5 курс / ОЗИЗО Общественное здоровье и здравоохранение / Научное_обоснование_механизмов_управления_младенческой
.pdf171
Kuzmin V.N., 2010; Kuznetsova T.V., 2011; Sultanaeva Z.M., 2012; Akhtyamova S.Kh., 2012; Mayorova O.V., 2012; Serdyukov A.G. 2014, Shapovalova M.A. 2014, Bushmeleva N.N., 2015, etc. At the same time, similar studies have not been systematically conducted on the territory of the Republic of Ingushetia, and the infant mortality rate in the Republic remains at a high level.
The high medical and social significance of this problem for the theory and practice of healthcare organization served as the basis for this study.
Purpose of the study
Based on an in-depth analysis of medical-demographic, organizational-medical and medical-social determinants in the Republic of Ingushetia, develop an organizational model for managing infant mortality.
The research taske
1.Perform an analysis of the dynamics of infant mortality in the Republic of Ingushetia with the determination of the structure of causes in the interval from 2017 to 2021.
2.To identify organizational and medical determinants of infant mortality.
3.Determine the medical-demographic and medical-social determinants of infant mortality.
4.Build an organizational model for managing infant mortality.
5.Develop measures aimed at reducing infant mortality and its consequences.
Scientific novelty.
For the first time against the backdrop of the National projects Health and Demography:
- Identified trends and causes of infant mortality in the Republic of Ingushetia; -Identified key microand macro-level organizational and medical determinants
of infant mortality;
-Identified key medical-demographic and medical-social determinants of infant mortality;
- A dynamic assessment of the key organizational-medical, medicodemographic and medico-social determinants of infant mortality, their short-, medium-
172
and long-term forecasting was carried out, their relationship with infant mortality rates
was assessed;
-The profile of the quality of medical care for children under 1 year of age was assessed, taking into account the influence of actual and potential (predicted) values of the determinants;
-New data have been obtained to build an organizational model for managing infant mortality.
Theoretical and practical significance work is determined by the results of the study, which made it possible to provide healthcare organizers with objective information about infant mortality trends in the Republic of Ingushetia, the impact of the targets of the National Healthcare Project on infant mortality, identifying key organizational, medical, medical, demographic and medical and social determinants of infant mortality, building an organizational model management of infant mortality for planning and evaluating the effectiveness of protecting the protection of motherhood and childhood, their adjustment in the process of designing state national programs.
Provisions for defense:
1.The key medical and demographic determinants of infant mortality should include the birth rate among mothers under the age of 20 and over 30 years, the incidence of mothers and the pathological conditions of newborns.
2.It is important to include the quality of diagnostics of diseases in children and the availability of pediatricians among the key organizational and medical determinants of infant mortality.
3.The key medical and social determinant of infant mortality should be considered the medical activity of mothers.
4.The construction and use of an organizational model for managing infant mortality will make it possible to carry out effective preventive measures and control the indicator.
Implementation into practice.
The results of the study are applied in the work:
Рекомендовано к изучению сайтом МедУнивер - https://meduniver.com/
173
•The Ministry of Health of the Republic of Ingushetia (in terms of the implementation of the organizational model for managing infant mortality, updating the procedures for routing pregnant women, women in childbirth, puerperas, children under one year old and children over the age of 1 year in the Republic) (Act of implementation No. 22/49/3 dated 12/16/2022 .);
•Republican Clinical Perinatal Center (in terms of long-term planning for improving medical care for women and children, aimed at reducing morbidity and mortality) (Act of implementation No. 852-11 dated 12/14/2022);
•Women's Consultation of the Sunzhensky District (in terms of increasing the effectiveness of preventive work with pregnant women and puerperas aimed at maintaining the health of the mother and newborn: on the organization of breastfeeding of newborns, compliance with the national vaccination schedule, timely seeking medical care for newborns) (Act of implementation No. 2786 -01-012 01.12.2022);
•Department of Economics and Health Management with a postgraduate course of the FGBOU HE Astrakhan State Medical University of the Ministry of Health of Russia (in terms of data on assessing infant mortality and its medical, demographic and medical and social determinants) (Act of implementation 0122/24 of 12/19/2022).
