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Introduction: In a legal context focused on the right and autonomy of the patient, some women wish to be able to choose their mode of childbirth. As midwives are primary care-givers for pregnant women with a physiological pregnancy, we wanted to find out whether it was ethically acceptable for them to accompany a woman in her decision to have a caesarean section.Purpose of research: This survey is an ancillary study of the CESARIA research program validated by the Comite de Protection des Personnes Sud Mediterranee IV and declared to the CNIL. Thirty-seven semi-directive interviews were conducted with midwives and women.Results: The majority of women and midwives share a vision of childbirth as “natural” and consider the request for caesarean section as a pathology. When formulated, this request places midwives in a situation of ethical tension. On the one hand, midwives wish to refer women to vaginal birth as the norm, and this choice embodies the ethical principles of beneficence and non-maleficence. On the other hand, midwives express a desire to respect patient choice and freedom, illustrating the ethical principle of respect for autonomy.Conclusions: The ethical issue of caesarean section on demand lies not so much in the decision to accept or not to accept a caesarean section but rather in listening to the request. Taking into consideration a medical indication more broadly than the simple obstetrical indication makes it possible to ethically support these requests while respecting the pregnant woman’s autonomy.

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.

Objective The objective of these guidelines is to define for women at low obstetric risk modalities that respect the physiology of delivery and guarantee the quality and safety of maternal and newborn care. Methods These guidelines were made by a consensus of experts based on an analysis of the scientific literature and the French and international recommendations available on the subject. Results It is recommended to conduct a complete initial examination of the woman in labor at admission (Consensus agreement). The labor will be monitored using a partogram that is a useful traceability tool (Consensus agreement). A transvaginal examination may be offered every two to four hours during the first stage of labor and every hour during the second stage of labor or before if the patient requests it, or in case of a warning sign. It is recommended that if anesthesia is required, epidural or spinal anesthesia should be used to prevent bronchial inhalation (grade A). The consumption of clear fluids is permitted throughout labor in patients with a low risk of general anesthesia (grade B). It is recommended to carry out a "low dose" epidural analgesia that respects the experience of delivery (grade A). It is recommended to maintain the epidural analgesia through a woman's self-administration pump (grade A). It is recommended to give the woman the choice of continuous (by cardiotocography) or discontinuous (by cardiotocography or intermittent auscultation) monitoring if the conditions of maternity organization and the permanent availability of staff allow it and, after having informed the woman of the benefits and risks of each technique (Consensus agreement). In the active phase of the first stage of labor, the dilation rate is considered abnormal if it is less than 1cm/4h between 5 and 7 cm or less than 1cm/2h above 7cm (level of Evidence 2). It is then recommended to propose an amniotomy if the membranes are intact or an oxytocin administration if the membranes are already ruptured, and the uterine contractions considered insufficient (Consensus agreement). It is recommended not to start expulsive efforts as soon as complete dilation is identified, but to let the presentation of the fetus drop (grade A). It is recommended to inform the gynecologist-obstetrician in case of nonprogression of the fetus after two hours of complete dilation with sufficient uterine dynamics (Consensus agreement). It is recommended not to use abdominal expression (grade B). It is recommended to carry out preventive administration of oxytocin at 5 or 10 IU to prevent PPH after vaginal delivery (grade A). In the case of placental retention, it is recommended to perform a manual removal of the placenta (grade A). In the absence of bleeding, it should be performed 30 minutes but not more than 60 minutes after delivery (Consensus agreement). It is recommended to assess at birth the breathing or screaming, and tone of the newborn to quickly determine if resuscitation is required (Consensus agreement). If the parameters are satisfactory (breathing present, screaming frankly, and normal tonicity), it is recommended to propose to the mother that she immediately place the newborn skin-to-skin with her mother if she wishes, with a monitoring protocol (grade B). Delayed cord clamping is recommended beyond the first 30 seconds in neonates, not requiring resuscitation (grade C). It is recommended that the first oral dose (2 mg) of vitamin K (Consensus agreement) be given systematically within two hours of birth. Conclusion These guidelines allow women at low obstetric risk to benefit from a better quality of care and optimal safety conditions while respecting the physiology of delivery.

