6 курс / Неонатология / Научное_обоснование_механизмов_управления_младенческой
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made it possible to rationally plan material and human resources in the implementation of organizational, medical, diagnostic and preventive measures activities [24].
Of great importance in reducing the perinatal mortality rate was the active commissioning of perinatal centers that provide pregnant women, women in labor, puerperas and their newborns with highly qualified medical care.
The improvement of the mechanisms for controlling perinatal morbidity and mortality was facilitated by the provision of modern medical equipment, the introduction of advanced areas of rehabilitation and care for newborns into medical practice, and personnel management [13, 15, 16, 17, 154, 155, 156, 157, 158]. The reduction in perinatal morbidity and mortality was ensured by the introduction of perinatal technologies, especially at level III, which included: monitoring of pregnant women at risk; prevention and correction of gestational complications in patients with hemostasis defects; extracorporeal methods of detoxification for the correction of disorders in preeclampsia; the use of glucocorticoids for the prevention of respiratory distress syndrome; a unified system of primary resuscitation of low birth weight newborns, the introduction of artificial surfactant in the first 10 minutes of life; nursing children with low body weight in incubators, with the formation of a "nest"; infusion therapy, including microdoses of heparin; management of low birth weight newborns at the stages of early rehabilitation using the technology of joint stay with the mother until discharge from the hospital [23, 198, 199, 200, 201].
It has been statistically proven that the perinatal mortality rate is higher in institutions of a lower organizational level of obstetric care; there was a significant difference in perinatal mortality rates between different institutions of the same (first and second) level of care [43, 177].
To optimize the work of obstetric institutions, it is important to ensure the routing of pregnant women from high-risk groups for perinatal mortality and to train specialists in institutions with the worst indicators [84, 89].
Antenatal fetal death is the main component of the perinatal mortality rate in the Republic of Crimea, which has a negative trend over the past 7 years. The increase in the contribution of antenatal fetal death to the structure of perinatal mortality reflected
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the low quality of medical care provided to pregnant women at the level of primary healthcare, including antenatal clinics [85, 101, 102, 104, 119, 120, 124, 136, 179, 180].
Numerous studies of the problem of perinatal mortality have confirmed the need for a comprehensive reform of perinatal care, which will ensure: the development and implementation of a national policy in this area, the organization of a regional system, the introduction of effective technologies recommended by WHO, the creation of a system for monitoring, evaluating and auditing maternal and perinatal mortality; introduction of clinical evidence-based protocols, modernization of care for newborns, creation of a monitoring system for children at risk, equipping perinatal centers with equipment according to their level. The effectiveness of implementation is ensured by the training of doctors, nurses and managers [24, 25, 26, 27, 36, 38, 40, 49, 50, 51, 93, 96, 102, 109, 110, 163, 166, 191, 192, 193].
1.4. Project approaches for managing infant mortality
The latest technological developments, achievements in fundamental and applied medical science provide medical professionals with increasingly effective, but most often more expensive methods of diagnosis, treatment and prevention, which leads to the global trend of increasing health care costs A number of scientific studies are presented, including in-depth analysis of the state of the organization, human resources and performance indicators of obstetric-gynecological and pediatric services [108]. The contribution of the Priority National Project "Health" to the development and improvement of the regional maternal and child health service was assessed. Sociological studies have been carried out to study women's opinions on the availability and quality of medical care in the maternal and child health service [25, 73, 138].
A close correlation was noted between the reduction in morbidity and mortality from respiratory distress syndrome in the early neonatal period and the introduction of high-tech nursing methods using modern respiratory equipment under the Birth
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Certificate program. A positive trend was revealed in relation to the amount of intrauterine hypoxia and asphyxia, which is due to an increase in the quality of correction of these conditions in the antenatal period due to the Birth Certificate program of the National Health Project. The introduction of investments in human capital at the stage of obstetrics provided a twofold increase in the average annual cost of fixed production assets, a fourfold increase in capital intensity, a threefold increase in capital productivity, which indicated the effective use of medical equipment purchased under the National Health Project and the use of new technologies in the treatment and diagnostic process. The return on equity ratio was positive. The economic efficiency of the medical organization has steadily increased due to the growth of tax revenues to the budget due to the steady growth in the wages of key personnel. Along with the improvement in the economic performance of the maternity hospital, the coefficient of medical effectiveness increased from 0, to 0,99 [138]. The authors proposed a scientifically substantiated medical-socio-economic model for quantifying the impact of national family planning programs, which can be used as the basis for calculating public health care costs [33, 34, 35, 138].
It has been statistically proven that an unreasonable decrease in the provision of pregnancy pathology beds by 1 unit can lead to an increase in the stillbirth rate by 0,15%o, and a shortage of such a staff unit as a neonatologist can become a factor that increases the infant mortality rate by 0,05 %o [70].
