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ORIGINAL RESEARCH |
1From the Institut National de la Santé et de la Recherche Médicale, UMR S149, Epidemiological Research Unit on Perinatal Health and Women’s Health, Pierre et Marie Curie University; and 2Obstetrics and Gynecology Department, Hôpital Cochin Saint-Vincent-de-Paul, Assistance Publique-Hôpitaux de Paris, and Paris René Descartes University, Paris, France.
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ABSTRACT |
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 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONAPPENDIXREFERENCES |
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METHODS: Using data from the PREMODA (PREsentation et MODe d’Accouchement: presentation and mode of delivery) study of 138 French maternity units, the delivery method in 3,654 low-risk nulliparas (live singleton fetus in cephalic presentation at term [37–41 weeks of gestation], born weighing 2,500–4,500 g, no uterine scar, no cesarean before labor, and no induction of labor for maternal or fetal disorders) was analyzed. Independent variables included maternal and fetal characteristics and the level of perinatal care of the maternity unit (level 1, 2a, 2b, and 3; where levels 2b and 3 routinely manage high-risk pregnancies). Univariable and multivariable analysis with a multilevel logistic model explored the factors associated with cesarean delivery during labor.
RESULTS: Overall, the rate of cesarean during labor was 11.7%. The rate was significantly higher in level 2b (odds ratio 1.5, 95% confidence interval 1.1–2.1) and 3 (odds ratio 1.3, 95% confidence interval 1.0–1.9) maternity units than in level 1 facilities. The size and status of the facilities did not significantly affect these rates. Risk factors for cesarean were older maternal age, non-French origin, gestational age of 41 weeks, male sex, and high birth weight.
CONCLUSION: Maternity units that frequently manage high-risk pregnancies (levels 2b and 3) have higher rates of cesareans during labor for their population of nulliparas at low risk than do facilities that deal mainly with low-risk pregnancies (level 1).
LEVEL OF EVIDENCE: II-2
In 1998, the government enacted regulations requiring the classification of maternity units according to the level of perinatal care available there. This classification was based on neonatal care. In France, however, a high level of neonatal care is most often correlated with a high level of maternal care, because management of high-risk pregnancies frequently entails management of high-risk neonates. This classification therefore reflects the level of perinatal care at the maternity unit. Women at low risk in France can choose to deliver in any hospital, whatever its level of care. Level 2b and 3 units are intended to provide management for high-risk pregnancies, but remain responsible for providing care for the patients in their geographic sector, including pregnancies at low risk. Moreover, some women without any risk factors want to ensure the "maximum safety" for their neonates and choose to give birth in a maternity ward with a neonatal critical or special care unit. The question thus arises: does management of pregnancies at high risk, associated with a high but justifiable cesarean rate, affect the same team’s management of women at low risk?
Groups in different countries have long examined the association between the status (private or public) or size of maternity units and their cesarean rates. The level of perinatal care associated with the maternity ward (levels 1, 2a, 2b or 3) is a relatively recent concept, but it may be more relevant in analyzing the influence of the management of high-risk pregnancies on the cesarean rates among low-risk patients.
We used data from the PREMODA (PREsentation et MODe d’Accouchement: presentation and mode of delivery) study, which involved 138 French maternity units, to estimate whether variations in the rates of cesareans during labor among nulliparas at low risk were associated with characteristics of the place of delivery and, in particular, with the level of perinatal care available there.9
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MATERIALS AND METHODS |
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ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONAPPENDIXREFERENCES |
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The inclusion criteria required women to be nulliparous, have a live singleton fetus in cephalic presentation at term (gestational age 
37 weeks). The exclusion criteria were cesarean delivery before labor, uterine scars, induction of labor for maternal or fetal disorders, gestational age 42 weeks or more, malformation, and birth weight less than 2,500 g or more than 4,500 g. These criteria for selecting the nulliparas at low risk were similar to those generally used.
