Prenatal and delivery care in the low-risk and general population


Jennifer Zeitlin and Camille Le Ray


This theme focuses on evaluating pregnancy and delivery care for all pregnant women in order to identify best practices and assess their implementation at all levels of the health system. In high-income countries with good access to prenatal and delivery care, a majority of women and babies will not experience complications, yet life-threatening complications can arise unexpectedly at any time in pregnancy, childbirth or the postpartum. The challenge is thus to guarantee optimal medical safety while avoiding over-medicalization and its negative effects on health and healthcare costs and promoting women’s participation in decisions about the birth.


The research projects focus on the general population of pregnant women and are grouped in 5 sub-objectives.

1) Optimizing labor and delivery care

Vaginal delivery is associated with less maternal morbidity and, in the absence of fetal complications, is at least as safe as a cesarean delivery for the infant. It is also the preferred option for the large majority of pregnant women. However numerous interventions are used during labour to reduce the risk of cesarean section. Our objective is to assess the benefits and risks of obstetrical interventions, such as labor induction, augmentation of labor, epidurals and instrumental vaginal delivery, which are widely used to facilitate labor with the aim of ensuring a natural delivery and a mother and newborn in good health.

2) Integrating the expectations of women in labor and delivery care

Demands from pregnant women for less medicalization during childbirth have led to an interest in the use of alternative practices during labor and delivery, but their effectiveness or potential adverse effects need to be investigated. More generally, while medical outcomes, such as cesarean rates and maternal and neonatal complications, are essential for evaluating the quality of care, they are not sufficient. These projects evaluate these practices, as well as maternal satisfaction, expectations and experiences.

3) Evaluating the organization of prenatal care and preventive actions during pregnancy

Health system factors are major determinants of perinatal health. Changes in maternity care provision, including evolving medical demography, less private sector involvement, implementation of care networks, require continual evaluation. Projects focus on sub-optimal use of the health system, including overuse of emergency care and other services or interventions resulting from poor coordination between providers within networks, preventive care and adherence of obstetric departments to best practice guidelines.

4) Investigating disparities in healthcare provision and social inequalities in perinatal health

Inequalities in perinatal health outcomes arise among others from sub-optimal organization or provision of health services and can interact with social factors to create social inequalities in health. These can be related to differential access to care, including prenatal screening and health services, as well as the quality of care in hospitals where disadvantaged populations receive their care. Projects also aim to identify how social factors modulate the care received and affect key health promoting behaviors; other studies also focus on the specific needs of migrant women. Research on these topics is done in relation with the theme on social inequalities.

5) Assessing trends in perinatal health and care across Europe

This research evaluates trends in health and care and the association between healthcare policies and practices and outcomes using national-level health indicators from the French Perinatal Surveys in France and compiled by the Euro-Peristat project in 31 European countries. New 2015 data on the Euro-Peristat core indicators will make it possible to evaluate recent trends in cesarean delivery, preterm birth and perinatal mortality and the risk factors associated with these trends, in particular increasing maternal age.

Principal data sources

  • The French National Perinatal Surveys (FPS), based on representative samples of births in 1995, 1998, 2003, 2010 and 2016, include an interview with the mothers, data extracted from the medical file, and information on department operations (see appendix 1).
  • EURO-PERISTAT brings together data collected routinely in the countries of the European Union as well as Iceland, Norway, Switzerland, for births in 2000, 2004, 2010 and 2014 (in progress).
  • MEDIP cohort (Methods of induction of labor and perinatal issues : a national cohort)
  • PASST trial (Alternative to intensive management of second stage of labor: a multicenter randomized controlled trial)
  • JUMODA: national population-based study on twin deliveries assessing the modes of delivery
  • PreCARE cohort study: multicenter on maternal social deprivation
  • Statistics from vital status registries (births and deaths) and causes of death, associated with data on the social characteristics of municipalities of residence, obtained mainly from the census.
  • Hospital discharge statistics (PMSI)
  • Implementation of ad hoc surveys, some of which have reached the stage of a search for funding.