Objective: To measure for each of the ten (10) groups of women defined in Robson’s classification, the cesarean section rate, group size and its contribution to the overall cesarean section rate in four maternities in Benin. Methods: This was a retrospective study over a period of 3 years, from January 1, 2014 to December 31, 2016. Two workshops were organized for training in data collection and interpretation of results. Results: A total of 5442 files were included for the four health facilities during the study period. The overall cesarean section rate was 43.9%. The most represented group (30.3%) was multiparous women without scarred uterus, with a single term fetus, in cephalic presentation, and spontaneous labour (Group 3). The largest contributor to the overall cesarean section rate was that of multiparous women with at least one uterine scar with a single fetus, eventually in cephalic presentation (Group 5) with 29.5%. Conclusion: Caesarean section rates are high in groups of women with a favourable prognosis for vaginal delivery. It is also high in women with scarred uterus (Group 5).

Depuis les années 1970, des mouvements militants internationaux dénoncent une approche médico- et techno-centrée de la naissance. En réponse à cette « techno-bio-médicalisation », le concept d’« accouchement humanisé » a émergé dans les années 1990 en Amérique latine puis s’est globalisé. Cet article propose d’analyser l’échec d’un projet japonais d’accouchement humanisé dans une maternité au Bénin. Sur la base d’observations participantes et d’entretiens, nous montrons que la proposition des actrices et acteurs du développement japonais se heurte à une forte incorporation de la « science obstétricale » par les soignant·e·s, et plus particulièrement par les sages-femmes béninoises. Plus précisément, en interdisant la présence d’un·e accompagnant·e auprès de la femme qui accouche et en refusant que celle-ci adopte une position autre que la position gynécologique, les sages-femmes reproduisent le modèle obstétrical dominant au détriment du confort et du bien-être des femmes. Since the 1970s, international activist movements have denounced a medical and techno-centric approach to birth. In response to this “techno-bio-medicalization” of birth, the concept of humanized childbirth emerged in the 1990s in Latin America and then became global. This article proposes to analyse the failure of a Japanese project of humanized childbirth in a maternity hospital in Benin. On the basis of participant observations and interviews, we show that the proposal of Japanese development actors came up against a strong incorporation of obstetrical science by the health workers and more particularly by the Beninese midwives. More specifically, by forbidding the presence of an attendant near the woman giving birth and by refusing to accept a position other than the gynaecological one, the midwives reproduce the dominant model of biomedicalization of childbirth to the detriment of women's comfort and psychological and social well-being.

In a legal context focused on the right and autonomy of the patient, some women wish to be able to choose their mode of childbirth. As midwives are primary care-givers for pregnant women with a physiological pregnancy, we wanted to find out whether it was ethically acceptable for them to accompany a woman in her decision to have a caesarean section.Purpose of research: This survey is an ancillary study of the CESARIA research program validated by the Comit#233; de Protection des Personnes Sud M#233;diterran#233;e IV and declared to the CNIL. Thirty-seven semi-directive interviews were conducted with midwives and women.The majority of women and midwives share a vision of childbirth as#8220;natural#8221; and consider the request for caesarean section as a pathology. When formulated, this request places midwives in a situation of ethical tension. On the one hand, midwives wish to refer women to vaginal birth as the norm, and this choice embodies the ethical principles of beneficence and non-maleficence. On the other hand, midwives express a desire to respect patient choice and freedom, illustrating the ethical principle of respect for autonomy.The ethical issue of caesarean section on demand lies not so much in the decision to accept or not to accept a caesarean section but rather in listening to the request. Taking into consideration a medical indication more broadly than the simple obstetrical indication makes it possible to ethically support these requests while respecting the pregnant woman#8217;s autonomy.

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.

Le concept de "violences gynécologiques et obstétricales" a émergé au début des années 2000 en Amérique latine dans les milieux militants et scientifiques. Il a été repris à partir des années 2010 dans les débats féministes et politiques français et européens. Les militantes féministes, notamment à travers les réseaux sociaux et les médias, ont joué un rôle important dans la construction de cette question de santé publique. Ce concept est aujourd'hui mobilisé dans l'espace public, politique et académique, en France et à l'international. Il recouvre des réalités et des pratiques médicales diverses et permet de rendre compte des expériences, à la fois objectives et subjectives, des femmes. Les travaux en sciences sociales qui mobilisent cette nouvelle approche conceptuelle sont de plus en plus nombreux. Ils portent cependant majoritairement sur l'accouchement, alors que le domaine de la gynécologie reste plus largement à explorer.

