Measuring the readiness to screen and manage intimate partner violence: Cross-cultural adaptation and psychometric evaluation of the PREMIS tool for perinatal care providers.

INTRODUCTION: Pregnancy and perinatal periods are significant risk factors of intimate partner violence (IPV), a major public health problem that could begin or intensify during these periods. Perinatal care providers have a major role in the identification and the management of IPV. This study aimed to cross-culturally adapt into French the Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS) tool, a reliable instrument to assess the knowledge, attitudes and preparedness to address IPV, and to evaluate its psychometric properties. METHODS: The PREMIS was cross-culturally adapted by conducting forward and backward translations, following international guidelines. An online cross-sectional study was conducted to assess the psychometric properties of the PREMIS-French in perinatal care providers: data completeness, factor analysis, score distribution, floor and ceiling effects, internal consistency, item-total correlations, inter-subscale correlations and test-retest reliability. RESULTS: The PREMIS was successfully translated and cross-culturally adapted to the context of metropolitan France. The results obtained from 360 perinatal care providers showed good acceptability. Exploratory factor analysis of the "Opinions" items resulted in a six-factor solution with six of the eight subscales of the original structure identified. Good internal consistency (Cronbach's alpha ranging from 0.54 to 0.97) and good test-retest reliability (intraclass correlation coefficients ranging from 0.46 to 0.92) for the "Background" and "Opinions" subscales were found. DISCUSSION: This study provides evidence of the good psychometric properties of the PREMIS-French. This valid instrument will help to understand perinatal care providers' barriers to IPV screening and management and will help to focus on specific lacks of knowledge for developing IPV education programs.

Protocol for the e-POWUS Project: multicentre blinded-randomised controlled trial of ultrasound speed choice to improve sonography quality in pregnant women with obesity.

INTRODUCTION: During pregnancy, maternal obesity increases the risk of fetal abnormalities. Despite advances in ultrasound imaging, the assessment of fetal anatomy is less thorough among these women. Currently, the construction of ultrasound images uses a conventional ultrasound propagation velocity (1540 m/s), which does not correspond to the slower speed of propagation in fat tissue.The main objective of this randomised study is to compare the completeness of fetal ultrasonography according to whether the operator could choose the ultrasound velocity (1420, 1480 or 1540 m/s) or was required to apply the 1540 m/s velocity. METHODS AND ANALYSIS: This randomised trial is an impact study to compare a diagnostic innovation with the reference technique. The trial inclusion criteria require that a pregnant woman with obesity be undergoing a fetal morphology examination by ultrasound from 20+0 to 25+0 gestational weeks.Randomisation will allocate women into two groups. The first will be the 'modulable speed' group, in which operators can choose the speed of ultrasound propagation to be considered for the morphological analysis: 1420, 1480 or 1540 m/s. In the second 'conventional speed' group, operators will perform the morphological examination with the ultrasound speed fixed at 1540 m/s. The adjudication committee, two independent experts, will validate the completeness of each examination and the quality of the images. ETHICS AND DISSEMINATION: This research protocol does not change the standard management. The only possible impact is an improvement of the ultrasound examination by improving the quality of the image and the completeness of morphological examination. The Agence du Médicament et produits de santé approved this study (2018-A03478-47). The anonymised data will be available on request from the principal investigator. Results will be reported in peer-reviewed journals and at scientific meetings. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov (http://www.clinicaltrials.gov) Registry (NCT04212234).

Cost-effectiveness threshold of first-trimester Down syndrome maternal serum screening for the use of cell-free DNA as a second-tier screening test.

INTRODUCTION: We aimed to identify the most relevant cost-effectiveness threshold of first-trimester Down syndrome (DS) maternal serum screening (T21T1) for the use of cell-free DNA (cfDNA) as a second-tier test in the French context. METHOD: A cost-effectiveness analysis was performed on 108,121 singleton pregnancies using a simulation model. The threshold of T21T1 screening was ranged from 1/51 to 1/1,000 in steps of 1/50. The most relevant threshold was based on cost-effectiveness ratio (CER; costs = direct medical costs after T21T1 screening/ effectiveness = number of DS cases identified). RESULTS: In the sample, 161 cases of DS were identified. At the threshold of ≥ 1/50, 47.2% of total DS cases were diagnosed. In the simulation model, for a threshold ≥ 1/250, 73.9% of total DS cases were diagnosed, for ≥ 1/500, 78.8% and for ≥ 1/1,000, only two additional cases were diagnosed. The slope of the cost increase was slight from threshold ≥ 1/250 (978,634 €), then steep up to 1/500 (1,966,576 €) and increased exponentially to 1/1,000 (3,980,216 €). The CER was 38,560 for a threshold ≥ 1/500. CONCLUSION: The most cost-effective threshold for cfDNA as a second-tier test seems to be ≥ 1/500. For higher thresholds, costs increase dramatically for only a few additional cases of DS identified.