Main publications since 2014

Linard M, Blondel B, Estellat C, Deneux-Tharaux C, Luton D, Oury JF, Schmitz T, Mandelbrot L, Azria E. Association between inadequate antenatal care utilisation and severe perinatal and maternal morbidity: an analysis in the PreCARE cohort. BJOG, 2017 Jun 20, Epub ahead of print).

Blondel B, Cuttini M, Hindori-Mohangoo AD, Gissler M, Loghi M, Prunet C, Heino A, Smith L, van der Pal-de Bruin K, Macfarlane A, Zeitlin J, Euro-Peristat Scientific C. How do late terminations of pregnancy affect comparisons of stillbirth rates in Europe? Analyses of aggregated routine data from the Euro-Peristat Project. BJOG 2018;125:226-234.

Gonthier C, Estellat C, Deneux-Tharaux C, Blondel B, Alfalate T, Schmitz T, Oury JF, Manderbrot L, Luton D, Ravaud P, Azria E. Association between maternal social deprivation and prenatal care utilization : the Precare cohort study. BMC Preg Child 2017;17:126.

Schmitz T, Prunet C, Azria E, Bohec C, Bongain A, Chabanier P, et al. Association Between Planned Cesarean Delivery  and Neonatal Mortality and Morbidity in Twin Pregnancies. Obstet Gynecol 2017;129:986-995.

Siddiqui A, Cuttini M, Wood R, Velebil P, Delnord M, Zile I, Barros H, Gissler M, Hindori-Mohangoo AD, Blondel B, Zeitlin J, Euro-Peristat Scientific C. Can the Apgar Score be Used for International Comparisons of Newborn Health? Paediatr Perinat Epidemiol 2017;31:336-345.

Bonnet MP, Prunet C, Baillard C, Kpéa L, Blondel B, Le Ray C. Anesthetic and Obstetrical Factors Associated With the Effectiveness of Epidural Analgesia for Labor Pain Relief: An Observational Population-Based Study. Reg Anesth Pain Med 2017;42:109-116.

Le Ray C, Lepleux F, De La Calle A, Guerin J, Sellam N, Dreyfus M, Chantry AA. Lateral asymmetric decubitus position for the rotation of occipito-posterior positions: multicenter randomized controlled trial EVADELA. Am J Obstet Gynecol 2016;215:511.e1-7.

Coulm B, Blondel B, Alexander S, Boulvain M, Le Ray C. Elective induction of labour and maternal request: a national population-based study. BJOG 2016;123:2191-2197.

Opatowski M, Blondel B, Khoshnood B, Saurel-Cubizolles MJ. New index of social deprivation during pregnancy: results from a national study in France. BMJ Open 2016;6:e009511.

Zeitlin J, Mortensen L, Cuttini M, Lack N, Nijhuis J, Haidinger G, Blondel B, Hindori-Mohangoo AD, Euro-Peristat Scientific C. Declines in stillbirth and neonatal mortality rates in Europe between 2004 and 2010: results from the Euro-Peristat project. J Epidemiol Community Health 2016;70:609-15.

Macfarlane AJ, Blondel B, Mohangoo AD, Cuttini M, Nijhuis J, Novak Z, Olafsdottir HS, Zeitlin J, Euro-Peristat Scientific C. Wide differences in mode of delivery within Europe: risk-stratified analyses of aggregated routine data from the Euro-Peristat study. BJOG 2016;123:559-68.

Delnord M, Szamotulska K, Hindori-Mohangoo AD, Blondel B, Macfarlane AJ, Dattani N, Barona C, Berrut S, Zile I, Wood R, Sakkeus L, Gissler M, Zeitlin J, Euro-Peristat Scientific C. Linking databases on perinatal health: a review of the literature and current practices in Europe. Eur J Public Health 2016;26:422-30.

