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Resume Objectif Emettre des recommandations concernant l’accueil, le suivi et la prise en charge non medicamenteuse de la femme pendant le travail. Methode Revue de la litterature menee entre janvier 2000 et septembre 2017 en langue anglaise et francaise a partir de la base de donnees Medline, de la Cochrane Library et recommandations des societes savantes etrangeres. Resultats Lors de l’examen initial d’une femme, il est recommande de prendre connaissance de son dossier de suivi de grossesse et de son eventuel projet de naissance ; de realiser une anamnese, de s’enquerir des souhaits et besoins physiologiques et emotionnels de la patiente ; et de realiser un examen clinique (Avis d’Expert [AE]). Si la femme semble etre en travail, il est recommande de proposer un toucher vaginal (AE). En cas de rupture prematuree des membranes, il est recommande de ne pas realiser systematiquement de toucher vaginal (TV) si la femme n’a pas de contractions uterines douloureuses (AE). Lors du premier stade du travail, la surveillance de la femme comprend au minimum : une surveillance des parametres hemodynamiques toutes les quatre heures ; une evaluation de la frequence des contractions uterines toutes les 30 minutes et durant dix minutes au cours de la phase active ; une surveillance des mictions spontanees ; la proposition d’un TV toutes les deux a quatre heures ou avant si la patiente le demande, ou en cas de signe d’appel (AE). Au cours du second stade, il est recommande d’utiliser un partogramme ; de surveiller les parametres hemodynamiques toutes les heures ; d’evaluer la frequence des contractions uterines toutes les 30 minutes et durant dix minutes ; de surveiller et noter les mictions spontanees ; de proposer un TV toutes les heures (AE). Que ce soit a l’admission ou lors du travail, il est recommande d’evaluer la douleur et de proposer a la patiente differents moyens de la soulager (AE). Il est recommande que toutes les femmes puissent beneficier d’un soutien continu, individuel et personnalise, adapte selon leur demande, au cours du travail et de l’accouchement (grade A) ; de mettre en œuvre les moyens humains et materiels necessaires permettant aux femmes de changer regulierement de position (AE). Conclusion Les pratiques systematiques doivent etre abandonnees pour ne garder que celles qui sont scientifiquement justifiees. La prise en charge de la douleur est indispensable que ce soit par des moyens medicamenteux ou non medicamenteux. Chaque femme doit pouvoir beneficier d’un soutien continu, individuel et personnalise, au cours du travail et de l’accouchement.

International audience; Over the past decade, women in Western countries have taken to various social media platforms to share their dissatisfactory experiences with hormonal contraception, which may be pills, patches, rings, injectables, implants or hormonal intrauterine devices (IUDs). These online testimonials have been denounced as spreading “hormonophobia”, i.e. an excessive fear of hormones based on irrational causes such as an overestimation of health risks associated with their use, that was already aroused by the recurring media controversies over hormonal contraception. In order to move toward a reproductive justice framework, we propose to study the arguments that women and men (as partners of female users) recently put forward against hormonal contraception to see whether they are related to hormonophobia. The aim of this article is to conduct a systematic review of the recent scientific literature in order to construct an evidence-based typology of reasons for rejecting hormonal contraception, in a continuum perspective from complaints to choosing not to use it, cited by women and men in Western countries in a recent time. The published literature was systematically searched using PubMed and the database from the French National Institute for Demographic Studies (Ined). A total of 42 articles were included for full-text analysis. Eight main categories emerged as reasons for rejecting hormonal contraception: problems related to physical side effects; altered mental health; negative impact on sexuality; concerns about future fertility; invocation of nature; concerns about menstruation; fears and anxiety; and the delegitimization of the side effects of hormonal contraceptives. Thus, arguments against hormonal contraception appeared complex and multifactorial. Future research should examine the provider-patient relationship, the gender bias of hormonal contraception and demands for naturalness in order to understand how birth control could better meet the needs and expectations of women and men in Western countries today.

Maternal mortality occurs mostly in contexts of poverty and health system collapse. Mali has a very high maternal mortality rate and this extremely high mortality rate is due in part to longstanding constraints in maternal health services. The central region has been particularly affected by the humanitarian crisis in recent years, and maternal health has been aggravated by the conflict. Sominé Dolo Hospital is located in Mopti, central region. In the last decade, a high number of pregnant or delivering women have died in this hospital.We conducted a retrospective and exhaustive study of maternal deaths occurring in Mopti hospital. Between 2007 and 2019, 420 women died, with an average of 32 deaths per year. The years 2014–2015 and the last 2 years have been particularly deadly, with 40 and 50 deaths in 2018 and 2019, respectively. The main causes were hypertensive disorders/eclampsia and haemorrhage. 80% of these women’s deaths were preventable. Two major explanations result in these maternal deaths in Sominé Dolo’s hospital: first, a lack of accessible and safe blood, and second, the absence of a reference and evacuation referral system, all of which are aggravated by security issues in and around Mopti.Access to quality hospital care is in dire need in the Mopti region. There is an urgent need for a safe blood collection system and free of charge for pregnant women. We also strongly recommend that the referral/evacuation system be reinvigorated, and that universal health coverage be strengthened.

