5 курс / ОЗИЗО Общественное здоровье и здравоохранение / Научное_обоснование_механизмов_управления_младенческой
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Individual researchers evaluated the features of the course of pregnancy and childbirth in women who underwent IVF, its multifactorial effect on the condition of the fetus and newborn, the duration of pregnancy, extragenital and obstetric pathology of the mother, as well as the dynamics of the development of the fetus itself. Selective data established a clear dependence of the level of perinatal mortality, stillbirth, early neonatal mortality on birth weight. The highest rates of perinatal mortality are typical for children weighing less than 1500 g (from 300 to 400 per 1000 births). In subsequent weight groups, perinatal mortality decreased markedly. The indicators of perinatal mortality with a fetal body weight of 3000 to 3500 g were minimal (3-7%o). This RF pattern was observed both in stillbirths and in early neonatal deaths [82].
Studies of the dynamics of infant mortality were carried out, taking into account the size of the child population. A significant decrease in infant mortality was revealed, accompanied by a decrease in rates against the background of the absence of increases in the birth rate over this period. Thus, in 2015 the indicator decreased by 30,9%, in 2016 - by 10,4%. The growth in the birth rate provided a negative contribution to the increase in infant mortality [100].
A historical overview of the assessment of infant mortality showed the uneven distribution of this demographic disaster and suggested that the causes of the phenomenon lie in the field of economy, ethnic composition and religious affiliation of the population [20].
Longitudinal studies revealed a twofold decrease in the death rate of children in the first year of their life in the post-Soviet period of Russia's development. Its dynamics was distinguished by a noticeable regional diversity, due to the complex impact of social, climatic, geographical, ethno-cultural factors, as well as differences in the existing opportunities to protect and improve the health of children. Its remaining significantly higher level in rural areas was noted. A fundamental feature of the dynamics of mortality in children in the first year of life in modern Russia until 2012, which was qualitatively different from the EU countries, was the steady trend of its “aging”: a decrease in the proportion of neonatal and an increase in postneonatal mortality, which was due to the underregistration of dead children in the first week of
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life - “ transfer" them into unrecorded stillborns or "fetuses" weighing less than 1000 g [100, 105, 106, 107].
The most important measures to reduce infant mortality in our country included the transition in 2012 to the international criteria for birth registration, inclusion in the number of live births of children with extremely low body weight (500-999 g), which required the use of the highest technologies aimed not only at preventing death, but also the disability of the specified contingent. As a result of the measures taken, domestic statistics of fetoinfantile losses became comparable with international ones. New organizational and methodological approaches made it possible to formulate Russian trends in infant mortality: an increase in infant mortality rates in urban areas and a decrease in rural areas, stabilization of the ratio in infant mortality rates of boys and girls of 1,2: 1,0, respectively, stabilization of neonatal and post-neonatal mortality rates, excess levels of early neonatal over late neonatal mortality, the predominance of perinatal over external causes in the structure of infant mortality [4, 5, 6, 8, 10, 19].
The results of regional studies reflecting both the dynamics of infant mortality and its structure have been studied. In Kabardino-Balkaria, the decrease in child mortality was due to a decrease in infant losses (by 57,7%), to the greatest extent due to a decrease in neonatal mortality (by 64,4%), primarily the mortality of children in the first week of life (by 71,2%). In the structure of the causes of infant mortality, the leading positions were consistently occupied by individual conditions that occur in the perinatal period and congenital anomalies. External causes took the third place in the structure of infant losses [10, 11, 129, 130]. In the northern regions of the Russian Federation, there was an increase in indicators constituting infant mortality of newborns, including early neonatal mortality. The increase in indicators occurred due to the registration of children with extremely low body weight [12]. To study the medical and social risk factors for the development of infant mortality in the Omsk region, a factor analysis was carried out. The sample size for the experimental and control groups was 225 observations, respectively. In the Omsk region in the period 2004-2013 there was a decrease in the infant mortality rate by 34,5%. Eight leading medical and social risk factors for infant mortality have been identified. In the total
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community of factors, the neonatal factor made the greatest contribution (22%), the second place was taken by the medical factor (12,5%), and the obstetric factor was in third place (10,8%) [26, 121, 122, 123].
Separate studies based on multivariate correlation and variance analysis have identified a different hierarchy of risk factors that directly affect the mortality rates of children under 1 year of age, primarily related to the organization of medical care for women and children, as well as medical, biological, social -hygienic characteristics on the territory of the Kursk region. When studying the causes of negative changes in medical and demographic indicators, and especially child mortality in modern conditions, scientists proceeded from the concept of multicomponent and multidirectional influence of environmental factors on a growing organism [47, 130]. In the course of the research, it was found that the main causes in the structure of infant mortality in the Kursk region are six nosological forms. I place was occupied by individual conditions arising in the perinatal period, the share of which was 39,7- 50,0%. In II place were congenital anomalies (8,7-31,0%). This was followed by respiratory diseases (13,0-26,0%), infectious and parasitic diseases (9,6-0,0%), injuries and poisonings (2,2-5,0%) and other diseases (8, 3-13,2%).
