6 курс / Неонатология / Научное_обоснование_механизмов_управления_младенческой
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Table 3.10 - The proportion of parents who applied to the local doctor in connection with the last ("fatal") disease in the group of children who died under the age of 1 year in the Republic of Ingushetia, (%).
Years |
Percentage of parents who went to the doctor in connection with the |
Total |
|
last disease |
|||
|
|
||
2017 |
30,0 |
100,0 |
|
2018 |
29,0 |
100,0 |
|
2019 |
31,0 |
100,0 |
|
2020 |
30,0 |
100,0 |
|
2021 |
30,0 |
100,0 |
A significant contribution to the formation of infant mortality was made by the untimely referral of a child to a hospital. So, in 25,0% and more% of cases (37,5% in 2017, 25,0% each in 2018 and 2019, 37,5% in 2020 and 33,3% in 2021) referral to inpatient treatment was delayed from 3 days and later, which increased the risk of infant mortality (Table 3.11).
Table 3.11 - Terms of referral to a hospital due to the last ("fatal") disease in the group of children who died under the age of 1 year in the Republic of Ingushetia, (%).
Years |
On the first |
From 1 to 3 |
From 3 to 7 |
From 7 to 30 |
Total |
|
day |
days |
days |
days |
|
2017 |
62,5 |
0 |
25,0 |
12,5 |
100,0 |
2018 |
75,0 |
0 |
0 |
25,0 |
100,0 |
2019 |
75,0 |
0 |
25,0 |
0 |
100,0 |
2020 |
62,5 |
0 |
37,5 |
0 |
100,0 |
2021 |
66,7 |
1 |
33,3 |
0 |
100,0 |
A low level of compliance with clinical protocols of patient management tactics at the outpatient stage in the group of children who died under the age of 1 year was revealed: 32% in 2019, 35,0% in 2017, 2018, 2021 and 38,0% in 2020 year (Table 3.12).
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Table 3.12 - Level of compliance with clinical protocols of patient management tactics at the outpatient stage in the group of children who died under the age of 1 year in the Republic of Ingushetia, %%
Years |
The level of compliance with clinical protocols of patient management |
Total |
|
tactics at the outpatient stage |
|||
|
|
||
|
|
|
|
2017 |
35,0 |
100,0 |
|
2018 |
35,0 |
100,0 |
|
2019 |
32,0 |
100,0 |
|
2020 |
38,0 |
100,0 |
|
2021 |
35,0 |
100,0 |
The level of compliance with clinical protocols of patient management tactics at the hospital stage was slightly higher: 49,0% in 2019, 50.0% in 2017, 2020, 2021, 51,0% in 2018, however, it also required significant adjustment (Table 3.13).
Table 3.13 - The level of compliance with clinical protocols of patient management tactics at the stage of inpatient care in the group of children who died under the age of 1 year in the Republic of Ingushetia, (%).
Years |
The level of compliance with clinical protocols of patient |
Total |
|
management tactics at the stage of inpatient treatment |
|||
|
|
||
2017 |
50,0 |
100,0 |
|
2018 |
51,0 |
100,0 |
|
2019 |
49,0 |
100,0 |
|
2020 |
50,0 |
100,0 |
|
2021 |
50,0 |
100,0 |
An analysis of the structure of infant mortality by terms of admission to the hospital testified to the dominance of early terms (on the first day and from 1 to 3 days), during which the death of infants occurred, which indicated the low efficiency of the work of the outpatient clinic link in the Republic. So, in 2017, 87,5% of babies died during the first three days, in 2018 - 70%, in 2019 – 57,1%, in 2020 – 57,2%, in 2021
– 62,5% , which accounted for more than half (Table 3.14).
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Table 3.14 - Structure of infant mortality by terms of admission to inpatient
treatment in the Republic of Ingushetia, (%).
|
In the first |
From 1 to |
From 3 to |
From 7 to |
From 30 |
|
|
Years |
30 |
and more |
Total |
||||
day |
3 days |
7 days |
|||||
|
days |
days |
|
||||
|
|
|
|
|
|||
2017 |
62,5 |
25,0 |
12,5 |
0 |
0 |
100,0 |
|
2018 |
45,0 |
35,0 |
0 |
20,0 |
0 |
100,0 |
|
2019 |
42,8 |
14,3 |
14,3 |
14,3 |
14,3 |
100,0 |
|
2020 |
42,9 |
14,3 |
14,3 |
14,3 |
14,2 |
100,0 |
|
2021 |
37,5 |
25,0 |
25,0 |
12,5 |
0 |
100,0 |
Assessment of the quality level of diagnosis of diseases in children who died under the age of 1 year at the stage of providing inpatient medical care in the Republic of Ingushetia indicated the presence of defects in the collection of anamnesis, completeness of the examination, interpretation of the results, and diagnosis. Thus, in 2017, the ratio of completeness in the collection of anamnesis was 50,0 to 50,0, in 2018, incomplete collection of anamnesis prevailed, amounting to 60,0%, and only starting from 2019, the anamnesis was collected completely (Table 3.15).
