6 курс / Неонатология / Научное_обоснование_механизмов_управления_младенческой
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An analysis of the morbidity of puerperas testified to the presence of predominantly positive medical and demographic trends. The incidence of postpartum women who gave birth to children in the Republic of Ingushetia in 2016-2020 was a steady downward trend in indicators. in general, and for individual nosological forms: anemia, threatened miscarriage, diseases of the genitourinary system, pathological conditions of the fetus, venous complications, diseases of the circulatory system, diseases of the endocrine system in puerperas. Hypertension, pre-eclampsia and Rh immunization did not show significant dynamic differences, and the disease of civilization - diabetes mellitus significantly and significantly increased.
The medical and social determinants of infant mortality included the following groups: unmarried (5,2%), living separately from parents (70,9%), in rural areas (36,2%), third and subsequent births ( 41,8%), with complications in childbirth (9,4%), with malnutrition during pregnancy (13,6%), with increased physical activity during pregnancy (31,5%), the presence of infectious diseases in the family ( 12,2%), the presence of sexually transmitted diseases in the anamnesis of pregnancy (11,3%), the absence of recovery after the transfer of these diseases (7,7%), the presence of diseases of the female genital area (in less than 20%), the presence of bad habits mother (9,86%), father (36,6%), genetic diseases (21,1%), failure to undergo genetic counseling to identify the risks of miscarriage (60,7%), high risk of developing genetic diseases (11,2%), gestational age of the newborn up to 37 weeks (6,6%), presence of somatic diseases (in 60,6% of women in labor), lack of preparation for childbirth (56,3%), artificial feeding of the newborn (9,4%), the presence of complications in childbirth (in 54% of women), an insufficient level of comfort in staying in the perinatal center, care, and drug provision (3%).
Actual numerical values of the determinants of infant mortality for 2017-2021 were used for forecasting, assessing the dynamics of their prospective values, provided that the National Health and Demography projects continue to operate. 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
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significantly, the indicators of 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.
Projected data indicate a possible significant improvement in the quality profile 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%,
-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%.
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. In the group of medical and demographic determinants, fertility indicators had high levels of significance for infant mortality (regression coefficient 1,02, correlation coefficient 0,98, determination coefficient 96,41, significance coefficient - 0.00001), fertility among mothers of older age groups (coefficient regression coefficient -0,39, correlation coefficient -0,91, determination coefficient 82,88, significance coefficient – 0,001), fertility among mothers under the
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age of 20 (regression coefficient -2,25, correlation coefficient -0,79, coefficient determination 62,18, significance coefficient – 0,02), pathological condition of the fetus (regression coefficient 8,8, correlation coefficient 0,93, determination coefficient 87,83, significance coefficient – 0,0005).
In the group of organizational and medical determinants, the most significant were the level of provision with pediatricians (regression coefficient -0,22, correlation coefficient -0,93, determination coefficient 88.18, significance coefficient – 0,0005).
In the group of medical and social determinants, the most significant was the level of medical activity of mothers (regression coefficient -0,86, correlation coefficient -0,86, determination coefficient 75,17, significance coefficient – 0,005).
As a result of a systematic assessment of the determinants of infant mortality, an organizational model for the management (control) of infant mortality has been formed, measures have been developed to reduce infant mortality, and centers of responsibility for organizing and conducting these measures have been identified.
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CONCLUSIONS
1.The infant mortality rate 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, accounting for up to 30% of neonatal mortality (from 2,1‰ in 2017 to 1,1‰ in 2021),
2.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 smallest - born in the range from 42 to 44 weeks of boys (9,1%) and girls (4,4%). Among the deceased infants, males predominated: more than 60% of those who died under the age of 1 year were boys and up to 40% were girls.
3.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.
4.The need for obstetric and gynecological care of the population of the Republic of Ingushetia increased intensively, as evidenced by the increase in the number of calls to the Perinatal Center, spent bed days (from 62197 to 77752), days of bed occupancy (from 239 to 307), bed turnover from 29, 3 to 45 days, calls from villagers (from 582 to 1835), bed-days spent by villagers (from 6596 to 11040). There is 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 steadily increased.
