RAVIT Marion

Résumé : La Mauritanie a introduit en 2002 un système de prépaiement des soins de santé maternelle, le forfait obstétrical. L’objectif de cette étude est de savoir si le forfait améliore la qualité de l’accès et réduit les inégalités dans le recours aux soins obstétricaux. Les données sont celles de l’enquête ménages MICS-Mauritanie de 2015. Deux méthodes ont été utilisées. La première est la méthode des indices de concentration. La seconde est la méthode de décomposition des inégalités par fonction d’influence recentrée qui estime des effets marginaux en tenant compte des caractéristiques des individus. Le forfait obstétrical permet aux femmes enceintes d’accéder à des soins de meilleure qualité et contribue à la réduction des inégalités d’accès.

Résumé : Background. - Testing for high-risk human papilloma virus (HR-HPV) is an effective approach to the prevention of cervical cancer. This study in the Atsinanana area of Madagascar aimed to compare the management of women screened by visual inspection after coloration with acetic acid (VIA) and the management of women screened by HPV with VIA as a triage test. Method. - During the last two screening campaigns, the first patients (between 28 and 120 women par center) were sampled using a dry swab, just before the acetic acid application, to test 14 genotypes of HR-HPV using Roche Diagnostics Cobas (R) Test. We compared current management practices based on primary VIA to those that would have been implemented if the clinician had followed the recommendations of the World Health Organization for HPV-based primary screening. We used a regression Poisson model with random effect and robust variance. Results. - Among the 250 screened-women, 28 (11.2%) had acidophilic lesions of the uterine cervix or suspected lesions of invasive cancer (IVA +). The HPV test was positive in 62 cases (24.8%). The HPV-based screening strategy would have reduced by 52% the number of women needing thermocoagulation treatment: 24 women (9.6%) with primary VIA-based screening vs. 13 women (5.2%) with primary HPV-based screening; RR: 0.52 and 95%CI: 0.27-1.02. The diagnosis of severe dysplastic lesion or invasive cancer would not have changed. Conclusion. - Primary HPV-based screening is a strategy that could be useful for low-resource countries like Madagascar. It would reduce the rate of false positives and unnecessary treatments compared to the current strategy based on primary IVA. The questions of the feasibility and cost-benefit of this strategy should be further explored.

Résumé : En Afrique Sub-Saharienne, seules 3% des femmes accouchent par césarienne, ce qui est bien en-dessous du taux minimum de 5% recommandé pour couvrir tous les besoins obstétricaux. En plus d’être insuffisant, l’accès à la césarienne dans cette sous-région est inégal puisque ce sont les femmes les plus riches et celles qui vivent en milieu urbain qui en bénéficient le plus. Le Mali et le Bénin ont introduit une politique de gratuité ciblant les césariennes, respectivement en 2005 et 2009. Les femmes enceintes continuent à payer pour se faire soigner, mais, en cas de césarienne, leurs soins sont gratuits. En Mauritanie, avec le soutien de l’Agence Française de Développement (AFD), un forfait obstétrical a été mis en œuvre progressivement depuis 2002, permettant aux femmes d’accéder à tous les soins durant la grossesse et l’accouchement, y compris la césarienne, contre le paiement d’une prime d’environ 15 euros. Cette thèse cherche à savoir si ces différentes réformes permettent réellement d’améliorer l’accès des femmes enceintes aux soins obstétricaux en général et à la césarienne en particulier.Retour ligne automatique Les politiques étudiées ici ont été mises en place dans les années 2000 sans processus spécifique d’évaluation. Nous avons utilisé des données existantes (Enquêtes démographiques et de santé et enquêtes à indicateurs multiple), représentatives de la population au niveau national et des méthodes quasi-expérimentales pour évaluer l’impact de ces réformes sur les taux d’utilisation des services de santé maternelle et néonatale. Nous avons également évalué les effets de ces politiques sur les inégalités de santé en comparant l’utilisation de la césarienne comme mode d’accouchement entre différents groupes de femmes, selon leur zone de résidence (urbain/rural), leur niveau d’éducation et leur niveau de richesse.Retour ligne automatique La première partie de cette thèse montre que l’utilisation des services de santé pour l’accouchement et la césarienne a été amélioré au Mali et au Bénin où la gratuité de la césarienne a été mise en place, comparativement à des pays sans ce type de réforme. En revanche, la gratuité de la césarienne n’a pas eu d’effet sur les inégalités de santé en ce qui concerne l’accès à la césarienne. La deuxième partie de la thèse montre que le forfait obstétrical en Mauritanie a permis une amélioration de l’utilisation des services de santé pour les femmes enceintes, sans cependant avoir eu d’effet sur les taux globaux de césarienne. Néanmoins, des effets sur les inégalités de santé sont à noter.Retour ligne automatique Les résultats de cette thèse renforcent l’idée que les paiements directs des soins dans les formations sanitaires en Afrique sub-saharienne constituent une barrière importante qui limite l’accès des femmes enceintes aux services de santé en général et à la césarienne en particulier. En revanche, il est important que les gouvernements se tournent désormais vers des mécanismes promouvants l’universalisme proportionné pour assurer un accès équitable aux soins de santé. Il est primordial que ces réformes, mises en œuvre depuis plus de dix ans, soient évaluées et que les décideurs aient pleinement connaissance de leurs effets afin d’assurer aux femmes enceintes un accès optimal aux soins et ainsi réduire la mortalité maternelle.