A French audit of maternity unit protocols for immediate postpartum hemorrhage: A cross-sectional study (HERA).

OBJECTIVES: The principal objective of this work was to assess how well the written protocols of maternity units used for the prevention and management of postpartum hemorrhage (PPH) corresponded to the 2004 French guidelines on this topic. The second objective was to assess whether or not this correspondence with the national guidelines varied according to hospital level (basic, specialized, and subspecialized) and status (teaching, public, and private). METHODS: This observational multicenter cross-sectional study took place in September 2010 and included French perinatal networks that volunteered to participate. We asked 300 French maternity units belonging to these networks to participate by emailing a copy of their department's protocol for PPH to the study team. This team designed and performed a clinical audit of these protocols, defining 16 criteria that incorporated the 2004 French guidelines for prevention and management of PPH. The main outcome measure was the percentage of units reporting protocols meeting these criteria. RESULTS: Of the 244 maternity units responding, 97.1 % had a written protocol but only 67.0 % had a local protocol. Protocol correspondence with the 2004 French guidelines was good for the criteria involving quantitative assessment of the quantity of blood loss (83.5 %) and secondary management of PPH (>80 %). Correspondence with the guidelines was poor in terms of defining PPH in the protocol (25.3 %) and of requiring the recording of the time of PPH diagnosis (53.2 %) and of the volume of blood loss (55.7 %). These results differed only slightly according to maternity unit status or level. CONCLUSION: In all, 67.0 % (159/237) of maternity units had a local protocol for PPH. The contents of these protocols should be improved to be closer to the national guidelines.

Temperature Elevation in an Instrumented Phantom Insonated by B-Mode Imaging, Pulse Doppler and Shear Wave Elastography.

Diagnostic ultrasound is the gold standard for obstetric scanning and one of the most important imaging techniques for perinatal and neonatal monitoring and diagnosis. Ultrasound provides detailed real-time anatomic information, including blood flow measurements and tissue elasticity. The latter is provided through various techniques including shear wave elastography (SWE). SWE is increasingly used in many areas of medicine, especially in detection and diagnosis of breast, thyroid and prostate cancers and liver disease. More recently, SWE has found application in gynaecology and obstetrics. This method mimics manual palpation, revealing the elastic properties of soft biological tissues. Despite its rising potential and expanding clinical interest in its use in obstetrics and gynaecology (such as for assessment of cervical ripening or organ development and structure during pregnancy), its effects on and potential risks to the developing fetus remain unknown. Risks should be evaluated by regulatory bodies before recommendations are made on the use of SWE. Because ultrasound is known to produce thermal and mechanical effects, this study measured the temperature increase caused by B-mode, pulse Doppler (PD) and SWE, using an instrumented phantom with 11 embedded thermocouples. Experiments were performed with an Aixplorer diagnostic ultrasound system (Supersonic Imagine, Aix-en-Provence, France). As expected, the greatest heating was detected by the thermocouple closest to the surface in contact with the transducer (2.9°C for SWE, 1.2°C for PD, 0.7°C for B-mode after 380-s excitation). Both conduction from the transducer face and direct heating owing to ultrasound waves contribute to temperature increase in the phantom with SWE associated with a larger temperature increase than PD and B-mode. This article offers a methodological approach and reference data for future safety studies, as well as initial recommendations about SWE safety in obstetrics and gynaecology.

Temperature Rise Caused by Shear Wave Elastography, Pulse Doppler and B-Mode in Biological Tissue: An Infrared Thermographic Approach.