When studying the prevalence of risk factors for the development of infant mortality cases, carried out at the population level, it was found that 19,4-38,8% of the surveyed families had unsatisfactory living conditions, 25,0-61,0% of those who died in the first year of life lived in socially disadvantaged families. Analysis of data on the presence of diseases in mothers of deceased children showed that up to 56,6% of women suffered from gynecological diseases, and 13,8-23,3% had extragenital pathology. The presence of a threat of miscarriage during pregnancy had from 25,0 to 54,2% of women. Deviations in the state of health at birth were found in 29,0-69,0% of children, 19,4-59,9% of the dead had intrauterine infections, and 30,0-35,0% were born prematurely. Antenatal visits from 2,0 to 18,0% were unsatisfactory, and in 10,0- 11,0% of cases they were not carried out at all. In 4,0-5,8% of cases, there was insufficient quality of medical care at the prehospital stage, in 4,0-11,7% of cases - in the admission department and in 6,1-11,7% of cases - in the children's department.
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More than half (56%) of children who died before the age of one had various comorbidities (malnutrition, rickets, intestinal infections). At the same time, defects in the preparation of medical documentation were revealed in 10,4% of cases. 37,7-53,4% of mothers did not follow the recommendations on the necessary feeding, 20,7-48,8% on hardening, 16,9-40,8% on the prevention of rickets, which indicated a low level of social responsibility of families, having children under the age of one year. Attention was drawn to the fact that 24,0-53,5% of women were not registered at the antenatal clinic at all, did not undergo the necessary examination to identify possible risk factors for the development of deviations in the state of health and the development of the unborn child. This fact characterized the complete absence of social and personal responsibility for the future of children. The causes of infant mortality in the perinatal period were classified as follows:
-diseases or condition of the mother or placenta, pathology of pregnancy and childbirth;
-diseases and condition of the fetus.
The first group of causes included complications from the placenta, umbilical cord and membranes - premature detachment of the placenta, pathology of the umbilical cord, etc.; such complications of pregnancy as toxicosis of the second half of pregnancy, premature rupture of amniotic fluid; directly complications of childbirth and delivery.
The causes of perinatal death from a child in developing countries were asphyxia and birth trauma, congenital malformations, and infections. Developed countries had a higher proportion of congenital anomalies and a lower proportion of intrapartum causes and infections [115, 116].
1.3. Assessment of the causes of perinatal mortality and development of
preventive measures.
According to Rosstat, in the whole of the Russian Federation in 2013, 1895822 children were born alive, 18395 died in the perinatal period, including 12226 stillbirths
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and 6169 deaths in the first 168 hours of life. The perinatal mortality rate in the Russian Federation in 2013 was 9,64%o, stillbirth – 6,41%o, early neonatal mortality – 3,25%o [45, 46, 47, 48, 49, 57, 59, 60, 202].
Most often in 2013, congenital anomalies as the cause of stillbirth appeared in the Northwestern (in 7,9%) and Volga (in 7,2%) federal districts. This was observed least often (3,4%) in the Urals Federal District.
At the same time, in cases of early neonatal death, congenital malformations as the main disease were noted in 16,2% in Russia as a whole. Most often, this was observed in the Central (in 20,8%) and Southern (in 19,7%) federal districts, and most rarely - again in the Urals Federal District (in 12,1%) [125, 126, 127, 128, 151, 201, 202].
In the territories of the Siberian Federal District, the highest proportion of stillbirths in the total indicator of perinatal losses was observed in the Trans-Baikal Territory and the Irkutsk Region, and the lowest in the Altai Territory and the Republic of Tyva. The level of perinatal mortality was unevenly presented across the territories of the Northern Federal District. The territories with a high level of perinatal mortality included the territories of the Republic of Altai, Khakassia, Omsk and Tomsk regions. They observed both a high proportion of stillbirths in the total indicator of perinatal losses (Omsk region – 66,1%, Tomsk region – 53,0%), and a very low level of stillbirths (Republic of Altai – 39,0%). Among the territories with the lowest rate of perinatal mortality (6,86%), the Republic of Tyva stood out, which, in terms of the level of socio-economic development, belonged to the most backward regions of Siberia, which raised questions about the accuracy of the data presented [48].
