6 курс / Неонатология / Научное_обоснование_механизмов_управления_младенческой
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of infant mortality. The prospective values of indicators-determinants of infant mortality had positive trends and confirmed the need to maintain the ongoing demographic policy of the state. Thus, the level of the pathological condition of the fetus will continue to decrease statistically significantly, the availability of pediatricians and nursing staff will increase, the levels of compliance with clinical protocols of patient management tactics at the outpatient stage, prenatal medical activity of mothers will increase (Table 6.2 – 6.3).
Table 6.2 - Dynamics of potential (theoretical) organizational-medical, medicaldemographic and medical-social determinants of infant mortality for 2022-2031.
Years |
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2022- |
2024- |
2026- |
2028- |
2030- |
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|
2023 |
2025 |
2027 |
2029 |
2031 |
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Indicators |
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Proportion of children, primary |
|
|
|
|
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|
Medical patronage, which was |
50,3-50,4 |
50,5-50,6 |
50,7-50,8 |
50,9-51,0 |
51,1-51,2 |
|
carried out later than 3 days,% |
|
|
|
|
|
|
Level of vaccination of newborns, % |
14,1-13,8 |
13,5-13,2 |
13,0-12,6 |
12,3-12,0 |
11,9-11,8 |
|
The proportion of children whose |
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|
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|
|
|
dispensary observation was not |
74,7-74,6 |
74,5-74,4 |
74,3-74,2 |
74,1-74,0 |
73,9-73,8 |
|
carried out in accordance with the |
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decreed terms and volume, % |
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The share of parents' visits to the |
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|
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|
doctor in connection with the child's |
30,3-30,4 |
30,5-30,6 |
30,7-30,8 |
30,9-31,0 |
31,1-31,2 |
|
last illness, % |
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|
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The level of compliance with clinical |
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protocols of patient management |
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|
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tactics at the outpatient stage in the |
35,9-36,2 |
36,5-36,8 |
37,1-37,4 |
37,7-38,0 |
38,3-38,6 |
|
group of children who died before 1 |
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year, % |
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The level of quality of diagnosis of |
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diseases in children who died under |
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|
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|
the age of one year at the stage of |
49,0-48,0 |
47,0-46,0 |
45,0-44,0 |
43,0-42,0 |
41,0-40,0 |
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provision of inpatient medical care, |
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% |
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Pathological condition of the fetus, |
67,5-56,2 |
44,8-33,5 |
22,2-10,6 |
10,4-10,2 |
10,1-10,0 |
|
‰ |
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Morbidity of mothers, ‰ |
778,3- |
816,9- |
845,5- |
874,1- |
902,6- |
|
802,6 |
831,2 |
859,8 |
888,4 |
916,9 |
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|
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The level of provision with medical |
20,6-19,9 |
19,2-18,5 |
17,8-11,1 |
16,4-15,8 |
15,1-14,4 |
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personnel, per 10,000 people |
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The level of provision with |
10,5-10,8 |
11,0-11,3 |
11,6-11,9 |
12,2-12,5 |
12,8-13,1 |
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pediatricians, per 10,000 people |
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The level of provision with nursing |
89,0-90,2 |
91,4-92,6 |
93,8-95,0 |
96,2-97,4 |
98,5-99,7 |
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staff, per 10,000 people |
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Birth rate among mothers under the |
29,2-32,5 |
35,7-39,0 |
42,3-45,6 |
48,9-52,2 |
55,5-58,8 |
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age of 20, ‰ |
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Birth rate among mothers of older |
42,6-43,2 |
43,7-44,2 |
44,7-45,2 |
45,8-46,2 |
46,8-47,3 |
|
age groups, ‰ |
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Medical activity of mothers, % |
76,8-78,0 |
79,2-80,4 |
81,5-82,7 |
83,9-85,1 |
86,3-87,4 |
Table 6.3 - Dynamics of potential (theoretical) organizational-medical, medical-
demographic and medical-social determinants of infant mortality in 2023-2041.