The aim of this study was to determine the interest in and relevance of the use of infrared thermography, which is a non-invasive full-field surface temperature measurement technique, to characterize the heterogeneous heating caused by ultrasound in biological tissue. Thermal effects of shear wave elastography, pulse Doppler and B-mode were evidenced in porcine tissue. Experiments were performed using a high-frequency echography Aixplorer system (Supersonic Imagine, Aix-en-Provence, France). For all three modes, ultrasound was applied continuously for 360 s while the temperature at the sample surface was recorded with a Cedip Jade III-MWIR infrared camera (Flir, Torcy, France). Temperature changes were detected for the three modes. In particular, "heat tunnels" crossing the sample were visualized from the early stages of the experiment. Heat conduction from the transducer was also involved in the global warming of the sample. The study widens the prospects for studies on tolerability, potentially in addition to classic approaches such as those using thermocouples.

Phthalate Exposure in Pregnant Women: Risk Perception and Preventive Advice of Perinatal Health Professionals.

Objectives The main objective of the PERI-HELPE study (Perception of Risk-HEaLth Professionals and Environment Study) was to describe the knowledge of perinatal health professionals about phthalates and the preventive advice they give to pregnant women about exposure to these chemicals. The secondary objective was to determine whether giving preventive advice was associated with the perception of phthalates. Methods A cross-sectional study was performed in 2015 in France. One hundred and eighty-nine perinatal health professionals (obstetricians, midwives and general practitioners) replied to an online self-administered questionnaire (participation rate: 11%). Results Only 17% of health professionals felt able to provide appropriate answers to pregnant women about phthalates. Advice was given by 23% (avoid plastic kitchen cling film) to 75% (prefer homemade dishes) about eating habits, by less than 42% for the use of cosmetics and less than 25% for that of consumer products. After adjusting for covariates, the awareness that pregnant women are daily exposed to phthalates (44% of professionals) was associated with dietary advice [avoid pre-packaged food (OR 2.2; 95% CI 1.1-4.4), prefer homemade dishes (OR 2.6; 95% CI 1.2-5.9) and avoid plastic kitchen cling film (OR 2.4; 95% CI 1.0-5.6)] but not with advice about cosmetics or consumer products. The perception of phthalate exposure as a high risk (66%) was not associated with preventive advice. Conclusions for Practice Our sample size was not very large but the findings nevertheless show the lack of knowledge of perinatal health professionals about phthalates. If they are to take on a preventive role, health professionals in France need to be better informed about phthalates and more fully trained in environmental health in general.

Laryngotracheoesophageal cleft, a rare differential diagnosis of esophageal atresia.

A laryngotracheoesophageal cleft, commonly called laryngeal cleft (LC), is a congenital malformation of the posterior part of the larynx creating an abnormal communication between the laryngotracheal axis and the pharyngoesophageal axis. The prenatal ultrasonographic features associating absent stomach, polyhydramnios and mediastinal "pouch sign" are usually considered pathognomonic for esophageal atresia. This observation demonstrates that they can also correspond to a severe form of laryngotracheoesophageal cleft extending to the carina.

In utero exposure to arsenic in tap water and congenital anomalies: A French semi-ecological study.

INTRODUCTION: Congenital anomalies (CA) are responsible for high rates of mortality and long-term disabilities. Research on their risk factors including environmental factors is needed. Studies on exposure to arsenic (As) in tap water and the risk of CA have not provided conclusive evidence, particularly when levels of exposure were low (from 10 to 50 µg As/L). The main objective of this study was to assess the association between exposure to As in tap water and the risk of any major CA. The secondary objectives were to assess this association for the most common types of congenital anomalies (in the heart, musculoskeletal, urinary and nervous systems). METHODS: A semi-ecological study was conducted from births recorded at the University Hospital of Clermont-Ferrand, France, in 2003, 2006 and 2010. The medico-obstetric data were available at individual level. Children with congenital anomalies were identified from the database of the regional registry of congenital anomalies: the Centre d'Etudes des Malformations Congénitales Auvergne (CEMC-Auvergne). As exposure was estimated from the concentrations of As measured during sanitary control of tap water supplied in the mothers' commune of residence (aggregate data). French guidelines for As in tap water were used to identify the two groups: "≥ 10 µg As/L group" and "[0-10) µg As/L group". Multivariable logistic regression models were fit. RESULTS: 5263 children (5.1% with a CA) were included. In stratified analysis by gender of the child, positive associations between As exposure exceeding 10 µg/L and risk of any major CA (adjusted OR = 2.41; 95%CI: 1.36-4.14) and of congenital heart anomalies (adjusted OR = 3.66; 95%CI: 1.62-7.64) were only shown for girls. No association was found for boys. CONCLUSION: This French semi-ecological study provides additional arguments for the association between exposure to As exceeding 10 µg/L in tap water and the risk of CA especially in a context of low exposure. Further studies are needed to better understand the interaction between arsenic exposure and child gender.

