Barriers to prenatal care in Europe.

BACKGROUND: In Europe, it is sometimes assumed that few barriers to prenatal care exist because extensive programs of health insurance and initiatives to promote participation in prenatal care have been established for many decades. METHODS: A case-control study was performed in ten European countries (Austria, Denmark, Germany, Greece, Hungary, Ireland, Italy, Portugal, Spain, and Sweden). Postpartum interviews were conducted between 1995 and 1996. A total of 1283 women with inadequate prenatal care (i.e., with 0, 1, or 2 prenatal care visits or a first prenatal care visit after 15 completed weeks of pregnancy) and 1280 controls with adequate prenatal care were included in the analysis combining data from the ten countries. RESULTS: Based on combined data of the ten countries, lack of health insurance was found to be an important risk factor for inadequate prenatal care (crude odds ratio [OR] at 95% confidence interval [CI]: 30.1 [20.1-47.1]). Women with inadequate prenatal care were more likely to be aged < 20 years (16.4% vs 4.8%) and with higher parity (number of children previously borne) than controls. They were more likely to be foreign nationals, unmarried, and with an unplanned pregnancy. Women with inadequate care were also more likely to have less education and no regular income. They had more difficulties dealing with health services organization and child care. Cultural and financial barriers were present, but after adjusting for confounders by logistic regression, perceived financial difficulty was not a significant factor for inadequate prenatal care (adjusted OR [95% CI]: 0.7 [0.4-1.3]). CONCLUSIONS: Personal, socioeconomic, organizational, and cultural barriers to prenatal care exist in Europe.

Depressive symptoms are often unrecognized in gynaecological practice.

We performed a study on depressive symptoms in gynaecological practice in Belgium, identifying depressive symptoms according to both practitioners' opinions and the scores on a scale developed to detect depression in general medical settings. According to the 170 participating gynaecologists, 12% of the 2174 women they interviewed had symptoms of depression. However, 35% had two or more positive answers on the Depression Scale, and 19% had four or more positive answers. Our results suggest that depressive symptoms are often not identified in clinical gynaecological practice.

Oxytocics in developing countries.

OBJECTIVES: A prospective multicenter study of obstetric practices was conducted in three developing countries (Benin, Congo and Senegal) to analyze oxytocic use during labor. One of the objectives was to assess the possible negative effects of the treatment regimens instituted during the labor monitoring phase. METHODS: Four health districts participated in the study. All women who gave birth in one of the participating health facilities over a 6-month period in Benin and Congo, and over a 3-month period in Senegal, were recruited. The number of deliveries studied in each district varied from 457 to 1048. For each case a partogram was used to assess the progress of labor and the onset of dysfunctional labor. Information was collected on the risk factors for dysfunctional labor, stillbirths and resuscitation of the neonate. RESULTS: Each of the four collaborating centers used oxytocics preferentially to treat dysfunctional labor, but even in normal labor (i.e. with a normal partogram) oxytocics were used in 4.4-21.5% of cases. In normal labor the incidence of neonatal resuscitation was higher in cases with than in those without oxytocic use: the relative risks (R.R.) varied from 1.9 to 5.6; the odds ratios varied from 2.4 to 7.0, and both were statistically significant in the four settings. In addition the stillbirth rate was always higher, though not significantly, when oxytocics were used in normal labor (R.R. 1.2-2.2). When the data of the four centers were pooled, the global relative risk for stillbirths was 1.9, and the 95% confidence interval was 1.1-3.4. Logistic regression analysis was carried out for five confounding factors (primiparity, a previous complicated delivery, presence of meconium, ruptured membranes and educational level) to adjust the odds ratio for the risk of neonatal resuscitation when oxytocics were used in normal labor. Except in the case of Abomey in Benin, where the variable 'presence of meconium' decreased the odds ratio from 6.4 to 3.4, the adjusted odds ratios remained similar to their non-adjusted values. In cases of non-dysfunctional labor, nurses and midwives used oxytocics more often than lesser trained health personnel (R.R. 4.0 [3.2-5.1]). CONCLUSION: Our results show that an obstetric treatment which is safe when used in certain well-defined indications, may have significant negative effects when used in situations where the same technical quality of care cannot be guaranteed.

