[Compulsory medical certificates of early childhood: unknown epidemiology tool]. / Les certificats médicaux obligatoires de la première enfance: un outil épidémiologique méconnu.

The delivery of three medical certificates has been made compulsory in 1970, the first during the first eight days of life, the second and the third respectively at 9 and 24 months. Thirty years later a survey has been conducted to evaluate the application and the efficiency of the system in 100 french departments. All the medical directors of the departmental MCH service send back the questionnaire. The number of annual birth by department is of 7,665 (mean) with extremities of 800 to 36,457. The covering of the concerned population is very good for the first certificate and increasing from 88.8% in 1992 to 94.9% in 1998; it is less good and not increasing for the CS9 (71.1%) and the CS24 (66%). The answers to each item are also variable according to the department but with an average of 86% (to refer to 650,000 annual births). The computer treatment of the certificates is increasing since ten years but 8 departments are still using manual analysis. In spite of the decentralization of MCH service each department is obliged to send to the Ministry of Health, each year, the results of 22 indicators which makes it possible to follow up the evolution of the situation of young children at the national level and to establish comparasons between departments. Simultaneously the certificates allow to guide the MCH activities, often at the canton level. The first certificate has been very useful for the study of perinatal problems and the third for the vaccination coverage. For example, some results are given and discussed (qualification of the examiner, neonatal mortality and socio-economical categories, mother âge, duration of pregnancy, birth weight, vaccination coverage...). Of course, the system is not perfect but is improving due to a better information of the medical personnel and of the families. It is still necessary to continue the research to underline the deficiencies and to correct them. Probably, in the future, the system will be extended to the registration of data obtained at the maternal school (3-4 years old) and the elementary school (5-6 years old).

[Epidemiological study of noted children under 6 years of age in danger in medicosocial services in a French department (Ille et Vilaine)]. / Etude épidémiologique des signalements d'enfants de moins de 6 ans en danger aux services médico-sociaux d'un département français (Ille et Vilaine).

An epidemiological study was conducted during 1 year (1989) in a French department (Ille et Vilaine) on children under 6 years of age reported by local medico-social services as being at risk of child abuse or neglect. This involved 786 children, ie an incidence of 1/80 children under 6. Among these children, 282 (35.9%) presented with clinical signs possibly related to abuse; only nine were hospitalized after being reported, showing the limits of the hospital to detect child abuse or neglect. The psycho-social characteristics of the families, the sources and motives of the reports, the criteria used to assess the risks run by the children, the care and protection measures were investigated through multifactor statistical analysis. Alcoholism, violence and parental immaturity were the most worrying factors. Social workers were at the origin of most reports and referrals (78%); most often they were alerted by socio-economic problems and parental immaturity. Physicians were in a better position to signal physical abuse, but they overlooked the situations of neglect. These were 388 children referred to the judiciary; 91 were removed from their families. Removal was ordered by courts in the presence of alcoholism, familial violence, disabled parents, offence records, insanitary housing, physical abuse or neglect, repeated hospitalizations. The perception of the risks was found to be a subjective notion depending upon the assessor's experience and tolerance thresholds, but also the quality of the professionals training and the organization of the services.

[Infantile mortality in Ile-et-Vilaine (1970-1986)]. / La mortalité infantile en Ille-et-Vilaine (1970-1986).

The rates and the causes of infantile mortality between 1970 and 1986 in the district of Ille-et-Vilaine are reported. During that period, infantile mortality rate decreased from 18.7 to 7.06% and from 12.4 to 3.6% during the first week (0-6 days), thereby suggesting the efficacy of medical care programs for this pediatric age group in France. Since 1980, with more accurate record keeping, using the recommended international classifications, there is a relative stagnation in the rate or early neonatal deaths (3.97 to 3.67) as compared to a sizable drop in the rates of late neonatal deaths (1.90 to 0.73) and post neonatal deaths (4.63 to 2.57). Congenital abnormalities have become the most important cause of death (34%) before prematurity (24.58%). However, the number of congenital anomalies should quickly decrease with prenatal screening programs leading to interruption of pregnancies. Although the percentage of infantile deaths due to prematurity has decreased from 66% between 1970 and 1974 to 24.58% in recent years, prematurity remains an important cause of death. Infections have decreased and the Sudden Infant Death Syndrome is currently the most important cause of death during the postneonatal period. The well known factors of risks are confirmed and particularly increased vulnerability of the population with a low socio-economic status which should lead to appropriate prevention programs. Despite these very impressive results, birth remains the most vulnerable period of life and current efforts should continue. Priority must be given to the improvement of prenatal care which requires good ongoing collaboration between obstetrics and pediatrics and the use of the Maternity Health Booklet.

