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Chercheurs, Enseignants-Chercheurs, Ingénieurs

DUMONT Alexandre

Epidemiologiste, Directeur de recherche, HDR, IRD.

Axe de recherche : Axe 1 - Santé, vulnérabilités et relations de Genre au Sud

Affectation géographique et adresse :
Ceped
45 rue des Saints-Pères
75006 Paris
Courriel : alexandre.dumont chez ird.fr

Recherches (en cours)

Champs de recherche : santé génésique (reproductive), accès aux soins, qualité des soins, inégalités de santés, recherche opérationnelle.

Programme(s) de recherche :

Zones géographiques étudiées :

Afrique de l’Ouest (Bénin, Burkina, Mali), Madagascar, Vietnam

Publications depuis 2016


  • Alam N., Hajizadeh M., Dumont Alexandre et Fournier P. (2015) « Inequalities in maternal health care utilization in sub-Saharan African countries : a multiyear and multi-country analysis », Plos One, 10 (4). DOI : 10.1371/journal.pone.0120922.
    Résumé : To assess social inequalities in the use of antenatal care (ANC), facility based delivery (FBD), and modern contraception (MC) in two contrasting groups of countries in sub-Saharan Africa divided based on their progress towards maternal mortality reduction. Six countries were included in this study. Three countries (Ethiopia, Madagascar, and Uganda) had <350 MMR in 2010 with >4.5% average annual reduction rate while another three (Cameroon, Zambia, and Zimbabwe) had >550 MMR in 2010 with only <1.5% average annual reduction rate. All of these countries had at least three rounds of Demographic and Health Surveys (DHS) before 2012. We measured rate ratios and differences, as well as relative and absolute concentration indices in order to examine within-country geographical and wealth-based inequalities in the utilization of ANC, FBD, and MC. In the countries which have made sufficient progress (i.e. Ethiopia, Madagascar, and Uganda), ANC use increased by 8.7, 9.3 and 5.7 percent, respectively, while the utilization of FBD increased by 4.7, 0.7 and 20.2 percent, respectively, over the last decade. By contrast, utilization of these services either plateaued or decreased in countries which did not make progress towards reducing maternal mortality, with the exception of Cameroon. Utilization of MC increased in all six countries but remained very low, with a high of 40.5% in Zimbabwe and low of 16.1% in Cameroon as of 2011. In general, relative measures of inequalities were found to have declined overtime in countries making progress towards reducing maternal mortality. In countries with insufficient progress towards maternal mortality reduction, these indicators remained stagnant or increased. Absolute measures for geographical and wealth-based inequalities remained high invariably in all six countries. The increasing trend in the utilization of maternal care services was found to concur with a steady decline in maternal mortality. Relative inequality declined overtime in countries which made progress towards reducing maternal mortality.

  • Arsenault C., Fournier P., Philibert A., Sissoko K., Coulibaly A., Tourigny C., Traore M. et Dumont Alexandre (2013) « Emergency obstetric care in Mali : catastrophic spending and its impoverishing effects on households », Bulletin - OMS, 91 (3), p. 207-216. DOI : 10.2471/blt.12.108969.
    Résumé : Objective To investigate the frequency of catastrophic expenditures for emergency obstetric care, explore its risk factors, and assess the effect of these expenditures on households in the Kayes region, Mali. Methods Data on 484 obstetric emergencies (242 deaths and 242 near-misses) were collected in 2008-2011. Catastrophic expenditure for emergency obstetric care was assessed at different thresholds and its associated factors were explored through logistic regression. A survey was subsequently administered in a nested sample of 56 households to determine how the catastrophic expenditure had affected them. Findings Despite the fee exemption policy for Caesareans and the maternity referral-system, designed to reduce the financial burden of emergency obstetric care, average expenses were 152 United States dollars (equivalent to 71 535 Communaute Financiere Africaine francs) and 20.7 to 53.5% of households incurred catastrophic expenditures. High expenditure for emergency obstetric care forced 44.6% of the households to reduce their food consumption and 23.2% were still indebted 10 months to two and a half years later. Living in remote rural areas was associated with the risk of catastrophic spending, which shows the referral system's inability to eliminate financial obstacles for remote households. Women who underwent Caesareans continued to incur catastrophic expenses, especially when prescribed drugs not included in the government-provided Caesarean kits. Conclusion The poor accessibility and affordability of emergency obstetric care has consequences beyond maternal deaths. Providing drugs free of charge and moving to a more sustainable, nationally-funded referral system would reduce catastrophic expenses for households during obstetric emergencies.

  • Belaid L., Dumont Alexandre, Chaillet N., Zertal A., De Brouwere Vincent, Hounton S. et Ridde Valéry (2016) « Effectiveness of demand generation interventions on use of modern contraceptives in low- and middle-income countries », Tropical Medicine and International Health, 21 (10), p. 1240-1254. DOI : 10.1111/tmi.12758.
    Résumé : OBJECTIVES To synthesise evidence on the implementation, costs and cost-effectiveness of demand generation interventions and their effectiveness in improving uptake of modern contraception methods. METHODS A Cochrane systematic review was conducted. Searches were performed in electronic databases (MEDLINE, EMBASE) and the grey literature. Randomised controlled trials, cluster randomised trials and quasi-experimental studies, including controlled before-after studies (CBAs) and cost and cost-effectiveness studies that aimed to assess demand interventions (including community-and facility-based interventions, financial mechanisms and mass media campaigns) in low-and middle-income countries were considered. Meta-analyses and narrative synthesis were conducted. RESULTS In total, 20 papers meeting the inclusion criteria were included in this review. Of those, 13 were used for meta-analysis. Few data were available on implementation and on the influence of context on demand interventions. Involving family members during counselling, providing education activities and increasing exposure to those activities could enhance the success of demand interventions. Demand generation interventions were positively associated with increases in current use (pooled OR 1.57; 95% CI: 1.46-1.69, P < 0.01). Financial mechanism interventions (vouchers) appeared effective to increase use of modern contraceptive methods (pooled OR 2.16; 95% CI: 1.91-2.45, P < 0.01; I-2 = 0%). Demand interventions improved knowledge (pooled OR 1.02; 95% CI 0.63-1.64, P = 0.93) and attitudes towards family planning and improved discussion with partners/husbands around modern contraceptive methods. However, given the limited number of studies included in each category of demand generation interventions, the dates of publication of the studies and their low quality, caution is advised in considering the results. Very limited evidence was available on costs; studies including data on costs were old and inconsistent. CONCLUSION Demand generation interventions contribute to increases in modern contraceptive methods use. However, more studies with robust designs are needed to identify the most effective demand generation intervention to increase uptake of modern contraceptive methods. More evidence is also needed about implementation, costs and cost-effectiveness to inform decisions on sustainability and scaling-up.
    Mots-clés : CONTRACEPTION, demand intervention, effectiveness costs, Family Planning, low- and middle-income countries, Systematic review.

  • Bouquier J., Fauconnier A., Fraser W. D., Dumont Alexandre et Huchon C. (2012) « Diagnostic d'une infection génitale haute. Quels critères cliniques, paracliniques ? Place de l'imagerie et de la coelioscopie ? », Journal de Gynécologie Obstétrique et Biologie de la Reproduction, 41 (8), p. 835-849. DOI : 10.1016/j.jgyn.2012.09.016.
    Résumé : Les infections génitales hautes (IGH) sont de diagnostic difficile. Nous proposons une revue systématique de la littérature sur les valeurs diagnostiques de l'interrogatoire, de l'examen clinique et des examens complémentaires biologiques et morphologiques. À l'issue de cette revue de la littérature, nous proposons un modèle diagnostique pour les IGH. Celui-ci est basé sur deux critères majeurs que sont la douleur annexielle provoquée et la douleur à la mobilisation utérine mais aussi sur des critères mineurs, spécifiques, augmentant la probabilité du diagnostic d'IGH. Ces critères mineurs sont basés sur l'interrogatoire, l'examen clinique, les examens biologiques et histologiques, mais aussi sur les signes échographiques ayant un rapport de vraisemblance positif élevé pour le diagnostic d'IGH dans la littérature. Les infections génitales hautes (IGH) sont de diagnostic difficile. Nous proposons une revue systématique de la littérature sur les valeurs diagnostiques de l'interrogatoire, de l'examen clinique et des examens complémentaires biologiques et morphologiques. À l'issue de cette revue de la littérature, nous proposons un modèle diagnostique pour les IGH. Celui-ci est basé sur deux critères majeurs que sont la douleur annexielle provoquée et la douleur à la mobilisation utérine mais aussi sur des critères mineurs, spécifiques, augmentant la probabilité du diagnostic d'IGH. Ces critères mineurs sont basés sur l'interrogatoire, l'examen clinique, les examens biologiques et histologiques, mais aussi sur les signes échographiques ayant un rapport de vraisemblance positif élevé pour le diagnostic d'IGH dans la littérature. Les infections génitales hautes (IGH) sont de diagnostic difficile. Nous proposons une revue systématique de la littérature sur les valeurs diagnostiques de l'interrogatoire, de l'examen clinique et des examens complémentaires biologiques et morphologiques. À l'issue de cette revue de la littérature, nous proposons un modèle diagnostique pour les IGH. Celui-ci est basé sur deux critères majeurs que sont la douleur annexielle provoquée et la douleur à la mobilisation utérine mais aussi sur des critères mineurs, spécifiques, augmentant la probabilité du diagnostic d'IGH. Ces critères mineurs sont basés sur l'interrogatoire, l'examen clinique, les examens biologiques et histologiques, mais aussi sur les signes échographiques ayant un rapport de vraisemblance positif élevé pour le diagnostic d'IGH dans la littérature.
    Mots-clés : DIAGNOSTIC, Likelihood ratio, Pelvic inflammatory disease, Sensitivity, Specificity.

