[Assessment of the outcome of anorexia nervosa: construction of a self-administered questionnaire based on the patients' perception]. / Evaluation du devenir de l'anorexie mentale: construction d'un autoquestionnaire basé sur la perception des patientes (étude préliminaire).

INTRODUCTION: Our working hypothesis is that a better insight into the outcome of patients suffering from anorexia nervosa should contribute to preventing relapses and further complications and assessing treatment efficiency. Through anorexia nervosa, the patients express the difficulty they have to view themselves as specific subjects. OBJECTIVE: The current classic outcome evaluation is based on the study of objective events, which only partially reflect the reality of the patients' outcome at a subjective level. The objective of this study was to set up a new assessing instrument of the outcome of patients suffering from anorexia nervosa, essentially based on the patients' perception of their experience. METHOD: The methodology used has been based on: (1) the conduct by the main investigator of unstructured interviews using "free association", with the help of an interview guide. The anorexia nervosa patients were recruited among those who were hospitalized on an isolation contract, or among outpatients under a psychiatrist/psychoanalyst's supervision, aged over 25 years old so that they may have started their reproductive life. The study included 30 patients; (2) the analysis of the interview contents backed by preexisting hypotheses and by new ones suggested by the expression of the patients' perception, so as to set up an inventory of new themes; (3) the construction of a self-administered questionnaire starting from the development of each theme into several questions taking up the patients' own words and offering 4 possible answers (disagree completely, disagree, agree, quite agree). RESULTS: The analysis of the interviews contents has led to the development of 11 themes. The self-administered questionnaire includes a total of 124 items stemming from the development of each theme into between 9 and 16 items that were mixed in the version submitted to patients. DISCUSSION: This original interpretation of the outcome of the patients through their experience provides a better understanding of their relation to desire and pleasure, and consequently of the evolution of their subjectivity. By integrating several aspects of the disease expression, our instrument constitutes an alternative to the combination of several non-specific tools in anorexia nervosa. It thus avoids the atomization of the pathology and respects the specificity of its structure. The analysis of the disease function in the emergence of their subjectivity rather than the static observation of its symptoms has led to the development of new themes. CONCLUSION: The validation of this new methodological approach of the follow-up of anorexia nervosa based on the patients' perception of the evolution of their disease, aside from anthropometrical or physiological parameters, will have to be tested on a new population of patients. A quantitative score will be developed in association with the self-administered questionnaire. Its use in further epidemiological studies will enable a scientific assessment of the patients' outcome, and better prevent further complications and relapses, by screening patients with a pejorative risk. The ultimate aim is to improve these patients' care.

[Twin delivery: a survey of French obstetrical policies]. / Accouchement des grossesses gémellaires: enquête sur les politiques des maternités françaises.

OBJECTIVES: To describe obstetrical policy variations concerning the delivery management in the case of twins, at term. PATIENTS AND METHODS: A mail survey was undertaken among the medical supervisors of the maternity wards belonging to the AUDIPOG Network (N=170). RESULTS: The participating rate was 73.35%. 124 answers were analysed. Elective caesarean was realized by 0.8% of participants for diamniotic twins and by 57% of cases for monamniotic twins An elective caesarean is planned for respectively 74% of answers if first (J1) and second twin (J2) are in a breech presentation, 81% if J1 is in breech and J2 in cephalic presentation, and 68% if J1 is in breech and J2 in transverse presentation. Delivery with J1 in breech and J2 in cephalic presentation had a higher risk than a delivery of a single breech at term. When J1 and J2 had a breech presentation 73% of participants thought that this delivery is more difficult than a delivery of a single breech at term. However, they were only 17.5% to consider that a delivery of twin with J1 in cephalic and J2 in breech presentation had a higher risk than a single breech delivery. DISCUSSION AND CONCLUSION: Medical policy variations are not extensive except for X-ray pelvimetry and the presence for the delivery of one paediatrician and one anaesthesiologist. An elective caesarean policy for twins is infrequent in France.