Practices during the active second stage of labor: A survey of French midwives.

OBJECTIVE: the principal objective of our study was to describe the practices reported by French midwives during the active second stage of labor (expulsion phase). DESIGN: this cross-sectional Internet survey questioned French midwives who attended at least one childbirth in 2013. SETTING: this open survey was posted on a website from June 15 through December 1, 2014. PARTICIPANTS: 1496 midwives from 377 maternity units participated in the study. MEASUREMENTS AND FINDINGS: the midwives most often reported suggesting horizontal positions during the active second stage (supine with footholds, lithotomy, lithotomy with knees turned in, or lateral positions). Non-horizontal positions were more often proposed by midwives in level I units (p<0.0001). Almost half the midwives responding (46.4%), especially those working in level III units (51.1%, p = 0.006), advised Valsalva pushing. The mean maximum pushing time was 35.3 minutes±12.8 minutes. Nearly all the midwives favored the 'hands on' technique at childbirth (91.4%), and 24% reported using warm compresses on the perineum at childbirth. KEY CONCLUSION: most midwives advised horizontal positions for childbirth. The practices of French midwives differed as a function of where they worked. The midwives, especially those in level III facilities, reported that they cannot always ensure 'physiological childbirth'. IMPLICATIONS FOR PRACTICE: the practices of French midwives must become more evidence-based. The development of professional guidelines for midwives in France appears essential. This study also helps to prioritise national training for midwives.

Exposure to arsenic in tap water and gestational diabetes: A French semi-ecological study.

INTRODUCTION: The increase in the prevalence of gestational diabetes mellitus (GDM) and its consequences for mother and children prompts research on their risk factors including environmental factors. Studies on exposure to arsenic (As) in tap water and the risk of GDM have not provided conclusive evidence, particularly when levels of exposure were low (from 10 to 50µg As/L). The main objective of this study was to assess the association between exposure to As in tap water and the risk of GDM. METHODS: A semi-ecological study was conducted from births recorded at the University Hospital of Clermont-Ferrand, France, in 2003, 2006 and 2010. Individual medical/obstetric data were available. As exposure was estimated from the concentrations of As measured during sanitary control of tap water supplied in the mothers' commune of residence (aggregate data). French guidelines for As in tap water were used to identify groups potentially exposed, designated "As +" (≥ 10µg As/L) and "As -" (< 10µg As/L). Multivariate logistic regression analysis was performed. RESULTS: 5053 women (5.7% with a GDM) were included. Overall, women in the As + group had a higher risk of GDM than those in the As - group (adjusted OR = 1.62; 95%CI: 1.01-2.53). Stratified analysis of pre-pregnancy body mass index (BMI) showed a positive association only for obese or overweight women (adjusted OR = 2.30; 95%CI: 1.13-4.50). CONCLUSION: This French semi-ecological study provides additional arguments for an association between As exposure and the risk of GDM in particular in a context of low exposure. Further studies are needed to assess a potential interaction between As exposure and body mass index.

Positions during the first stage and the passive second stage of labor: A survey of French midwives.

OBJECTIVE: the objective of our study was to describe the practices reported by French midwives during labor (first stage and passive phase of the second stage). DESIGN: this cross-sectional internet questionnaire surveyed French midwives who attended at least one delivery in 2013. SETTING: this open survey was posted on a website from June 15 through December 1, 2014. PARTICIPANTS: 1496 midwives from 377 maternity units participated in the study. Nearly 93% of the midwives worked in an obstetric unit, 5.9% had a mixed practice, and 1.3% worked in private practice. MEASUREMENTS AND FINDINGS: during the first stage of labor, midwives reported suggesting that women without epidural analgesia use a birthing ball (98.1%) and that they walk around (97.4%). For women with epidural analgesia, most suggested motion in horizontal positions. Epidural analgesia was proposed more often by midwives from level II (75.7%) and level III (73.5%) maternity wards than by those at level 1 units (57.7%) (p<0.0001). The midwives preferred a lateral position during the first stage for women with epidural analgesia and during the second stage for women both with and without it. Midwives in practice for 5 years or less suggested a kneeling position for women with epidural analgesia more often than more experienced midwives. KEY CONCLUSION: the practices of French midwives vary with their place of practice and their experience. IMPLICATIONS FOR PRACTICE: to promote normal labor, French midwives must reappropriate vertical positions and analgesic alternatives to epidurals.