Résumé : Introduction Mali and Benin introduced a user fee exemption policy focused on caesarean sections in 2005 and 2009, respectively. The objective of this study is to assess the impact of this policy on service utilisation and neonatal outcomes. We focus specifically on whether the policy differentially impacts women by education level, zone of residence and wealth quintile of the household. Methods We use a difference-in-differences approach using two other western African countries with no fee exemption policies as the comparison group (Cameroon and Nigeria). Data were extracted from Demographic and Health Surveys over four periods between the early 1990s and the early 2000s. We assess the impact of the policy on three outcomes: caesarean delivery, facility-based delivery and neonatal mortality.

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.

Résumé : In Mauritania, obstetrical risk insurance (ORI) has been progressively implemented at the health district level since 2002 and was available in 25% of public healthcare facilities in 2015. The ORI scheme is based on pre-payment scheme principles and focuses on increasing the quality of and access to both maternal and perinatal healthcare. Compared with many community-based health insurance schemes, the ORI scheme is original because it is not based on risk pooling. For a pre-payment of 16–18 USD, women are covered during their pregnancy for antenatal care, skilled delivery, emergency obstetrical care [including caesarean section (C-section) and transfer] and a postnatal visit. The objective of this study is to evaluate the impact of ORI enrolment on maternal and child health services using data from the Multiple Indicator Cluster Survey (MICS) conducted in 2015. A total of 4172 women who delivered within the last 2 years before the interview were analysed. The effect of ORI enrolment on the outcomes was estimated using a propensity score matching estimation method. Fifty-eight per cent of the studied women were aware of ORI, and among these women, more than two-thirds were enrolled. ORI had a beneficial effect among the enrolled women by increasing the probability of having at least one prenatal visit by 13%, the probability of having four or more visits by 11% and the probability of giving birth at a healthcare facility by 15%. However, we found no effect on postnatal care (PNC), C-section rates or neonatal mortality. This study provides evidence that a voluntary pre-payment scheme focusing on pregnant women improves healthcare services utilization during pregnancy and delivery. However, no effect was found on PNC or neonatal mortality. Some efforts should be exerted to improve communication and accessibility to ORI. Maternal health, neonatal mortality, pre-payment scheme, universal health coverage, Mauritania, Sub-Saharan Africa Topic: pregnancycesarean sectionhealth care facilityinsurancemauritaniamotherspostnatal careobstetricsprenatal careneonatal mortalityhealth care usemalnutrition-inflammation-cachexia syndrome

Résumé : Background: Caesarean section rates are increasing worldwide, and since the 2000s, several researchers have investigated women’s demand for caesarean sections. Question: The aim of this article was to review and summarise published studies investigating caesarean section demand and to describe the methodologies, outcomes, country characteristics and country income levels in these studies. .Methods This is a systematic review of studies published between 2000 and 2017 in French and English that quantitatively measured women’s demand for caesarean sections. We carried out a systematic search using the Medline database in PubMed. Findings The search strategy identified 390 studies, 41 of which met the final inclusion criteria, representing a total sample of 3 774 458 women. We identified two different study designs, i.e., cross-sectional studies and prospective cohort studies, that are commonly used to measure social demand for caesarean sections. Two different types of outcomes were reported, i.e., the preferences of pregnant or non-pregnant women regarding the method of childbirth in the future and caesarean delivery following maternal request. No study measured demand for caesarean section during the childbirth process. All included studies were conducted in middle- (n = 24) and high-income countries (n = 17), and no study performed in a low-income country was found. Discussion Measuring caesarean section demand is challenging, and the structural violence leading to demand for caesarean section during childbirth while in the labour ward remains invisible. In addition, the caesarean section demand in low-income countries remains unclear due to the lack of studies conducted in these countries. Conclusion We recommend conducting prospective cohort studies to describe the social construction of caesarean section demand. We also recommend conducting studies in low-income countries because demand for caesarean sections in these countries is rarely investigated.