The term breech presentation: Neonatal results and obstetric practices in France.

OBJECTIVE: Compare neonatal complications according to the planned mode of delivery and according to whether the women gave birth at a maternity unit that applied "consensus" guidelines. STUDY DESIGN: The study used the database of the AUDIPOG Sentinel Network (n=71,919 pregnancies between 1994 and 2000). The principal outcome was a composite variable that included neonatal morbidity and mortality. A survey of obstetric practices was sent to 175 maternity units belonging to the network. Consensus guidelines were defined from the survey responses and taken into account in the database analysis. RESULTS: Neonatal complications did not differ between the group of women with term babies in breech presentation for whom vaginal delivery was planned and those for whom an elective caesarean was planned (adjusted OR=1.33; 95% CI: 0.63-2.80). The survey allowed us to define a set of six criteria for deciding on mode of delivery; it established a consensus, followed by 42% of the maternity units in the study. The rate of neonatal complications among the women with planned vaginal delivery was lower for those giving birth in units that applied the consensus guidelines than among those in the other units: adjusted OR=0.27 (95% CI: 0.09-0.85). CONCLUSION: The risk of neonatal morbidity according to planned mode of delivery for term breech babies was lower for those giving birth in units that applied the consensus guidelines than among those in the other units.

Perinatal care regionalization and acceptability by professionals in France.

BACKGROUND: For twenty years, most of industrial countries developed recommendations on regionalization of perinatal care. Perinatal regionalization is particularly aimed at improving morbidity and mortality outcomes of low birth weight newborns by transferring pregnant women to the maternity units having a medical or neonatal environment suited to the risks incurred by mothers or babies. Perinatal regionalization cannot be effective without being well accepted by the majority of professionals. The objectives of this study were then to identify professionals'expectations and objections to perinatal regionalisation and to compare them from a professional group to another one. METHODS: Professionals of 3 French perinatal networks were under consideration: the Rhône, the Auvergne and the Gard-Lozère networks. The study included two stages: 1) a psychosociological qualitative study, based on professionals'interviews, aimed at identifying main concerns of professionals and developing a questionnaire; then 2) an epidemiological quantitative study, using this questionnaire within French networks. In the questionnaire, 8 dimensions explored the professionals'views: constraints related to regulation aspects and to the setting up of maternity units care levels, risk of loss of professionals' competence and prestige, consequences on medical practices, on inter-professional relationship, on work organization and financial aspects, and related to the new role of 'private practice'professionals, legal consequences. RESULTS: The response rate of the epidemiological study was 80%. The results permitted to construct 8 dimension scores describing the reasons of poor acceptability of regionalization. After taking into account the age, the sex, the network and the juridical status of the institution, the study revealed a significant poorer acceptability of regionalization by most of medical specialty groups (anesthetists, obstetricians, midwives and "private practice" professionals) compared with neonatologists, or by "private" professionals (professionals working in private clinics and "private practice" professionals) compared with professionals working in university or community hospitals. The study described also network setting up conditions related to its functioning. CONCLUSION: By identifying clearly professionals 'objections and expectations, this study should facilitate improvement in the organization of studied perinatal networks.

[Early postpartum hospital discharge in France]. / Sortie précoce dans le post-partum: état des lieux en France.