Cesarean delivery during labor was the principal endpoint. Other data about maternal and neonatal outcomes were recorded: instrumental interventions, maternal intensive care, 5-minute Apgar score below 7, and transfer to neonatal intensive care. We collected the following data about obstetric practices: induction of labor, oxytocin use in spontaneous labor, mode of rupture of membranes, total duration of labor, and duration of its second stage. Data concerning use of continuous fetal monitoring were not collected, but use of such monitoring is standard practice in the French maternities. The PREMODA study did not collect data about epidural analgesia. The National Perinatal Survey conducted in 2003, however, indicates that such analgesia was used in 75% of French deliveries.1
Factors related to the hospital were
We had no specific data about the presence of physicians of each specialty. In France, however, presence of pediatricians and neonatologist in the maternity unit is regulated by law: in maternity facilities with a NICU, at least 1 neonatologist must be present at all times. In maternity facilities with a neonatal unit, the neonatologist must be present during the daytime but not necessarily at night or on weekends. In maternity facilities without a neonatal unit, the presence of a pediatrician is not required. In maternity facilities with more than 1,500 deliveries per year, at least 1 anesthesiologist and 1 obstetrician must be present in the facility 24 hours per day, 7 days per week. Maternal factors examined were age and geographic origin. Neonatal factors were term of pregnancy, birth weight, and gender.
The statistical analysis used Stata 8.0 software (Stata Corporation, College Station, TX). For the univariable analysis, we calculated the crude odds ratios and 95% confidence intervals of the various factors (maternal, neonatal, obstetric, and structural) that might be associated with a cesarean during labor. In the multivariable analysis, we included all variables with P < .1, in the univariable analysis. For this multivariable analysis, we used a multilevel logistic regression model (gllamm procedure) to estimate random center effect and adjusted odds ratios for the factors associated with a cesarean during labor (Rabe-Hesketh S, Skrondal A, Pickles A. Gllamm manual. U. C. Berkeley Division of Biostatistics Working Paper Series; 2004). We used a random-intercept explained in part by covariables measured for each maternity facility (cluster). We used a logistic multilevel mode for the multivariable analysis because of the hierarchical structure of our data; the first level corresponded to individual data (women) and the second level to the maternity unit. These models take into account the lack of independence of observations within a single facility, and they make it possible to study the effects of the characteristics of maternity units. Moreover, they provide more accurate measures of confidence intervals than classic logistic models which tend to underestimate them when data have a hierarchical structure.
Because the percentage of missing data was low, we did not create a specific class for missing data. The analysis did not consider observations with missing data. We compared percentages with the 
2 test and means with analysis of variance or with the Kruskal-Wallis nonparametric test when the variances were unequal according to Bartlett’s test.
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RESULTS |
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In our population of nulliparas at low risk, 429 (11.7%) had a cesarean delivery during labor. Labor was induced for 645 patients (17.7%), 322 (49.9%) because of prolonged pregnancy. The percentage of maternal and neonatal complications was low: 4 (0.1%) women were transferred to intensive care, 21 (0.6%) newborns had a 5-minute Apgar score less than 7, and 27 (0.7%) were transferred to intensive care (Table 2). Neonatal outcomes did not differ significantly according to the level of perinatal care offered by the maternity unit.
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Cesareans during labor were more frequent for nulliparas older than 35 years (adjusted odds ratio [OR] 1.5, 95% confidence interval [CI] 1.0–2.2), women of non-French origin (adjusted OR 1.7, 95% CI 1.3–2.2), and for those whose infants were born at 41 weeks (adjusted OR 1.6, 95% CI 1.3–2.0), male (adjusted OR 1.3, 95% CI 1.0–1.6), or at birth weight greater than 3,500 g (Table 3).