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.

Cambodia is one of the nine countries worldwide to have reduced its maternal mortality rate by more than 75 per cent between 1990 and 2015. Whilst prior to the 2000s, childbirth in Cambodia used to be a private event, it has now become a biomedical event for women and their families. This chapter describes the findings of mixed-method research challenging the idealized vision of the United Nations regarding maternal health in Cambodia by describing obstetrical practices on the ground, from an empirical study led in several clinical settings in Phnom Penh, through participant observation, semi-structured interviews with health-care professionals and patients, questionnaires with pregnant women, to the examination of medical records from four Phnom Penh maternity wards. The findings demonstrate that the biomedicalization of childbirth in Cambodia has been accompanied by technologized delivery with extremely frequent use of surgical practices. In order to understand the population’s adherence to these practices, the chapter draws out a number of anthropological and demographic arguments. These biomedical practices are part of a symbolism of the body where the body is conceived as a receptacle, where the body humours must be able to circulate appropriately, and where the hot/cold balance must be respected. Childbirth as an opening of the body represents a danger for women because it threatens this equilibrium.

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.

Resume Objectifs Cet article interroge le contexte dans lequel la position gynecologique s’est imposee et ce que cette norme peut reveler de la societe francaise. En effet, selon la derniere enquete nationale perinatale en 2016, 95,5 % des femmes accouchant en France ont accouche en position gynecologique bien que cette posture ne soit pas la plus favorable. Dans cette position, la femme est allongee sur le dos, les jambes posees dans les etriers. Materiels et methode D’abord en retracant un historique de cette position d’accouchement, puis a travers une observation dans des salles de naissances completee d’entretiens semi-directifs avec des sages-femmes, nous montrerons comment l’institution medicale francaise, a travers cette position, contribue a construire une vulnerabilite corporelle naturalisee des femmes. Resultats Cet article souhaite demontrer que la position gynecologique s’inscrit dans la normalisation de la medecine moderne et de l’accouchement aujourd’hui en France et qu’elle est le produit d’un ordre social construit et controle.

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.

Dans les années 1990-2000, la communauté internationale s’est engagée pour la lutte contre les inégalités entre les femmes et les hommes. Les institutions se sont alors dotées d’outils permettant de mesurer les évolutions dans ce domaine à l’échelle internationale. Divers « indices d’inégalité de genre » ont été élaborés. S’ils ont subi des critiques méthodologiques menant à des réajustements, les cadres conceptuels utilisés n’ont en revanche jamais été analysés à l’aune des savoirs sur le genre. Notre analyse porte sur les indices du FEM, de l’OCDE et du PNUD et révèle que ces indices reposent sur des postulats qui participent d’une vision située et réductrice des rapports sociaux de sexe. Par ailleurs, les domaines dans lesquels sont mesurées les inégalités de genre tendent à réifier les rôles sociaux traditionnels attribués aux femmes et des hommes. Enfin, ces indices, parce qu’ils sont le résultat d’une approche située, mettent en avant certaines formes d’inégalités de genre et en oublient d’autres, ce qui limite largement leur utilisation dans un cadre comparatiste et scientifique.

Caesarean section can prevent maternal and neonatal mortality and morbidity. However, it involves risks and high costs which can be a burden, especially in low and middle income countries. The international healthcare community considers the optimal caesarean rate to be between 10% and 15%. The aim of this study is to assess its magnitude and correlates among women of reproductive age in urban and rural areas in Vietnam. We analyzed microdata from the national Multiple Indicator Cluster Survey (MICS) conducted in 2013-2014 using representative sample of households at the national level as well as regarding the urban and the rural areas. A total of 1,378 women who delivered in institutional settings in the two years preceding the survey were included. Frequency and percentage distributions of the variables were performed. Bivariate and multivariate logistic regression analysis were undertaken to identify the factors associated with caesarean section. Odds ratios with 95% confidence interval were used to ascertain the direction and strength of the associations. The overall CS rate among the women who delivered in healthcare facilities in Vietnam is particularly high (29.2%) with regards to WHO standards. After controlling for significant characteristics, living in urban areas more than doubles the likelihood of undergoing a CS (OR = 2.31; 95% CI 1.79 to 2.98). Maternal age at delivery over 35 is a major positive correlate of CS. Beyond this common phenomenon, distinct lines of socioeconomic and demographic cleavage operate in urban versus rural areas. The differences regarding correlates of CS according to the place of residence suggest that specific measures should be taken in each setting to allow women to access childbirth services appropriate to their needs. Further research is needed on this topic.