  • Briand Valérie, Dumont Alexandre, Abrahamowicz M., Sow A., Traoré M., Rozenberg P., Watier L. et Fournier P. (2012) « Maternal and perinatal outcomes by mode of delivery in Senegal and Mali : a cross-sectional epidemiological survey », Plos One, 7 (10). DOI : 10.1371/journal.pone.0047352.
    Résumé : Objective: In the context of rapid changes regarding practices related to delivery in Africa, we assessed maternal and perinatal adverse outcomes associated with the mode of delivery in 41 referral hospitals of Mali and Senegal. Study Design: Cross-sectional survey nested in a randomised cluster trial (1/10/2007-1/10/2008). The associations between intended mode of delivery and (i) in-hospital maternal mortality, (ii) maternal morbidity (transfusion or hysterectomy), (iii) stillbirth or neonatal death before Day 1 and (iv) neonatal death between 24 hours after birth and hospital discharge were examined. We excluded women with immediate life threatening maternal or fetal complication to avoid indication bias. The analyses were performed using hierarchical logistic mixed models with random intercept and were adjusted for women's, newborn's and hospitals' characteristics. Results: Among the 78,166 included women, 2.2% had a pre-labor cesarean section (CS) and 97.8% had a trial of labor. Among women with a trial of labor, 87.5% delivered vaginally and 12.5% had intrapartum CS. Pre-labor CS was associated with a marked reduction in the risk of stillbirth or neonatal death before Day 1 as compared with trial of labor (OR = 0.2 [0.16-0.36]), though we did not show that maternal mortality (OR = 0.3 [0.07-1.32]) and neonatal mortality after Day 1 (OR = 1.3 (0.66-2.72]) differed significantly between groups. Among women with trial of labor, intrapartum CS and operative vaginal delivery were associated with higher risks of maternal mortality and morbidity, and neonatal mortality after Day 1, as compared with spontaneous vaginal delivery. Conclusions: In referral hospitals of Mali and Senegal, pre-labor CS is a safe procedure although intrapartum CS and operative vaginal delivery are associated with increased risks in mothers and infants. Further research is needed to determine what aspects of obstetric care contribute to a delay in the provision of intrapartum interventions so that practices may be made safer when they are needed.

  • Briand Valérie, Dumont Alexandre, Abrahamowicz M., Traore M., Watier L. et Fournier P. (2012) « Individual and institutional determinants of caesarean section in referral hospitals in Senegal and Mali : a cross-sectional epidemiological survey », Bmc Pregnancy and Childbirth, 12. DOI : 10.1186/1471-2393-12-114.
    Résumé : Background: Two years after implementing the free-CS policy, we assessed the non-financial factors associated with caesarean section (CS) in women managed by referral hospitals in Senegal and Mali. Methods: We conducted a cross-sectional survey nested in a cluster trial (QUARITE trial) in 41 referral hospitals in Senegal and Mali (10/01/2007-10/01/2008). Data were collected regarding women's characteristics and on available institutional resources. Individual and institutional factors independently associated with emergency (before labour), intrapartum and elective CS were determined using a hierarchical logistic mixed model. Results: Among 86 505 women, 14% delivered by intrapartum CS, 3% by emergency CS and 2% by elective CS. For intrapartum, emergency and elective CS, the main maternal risk factors were, respectively: previous CS, referral from another facility and suspected cephalopelvic-disproportion (adjusted Odds Ratios from 2.8 to 8.9); vaginal bleeding near full term, hypertensive disorders, previous CS and premature rupture of membranes (adjusted ORs from 3.9 to 10.2); previous CS (adjusted OR=19.2 [17.2-21.6]). Access to adult and neonatal intensive care, a 24-h/day anaesthetist and number of annual deliveries per hospital were independent factors that affected CS rates according to degree of urgency. The presence of obstetricians and/or medical-anaesthetists was associated with an increased risk of elective CS (adjusted ORs [95% CI] = 4.8 [2.6-8.8] to 9.4 [5.1-17.1]). Conclusions: We confirm the significant effect of well-known maternal risk factors affecting the mode of delivery. Available resources at the institutional level and the degree of urgency of CS should be taken into account in analysing CS rates in this context.
    Mots-clés : Africa, caesarean section, epidemiology.


  • Chaillet N., Dumont Alexandre, Abrahamowicz M., Pasquier J. C., Audibert F., Monnier P., Abenhaim H. A., Dube E., Dugas M., Burne R. et Fraser W. D. (2015) « A cluster-randomized trial to reduce cesarean delivery rates in Quebeca », New England Journal of Medicine, 372 (18), p. 1710-1721. DOI : 10.1056/NEJMoa1407120. http://www.documentation.ird.fr/hor/PAR00013057.
    Résumé : BACKGROUND In Canada, cesarean delivery rates have increased substantially over the past decade. Effective, safe strategies are needed to reduce these rates. METHODS We conducted a cluster-randomized, controlled trial of a multifaceted 1.5-year intervention at 32 hospitals in Quebec. The intervention involved audits of indications for cesarean delivery, provision of feedback to health professionals, and implementation of best practices. The primary outcome was the cesarean delivery rate in the 1-year postintervention period. RESULTS Among the 184,952 participants, 53,086 women delivered in the year before the intervention and 52,265 women delivered in the year following the intervention. There was a significant but small reduction in the rate of cesarean delivery from the preintervention period to the postintervention period in the intervention group as compared with the control group (change, 22.5% to 21.8% in the intervention group and 23.2% to 23.5% in the control group; odds ratio for incremental change over time, adjusted for hospital and patient characteristics, 0.90; 95% confidence interval [CI], 0.80 to 0.99; P = 0.04; adjusted risk difference, -1.8%; 95% CI, -3.8 to -0.2). The cesarean delivery rate was significantly reduced among women with low-risk pregnancies (adjusted risk difference, -1.7%; 95% CI, -3.0 to -0.3; P = 0.03) but not among those with high-risk pregnancies (P = 0.35; P = 0.03 for interaction). The intervention group also had a reduction in major neonatal morbidity as compared with the control group (adjusted risk difference, -0.7%; 95% CI, -1.3 to -0.1; P = 0.03) and a smaller increase in minor neonatal morbidity (adjusted risk difference, -1.7%; 95% CI, -2.6 to -0.9; P<0.001). Changes in minor and major maternal morbidity did not differ significantly between the groups. CONCLUSIONS Audits of indications for cesarean delivery, feedback for health professionals, and implementation of best practices, as compared with usual care, resulted in a significant but small reduction in the rate of cesarean delivery, without adverse effects on maternal or neonatal outcomes. The benefit was driven by the effect of the intervention in low-risk pregnancies.

  • Chaillet N., Dumont Alexandre, Abrahamowicz M., Pasquier J. C., Audibert F., Monnier P., Abenhaim H. A., Dube E., Dugas M., Burne R. et Fraser W. D. (2015) « A cluster-randomized trial to reduce cesarean delivery rates in Quebec », Obstetrical and Gynecological Survey, 70 (9), p. 546-548. DOI : 10.1097/01.ogx.0000471595.46762.64.
    Résumé : In developed countries, cesarean delivery rates are high and increasing. Strategies to reduce cesarean delivery rates have been the subject of recent studies and guidelines. While these studies suggest strategies involving audits and feedback are generally effective, there have not been large randomized trial data assessing the effects of a multifaceted strategy. This trial aims to assess whether the rate of cesarean delivery would be reduced by a multifaceted intervention promoting on-site training with audits and feedback. The QUARISMA (Quality of Care, Obstetrics Risk Management and Mode of Delivery) trial was conducted between April 1, 2008, and October 31, 2011, at 32 public hospitals in Quebec. Hospitals included had to have a 17% cesarean delivery rate or higher and at least 300 deliveries the year before. For inclusion, infants had to be born at least 24 weeks' gestation and weigh at least 500 g at delivery. Hospitals were randomly assigned to either a control or intervention group. The study spanned 3.5 years, first with a yearlong baseline period followed by a 1.5-year intervention period, and concluded with a yearlong postintervention period. Instructors from the Society of Obstetricians and Gynecologists of Canada provided training in evidence-based clinical practices. The intervention program also included clinical audits. There was no financial incentive. There was no intervention in the control groups. A total of 184,952 women delivered during the study period. In the control group, the baseline cesarean delivery rate was 23.2%, and in the intervention group, the rate was 22.5%. After intervention, the rate of cesarean delivery was 23.5% in the control group and 21.8% in the intervention group (P = 0.04). In both groups, rates of labor induction increased, but increased more in the control group than in the intervention group (adjusted odds ratio, 0.82; 95% confidence interval, 0.76-0.87; P < 0.001; adjusted risk difference, -3.8%; 95% confidence interval, -5.1% to -2.7%). A statistically significant reduction in the cesarean delivery rate was seen in low-risk pregnancies (-1.7%, P = 0.03) but not among high-risk pregnancies (P = 0.35). The reduction was significant but small. Interestingly, both major and minor neonatal morbidity in both low- and high-risk pregnancies was significantly reduced after intervention (adjusted risk difference, -0.7% for major morbidity [P = 0.03] and -1.7% for minor morbidity [P < 0.001]). This trial confirmed previous studies suggesting benefits of a multifaceted strategy involving audits and feedback. It is not clear, however, which aspects of the intervention program were responsible for the reduction in the rate of cesarean deliveries.

