Editorial

Fetal Diagn Ther 1992;7:169-172

Département Obstétrique et Gynécologique, Hôpital Cochin, Université René-Dcscartes. Paris, France

20 Years of Perinatal Medicine in France: Successes and Failures

Today evaluation is a recognized tool, and it seems crucial to me to take this opportunity to assess 20 years of French health policy as regards safe childbirth. I will be looking at the areas where gains have been made, and those areas where on the contrary we have failed. We have clearly made progress as regards infant survival rate: neonatal death rate has gone from 23.4 infants per 1,000 in 1970 to only 7/1,000 in 1990 in France. On an inter­ national scale, France ranks among the best, after Japan and the Scandinavian countries. This improvement is the result of almost vir­ tual eradication of deaths due to fetal distress - an achievement that can be credited to sys­ tematic obstetrical monitoring and a consid­ erable rise in the rate of cesarean sections (5% in 1970 to 12% in 1989). We also have been successful in reducing differences in perinatal outcome between Caribbean born women and European born women in the islands of Martinique and Guadeloupe [Papiernik et al., 1992], The decline in per partum anoxia is similar to rates reported in comparable Euro­ pean countries such as Great Britain and Ger­ many. One major factor in reducing perinatal risk in France has been a novel prematurity pre­ vention policy. The preventive measures ap­ plied through this policy have generally met with approval in France. However, not all pregnant women, and not all employers, fol­

low the new rules. The birth rate for infants born at less than 34 weeks of pregnancy has dropped from 2.4% of all births in 1972 to 1.2% in 1981 to 0.9% in 1988. At the same time, the number of infants with birth weights under 1,500 g has dropped from 1.4% in 1972 to 0.7% in 1981, but remained stable from 1981 to 1988. This reduction in the most severe premature births has reduced the num­ ber of infants transferred to neonatal inten­ sive care units [Rumeau-Rouquette et al.; Pa­ piernik et al.]. The French prematurity policy has various counterparts in other European countries. No such policy however has ever been applied in the United States because the idea of a preg­ nancy leave has never been accepted. The US statistics for premature births have not de­ clined. nor have the differences between Cau­ casian preterms (7%) vs. Afro-American pre­ terms (13%). In contrast, a Norwegian assess­ ment of Papiernik prevention measures shows a drop in the number of infants with cerebral palsy stemming from severe preterm birth [Meberg, 1990] due to the reduction of preterm births. The French prematurity policy has been costly because of the financial impact of preg­ nancy leaves to the nation. However, it has not had an iatrogenic effect as would have been the case for excessive prescription of betamimetic drugs.

Prof. Emile Papiernik. MD Clinique Universitaire Baudclocquc Hôpital Cochin 123, boulevard dc Port-Royal F-75674 Paris Cedex 14 (France)

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Emile Papiernik

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ished the number of multiple defects and their associated fetal loss. This policy also has its drawbacks, in particular as concerns unde­ tected heart defects, which for example have not declined below 50%. This perinatal prevention policy has not always been successful. In two critical areas, we need to examine our limits more closely. We have not been able to reduce the number of handicaps due to perinatal causes, and this failure may even be on the rise in the future. We have not been able to reduce the number of trisomy 21 infants, despite all our efforts to screen for this disease. The statistics for infants developing severe handicaps such as cerebral palsy has not de­ clined over the last 10 years and may even be increasing. This is what emerges from a longi­ tudinal study by developmental pediatricians on all children born in a certain geographical area in Sweden and Finland. Hagberg shows that in one county in Sweden, the rate of severe handicaps per 1.000 births dropped significantly in the 1970s following the intro­ duction of modern obstetrical techniques and neonatal intensive care. This drop was ob­ served for full-term infants with normal birth weights. But since the end of the 1970s and in the 1980s, no progress has been observed: rather there has been a resurgence in the rate of defects per 1,000 births. Hagberg contends that these statistics re­ flect more aggressive attempts on the part of neonatal intensive care staff. Reports from a number of other countries confirm that there has been a considerable change in therapeutic attitude among neonatal pediatricians as re­ gards infants with low birth weight or extreme preterms. The methods used in intensive care on infants weighing over 1,500 g have grad­ ually been applied to infants below 1,500 g. The pediatric outcomes have also changed: 72 healthy survivors per 1,000 births in 1960 for infants weighing less than 1,500 g (67 severe