It is necessary to use a task assignment model in the obstetrics and childhood service, aimed at timely diagnosis and maintaining the health of the child population. The use of screening programs for congenital malformations contributed to their early detection, optimal treatment, rehabilitation and quality of life. Improving the methods of antenatal diagnosis of fetal malformations, the introduction of modern neonatal screening technologies are one of the main reserves for reducing the mortality of the population due to this pathology. Based on the results of many years of experience in the use of the proposed automated information systems in the territories of the Central Federal District (Ivanovo, Vladimir, Kostroma regions), it was noted that this technology improves the regionalization of perinatal care in the territories due to a
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greater concentration of high-risk pregnant women in obstetric hospitals of the corresponding risk group [30]. Positive results have been noted in reducing infant mortality, which was a consequence of expanding the practice of medical genetic counseling, prenatal diagnosis, and improving the quality of specialized medical care for newborns with congenital malformations [44, 171, 172, 173].
The issue of infant mortality management included the introduction into practical healthcare of a method for predicting the formation of congenital malformations of the fetus in pregnant women in the first trimester of pregnancy [47, 174]. Evaluation of indicators using a polynomial trend found that the proportion of conditions of the perinatal period in the structure of infant mortality did not have a steady downward trend. Cases of infant deaths due to congenital developmental anomalies, including as a result of accidents, have been identified. Congenital malformations in the structure of MS in 2002-2008 moved from 3 rd to 2 nd place, and in 2006 even to 1st place, although the analysis of indicators did not reveal a steady downward trend. A significant increase in the proportion of infant deaths from injuries, poisoning and other external causes has been noted. Based on the study of indicators using a polynomial trend, it was concluded that the number of accidents in the structure of infant mortality had a steady upward trend.
Respiratory diseases as a cause of death in infants have lost their leading role, having shifted from 2 nd to 4-5 th place. The results of the analysis of indicators made it possible to predict a further decrease in the proportion of respiratory diseases in the structure of causes of infant mortality [53]. Models of infant mortality and stillbirth built in the course of research emphasize the need to shift priorities in making organizational decisions regarding the optimization of the number of beds and medical personnel from general economic approaches to rational, relevant approaches that take into account the specific features of each region [72, 139].
The general principles of a harmonized approach in the field of planning, implementation of management decisions to reduce infant mortality at the level of a constituent entity of the Russian Federation are substantiated using modern innovative technologies for transferring information between health authorities and institutions,
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territorial bodies of the Federal State Statistics Service and the Civil Registry Office [45]. Strengthening the material and technical base of obstetric and childhood institutions, increasing the availability of high-tech types of medical care for women and children, training and retraining of personnel, and developing preventive medical care; optimization of social assistance to families with young children [52, 53, 111, 162].
1.5. Regional aspect in the study of infant mortality
The regional aspect of studying infant mortality is strategically important, since this indicator characterizes the reproductive potential, living conditions, the quality of medical care, the level of development of the regions and the economic and social changes taking place in them, indirectly assessing not only the socio-economic situation, but also the specifics of fertility, population mortality [117, 118, 134, 147, 148, 149, 150, 152, 159, 160, 161, 167, 168, 169, 176, 178, 181, 189, 190, 195, 196, 197]. According to medical and demographic studies, all regions of the Russian Federation were divided into 3 clusters. The 1st cluster turned out to be the most numerous. It includes 52 regions, including mainly the regions of the Central Federal District (Bryansk, Vladimir, Kursk, Lipetsk regions), the Urals Federal District (Kurgan, Tyumen, Chelyabinsk regions, etc.), the North-Western Federal District (Republic of Karelia, Republic of Komi, etc.), Southern Federal District (Astrakhan, Volgograd regions), Volga Federal District, Siberian Federal District (Republic of Khakassia, Altai Territory, Trans-Baikal Territory, etc.). The regions of the 1st cluster are characterized by the largest number of abortions, the largest emissions of pollutants into the atmosphere, and the average values of indicators characterizing medical care. In this cluster, the minimum values of the number of births by women aged 45-49 years and the maximum - at the age of 20 years were observed. The 2nd cluster included 5 regions: the Republic of Dagestan, the Republic of Ingushetia, the Chechen Republic, the Republic of Tyva and the Chukotka Autonomous Okrug. In them in which there was a high average value of the infant mortality rate. In terms of the capacity of
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outpatient clinics, this cluster occupied a leading position, and in terms of the number of abortions, the cluster had the lowest values. These regions have the highest rates of childhood morbidity from all causes. Compared to other clusters in these regions, there were low indicators of medical provision. In this cluster, women gave birth at the age of 20 and at least at the age of 45. Funding for social security in the regions of this cluster was of minimal importance, and the number of doctors in these regions is relatively small. The regions of this cluster had a favorable environmental background, since emissions of pollutants into the atmosphere had minimal values.