  • Chaillet N., Dumont Alexandre, Bujold E., Pasquier J. C., Audibert F., Dube E., Dugas M., Burne R., Abrahamowicz M. et Fraser W. D. (2014) « Quality of care, obstetrics risk management and mode of delivery in Quebec (QUARISMA) : a cluster-randomized trial », American Journal of Obstetrics and Gynecology, 210 (1), p. S2. DOI : 10.1016/j.ajog.2013.10.034.

  • Dortonne J.R. et Dumont Alexandre (2014) « Préparer le cycle de l'audit », in Audit des décès maternels dans les établissements de santé : guide de mise en oeuvre, éd. par Alexandre Dumont, M. Traoré, et J.R. Dortonne, Marseille : IRD, p. 37-42. (Didactiques). ISBN : 9782709918.
    Mots-clés : accouchement, AUDIT, CAUSE DE DECES, CENTRE DE SANTE, COLLECTE DE DONNEES, EVALUATION, femme, GROSSESSE, HOPITAL, METHODOLOGIE, MORTALITE, OBSTETRIQUE, QUALITE, RECOMMANDATIONS, SANTE DE LA REPRODUCTION, SOINS DE SANTE PRIMAIRES, SOURCE D'INFORMATION.

  • Dortonne J.R. et Dumont Alexandre (2014) « Collecter les informations », in Audit des décès maternels dans les établissements de santé : guide de mise en oeuvre, éd. par Alexandre Dumont, M. Traoré, et J.R. Dortonne, Marseille : IRD, p. 43-51. (Didactiques). ISBN : 9782709918.
    Mots-clés : accouchement, AUDIT, CAUSE DE DECES, CENTRE DE SANTE, ENQUETE, ENTRETIEN, EVALUATION, femme, GROSSESSE, HOPITAL, METHODOLOGIE, MORTALITE, OBSTETRIQUE, PERSONNEL DE SANTE, QUALITE, RECOMMANDATIONS, SANTE DE LA REPRODUCTION, SOINS DE SANTE PRIMAIRES.


  • Dossa Nissou I., Philibert Aline et Dumont Alexandre (2016) « Using routine health data and intermittent community surveys to assess the impact of maternal and neonatal health interventions in low-income countries: A systematic review », International Journal of Gynecology & Obstetrics, 135 (S1) (novembre), p. S64-S71. DOI : 10.1016/j.ijgo.2016.08.004. http://doi.wiley.com/10.1016/j.ijgo.2016.08.004.
  • Dumont Alexandre (2012) « Comment réduire la mortalité maternelle ? », Bulletin de l'Académie Nationale de Médecine, 196 (8), p. 1521-1534.
    Mots-clés : ACCES AUX SOINS, CENTRE DE SANTE, EFFICACITE, femme, FORMATION PROFESSIONNELLE, GROSSESSE, ITINERAIRE THERAPEUTIQUE, MORTALITE, OBSTETRIQUE, PAUVRETE, POLITIQUE DE SANTE, PRISE EN CHARGE MEDICALE, SANTE COMMUNAUTAIRE, SYSTEME D'INFORMATION.

  • Dumont Alexandre, Abrahamowicz M., Fournier P., Traoré M. et Fraser W. D. (2013) « Qualité des soins, gestion du risque et technologie obstétricale (QUARITE) : un essai contrôlé en grappe pour réduire la mortalité maternelle hospitalière au Sénégal et au Mali », in Santé publique et prévention : livre des résumés présentés au congrès, 61: p. S242-S243. DOI : 10.1016/j.respe.2013.07.132.
    Mots-clés : ENQUETE, femme, GROSSESSE, MORTALITE, PROTECTION MATERNELLE ET INFANTILE, SANTE PUBLIQUE, SERVICE DE MATERNITE.
  • Dumont Alexandre et Bouvier-Colle M. H. (2013) « Care assessment's difficult relation with maternal mortality », Lancet, 381 (9879), p. 1695-1696.

  • Dumont Alexandre (2014) « Historique, émergence des politiques d'audit », in Audit des décès maternels dans les établissements de santé : guide de mise en oeuvre, éd. par Alexandre Dumont, M. Traoré, et J.R. Dortonne, Marseille : IRD, p. 21-25. (Didactiques). ISBN : 9782709918.
    Mots-clés : accouchement, CENTRE DE SANTE, EVALUATION, femme, GROSSESSE, HISTOIRE, HOPITAL, METHODOLOGIE, OBSTETRIQUE, POLITIQUE DE SANTE, QUALITE, RECOMMANDATIONS, SANTE DE LA REPRODUCTION, SOINS DE SANTE PRIMAIRES.

  • Dumont Alexandre, Fournier P., Abrahamowicz M., Traoré M., Haddad S. et Fraser W. D. (2013) « Quality of care, risk management, and technology in obstetrics to reduce hospital-based maternal mortality in Senegal and Mali (QUARITE) : a cluster-randomised trial », The Lancet, 382 (9887), p. 146-157. DOI : 10.1016/S0140-6736(13)60593-0.
    Mots-clés : ACCES AUX SOINS, ANALYSE DE REGRESSION, ETUDE COMPARATIVE, femme, GROSSESSE, HOPITAL, INFRASTRUCTURE SANITAIRE, MORTALITE, MORTALITE MATERNELLE, NAISSANCE, OBSTETRIQUE, PERSONNEL DE SANTE, POLITIQUE DE SANTE, PROTECTION MATERNELLE ET INFANTILE, QUALITE, QUALITE DES SOINS, SANTE DE LA REPRODUCTION, SERVICE DE MATERNITE, SYSTEME DE SANTE, URGENCE.

  • Dumont Alexandre et Fournier P. (2014) « Est-ce que c'est efficace ? », in Audit des décès maternels dans les établissements de santé : guide de mise en oeuvre, éd. par Alexandre Dumont, M. Traoré, et J.R. Dortonne, Marseille : IRD, p. 97-106. (Didactiques). ISBN : 9782709918.
    Mots-clés : accouchement, AUDIT, CENTRE DE SANTE, EFFICACITE, EVALUATION, femme, GROSSESSE, HOPITAL, METHODOLOGIE, MORTALITE, OBSTETRIQUE, QUALITE, RECOMMANDATIONS, SANTE DE LA REPRODUCTION, SOINS DE SANTE PRIMAIRES.

  • Dumont Alexandre, Gueye M., Sow A., Diop I., Konate M.K., Dambé P., Abrahamowicz M. et Fournier P. (2012) « Utilisation des données recueillies en routine pour évaluer l'activité des maternités au Mali et au Sénégal (essai QUARITE) », Revue d'Epidémiologie et de Santé Publique, 60 (6), p. 489-496. DOI : 10.1016/j.respe.2012.05.005.
    Mots-clés : DONNEES STATISTIQUES, EVALUATION, HOPITAL, PREVENTION SANITAIRE, PROTECTION MATERNELLE ET INFANTILE, SANTE DE LA REPRODUCTION, SERVICE DE MATERNITE, SYSTEME D'INFORMATION, SYSTEME DE SANTE.

  • Dumont Alexandre, Traoré M. et Dortonne J.R., ss la dir. de (2014) Audit des décès maternels dans les établissements de santé : guide de mise en oeuvre, Marseille : IRD. (Didactiques). ISBN : 9782709918.
    Résumé : Cet ouvrage propose des outils élaborés et testés dans le cadre du projet Quarité (Qualité des soins, gestion du risque et techniques obstétricales dans les pays en développement) pour mettre en oeoeuvre une revue systématique des décès maternels. En s&8217;appuyant sur des exemples concrets en Afrique, en France et au Royaume-Uni, et sur différentes expériences de terrain, il passe en revue les défis que soulève cette démarche. Ce guide est destiné aux cliniciens, gestionnaires et décideurs oeuvrant dans le domaine de la santé maternelle et néonatale pour améliorer la qualité des soins fournis aux femmes enceintes. Il présente les outils indispensables pour collecter et analyser les informations, élaborer des recommandations pertinentes, technologiquement adaptées et potentiellement efficaces pour réduire la mortalité maternelle.
    Mots-clés : accouchement, AUDIT, CENTRE DE SANTE, EVALUATION, femme, GROSSESSE, HOPITAL, METHODOLOGIE, MORTALITE, OBSTETRIQUE, QUALITE, RECOMMANDATIONS, SANTE DE LA REPRODUCTION, SOINS DE SANTE PRIMAIRES.