Kpéa L, Bonnet MP, Le Ray C, Prunet C, Ducloy-Bouthors AS, Blondel B. Initial Preference for Labor Without Neuraxial Analgesia and Actual Use: Results from a National Survey in France. Anesth Analg. 2015;121:759-66.

Le Ray C, Blondel B, Prunet C, Khireddine I, Deneux-Tharaux C, Goffinet F. Stabilising the caesarean rate: which target population? BJOG 2015;122:690-9.

Hermann M, Le Ray C, Blondel B, Goffinet F, Zeitlin J. The risk of prelabor and intrapartum cesarean delivery among overweight and obese women: possible preventive actions. Am J Obstet Gynecol 2015;212:241.e1-9.

Coulm B, Blondel B, Alexander S, Boulvain M, Le Ray C. Potential avoidability  of planned cesarean sections in a French national database. Acta Obstet Gynecol Scand 2014;93:905-12.

Schmitz T, Fuchs F, Closset E, Rozenberg P, Winer N, Perrotin F, Verspyck E, Azria E, Carbonne B, Lepercq J, Maillard F, Goffinet F, Groupe de Recherche en Obstétrique et Gynécologie (GROG). Outpatient cervical ripening by nitric oxide donors for prolonged pregnancy: a randomized controlled trial. Obstet Gynecol 2014;124:1089-97.

National collaborations

  •  Research Group in Obstetrics and Gynecology (GROG)
  • Perinatal networks: AURORE (région Rhône-Alpes), RPPS (Paris), network 92 (Hauts de Seine), MYPA (Yvelines), OMBREL (Métropole Lilloise), Alsace, Basse Normandie
  • Maternity centers: Assistance Publique Hôpitaux de Paris (Trousseau, Bichat, Beaujon, Louis Mourier, Bicêtre), St Joseph (Paris), Hôpital Femme-Mère-Enfant (Lyon), CHU Paule de Vigier (Toulouse), CHU Poissy, CH Diaconesses (Paris), CHU Côte de Nacre (Caen), CHRU Jeanne de Flandres (Lille), CHU de Montpellier
  • Centre d’Investigation clinique, Paris Centre
  • Programme de Surveillance de la Santé Périnatale, Santé publique France.
  • Registre de Handicap de l’Enfant et Observatoire Périnatal (RHEOP), CHU de Grenoble (Anne Ego)
  • ORS Ile de France, Perinat-ARS

International collaborations

  • Euro-Peristat Project includes representatives of 28 European Union Member States, as well as Iceland, Norway, and Sweden. Members are clinicians and researchers who work with perinatal data from routine sources, such as birth registers and hospital data.
  • ROAM(Reproductive Outcome and Migration): a network of researchers from 20 institutions in Canada, Europe, the United States, and Australia focusing on the reproductive health of migrant women.
  • Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, Elizabeth Howell, Natalia Egorova, Paul Hebert

Staff participating in this theme

Elie Azria (obstetrician, epidemiologist), Pauline Blanc-Petitjean (midwife, doctoral student), Béatrice Blondel (epidemiologist), Camille Bonnet (statistician), Marie-Pierre Bonnet (anesthesiologist, critical care specialist, epidemiologist), Gérard Bréart (epidemiologist), Anne Chantry (midwife, epidemiologist), Nathalie Codet (assistant), Marie Delnord (epidemiologist), Mélanie Durox (survey coordinator), Jeanne Fresson (epidemiologist), Aude Girault (obstetrician, doctoral student), François Goffinet (obstetrician, epidemiologist), Elodie Lebreton (statistician, doctoral student), Camille Le Ray (obstetrician, epidemiologist), Isabelle Monier (midwife, epidemiologist), Marie-Josèphe Saurel-Cubizolles (epidemiologist), Priscille Sauvegrain (midwife,  sociologist), Thomas Schmitz (obstetrician), Solène Vigoureux (obstetrician, doctoral student), Jennifer Zeitlin (epidemiologist).