BACKGROUND: Early postpartum discharge is a recent practice in France and for which there are few national data. METHODS: The Sentinel AUDIPOG network was used to describe the practice of postpartum early discharge (< 3 days in case of vaginal delivery and < 5 days in case of caesarean section) from 1994 till 2002, after standardization on the distribution according to the type of hospital and the region (n = 128232). Secondarily, the prognostic medical factors of an early postpartum hospital discharge were researched, in univariate analysis and logistic regression analysis, of the births of 2001-2002. RESULTS: Early postpartum discharges concerned 3% of the deliveries in 1997 and 7% in 2002. Eearly postpartum discharge was more frequent in the level II and III obstetric facilities, in non- university hospitals, in facilities with more than 1 500 deliveries a year, in urban hospitals and in Paris and the surrounding area. The women leaving early in the postpartum were more often multiparas, with no pregnancy pathology, with a single pregnancy, without postpartum hemorrhage, and a child > 2500 g without risk of infection. At present, 40% of vaginal delivery and 25% of caesarean section primiparas and 55% of vaginal delivery and 30% of caesarean section multiparas could be discharged early. CONCLUSION: The reduction of the postpartum hospital stay is inevitable but it is advisable to take care that the women who are discharged are medically fit for discharge.

[Prenatal health in 2002-2003. Survey of medical practice. Results from the Audipog sentinel network]. / La santé périnatale en 2002-2003. L'observatoire des pratiques médicales. Résultats du réseau sentinelle Audipog.

Perinatal health survey has been ensured for 10 years by the AUDIPOG Sentinel Network (AUDIPOG, Association of Users of Computerized Files in Perinatology, Obstetrics and Gynecology). It was created, in 1994, by a group of birth specialists having the same concern for a common system of perinatal health survey and assessment of medical practices. Every year, the network includes about 100 voluntary maternity units pooling data about pregnant women and their newborns. To date, the AUDIPOG database comprises 180,000 births gathered between 1994 and 2003, including 78,287 births for the 2002 and 2003 period. The use of a standardization method of the rates makes it possible to provide valid estimations at the national level. This report presents the perinatal health indicators in 2002-2003 and confirms a very alarming situation: the rate of preterm births has not decreased since 1999 (7.1% of births) and high prematurity (< 33 weeks of gestation) affects 1.6% of newborns. Only 65% of high premature infants are born in care level III maternity units, while the figure of 80% has been reached as soon as 1999 and has not stopped to decrease since. The rate of cesarean section keeps on increasing, reaching 18.7% including 9.6% before the beginning of labour. The AUDIPOG network constitutes a continuous, and in real time, perinatal health survey and also a tool to assess medical practices. Members of the Audipog network can log in to the common data base, using the AUDIPOG website (http://audipog.inserm.fr), in order to find answers to their own questionnings and to compare their practices with the external reference formed by the network: such an access represents an innovating method of self-assessment of medical practices and quality control.

[Breech presentation at term: a survey on obstetrical practice in France and a search for a homogeneous attitude associated with lower neonatal risk]. / La présentation du siège à terme: enquête sur les pratiques obstétricales en France et recherche d'une homogénéité d'attitudes associées à un moindre risque néonatal.

OBJECTIVES: 1- In order to define a "consensual attitude" in case of breech presentation, we queried the AUDIPOG network on obstetrical practice in search for the more frequently accepted criteria for normal delivery. 2- For consensual practices that could be identified, early neonatal complications were compared between women cared for in maternity wards applying these practices and those cared for in maternity wards not applying these practices. MATERIALS AND METHODS: 1- A confidential survey was sent to participating obstetrics units to determine their practical attitude in case of breech presentation. A consensual attitude was established on the basis of their responses. 2- Crude and adjusted comparisons were made concerning neonatal results between the consensual and non consensual groups of obstetrics units. RESULTS: Response rate was 85% for 175 obstetrics departments consulted. Six criteria were identified leading to classification of 42% of the units as consensual obstetrics units. The risk of major neonatal complications was lower in the consensual group than in the non-consensual group: adjusted OR=0.27 (95% CI: 0.09-0.85). CONCLUSION: A questionnaire on obstetrical practice can help define consensual attitudes associated with lower risk of neonatal complications.

[Breech presentation at term: evolution of French practices and an analysis of neonatal results in regards to obstetrical management of breech presentation, from AUDIPOG Database]. / La présentation du siège à terme: évolution des pratiques en France et analyse des résultats néonatals en fonction des pratiques obstétricales, à partir du Réseau Sentinelle AUDIPOG.