Resume Objectifs Evaluer si la taille et la forme du bassin, la statique rachidienne, la brievete anatomique perineale et les dimensions du hiatus genital sont des elements anatomiques associes a l’apparition de lesions pelviperineales obstetricales. Certaines situations particulieres, comme l’obesite, l’ethnie et l’hyperlaxite seront egalement etudiees. Methodes Une recherche bibliographique a l’aide des bases de donnees Pubmed et de la Cochrane Library a ete realisee jusqu’en mai 2018. Les publications en langues anglaise et francaise ont ete selectionnees par lecture initiale des abstracts. Les essais randomises, les meta-analyses, les etudes cas-temoins et les grandes cohortes ont ete etudiees de maniere privilegiee. Resultats Un angle sous-pubien Conclusions Les evaluations prenatales du bassin, de la statique rachidienne, de la distance anovulvaire et du hiatus genital ne permettent pas de predire la survenue de lesions pelviperineales obstetricales. L’obesite et l’ethnie ne sont pas des facteurs de risque de LOSA.

Resume Objectif Evaluer l’efficacite des differentes interventions pendant la grossesse (massage perineal prenatal, dispositif Epi-No, exercices de renforcement des muscles du plancher pelvien) sur la protection perineale dans le post-partum. Methodologie Une revue systematique de la litterature a ete menee sur PubMed, incluant des articles en langue francaise et anglaise publies avant mai 2018, afin d’evaluer l’efficacite de ces trois interventions sur la protection perineale dans le post-partum. Resultats Le massage perineal au cours de la grossesse diminue le taux d’episiotomie (NP1) ainsi que les douleurs perineales et l’incontinence aux gaz dans le post-partum (NP2). Il ne diminue pas le taux de LOSA (NP1), ou le taux d’incontinence urinaire en post-partum (NP2). L’utilisation du dispositif Epi-No n’apporte pas de benefice en termes de protection perineale obstetricale (NP1). Enfin, les exercices prenataux de renforcement des muscles du plancher pelvien ne previennent pas du risque de lesions perineales obstetricales (NP2) ; ils diminuent la prevalence de l’incontinence urinaire dans le post-partum entre 3 et 6 mois mais ne diminuent pas la prevalence de l’incontinence urinaire a 12 mois du post-partum (NP2). Conclusion Le massage perineal pendant la grossesse doit etre encourage chez les femmes souhaitant le pratiquer (grade B). Ce qui semble etre efficace est un massage perineal pratique par la femme ou le partenaire, au minimum trois fois par semaine, initie a 34 semaines de grossesse (36 SA). L’utilisation du dispositif Epi-No pendant la grossesse n’est pas recommandee pour prevenir les LOSA (grade B). Pour prevenir les LOSA, il n’est pas recommande de pratiquer des exercices de renforcement des muscles du plancher pelvien pendant la grossesse (grade B). Pour la prevention de l’incontinence urinaire, l’absence d’effet demontre a moyen terme ne permet pas de formuler une recommandation (accord professionnel).

Resume Introduction L’objectif de ces RPC etait d’analyser l’ensemble des interventions possibles au cours de la grossesse et de l’accouchement permettant de prevenir les lesions obstetricales du sphincter anal (LOSA) et les symptomes perineaux postnataux. Materiel et methodes Ces recommandations ont ete elaborees selon la methode decrite dans le guide methodologique de la HAS. Resultats En cas d’antecedent de maladie de Crohn, de LOSA, de mutilation sexuelle, ou de lesion peri-anale, un examen clinique prenatal du perinee est recommande (Accord Professionnel). Juste apres l’accouchement, il est recommande d’examiner le perinee a la recherche d’une LOSA (Grade B) ; en cas de doute diagnostique, il est recommande de demander un second avis (Grade C). En cas de LOSA, Il est recommande de decrire de maniere detaillee les lesions (avec leur degre) ainsi que leur reparation (Grade C). Le massage perineal pendant la grossesse doit etre encourage chez les femmes souhaitant le pratiquer (Grade B). Aucune intervention avant le degagement de la presentation n’a clairement demontre son efficacite pour reduire le risque de lesions perineales. Il est recommande de controler manuellement le degagement de la presentation cephalique et de soutenir le perinee posterieur afin de diminuer le risque de LOSA (Grade C). Au cours d’un accouchement normal, la pratique d’une episiotomie n’est pas recommandee pour reduire le risque de LOSA (Grade A). En cas d’accouchement instrumental, une episiotomie peut etre indiquee pour eviter une LOSA (Grade C). Lorsqu’une episiotomie est realisee, il est recommande de choisir une incision mediolaterale (Grade B). Il est recommande d’expliquer l’indication et de recueillir l’accord de la femme avant de pratiquer une episiotomie. Il n’est pas recommande de proposer une cesarienne programmee en prevention primaire de lesions ou de dysfonctions perineales (Grade B). Au cours de la grossesse et a nouveau en salle de travail, il est recommande de s’interesser aux attentes et d’informer les femmes sur les modalites de l’accouchement.