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.

La perineorraphie est une pratique chirurgicale biomedicale qui vise a resserrer fortement le perinee des femmes apres un accouchement par voie basse. Au Cambodge, par cette pratique, et a travers l’institution biomedicale, les soignant∙e∙s construisent un corps feminin qui s’inscrit dans une representation symbolique du corps fortement genree, ou le corps feminin, faible et vulnerable, doit etre faconne sur mesure, de maniere a repondre aux attentes du corps masculin. Cet article souhaite montrer qu’en rendant les femmes conformes a leur role d’epouse, l’institution biomedicale participe a la reproduction de la structure ; il vise egalement a interroger les logiques des acteurs, notamment l’incorporation de la pratique par les soignantes qui disent rendre ainsi service aux autres femmes.

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.

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.

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.

First documented in 1741, the practice of episiotomy substantially increased worldwide during the 20th century. However, research shows that episiotomy is not effective in reducing severe perineal trauma and may be harmful. Using a mixed-methods approach, we conducted a study in 2013-14 on why obstetricians and midwives in a large maternity hospital in Phnom Penh, Cambodia, still do routine episiotomies. The study included the extent of the practice, based on medical records; a retrospective analysis of the delivery notes of a random sample of 365 patients; and 22 in-depth interviews with obstetricians, midwives and recently delivered women. Of the 365 women, 345 (94.5%, 95% CI: 91.7-96.6) had had an episiotomy. Univariate analysis showed that nulliparous women underwent episiotomy more frequently than multiparous women (OR 7.1, 95% CI 2.0-24.7). The reasons given for this practice by midwives and obstetricians were: fear of perineal tears, the strong belief that Asian women have a shorter and harder perineum than others, lack of time in overcrowded delivery rooms, and the belief that Cambodian women would be able to have a tighter and prettier vagina through this practice. A restrictive episiotomy policy and information for pregnant women about birthing practices through antenatal classes should be implemented as soon as possible.

Background: the vulva has often raised debate in society and brought up multiple questions. Surrounded by taboos and preconceived ideas dating back several centuries, it is now the source of a growing phenomenon: nymphoplasty. In a society evolving towards the encouragement of difference and body acceptance, young people are subjected to two opposing standards that can influence their views of the female sex.Objectives: to study student’s representations, preconceptions and anatomical knowledge of the female sex, and to compare these preconceptions according to the sex of the students.Methods: the quantitative observational tranverse study, used an anonymous online questionnaire, LimeSurvey®, which was distributed to students from Île de France, aged 18 to 25.Results: we collected 139 responses, including 107 female and 32 male students, working in different faculties in Ile de France. We have found that the vagina is fundamental in the perception of the female sex. Almost half of the students (49.5%) consider that the subject of the female sex is still taboo, although for a majority of them (75%) it is in the process of liberalization. The study showed that the representations of the female sex were more positive among male students than among female students (p Conclusion: our study shows the influence of ancestral portrayals of the female sex to this day. It highlights the severity of womens perspective towards their own sex, which is out of step with that of men. It shows the impact of sexual violence on the reproductive health of young women and the importance for health professionals to diagnose it. Debate on the female sex is advancing, but has not yet put an end to certain preconceived ideas and certain taboos.; Contexte : la vulve a souvent posé débat dans la société et soulevé de multiples questions. Entourée de tabous et d’idées préconçues remontant à plusieurs siècles, elle est aujourd’hui à l’origine d’un phénomène en expansion : la nymphoplastie. Dans une société évoluant vers la promotion de la différence et de l’acceptation de son corps, les jeunes sont soumis à deux courants opposés pouvant influencer leurs visions du sexe féminin.Objectif : l’objectif de cette étude est d’étudier les représentations, les préconceptions et connaissances anatomiques, en lien avec ces représentations, qu’ont les étudiant.es du sexe féminin, et de comparer ces préconceptions selon le sexe des étudiant.es.Population et méthode : nous avons réalisé une étude quantitative observationnelle, à l’aide d’un questionnaire anonyme en ligne de type LimeSurvey®, diffusé auprès d’étudiant.es d’Île de France âgés de 18 à 25 ans.Résultats : nous avons recueilli 139 réponses, comprenant 107 étudiant.es de sexe féminin et 32 de sexe masculin, travaillant dans différentes facultés d’Île de France. Nous avons constaté que le vagin occupe une place centrale dans les représentations du sexe féminin. Près de la moitié des étudiant.es (49,5%) considère que le sujet du sexe féminin est encore tabou bien que pour une majorité d’entre eux (75%) il est en voie de libéralisation. L’étude a montré que les représentations du sexe féminin étaient plus positives chez les étudiant.es de sexe masculin que chez ceux de sexe féminin (pConclusion : notre étude montre l’influence qu’exercent encore aujourd’hui des représentations ancestrales du sexe féminin. Elle met en avant la sévérité du regard des femmes envers leur propre sexe en décalage avec celui porté par les hommes. Elle montre la place qu’occupent les violences sexuelles dans la santé génésique des jeunes femmes et l’importance pour les professionnels de santé de les diagnostiquer. Les discours sur le sexe féminin se libéralisent, mais n’ont pas encore mis fin à certaines idées préconçues et à certains tabous.