  • Dumont Alexandre et Traoré M. (2014) « Les différentes étapes pour la mise en oeuvre des audits de décès maternels », in Audit des décès maternels dans les établissements de santé : guide de mise en oeuvre, éd. par Alexandre Dumont, M. Traoré, et J.R. Dortonne, Marseille : IRD, p. 27-36. (Didactiques). ISBN : 9782709918.
    Mots-clés : accouchement, AUDIT, CENTRE DE SANTE, ENTRETIEN, EVALUATION, femme, FORMATION PROFESSIONNELLE, GROSSESSE, HOPITAL, METHODOLOGIE, MORTALITE, OBSTETRIQUE, PERSONNEL DE SANTE, QUALITE, RECHERCHE PLURIDISCIPLINAIRE, RECOMMANDATIONS, SANTE DE LA REPRODUCTION, SOINS DE SANTE PRIMAIRES, SURVEILLANCE SANITAIRE.

  • Faye A., Dumont Alexandre, Ndiaye P. et Fournier P. (2014) « Development of an instrument to evaluate intrapartum care quality in Senegal : evaluation quality care », International Journal for Quality in Health Care, 26 (2), p. 184-189. DOI : 10.1093/intqhc/mzu018.
    Résumé : To evaluate the reliability of direct observation for measuring intrapartum care and compare this method with clinical audits using objective criteria based on patients medical charts. Cross-sectional study, data collected by two independent evaluators. Hospital in Dakar, Senegal. Thirty consecutive intrapartum care episodes provided by midwives and the corresponding medical charts. The presence or absence of each of twelve criteria selected on the basis of national and international norms for monitoring of labour and delivery (six criteria) and the immediate postpartum period (six criteria). For direct observation, the labour and delivery mean quality scores ranged from 5.34 to 5.77. In contrast, for the chart-based method, the scores ranged from 0.32 to 0.45. For postpartum care evaluated only with direct observation, the scores were also high (5.215.65). For direct observation, inter-evaluator agreement was high: kappa coefficients varied from 0.78 to 0.93 depending on the criterion (total score ICC 0.74). For the chart-based method, inter-evaluator agreement was also high: 0.66 to 1 (total score ICC 0.72). Comparison of the two methods showed strong differences by items and subscores. Using direct observation, the quality of obstetric care was high for both the monitoring of labour and delivery and postpartum care. Both measurement instruments showed high reliability. The chart-based method underestimated the quality of care because of poor medical record documentation. Medical-record-based measurement may not be appropriate for the evaluation of the quality of obstetric care in Senegal and other low-income settings.
    Mots-clés : obstetric care, quality, reliability, Senegal.

  • Faye A., Fournier P., Diop I., Philibert A., Morestin F. et Dumont Alexandre (2013) « Developing a tool to measure satisfaction among health professionals in sub-Saharan Africa », Human Resources for Health, 11. DOI : 10.1186/1478-4491-11-30.
    Résumé : Background: In sub-Saharan Africa, lack of motivation and job dissatisfaction have been cited as causes of poor healthcare quality and outcomes. Measurement of health workers' satisfaction adapted to sub-Saharan African working conditions and cultures is a challenge. The objective of this study was to develop a valid and reliable instrument to measure satisfaction among health professionals in the sub-Saharan African context. Methods: A survey was conducted in Senegal and Mali in 2011 among 962 care providers (doctors, midwives, nurses and technicians) practicing in 46 hospitals (capital, regional and district). The participation rate was very high: 97% (937/962). After exploratory factor analysis (EFA), construct validity was assessed through confirmatory factor analysis (CFA). The discriminant validity of our subscales was evaluated by comparing the average variance extracted (AVE) for each of the constructs with the squared interconstruct correlation (SIC), and finally for criterion validity, each subscale was tested with two hypotheses. Two dimensions of reliability were assessed: internal consistency with Cronbach's alpha subscales and stability over time using a test-retest process. Results: Eight dimensions of satisfaction encompassing 24 items were identified and validated using a process that combined psychometric analyses and expert opinions: continuing education, salary and benefits, management style, tasks, work environment, workload, moral satisfaction and job stability. All eight dimensions demonstrated significant discriminant validity. The final model showed good performance, with a root mean square error of approximation (RMSEA) of 0.0508 (90% CI: 0.0448 to 0.0569) and a comparative fit index (CFI) of 0.9415. The concurrent criterion validity of the eight dimensions was good. Reliability was assessed based on internal consistency, which was good for all dimensions but one (moral satisfaction < 0.70). Test-retest showed satisfactory temporal stability (intra class coefficient range: 0.60 to 0.91). Conclusions: Job satisfaction is a complex construct; this study provides a multidimensional instrument whose content, construct and criterion validities were verified to ensure its suitability for the sub-Saharan African context. When using these subscales in further studies, the variability of the reliability of the subscales should be taken in to account for calculating the sample sizes. The instrument will be useful in evaluative studies which will help guide interventions aimed at improving both the quality of care and its effectiveness.
    Mots-clés : Health workers, Job satisfaction, Measurement, sub-Saharan Africa.

  • Fournier P., Dumont Alexandre, Tourigny C., Philibert A., Coulibaly A. et Traore M. (2014) « The free caesareans policy in low-income settings : an interrupted time series analysis in Mali (2003-2012) », Plos One, 9 (8). DOI : 10.1371/journal.pone.0105130.
    Résumé : Introduction: Several countries have instituted fee exemptions for caesareans to reduce maternal and newborn mortality. Objectives: To evaluate the effect of fee exemptions for caesareans on population caesarean rates taking into account different levels of accessibility. Methods: The observation period was from January 2003 to May 2012 in one Region and covered 11.7 million person-years. Exemption fees for caesareans were adopted on June 26, 2005. Data were obtained from a registration system implemented in 2003 that tracks all obstetrical emergencies and interventions including caesareans. The pre-intervention period was 30 months and the post-intervention period was 83 months. We used an interrupted time series to evaluate the trend before and after the policy adoption and the overall tendency. Findings: During the study period, the caesarean rate increased from 0.25 to 1.5% for the entire population. For women living in cities with district hospitals that provided caesareans, the rate increased from 1.7% before the policy was enforced to 5.7% 83 months later. No significant change in trends was observed among women living in villages with a healthcare centre or those in villages with no healthcare facility. For the latter, the caesarean rate increased from 0.4 to 1%. Conclusions: After nine years of implementation policy in Mali, the caesarean rate achieved in cities with a district hospital reached the full beneficial effect of this measure, whereas for women living elsewhere this policy did not increase the caesarean rate to a level that could contribute effectively to reduce their risk of maternal death. Only universal access to this essential intervention could reduce the inequities and increase the effectiveness of this policy.

  • Huchon C., Arsenault C., Tourigny C., Coulibaly A., Traore M., Dumont Alexandre et Fournier P. (2014) « Obstetric competence among referral healthcare providers in Mali », International Journal of Gynecology and Obstetrics, 126 (1), p. 56-59. DOI : 10.1016/j.ijgo.2014.01.014.
    Résumé : Objective: To determine the factors associated with obstetric competency and clinical practice among obstetric care providers in referral health centers in Mali. Methods: The present cross-sectional study was conducted between March and May 2012 among 140 obstetric care providers (obstetric nurses, midwives, and physicians) working in referral health centers in Mali. Emergency obstetric care knowledge and skills were evaluated with clinical vignettes developed using national Malian guidelines. The vignettes covered 5 areas of emergency obstetric care, and the results were used to generate a competency score. A backward stepwise random-effects model using a maximum likelihood estimator was applied to evaluate variables independently associated with competency score. Results: Out of 100, the mean +/- SD score was 57.8 +/- 11.2 for obstetric nurses, 66.4 +/- 14.7 for midwifes, and 78.6 +/- 13.4 for physicians (P < 0.001). Three variables were significantly associated with a higher competency score: professional qualification, working in an urban setting, and working in a health center with a smaller number of obstetric care providers. Conclusion: Increasing the in-service training of both rural staff and lower-level healthcare workers working in larger health centers via facility-based maternal death reviews might help to improve clinical practice and maternal health outcomes.
    Mots-clés : Clinical vignette, Emergency obstetric care, Obstetric knowledge, Referral care, sub-Saharan Africa.

