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TABLE I-LEGISLATIVE PROVISIONS FROM

1970 TO 1978

of

REFERENCES

1. Wilson JG. Environment and birth defects. New York: Academic Press, 1973. 2. Emery AEH. Elements of medical genetics, 4th ed. Edinburgh: ChurchillLivingstone, 1975. 3. De Vore GR, Hobbins JC. Diagnosis of structural abnormalities in the fetus. In: Warshaw JB, ed. Symposium on fetal disease. (Clin Perinatol, vol. VI.) Philadelphia: WB Saunders Co, 1979: 293-320. 4. Warkany J. Terathanasia. Teratology 1978; 17: 187-92. 5. Smithells RW, Sheppard S, Schorah CJ. Vitamin deficiencies and neural tube defects. Arch Dis Child 1976; 51: 944-50. 6. Jacobs PA, Melville M, Ratcliffe S, et al. A cytogenetic survey of 11,680 newborn infants. Ann Hum Genet 1974; 37: 359-76. 7. Boué A, Boué J. Chromosome anomalies associated with fetal malformations. In: Scrimgeour JB, ed. Towards the prevention of fetal malformation. Edinburgh: University Press, 1978; 49-65. 8. Ferguson-Smith M. Maternal age specific incidence of chromosome aberrations at amniocentesis. In: Murken J-D, Stengel-Rutkowski S, Schwinger E, ed. Prenatal diagnosis. Stuttgart: Ferdinand Enke, 1979; 1-21. 9. Kleihauer E, Braun H, Betke K. Demonstration von fetalem hämoglobin in den erythrocyten ein blutansstrichs. Klin Wsch 1957; 35: 637. 10. Lorber J. Ethical problems in the management of myelomeningocele and

TABLE II-SUPERVISION OF PREGNANCY IN

1972

AND

1976*

hydrocephalus. J Roy Coll Phycns 1975; 10: 47-60. GD, Drummond M. Results of selective early operation in myelomeningocele. Arch Dis Child 1973; 48: 676-83. 12. U.K. Collaborative study on serum-alpha-fetoprotein in relation to neural tube defects: maternal serum AFP measurement in antenatal screening for anencephaly and spina bifida in early pregnancy. Lancet 1977; i: 11. Stark

1323-32. 13.

Scrimgeour JB, Brock DJH.

Maternal plasma alphafetoprotein screening for fetal neural tube defects. In: Murken J-D, Stengel-Rutkowski S, Schwinger E, eds. Prenatal diagnosis. Stuttgart: Ferdinand Enke, 1979; 124-26. 14. Galjaard H. Early diagnosis and prevention of genetic disease: Molecules and the obstetrician. In: Scrimgeour JB, ed. Towards the prevention of fetal malformation. Edinburgh: University Press, 1978; 3-18.

FRANCE F. BEAUFILS* A.

*data from Rumeau-Rouquette et al.I

expenses for examination and

BOUɆ

Société Francaise de Médecine Périnatale

A PERINATAL mortality of 26 per 1000 (22 000 stillbirths and early neonatal deaths in 850 000 births) and 40 000 children surviving the first year with a handicap of perinatal origin at an annual cost to the nation (including medical and social services and loss of earnings) equivalent to 2-3% of the gross national product: such were the figures which, in 1970, stimulated a programme of joint action by public agencies, physicians, obstetricians, and neonatologists. The 6th and 7th Plans (1971-75; 1976-80) addressed numerous issues-research, teaching, equipment, legislation-and the fall in perinatal mortality to 14-7 per 1000 in 1978 is evidence of their success. The countries which France used as models also made progress and thus maintained their leads.

care

(including hospital

EQUIPMENT The setting of standards by the Ministry of Health resulted in the closure or amalgamation of several public and private maternity units, especially those with fewer than 15 beds. Nevertheless, in 1976 there were still many small units (table III). 54 million francs was allocated to renovation of public maternity units and the

PREVENTION

Table I summarises the legislation introduced to reduce fetal and neonatal morbidity. In 1965, financial support had been made contingent upon 4 antenatal visits. There were suggestions that the number of obligatory visits should be increased, but more than 60% of women now attend more than 4 times (table II), and emphasis is being put on the quality of antenatal care provided at these visits. In addition, since 1975 midwives have provided domiciliary supervision; and, since 1978, all

*Department of Paediatrics, Hôpital Bretonneau, 2 rue Carpeaux, 75877 Paris Cedex 18, France. †Groupe de Recherches de Biologie Prénatale V.73, Château de Longchamp, 75016 Paris.

treat-

the sixth month of pregnancy are paid by the State. In some circumstances, prenatal and postnatal leave may be extended from 16 to 20 weeks. As to care of the newborn baby, this has been improved by compulsory health certification after the 8th postnatal day; again, all medical costs during the first month can be recovered from the State. Prevention of congenital anomalies (26.4per 1000 live births in 1976) has been reinforced by establishment of more genetic counselling clinics and antenatal diagnosis centres. All newborn babies are screened for phenylketonuria, and in 1979 hypothyroidism was added to the programme.

ment) after

TABLE III-DISTRIBUTION OF MATERNITY

’data from Rumeau-Rouquette et al.’