The degree of reliability of the results.
The reliability of the results of the study is confirmed by the data of official statistical observation, a sufficient number of observation units, the use of modern research methods and statistical processing. Correlation-regression analysis was used to analyze the strength and direction of the relationship between quantitative variables.
Approbation of the results.
The main results of the study were reported and discussed at:
-V International Conference of the Caspian States "Actual Issues of Modern Medicine" (Astrakhan, 2020);
-II Interdisciplinary Medical Scientific and Practical Forum “Actual Issues of Medical Practice. Lower Volga" (Astrakhan, 2021)
-VII International Conference of the Caspian States "Actual Issues of Modern Medicine" (Astrakhan, 2022);
174
- An inter-departmental conference dedicated to discussing the results of a completed thesis on the topic: "Scientific substantiation of the mechanisms for managing infant mortality."
Communication of work with scientific programs.
The dissertation was carried out in accordance with the research plan of the FGBOU HE Astrakhan State Medical University of the Ministry of Health of the Russian Federation within the framework of the Problem "Habitat, Occupational Health and Health". A preliminary discussion of the dissertation took place at a joint conference of departments of the Astrakhan State Medical University of the Ministry of Health of the Russian Federation.
Publications.
The main provisions of the dissertation are published in 8 printed works, 3 of which are in publications recommended by the Higher Attestation Commission of the Ministry of Education and Science of the Russian Federation for the publication of the main scientific results of dissertations for the degree of candidate of medical sciences, 1 in the international database, 1 in RSCI.
The author's personal contribution to the study.
The author defined the goal and formulated the objectives of the study, compiled a program, determined the stages and tactics of the study, performed an analytical review of the literature and regulations governing prevention issues on the topic under study, developed questionnaires for conducting a sociological survey, collected and processed material, summarized the material and analysis of research results. The share of the author's participation in the collection and accumulation of material is 90%, in the processing of the material - 80%, in the generalization and analysis of the results of the study - 100%.
Compliance of the dissertation with the passport of the scientific specialty.
The scientific provisions of the dissertation correspond to the passport of the
specialty 3.2.3 - Public health, sociology and healthcare organization
The structure and scope of the dissertation.
Рекомендовано к изучению сайтом МедУнивер - https://meduniver.com/
175
The work consists of introduction, 6 chapters, conclusion, conclusions, practical recommendations, bibliography. The dissertation is presented on 167 pages of typewritten text. The text is illustrated with 30 tables and 69 figures. The literature index includes 217 sources (195 domestic and 21 foreign authors).
176
CHAPTER 1. ASSESSMENT OF THE PROBLEM OF INFANT MORTALITY
IN SCIENTIFIC RESEARCH PRACTICE
(ACCORDING TO LITERATURE)
1.1. The relevance of the problem of infant mortality in the Russian Federation
The demographic processes taking place in modern society determine the size of the population, its density, life and labor potentials, the ability to reproduce, the types and rates of economic growth, socio-economic stability and national security. That is why a detailed study of demographic processes and their individual components is an extremely urgent problem. The formation of the population is due, first of all, to the natural movement of the population: births and deaths. Both of these demographic processes have certain characteristics, socio-economic determinants, structure, trends, forecasts [24]. Despite the presence of numerous domestic and foreign studies of fertility rates and its derivatives, total, age-specific and infant mortality, natural population growth as indicators that focus on socio-economic causes and consequences, the need for monitoring and detailed study of infant mortality and its determinants remains still relevant, since infant mortality actually accumulates not only social characteristics, but also organizational, medical, clinical and economic determinants, which gives it a special multifactorial status as a demographic process and phenomenon at the same time. The level of infant mortality, as well as life expectancy, assesses the general state of health and quality of life of the population, and in a broader sense, the level of economic development and social well-being of society, since this indicator is extremely sensitive to changes in all socio-economic parameters, especially in cases when their dynamics acquires a negative or crisis character [55].
