France has become one of the bad students of the European Union. There is no question here of deficit or weight of the debt, but … infant mortality. Since 2015, Paris has posted an above -average rate. According to a report from the National Institute of Demographic Studies, France has now slipped into 23rd in 27. Out of a thousand babies born in France, 4.1 on average died before their first birthday – often a few days after their birth. Based on this figure – of which they made the title of a book published these days – Journalists Anthony Cortes and Sébastien Euruquin investigated the reasons for this degradation. If the medical authorities point to the rise in poverty and the age of mothers, the two authors insist on several hypotheses – distance from maternities, lack of doctors, a policy of the figure – to explain this regression which brings us back to the infant mortality rates of the early years 2,000. Maintenance.
L’Express: In the 1970s, demographer Emmanuel Todd prophesied the end of the USSR due to the increase in infant mortality. Does the French degradation suggest such a dark future?
Anthony Cortes: Far be it from us to ask ourselves in prophets, especially since Emmanuel Todd has partly returned to this thesis, to add other factors to this collapse. Now, the infant mortality rate says a lot about the state of health of a company, a health system that can no longer meet certain needs of its population. From there to predict that he announces an intense degradation of public services which could be fatal to our company, there is a chasm – which we will not cross. Our work is to question a number of factors in order to understand the reason for this phenomenon.
Sébastien Huruquin: We are more alarmist than pessimists. The will behind this book is to believe in a possible start, alerting to what could happen if we do not change things. France is launched in a rare negative trajectory in Europe. If infantile mortality was better treated in political priorities, we could change things.
Does this increase in infant mortality have the same causes everywhere in France? Are territories more affected than others?
Anthony Cortes: The question arises in the rural world. In the 1970s, the State chose to close small maternities for security reasons. This policy has given results, since an infant mortality rate of 18 per 1,000 to 4.8 per 1,000 in 1998. But in the late 1990s, medical deserts began to appear in the territory, which helped to remove women from healthcare services. Today, nearly 900,000 women are over 30 minutes from a maternity hospital. So we ask ourselves: have we not gone too far in this logic, without questioning the territorial network? We saw it by going to the lot. In fifteen years, three of his four maternities have closed. The rate of women of childbearing age, living more than 45 minutes from an establishment, increased from 6 to 24 %. At the same time, the lot has become the department with the highest infant mortality rate in mainland France.
The question also arises in the suburbs. Seine-Saint-Denis has a infant mortality rate much higher than the national average: 5.8 %. It is also a department where 17 % of the population lives below the poverty line, and where the prevention structures are denied. Maternal and child protection centers, making it possible to support mothers and children, see their funding decrease from year to year. In twenty years, the number of women followed has been divided by two. There is therefore a double table, with two populations increasingly neglected by public power in this area: the rural world and the suburbs.
You speak at length about the 1998 perinatal decrees, which set the conditions that health establishments must practice obstetric activities. These texts precisely set limits, presenting the criteria according to which maternities can become dangerous …
Sébastien Huruquin: The idea was then to continue in line with the 1972 decree, in order to increase the quality and maternity safety standards, in particular by fixing the famous threshold of 300 deliveries. Below this threshold, the health authorities consider that staff do not practice enough to be able to react effectively in risky maternities. They also set the rate of supervision in maternities. Today, a midwife can take care of four, five, or even six mothers at the same time during childbirth. In the Nordic countries, so often taken as an example by doctors, there is a midwife per patient. This changes everything, especially at a time when the needs, aspirations and profiles of women are no longer the same in 1998. However, these decrees will soon be thirty years old, and have not been revisited since.
Anthony Cortes: The 1998 decree set the number of minimal deliveries to be carried out each year at 300, the Academy of Medicine pushes to have 1,000 deliveries, but one can wonder about the relevance of its maintenance. Today, ten departments have only one maternity hospital. Do we continue to reason according to a threshold? Shouldn’t we change the paradigm, wonder about the territorial network?
Sébastien Huruquin: Let’s take the example of the lot. Only one is only one maternity in the department. It is about 650 deliveries per year. If we continue in this logic, will we tell women that they can no longer give birth in their department?
The Academy of Medicine evokes the rise in poverty and the age of mothers to explain the increase in infant mortality. You prefer to mention small maternity closures. Why these differences in analysis?
Anthony Cortes: Obviously, age and level of wealth play in the equation. Of course later pregnancies and more precarious mothers are factors that make delivery more difficult. But why do you only take away in individual explanations when the crisis, as regional health agencies (ARS) have already pointed out, is “multifactorial”? If this is the case, it is necessary to measure each element, to understand what is played out in the overall problem.
Sébastien Huruquin: The position of learned societies is to close small maternities without questioning the distance between hospital and location. Admittedly, as we said, this policy has proven itself in the 1970s. But today, the situation has changed, women have changed, and the increase in the infant mortality rate deserves that we linger on this development. We do not contradict doctors that individual factors play a role in this evolution. What data, today, shows precisely that small medical houses are intrinsically more dangerous than large maternities? We don’t have enough to feed the debate. We regret it, in the same way as doctors who do not share our analysis on the closure of small maternities.
Questioned by L’Express in 2023, Professor Yves City – which you quote in your book – defended a model of large maternity, designed for deliveries, accompanied by smaller structures, distributed in the territory, which would accompany women before and after childbirth. Isn’t that the solution?
Anthony Cortes: The medical authorities actually militate rather for the adoption of the Swedish model: large structures accompanied by medical transport solutions. It could be a very good thing, but, in France, it does not exist. Let us add that we do not have the same topography as Sweden. Let us mention the lot again: we have made the journeys to maternity, winding, complicated roads. Accompany this journey with a particular meteorological data, which makes the road impracticable, and imagine a woman close to giving birth. Can we really adapt the road to this type of medical transport?
Sébastien Huruquin: The Academy of Medicine believes that a woman can always give birth in a Samu truck than in a small maternity. But let’s take the example of the Pyrénées-Orientales, where certain villages of 1,000 to 2,000 inhabitants are more than 45 minutes from Perpignan. In these places, it is often not the Samu truck that comes to seek women, but firefighters from the village. How do you do if a mother gives birth before her arrival at maternity? Firefighters are not trained, and are even often paralyzed at the idea of practicing childbirth.
How is a register of births in maternities, which does not exist today, would it make it possible to fight against infant mortality?
Sébastien Huruquin: We clearly lack statistical data. A birth register with a dashboard, a multitude of data, would make it possible to carry out studies in order to better understand infant mortality. Does the degradation of the infant mortality rate come from the individual responsibility of mothers? Can this rate be crossed with their weights, their possible addictions, the polluting factors that can affect their pregnancy? We could see which departments are the most affected, which childbirth techniques can be dangerous … Without this register, today, in reality, we are blind.
.