Objective To determine what factors related to health services in France might explain substandard care of severe morbidity due to obstetric haemorrhage.Design Retrospective questionnaire survey. Setting Three administrative regions of France.Population All women who were pregnant or had recently given birth during the year before the survey. Methods A European survey (MOMS-B) de®ned severe haemorrhages as blood loss^1500mL. A speci®c questionnaire was added in France to analyse the quality of care of these haemorrhages. The survey was carried out in three different administrative regions: Champagne-Ardenne, the Centre and Lorraine. An expert committee was appointed and began by establishing a framework for qualitative assessment. One hundred and sixty-®ve cases of severe haemorrhage were reviewed and classi®ed into one of three levels of care: appropriate, inadequate or mixed. Inadequate care and`mixed' care were both considered substandard. The 165 cases were coded and then studied with uni-and multivariate analysis (logistic regression with SAS and SPSS software).Results Of the 165 cases identi®ed, 51 % (85/165) were vaginal, 19% (31/165) operative vaginal, and 30% (49/ 165) caesarean. The leading cause of haemorrhage was uterine atony. Overall, 62% of the cases received appropriate care, 24% received totally inadequate care and 14% mixed care. After adjustment for sociodemographic factors, antenatal care and organisational aspects, the lack of a 24-hour on-site anaesthetist at the hospital and a low volume of deliveries (,500 births per year) were the factors associated with substandard care.Conclusion Organisational features are so important that application of good clinical practices for safer motherhood reinforce the need for new organisation of obstetric services. For the ®rst time, the presence of an anaesthetist is shown to have a measurable effect on the quality of care for women giving birth. These results need to be con®rmed by others.

Unfavorable social situation and organizational factors are associated with the reported choice to give birth without epidural analgesia. This finding suggests that women are not always in a position to make a real choice. It would be useful to improve the understanding of how pregnant women define their preferences and to know how these preferences change during pregnancy and labor.

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