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The percentage of cesareans in the low-risk nulliparous population varied according to the characteristics of the maternity units. In the level 2b facilities, 141 (13.2%) low-risk nulliparas had a cesarean delivery compared with 164 (12.3%) in level 3 facilities, 59 (10.2%) in level 2a, and 65 (9.7%) in level 1 (P = .08). In the univariable analysis, the size and status (public or private) of units did not significantly affect the percentage of caesareans during labor. In maternity units with more than 2,500 deliveries per year, 119 (12.3%) nulliparas at low risk had a cesarean compared with 231 (11.7%) in those with 1,500–2,500 deliveries per year and 79 (11.1%) in the smaller units (less than 1,500 deliveries per year) (P = .73). Forty-nine (10%) low-risk nulliparous women delivering in private clinics had cesareans, 234 (11.5%) in public hospitals, and 146 (13.0%) in university hospitals (P = .19). After adjustment, the rate of cesareans during labor was significantly higher in level 2b (adjusted OR 1.5, 95% CI 1.1–2.1) and 3 (adjusted OR 1.3, 95% CI 1.0–1.9) maternity units than in level 1 facilities.
Indications for caesarean during labor were 157 (36.6%) failure of indication to progress, 117 (27.3%) failure to progress, together with abnormal signs during fetal monitoring, 97 (22.6%) anomalies observed with fetal heart monitoring, and 58 (13.5%) another reason or no specified reason. The distribution of these indications did not differ significantly according to the level of perinatal care (P = .2).
Practices for the management of labor varied according to the level of care, as shown in Table 4. Level 1 units used oxytocin significantly more often (n = 347, 83.4%) than level 2a (n = 285, 70.0%), 2b (n = 519, 77.7%), or 3 (n = 678, 72.3%) facilities (P < .001) for low-risk nulliparas in spontaneous labor. Duration of the second stage and total labor were shorter in level 1 maternity units. Induction of labor was also more frequent in Level 1 units (P < .001). Nonetheless, after stratification for mode of onset of labor, level 1 units still performed fewer cesarean deliveries during labor than level 2b and 3 facilities (Table 5).
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DISCUSSION |
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Criteria for defining low-risk nulliparas are not homogeneous from study to study. Some assess the risk at the beginning of pregnancy, at the first obstetric consultation.14 But authors most often use the definition by Cleary et al11 of the standard nullipara at the end of pregnancy, a definition similar to ours.10–12,15,16 We excluded cesareans before onset of labor because as a general rule these are performed for nulliparas in France only in pregnancies with complications. "Convenience c-sections" remain a marginal practice in France. In PREMODA, of 4,218 nulliparas with a cephalic fetus at term, only 101 (2.4%) had a cesarean before labor, and 98 were performed for medical indications. The very low percentage of maternal and neonatal complications in our population of low-risk nulliparas confirms the validity of the inclusion and exclusion criteria chosen to define the nulliparas at low risk. Moreover, our cesarean rate is close to those of other recent studies in low-risk nulliparous populations.12,16
The sample of the PREMODA control group is representative within each maternity ward because it selected every singleton in cephalic presentation delivered at term with a delivery log number that was a multiple of 20. This study was based on prospective data collected rigorously; local investigators from every maternity unit were responsible for checking its exhaustiveness and quality. They sent the data regularly to a regional coordination office, which sent it on to the national office responsible for its prospective analysis. At the end of the study, a national coordinator (Marion Carayol) visited 22 facilities, each selected randomly within a region, to assess the quality of data collection.