20 Years of Perinatal Medicine in France: Successes and Failures

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The survival rate for preterm infants has risen considerably through the use of ad­ vanced techniques in infant intensive care in both the delivery room and in neonatal inten­ sive care units. This has its negative side as well, which will be dealt with in the section on drawbacks and failures. Prematurity prevention mea­ sures have considerably increased expenses in terms of more medical, obstetric and pediat­ ric staff on call. After years of relying on the SAMU (the emergency medical ambulance system) to come to the place of birth to trans­ fer an infant in distress to intensive care, the idea of transferring a fetus in utero by placing the mother in a maternity ward associated to a neonatal intensive care unit is gradually gaining ground in France. This regionalization policy has been spec­ tacularly successful in the United States. There has been a remarkable increase in the survival rate of severe preterms or infants with low birth weights when complicated pregnancies are handled in level III units associating maternity wards and neonatal in­ tensive care units. This advance in neonatal care has not however compensated for the lack of a prevention policy in the United States, and this explains why the US ranks 22nd among the industrialized nations in terms of infant mortality (as compared to 6/1.000 in Japan, 7/1,000 in Sweden and 9/1,000 in France). Because a policy of ultrasound scan is ap­ plied in France at the appropriate time in pregnancy, the country has an excellent rec­ ord for screening of birth defects. Ultrasound scans were introduced in France in 1975 and became more widespread between 1980 and 1985. Currently practically all women un­ dergo scans between weeks 19 and 23 of preg­ nancy. This has led to the disappearance of anencephalies at birth, has reduced spina bif­ ida by two-thirds and has considerably dimin­

Pediatric staff is gradually becoming aware of the negative effects of certain decisions. Discussion has been instigated on the limits of neonatal care. Some teams have estab­ lished therapeutic termination criteria when brain damage of infants in neonatal intensive care is overly massive. Some issues however have not been dealt with - including the lower limit below which an infant will not be admit­ ted to intensive care. Clearly, these decisions are hard to make. Since the 1970s there have been major health policy efforts worldwide to eliminate trisomy 21 (Down syndrome). Proof that tri­ somy 21 could be detected from chromosome analysis of cells in the amniotic fluid led to a proposition of amniocentesis performed for at-risk women (aged 38 and over in France, 35+ in Great Britain and Germany and other countries in Europe). Screening lifted a prohibition on older women to become pregnant. Prior to amnio­ centesis, women were told to have children before the age of 35 because the risk of Down syndrome was less. Screening removed the age barrier. It is more than likely that this has played a role in the shift upwards in mothers’ ages at the birth of their first and second chil­ dren, which has risen markedly in France in the last 10 years. Screening for Down syndrome has been presented as successful as a policy and is viewed as such societally. However, assess­ ment of screening for trisomy 21 shows that this policy has been a total failure. All the available statistics in France (data collection on malformations by geographic zone) indicate that the number of infants born with trisomy 21 has not decreased in the last 20 years in France. Assessments can be made from records of birth defects and there are four such regional record centers in France. The Bouches-du-Rhône and the Paris center records clearly show that the number of tri­