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5.In the cohort of infants who formed the infant mortality rate, in the period of 2017-2021, there was a 2% absolute increase in the proportion of children whose primary medical patronage was carried out later than a day. The lack of dynamics in vaccination levels was revealed, the persistence of a low level (15% in the period 20172021), the persistence of a high (75%) proportion of children whose dispensary observation was not carried out in accordance with the decreed terms and volume, a low (30%) proportion of parents' requests to the doctor in connection with the last illness of the child, low (35%) level of compliance with clinical protocols of patient management tactics at the outpatient stage in the group of children who died under 1 year old, insufficient (50%) level of quality in diagnosing diseases in children who died under the age of year at the stage of inpatient care, an increase in the proportion of mothers who gave birth to children in 2017 - 2021, under the age of 20: from 16,5% to 26,2% and older age groups: from 40,1% to 42,5 %
6.The key organizational and medical determinants were the level of availability of pediatricians (correlation coefficient -0,93, determination coefficient 88,18, significance coefficient – 0,0005), the level of quality of diagnosis of diseases in children who died under the age of one year at the stage of inpatient medical care. assistance (regression coefficient 0,5, correlation coefficient -0,5, determination coefficient 88,18, significance coefficient – 0,03).
7.The key medical and demographic determinants of infant mortality were birth rates (correlation coefficient 0,98, determination coefficient 96,41, significance coefficient – 0,00001), fertility in mothers of older age groups (correlation coefficient -0,91, determination coefficient 82,88 , significance coefficient – 0,001), birth rate among mothers under the age of 20 (correlation coefficient -0,79, determination coefficient 62,18, significance coefficient – 0,02), maternal morbidity (correlation coefficient 0,7, determination coefficient 84,52, significance coefficient – 0,06), pathological condition of the fetus (correlation coefficient 0,93, determination coefficient 87,83, significance coefficient – 0,0005).
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8.The key medical and social determinant was the level of medical activity of mothers (correlation coefficient -0,86, determination coefficient 75,17, significance coefficient – 0,005).
9.The results of a systematic assessment of the determinants of infant mortality made it possible to propose an organizational model for the management (control) of infant mortality, containing key determinants, measures to reduce infant mortality, and defining centers of responsibility.
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PRACTICAL RECOMMENDATIONS
1.Regional health authorities to actively use the organizational model of management (control) of infant mortality.
2.Regional health authorities to increase the level of provision with pediatricians in remote areas by 2,3% and achieve an indicator of at least 12,5 per 10,000 children, strengthen the pediatric service through monetary and non-monetary motivation, the use of federal and regional programs to support the system health care, development of a mentoring system for young professionals.
3.Regional health authorities should actively develop the targeted direction in the training of pediatricians, implement the targeted direction for training, taking into account the territory of residence aimed at training and subsequent employment.
4.Regional health authorities should create favorable conditions for practiceoriented training of pediatricians, conclude practical training agreements with educational organizations that train medical personnel.
5.When conducting external quality control of medical care and medical activities of medical organizations providing maternal and child health care, regional health authorities should include in the assessment system the key organizational, medical, medical, demographic and medical and social determinants of infant mortality: the level of availability of pediatricians, the level quality of diagnosis of diseases in children. birth rate in mothers of older and younger age groups, the level of medical activity of mothers.
6.Heads of medical organizations to form mechanisms to increase the effectiveness of preventive work with pregnant women and puerperas aimed at maintaining the health of the mother and newborn: planning pregnancy and childbirth, organizing breastfeeding of newborns, observing the national vaccination schedule, timely seeking medical care for newborns.
7.Heads of medical organizations to modernize the technology of internal quality control of medical care for women and children through a systematic analysis of defects in the provision of care and long-term planning of measures to improve it.
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