Our data include deliveries from 138 establishments representing more than one fifth of all French maternity units. Although our study is large, it includes only a sample of French maternity units, and thus, our results cannot necessarily be extrapolated to all French maternity units: the geographic distribution and structural characteristics of the units in our study differ from those of all maternity units in France. The 2003 national perinatal survey found that 36.5% of births took place in level 1 and 18.8% in level 3 maternity units (compared with 18.4% and 36.6%, respectively, in our study).1 Comparisons with this national survey are difficult, however, because its results concern all women giving birth and not the subgroup of low-risk nulliparas. Another French multicenter study found that 31% of nulliparas at low risk delivered in level 3 units.12
The PREMODA study is based on the willingness of maternity units to volunteer to provide data. The facilities that participate in our study were therefore probably more motivated to assess their obstetric practices than French maternity units as a whole. This is particularly true for the participating level 1 units. Although level 2 and 3 facilities are used to employing and evaluating protocols for the management of problem pregnancies, level 1 units face such assessment problems less often. We therefore think it likely that the level 1 units that agreed to participate in our study are not totally representative of all level 1 facilities. Nevertheless, the number and diversity (level, status, and size) of the participating units and the quality of the data collection allow us to think that our results reflect the general practices of the obstetric teams in different facilities. Although the study population is not strictly representative of the French population, it provides us with sufficient power to analyze the relation between level of perinatal care and the rate of cesareans during labor.
Several hypotheses may explain the differences in these cesarean rates as a function of level of perinatal care. Perhaps, in high-risk facilities, physicians are more likely to expect problems and may encourage the use of cesarean deliveries. On the other hand, in low-risk facilities, midwives expect successful vaginal delivery and use active management of labor to achieve it, as seen by the high rate of oxytocin use. Despite their higher induction rates, level 1 maternity units had a significantly lower rate of cesareans during labor than the higher-rated facilities. Moreover, management of medical interventions during labor seemed to differ according to the level of care: obstetric teams in level 1 units used oxytocin significantly more often than those in other maternity units. It is possible that labor proceeds better in level 1 units. Meta-analyses have shown that "active management" of labor in nulliparas can reduce its duration and tends to reduce the percentage of cesarean deliveries, although not quite significantly.17,18
On the other hand, midwives in level 1 units manage labor only for low-risk women and may be more available to these women than are the midwives in level 2 and 3 units, who are responsible simultaneously for patients at higher risk, including in utero transfers and premature deliveries. Support for women during labor is essential for the success of vaginal delivery. Numerous studies show that midwives’ continuous presence has a positive effect on both labor (diminution of its duration and of analgesia use) and delivery(reduction in instrumental interventions and caesareans).19,20 We thus suggest 2 hypotheses for the success of vaginal delivery in level 1 facilities: the effective management of interventions during labor and the availability of midwives. The results we observed, that is, more interventionism but fewer cesareans during labor, are not really paradoxical in the French context, where obstetricians’ attention to medicalization seems to focus primarily on decreasing the cesarean rate, rather than on any of its other aspects.
Another hypothesis centers on the availability of certain types of personnel or on the organization of care in maternity units by level of care. If it is easier to perform a cesarean delivery a in level 3 or 2b unit because of the availability of personnel (such as anesthesiologists or nursing support staff), this might affect obstetric decision-making. This has not been studied in relation to cesareans, but the organization of care has been found to influence medical practices in other situations, such as the transfer of newborns to neonatal units.21
The patient’s choice of maternity ward can also in itself serve as an explanation. Some low-risk patients prefer to give birth in a maternity ward with a NICU or special care nursery to maximize their newborns’ safety. These patients, especially well informed, may be more likely to have a cesarean during labor than the less anxious patients willing to give birth in level 1 facilities. The mother’s socioeconomic situation does not seem in other studies to be associated with the rate of cesareans during labor.22 A recent study of the criteria for the choice of delivery facility among low-risk patients in France showed that this decision has multiple determinants that vary according to region, maternal age, parity, educational level, and national origin. Some of these factors in turn are associated with the rate of cesareans during labor.23 Geographic origin appears to play a role in the risk of cesareans during labor, which occur at a higher rate among women born outside of France. Their lower socioeconomic status, perhaps mediated by less good prenatal care, may explain this finding. Others have reported a similar relation with the mother’s country of birth in populations of low-risk nulliparas.24 The other risk factors for cesarean delivery during labor (maternal age, term gestation, birth weight, and male sex) were the same as those usually reported in the literature.14,25–29
Cesarean deliveries in nulliparas are the principal factor in the global augmentation of cesareans observed since the end of the 1970s.30,31 Better management of nulliparas at term should make it possible to reduce the primary cesarean rate and therefore the global rate, as some authors have shown.32 If this is our aim, then level 2b and 3 maternity units must assess their management of nulliparas at low risk to attempt to explain the differences observed in comparison with level 1 units. Certainly, we cannot assess the quality of a maternity unit solely by its caesarean rate, and an overall assessment would require us to look as well for the possible harmful effects of a low cesarean rate on mothers and babies. Our study lacks the power to answer this question, given the low frequency of complications (0.1% of maternal intensive care transfers and 1.0% neonatal). Nonetheless, the level 1 maternity units must also look into the possible consequences, in particular neonatal, of their low cesarean rates. The price of reducing the cesarean rate in low-risk nulliparas must not be an increase in the neonatal risk.
