Background and Objectives: Postpartum haemorrhage (PPH) and mother to child transmission (MTCT) of the Human Immune Deficiency Virus (HIV) are major threats to maternal and foetal health, especially in low and middle income countries. This thesis addressed two main objectives: 1) to investigate strategies for the prevention of PPH, with a focus on misoprostol; 2) to investigate strategies for prevention of mother to child transmission (PMTCT) of HIV, with a focus on the male partner. Methods: We employed a number of study designs including a cross sectional design, a retrospective chart review, and a systematic review which included Classical and Bayesian approaches of meta- analysis. Key methodological issues addressed include the use of propensity score matching methods to address channeling bias; comparison and combination of evidence from different sources; sensitivity analysis in health research; and methods for developing new tools for measurement in health research. Results and Conclusions: Our findings suggests that an oxytocin-misoprostol combination is better than the current standard of care of oxytocin-only which is recommended by the World Health Organisation for the prevention of PPH. Secondly, effectiveness data from well-designed observational studies may be used to inform clinical decisions on misoprostol in the prevention of PPH. Thirdly, using a new tool we have created, it is possible to objectively identify HIV positive women who lack the support of their male partners in adhering to PMTCT recommendations. / Background and Objectives: Postpartum haemorrhage (PPH) and mother to child transmission (MTCT) of the Human Immune Deficiency Virus (HIV) are major threats to maternal and foetal health, especially in low and middle income countries. This thesis addressed two main objectives: 1) to investigate strategies for the prevention of PPH, with a focus on misoprostol; 2) to investigate strategies for prevention of mother to child transmission (PMTCT) of HIV, with a focus on the male partner. Methods: We employed a number of study designs including a cross sectional design, a retrospective chart review, and a systematic review which included Classical and Bayesian approaches of meta- analysis. Key methodological issues addressed include the use of propensity score matching methods to address channeling bias; comparison and combination of evidence from different sources; sensitivity analysis in health research; and methods for developing new tools for measurement in health research. Results and Conclusions: Our findings suggests that an oxytocin-misoprostol combination is better than the current standard of care of oxytocin-only which is recommended by the World Health Organisation for the prevention of PPH. Secondly, effectiveness data from well-designed observational studies may be used to inform clinical decisions on misoprostol in the prevention of PPH. Thirdly, using a new tool we have created, it is possible to objectively identify HIV positive women who lack the support of their male partners in adhering to PMTCT recommendations. / Thesis / Doctor of Philosophy (PhD)

En France, 73.3% des décès maternels liés à une hémorragie du post partum (HPP) ont été jugés comme « évitables » par le comité national d’experts en 2006. Le premier objectif de cette recherche a été l’observation des événements indésirables graves (EIG) en obstétrique et l’analyse des facteurs contributifs. Trois études ont été réalisées et ont montré une proportion de cas potentiellement évitables de 22% pour les embarrures, 72% pour les asphyxies néonatales et 73% pour les transferts maternels en service de réanimation. Le second objectif a été l’amélioration de la qualité de la prise en charge de l’HPP, première cause de mortalité maternelle. Deux études ont été réalisées. La première étude a montré que le protocole de prise en charge de l’HPP était appliqué partiellement après sa diffusion passive dans un réseau périnatal en Rhône Alpes. La seconde étude, PITHAGORE 6, un essai randomisé initié dans six réseaux de périnatalité en France pour mesurer l’impact d’un programme d’intervention multifacettes, a permis de réduire le taux d’HPP graves. De nouvelles méthodes doivent être développées en intégrant l’apport des sciences humaines pour optimiser la sécurité des soins en périnatalité. / In France, 73,3% of maternal deaths from post partum haemorrhage (PPH) were considered as «avoidable» by national experts committee in 2006. The first goal of this research was to observe adverse events (AEs) in obstetrics and to analyse latent and active conditions. The three observational studies highlighted that 22% of depressed skull fractures, 72% of birth asphyxia and 73% of maternal transfers to intensive care unit care might have been avoidedThe second aim was to improve PPH management, which is a leading cause of maternal mortality. Two studies were realized. The first has shown that regional guideline of PPH management was partly applied after passive dissemination in a regional perinatal network. The second study, PITHAGORE 6, a randomised trial conducted in six perinatal networks to assess impact of multi-faceted intervention program, reduced the rate of severe PPH. New methods have to be developed and might take into account human sciences to improve safety in perinatal care.