Combined use of nicotine patch and gum in smoking cessation: a placebo-controlled clinical trial.

BACKGROUND: Smoking is considered as an addiction to nicotine for most subjects consuming 10 cigarettes or more per day. Hence, nicotine replacement therapy by way of gum, patch, or spray has been advocated. The rationale of this study is to evaluate the possible beneficial effects of adding nicotine gum to the routine of subjects using the nicotine patch. The effect of the nicotine patch against the placebo, both groups receiving placebo nicotine gum, has also been assessed. METHODS: Healthy subjects (374) were randomized at their work-setting in a 1-year double-blind placebo-controlled trial: 149 subjects to active nicotine patch + active gum (group 1), 150 to active nicotine patch + placebo gum (group 2), and 75 to placebo patch + gum (group 3). Treatment duration was 12 weeks with a 16-hr transdermal patch of 15 mg, followed by a 6 + 6-weeks weaning period on respectively 10 and 5 mg patches. Gum use was not restricted during the first 6 months, with recommendations to use at least four pieces a day. A strict definition of smoking abstinence was used in this study, which did not allow smoking any cigarette after Week 1. Nonsmoking status at each visit, as reported by the subjects, was verified by CO below 10 ppm in expired air. RESULTS: Abstinence rates in group 1 against group 2 were 34.2 and 22.7% (P = 0.027) at 12 weeks, 27.5 and 15.3% (P = 0.010) at 24 weeks, and 18.1 and 12.7% (P = 0.191) at 52 weeks. In group 3, abstinence rates were 17.3, 14.7, and 13.3% respectively at 12, 24, and 52 weeks. Using logistic regression with adjustment for six baseline covariates, odds ratios for abstinence (with 95% CI) were computed. For group 1/group 2, OR at 12, 24, and 52 weeks were 1.72 (1.03-2.94) (P = 0.039), 2.04 (1.14-3.57) (P = 0.018), and 1.47 (0.76-2.76) (P = 0.125). No significant differences in OR were observed when comparing groups 2 and 3. Time to relapse is significantly longer in group 1 as compared to that of group 2 (P = 0.041), whereas no significant differences between groups 2 and 3 were observed. No significant differences between the three groups in systemic and local adverse drug events were observed. CONCLUSION: Adding active gum use to active patch use in subjects smoking 10 cigarettes or more a day increased abstinence rates, which are statistically significant up to 24 weeks.

[Levels of low birth-weight in Europe: registration problems and effects of medical interventions]. / Les taux d'insuffisance pondérale à la naissance en Europe: problèmes d'enregistrement et effets des interventions médicales.

The rate of low birthweight births, percentage of live births weighing less than 2500 grams is one of the perinatal health indicators recommended by the World Health Organisation. A review of the literature has revealed numerous problems related to this indicator. Some countries, including France and the Netherlands do not collect birthweight data. Elsewhere, there are more than 10% "unknown birthweight". The poorest registration is for birthweights below 1000 grams. Exclusion of babies who were registered as stillborn, when in fact they died shortly after birth can cause underregistration of low birthweights. Conversely, inclusion of true stillbirths will bring on an overestimation of low birthweight rate. Some countries have too few births to deliver accurate rates. Rates of medical interventions, such as infertility treatment and elective induction should be taken into account when analyzing differences between countries. Improvement in quality of registration and caution in the use of this indicator are warranted.

Randomised controlled trial of routine cervical examinations in pregnancy. European Community Collaborative Study Group on Prenatal Screening.

Preterm delivery is strongly associated with neonatal mortality and morbidity. In some European countries, cervical examinations are used routinely during pregnancy to identify women at risk of preterm delivery. We sought to evaluate the efficacy and secondary effects of these routine cervical examinations. We did a randomised controlled trial in seven European countries, comparing two policies--namely, an attempt to do a cervical examination at every prenatal visit (2803 women) and avoidance of cervical examination if possible (2799). The median number of cervical examinations was 6 in the experimental group and 1 in the controls. There were 6.7% preterm (< 37 weeks) deliveries in the experimental group and 6.4% in the control group (risk ratio 1.05 [95% confidence interval 0.85-1.29]; non-significant). The low birthweight rate was 6.6% in the experimental group and 7.7% in the controls (non-significant). Premature rupture of membranes was not significantly more frequent in the experimental group (27.1% vs 26.5%). Our findings do not support the routine use of cervical examinations during pregnancy.