In the structure of perinatal mortality, both in the Russian Federation as a whole and in the Northern Federal District, two features were noted. First, half of the irretrievable losses were full-term babies. Secondly, against the background of the continuing growth of the share of stillbirths in perinatal mortality, the share of antenatal stillbirths increased at a faster pace, the decline of which is slower than that of other components of perinatal mortality. As is known, antenatal fetal death is extremely dangerous due to the development of severe obstetric complications, mainly
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coagulopathic bleeding. A special study in 80 regions of Russia revealed a correlation between antenatal stillbirth rates and bleeding rates [49].
There was an increase in the whole country and in the Siberian Federal District in the number of full-term babies born with intrauterine growth retardation syndrome. According to many experts, such features of newborn children by weight are associated with the inclusion of a qualitatively different, possibly marginal group of women in the process of childbearing. That is, there was a transformation of the social structure of women in labor, which significantly influenced the characteristics of reproductive indicators both in the Russian Federation and in the Siberian Federal District [48].
Reducing perinatal mortality is impossible without an analysis of the factors affecting maternal health, the course of pregnancy and childbirth. Therefore, factors that directly or indirectly have an adverse effect on the condition of the fetus and newborn were studied. The prematurity factor was one of the main causes of perinatal mortality. With an increase in the duration of pregnancy up to 35-40 weeks, the frequency of stillbirths and early neonatal deaths decreased and practically did not depend on the period in which it occurred. During childbirth, the risk of perinatal losses increased due to complications of the birth act and confirmed the high perinatal mortality of premature babies. Most often, immature children died in the antenatal and postnatal periods in all age groups of young women. Intranatal death of children was facilitated by both rapid and prolonged labor [57, 60, 108, 153].
The analysis of perinatal mortality and assessment of the level of health of newborns revealed serious problems. Statistical reporting data did not previously contain official records of fetuses born at 22-27 weeks of gestation weighing 500-999 grams, and therefore it was possible to transfer data on dead children with very low body weight to the category of "prenatal losses", which, in turn, , underestimated the levels of stillbirth and perinatal mortality. The value of perinatal mortality was replenished by the “delayed” death of newborns in the late neonatal period, due to the use of effective resuscitation technologies and the ability to artificially maintain the vital functions of the child during the first week of life [49, 50, 175].
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In developing measures to prevent perinatal mortality, a detailed analysis of its causes was of great importance, especially among high-risk women who underwent IVF.
Some researchers proposed to analyze the underlying disease, which caused the death of a child, according to the nosological principle separately in groups of stillborn and deceased newborns. In this case, only the underlying disease represented by one nosological form was taken into account, which itself directly or through associated complications led to the death of the fetus and newborn. To develop measures to prevent perinatal death in women undergoing IVF, each death was analyzed in terms of its preventability. Most researchers divided all cases of perinatal death into preventable, conditionally preventable and unavoidable. Preventable cases, ranging from 25 to 40%, were considered those whose cause could be eliminated not only by medical supervision of the pregnant woman in the antenatal clinic, but also by providing special obstetric and medical care to the pregnant woman and the woman in labor in the maternity hospital, as well as by the right choice of treatment tactics newborn, timely transfer of children to specialized departments for premature and sick newborns.
The cases of death, the cause of which is currently difficult to eliminate, included fetal deformities, umbilical and placental pathology, and profound prematurity of newborns. Measures to eliminate these causes are largely associated with the further development of fundamental research and the material and technical equipment of obstetric institutions.
In the structure of causes in general, the leading place is occupied by intrauterine hypoxia (asphyxia) during childbirth. The share of this cause ranged from 38,5% to 43,5%, while there was no clear trend to decrease or increase. The second leading cause of perinatal mortality was respiratory distress syndrome and other respiratory conditions. Their share in the structure of the causes of perinatal mortality had a downward trend, which was explained by the introduction of new technologies in intensive care units for nursing underweight children.
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In third place among the causes of perinatal mortality were congenital malformations, the proportion of which increased. Timely antenatal diagnosis made it possible to reduce the significance of this pathology in the structure of the causes of perinatal mortality and led to a decrease in the indicator itself.
The role of congenital pneumonia and infections specific to the perinatal period in the structure of causes of perinatal mortality increased. The decrease in the proportion of birth trauma was explained by the expansion of indications for abdominal delivery, including in the interests of the fetus [45, 46, 82, 83, 84, 85, 86, 114]. The decrease in perinatal mortality with an increase in the frequency of caesarean section occurred only up to a certain point. According to WHO recommendations, an increase in the frequency of this operation by more than 10% is inappropriate.
Analyzing the causes of death of children in the perinatal period, due to the condition of the mother who underwent the IVF procedure, an increase in extragenital pathology, including endocrine pathology, was revealed, which, combined with the threat of miscarriage, led to fetoplacental insufficiency. The main cause of perinatal losses was the pathology of the placenta and umbilical cord.