Years |
2032-2033 |
2034-2035 |
2036-2037 |
2038-2039 |
2040-2041 |
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Indicators |
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Proportion of children, primary |
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Medical patronage, which was |
51,3-51,4 |
51,5-51,6 |
51,7-51,8 |
51,9-52,0 |
52,1-52,2 |
|
carried out later than 3 days,% |
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|
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Level of vaccination of newborns, |
11,1-10,8 |
10,5-10,2 |
9,9- |
9,3- |
8,7- |
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% |
9,6 |
9,0 |
8,4 |
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The proportion of children whose |
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dispensary observation was not |
73,7-73,6 |
73,5-73,4 |
73,3-73,2 |
73,1-73,0 |
72,9-72,8 |
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carried out in accordance with the |
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decreed terms and volume, % |
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The share of parents' visits to the |
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doctor in connection with the |
31,3-31,4 |
31,5-31,6 |
31,7-31,8 |
31,9-32,0 |
32,1-32,2 |
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child's last illness, % |
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The level of compliance with |
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clinical protocols of patient |
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management tactics at the |
38,9-39,2 |
39,5-39,8 |
40,1-10,4 |
10,7-41,0 |
41,3-41,6 |
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outpatient stage in the group of |
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children who died before 1 year, |
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% |
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The level of quality of diagnosis |
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of diseases in children who died |
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under the age of one year at the |
39,0-38,0 |
37,0-36,0 |
35,0-34,0 |
33,0-32,0 |
31,0-30,0 |
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stage of provision of inpatient |
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medical care, % |
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Morbidity of mothers, ‰ |
931,2- |
959,8- |
988,4- |
1017,0- |
1045,6- |
|
945,5 |
974,1 |
1002, |
1031,3 |
1059,9 |
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The level of provision with |
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|
9,5- |
8,2- |
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medical personnel, per 10,000 |
13,7-13,0 |
12,3-11,6 |
10,9-10,2 |
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8,9 |
7,5 |
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people |
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The level of provision with |
13,4-13,7 |
13,9-14,2 |
14,5-4,81 |
15,1-15,4 |
15,7-6,01 |
|
pediatricians, per 10,000 people |
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The level of provision with |
100,9- |
103,3- |
105,7- |
108,1- |
110,4- |
|
nursing staff, per 10,000 people |
102,1 |
104,5 |
106,9 |
109,3 |
111,6 |
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Birth rate among mothers under |
62,1-65,4 |
68,7-72,0 |
75,3-78,6 |
81,9-85,2 |
88,5-91,8 |
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the age of 20, ‰ |
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Birth rate among mothers of older |
47,8-48,4 |
48,9-49,4 |
49,9-50,4 |
51,0-51,5 |
52,0-52,5 |
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age groups, ‰ |
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Medical activity of mothers, % |
88,6-89,8 |
91,0-92,2 |
93,3-94,5 |
95,7-96,9 |
98,1-99,2 |
Evidence indicates a possible significant improvement in the quality profile of
care for children under 1 year of age.
Figure 6.1. Comparative profile of the quality of medical care for children under the age of 1 year.
Ceteris paribus (further financing of the healthcare system under the National Healthcare Project), a number of predicted indicators will improve their values in the interval from 2017 to 2041:
- The proportion of children whose dispensary observation was not carried out in accordance with the decreed terms and volume will decrease from 73,7% to 72,8%,
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-The level of compliance with clinical protocols of patient management tactics at the outpatient stage in the group of children who died before 1 year of age will increase from 38,9% to 41,6%,
-The level of provision with pediatricians will increase from 13,4 to 16 per 10,000 thousand child population,
-The level of provision with nursing staff will increase from 100,9 to 111,6 per 10 thousand population,
-Antenatal medical activity of mothers will increase from 88,6% to 99,2%,
-The share of parents' visits to the doctor in connection with the last illness of the child will increase from 31,3% to 32,2% (table 6.3, figure 6.1).
To determine the key determinants of infant mortality, a correlation analysis was carried out between the series of indicators of infant mortality and its determinants, and their statistical significance for infant mortality was confirmed through regression coefficients, correlation, determination, and the probability of an error-free forecast. Key determinants are represented by 3 groups: medical-demographic organizationalmedical and medical-social determinants.
Thus, high levels of significance were noted for fertility rates (regression coefficient 1,02, correlation coefficient 0,98, determination coefficient 96,41, significance coefficient – 0,00001), fertility among mothers of older age groups (regression coefficient -0,39 , correlation coefficient -0,91, determination coefficient 82.88, significance coefficient – 0,001), fertility among mothers under the age of 20 (regression coefficient -2,25, correlation coefficient -0,79, determination coefficient 62,18, coefficient significance – 0,02), pathological condition of the fetus (regression coefficient 8,8, correlation coefficient 0,93, determination coefficient 87,83, significance coefficient – 0,0005), level of provision with pediatricians (regression coefficient -0,22, correlation coefficient -0,93, determination coefficient 88,18, significance coefficient – 0,0005), medical activity of mothers (regression coefficient -0,86, correlation coefficient -0,86, determination coefficient 75,17, significance coefficient – 0,005) (Table 6.4).