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.

Resume Au moment ou les sages-femmes francaises sont de plus en plus nombreuses a entreprendre des recherches scientifiques, cet article souhaite interroger les tensions qu’il peut exister entre notre code de deontologie de sage-femme et les modalites concretes de l’enquete de terrain. A travers l’exemple d’une recherche doctorale en sciences sociales menee a Phnom-Penh au Cambodge sur certaines pratiques qui touchent au perinee des femmes (episiotomie et perineorraphie), cet article illustre la richesse, mais aussi les difficultes de la production de donnees auxquelles peut etre confrontee une sage-femme dans le cadre de sa recherche.

C-sections are an increasingly performed medical practice which can save lives but may also lead to major complications. Through a mixed methods study conducted in 2015 in Cambodia, we aimed to analyze the reasons for requesting a c-section and to explore factors that are associated with c-sections. 60% of the women in the cohort who gave birth by c-section reported having requested it. Through 31 in-depth interviews, we determined the reasons given by women for requesting a c-section before and during labour. Before labour, reasons for requesting a c-section were: choosing the delivery date; bringing luck and joy to the family; protecting the genitals, and the belief that c-section is safer for the mother and for the baby. Reasons given during labour were fear, pain, and having no more energy. We also observed two major factors driving the women's request for a c-section: family support for requesting a c-section, and the over-usage of ultrasound examinations. Our multivariate analysis of the interviews of 143 women before and after delivery showed that having a previous c-section, delivering in a private facility, being older than median at the time of sexual debut, residing outside of Phnom Penh and having the delivery costs covered by the family were all factors independently and significantly associated with a higher chance of c-section delivery. We conclude that women are not well informed to give consent for c-delivery, and that their request is often affected by false belief and poor knowledge.

Background Benin and Mali introduced user fee exemption policies focused on caesarean sections (C-sections) in 2005 and 2009, respectively. These policies had a positive impact on access to C-sections and facility based deliveries among all women, but the impact on socioeconomic inequality is still highly uncertain. The objective of this study was to observe whether there was an increase or a decrease in urban/rural and socioeconomic inequalities in access to C-sections and facility based deliveries after the free C-section policy was introduced. Methods We used data from three consecutive Demographic and Health Surveys (DHS): 2001, 2006 and 2011–2012 in Benin and 2001, 2006 and 2012–13 in Mali. We evaluated trends in inequality in terms of two outcomes: C-sections and facility based deliveries. Adjusted odds ratios were used to estimate whether the distributions of C-sections and facility based deliveries favoured the least advantaged categories (rural, non-educated and poorest women) or the most advantaged categories (urban, educated and richest women). Concentration curves were used to observe the degree of wealth-related inequality in access to C-sections and facility based deliveries. Results We analysed 47,302 childbirths (23,266 in Benin and 24,036 in Mali). In Benin, we found no significant difference in access to C-sections between urban and rural women or between educated and non-educated women. However, the richest women had greater access to C-sections than the poorest women. There was no significant change in these inequalities in terms of access to C-sections and facility based deliveries after introduction of the free C-section policy. In Mali, we found a reduction in education-related inequalities in access to C-sections after implementation of the policy (p-value = 0.043). Inequalities between urban and rural areas had already decreased prior to implementation of the policy, but wealth-related inequalities were still present. Conclusions Urban/rural and socioeconomic inequalities in C-section access did not change substantially after the countries implemented free C-section policies. User fee exemption is not enough. We recommend switching to mechanisms that combine both a universal approach and targeted action for vulnerable populations to address this issue and ensure equal health care access for all individuals.

IntroductionMali 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.MethodsWe 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.ResultsWe analyse 99 800 childbirths. The free caesarean policy had a positive impact on caesarean section rates (adjusted OR=1.36 (95% CI 1.11 to 1.66; P≤0.01), particularly in non-educated women (adjusted OR=2.71; 95% CI 1.70 to 4.32; P≤0.001), those living in rural areas (adjusted OR=2.02; 95% CI 1.48 to 2.76; P≤0.001) and women in the middle-class wealth index (adjusted OR=3.88; 95% CI 1.77 to 4.72; P≤0.001). The policy contributes to the increase in the proportion of facility-based delivery (adjusted OR=1.68; 95% CI 1.48 to 1.89; P≤0.001) and may also contribute to the decrease of neonatal mortality (adjusted OR=0.70; 95% CI 0.58 to 0.85; P≤0.001).ConclusionThis study is the first to evaluate the impact of a user fee exemption policy focused on caesarean sections on maternal and child health outcomes with robust methods. It provides evidence that eliminating fees for caesareans benefits both women and neonates in sub-Saharan countries.