The role of infectious diseases of the mother who lost her child due to intrauterine infection increased.
The highest prevalence of perinatal mortality occurred in women bearing a male fetus. Women carrying a male child were more likely to have early neonatal mortality. This could be due not only to complications of pregnancy and childbirth, but also to a high incidence of congenital malformations, which were diagnosed 1,5 times more often than in women carrying a female child [86, 87].The highest prevalence of perinatal mortality was characteristic of conception in the spring, which was combined with a high frequency of pregnancy complications such as the threat of abortion, polyhydramnios, intrauterine growth retardation, exacerbation of chronic infections during pregnancy. These types of pathology were diagnosed more often than at conception in other seasons of the year. There was no seasonal dependence in the prevalence of antenatal mortality, and there was a pronounced dependence on the season of conception in the frequency of intrapartum and early neonatal deaths.
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With the maximum rates of intrapartum mortality in spring, there was a tendency for its decrease in the summer-autumn period and again its jump to the winter period. The prevalence of early neonatal mortality, depending on the seasons of conception, has a spasmodic character: a peak in the autumn period of the calendar year with a downward trend in the summer and winter seasons [90].
An equally significant reason was congenital malformations, which were not detected at the level of antenatal clinics in a significant number of cases, or were detected in late pregnancy.
The role of congenital pneumonia in the structure of causes of perinatal mortality was somewhat reduced due to the timely start of treatment for children from mothers at risk of intrauterine infection, as well as the use of modern technologies that reduce mortality. Of great importance for reducing this pathology was the diagnosis of infection in pregnant women and their timely and high-quality treatment.
Birth trauma, which previously occupied a significant share in the structure of the main causes of perinatal mortality, has now occurred in isolated cases, which was facilitated by prenatal diagnosis, as well as careful management of labor and the expansion of indications for operative delivery.
Numerous studies have determined that the majority of nosologies were manageable and socially conditioned. Thus, growth retardation and malnutrition, morphofunctional immaturity of fetuses and newborns correlated with an increase in anemia and chronic diseases in pregnant women and puerperas. The authors believed that congenital anomalies can also be classified as manageable, since their growth can be associated with both unfavorable environmental and industrial aggression, as well as with the effectiveness of prenatal diagnosis and timely recovery of women [14]. A detailed study of the causes of perinatal mortality provided the possibility of predicting it and identifying reserves for improving perinatal outcomes [21, 22, 49, 53, 54, 56, 58; 140, 141, 142, 143, 144, 145, 146, 186, 187, 188].
Among the factors positively influencing the prognosis of the survival of children with extremely low body weight, most experts attributed: the possibility of antenatal prevention of respiratory distress syndrome, delivery by caesarean section,
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antenatal antibiotic therapy, leading to a decrease in the frequency of intrauterine sepsis. Of the postnatal factors, the prevention of respiratory distress syndrome (administration of surfactants), hypothermia, and acidosis at birth were important. Survival, long-term prognosis of development and health indicators of highly premature infants in follow-up depended on the conditions of their nursing, which were optimal in highly specialized clinics and perinatal centers established in economically developed countries since the beginning of the 70s of the last century [49, 50].
The ability to accurately predict and prevent adverse outcomes in children's development depended on knowledge of the fundamental principles of the etiology and mechanisms of pathological processes in the fetus and newborn in the neonatal period [50, 51, 52, 164, 194].
The introduction of an accounting indicator - fetoinfantile losses, which combines information on the age and causal structure of fetal and infant mortality, made it possible to determine, on the one hand, endogenous causes (genetic factors, the initial state of health of parents, the health of the pregnant woman, the course of pregnancy), and on the other hand, exogenous factors ( social and economic conditions of life, ethnic norms and foundations, psychological and behavioral reactions, and medical and organizational defects in obstetric and perinatal care, which cause preventable pathology of the child, primarily in the process of his birth) [61, 62]. Criteria for hospitalization of mothers and newborns were developed depending on the risk groups for the 2nd (inter-district) and 3rd (republican) levels, which were revised twice. Preference was given to "in utero" transportation to ensure the birth and care of extremely low birth weight newborns under optimal conditions. A map of a newborn in need of transportation has been developed and remote counseling has been introduced. Regional perinatal care has proven to be highly effective when combined with other innovations [40, 41, 42, 74, 75, 90, 182, 183, 184, 185]. Of strategic importance was the analysis of regional aspects of perinatal mortality, which made it possible to develop an effective system of differentiated measures aimed at reducing it, and detailed information on the levels and causes of perinatal mortality in the regions
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