OBJECTIVES: To describe the evolution of medical practices in breech presentation at term and to compare early neonatal complications according to initial obstetrical decision on the type of delivery. METHODS: 71919 pregnancies are included in the AUDIPOG Database from 1994 to 2000. Among this cohort, pregnant women with a singleton in breech, at term were selected which represented 2136 women after the exclusion of in utero deaths and medical abortions. The first outcome was global criteria of severe early neonatal complications ("death during per or immediate post partum or transfer of the newborns to an intensive care or surgery unit"). The size of the sample authorized a power of 90%. RESULTS: The rate of cesarean section before labor was 40%. We found 2.3% of early neonatal complications in the group in which labor was accepted vs. 1.9% in the group with cesarean section performed before labor (p>0.05). After having taken into account prognostic factors, we do not see a significant difference for the risk of neonatal complications between the two groups (OR=1.33; 95% CI: 0.63-2.80). CONCLUSION: The analysis of the AUDIPOG Database describes the French obstetrical practice in breech presentation at term. We do not find a different risk in morbi-mortality as regards to the initial obstetrical choice regarding the type of delivery, but the absence of randomization in our study does not authorize a strong medical evidence to guide national recommendations.

[Perinatal health indicators in 2001 and its evolution since 1994. Results from the Audipog sentinel network]. / La santé périnatale en 2001 et son évolution depuis 1994. Résultats du réseau sentinelle Audipog.

The AUDIPOG association (Association of Users of Computerized Files in Perinatalogy, Obstetrics and Gynaecology) proposed in 1994 the setting up of the Sentinel Network, including voluntary public and private maternity units from all areas in France. Each year, every member sends individual data related to a sample of births to the AUDIPOG Network. Today, the common database comprises 95,000 births collected during one month by all members of the network. Thanks to a standardization procedure, the perinatal health indicators, obtained from the common database, are valid estimations at the national level. The results of a given year are published at the beginning of the following year, providing a continual survey of perinatal indicators in France. Since the regionalization of perinatal services, a common perinatal information system is of great importance for a continual survey of perinatal health indicators and assessment of medical practices. Among the most important results of this perinatal network, we observed an increase in the rate of multiple pregnancies from 3.5% of births in 1998 to 4.2% in 2001. The increase of multiple births seems to be related to a lower maternal age in case of procreative medical assistance. As a consequence, the rate of preterm births was also increased, resulting in 7.2% of all births. In another section a regular increase in the rate of cesarean sections, from 16.3% in 1999 to 17.6% was observed in 2001. Cesarean sections before labour are chiefly concerned. From 1999, each member of the AUDIPOG network is given access to the entire common database, on the Internet AUDIPOG site, in order to describe medical practices when faced with a particular clinical situation of interest. This access to the common database aids self-assessment of medical practices and quality improvement (http://audipog.inserm.fr).

Definition of fetal growth restriction according to constitutional growth potential.

Identification of newborn babies with fetal growth restriction remains a problem both from the multi-factorial aspect of fetal growth and from statistical definition. Besides the usual terms: "Small for gestational age" (SGA) and intrauterine growth retardation (IUGR), often used synonymously, the term "fetal growth retardation" was recently introduced in reference to the genetic growth potential of infants. From a sample of 72,000 births, we have designed a statistical model in order to estimate the expected birth weight taking into account gestational age, sex, birth rank, maternal age, height and pregravid weight, we then calculated an individual limit of birth weight under that a newborn must be considered as having a "fetal growth restriction" quoted FwGR. This new approach allowed us to identify 2 groups of newborns with FGR, one classically identified as SGA (noted FwGR(I)) (3.9%), and the other newly identified as FGR (noted FwGR(II)) (1.4%). In contrast, this approach allowed us to identify a group of "constitutionally small" infants according to their constitutional growth potential (1.1%). In other words, among infants usually defined as SGA (5%), 22% appeared in fact to be "constitutionally small" and therefore misclassified. As an initial validation, we observed that the proportion of maternal hypertension during pregnancy was low in the "constitutionally small" infants (close to that of the normal group), and three times higher in the newly identified group FwGR(II) than in the normal group. Following these results, it seems to be meaningful to follow-up this new group of FwGR(II) infants, in terms of catch-up growth and neurodevelopmental outcome.