The completeness of the examination suffered in 2017 and 2018, duplicating the ratio of history taking in similar periods: 50,0 to 50,0 in 2017 and 40,0 to 60,0 in 2018. Starting from 2019, the survey has been complete (Table 3.15).
The results were not always correctly interpreted and accounted for the largest share: 62,5% in 2017, 75,0% in 2020, 80,0% and 100% of cases in 2018 and 2019 (Table 3.15).
The identified defects in the organization of the survey also affected the quality of diagnosis, which did not ensure its high accuracy: 25,0% in 2017, 20,0% in 2018, 70,0% in 2019, 75,0% in 2020 and 80,0% in 2021 (Table 3.15).
Table 3.15 - The structure of the quality of diagnosis of diseases in children who died under the age of 1 year, at the stage of providing inpatient medical care in the Republic of Ingushetia, (%).
Years |
Collection of |
Examination |
Interpretation of |
Establishing |
|
anamnesis |
completeness |
results |
diagnosis |
||
|
224
|
Full |
Not full |
Full |
Not full |
carried out inadequately |
Not carried out |
Accurate |
Not accurate |
|
|
|
|
|
|
|
|
|
2017 |
50,0 |
50,0 |
50,0 |
50,0 |
62,5 |
37,5 |
25,0 |
75,0 |
2018 |
40,0 |
60,0 |
40,0 |
60,0 |
100,0 |
0 |
20,0 |
80,0 |
2019 |
100,0 |
0 |
100,0 |
0 |
100,0 |
0 |
70,0 |
30,0 |
2020 |
100,0 |
0 |
100,0 |
0 |
75,0 |
25,0 |
75,0 |
25,0 |
2021 |
100,0 |
0 |
100,0 |
0 |
80,0 |
20,0 |
80,0 |
20,0 |
Thus, the level of infant mortality in the Republic of Ingushetia had a steady downward trend from 10,9 ‰ to 5,5 ‰ in the interval from 2017 to 2021, in the period before the implementation of the National Health and Demography projects and after the start of their implementation. Structural components of infant mortality were also characterized by similar positive trends: neonatal (from 6.8‰ in 2017 to 4.4‰ in 2021), early neonatal, which accounted for more than 70% in the structure of neonatal mortality (from 4,8‰ in 2017 to 3,2 ‰ in 2021), late neonatal mortality, accounting for up to 30% of neonatal mortality (from 2,1 ‰ in 2017 to 1,1 ‰ in 2021), early neonatal mortality was equated to endogenous mortality, closer to the time childbirth and closely (r=0,7) related to maternal health. Late neonatal mortality was largely due to exogenous causes, on which it is necessary to work long and systematically with the help of adequate measures to prevent complications of pregnancy and childbirth, somatic diseases, fight bad habits, and increase medical activity.
In the structure of mortality, infants of the first half of life were in the lead - 65%, of which infants of the second month of life - 30% and the fourth month of life - 15% prevailed. This age group of the deceased included children who survived the neonatal age as a result of intensive treatment in obstetric and other specialized institutions (cardiac surgery, etc.), who had severe, more often congenital pathology (CM, IUI, etc.).), which arose even antenatally and is closely related to the pathology of the mother. The dynamics of late neonatal mortality was positive, characterizing a decrease in levels from 2,1‰ in 2017 to 1,1‰ in 2021. The stillbirth rate significantly and significantly decreased from 14‰ in 2017 to 1,2‰ in 2021.
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The assessment of the activities of maternal and child health services, proposed by WHO through the indicator of the effectiveness of anteand postnatal prevention of infant mortality, was carried out by the coefficient P/R (ratio of late and early mortality), the values of which were equal to: 0,11 in 2017, 0.12 - in 2018, 0,10 in 2019, 0,2 in 2020, 0,19 in 2021. All values fit into the category "Very high level of prevention", characterized by the values "0,3 and <".
The gestational structure of infant mortality was represented mainly by infants born at 37-41 weeks of fetal development both among boys (48,9%) and girls (65,2%), to a lesser extent, by boys born before 36 weeks of gestation (42,0%) and girls (30,4%), and in the least - born in the interval from 42 to 44 weeks of boys (9,1%) and girls (4,4%).