The comparison of practices between maternity units is a starting point for an assessment in each unit aimed at improving the management of low-risk nulliparas during labor and thereby, perhaps reducing the cesarean rate. Currently, there is no consensus about the management of nulliparas at low risk and in particular about the "optimal" cesarean rate. The organization of care of high-risk pregnancies may have an impact on the care of women with uncomplicated pregnancies. A reflection about the place of low-risk women in the level 2b and 3 maternity units should be engaged to improve their management and optimize their cesarean rate.
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APPENDIX |
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Writing Committee: F. Goffinet,1,2 M. Carayol,1 J. M. Foidart,6 G. Bréart.1,3.
Scientific Committee: F. Goffinet,1,2 S. Alexander,5 J. M. Foidart,6 S. Uzan,3 D. Subtil,4 G. Bréart.1,3
Data Monitoring and Analysis Committee: M. Carayol,1 F. Goffinet,1,2 D. Subtil,4 S. Alexander,5 J. M. Foidart,6 G. Bréart.1,3
Maternity Units Participating in the PREMODA Study
Région Alsace: Coordinator: Prof. Langer: CHU de Strasbourg (Prof. Langer), CMCO de Schiltigheim (Dr. Vayssiere), CHR de Haguenau (Dr. Lehmann), CMC de Colmar (Dr. Kutnahorsky), CHR de Mulhouse (Dr. Wiedemann), Clinique Sainte Anne, Strasbourg (Dr. Jeanmougin), Clinique Diaconat, Mulhouse (Dr. Blum). Basse-Normandie: Coordinator: Prof. Dreyfus: CHU de Caen (Prof. Dreyfus/Dr. Denoual-Ziad), CH de Cherbourg (Dr. Ulmann), CH de Lisieux (Dr. Zerger), CH de Saint Lo (Dr. Refahi), CH de Flers (Dr. André), CH de la Ferté Macé (Dr. Nelle). Région Bretagne: Coordinator: Prof. Grall: CHU de Brest (Prof. Collet), CHU Hôtel Dieu, Rennes (Prof. Poulain), CHU Hôpital Sud, Rennes (Mme. Pérrigot), CH de Lorient (Dr. Getin), Clinique mutualiste de la Sagesse, Rennes (Dr. Aussel), CH de Saint Brieuc (Dr. Giono-Renaud), CH de Saint Malo (Dr. Weyl), CH de Vannes (Mme. Pierson), CH de Cornouaille (Dr. Germain). Région Centre: Coordinator: Prof. Perrotin: CHU Bretonneau, Tours (Dr. Alonso), CHU Beffroi, Tours (Dr. Rapp), CH de Blois (Dr. Montmasson), CHR d’Orléans (Dr. Ceccaldi), CHG de Chartres (Dr. Guilbaud). Région Franche-Comté: Coordinator: Prof. Schaal: CHU de Besançon (Dr. Riethmuller), CHG de Montbéliard (Dr. Zurlinden), CHG de Belfort (Dr. Terzibachian). Région Haute-Normandie: Coordinator: Prof. Verspyck: CHU de Rouen (Prof. Verspyck), CH de Mont Saint Aignan (Dr. Fournet), CH du Havre (Dr. Degré), CH d’Elbeuf (Dr. Paquet), CH de Dieppe (Dr. Gandour), Clinique Saint-Romain, Rouen (Dr. Thobois). Région Ile de France: Réseau Sud Ouest Francilien: Coordinator: Dr. Audibert: CHU de Clamart (Dr. Audibert), Clinique des Vallées, Châtenay-Malabry (Dr. Prof.oust), Clinique de Meudon la Forêt (Dr. Chene), CH de Dourdan (Dr. Lambert), CH Sud Francilien site d’Evry (Mme. Lose), CH de Fontainebleau (Dr. Fillippini), CH d’Orsay (Dr. Devianne); Réseau Ile de France Port-Royal: Coordinator: Dr. Harvey: CHU Cochin, Paris (Dr. Kayem), CHU Saint Vincent de Paul, Paris (Prof. Lepercq), CHU Saint Antoine, Paris (Prof. Carbonne), CH Notre Dame de Bonsecours, Paris (Dr. Grovangrandi), CHU Beaujon, Paris (Mme. Grapin), CHU de Colombes (Dr. Crenn-Hebert), CH de Neuilly sur Seine (Dr. Galimard), CH de Saint Cloud (Mme. Pecourt), Hôpital Militaire Begin, Saint Mandé (Dr. Ponties), Clinique Armand Brillard, Nogent sur Marne (Dr. Helvin), CH Les Diaconesses, Paris (Dr. Harvey); Réseau de Poissy: Coordinator: Dr. Rozenberg: CHI de Poissy-Saint Germain (Mme. Bertaud); Réseau inter-maternités de Saint-Denis: Coordinator: Prof. Uzan: CH de Bondy (Dr. Seince), CHI de Montreuil (Dr. Chitrit), CHI de Villepinte (Dr. Debièvre), Clinique Vauban, Livry-Gardan (Dr. Kamoun), Clinique du bois d’amour, Drancy (Dr. Masson), CH de Montfermeil (Dr. Ropert), CHG de Saint-Denis (Dr. Ekoukou), Clinique de l’Estrée, Stains (Dr. Franche); Réseau Tenon: Coordinators: Prof. Uzan and Dr. Berkane: CHU Tenon, Paris (Dr. Berkane), CHU Bichat, Paris (Prof. Mandelbrot); CHI de Créteil (Prof. Haddad et Dr. Touboul); CH de Saint Maurice (Dr. Bardou). Région Limousin: Coordinator: Prof. Philippe: CH de Brive (Mme. Peron), CH de Tulle (Mme. Barbé), CHU de Limoges (Dr. Eyraud), CH d’Ussel (Mme. Leclerc). Région Lorraine: Coordinator: Prof. Boutroy, Dr. Thiebaugeorges: CHU de Nancy (Dr. Thiebaugeorges), CH d’Epinal (Dr. Scotton), CHR Bonsecours, Metz (Dr. Lemarié), CH de Thionville (Dr. Szwarcberg), CH Sainte Croix, Metz (Dr. Ragage), Polyclinique Majorelle, Nancy (Dr. Cledat), Clinique Arc en Ciel, Epinal (Dr. Gaillet-Schiochet), Clinique Claude Bernard, Metz (Dr. Adami). Nord Pas de Calais: Coordinator: Prof. Subtil: CH d’Arras (Mme. Finet), CH de Béthune (Dr. Hay), CH de Boulogne (Dr. Churlet), Clinique Côte d’Opale, Saint Martin les Boulognes (Dr. Renault), CH de Douai (Dr. Dognin), Clinique Saint Amé, Lambre-lez-Douai (Dr. Doutrelant), Clinique Villette, Dunkerque (Mme. Gosselin, Mme. Deroose), CH de Maubeuge (Dr. Hubert), CH de Roubaix (Dr. Le Goueff), CH de Seclin (Dr. Biausque), CH de Valenciennes (Dr. Massoni), CHU de Lille (Prof. Subtil), Clinique Cotteel, Villeneuve d’Ascq (Mme. Dumon). Région Pays de Loire: Coordinator: Dr. Winer: CHD La Roche sur Yon (Dr. Barreteau), CH