The 3rd cluster included 23 regions: the Far Eastern and Siberian Federal Districts (Omsk Region, Primorsky Territory, etc.), the Volga Federal District (Samara Region, the Republic of Tatarstan, the Republic of Bashkortostan, etc.). This cluster had the lowest average infant mortality rate. In terms of the number of doctors, the cluster occupied a leading position, which was a positive factor for reducing the infant mortality rate. The regions of this cluster received the maximum budget funding for the social security of the population [73].
Given the fact that over the past years the North Caucasian Federal District has demonstrated high rates of infant mortality due to high birth rates in its regions, it is necessary not only to dynamically control, but also to deeply analyze the causes of the negative dynamics of infant mortality. The North Caucasian Federal District occupied the last place in the infant mortality rate, and its indicators were almost two times higher than those of the Northwestern Federal District [61, 72, 73].
A comparative analysis of infant mortality rates in the Southern and Central Federal Districts showed that in the Southern Federal District in 2015, infant mortality was higher than the level of the Central Federal District by 0,3%o. And in 2016, this indicator in the studied districts became the same.
An analysis between the place of residence and the level of infant mortality showed that in rural areas the health of newborns can be influenced by the environment [95; 137]. In the Central Black Earth economic region and the Voronezh region for the period from 2005 to 2015, there was a positive trend in the decline in indicators, and priority areas for their further improvement were identified [96; 100]. In the Astrakhan
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region, the study of infant mortality was carried out from the angle of the analysis of congenital pathology. A significant prevalence of infant mortality from congenital malformations among the urban population was noted [131, 132, 133]. An analysis of infant mortality in the Republic of Kalmykia testified to the presence of a difficult situation and the formation of negative trends [135].Thus, the accumulated domestic and foreign organizational and research experience in the study of infant mortality indicates its multidimensionality, multifactorial nature, difficult controllability, and high significance for the territory requiring detailed monitoring. The National Projects "Demography" and "Health Care", which have been operating since 2018, confirm the need to regulate the processes of infant mortality, especially in regions with high birth rates, which include the Republic of Ingushetia. These circumstances formed the basis for the present study.
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CHAPTER 2. PROGRAM, MATERIALS AND RESEARCH METHODS
The study was conducted on the basis of the Republican Clinical Perinatal Center in Nazran, which is the region's leading highly specialized, innovative center providing high-quality medical services. Residents of the Republic of Ingushetia applied to him. The market share of obstetric services of this Perinatal Center was 85%.
The object of the study were pregnant women, women in labor, puerperas who received medical services in this medical organization, newborns, and obstetric services.
The subject of the study was a set of theoretical, methodological and practical issues related to the medical and social assessment of measures to combat infant mortality in the Republic of Ingushetia and the development of a model for managing infant mortality for planning national programs.
Research hypothesis. An effective organization and functioning of the system for controlling the determinants of infant mortality improves the medical and demographic characteristics of the population, reduces infant mortality and increases the viability of the human population.
Purpose - Based on an in-depth analysis of the medical-demographic, organizational-medical and medical-social determinants in the Republic of Ingushetia, to develop an organizational model for managing infant mortality.
The work was carried out in stages, according to a pre-developed program using various methods of collecting information depending on the goal and objectives (Table 2.1).
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Table 2.1 - Research program
Research objectives |
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To |
identify |
Analytical, |
Births and deaths |
Statistical reporting |
2021 |
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current trends |
statistical |
under the age of 1 year |
data of the Republic |
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in |
infant |
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in 2017–2021 in |
of Ingushetia for |
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mortality |
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2017 - 2021 |
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7. |
Analyze |
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Analytical, |
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evaluate |
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Analyze |
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Research objectives |
Research methods |
Units of observation |
Sources of |
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9. |
Build |
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Analytical, |
Organizational- |
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Develop |
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Organizational- |
Research materials: |
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measures |
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medical, |
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aimed |
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mortality |
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At the first stage, the study of literary sources on the problem of infant mortality and state measures to combat it, the assessment of the conditions for the implementation of the National Healthcare Project in the Republic of Ingushetia was carried out.
At the second stage, statistical data was collected at the Nazran Perinatal Center based on market reports for 2017-2021, statistical data on the birth rate, mortality of the Republic of Ingushetia based on the materials of the territorial body of the federal state statistics service, a sociological survey of women mothers and analysis of the results of a survey of women - mothers who gave birth to children in the Republican Perinatal Center.
At the third stage, the calculation of medical-social and medical-demographic and organizational-medical indicators related to motherhood and childhood in the Republic of Ingushetia, and their trends was carried out.
At the fourth stage, the relationship between the determinants of infant mortality and the infant mortality rate in dynamics in the interval from 2017 to 2021
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