[Autopsy in neonatal death]. / Apport de l'autopsie lors du décès néonatal.

Among 125 neonatal deaths which occurred between 1985 and 1987 in a neonatal intensive care unit, 90 autopsies (72%) were performed. Autopsies in 58 cases (64%) confirmed antemortem conclusions. In 26 cases (28%) post-mortem examination rectified antemortem findings whereas in 6 cases (6.6%) it did not contribute to a better understanding of the cause of death. When there was a risk of an heritable disease and genetic counselling was necessary (31 cases), the autopsy permitted to provide the diagnosis in 4 cases and to reassure the family in 17. In 23 cases the post-mortem examination had to be completed by perimortem studies to be contributive. As no antemortem data allowed to predict the value of the autopsy, a postmortem study should by systematically requested in cases of death during the neonatal period.

[Stillbirths in Ile-et-Vilaine]. / Etude de la mortinatalité en Ille-et-Vilaine.

The study of stillbirths is a way to approach foetal medicine and a good opportunity to foster a closer relationship between obstetricians, pediatricians and public health physicians, which will lead to preventive measures known to be effective in decreasing mortality rates. Four hundred and ninety pregnancies which ended in stillbirths were investigated: 61 before 27 weeks of amenorrhea, 228 between 28th and 36th weeks, 194 after 37 weeks. The different causes were identified: intrauterine growth retardation and pathological pregnancies remain the most important causes but the authors attract attention to a category of foetal deaths occurring at the end of the pregnancy without any evident cause and for which "postmaturity" was likely. The data attract attention on the necessity to carry out research on stillbirths through a closer collaboration between obstetricians and pediatricians and suggest that appropriate preventive measures may lead to a significant reduction of the 25% of avoidable deaths.

[Toward a reduction of perinatal mortality]. / Pour une réduction de la mortalité périnatale.

Having studied perinatal mortality in Ille-et-Vilaine from 1972 onwards, the authors have come to realise how out of date the present method of working out perinatal mortality is because it only takes account of late intra-uterine death and early neonatal mortality of infants weighing at least 1 kilogram. The old method does not take notice of the changes that have occurred because of the progress that has taken place in obstetrics and neonatology such as the survival of an increasing number of newborn that weigh less than 1,000 grams or of the fact that the distinction between early and late neonatal death seems to be less and less valid. It does not add up to the total of "lost pregnancies". Furthermore, it does not make it possible to compare our figures with those published in foreign countries. The authors therefore feel that a new definition of perinatal mortality should be made, and this should satisfy the four following requirements: It should include on the one hand all fetuses and newborn that weigh at least 500 grams and on the other hand it should include early and late mortality and even mortality that occurs after the neonatal period. It should take into account the problem of false still-births. It should take into account fetal malformations and abnormalities that have called for therapeutic abortions because they are among the principal causes of perinatal mortality. It should study all the statistics and publications on this subject.

[The results obtained from the first certificate of health between 1972 and 1979 at Ille-et-Vilaine (author's transl)]. / Résultats tirés du premier certificat de santé de 1972 à 1979 en Ille-et-Vilaine.

The authors describe and comment on some of the results that have been obtained in a French département (Ille-and-Vilaine) using the information obtained from the first health certificate which has been set up compulsorily for all children in the eight days following delivery. This analysis makes it possible to carry out an annual survey of the demographic course of affairs (birth rate, perinatal mortality rate) and compare these with France as a whole. The certificate gives interesting information about labour (multiple births, Caesarean births, the state of the infant at birth, weight, length, skull circumference, prematurity and small for dates), and the pathology of the first week of life (transfer to other hospitals and death). Malformations are as yet poorly registered and there is need to obtain more information from doctors. Correlations can be established, as for example between neonatal mortality and social class. Finally, using this first certificate will make it possible to open a file on high-risk women for a possible future pregnancy. the authors point out that the contents obtained in the first certificate had to be modified and will later give extra information about the pregnancies, the number of antenatal visits, the number of admissions to hospital, and the preparation for delivery, etc. The results that have up till now been given for various maternity departments allow each obstetrician to audit the work in his department.