Estimation of an expected caesarean section rate taking into account the case mix of a maternity hospital. Analysis from the AUDIPOG Sentinelle Network (France). Obstetricians of AUDIPOG. Association of Users of Computerised Files in Perinatalogy, Obstetrics and Gynaecology.

OBJECTIVE: To provide maternity unit with an expected caesarean section rate, according to its case mix (i.e. women's characteristics associated with caesarean section risk). DESIGN: Cohort study. SETTING: 149 maternity units in France. SAMPLE: 40,512 single births collected by the French Sentinelle Network, in January every year, from 1994 until 1998. METHODS: Univariate analysis was used to identify caesarean section risk factors, and multivariate analysis to adjust for the role of the maternity units' characteristics, after taking into account the women's characteristics. A two-level logistic model was used to show that the caesarean section rate varied according to maternity units' characteristics and to estimate therefore expected caesarean section rates (before and during labour), for each maternity unit, according to its case mix. MAIN OUTCOME: Caesarean section rates (before and during labour). RESULTS: Within the Sentinelle Network the caesarean section rate was 15.0% (7.6% were before labour). The joint effect of the size and juridical status on caesarean section risk was studied. The reference hospital was university maternity units with more than 2000 deliveries/year. Community or private maternity units with more than 2000 deliveries/year carried out fewer prophylactic caesarean sections than the reference hospital (ORadj = 0.7 and 0.6, respectively). Conversely, private maternity units with fewer than 2000 deliveries/year performed more prophylactic caesarean sections than the reference hospital (ORadj = 1.7). The two-level logistic model showed that a maternity unit effect still existed after taking into consideration both women's characteristics and those of the maternity unit, and estimated expected caesarean section rates. CONCLUSION: Knowledge of the expected caesarean section rate constitutes a personal reference to which the maternity hospital can compare its observed caesarean section rate, and is thus likely to have a significant effect on delivery practices.

Psychological prevention of early pre-term birth: a reliable benefit.

OBJECTIVES: After a previous study had shown the existence of psychological risk factors of pre-term delivery, we designed a study aimed at assessing the effect of psychotherapeutic support of pregnant women hospitalised with pre-term labour, followed by a second multicentric study aimed at demonstrating the reliability of such an intervention. METHODS: Both studies were conducted in two successive cohorts of patients hospitalised with pre-term labour at 18-35 weeks of gestation. The initial study comprised 157 patients in each group, whereas the reliability study comprised 191 patients in the experimental group versus 202 in the control group. In each experimental group, the patients were offered psychotherapeutic support in addition to the usual clinical management. The psychological support included interviews with a psychologist and a collaborative work plan implemented with the nursing staff. RESULTS: The analysis, conducted in the 'intention to treat' manner, shows a significant decrease in the early pre-term birth rate (< 35 weeks) from 25.7 to 5.9% (p < 0.0001). After controlling for confounding factors, the adjusted relative risk was 0.16 [95% confidence interval (CI) = 0.07-0.37]. These results were confirmed, at a lesser level, in the reliability study, where the early pre-term birth rate changed from 15.7 to 7.2% (p < 0.02) and the adjusted relative risk was 0.35 (95% CI = 0.16-0.78). CONCLUSION: This study offers new and major results related to the prevention of delivery before 35 weeks of gestation, both in the initial study as well as in the reliability study. Thus, providing this type of psychological support to women hospitalised for pre-term labour, in the context of antenatal care, can help to avoid early pre-term births and their complications in terms of brain damage and neuropsychological development.