Introduction / ObjectiveSexuality can be impacted by a pregnancy. We explore the determinants of sexuality in post partum.Methods331 adult and french-speaking women pregnant of singleton, were interviewed in 2 Ile-de-France maternities at the end of pregnancy, then re-interviewed by phone 1 and 8 months after the childbirth (n=257 and n=191 respectively). The data were analyzed by Excel®, Stata®, using χ ² or Fischer tests.Results At 8 month, 93,7% of the women resumed sexual intercourses (SI). The determinants of the SI resumption are the marital life, the satisfaction of the current relation with the spouse, the level of study and the occupation of the spouse, the perineal tears, and the presence of the spouse during the childbirth. pleasure felt during the SI is associated to the perineal rehabilitation, felt benefits on sexuality, the sufficient participation of the spouse in the domestic tasks, the presence of the spouse during the childbirth. We could not show any association with the route of delivery or the episiotomy. 50,3% of the women felt pain during pain during SI and 82,5% did not get any councelling about sexuality during the post partum period.ConclusionThe determinants of sexuality in post partum are multiple. Reinforcing the councelling role of the health professionals about sexuality after childbirth would be useful. We also suggest exploring non-penetrative sexuality, as well as the influence of breast feeding.; Introduction / ObjectifsLa grossesse peut venir perturber la sexualité des femmes et des couples. Nous explorons les déterminants de la sexualité en post partum.Matériel et méthodes331 femmes francophones, majeures et enceintes de singleton ont été interrogées dans 2 maternités d’Île-de-France en fin de grossesse puis réinterrogées par téléphone 1 et 8 mois après l’accouchement (n=257 et n=191 respectivement). Les données ont été traitées par Excel®, Stata®, par tests de χ² ou de Fischer.Résultats À 8 mois, 93,7% des femmes ont repris les rapports sexuels (RS). Les déterminants de la reprise des RS sont la vie maritale, la satisfaction de la relation actuelle avec le conjoint, le niveau d’étude et la profession du conjoint, les déchirures périnéales, et la présence du conjoint à l’accouchement. Le plaisir ressenti pendant les RS est associé à la rééducation du périnée, ses bienfaits ressentis, la participation suffisante du conjoint aux tâches domestiques, la présence du conjoint à l’accouchement. Nous n’avons pas pu montrer de lien avec la voie d’accouchement ou l’épisiotomie. 50,3 % des femmes ont eu des douleurs à la reprise des RS et 82,5% n’ont pas eu de conseils sur la sexualité en post partum.ConclusionLes déterminants de la sexualité en post partum sont multiples. Renforcer le rôle des professionnels de santé en matière de conseils sur la sexualité après l’accouchement serait utile. Nous suggérons aussi d’explorer la sexualité non-pénétrative, ainsi que l’influence de l’allaitement.