de Saint Nazaire (Dr. Gerard), Clinique du jardin des plantes, Saint Nazaire (Dr. Rousseau), CH de Cholet (Dr. Aireau), CHU de Nantes (Dr. Winer), Maison de naissance, St Sébastien/Loire (Dr. Berlivet), CHUd’Angers (Dr. Gilard). Picardie: Coordinator: Prof. Gondry: CHU d’Amiens (Prof. Gondry), Clinique Sainte Claire, Amiens (Dr. Degroote), CHG de Beauvais (Dr. Manela), CHG de Creil (Dr. Cesbron), CHG de Laon (Dr. Boury), CHG de Saint Quentin (Dr. Closset), CHG de Soissons (Dr. Abboud). Région Poitou-Charentes: Coordinator: Prof. Pierre: CHU de Poitiers (Prof. Pierre), Clinique du Fief de Grimoire, Poitiers (Dr. Bascou), CHG de Niort (Dr. Breheret), CHG d’Angoulême (Dr. Tariel), CHG de la Rochelle (Dr. Quentin), Clinique Sainte Anne, Châtellerault (Dr. Boisselier), CHG de Châtellerault (Dr. Godard), CHG de Bressuire (Dr. Villemonteix), CHG de Saintes (Dr. Trousselle). Région Prof.ovence Alpes Côtes d’Azur: Coordinator: Prof. D’Ercole: CHU la Conception, Marseille (Dr. Agostini), CHR de Draguignan (Dr. Diquelou), CHR de Hyères (Dr. Eymery), CHR de la Ciotat (Dr. Pechikof), CHU Hôpital Nord, Marseille (Prof. D’Ercole), CHR de Salon de Prof.ovence (Dr. Maldiney), CHR de la Seyne sur Mer (Dr. Joly). Région Rhône-Alpes Lyon: Coordinator: Dr. Vaudoyer: CHU l’Hôtel Dieu, Lyon (Dr. Vaudoyer), CHU la Croix Rousse, Lyon (Prof. Gaucherand), CHU Lyon Sud, Lyon (Dr. Coste). Région Rhône-Alpes Grenoble: Coordinator: Dr. Vendittelli: CHU Nord et Sud, Grenoble (Dr. Venditelli), Clinique Belledone, Saint Martin d’Hères (Dr. Benbassa), Clinique des Cédres, Grenoble (Dr. Boschetto), Clinique Mutualiste, Grenoble (Dr. Leger), CHU de Saint Etienne (Dr. Collet), CH de Bourg en Bresse (Dr. Frobert), CH d’Alberville (Dr. Dardenne), CH de Chambéry (Dr. Houman), CH d’Annecy (Dr. Bernardi), CH de Valence (Dr. Broussard), CH de Roanne (Dr. Gaja), CH d’Evian les Bains et de Thonon les Bains (Dr. Thery), CH de Saint Julien en Genevois (Dr. Tognelli), CH de Firminy (Dr. Albersammer).
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Footnotes |
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This study was mainly supported by 2 grants from the Ministry of Health (AOM01123 [PH-RC 2001] and AOM03040 [PH-RC 2003]). It was also partly funded by the French College of Gynecologists and Obstetricians, the French Society of Perinatal Medicine, and the Belgian National Funds for Scientific Research.
Corresponding author: François Goffinet, INSERM Unit 149, 123 Boulevard de Port-Royal, 75014 Paris, France; e-mail: goffinet{at}cochin.inserm.fr. 
doi:10.1097/01.AOG.0000218098.70942.a2
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