To assess the causes of infant mortality, an analysis was made of the place of residence, the pathology of the antenatal and neonatal periods of life, the state of dispensary observation, patronage work for children, the type of feeding, vaccination of infants, the timing of contacting an outpatient clinic and hospital, the compliance of diagnostic and treatment procedures with clinical protocols of medical treatment. - diagnostic process.
An analysis of the sex structure among deceased infants reflected the general trend in the human population - the predominance of males at the time of birth: more than 60% of those who died under the age of 1 year were boys and up to 40% were girls.
The geographical structure of infant mortality demonstrated its predominance in the Nazran district of the Republic of Ingushetia as the most densely populated.
Causes of infant mortality in the Republic of Ingushetia were assigned to class XVI "Certain conditions arising in the perinatal period" and class XVII "Congenital anomalies [malformations], deformities and chromosomal disorders." The structure of causes in the studied interval from 2017 to 2021 changed from priority: birth trauma, stunted growth and malnutrition of the fetus, and congenital anomalies [malformations], deformities and chromosomal disorders in 2017 to priority in 2021 infectious diseases specific to perinatal period.
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Examination of defects in the work of the pediatric service in the system of primary health care showed defects in the work of the outpatient department: untimely conduct of primary patronage, inconsistencies in the order of dispensary observation with clinical protocols, low level of vaccination, breastfeeding, untimely appeal of parents of deceased children for medical care in an outpatient clinic polyclinic and routing violation.
Assessment of the quality level of diagnosis of diseases in children who died under the age of 1 year at the stage of inpatient medical care in the Republic of Ingushetia indicated the presence of defects in the collection of anamnesis, completeness of the examination, interpretation of the results, and diagnosis.
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CHAPTER 4. ORGANIZATIONAL AND MEDICAL DETERMINANTS OF
INFANT MORTALITY
4.1. Macro-level organizational and medical determinants.
The organization of medical care makes an important contribution to public health, the formation of medical and demographic indicators, including infant mortality. To manage this component of public health, it is important to assess the availability of human resources, compare the actual availability of personnel and the targets of the National Health Project.
The federal project "Providing medical organizations of the healthcare system with qualified personnel" is part of the National Healthcare Project, and is aimed at eliminating the shortage of personnel in the industry, increasing the prestige of the profession of a medical worker. In this study, it was important to assess the organizational and medical conditions of the republican health care, which determine the health of the population, influencing the key indicators of its assessment, which include infant mortality, and to compare planned (according to the federal project) and actual (republican) indicators of staffing.
Despite the fact that the planned indicators had a starting point of 2019, the comparison turned out to be not only possible, but also informative. Thus, it was found that the indicator of provision with medical workers in the Republic of Ingushetia was stable, amounting to 44% and twice lagged behind the planned indicator, the value of which was in the range from 77,7% to 83,9% (Table 4.1).
Table 4.1 - Indicators of provision of the healthcare system with medical
workers, (per 1000 population).
Years |
|
|
|
|
|
|
2017 |
2018 |
2019 |
2020 |
2021 |
Indicator |
|
|
|
|
|
|
|
|
|
|
|
228
The actual indicator |
|
|
|
|
|
of provision with |
|
|
|
|
|
medical workers in |
44,1 |
44,1 |
43,1 |
44,5 |
44,5 |
the Republic of |
|
|
|
|
|
Ingushetia |
|
|
|
|
|
Target indicator of |
|
|
|
|
|
availability of |
|
|
|
|
|
medical workers |
81,0 |
81,0 |
81,0 |
77,7 |
83,9 |
Indicator “Sufficiency of the population with doctors providing primary health care, pers. per 10,000 population”, included in the socially significant result “Provision of the population with the necessary number of medical workers”, was also evaluated in comparison with the targets of the federal project. A threefold lag of the actual (24.0% - 25,2%) indicator from the planned one (84,2% - 90,0%) was revealed (Table 4.2)
Table 4.2 - Indicators of the provision of the population with doctors, (per 10,000 population).
Years |
|
|
|
|
|
|
|
2017 |
2018 |
2019 |
2020 |
2021 |
|
Indicator |
|
|
|
|
|
|
|
|
|
|
|
|
|
The actual |
|
|
|
|
|
|
indicator of |
|
|
|
|
|
|
the provision |
24,0 |
24,4 |
24,8 |
25,1 |
25,2 |
|
of the |
||||||
|
|
|
|
|
||
population |
|
|
|
|
|
|
with doctors |
|
|
|
|
|
|
Target |
|
|
|
|
|
|
indicator of |
|
|
|
|
|
|
provision of |
90,0 |
90,0 |
90,0 |
84,2 |
84,3 |
|
the population |
|
|
|
|
|
|
with doctors |
|
|
|
|
|
Indicator “Sufficiency of medical workers providing emergency medical care, pers. per 10 thousand population” of the socially significant result “Provision of the population with the necessary number of medical workers” of the Republic did not differ much from the planned criteria of the Project (Table 4.3).