  • Huchon C., Dumont Alexandre, Chantry A. A., Falissard B. et Fauconnier A. (2014) « Triage using a self-assessment questionnaire to detect potentially life-threatening emergencies in gynecology », World Journal of Emergency Surgery, 9. DOI : 10.1186/1749-7922-9-46.
    Résumé : Objective: Acute pelvic pain is a common reason for emergency room visits that can indicate a potentially life-threatening emergency (PLTE). Our objective here was to develop a triage process for PLTE based on a self-assessment questionnaire for gynecologic emergencies (SAQ-GE) in patients experiencing acute pelvic pain. Methods: In this multicenter prospective observational study, all gynecological emergency room patients seen for acute pelvic pain between September 2006 and April 2008 completed the SAQ-GE after receiving appropriate analgesics. Diagnostic procedures were ordered without knowledge of questionnaire replies. Laparoscopy was the reference standard for diagnosing PLTE; other diagnoses were based on algorithms. In two-thirds of the population, SAQ-GE items significantly associated with PLTEs (P < 0.05) by univariate analysis were used to develop a decision tree by recursive partitioning; the remaining third served for validation. Results: Of 344 derivation-set patients and 172 validation-set patients, 96 and 49 had PLTEs, respectively. Items significantly associated with PLTEs were vomiting, sudden onset of pain, and pain to palpation. Sensitivity of the decision tree based on these three features was 87.5% (95% confidence interval (95% CI), 81%-94%) in the derivation set and 83.7% in the validation set. Derivation of the decision tree provided probabilities of PLTE of 13% (95% CI, 6%-19%) in the low-risk group, 27% (95% CI, 20%-33%) in the intermediate-risk group and 62% (95% CI, 48%-76%) in the high-risk group, ruling out PLTE with a specificity of 92.3%; (95% CI, 89%-96%). In the validation dataset, PLTE probabilities were 16.3% in the low-risk group, 30.6% in the intermediate-risk group, and 44% in the high-risk group, ruling out the diagnosis of PLTE with a specificity of 88.6%. Conclusion: A simple triage model based on a standardized questionnaire may assist in the early identification of patients with PLTEs among patients seen in the gynecology emergency room for acute pelvic pain.
    Mots-clés : Gynecologic emergencies, QUESTIONNAIRE, Sensitivity, Triage.

  • Huchon C., Dumont Alexandre, Traore M., Abrahamowicz M., Fauconnier A., Fraser W. D. et Fournier P. (2013) « A prediction score for maternal mortality in Senegal and Mali », Obstetrics and Gynecology, 121 (5), p. 1049-1056. DOI : 10.1097/AOG.0b013e31828b33a4.
    Résumé : OBJECTIVE: To develop and validate a maternal mortality score to identify patients at risk of in-hospital death in developing countries. METHODS: We performed a prospective observational study in 46 referral hospitals in Senegal and Mali, starting October 1, 2007. Derivation of a maternal mortality score was performed, using generalized estimating equation, on patients included during the first 6 months of the study (301 deaths out of 43,624 deliveries) and validated on patients included during the next 6 months (345 deaths out of 46,328 deliveries). RESULTS: Nine criteria were independently associated with maternal death: severe anemia in pregnancy, malaria diagnosed during pregnancy, parity greater than 4, fewer than three antenatal visits, referral from another health facility, antepartum or postpartum hemorrhage, preeclampsia or eclampsia, uterine rupture, and genital infection or sepsis. The maternal mortality score, ranging from 0 to 100, occupies an area under the receiver operating characteristics curve of 0.89 (95% confidence interval [CI] 0.87-0.91). The low-risk group for maternal mortality, based on a score less than 10, has a negative predictive value of 99.9% (95% CI 99.8-99.9) and a negative likelihood ratio of 0.18, ruling out maternal mortality with a probability of 0.13% (95% CI 0.09-0.17). Sensitivity of the score to identify patients at risk of in-hospital death was 85.0% (95% CI 80.5-88.8). Validation of the score yielded a sensitivity of 87.8% (95% CI 83.9-91.1), a negative predictive value of 99.9% (95% CI 99.8-99.9), and a probability of maternal death of 0.12% (95% CI 0.08-0.17) in the low-risk group. CONCLUSION: The maternal mortality score could help health care professionals to identify patients at risk of maternal mortality who need careful management.


  • Kaboré Charles, Ridde Valéry, Kouanda Séni, Queuille Ludovic, Somé Paul-André, Agier Isabelle et Dumont Alexandre (2016) « DECIDE: a cluster randomized controlled trial to reduce non-medically indicated caesareans in Burkina Faso », BMC Pregnancy and Childbirth, 16 (1). DOI : 10.1186/s12884-016-1112-8. http://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-016-1112-8.

  • Kouanda S., Coulibaly A., Ouedraogo A., Millogo T., Meda B. I. et Dumont Alexandre (2014) « Audit of cesarean delivery in Burkina Faso », International Journal of Gynecology and Obstetrics, 125 (3), p. 214-218. DOI : 10.1016/j.ijgo.2013.11.010.
    Résumé : Objective: To assess the level and determinants of unnecessary cesarean delivery. Methods: In a retrospective study, the medical charts were reviewed for 300 low-risk women who underwent intrapartum cesarean delivery at 10 referral hospitals in Burkina Faso between May 2009 and April 2010. In this context, cesarean deliveries were delegated to clinical officers who have less training than doctors. Results: Among the 300 study patients, 223 women (743%) were referred from primary healthcare facilities. The reason for referral was not medically justified for 35 women. Cesarean was performed by a gynecologist-obstetrician (46.0%), a trained doctor (35.0%), or a clinical officer (19.0%). Acute fetal distress and fetopelvic disproportion were the main indications recorded for intrapartum cesarean delivery. These diagnoses were not confirmed by an obstetrician-gynecologist in 12.0% of cases. Clinical officers were associated with a higher risk of unnecessary cesarean delivery compared with gynecologist-obstetricians by multivariate analysis (odds ratio, 4.46; 95% confidence interval, 1.44-13.77; P = 0.009). Conclusion: Verification of cesarean indications by highly qualified personnel (i.e. second opinion), in-service training, and supervision of health workers in primary healthcare facilities might improve the performance of the referral system and help to reduce unnecessary cesarean deliveries in Burkina Faso.
    Mots-clés : Low-resource settings, Task shifting, Unnecessary cesarean delivery.


  • Kouanda Seni, Kabra Rita et Dumont Alexandre (2016) « Maternal and neonatal health in Africa at MDG end: Availability of and access to maternal health services, and outcomes of intervention strategies », International Journal of Gynecology & Obstetrics, 135 (S1) (novembre), p. S1-S1. DOI : 10.1016/j.ijgo.2016.09.001. http://doi.wiley.com/10.1016/j.ijgo.2016.09.001.

  • McLean Pirkle C., Dumont Alexandre, Traore M. et Zunzunegui M. V. (2014) « Training and nutritional components of PMTCT programmes associated with improved intrapartum quality of care in Mali and Senegal », International Journal for Quality in Health Care, 26 (2), p. 174-183. DOI : 10.1093/intqhc/mzu013.
    Résumé : Scale-up of prevention of mother-to-child transmission (PMTCT) of HIV programmes in sub-Saharan Africa has stimulated interest to assess whether these programmes can indirectly affect other health priorities. This study assesses whether PMTCT programmes, or components of these programmes, are associated with better obstetrical quality of care and how PMTCT may reinforce existing maternal health programmes. Cross-sectional analysis of data from a cluster-randomized trial called QUARITE. Mali and Senegal, West Africa. Thirty-one referral hospitals and 612 obstetrical patients. The exposure of interest was PMTCT measured with a scale containing 10 components describing different prongs of a hospital PMTCT programme. Other variables of interest included: presence of a quality of care improvement programme, hospital resources and patient demographic characteristics. Obstetrical quality of care measured through a validated chart abstraction tool. Of 45 points, the mean hospital PMTCT score was 26.1 (SD: 6.7). Total PMTCT score was not significantly associated with quality of care, but programme component scores were. After adjustment for known predictors of quality of care, staff training in PMTCT (P 0.03) and complementary nutritional services (P 0.03) were significantly associated with better quality obstetrical care. A point increase in scores for either of these components was associated with 40 greater odds of good obstetrical care. PMTCT training and nutritional components are significantly associated with better quality intrapartum care. Health professionals training in maternal healthcare and PMTCT could be combined to improve the quality of obstetric care in the region.
    Mots-clés : health systems, Maternal health, Obstetrics, PMTCT, quality of care, West Africa.

  • Ndour C., Dossou Gbété S., Bru N., Abrahamowicz M., Fauconnier A., Traoré M., Diop A., Fournier P. et Dumont Alexandre (2013) « Predicting in-hospital maternal mortality in Senegal and Mali », Plos One, 8 (5). DOI : 10.1371/journal.pone.0064157.
    Mots-clés : ANALYSE STATISTIQUE, CLASSIFICATION, FACTEUR DE RISQUE, femme, GROSSESSE, HOPITAL, MORTALITE, OBSTETRIQUE, PERSONNEL DE SANTE, PREVENTION SANITAIRE, PROTECTION MATERNELLE ET INFANTILE.


  • Philibert Aline, Ravit Marion, Ridde Valéry, Dossa Inès, Bonnet Emmanuel, Bedecarrats Florent et Dumont Alexandre (2016) « Maternal and neonatal health impact of obstetrical risk insurance scheme in Mauritania: a quasi experimental before-and-after study », Health Policy and Planning (octobre 22), p. 13. DOI : 10.1093/heapol/czw142. https://academic.oup.com/heapol/article-lookup/doi/10.1093/heapol/czw142.