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Table 6.4 - Indicators for assessing the statistical significance of the determinants of infant mortality
Years
Indicators
Fertility, ‰
Proportion of children, primary medical patronage for which was carried out later than 3 days, %
Level of vaccination of newborns, %
The proportion of children whose dispensary observation was not carried out in accordance with the decreed terms and volume, %
The share of parents' visits to the doctor in connection with the child's last illness, %
The level of compliance with clinical protocols of patient management tactics at the outpatient stage in the group of children who died before 1 year, %
The level of quality of diagnosis of diseases in children who died under the age of one year at the stage of provision of inpatient medical care,
%
Pathological state of the fetus, ‰
Morbidity of mothers, ‰
The level of provision with medical personnel, per 10,000 people
The level of provision with pediatricians, per 10,000 people
The level of provision with nursing staff, per 10,000 people
Birth rate among mothers under 20‰
Birth rate among mothers of older age groups, ‰
Medical activity of mothers, %
Regression coefficient (b) |
Correlation coefficient (R) |
Determination coefficient (R2) |
Significance factor (p) |
1,02 |
0,98 |
96,41 |
0,00001 |
-0,05 |
-0,13 |
1,95 |
0,7 |
0,18 |
0,32 |
10,72 |
0,42 |
0,06 |
0,32 |
10,72 |
0,4 |
-0,06 |
-0,32 |
10,72 |
0,4 |
-0,18 |
-0,32 |
10,72 |
0,4 |
0,5 |
0,6 |
13,06 |
0,03 |
8,80 |
0,93 |
87,83 |
0,0005 |
22,35 |
0,71 |
4,52 |
0,06 |
0,53 |
0,44 |
20,24 |
0,2 |
-0,22 |
-0,93 |
88,18 |
0,0005 |
-0,70 |
-0,61 |
37,94 |
0,1 |
-2,25 |
-0,79 |
62,18 |
0,02 |
-0,39 |
-0,91 |
82,88 |
0,001 |
-0,85 |
-0,86 |
75,17 |
0,005 |
An analysis of the results of a systematic assessment of the health factors of children under the age of one and infant mortality rates made it possible to propose an organizational model for managing (controlling) infant mortality, in which medical-
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demographic, organizational-medical, medical-social ones are represented by groups of clusters that cause them, and measures aimed at reducing the negative impact of determinants, and the centers of responsibility for carrying out these activities have been identified (figure 6.2).
Determinants of infant mortality
KEY
DETERMINANTS
HEALTH
AND
DEMOGRAP
HIC
ORGANIZA
TIONAL
AND
MEDICAL
MEDICAL
AND
SOCIAL
Indicators
Birth rate among women under 20, over 30
Morbidity of
mothers
Pathological conditions of newborns
The quality of diagnosis of diseases of children
Provision with pediatricians
Level of medical activity of mothers
Events
Planning for pregnancy and childbirth
Prevention of somatic pathology
Dealing with complications in childbirth
Preparation of
doctors
Measures of social support for health workers
Provision of transport for medical organizations
Genetic counseling, the fight against bad habits, good nutrition, adequate physical activity
RESPONSIBILITY
CENTERS
perinatal center
Educational organization, research organization
Health authorities
perinatal center
MOs providing primary health care
Figure 6.2. Flowchart of the organizational model for managing infant mortality
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CONCLUSION
One of the most important indicators for assessing socio-economic well-being is infant mortality. This indicator reflects the work of the healthcare industry and its key component - the obstetrics system, evaluates the effectiveness of the Federal State Programs for the Reproductive Health of Youth, and captures national characteristics and demographic priorities of the population.