Résumé : The experience of childbirth has been technologized worldwide, leading to major social changes. In France, childbirth occurs almost exclusively in hospitals. Few studies have been published on the opinions of French women regarding obstetric technology and, in particular, caesarean section. In 2017–2018, we used a mixed methods approach to determine French women’s preferences regarding the mode of delivery, and captured their experiences and satisfaction in relation to childbirth in two maternity settings. Of 284 pregnant women, 277 (97.5%) expressed a preference for vaginal birth, while seven (2.5%) women expressed a preference for caesarean section. Vaginal birth was also preferred among 26 women who underwent an in-depth interview. Vaginal birth was perceived as more natural, less risky and less painful, and to favour mother–child bonding. This vision was shared by caregivers. The women who expressed a preference for vaginal birth tended to remain sexually active late in their pregnancy, to find sexual intercourse pleasurable, and to believe that vaginal birth would not enlarge their vagina. A large majority (94.5%) of women who gave birth vaginally were satisfied with their childbirth experience, compared with 24.3% of those who underwent caesarean section. The caring attitude of the caregivers contributed to increasing this satisfaction. The notion of women’s ‘empowerment’ emerged spontaneously in women’s discourse in this research: women who gave birth vaginally felt satisfied and empowered. The vision shared by caregivers and women that vaginal birth is a natural process contributes to the stability of caesarean section rates in France.

Résumé : The experience of childbirth has been technologized worldwide, leading to major social changes. In France, childbirth occurs almost exclusively in hospitals. Few studies have been published on the opinions of French women regarding obstetric technology and, in particular, caesarean section. In 2017–2018, we used a mixed methods approach to determine French women’s preferences regarding the mode of delivery, and captured their experiences and satisfaction in relation to childbirth in two maternity settings. Of 284 pregnant women, 277 (97.5%) expressed a preference for vaginal birth, while seven (2.5%) women expressed a preference for caesarean section. Vaginal birth was also preferred among 26 women who underwent an in-depth interview. Vaginal birth was perceived as more natural, less risky and less painful, and to favour mother–child bonding. This vision was shared by caregivers. The women who expressed a preference for vaginal birth tended to remain sexually active late in their pregnancy, to find sexual intercourse pleasurable, and to believe that vaginal birth would not enlarge their vagina. A large majority (94.5%) of women who gave birth vaginally were satisfied with their childbirth experience, compared with 24.3% of those who underwent caesarean section. The caring attitude of the caregivers contributed to increasing this satisfaction. The notion of women’s ‘empowerment’ emerged spontaneously in women’s discourse in this research: women who gave birth vaginally felt satisfied and empowered. The vision shared by caregivers and women that vaginal birth is a natural process contributes to the stability of caesarean section rates in France.

Résumé : Objective: To assess new estimates of caesarean section (c-section) rates in facilities in two sub-Saharan countries using the Robson classification. Methods: This study is a retrospective study. Workshops were organized in Mali and Benin in 2017 to train health care professionals in the use of the Robson classification. Nine health facilities in Mali and Benin were selected to participate in the study. Data for deliveries performed in 2014, 2015, and 2016 were included. Results: A total of 12,472 deliveries were included. The overall c-section rate was high in facilities in both countries: 31.0% in Mali and 43.9% in Benin. Women classified as high-risk (groups 6-10) were small relative contributors to the overall c-section rate (19.3% in Mali and 25.3% in Benin), while low-risk women (groups 1-4) were high relative contributors (55.4% in Mali and 45.2% in Benin). C-section rates in women who had undergone a previous c-section were especially high in both countries (84.0% in Mali; 82.5% in Benin). This group was the largest contributor to the overall c-section rates in both countries. Conclusions: We found high c-section rates in facilities in Mali and Benin, particularly for low-risk women and for women with a previous c-section. Further investigations should be carried out to understand why the c-section rates are so high in these facilities. Strategies must be implemented to avoid unnecessary c-sections, which potentially lead to further complications, particularly in countries with high fertility rates.