Decree of the President of the Russian Federation dated May 7, 2018 No. 204 “On National Goals and Strategic Objectives for the Development of the Russian Federation for the Period until 2024” in two National Projects “Demography” and “Healthcare” defines strategic goals and targets, which include: mortality rates of the
Рекомендовано к изучению сайтом МедУнивер - https://meduniver.com/
177
working-age population (up to 350 cases per 100 thousand population), mortality from diseases of the circulatory system (up to 450 cases per 100 thousand population), mortality from neoplasms, including malignant ones (up to 185 cases per 100 thousand population ), infant mortality (up to 4,5 cases per 1 thousand born children). The reduction in infant mortality is planned from 5,6 in 2017 to 4,5 per 1,000 children born in 2024 (by 19,6%).
The 2000s saw the highest rates of infant mortality in Russia as a whole. Until 2003, stabilization was observed, since 2003 - a steady annual decline to 15,8 in 2007. The lowest rates were observed in the Leningrad, Samara, Vladimir regions, the highest - in the Kursk, Rostov, Magadan regions, the Republic of Tyva, the Jewish Autonomous Region and the Chukotka Autonomous Region. Among boys, infant mortality rates were on average higher than among girls by 20-30%. In some territories, the mortality of girls was higher than that of boys (Kirov, Sakhalin, Amur, Kamchatka regions, the Republics of Kalmykia and Mordovia). The leading causes of infant mortality rate were determined by the level of material and technical equipment of obstetric hospitals and methods of antenatal protection of the fetus. The introduction of modern methods of monitoring the condition of the fetus significantly reduced the level of this indicator.
In assessing the quality of obstetric, resuscitation and intensive care for newborns, the structural ratio of stillbirth and early neonatal mortality was important. An increase in the proportion of stillborns with the same level of perinatal losses indicated insufficient antenatal protection of the fetus, shortcomings in the management of labor and resuscitation of newborns [12].
1.2. Infant mortality and its determinants.
Decree of the President of the Russian Federation of June 01, 2012 No. 761 "On the National Strategy for Action in the Interests of Children for 2012-2017" determined the main directions and objectives of the state policy in the interests of children and the key mechanisms for its implementation. The latter are based on generally recognized
178
principles and norms of international law. A strategy was implemented to reduce infant mortality, which could not but affect the dynamics of infant and child mortality. However, contradictory changes occurred in the structure of causes. On the one hand, it was possible to significantly reduce losses from a number of preventable causes that occupied leading positions in the mortality of children under one year old - respiratory diseases and infections. On the other hand, their place was also taken by completely preventable cases of death from poisoning and injuries at these ages, as well as illdefined conditions, which, according to individual studies, mask some of the deaths from external causes [18, 19, 20, 62].
Infant mortality, classified by the World Health Organization as one of 12 indicators, reflecting the level and quality of life of the population, was considered as a multifactorial problem. Among these factors, one can distinguish hereditary burden due to congenital pathology, adverse environmental factors (smoking, drinking alcohol), extragenital and gynecological pathology, and complicated pregnancy. Factors that are subject to correction, such as obstetric care, and factors that are difficult to influence (social and hygienic) or impossible (heredity, living in unfavorable sanitary and hygienic environmental conditions) were identified. The most significant risk factor for infant mortality from congenital malformations was chronic infectious and inflammatory pathology, both gynecological and extragenital [1, 2, 3, 64, 112, 113].
The formation of congenital malformations of the fetus was determined by the significant influence of socially determined factors - bad habits. Among women with a history of infant mortality from congenital malformations, there were significantly more smokers (28,0%) compared with the control group [67, 70].