[Survey on the continuity of contraception in Algiers]. / Enquete sur la continuite de la contraception a Alger.

PIP: The data collection system of Algeria's family planning program allows estimation of the number of women using contraceptives, the methods used, and consumption of supplies, but does not permit estimation of the duration of use, the number of times the method has been changed, or the place where supplies are obtained. This work presents results of a retrospective survey conducted in the wilaya of Algiers in 1993. The records of women in 30 randomly selected maternal-child health centers in Algiers who began contraceptive use in 1990 through 1992 were analyzed. Records of 443 oral contraceptive (OC) users and 337 IUD users were included. The analysis indicated that IUD users were older and had more children that OC users. Among IUD and OC users respectively, 0% and 5% were aged 15-19, 4.5% and 11% were 20-24, 22% and 31.5% were 25-29, 25.5% and 26% were 30-34, 22% and 13% were 35-39, and 26% and 16% were 40 or over. 0.3% of IUD users and 29% of OC users were nulliparas, 44% and 34.5% were at parity 1 or 2, and 54% and 34% were at parities over 2. Users were divided into the three categories of active, defined as continuing use and attending the clinic within the past three months for OC users or one year for IUD users; lost to follow-up and stopping method use. 65.3% of IUD users and 44.2% of OC users were active. 31% of IUD users and 52% of OC users were lost to follow-up. 4% in each group were known to have terminated method use, 52% to become pregnant, 3% for lack of supplies, and 3% due to secondary effects. The probabilities of continuing use of the IUD and OCs respectively were 74% and 67% at six months, 67% and 54% at twelve months, 58% and 43% at eighteen months, and 52% and 32% at twenty-four months. Over half of IUD users continue use for thirty-six months or more, but the average duration of OC use is only 14.7 months.^ieng

[Cholecystectomy by celioscopy: indications and safety of the method. Apropos of a consecutive series of 300 patients]. / Cholécystectomie par coelioscopie: indications et sécurité de la méthode. A propos d'une série consécutive de 300 patients.

We performed a laparoscopic cholecystectomy in 300 patients with gallstone disease complicated or not. The rate success was 97%, however involved the pathology might be. Indeed, 15% of the patients had an acute cholecystitis (10% catarrhalis, 5% empyema). Twenty-four patients with common bile duct stones had a complete endoscopic management of the biliary disease: endoscopic sphincterotomy and laparoscopic cholecystectomy. Operative mortality was absent and overall morbidity was 3.7%, exclusively minor.

[Treatment of familial rectocolonic polyposis with total colectomy using ileorectal anastomosis in 6 members of a family: the value of early diagnosis]. / Traitement de la polypose rectocolique familiale par colectomie totale avec anastomose iléo-rectale chez six membres d'une fratrie: intérêt d'un diagnostic précoce.

We report on the observation of six cases in a family of eight, all under 30, in whom the diagnosis was obtained at first hand by rectosigmoidoscopy. This procedure appears sufficient as the number of polyps tends to decrease with increasing distance from the anal margin. The recent finding of abnormalities of chromosome 5 (long arm) permits the identification of carriers of this genotype by simple blood examination (DNA probe), thus greatly enhancing the possibilities of screening for the disease. Each of our cases was managed with subtotal colectomy and ileorectal anastomosis. Preservation of the rectum was preferred to other techniques as all subjects were young, mildly affected and with good motivation for twice-yearly endoscopic follow-up. The surgical technique appears simple and quite safe with satisfactory functional results and easy feasibility of endoscopic surveillance.

[Oromandibular and limb malformation syndromes. Reflections on hypoglossia-hypodactyly]. / Les syndromes malformatifs oromandibulaires et des membres. Réflexions sur l'hypoglossie-hypodactylie.

Oromandibular and limb syndromes present particular types of orofacial lesions. Six personal cases and about one hundred cases reported in the literature are reviewed using Hall's classification. Etiopathogenic mechanisms are being increasingly related to fetal epigenetic and environmental factors.