  • Pirkle C. M., Dumont Alexandre, Traore M. et Zunzunegui M. V. (2013) « Effect of a facility-based multifaceted intervention on the quality of obstetrical care : a cluster randomized controlled trial in Mali and Senegal », Bmc Pregnancy and Childbirth, 13. DOI : 10.1186/1471-2393-13-24.
    Résumé : Background: Maternal mortality in referral hospitals in Mali and Senegal surpasses 1% of obstetrical admissions. Poor quality obstetrical care contributes to high maternal mortality; however, poor care is often linked to insufficient hospital resources. One promising method to improve obstetrical care is maternal death review. With a cluster randomized trial, we assessed whether an intervention, based on maternal death review, could improve obstetrical quality of care. Methods: The trial began with a pre-intervention year (2007), followed by two years of intervention activities and a post-intervention year. We measured obstetrical quality of care in the post-intervention year using a criterion-based clinical audit (CBCA). We collected data from 32 of the 46 trial hospitals (16 in each trial arm) and included 658 patients admitted to the maternity unit with a trial of labour. The CBCA questionnaire measured 5 dimensions of care-patient history, clinical examination, laboratory examination, delivery care and postpartum monitoring. We used adjusted mixed models to evaluate differences in CBCA scores by trial arms and examined how levels of hospital human and material resources affect quality of care differences associated with the intervention. Results: For all women, the mean percentage of care criteria met was 66.3 (SD 13.5). There were significantly greater mean CBCA scores in women treated at intervention hospitals (68.2) compared to control hospitals (64.5). After adjustment, women treated at intervention sites had 5 points' greater scores than those at control sites. This difference was mostly attributable to greater clinical examination and post-partum monitoring scores. The association between the intervention and quality of care was the same, irrespective of the level of resources available to a hospital; however, as resources increased, so did quality of care scores in both arms of the trial. Conclusions: Patients treated at hospitals with maternal death review had greater CBCA scores suggesting that the intervention improves quality of care. Results indicate that the intervention mostly improves clinical examination at admission and post-partum monitoring. They also indicate that quality of care scores can be maximized by increasing the availability of human and material resources to hospitals in the region.
    Mots-clés : Criterion based clinical audit, Maternal death review, Obstetrics, quality of care, West Africa.

  • Pirkle C. M., Dumont Alexandre, Traore M. et Zunzunegui M. V. (2012) « Validity and reliability of criterion based clinical audit to assess obstetrical quality of care in West Africa », Bmc Pregnancy and Childbirth, 12. DOI : 10.1186/1471-2393-12-118.
    Résumé : Background: In Mali and Senegal, over 1% of women die giving birth in hospital. At some hospitals, over a third of infants are stillborn. Many deaths are due to substandard medical practices. Criterion-based clinical audits (CBCA) are increasingly used to measure and improve obstetrical care in resource-limited settings, but their measurement properties have not been formally evaluated. In 2011, we published a systematic review of obstetrical CBCA highlighting insufficient considerations of validity and reliability. The objective of this study is to develop an obstetrical CBCA adapted to the West African context and assess its reliability and validity. This work was conducted as a sub-study within a cluster randomized trial known as QUARITE. Methods: Criteria were selected based on extensive literature review and expert opinion. Early 2010, two auditors applied the CBCA to identical samples at 8 sites in Mali and Senegal (n = 185) to evaluate inter-rater reliability. In 2010-11, we conducted CBCA at 32 hospitals to assess construct validity (n = 633 patients). We correlated hospital characteristics (resource availability, facility perinatal and maternal mortality) with mean hospital CBCA scores. We used generalized estimating equations to assess whether patient CBCA scores were associated with perinatal mortality. Results: Results demonstrate substantial (ICC = 0.67, 95% CI 0.54; 0.76) to elevated inter-rater reliability (ICC = 0.84, 95% CI 0.77; 0.89) in Senegal and Mali, respectively. Resource availability positively correlated with mean hospital CBCA scores and maternal and perinatal mortality were inversely correlated with hospital CBCA scores. Poor CBCA scores, adjusted for hospital and patient characteristics, were significantly associated with perinatal mortality (OR 1.84, 95% CI 1.01-3.34). Conclusion: Our CBCA has substantial inter-rater reliability and there is compelling evidence of its validity as the tool performs according to theory.
    Mots-clés : Criterion-based clinical audit, quality of care, Questionnaire development, reliability, resource-limited settings, Validity.

  • Pirkle C. M., Dumont Alexandre et Zunzunegui M. V. (2012) « Medical recordkeeping, essential but overlooked aspect of quality of care in resource-limited settings », International Journal for Quality in Health Care, 24 (6), p. 564-567. DOI : 10.1093/intqhc/mzs034.
    Résumé : Medical recordkeeping is essential to assuring quality health care. Records aid in the medical management of patients while serving epidemiological purposes. Medical recordkeeping is often inadequate in resource-limited settings, which threatens the quality of health care. In this study, by way of example, we make the case for increased attention to medical recordkeeping by illustrating how poor charting and archiving can threaten the quality of care. We make suggestions to improve the adequacy of medical recordkeeping by emphasizing recent technological innovations applied to resource-limited settings and the need to instil a culture of recordkeeping.
    Mots-clés : hospital care, medical recordkeeping, Quality improvement, resource-limited settings.

  • Polena V., Huchon C., Ramos C. V., Rouzier R., Dumont Alexandre et Fauconnier A. (2015) « Non-invasive tools for the diagnosis of potentially life-threatening gynaecological emergencies : a systematic review », Plos One, 10 (2). DOI : 10.1371/journal.pone.0114189.
    Résumé : Objective To identify non- invasive tools for diagnosis of the major potentially life-threatening gynaecological emergencies (G-PLEs) reported in previous studies, and to assess their diagnostic accuracy. Methods MEDLINE; EMBASE; Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library) were searched to identify all eligible studies published in English or French between January 1990 and December 2012. Studies were considered eligible if they were primary diagnostic studies of any designs, with a gold standard and with sufficient information for construction of a 2 x 2 contingency table, concerning at least one of the following G-PLEs: complicated ectopic pregnancy, complicated pelvic inflammatory disease, adnexal torsion and haemoperitoneum of any gynaecological origin. Extraction of data and assessment of study quality were conducted by two independent reviewers. We set the thresholds for the diagnostic value of signs retrieved at Sensibility >= 95% and LR- <= 0.25, or Specificity >= 90% and LR+ >= 4. Results We identified 8288 reports of diagnostic studies for the selected G-PLEs, 45 of which met the inclusion criteria. The methodological quality of the included studies was generally low. The most common diagnostic tools evaluated were transvaginal ultrasound (20/45), followed by medical history (18/45), clinical examination (15/45) and laboratory tests (14/45). Standardised questioning about symptoms, systolic blood pressure < 110 mmHg, shock index>0.85, identification of a mass by abdominal palpation or vaginal examination, haemoglobin concentration < 10 g/dl and six ultrasound and Doppler signs presented high performances for the diagnosis of G-PLEs. Transvaginal ultrasound was the diagnostic tool with the best individual performance for the diagnosis of all G-PLEs. Conclusion This systematic review suggests that blood pressure measurement, haemoglobin tests and transvaginal ultrasound are cornerstone examinations for the diagnosis of G-PLEs that should be available in all gynaecological emergency care services. Standardised questioning about symptoms could be used for triage of patients.

  • Popowski T., Huchon C., Fathallah K., Falissard B., Dumont Alexandre et Fauconnier A. (2015) « Impact of accreditation training for residents on sonographic quality in gynecologic emergencies », Journal of Ultrasound in Medicine, 34 (5), p. 829-835. DOI : 10.7863/ultra.34.5.829.
    Résumé : Objectives-To assess the impact of an educational intervention based on an original accreditation training program on the quality of emergency sonography performed by obstetrics and gynecology (Ob/Gyn) residents. Methods-We conducted a prospective before-after study on residents who performed bedside standardized sonographic examinations as first-line investigations in patients seen at our gynecologic emergency department. In both periods, the residents followed a 1-hour class taught by a board-certified Ob/Gyn sonography expert (opinion leader) and received a written standardized imaging protocol. An accreditation training process was implemented for the new residents at the beginning of the second period: 5 complete sonographic examinations were required for each resident, and facilitated feedback from the opinion leader was performed using a dedicated sonographic quality score. During both periods, all consecutive sonograms were collected and stored. The primary outcome was the sonographic quality score. A mixed model for repeated measures was used to compare scores in both periods from 20 consecutive sonographic examinations performed by 5 residents who were different in each period. Results-The mixed model analysis showed an increase in quality scores in the post-accreditation training compared to the pre-accreditation training period (estimated coefficient +/- SD, 4.13 +/- 0.51; t = 8.16). The sonographic examination order also had a significant effect in both periods (estimated coefficient +/- SD, 0.11 +/- 0.03; t = 3.99). Conclusions-An accreditation training process including facilitated feedback from a local opinion leader improved the quality of sonographic examinations performed by Ob/Gyn residents in women presenting to a gynecologic emergency department.
    Mots-clés : accreditation, gynecologic emergency, residency training, sonography, ultrasound education.