Table 4.3 - Indicators of provision of the population with medical workers providing emergency medical care (per 10,000 population).
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Years |
|
|
|
|
|
|
|
2017 |
2018 |
2019 |
2020 |
2021 |
|
Indicator |
|
|
|
|
|
|
|
|
|
|
|
|
|
The actual indicator |
|
|
|
|
|
|
of provision with |
|
|
|
|
|
|
medical workers |
5,8 |
6,2 |
6,5 |
8,0 |
8,2 |
|
providing |
||||||
|
|
|
|
|
||
emergency medical |
|
|
|
|
|
|
care |
|
|
|
|
|
|
Target indicator for |
|
|
|
|
|
|
the availability of |
|
|
|
|
|
|
medical workers |
7,6 |
7,6 |
7,6 |
7,6 |
7,6 |
|
providing |
||||||
|
|
|
|
|
||
emergency medical |
|
|
|
|
|
|
care |
|
|
|
|
|
Indicator “Sufficiency of the population with doctors providing specialized medical care, pers. per 10,000 population” of the socially significant result “Provision of instruction with the necessary number of medical workers” of the Republic (14,6% - 16,8%) was slightly ahead of the planned one (15,01%) (Table 4.4).
Table 4.4 - Indicators of provision of the population with medical workers providing specialized medical care (per 10,000 population).
Years |
|
|
|
|
|
|
|
2017 |
2018 |
2019 |
2020 |
2021 |
|
Indicator |
|
|
|
|
|
|
|
|
|
|
|
|
|
The actual |
|
|
|
|
|
|
indicator of |
|
|
|
|
|
|
provision with |
|
|
|
|
|
|
medical workers |
14,6 |
15,0 |
15,8 |
16,6 |
16,8 |
|
providing |
|
|
|
|
|
|
specialized |
|
|
|
|
|
|
medical care |
|
|
|
|
|
|
Target indicator of |
|
|
|
|
|
|
availability of |
|
|
|
|
|
|
medical workers |
15,01 |
15,01 |
15,01 |
15,01 |
15,01 |
|
providing |
||||||
|
|
|
|
|
||
specialized |
|
|
|
|
|
|
medical care |
|
|
|
|
|
Indicator “Sufficiency of the population with paramedical workers working in state and municipal medical organizations, pers. per 10 thousand population” of the
230
Republic (82,6% - 89,9%) did not lag behind the project targets (83,7% - 89,1%) (Table 4.5).
Table 4.5 - Indicators of provision of the population with paramedical workers, (per 10,000 population).
Years |
|
|
|
|
|
|
Indicator |
2017 |
2018 |
2019 |
2020 |
2021 |
|
|
|
|
|
|
||
|
|
|
|
|
|
|
The actual indicator of provision with |
85,9 |
82,6 |
82,6 |
86,5 |
89,9 |
|
paramedical workers |
||||||
|
|
|
|
|
||
Target indicator of provision with |
86,8 |
86,8 |
86,8 |
83,7 |
89,1 |
|
paramedical workers |
||||||
|
|
|
|
|
The indicators "The share of specialists admitted to professional activities through the accreditation procedure, of the total number of working specialists, %" of the task "Liquidation of staff shortages in medical organizations providing primary health care" at the first stages of the project had a zero value, but by 2021 (30,0%) were statistically significantly ahead of the planned ones (23,7%) (Table 4.6).
Table 4.6 - The share of specialists admitted to professional activities through the accreditation procedure, (%).
Years |
|
|
|
|
|
|
Indicator |
2017 |
2018 |
2019 |
2020 |
2021 |
|
|
|
|
|
|
||
|
|
|
|
|
|
|
The share of specialists who passed the |
0 |
0 |
0 |
0 |
30 |
|
accreditation procedure |
||||||
|
|
|
|
|
||
The share of specialists who passed the |
2,0 |
2,0 |
2,0 |
2,6 |
23,7 |
|
accreditation procedure |
||||||
|
|
|
|
|
There was a significant (fourfold) shortage of general practitioners. The security of the population of general practitioners was 0,02 per 10,000 population instead of the standard: 1 position per attached population of 1,200 adults. The availability of district therapists lagged behind the standard by almost 2 times, amounting to (3,5 – 3,8). The availability of pediatricians approached the standard, but did not reach it, practically not changing in dynamics (9,0-10,2) (Table 4.7).
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