Gynecological follow-up care: What are the spatial dynamics since the expansion of midwives’ competencies?
- Cet article est une traduction de :
- Soins de suivi gynécologique : quelles dynamiques territoriales depuis l’élargissement des compétences des sages-femmes ? []
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Keywords:
Territorial classification, gynecological follow-up, midwives, healthcare access, gynecologistsTexte intégral
1Since 2009 and the enactment of the Hospital, Patients, Health, and Territory (HPHT) law, midwives have been authorized to perform gynecological follow-up procedures outside of pathology and pregnancy (such as cervico-vaginal smears and contraceptive procedures), thereby becoming a complementary service to that provided by gynecologists and general practitioners. This expansion of competencies comes in the context of a declining number of healthcare workers and unequal geographical distribution of gynecologists and general practitioners. Health workers qualified in gynecological follow-up can practice independently or within healthcare structures (hospitals, health centers, medico-social establishments). Improving access to gynecological follow-up care is a well-recognized issue by public authorities. Our aim in this article is to study how accessibility, utilization of gynecological follow-up care, and territorial reorganization of healthcare services have evolved since the expansion of midwives’ competencies.
2Our study focuses on two types of gynecological follow-up procedures: contraceptive procedures (intrauterine device and pharmacological implant) and cervico-vaginal smears, which allow for cervical cancer and sexually transmitted infection screening. The data used come from the national health data system (NHDS), and we analyze the period between 2016, when gynecological follow-up procedures performed by midwives began to be reimbursed at the same rates as those performed by gynecologists and general practitioners, and 2022.
3First, we document recent changes in several territorial indicators through a descriptive analysis, providing information on the accessibility to gynecological follow-up, utilization, configurations, and diversity of the service offerings and their evolutions. Then, we construct a synthetic typology of French territories based on these indicators and multivariate analysis methods: a principal component analysis (PCA) followed by a hierarchical clustering (HC).
4Since 2016, there has been a growing activity in the two types of gynecological follow-up procedures studied, particularly cervico-vaginal smears. Midwives have significantly contributed to this increase and accounted for 22.7 % of total gynecological follow-up procedures in 2022, compared to 4 % in 2016. At the same time, fewer gynecologists are actively working in this field and performing fewer contraceptive procedures. The overall increase in activity has led to improved accessibility for the two types of procedures studied, increased utilization of cervico-vaginal smears, and reduced territorial inequalities associated with these indicators.
5Our classification reveals four types of territories. The first class consists mainly of low-density rural areas where accessibility to care has greatly improved between 2016 and 2022 but remains low, with a healthcare offering mainly composed of general practitioners and midwives, who have significantly increased their activity. The second class territories, mainly rural and some urban areas in the Paris region, are characterized by low accessibility to care evolving at a slower pace than other territories. The healthcare offering is primarily represented by a single type of provider (private or health establishments). Class 3 territories have mixed profiles, peri-urban areas around large cities (Nantes, Bordeaux, Lyon) and rural areas around small towns. In 2016, they had similar levels of accessibility to class 2 but showed greater improvements, with a more diversified healthcare offering over the period, involving more healthcare professionals and establishments in gynecological follow-up. The fourth class territories, mainly urban but also some rural areas structured around small towns, stand out with higher access to care than all other territories, significant progress over the period, and a varied healthcare offering. The utilization of gynecological follow-up care is also higher in these territories, with a shorter median access time to care than in other territory types.
6The expansion of midwives’ competencies in gynecological follow-up care has led to a significant increase in their activity and contributed to the overall increase observed from 2016 to 2022. This increase, linked to the rising number of professionals and health establishments involved in gynecological follow-up and their distribution across the territory, has resulted in an overall improvement in accessibility and utilization of these services and helped reduce territorial inequalities related to gynecological follow-up. However, accessibility inequalities persist, particularly between some low-density rural areas where the healthcare offering remains insufficient and some urban areas with a higher concentration of professionals and health structures. These inequalities do not necessarily result in lower utilization in territories with low accessibility but rather in longer access times to care for women living in these territories.
Table des illustrations
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Titre | Figure 1: Spatial distribution of french territories according to their class |
URL | http://journals.openedition.org/rfst/docannexe/image/2354/img-1.png |
Fichier | image/png, 431k |
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Thomas Karnycheff, Véronique Lucas-Gabrielli, Julien Mousquès et Guillaume Chevillard, « Gynecological follow-up care: What are the spatial dynamics since the expansion of midwives’ competencies? », Revue francophone sur la santé et les territoires [En ligne], Varia, mis en ligne le 18 décembre 2024, consulté le 25 mars 2025. URL : http://journals.openedition.org/rfst/2354 ; DOI : https://doi.org/10.4000/12yp1
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