Congenital unilateral renal agenesis: Prevalence, prenatal diagnosis, associated anomalies. Data from two birth-defect registries.

BACKGROUND: The different mechanisms leading to a solitary kidney should be differentiated because the long-term outcome might be different. The fetal period is the best moment to make a true diagnosis of congenital unilateral renal agenesis (URA). The objective was to determine the prevalence of URA at birth. The secondary objectives were to describe the evolution of sensitivity of prenatal diagnosis over time and the different forms of URA (isolated and associated with other malformations) detected up to 1 year. METHODS: The cases were retrospectively identified through two French population-based birth defect registries (Auvergne and Bas-Rhin) between 1995 and 2013. Stillbirths and fetuses up to 22 weeks of gestation and infants up to 1 year old with URA were included. RESULTS: A total of 177 cases of URA were registered. The prevalence at birth was 4.0/10,000. The overall prenatal prevalence was 3.6/10,000 (isolated URA: 2.8/10,000). URA were isolated (59.9%), associated with isolated contralateral congenital anomaly of kidney or urinary tract (CAKUT) (7.3%) and with other extra-renal anomalies (32.8%). The total proportion of contralateral CAKUT was 15%. Only three cases presented an aneuploidy, prenatally detected and conducting to a termination of pregnancy. The sensitivity of prenatal diagnosis improved over time (from 54.2% in 1995 to 1997 to 95.8% in 2010 to 2013; p = 0.002). CONCLUSION: Our study provides estimates of prevalence of URA at birth. A longitudinal cohort from the antenatal period to puberty should be performed to determine the prognosis of the contralateral kidney among these children with isolated, associated with contralateral CAKUT and URA with extra-renal anomalies. Birth Defects Research 109:1204-1211, 2017. © 2017 Wiley Periodicals, Inc.

Exposure of hospitalised pregnant women to plasticizers contained in medical devices.

BACKGROUND: Medical devices (MDs) in polyvinyl chloride (PVC) are not a well-known source of exposure to plasticizers, in particular during pregnancy. Because of its toxicity, the di-(2-ethylhexyl) phthalate (DEHP) has been replaced by other plasticizers such as di (isononyl)-cyclohexane-1,2-dicarboxilic acid (DINCH), tri-octyltrimellitate (TOTM) and di-(isononyl) phthalate (DiNP). Our study aimed to quantify the plasticizers (DEHP and alternative plasticizers) contained in PVC medical devices used for hospitalised pregnant women and to describe which these MDs had been used (type, number, duration of exposure). METHODS: The plasticizers contained in the MDs used for daily care in the Obstetrics Department of a French University Hospital were extracted from PVC (after contact with a chloroform solution), identified and quantified by gas-chromatography-mass-spectrometry analysis. A total of 168 pregnant women hospitalised in the Obstetrics Department with at least one catheter were included in the observational study. The median number of MDs containing plasticizers used and the daily duration of exposure to the MDs were compared in three groups of pregnant women: "Pathology group" (women hospitalised for an obstetric disorder who did not give birth during this hospitalisation; n = 52), "Pathology and delivery group" (hospitalised for an obstetric disorder and who gave birth during this stay; n = 23) and "Delivery group" (admitted for planned or spontaneous delivery without obstetric disorder; n = 93). RESULTS: DiNP, TOTM and DINCH were the predominant plasticizers contained in the MDs at an amount of 29 to 36 g per 100 g of PVC. Women in the "Pathology group" (preterm labour or other pathology) were exposed to a median number of two MDs containing TOTM and one MD containing DiNP, fewer than those in the "Pathology and delivery group" (p < 0.05). Women in the "Pathology group" had a median exposure of 3.4 h/day to MDs containing DiNP and 8.2 h/day to MDs containing TOTM, longer than those in the "Delivery group" (p < 0.01). CONCLUSIONS: Our study shows that the medical management of pregnant women in a hospital setting entails exposure to MDs containing alternative plasticizers (DiNP, TOTM and DINCH).

Perception of Environmental Risks and Health Promotion Attitudes of French Perinatal Health Professionals.

