The drastic closure of maternity wards over the past 40 years has been justified by a desire to improve childbirth safety. The analysis of the scientific proofs is however disappointing to justify one of the constituent elements of the French medical deserts.
Between 1996 and 2016, one in three maternity wards closed in France and the number of establishments with over 3,000 deliveries per year tripled in parallel. The initial goal was to make childbirth safer. But in some regions, the closure of a maternity ward has been added to other elements to participate in the creation of a medical desert.
The perinatal decrees of 1998 defined three types of maternities according to the level of specialization of the establishments. A facility is said to be “type 1” if it has an obstetrics department (mainly private clinics and small maternity wards), “type 2” if it has a neonatology department in the same place as the obstetrics and “type 3” if it has a neonatal resuscitation department and a neonatology department, in addition to the obstetrics department and in the same place (dress).
A threshold set by decree
One of the main arguments used to justify the closure of small maternities (type 1) is a potential endangerment of mothers and children below 300 deliveries per year.
“This threshold was established on the principle that too little activity does not allow the teams the practice necessary for the safety of care to deal with an incident during childbirth”, details a report from the Court of Auditorswhile specifying at the bottom of the page that this threshold “does not appear to have been the subject of any specific study when it was set”.
This minimum threshold was therefore established by decree in 1998 and the analysis of the literature reveals that while it appears to be logical, it is based on only a few data scientists available and none has come to formally establish this threshold, except perhaps for pregnancies at high risk.
Mainly socio-economic criteria
The argument of the lack of practice of doctors and midwives due to a low rate of births in a maternity does not take into account the modes of exercise. This is particularly the case since the establishment of the Territorial Hospital Communities (CHT): the doctors and midwives all work in other establishments in the region, since the CHTs aim to pool logistical and human resources. between different public institutions. They are therefore experienced in childbirth since they practice in several different hospitals.
In reality, it is mainly socio-economic factors that play a role, and above all the availability of personnel at certain times of the year (weekend). Circumstances that could complicate the transport of patients (weather, etc.) are also very important but always fully understood. Fortunately, the quality of care for pregnant women at the time of their delivery also depends on the coordination between large and small maternities, as well as the offer of follow-up at home. after leaving maternity (accompaniment by midwives).
The real cause of closures is also economic
the report of the Court of Auditors for 2014-2015 points out “the structural underfunding of maternity wards, which can only find a balance from 1,100 to 1,200 deliveries per year, due to an old disconnection between tariffs and real costs”. “Despite an evolution tending to develop a specific tariff linked to the care of the newborn, it is permissible to wonder about the adaptation of the pricing to the activity (T2A) to these establishments”.
While the demography of health professionals in the gynecologist-obstetrician, anesthetist-resuscitator, pediatrician and midwifery sectors is higher than ever, there are, paradoxically, very pronounced territorial inequalities that future demographic changes in these professions , could still dig. If the demography of the medical health professions in the sector is high, it is because there is a greater concentration there than in other specialties of the contribution of doctors with foreign diplomas, but whose sustainability is not guaranteed.
A major reorganization of care
Maternities carrying out fewer than 300 deliveries per year and unable to justify a geographical exception could be converted into local perinatal centers in the decrees of 1998. These centers now provide pre- and post-natal consultations, preparation courses for birth, education in newborn care and family planning consultations, but no longer give birth.
Nearly 80% of births are now concentrated in type 2 or 3 maternities, and these are the ones that take care of pregnancies for which care needs are anticipated and so-called pathological pregnancies. Due to the closure of many level I maternities, births are now concentrated in level II and III maternities. This overload may have been the cause of difficulties in accessing these latter establishments for pathological pregnancies (twin or premature births). According to the 2016 Dress survey, these difficulties are in the process of being resolved.
A reorganization that bears fruit?
This reorganization of maternity wards was however accompanied by an undeniable improvement in the consideration of women’s needs according to the 2016 survey by Dress. The availability of self-controlled epidural analgesia has increased. A post-caesarean rehabilitation program is present in 2 out of 3 maternities and support by a midwife when leaving the maternity ward has become widespread.
The powers of midwives have also expanded: they carry out 87% of vaginal deliveries (without recourse to forceps-type instrumentalisation) in 2016 according to the DREES survey. They are very involved in pre- and post-natal follow-up and can carry out consultations.
This article, the result of a few interviews and the analysis of the literature on the subject, aims to expose the data currently available and is part of a series of 3 articles to document the Great National Debate
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