways, 28.7% of maternities have a structured unit within their establishment and 81% state that they have mobilizable caregivers. Multidisciplinary meetings for the coordination of the various stakeholders are held by 85.8% of maternity units. Collaboration with networks and associations is emphasized. CONCLUSION: A large proportion of maternities seek to identify women in situation of psycho-social vulnerabilities and to organize care paths. However, the resources implemented still appear insufficient for many maternity units. Each maternity hospital has resources and is developing initiatives to deal with the difficulties of care.

[Current knowledge on contraceptive knowledge in France: CNGOF Contraception Guidelines]. / Contexte de la contraception en France. RPC Contraception CNGOF.

OBJECTIVE: To summarize current knowledge on contraceptive coverage in France and worldwide, describe the effectiveness of different types of contraceptives, describe the characteristics of women using contraception, contraceptive failure situations and describe the different medical risks associated with contraceptive methods. METHODS: Consultation of the Medline database and of national or international reports on contraception. RESULTS: Contraceptive coverage in France is high: 97% of women in 2013 use a contraceptive method (among fertile, sexually active women without a desire for pregnancy), with a majority using medical methods (72% using pills and other hormonal contraceptives, intrauterine devices and 25% using natural and traditional barrier methods). The 2013 pill scare called into question the use of estrogen-progestogenic contraception and the information provided by doctors, but the pill remains the first contraceptive method followed by the intrauterine device, condoms and the traditional and natural methods. Lifetime contraceptive coverage changes according to a defined standard in France: condoms for the teen-agers, pills before pregnancy and then intrauterine devices after childbirth. Sterilization is very rarely chosen and offered. Contraception in France remains a predominantly female domain. Women and couples should be informed about all contraceptive methods, allowing them to choose the method that best suits their health, living conditions and sexuality.

[Contraception: CNGOF Guidelines for Clinical Practice (Short Version)]. / Contraception : Recommandations pour la Pratique Clinique du CNGOF (texte court).

The French College of Obstetrics and Gynecology (CNGOF) releases its first global recommendations for clinical practice in contraception, to provide physicians with an updated synthesis of available data as a basis for their practice. The French Health Authority (HAS) methodology was used. Twelve practical issues were selected by the organizing committee and the task force members. The available literature was screened until December 2017, and allowed the release of evidence-based, graded recommendations. This synthesis is issued from 12 developed texts, previously reviewed by experts and physicians from public and private practices, with an experience in the contraceptive field. Male and female sterilization, as well as the use of hormonal treatments without contraceptive label were excluded from the field of this analysis. Specific practical recommendations on the management of contraception prescription, patient information including efficacy, risks, and benefits of the different contraception methods, follow up, intrauterine contraception, emergency contraception, local and natural methods, contraception in teenagers and after 40, contraception in vascular high-risk situations, and in case of cancer risk are provided. The short/mid-term future of contraception mostly relies on improving the use of currently available methods. This includes reinforced information for users and increased access to contraception for women, whatever the social and clinical context. That is the goal of these recommendations.

[Observational study of a social device for women in precarious situations during pregnancy and post-partum]. / Étude observationnelle d'un dispositif d'aide aux femmes en situation de précarité pendant la grossesse et le post-partum.

OBJECTIVES: To assess the impact of the Regional experimental accompanying nutrition and breast-feeding for pregnant women (PRENAP) 75 social device on the duration of postpartum hospitalization and breast-feeding for pregnant women in precarious situation. METHODS: A retrospective observational study took place between November 2013 and May 2015 in a type III Parisian maternity. Comparison of sociodemographic, perinatal and postpartum characteristics of women in precarious situations (no stable housing and no social care or universal medical coverage or state medical aid) was done according to whether they were included in the system PRENAP or not. RESULTS: Over the study period, 344 (4.6%) women in precarious situations gave birth in this maternity. Among these women, the women included in the PRENAP system were more frequently in a very unfavorable social situation than those who were not included. The inclusion in the PRENAP device did not reduce the hospitalization in post-partum. Breast-feeding was chosen more frequently by the women included in the PRENAP device. CONCLUSION: The PRENAP device seems to favor the use of breast-feeding, but is not associated with a diminution of the hospitalization time in post-partum. This social device, which seems to be beneficial in terms of social and medical support for women in precarious situations, deserves to be evaluated prospectively.

[Epidemiology of induced abortion in France]. / Épidémiologie de l'interruption volontaire de grossesse en France.

OBJECTIVES: Conduct a synthesis of existing knowledge about the frequency of induced abortion or termination of pregnancy and unplanned pregnancies, the exposure factors of unplanned pregnancies and abortion and the associated morbidity and mortality. METHODS: Consultation of The Medline database, and national and international reports on abortions in France and in developed countries. RESULTS: Voluntary termination of pregnancy is an induced abortion, opted for non-medical reasons, which in France can be performed before 14 weeks of gestation. Abortion is a common procedure, with rare complications, amounting to about 220,000 procedures per year in France with a stable rate over decades. Similarly to births, women aged 20 to 24 are most affected. The possibility of an abortion exists for all women; this potential event, however, is not equal for each and varies by age of women, socio-professional situations, geographical origins, marital status and past or present domestic and sexual violence. The French historical analysis shows that for 50 years the increase in contraceptive prevalence rate is associated with a decrease in the frequency of unplanned pregnancies. It is therefore possible that the prevention of unplanned pregnancy through early uptake of contraception and contraception options by women is related to a woman's lifestyle. Nonetheless, the number of abortion remains stable since its decriminalization despite the large increase in medicalized contraceptive prevalence rate. CONCLUSION: Good knowledge of the epidemiology of voluntary termination of pregnancy and unplanned pregnancies is a prerequisite to better adopt prevention and case management strategies.