The exposure of pregnant women to environmental contaminants is a subject of international concern. However, the risk perception of these contaminants by health professionals (HP) has not been extensively investigated. The main objective of the PERI-HELPE study (Perception of Risk-HEaLth Professionals & Environment Study) was to assess the risk perception of environmental exposure of pregnant women by perinatal HPs. The secondary objectives were to describe the preventive attitudes of perinatal HPs concerning chemicals exposure of pregnant women and to identify the barriers to preventive attitude. A cross-sectional study was performed in 2015 in France. One hundred eighty-nine HPs (obstetricians, midwives, and general practitioners) replied to an online self-administered questionnaire (participation rate: 11%). Carbon monoxide, pesticides and lead were the contaminants most frequently perceived as a high risk for pregnant women. A minority of HPs asked women about their chemical exposure and advised them to reduce exposure. The lack of information, training and scientific evidence in environmental health were the main difficulties declared by the HPs to advise pregnant women. Despite the low response rate, our findings provide important information to encourage French health authorities to take into account the difficulties encountered by HPs and set up appropriate training programs in Environmental health.

Policies for management of postpartum haemorrhage: the HERA cross-sectional study in France.

OBJECTIVE: The principal objective of this study was to describe the policies reported by French maternity units for the prevention and early management of postpartum haemorrhage (PPH). The second objective was to assess their variation according to hospital level and status. STUDY DESIGN: Cross-sectional observational study of French maternity units, from January 2010 to April 2011. The medical supervisor (obstetrician or midwife) of participating maternity wards completed a questionnaire designed to ascertain the unit's protocol for preventing and managing PPH after both vaginal and caesarean deliveries at a gestational age >22 weeks (or a birth weight >500g). The main outcome measure was the percentage of units reporting protocols adhering to the principal criteria for adequate management defined by the 2004 French guidelines for PPH. RESULTS: 252 maternity units participated in the survey. Almost all units had a written protocol for PPH (97.2%). For vaginal deliveries, 82.5% of units had a definition of PPH (>500ml) and 92.8% had a policy of preventive oxytocin use. For caesareans, only 23.8% defined PPH (as >1000ml), 68.8% used manual delivery of the placenta, and 76.9% recommended oxytocin injection immediately after the birth. The first-line medication for PPH was oxytocin (96.3%) and the second-line treatment a prostaglandin (97.5%). Level III maternity units had a definition of haemorrhage for vaginal deliveries more often than did other levels of care (P=0.04). Manual removal of the placenta after caesareans was significantly more frequent in level I than level III units (P=0.008) and in private than other types of maternity units. Medical management of haemorrhage did not differ according to level of care or maternity status. CONCLUSIONS: The responses by maternity unit supervisors showed significant improvement in the management of PPH accordingly to the 2004 French guidelines, especially for the third stage of labour. This improvement did not differ between hospitals by levels of care or legal status.

Incidence of immediate postpartum hemorrhages in French maternity units: a prospective observational study (HERA study).

BACKGROUND: Most estimates of postpartum hemorrhage (PPH) are calculated from studies that use administrative or medical birth databases, and only a few from prospective observational studies. Our principal objective was to estimate the incidence of PPH according to their severity (mild or severe) in vaginal deliveries (>500 mL, ≥1000 mL) and cesareans (>1000 mL and ≥1500 mL). The secondary objectives were to describe the incidence of PPH according to maternity unit characteristics, causes, and types of PPH management. METHODS: This prospective observational study took place in French maternity wards. Women who gave birth at a term ≥ 22 weeks were eligible for the study. 182 maternity units participated in a study with prospective data collection from 1 February, 2011, to 31 July, 2011. The main outcome measure was PPH incidence. RESULTS: PPH incidence after vaginal delivery was 3.36 % [95 % CI: 3.25-3.47 %] and after cesareans 2.83 % [95 % CI: 2.63-3.04 %]. The incidence of severe PPH after vaginal delivery was 1.11 % [95 % CI: 1.05-1.18 %] and after cesareans 1.00 % [95 % CI: 0.88-1.13 %]. This incidence rate varied according to maternity unit characteristics. The principal cause of PPH for both modes of delivery was uterine atony (57.7 % for vaginal births and 66.3 % for cesareans). Vascular embolization was more frequent among women with cesareans (10.0 vs. 2.9 %), who also required transfusions more often (44.4 vs 12.7 %). CONCLUSIONS: The incidence of PPH was lower than the rate expected from the literature. Effective treatment of uterine atony and optimizing the identification of blood loss remain important priorities.