Free antenatal and postnatal care: seventy years of the protection maternelle et infantile (PMI)

The initiative

The system of Protection Maternelle Infantile (PMI) - mother and children protection - was founded in 1945 and has been evolving to meet the needs of contemporary French mothers. The responsibility for its administration was transferred to individual départements in 1986.

The PMI consists of a network of free points of contact to support future and current mothers and their young children (of up to six years old). The network consists of 5,100 “points fixes de consultations” - centres that offer consultations - guaranteeing the accessibility of its services throughout the country. It offers multidisciplinary care, addressing medical, social and educational needs, for example, and serves to reduce social inequality and unequal access to healthcare.

It provides a large range of free services including: contraception, access to social services, and tailor-made solutions in PMI offices or at home. The available services are provided by a wide range of professionals: e.g., doctors, nurses, midwives, relationship counsellors,early childhood educators and child psychologists.

The challenge

In terms of mother and child health, “la France occupe une position moyenne en Europe” (a middle-ranking position in Europe). [1] The postnatal mortality rate during the first month after birth is 2.1 per 1000 – in this respect, France is ranked 14th among EU member states. However, there are major social and regional inequalities and this is something that needs to be addressed by the French government.

The public impact

The impact on families and children from low-income social backgrounds is particularly important. In 2010, the PMI networks covered 18 percent of pregnant women and 20 percent of children under 6 years old.  In 2012, 72 percent of three- to four-year-olds benefited from a health check through the PMI system.

Stakeholder engagement

The internal stakeholders that fund and administer the scheme are the French government and the individual départements, of which there are currently 101. The national budget dedicated to PMI amounts to €700 million per year. The stakeholders also include health and social services professionals - and others who provide services to mothers and children - and the PMI users themselves. The external stakeholders are principally NGOs.

In November 2015, the Etats Généraux de la Naissance et de la PMI (the national conference on birth and PMI) met in Paris and comprised local government and PMI employees, members of professional associations and patients to discuss the role of the PMI in the health system. The conference celebrated the organisation's 70th anniversary.

Political commitment

The fact that an annual budget of €700 million is allocated to PMI is indicative of national and local government's ongoing commitment: the policy of PMI is the first article in the law on national health.

During the Etats Généraux, the mayor of Paris, Anne Hidalgo, reaffirmed that an ambitious public health policy is founded on the provision of a universal and accessible service.

Public confidence

The PMI network covers 20 percent of pregnant women. This relatively high level of public involvement shows citizens' trust in the system. Public confidence is developed in a number of ways, including:

• At home consultations, which are offered in order to reach a higher number of people.
• The comprehensive system of care leads to a reduction of administrative procedures and increase the trust of patients.

The consultations are designed to be appropriate for mothers and their children.

Clarity of objectives

The objectives of maintaining a free, universal and easy-to-access antenatal and postnatal system are clear.  However, in order to achieve greater social outreach and diversity, the PMI currently focuses on encouraging women and children from low-income social backgrounds to make use of its services. According a report from the economic, social and environmental council, this focus could become a threat to the future of the PMI. Indeed, the PMI should be seen primarily as a cohesive universal service and not as a service targeting only the disadvantaged.

The same report insists on the necessity of redefining the role of the PMI within the health system, though, which seems at present to be unclear. One of the report's recommendations is to create a regular steering committee  to monitor the organisation's progress.

Strength of evidence

The data that informs the PMI’s direction come from reliable sources such as the ‘direction de la recherche, des études, de l'évaluation et des statistiques’ (DREES), the organisation responsible for providing policymakers with statistical analysis  and policy evaluations.  The policy direction is based on DREES’ close analysis of the individuals who use PMI, where they use it and what they use it for.

Feasibility

The financial feasibility is guaranteed by the government’s rolling funding. The forward planning on the likely usage of PMI services is based on one half-day consultation a week for 200 children born during the current year. However, the policy does not appear to take into account any lack of human resources, especially the shortage of doctors which was highlighted by the DREES study.

Management

Since decentralisation in 1986, the PMI has been governed at the departmental level. Agences régionales de santé (ARSs) are responsible for implementing the regional health policies that govern the PMI.

ARSs are advised by a “commission for coordination of public policies that contains representatives of the state, general councils and other local authorities, as well as local SHI fund representatives, … dedicated to prevention, school health, occupational health and PMI … The Surveillance Council (Conseil de surveillance), headed by the regional prefect, is in charge of approving the budgets and expenses of the ARS and providing opinions on the PRS, the main regional capacity planning tool.” [2] The PMI is overseen at national level by the Ministry of Health.

Measurement

The impact of the policy is measured through the collection of data in the PMI centres. The data enables DREES, in particular, to provide a wide array of metrics to assess whether the PMI's objectives are being met.  So, the DREES April 2015 study, ‘Les services de PMI : plus de 5 000 sites de consultations en 2012', includes - to take just a few examples - the following metrics:

• Distribution of interviews, activities , consultations

  and home visits.

• Number of consultations and home visits per 1,000 children under six years of age.
• Number of antenatal and postnatal consultations and home.
• Relative involvement of professions in PMI interventions (from doctors, midwives, child psychologists, etc). [3]

Alignment

The ‘Etats généraux' in November 2015 brought together all the relevant actors involved in the PMI in a single conference. They agreed on forms of cooperation to achieve the organisation's current objectives, the provision of universal antenatal and postnatal care to mothers and their young children. For example, it was agreed that better communication is needed between national policymakers and departmental administrators.

The PMI is embedded in French society and has good working relations with  social welfare services, local councils, schools, neighbourhood associations, nurseries, hospitals, and local health services.

Bibliography

La protection maternelle et infantile, Christiane Basset, October 2014,  LES AVIS DU CONSEIL ÉCONOMIQUE, SOCIAL ET ENVIRONNEMENTAL

Les services de PMI : plus de 5 000 sites de consultations en 2012, Élise Amar, Françoise Borderies, April 2015, DREES

1945-2015, 70 ans de protection maternelle et infantile á Paris, 3 November 2015, Etats Généraux de la Naissance et de la PMI

Health Systems in Transition, Karine Chevreul, Karen Berg Brigham, Isabelle Durand-Zaleski, Cristina Hernández-Quevedo, Health System Review 2015, The European Observatory on Health Systems and Policies

Étude sur la protection maternelle et infantile, November 2006, L'Inspection générale des affaires sociales (IGAS)

PMI : un retour explicite dans la politique nationale de santé, Catherine Maisonneuve, 27 April 2015, La gazette.fr