[Urogynecology pelvic organ prolapse French surgical training during and after residency]. / Formation des internes et jeunes assistants de gynécologie-obstétrique en statique pelvienne en France.

OBJECTIVES: For the treatment of prolapse, the vaginal route is less standardized than laparoscopy and seems abandoned by younger doctors. Our objectives were to evaluate the surgical experience of resident and youth gynecology and obstetrics assistants in pelviperineology and the level of confidence and mastery of the different surgical treatment of pelvic. METHODS: An anonymous questionnaire sent via an Internet platform interviewing residents and young assistants of gynecology and obstetrics (promotion 2005 to 2010) in France on their surgical training in pelviperineology. RESULTS: Twenty-nine percent (208/724) of the persons contacted responded with two thirds of residents and one third of young assistants, all regions of France were represented. Sixty-four percent of respondents wanted to favor a surgical career. The laparoscopic sacrocolpopexy was declared to be the best method mastered while residents and young assistants reported being more often leading operator in vaginal techniques during their medical training. CONCLUSION: Surgical practice during medical training of resident and young assistants did not seem associated with declared mastery level of technique. Different clinical surgical practice training techniques such as simulation, cadaveric study, movies on surgical technics may also improve the level of confidence and mastery of young doctors for surgical techniques.

[Induced abortion: Guidelines for clinical practice - Text of the Guidelines (short text)]. / L'interruption volontaire de grossesse : recommandations pour la pratique clinique ­ Texte des recommandations (texte court).

OBJECTIVE: Develop recommendations for the practice of induced abortion. MATERIALS AND METHODS: The Pubmed database, the Cochrane Library and the recommendations from the French and foreign Gyn-Obs societies or colleges have been consulted. RESULTS: The number of induced abortions (IA) has been stable for several decades. There are a lot of factors explaining the choice of abortion when there is an unplanned pregnancy (UPP). Early initiation and choice of contraception in connection to the woman's life are associated with lower NSP. Reversible contraceptives of long duration of action should be positioned fist in line for the teenager because of its efficiency (grade C). Ultrasound before induced abortion must be encouraged but should not be obligatory before performing IA (Professional consensus). As soon as the sonographic apparition of the embryo, the estimated date of pregnancy is done by measuring the crown-rump length (CRL) or by measuring the biparietal diameter (BIP) from 11 weeks on (grade B). Reliability of these parameters being±5 days, IA could be done if measurements are respectively less than 90mm for CRL and less than 30mm for BIP (Professional consensus). A medical IA performed with a dose of 200mg mifepristone combined with misoprostol is effective at any gestational age (EL1). Before 7 weeks, mifepristone followed between 24 and 48hours by taking misoprostol orally, buccally sublingually or eventually vaginally at a dose of 400 ug possibly renewed after 3hours (EL1, grade A). Beyond 7 weeks, misoprostol given vaginally, sublingually or buccally are better tolerated with fewer side effects than oral route (EL1). It is recommended to always use a cervical preparation during an instrumental abortion (Professional consensus). Misoprostol is a first-line agent for cervical preparation at a dose of 400 mcg (grade A). Aspiration evacuation is preferable to curettage (grade B). A perforated uterus during an instrumental suction should not be considered as a scarred uterus (Professional consensus). IA is not associated with increased subsequent risk of infertility or ectopic pregnancy (EL2). The pre-abortion medical consultations does not affect, most of the time, the decision to request an IA. Indeed, a majority of women is quite sure of her choice during these consultations. Acceptability of the method of IA and satisfaction appears to be larger when they are able to choose the abortion method (grade B). There is no relationship between an increase in psychiatric disorders and IA (EL2). Women with psychiatric histories are at increased risk of mental disorders after the occurrence of an UPP (EL2). In case of instrumental abortion, oral estrogen-progestogen contraceptives and the patch should be started from the day of the abortion, the vaginal ring inserted within 5 days of IA (grade B). In case of medical abortion, the vaginal ring should be inserted within a week of taking mifepristone, oral estrogen-progestogen contraceptives and the patch should be initiated on the same day or the day after taking prostaglandins (grade C). In case of instrumental abortion, the contraceptive implant may be inserted on the day of the abortion (grade B). In case of medical abortion, the implant can be inserted on the day of mifepristone (grade C). The copper Intrauterine Device (IUD) and levonorgestrel should be inserted preferably on the day of instrumental abortion (grade A). In case of medical abortion, an IUD can be inserted within 10 days following mifepristone after ensuring by ultrasound of the absence of intrauterine pregnancy (grade C). CONCLUSION: The implementation of these guidelines may promote a better and more homogenous care for women requesting IA in our country.