Introduction / ObjectiveIn France the caesarean section rate doubled in twenty years and is stable since 2003 at about 21%. This review aims to understand the French distinctiveness, by exploring the following topics: the perception and the real experience of this way of delivery, and if there is a real a wife demand for the caesarean.Methods26 semi-leading qualitative interviews have been leaded in the Institut Mutualiste Montsouris in Paris. Among 7 patients close to delivery and 19 who had delivered by caesarean section were interviewed. They have been transcribed and analysed by themes.Results We can resume that caesarean is considered by women as the last issue. Woman esteem feel damaged as they were unable to deliver alone, without medical assistance. Furthermore cesarean may impact the relationship with their child due to the separation, even if it is fully appreciated that father can have special time with the baby. Some of them consider caesarean as a way to avoid pains, others perceive it more painful. Some of patients experience caesarean with serenity when it is prepared. They recognize to be ambivalent knowing the importance of the preparation but considering it stressful and they avoid details during the preparation. Regarding sexuality, it does not seem to influence the idea of women have about caesarian in France. Concerning the choice from women to have caesarian, it is marginal. And not assumed by couples if requested. The patient fears to be judged by the medical profession and finally having negatives consequences in their pregnancy monitoring. Patient’s confidence in medical profession is high and the majority follows doctor’s recommendations: even if it is well appreciated to be involved in the decision, Doctors have the competences to decide. Two elements seem to allow women to have a good caesarian experience: a supportive attitude from the medical profession during the surgery, and the involvement of the future dad.ConclusionIn France women prefer in majority a normal delivery than a caesarian. They trust medical profession. It means that the medical profession approach is an answer to the increase of the caesarian demand. To be experienced as a real delivery, and not only as a surgical procedure, it would be helpful that all the perinatal medical professionals think together about how to humanize this surgical procedure.; Introduction / ObjectifsEn France, le taux de césarienne a doublé en 20 ans et depuis 2003 il s’est stabilisé autour de 21%. L’objectif de cette étude est de comprendre cette spécificité française en explorant les thèmes suivants : la perception et le vécu de cette voie d’accouchement, ainsi que l’existence ou non d’une demande de césarienne de la part des femmes. Matériel et méthodes26 entretiens qualitatifs semi-directifs ont été menés à l’Institut Mutualiste Montsouris à Paris, auprès de 7 patientes en fin de grossesse et 19 patientes ayant accouché par césarienne. Ces entretiens ont été analysés par thématique après avoir été retranscrits. Résultats Il ressort des entretiens que la césarienne est majoritairement perçue par les femmes comme une solution de dernier recours. Elle peut entraver l’estime de la femme, qui se sent incapable de mettre au monde son enfant sans aide médicale. Elle impacte également la qualité de la relation entre la mère et son enfant, notamment à cause du temps de séparation, bien que cela soit compensé par le moment privilégié offert au père à ce moment-là. Certaines femmes voient la césarienne comme un moyen d’échapper aux douleurs de l’accouchement par voie basse, d’autres la perçoivent comme plus douloureuse. Certaines patientes vivent sereinement leur césarienne, notamment quand elles ont y été préparées en cours de préparation à l’accouchement. Elles reconnaissent être ambivalentes, à la fois conscientes de l’importance d’être préparées à cette éventualité mais considèrent ce thème comme anxiogène et ne souhaitent pas nécessairement plus de détails durant ces séances. Quant à la sexualité, il semble que ce facteur influence peu l’image que les femmes se font de la césarienne en France. Concernant la demande d’une césarienne à l’initiative des femmes, celle-ci est marginale. Quand elle existe, elle n’est pas assumée par les couples. La patiente craint d’être jugée par le corps médical et que le suivi de sa grossesse en pâtisse. Le niveau de confiance vis-à-vis du corps médical est tel que la majorité des patientes adhère à la recommandation du médecin qui selon elles, a la compétence nécessaire pour choisir la voie d’accouchement. Cependant, elles veulent être impliquées dans la décision, mais il s’agit là plus d’un élément de forme que de fond. Deux éléments clés semblent permettre à la femme de bien vivre la césarienne : l’attitude bienveillante de l’équipe médicale pendant l’intervention chirurgicale, ainsi que la présence du père. ConclusionEn France, les femmes préfèrent majoritairement accoucher par voie basse plutôt que par césarienne. Le corps médical bénéficie d’un véritable « capital confiance » de la part des patientes. L’attitude des soignants, en France, fait donc office de rempart face à une demande émergente de césarienne. Afin que les femmes puissent la vivre comme un accouchement et non pas uniquement comme un acte chirurgical, il serait judicieux que tous les acteurs de la périnatalité se réunissent pour réfléchir à humaniser davantage cet acte chirurgical.