In previous studies, a detailed assessment of the problems of maternal and child health, the factors causing them, was carried out, dynamic monitoring of demographic indicators and components of survival and fertility tables was carried out. The study of infant mortality as a system with its determining factors and the development of ways to control this indicator has not been previously carried out. According to the Public Chamber of the Russian Federation, the Republic of Ingushetia was among the leaders of the National Birth Rate, which automatically entailed an increase in infant mortality. For the Republic of Ingushetia, the problem of minimizing infant mortality is extremely relevant. The implementation of the state national programs Demography and Public Health provides a reduction in the level of infant mortality, but does not reach the desired minimum. That is why a systematic study of infant mortality served as the basis for conducting this study, the purpose of which was: based on an in-depth medical and demographic analysis and medical and social assessment of measures to combat infant mortality in the Republic of Ingushetia, to develop an organizational model for managing infant mortality for forecasting and planning national programs. To achieve this goal, it was supposed to solve the problems of identifying current trends in infant mortality in the Republic of Ingushetia with determining the structure of causes, analyzing and evaluating the medical, demographic and medical and social organizational and medical determinants of infant mortality, building an organizational model for managing infant mortality for forecasting and planning national programs, development of measures aimed at reducing infant mortality and its consequences.
The methods of sociological survey, expert assessments, relative values, dynamic series, correlation and regression analysis, mathematical modeling and
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software products used in the work: a database, Excel spreadsheets, and the statistical package Statgraphic made it possible to complete all the research tasks and achieve the goal.
As a result of the study, in the period before the start of the implementation of the National Health and Demography projects and after the start of their implementation, a significant decrease in the level of infant mortality in the Republic of Ingushetia from 10,9‰ to 5,5‰ was revealed. Positive trends were also noted among the structural components of infant mortality: 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, accounting for up to 30% of neonatal mortality (from 2,1‰ in 2017 to 1,1‰ in 2021).
In the structure of infant mortality, infants of the first six months of life were in the lead - 65%, of which infants of 2 months of life - 30% and 4 months of life - 15% prevailed.
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 decreased significantly and significantly from 14‰ in 2017 to 1,2‰ in 2021.The rapid assessment of the activities of maternal and child health services, proposed by WHO through the indicator of the effectiveness of ante - and 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 <". However, control of infant mortality is possible only through a detailed analysis of its causes: age-sex, gestational, geographical, quality of medical care.
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 range from 42 to 44 weeks of boys (9,1%) and girls (4,4%).
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An analysis of the sex structure of 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.
Examination of defects in the work of the pediatric service in the system of primary health care for children who died under the age of 1 year showed shortcomings in the work of the outpatient clinic link: untimely primary patronage, inconsistency in the order of dispensary observation with clinical protocols, low level of vaccination, breastfeeding, untimely appeals of parents of deceased children for medical care to an outpatient clinic and violation of routing in the provision of medical care to children under the age of 1 year.
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.
An assessment of the provision of medical personnel in the health care of the Republic showed a significant lag in the actual number of medical personnel from the normative one, established by the target indicators of the Federal project. The actual values of the provision of medical personnel during the project activities increased, but did not always reach the required values. The exception was the indicator of provision with paramedical personnel, which reached the required level by 2021.
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Analysis of the activities of the hospital for 2017 - 2021 reflected the increased workload of medical personnel, an increase in the intensity of work due to steady growth:
-appeals to the perinatal center;
-number of bed-days spent;
-number of days the bed is occupied;
-bed turnover;
-appeals of rural residents;
-number of bed-days spent by rural residents;
-the number of patients admitted to the gynecological department and the reduction in the proportion of gynecological patients;
-rural residents among those admitted to the gynecological department;
-bed-days spent by rural residents in the gynecological department;
-the number of women admitted to the department of pathology of pregnancy and the number of bed-days they spent.
There has been an emerging trend towards a decrease in the average bed downtime from 4,3 to 1,25 days.
The intensity of the work of the perinatal center increased due to the increase in the number of births. At the same time, the growth trend was stable and formed.
In addition to the described systemic macroand micro-level organizational and medical factors that cause a decrease in the quality of medical care for children under 1 year of age and the formation of an infant mortality rate, medical and social (factors of the medical activity of women who took part in the formation of the population of newborns and pathology of women) and medical -demographic factors. The current demographic trend of declining birth rates in the Republic of Ingushetia has also contributed to some reduction in infant mortality. The increase in age-specific fertility (fertility) in women of young ages (up to 20 years old) and older than 30-34 and 35-39 years old as risky women-mothers for health reasons was alarming: the immaturity of the young mother's body in the first case and the load of chronic pathology of the agerelated organism - in second.
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