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handicaps and 14 minor handicaps) as com­ pared to 568 healthy survivors per 1,000 births between 1980 and 1985 with 101 se­ vere birth handicaps and 59 cases of minor handicaps [Hack and Fanaroff]. The figures are even more astounding for infants weighing less than 1,000 g at birth. Practically all these infants died at birth in 1960 (17 healthy survivors/1.000 and 23 with severe handicaps and 40 with minor handi­ caps). Between 1980 and 1985, 345 in­ fants/1.000 weighing less than 1,000 g at birth survived normally with 104 severe handicaps and 75 mild handicaps [Hack and Fanaroff]. These outcomes can be interpreted in two ways. The first is to evaluate the risk of handi­ cap per number of survivors - and this risk has diminished. This has prompted pediatri­ cians to continue their efforts, in particular since there has been clearcut progress as re­ gards the number of normal surviving infants. The second interpretation, which is just as valid but less favorable, is to assess the total number of handicaps per 1,000 births, i.e. to compute the risk of handicap for any preg­ nant woman. This risk has not decreased but rather risen. Thus the price to pay individu­ ally and societally for the survival of prema­ ture infants is high as regards possible handi­ cap. The financial cost is high as well, since a baby weighing less than 1,000 g admitted to neonatal intensive care is likely to stay on the ward for an average of 90 days at roughly 1.000 US$ a day (6,000 French francs). These infants overload the ward and only a few infants arc enough to fill beds for a long period of time. The lack of reduction in the number of handicaps should be considered as a failure of our general perinatal policy. Our main objec­ tive has been to reduce defects. Observation shows that advances in techniques and medi­ cal attitudes have in fact led to opposite result.

somy 21 infants has not declined. Rather what has increased is the number of induced abortions performed on the basis of fetal ka­ ryotypes conducted systematically on women over 38, or on the basis of abnormalities detected by ultrasound scans in the second tri­ mester indicating fetal malformation. What has happened? Clearly this policy has been effective for women over 38. They may, if they desire (60% do so), have an amniocentesis or a trophoblast biopsy. And those who undergo these examinations no longer have trisomy 21 infants. Down syn­ drome babies are born to women who do not fall into the at-risk category. Analysis of the age distribution for mothers at birth shows that the shift upwards in age at pregnancy is responsible for moving women from a low risk group (the risk is 1/1,400 between 20 and 29) to a group where this risk doubles (1/700

at the ages of 30-37). This age shift fully accounts for the persistence in the number of trisomy 21 births despite screening. This is a bitter pill to swallow, given the concerted efforts at efficient screening of tri­ somy 21. Screening thus tacitly allowed a shift in the age bracket at pregnancy to take place because elderly pregnancies were presented as risk-free. This shift, authorized medically, completely undermined the benefits of the screening policy. We need to set up different screening poli­ cies and techniques. We need to screen all pregnant women for trisomy 21, with a tech­ nique that is less aggressive than amniocente­ sis. New techniques such as monoclonal anti­ bodies, cell sorting and genetic engineering will provide specific screening techniques for trisomy 21, and these should soon be on the market.

References Mcberg A: Declining incidence of low birthweight - Impact on perinatal mortality and incidence of cerebral palsy. J Perinat Med 1990:18:195-

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Papiernik E, Bouyer J. Dreyfus J. Collin D, Winisdorffer G. Gueguer. S, Le­ comte M, Lazar P: Prevention of preterm births: A perinatal study in Haguenau. France. Pediatrics 1985: 76:154-158.

Papiernik E. Goujon H, Demculemecster R. Mezin R: Evaluation d'une action de santé publique pour l’amé­ lioration de la securité à la naissance en Martinique: 1977-1984. J Gyne­ col Obstet Reprod 1992:21:347354. Rumeau-Rouquette C. du Mazaubrun C. Rabarizon V: Naître en France, 10 ans d’évolution. INSERM/DOIN Paris, 1984. vol. 1.

20 Years of Perinatal Medicine in France: Successes and Failures

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Hack M. Fanaroff AA: Outcomes of extrcmcly-low-birth-weight infants be­ tween 1982 and 1988. N Engl J Med 1989:321:1642. Hagberg B. Hagberg G. Zetterström R: Decreasing perinatal mortality - In­ crease in cerebral palsy morbidity? Acta Pacdiatr Scand 1989:78:664670.

20 years of perinatal medicine in France: successes and failures.

Editorial Fetal Diagn Ther 1992;7:169-172 Département Obstétrique et Gynécologique, Hôpital Cochin, Université René-Dcscartes. Paris, France 20 Yea...
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