HOSPITALS*

1353

purchase of equipment for echography, cardiotocography, resuscitation, and so on. The neonatology beds are provided sometimes by paediatric departments, sometimes by obstetric departments. But most of the seriously ill newborn babies are admitted to neonatal intensive-care units. We still need more neonatal units. TEACHING, EDUCATION,

RESEARCH

The Ministry of Health says that since 1970 it has paid for the training of 35 000 people, but this is probably an underestimate in view of the great number of regional and national meetings, educational publications, and so on. But the number of teaching posts created is small. In obstetrics, between 1971 and 1975 there were only 18 new professorships and 21 new associate and assistant professorships. Figures for neonatology cannot be given since this discipline is included in ’

pwdiatrics. As to research, apart from the usual grants for salaries, equipment, &c., INSERM (Institut National de la Sante et de la Recherche Medicale) has provided 18 million francs since 1971 for special projects in perinatal medicine. In addition, during the same period the Délégation Générale a la Recherche Scientifique et Technique has given 56 million francs for fundamental research on the biology of reproduction and development and for training of young French scientists and doctors abroad. TRENDS IN PERINATAL HEALTH

The accompanying figure shows the changes in perinatal mortality from 1955 to 1978. In 1970, the objective for 1980 was a perinatal mortality of 18 per 1000 live births: this was achieved in 1975. The 1977 rate was 15-6, and the provisional figure for 1978 is about 14.7. Preterm deliveries fell from 8-2% in 1972 to 6.8% in 1976; the proportion of small-for-dates infants is unchanged at about 5%. The decline in mortality is attributable largely to a reduction of neonatal deaths rather than stillbirths. This were born in better may be partly because the babies

Perinatal mortality rates in three countries. For France, heavy line is observed rate; 1 is expected evolution, middle hypothesis; and 2 is expected evolution, favourable hypothesis.

was probably the imof neonatal care: the mortality rate in proved quality most neonatal intensive-care units fell from 30% to under 20%. It is not possible to say what part has been played in this progress by public-health activities, what by teaching, what by changes in habits of living. We do know, however, that the supervision of pregnant women and newborn infants has been much improved (table 11). In the INSERM study of 1972-76 67% of newborn infants had been examined by a paediatrician, and the proportion will certainly have been increased by the recommendations of 1978 (table i). The INSERM investigators also had some advice on future projects. In three administrative regions the perinatal mortality was much higher (around 20 per 1000) than average. Accordingly, special campaigns were started in these regions. The INSERM workers showed that quality of supervision was strongly influenced by socioeconomic factors-for instance, women without a ’ professional diploma attend for antenatal visits less often than those with diplomas, and the highest attendance rates are seen in those with university degrees. In prevention, special attention needs to be paid to immigrants, who account for 17.7% of deliveries. Progress has to be made in prevention of intrauterine growth retardation. We surmise that, in both perinatal mortality and perinatal morbidity, the full effects of the most recent preventive measures will not be felt for some years to come.

conditions, but the main factor

We thank Dr A. C. Rousseau of the Maternity and Child Problems Division of the Ministry of Health, for providing many documents, and Dr Samuel Berenberg for preparing the English script. Many of the data and figures are from Rumeau-Rouquette et al.I

Reprints of this article are not available but the series will be published later.

a

collected reprint of

REFERENCE

1.

Rumeau-Rouquette C, Breart C, Du Mazaubrun C, Crost M, Rabanson Y. Evolution de la pathologie périnatale et de la prévention en France: enquêtes nationales INSERM 1972-76. J Gynécol Obstet Biol Reprod 1978; 7: 905-16.

"... the parapsychologists plead ... that they deserve to be taken on trust. Although their experiments cannot be repeated, nor demonstrated to order, they should still be treated as scientific knowledge, because the people who do the work are vouched for by genuine scientists. As Pliny observed, the cobbler should stick to his last: scientific ability is no guarantee of good judgment in gardening, politics or theology. The validity of ESP could, of course, be established in a very simple way. If some practitioner of the art would publicly and accurately forecast the outcome of elections, stock market changes or sporting events, all arguments would cease. No performance of this kind has ever been given and current research does not envisage anything so straightforward. The enthusiasts record large numbers of guesses about trivial issues, such as the designs on cards, and claim that any departure from the so-called laws of chance is proof of the supernatural. These are feeble weapons of persuasion, which the great wizards of the past have scorned. Nostradamus and the rest of them made thumping big prophecies which could be proved true or false without slide rules and books of tables. Their modern counterparts will need to do something of the same kind if extra-sensory perception is not to moulder along with phrenology, palmistry and astrology in the dustbin of science."-JOHN LENIHAN. Science in Action. Institute of Physics, Bristol and London, 1979. Pp. 223. ,E7 50.

Better perinatal health. France.

1352 of known factors such prevent many. as alcohol we Reprints of this article are not available but the series will be published later. should...
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