  • Ramanah R., Dumont Alexandre, Schepens F., Traore M., Gaye A., Schaal J. P., Riethmuller D. et Rude N. (2014) « Satisfaction des soins obstétricaux : élaboration et validation d'une échelle de mesure de la qualité des soins = Satisfaction with obstetrical care : development and validation of a scale on quality of care », Gynécologie Obstétrique et Fertilité, 42 (7-8), p. 477-482. DOI : 10.1016/j.gyobfe.2014.05.002.
    Résumé : Objectives. - To develop and validate a subjective and multidimensional scale to measure satisfaction in obstetrical care (SSO) during labour, delivery and two hours postpartum, which is relevant to the French-speaking context. Patients et methods. - Forty partially directed patient interviews during the 48 hours after delivery and four care-giver interviews were conducted to build up the questionnaire. After a prior feasibility study on 40 patients, the psychometric validity of the questionnaire was evaluated by calculating the Cronbach coefficient of reliability for 432 patients. Results. - Hundred and eighty items were initially obtained after content analysis of the patient interviews. Expert meetings finally selected 49 items classified within 5 dimensions. The feasibility study showed that the questionnaire was easily accepted and understood with a mean time of 15 minutes to answer it. Cronbach coefficients were respectively at 0.941, 0.949, 0.808, 0.814 et 0.869 for the 5 dimensions. Discussion and conclusion. - SSO questionnaire is a reliable and relevant scale to measure immediate postpartum quality of care in French.
    Mots-clés : Immediate postpartum, Obstetric, Psychometric validation, QUESTIONNAIRE, Satisfaction in care.

  • Ravit Marion, Philibert A., Tourigny C., Traore M., Coulibaly A., Dumont Alexandre et Fournier P. (2015) « The hidden costs of a free caesarean section policy in West Africa (Kayes region, Mali) », Maternal and Child Health Journal, 19 (8), p. 1734-1743. DOI : 10.1007/s10995-015-1687-0.
    Résumé : The fee exemption policy for EmONC in Mali aims to lower the financial barrier to care. The objective of the study was to evaluate the direct and indirect expenses associated with caesarean interventions performed in EmONC and the factors associated with these expenses. Data sampling followed the case control approach used in the large project (deceased and near-miss women). Our sample consisted of a total of 190 women who underwent caesarean interventions. Data were collected from the health workers and with a social approach by administering questionnaires to the persons who accompanied the woman. Household socioeconomic status was assessed using a wealth index constructed with a principal component analysis. The factors significantly associated with expenses were determined using multivariate linear regression analyses. Women in the Kayes region spent on average 77,017 FCFA (163 USD) for a caesarean episode in EmONC, of which 70 % was for treatment. Despite the caesarean fee exemption, 91 % of the women still paid for their treatment. The largest treatment-related direct expenses were for prescriptions, transfusion, antibiotics, and antihypertensive medication. Near-misses, women who presented a hemorrhage or an infection, and/or women living in rural areas spent significantly more than the others. Although abolishing fees of EmONC in Mali plays an important role in reducing maternal death by increasing access to caesarean sections, this paper shows that the fee policy did not benefit to all women. There are still barriers to EmONC access for women of the lowest socio-economic group. These included direct expenses for drugs prescription, treatment and indirect expenses for transport and food.
    Mots-clés : caesarean section, EmONC, Expenses of care, Fee exemption, Maternal health, West Africa.

  • Rouleau D., Fournier P., Philibert A., Mbengue B. et Dumont Alexandre (2012) « The effects of midwives' job satisfaction on burnout, intention to quit and turnover : a longitudinal study in Senegal », Human Resources for Health, 10. DOI : 10.1186/1478-4491-10-9.
    Résumé : Background: Despite working in a challenging environment plagued by persistent personnel shortages, public sector midwives in Senegal play a key role in tackling maternal mortality. A better understanding of how they are experiencing their work and how it is affecting them is needed in order to better address their needs and incite them to remain in their posts. This study aims to explore their job satisfaction and its effects on their burnout, intention to quit and professional mobility. Methods: A cohort of 226 midwives from 22 hospitals across Senegal participated in this longitudinal study. Their job satisfaction was measured from December 2007 to February 2008 using a multifaceted instrument developed in West Africa. Three expected effects were measured two years later: burnout, intention to quit and turnover. Descriptive statistics were reported for the midwives who stayed and left their posts during the study period. A series of multiple regressions investigated the correlations between the nine facets of job satisfaction and each effect variable, while controlling for individual and institutional characteristics. Results: Despite nearly two thirds (58.9%) of midwives reporting the intention to quit within a year (mainly to pursue new professional training), only 9% annual turnover was found in the study (41/226 over 2 years). Departures were largely voluntary (92%) and entirely domestic. Overall the midwives reported themselves moderately satisfied; least contented with their "remuneration" and "work environment" and most satisfied with the "morale" and "job security" facets of their work. On the three dimensions of the Maslach Burnout Inventory, very high levels of emotional exhaustion (80.0%) and depersonalization (57.8%) were reported, while levels of diminished personal accomplishment were low (12.4%). Burnout was identified in more than half of the sample (55%). Experiencing emotional exhaustion was inversely associated with "remuneration" and "task" satisfaction, actively job searching was associated with being dissatisfied with job "security" and voluntary quitting was associated with dissatisfaction with "continuing education". Conclusions: This study found that although midwives seem to be experiencing burnout and unhappiness with their working conditions, they retain a strong sense of confidence and accomplishment in their work. It also suggests that strategies to retain them in their positions and in the profession should emphasize continuing education.


  • Souza Jp, Betran Ap, Dumont Alexandre, de Mucio B., Gibbs Pickens Cm, Deneux-Tharaux Catherine, Ortiz-Panozo E, Sullivan E, Ota E, Togoobaatar G, Carroli G, Knight H, Zhang J, Cecatti Jg, Vogel Jp, Jayaratne K, Leal Mc, Gissler M, Morisaki N, Lack N, Oladapo Ot, Tunçalp ö, Lumbiganon P, Mori R, Quintana S, Costa Passos Ad, Marcolin Ac, Zongo A., Blondel B, Hernández B, Hogue Cj, Prunet C, Landman C, Ochir C, Cuesta C, Pileggi-Castro C, Walker D, Alves D, Abalos E, Moises Ecd, Vieira Em, Duarte G, Perdona G, Gurol-Urganci I, Takahiko K, Moscovici L, Campodonico L, Oliveira-Ciabati L, Laopaiboon M, Danansuriya M, Nakamura-Pereira M, Costa Ml, Torloni Mr, Kramer Mr, Borges P, Olkhanud Pb, Pérez-Cuevas R., Agampodi Sb., Mittal S., Serruya S., Bataglia V., Li Z., Temmerman M. et Gülmezoglu Am (2016) « A global reference for caesarean section rates (C-Model): a multicountry cross-sectional study », BJOG: An International Journal of Obstetrics & Gynaecology, 123 (3), p. 427-436. DOI : 10.1111/1471-0528.13509. http://doi.wiley.com/10.1111/1471-0528.13509.

  • Toret-Labeeuw F., Huchon C., Popowski T., Chantry A. A., Dumont Alexandre et Fauconnier A. (2013) « Routine ultrasound examination by OB/GYN residents increase the accuracy of diagnosis for emergency surgery in gynecology », World Journal of Emergency Surgery, 8. DOI : 10.1186/1749-7922-8-16.
    Résumé : Introduction: Diagnostic accuracy of first-line sonographic evaluation by obstetrics/gynecology residents in determining the need for emergency surgery in women with acute pelvic pain is unknown. Aim of this study was to evaluate the diagnostic accuracy of routine ultrasound evaluation by obstetrics/gynecology residents, available 24 hours a day, in patients with acute pelvic pain. Methods: A cross-sectional retrospective study included consecutive patients who underwent emergency laparoscopy for acute pelvic pain at a teaching hospital gynecologic emergency unit, between January 1, 2004, and December 31, 2006. The laparoscopic diagnosis was the reference standard. Gynecologic and nongynecologic conditions requiring immediate surgery to avoid severe morbidity or death were defined as surgical emergencies. In all patients, obstetrics/gynecology residents routinely performed clinical examination and standardized ultrasonography was routinely recorded. Sonograms were re-interpreted for the study, blinded to physical examination and laparoscopic findings, according to evidence-based predetermined criteria. Sensitivity, specificity, and likelihood ratios were computed for clinical data alone, sonographic data alone, and the combination of both. Results: Emergency laparoscopy was performed in 234 patients, diagnosing 139 (59%) surgical emergencies. Clinical and sonographic examinations performed by the residents each independently predicted a need for emergency surgery. Combining both examinations was superior over each examination alone and had an acceptable false-negative rate of 1%. Conclusions: First-line combined clinical and sonographic examination by obstetrics/gynecology residents is effective in ruling out surgical emergencies in patients with acute pelvic pain.
    Mots-clés : Acute pelvic pain, gynecologic emergency, Laparoscopy, Physical examination, Sensitivity, Specificity, Ultrasonography.

