Evelyne Combier

Variations in breastfeeding rates for very preterm infants between regions and neonatal units in Europe: results from the MOSAIC cohort.

Objectives To compare breastfeeding rates at discharge for very preterm infants between European regions and neonatal units, and to identify characteristics associated with breast feeding using multilevel models. Methods Population-based cohort of 3006 very preterm births (22–31 weeks of gestation) discharged home from neonatal units in eight European regions in 2003. Results Breastfeeding rates varied from 19% in Burgundy to 70% in Lazio, and were correlated with national rates in the entire newborn population. Women were more likely to breast feed if they were older, primiparous and European; more premature, smaller and multiple babies or those with bronchopulmonary dysplasia were breast fed less. Variations across regions and neonatal units remained statistically significant after adjusting for maternal, infant and unit characteristics. Conclusion It is possible to achieve high breastfeeding rates for very preterm infants, but rates varied widely across regions and neonatal units throughout Europe.

Socio-demographic risk factors for perinatal mortality A study of perinatal mortality in the French district of Seine-Saint-Denis

OBJECTIVES To investigate the impact of a set of socio-demographic risk factors commonly associated with perinatal mortality -- age, parity, marital status, educational attainment, occupation, and ethnic origin in the French district of Seine-Saint-Denis. METHODS The study has a case-control design with prospective identification of cases. It includes all singleton non-malformed perinatal deaths which occurred between October 1, 1989 and September 30, 1992. Logistic regression is used to estimate odds ratios. Base incidence rates are generated by incorporating sampling information for the controls. RESULTS All socio-demographic variables are significantly related to the risk of perinatal mortality in univariate analyses. Some of the increased risk due to social factors is explained by differential age and parity distributions. In multivariate models, however, only parity and country of origin are significant. Women born in the French overseas departments and territories and Sub-Saharan Africa have the highest odds ratios. CONCLUSIONS Women born outside of continental France face an elevated risk of experiencing a perinatal death even after controlling for age, parity and socioeconomic factors. Although, this excess risk may reflect residual variation in socioeconomic status, alternative explanations such as standards of prenatal care, medical problems during pregnancy and delivery, and cultural practices should be explored.

Distribution of maternity units and spatial access to specialised care for women delivering before 32 weeks of gestation in Europe

Survival and quality of life are improved for very preterm babies when delivery occurs in a maternity unit with on-site neonatal intensive care (level III unit). We investigated the impact of distance on the probability of delivering in such a unit for births before 32 weeks of gestation from 9 European regions with diverse perinatal health systems (the MOSAIC cohort). We analysed distances between womens homes, and the nearest level III in population quartiles, adjusting for maternal and pregnancy characteristics. Living farther away from a level III reduced access to specialised care everywhere; in some regions women residing in the fourth quartile were half as likely to deliver in level III units as those in the first. To improve regionalized perinatal care the spatial location of level III units should be taken into account.

Neighbourhood socio-economic characteristics and the risk of preterm birth for migrant and non-migrant women: a study in a French district.

Neighbourhood-level deprivation is associated with preterm birth; preterm birth rates are also higher for some, but not all migrant groups. We studied the impact of neighbourhood characteristics (a deprivation score and the proportion of foreign-born residents) on singleton preterm birth in the French district of Seine-Saint-Denis for women born in France, North Africa, sub-Saharan Africa and other countries. Multilevel logistic regression models were adjusted for maternal demographic and health care characteristics. For women born in France, the preterm birth rate rose with neighbourhood deprivation quintile (3.8% in the first to 5.7% in the fifth, adjusted odds ratio: 1.40 [95% confidence interval 1.14, 1.72]) and with increasing proportions of foreign-born residents. Preterm birth rates were not higher in more deprived neighbourhoods for women born outside of France and were lower in neighbourhoods with more foreign-born residents; in multilevel models, the inverse association with deprivation remained significant for women from sub-Saharan Africa. Area-based deprivation measures should be used with caution in populations with large numbers of migrants. These results raise questions about the health benefits of clustering for migrant communities as well as the negative consequences of acculturation.

Perinatal health inequalities and accessibility of maternity services in a rural French region: closing maternity units in Burgundy.

Maternity unit closures in France have increased travel time for pregnant women in rural areas. We assessed the impact of travel time to the closest unit on perinatal outcomes and care in Burgundy using multilevel analyses of data on deliveries from 2000 to 2009. A travel time of 30min or more increased risks of fetal heart rate anomalies, meconium-stained amniotic fluid, out-of-hospital births, and pregnancy hospitalizations; a positive but non-significant gradient existed between travel time and perinatal mortality. The effects of long travel distances on perinatal outcomes and care should be factored into closure decisions.