One of the most important risk factors for the occurrence of congenital malformations and chromosomal abnormalities is a burdened hereditary history. According to the literature, the hereditary burden of women due to congenital pathology increases the risk of congenital malformations of the fetus [68]. In the main group, the presence of congenital malformations and chromosomal abnormalities in
Рекомендовано к изучению сайтом МедУнивер - https://meduniver.com/
179
the family occurred in 27,3% of women, which is significantly more than in the control group, where this symptom was not found [71, 72, 73, 77].
When analyzing the somatic status of women in the main group, it was found that they had a greater burden of extragenital pathology (75,3%), which statistically significantly distinguished them from the control group. They were characterized, first of all, by a high frequency of chronic infectious and inflammatory diseases of various localization: urinary tract and nasopharynx. In the structure of extragenital pathology, the leading place was occupied by anemia, the incidence rate of which increased by 3,8% from the average for the analyzed 5-year period. The role of anemia during gestation increased due to its special social significance as an integral criterion for the social well-being of the population. The indicator of the frequency of anemia in pregnant women, along with indicators of maternal and infant mortality, as well as the number of births with low body weight, was proposed by WHO to assess the social status of the country's population [55, 56, 57].
The researchers confirmed the fact that diabetes mellitus is a disease that tends to grow intensively, and the most perinatally significant extragenital pathology. Careful adherence to the local clinical protocol led to a decrease in the frequency of complications in this pathology.
The risk factors for mortality in children of the first year of life included body weight at birth. Thus, an analysis of newborn mortality in the Omsk region depending on body weight showed that the highest mortality was observed among children with a birth weight of up to 1000 g (in 2011, the mortality rate was 29,5 per 100 births of the corresponding weight).The correlation between neonatal mortality and extremely low birth weight (up to 1000 g) was 0,66.
In the early age periods (0-7 days, 8-28 days), the main determinants were biological - sex, age, feeding pattern. Of the social characteristics, the main factor was defined as “per capita income”. The factor of "well-being of living conditions" was also singled out, but the strength of its influence was leveled by the level of mother's culture. At the same time, the level of infant mortality in the “main” and “control” zones was different, which was explained by the degree of atmospheric air pollution
180
and affected the health of mothers permanently living in conditions of environmental trouble [77, 80].
When evaluating the organization of medical care, the main factors of untimely hospitalization were singled out; the state of severity of hospitalization; pathogenetically unjustified treatment, which increase the “risk of death” by more than 4 times [58].
Somatic and reproductive health of women and children was influenced by fertility. High fertility rates in regions with low per capita income were accompanied by a natural increase in reproductive losses and a decrease in the viability of offspring. Demographic and health studies have found that maternal age at birth, birth intervals, use of contraception, and duration of breastfeeding directly affect maternal and child survival, maternal, infant, and perinatal mortality, as well as maternal and child. Sufficiently long intervals between births have been found to provide health and survival benefits for newborns, infants, and children under 5 years of age. The experts of the World Health Organization recommended to observe the duration of the intergenetic period for 2-3 years [62, 77, 80].
An increase in the number of children born, ceteris paribus, contributed to an increase in infant and child mortality and indirectly influenced overall mortality [62, 81, 91, 94].
Family planning was the best way to curb unbalanced population growth and reduce the severity of the negative consequences for the economy and the environment associated with it, an effective way to influence the reproduction of the population at the national and regional levels. It made it possible to avoid an unwanted pregnancy, regulate the intervals between pregnancies, choose the time of birth of a child depending on the age of the parents, and set the number of children in the family. Family planning helped reduce maternal mortality by at least 20% and child mortality by 25% [61, 97, 98, 99].
Numerous studies assessing the quality of obstetric care have revealed defects in prenatal diagnosis in cases of birth of children with malformations and death [68; 69; 78; 79].
Рекомендовано к изучению сайтом МедУнивер - https://meduniver.com/