  • Tort J., Rozenberg P., Traore M., Fournier P. et Dumont Alexandre (2015) « Factors associated with postpartum hemorrhage maternal death in referral hospitals in Senegal and Mali : a cross-sectional epidemiological survey », Bmc Pregnancy and Childbirth, 15. DOI : 10.1186/s12884-015-0669-y.
    Résumé : Background: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in Sub-Saharan-Africa (SSA). Although clinical guidelines treating PPH are available, their implementation remains a great challenge in resource poor settings. A better understanding of the factors associated with PPH maternal mortality is critical for preventing risk of hospital-based maternal death. The purpose of this study was thus to assess which factors contribute to maternal death occurring during PPH. The factors were as follows: women's characteristics, aspects of pregnancy and delivery; components of PPH management; and organizational characteristics of the referral hospitals in Senegal and Mali. Methods: A cross-sectional survey nested in a cluster randomized trial (QUARITE trial) was carried out in 46 referral hospitals during the pre-intervention period from October 2007 to September 2008 in Senegal and Mali. Individual and hospital characteristics data were collected through standardized questionnaires. A multivariable logistic mixed model was used to identify the factors that were significantly associated with PPH maternal death. Results: Among the 3,278 women who experienced PPH, 178 (5.4 %) of them died before hospital discharge. The factors that were significantly associated with PPH maternal mortality were: age over 35 years (adjusted OR = 2.16 [1.26-3.72]), living in Mali (adjusted OR = 1.84 [1.13-3.00]), residing outside the region location of the hospital (adjusted OR = 2.43 [1.29-4.56]), pre-existing chronic disease before pregnancy (adjusted OR = 7.54 [2.54-22.44]), prepartum severe anemia (adjusted OR = 6.65 [3.77-11.74]), forceps or vacuum delivery (adjusted OR = 2.63 [1.19-5.81]), birth weight greater than 4000 grs (adjusted OR = 2.54 [1.26-5.10]), transfusion (adjusted OR = 2.17 [1.53-3.09]), transfer to another hospital (adjusted OR = 13.35 [6.20-28.76]). There was a smaller risk of PPH maternal death in hospitals with gynecologist-obstetrician (adjusted OR = 0.55 [0.35-0.89]) than those with only a general practitioner trained in emergency obstetric care (EmOC). Conclusions: Our findings may have direct implications for preventing PPH maternal death in resource poor settings. In particular, we suggest anemia should be diagnosed and treated before delivery and inter-hospital transfer of women should be improved, as well as the management of blood banks for a quicker access to transfusion. Finally, an extent training of general practitioners in EmOC would contribute to the decrease of PPH maternal mortality.
    Mots-clés : Maternal mortality, Postpartum hemorrhage, sub-Saharan Africa.


  • Tort Julie, Traoré Mamadou, Hounkpatin Benjamin, Bodin Cécile, Rozenberg Patrick et Dumont Alexandre (2016) « Initial management of postpartum hemorrhage: A cohort study in Benin and Mali », International Journal of Gynecology & Obstetrics, 135 (S1) (novembre), p. S84-S88. DOI : 10.1016/j.ijgo.2016.08.016. http://doi.wiley.com/10.1016/j.ijgo.2016.08.016.

  • Traore M., Arsenault C., Schoemaker-Marcotte C., Coulibaly A., Huchon C., Dumont Alexandre et Fournier P. (2014) « Obstetric competence among primary healthcare workers in Mali », International Journal of Gynecology and Obstetrics, 126 (1), p. 50-55. DOI : 10.1016/j.ijgo.2014.01.012.
    Résumé : Objective: To determine individual and contextual factors associated with emergency obstetric and neonatal care (EmONC) competency among primary healthcare staff in Mali. Methods: Between November 2011 and April 2012, a competency test was administered to 196 healthcare workers in 65 community health centers in Mali. The test was scored from 0 to 100, and differences among 5 areas of EmONC were assessed. A multilevel linear regression model was used to determine individual and contextual factors associated with score. Results: The mean score was 66.7 (minimum, 15.9; maximum, 97.7). Knowledge was most deficient for postpartum infection and hypertensive complications. Type of health worker, years of experience, number of days absent, and availability of guidelines for management of obstetric complications within the health center were positively associated with test score (P < 0.05). Availability of guidelines was associated with higher competency of physicians, health technicians, and obstetric nurses (P < 0.001), and seemed to influence the competency of healthcare workers with fewer than 10 years of experience in particular. Conclusion: Guidelines must be developed that will facilitate standardization of the management of postpartum infection and other less common complications for which healthcare workers show low competence. Strategies to increase use of these guidelines will be necessary.
    Mots-clés : Clinical vignette, Emergency obstetric care, Obstetric knowledge, Primary healthcare, sub-Saharan Africa.

  • Traoré M. et Dumont Alexandre (2014) « Emettre des recommandations », in Audit des décès maternels dans les établissements de santé : guide de mise en oeuvre, éd. par Alexandre Dumont, M. Traoré, et J.R. Dortonne, Marseille : IRD, p. 61-67. (Didactiques). ISBN : 9782709918.
    Mots-clés : accouchement, AUDIT, CENTRE DE SANTE, EVALUATION, femme, GROSSESSE, HOPITAL, METHODOLOGIE, MORTALITE, OBSTETRIQUE, QUALITE, RECOMMANDATIONS, SANTE DE LA REPRODUCTION, SOINS DE SANTE PRIMAIRES.

  • Zongo A., Dumont Alexandre, Fournier P., Traore M., Kouanda S. et Sondo B. (2015) « Effect of maternal death reviews and training on maternal mortality among cesarean delivery : post-hoc analysis of a cluster-randomized controlled trial », European Journal of Obstetrics and Gynecology and Reproductive Biology, 185, p. 174-180. DOI : 10.1016/j.ejogrb.2014.12.023.
    Résumé : Objectives: To explore the differential effect of a multifaceted intervention on hospital-based maternal mortality between patients with cesarean and vaginal delivery in low-resource settings. Study design: We reanalyzed the data from a major cluster-randomized controlled trial, QUARITE (Quality of care, Risk management and technology in obstetrics). These subgroup analyses were not prespecified and were treated as exploratory. The intervention consisted of an initial interactive workshop and quarterly educational clinically oriented and evidence-based outreach visits focused on maternal death reviews (MDR) and best practices implementation. The trial originally recruited 191,167 patients who delivered in each of the 46 participating hospitals in Mali and Senegal, between 2007 and 2011. The primary endpoint was hospital-based maternal mortality. Subgroup-specific Odds Ratios (ORs) of maternal mortality were computed and tested for differential intervention effect using generalized linear mixed model between two subgroups (cesarean: 40,975; and vaginal delivery: 150,192). Results: The test for homogeneity of intervention effects on hospital-based maternal mortality among the two delivery mode subgroups was statistically significant (p-value: 0.0201). Compared to the control, the adjusted OR of maternal mortality was 0.71 (95% CI: 0.58-0.82, p = 0.0034) among women with cesarean delivery. The intervention had no significant effect among women with vaginal delivery (adjusted OR 0.87, 95% CI 0.69-1.11, p = 0.6213). This differential effect was particularly marked for district hospitals. Conclusion: Maternal deaths reviews and on-site training on emergency obstetric care may be more effective in reducing maternal mortality among high-risk women who need a cesarean section than among low-risk women with vaginal delivery.
    Mots-clés : Cesarean delivery, Emergency obstetric care, Maternal mortality, Quality improvement, sub-Saharan Africa.

  • Zongo A., Traoré M., Faye A., Gueye M., Fournier P. et Dumont Alexandre (2012) « Effet de l'organisation des services de gynéco-obstétrique sur la mortalité maternelle hospitalière au Mali », Revue d'Epidémiologie et de Santé Publique, 60 (4), p. 265-274. DOI : 10.1016/j.respe.2012.02.006.
    Résumé : Position du problème - La mortalité maternelle en Afrique subsaharienne, en particulier dans les hôpitaux de référence, reste très élevée. Les solutions sont connues mais leur mise en oeuvre dans des systèmes de santé fragiles et en développement représente un défi important tant sur le plan de la disponibilité des ressources que de l'organisation. L'objectif de cette étude est d'évaluer l'effet de l'organisation des services sur la mortalité des femmes qui accouchent dans les hôpitaux de référence au Mali. Méthodes - Une enquête épidémiologique multicentrique transversale à visée analytique a été réalisée dans 22 hôpitaux. Les données cliniques incluant le statut vital avant la sortie de 42 929 femmes qui ont accouché dans ces hôpitaux en 2007 à 2008 ont été collectées. L'organisation des services a été évaluée à partir de critères objectifs définis par un comité d'experts. Des modèles de régression logistique multiniveau ont été utilisés pour estimer l'effet de l'organisation des services sur la mortalité maternelle hospitalière, en tenant compte des caractéristiques des patientes et des hôpitaux. Résultats - Les résultats montrent qu'une organisation optimale des services de gynécologie-obstétrique, évaluée à partir de huit critères objectifs, réduit la mortalité maternelle hospitalière de 41 % par rapport à la mortalité des femmes qui accoucheraient dans des hôpitaux de référence au Mali dans lesquels un des huit critères ne serait pas respectés (RCa=0,59 ; IC à 95 %=0,34_0,92). Indépendamment de l'organisation des services, les mesures qui facilitent l_accessibilité financières aux soins obstétricaux ont un impact important sur le pronostic de ces femmes. Conclusion - Les critères d'une organisation optimale intègrent la gestion du travail et de l'accouchement par du personnel qualifié, une organisation du travail qui favorise la prise en charge rapide des urgences obstétricales et l'utilisation systématique du partogramme pour les accouchements et de protocoles standardisés pour la prise en charge des complications. Ce sont des dispositions applicables dans le contexte malien pour réduire la mortalité maternelle hospitalière.
    Mots-clés : Hospital-based maternal mortality, Mali, Mortalité maternelle-hôpital, Organisation des services, Organization of obstetric care services.
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