Transvaginal ultrasonography of the uterine cervix in hospitalized women with preterm labor.

OBJECTIVE: The aim of this study was to examine the relation between cervical length and the presence of funneling and the risk of preterm delivery. METHOD: This prospective blind cohort involved 200 hospitalized women with preterm labor in a tertiary care hospital. Women were recruited for a single transvaginal ultrasonography to assess cervical length and presence of funneling. The main outcome measures were: (1) relative risks (RR) and adjusted odds ratios of preterm delivery (<37 weeks' gestation); (2) time interval between the cervical ultrasonography date to 37 weeks' gestation or to-preterm birth. RESULTS: The RR of preterm delivery according to the cervical length (cut-off of <30 mm) was 2.79 (95% CI 1.70--4.59). The RR according to the presence of funneling (cut-off of >5 mm) was 1.39 (95% CI 0.99--1.95). The adjusted odds ratio was 3.92 (95% IC 1.75--8.75) for cervical length and 0.77 (95% CI 0.35--1.67) for funneling. Women with a cervical length of <30 mm had a significantly shorter interval from ultrasonography date up to 37 weeks' gestation than did women with a cervical length of >30 mm (P<0.003). CONCLUSION: Ultrasonographic mensuration of the cervix provides predictive information on the risk of preterm delivery.

[Indicators and evaluation tools for perinatal care networks]. / Indicateurs et outils d'évaluation des réseaux de soins périnatals.

Since the regionalization of perinatal services and the laws on the safety of child-birth were announced on the 9th October 1998, conventions and rules establishing relationships between doctors in perinatal networks have gradually been set up. In order to assess the impact, functioning and effectiveness of this care organisation on the health of mothers an childs, a common study design is essential. Such a common protocol, with the same methodology, allows the comparison of observed results from one perinatal network to another. With this objective, four leading societies in the field, the French National College of Gynaecologists and Obstetricians (CNGOF), the National Federation of Neonatal Pediatricians (FNPN), the French Society of Perinatal Medicine (SFPM) and the Association of Computerised Medical Records in Perinatalogy, Obstetrics and Gynaecology (AUDIPOG) set up a workshop in order to elaborate a common text, which was adopted by the Administrative Councils of the four societies. This contractual text, co-operatively elaborated, is now introduced to the scientific community. It was prepared from scientific papers and international recommendations in the field of perinatal regionalization, leading to a protocol giving information on objectives, study population, study design and assessment criteria. For this, a list of questions was proposed, including the impact of perinatal network, its acceptability by doctors and families, its functioning and its effectiveness on the health of mother and child. The means of data collection were then presented, whether from institutional sources of perinatal data (completed from specific registers or studies), or from the information system France-Perinat, especially designed for the evaluation of the perinatal networks.

Evolution of GH secretion in urine during an in-patient slimming course in obese children.

OBJECTIVE: To estimate the change in GH excretion in urine (GH-U) during a slimming course, and if increased, to assess the components of the course related to the increase in obese children. DESIGN: Observational follow-up study of patients admitted for primary obesity to an in-patient slimming course lasting at least 10 weeks. SUBJECTS: 48 complete observations out of 54 consecutive pre-pubertal patients admitted to a paediatric centre for treatment of primary obesity (BMI greater than the 90th percentile of the national reference curves). MEASUREMENTS: GH excretion in urine by immunoradiometric assay, at entry and after 10 weeks, various anthropometric measurements, nutritional intake and departure from the prescribed diet, time spent in physical activity, sleep duration. RESULTS: A mean decrease of 0.90 standard deviations for BMI was accompanied by a 34% increase of GH-U. Time spent in physical activity was the only component of the course found to be related to the magnitude of GH-U increase. CONCLUSION: The results of this observational study confirm that GH-U is increased after a slimming course in children, and suggest that physical activity is a major contributor to the restoration of normal GH-U levels.