In France, analysis of data from the national confidential survey on maternal mortality (ENCMM) for the 2007-2009 period showed that the risk of maternal mortality due to complications during or immediately after the birth was higher in the maternity units of private for-profit clinics (hereafter private maternity clinics) than in university hospital maternity units [1]. This excess risk was especially notable for mortality due to hemorrhage (3 times higher in private clinics as compared to university hospitals) — an outcome considered an indicator of the quality of care at childbirth [2].

The French profile of maternal mortality is also characterized by a maternal mortality ratio 1.5 times higher in Paris region than in the rest of mainland France, especially for mortality from hemorrhage. This ratio has not changed across the last several three-year survey periods [3] and persists after taking women's individual characteristics into account [4]. These epidemiologic results guided our analysis to search for explanatory factors associated with the organization and quality of care at childbirth.

These reports inspired the MATORG project; its global objective is to identify the dimensions of the organization of care around delivery that might influence care quality and maternal health. The project's first component was a sociological survey in Paris region.

A systemic rather than individual perspective is recommended for studying the associations between organization of care and patient safety in hospitals [5,6]. The sociological approach analyzes risks for safety and quality of care while integrating social factors. These can include governance of healthcare establishments, division of labor among healthcare professionals, and the use of scientific and technical innovations [5,7,8]. This approach also stresses conflicts among staff that can degrade the quality of care [9], thus underlining the importance of power relationships between professionals [7].

Several sociological studies have examined the safety of obstetric care. A British investigation mentioned the delays in management resulting from the difficulty in managing the division of tasks between obstetricians and midwives in hospitals [10]. A survey around the year 2000 in hospitals in northwest France showed that the rationalization of work could lead to technicizing childbirth [11]. It suggested that some interventions, such as instrumental delivery by forceps or vacuum extraction or induction of labor by oxytocin, theoretically designed to counter situations at risk for mothers or infants, are sometimes used for deliveries at times when diverse obstetric professionals (anesthesiologist, obstetrician, midwife) are present, to reduce night, weekend, and even vacation work. It also found greater technicization in small public hospitals than in university hospital centers, which had more staff [11]. To our knowledge, no equivalent work has taken place in private maternity units in France.

Our study's objective was to identify the organizational characteristics of private maternity units and analyze how they might influence care quality and safety. We studied the organization of work around childbirth and staff scheduling at a period when the difficulty of hiring qualified healthcare staff in France was just beginning to be felt; it has since worsened substantially.