Medical and Social Problems of Reproductive Health and the Development of an Organizational Model of a Health Care System for Women of Reproductive Age

The dissertation is devoted to a comprehensive study of the medical and social problems of reproductive health of women of reproductive age and the development of an organizational model of a health care system on the basis of materials from the Nizhny Novgorod Region. The research analyzes reproductive-demographic trends in the Russian Federation and the Nizhny Novgorod Region, including the dynamics of maternal and infant mortality, the level of pregnancy failure, gynecological morbidity, and the problem of abortions. The methods of statistical analysis, medical and social expertise, and organizational experiment were employed in the work to evaluate the state of reproductive health of the population and to identify risk factors in women with threat of pregnancy failure.

On the basis of the conducted research, a target comprehensive program for the protection of reproductive health of the population of the Nizhny Novgorod Region has been developed, a mathematical model of short-term forecasting of maternal and infant mortality indicators has been created, and an organizational model of an inter-agency system of reproductive health monitoring has been tested. The proposed solutions are aimed at the improvement of medical care for women of reproductive age in the conditions of municipal curative-preventive institutions and have practical significance for health care bodies of the Volga Federal District.

Relevance of the Problem

Social and economic and political transformations in the Russian Federation over the last decade of the previous century have caused a systemic crisis in society. Crisis phenomena have manifested themselves to the greatest extent in the social sphere.

The deterioration of the material well-being of the majority of the population led to a sharp restriction of birth rate, which declined by more than half in a short period of time. Against the background of a significant increase in the mortality level since the beginning of the 1990s of the twentieth century, a clear trend toward natural population decline has been emerging and intensifying [79, 104, 110, 207, 210].

Depopulation, which has reached 10.0% at the present time, represents a process that has a tendency to intensify. With the preservation of the negative direction of the natural population decline indicator and the reduction of migration rates, forecasting further depopulation in the nearest perspective becomes obvious [240].

As noted in the State Report "On the State of Health of the Population" (2002), the number of children under 16 years of age in recent years has decreased by 4.7 million people, or by 13.1%, including children under 8 years of age — by 6.8 million people, or by 36%. In the 21st territory of the country, the share of children and adolescents amounts to 17.2–19.8%, that is, less than one fifth [127, 96].

Under these conditions, particular importance is attached to the analysis of the reproductive behavior of women of reproductive age and the development of a complex of measures aimed at improving the state of the reproductive sphere of the contemporary population [17, 27, 84].

The study of this problem has been undertaken by large scientific collectives: the Ivanovo Research Institute of Motherhood and Childhood named after N.I. Gorodkov [26], the Scientific Center of Obstetrics, Gynecology and Perinatology of the Russian Academy of Medical Sciences [92, 185].

However, the study and protection of reproductive health, as well as the organization of medical provision, remains one of the most urgent problems, since it directly affects the reproduction of the population and, consequently, the economic development and national security of the country [37, 43].

Over the last decade, the number of practically healthy women of reproductive age has substantially decreased and amounts to 15–18%. It has been established that pregnant women with health impairments constitute 91.3%. The frequency of anemias has increased by 2.5 times, diseases of the urogenital system — by 1.8 times, various manifestations of toxemia — by 3–4.5 times. In connection with this, the share of normal births is gradually decreasing, amounting to only 31.6% of their total number, and the number of pathological births has increased by 2.6 times in recent years [25, 184, 187].

The frequency of operative deliveries associated with pathology in the mother and offspring is steadily increasing, which indirectly testifies to the deterioration of women's health. The frequency of delivery by cesarean section has increased by 61%, and the share of operative interventions in births — by 51%.

According to WHO data, 585 thousand women die annually in connection with pregnancy and childbirth. The lowest maternal mortality is observed in developed countries: in the USA, England, France, and Japan it is less than 10.0, and in Canada and Sweden — within 1.3 per 100 thousand live births. In Russia, this indicator has stabilized at the level of 45–50 per 100 thousand live births, and only in 2003 did it decrease to 33.6, but this still exceeds by an order the indicator of economically developed countries.

In the Nizhny Novgorod Region, the maternal mortality indicator decreased from 61.9 in 1997 to 35.8 in 2003. In the conditions of an unfavorable demographic situation and the deterioration of the health status of women of reproductive age and children, the task of reducing fetal and infant losses acquires particular urgency [7, 8].

According to WHO and a number of authors, perinatal mortality in various countries ranges from 7 to 50 per 1000 births and has no pronounced tendency toward reduction [16, 18, 196].

In Russia, perinatal mortality is registered in the range of 14.7–18.5%; in the Nizhny Novgorod Region it decreased from 16.3% in 1997 to 13.2% in 2003. Common to all regions are the problems of family health, reproductive health of women, and the formation of reproductive behavior [16].

In the conditions of a sharp decline in birth rate and a high level of maternal and infant mortality, the urgency of protecting the reproductive health of women and the development of the foundations of perinatology in specific socio-economic conditions of regions significantly increases. Under these circumstances, the problem of pregnancy failure remains highly urgent, since there is a tendency toward the increase of this indicator [188, 8].

According to the Nizhny Novgorod Region, the pregnancy failure indicator has increased by 1.3 times over the last fifteen years, from 9.8% in 1997 to 12.6% in 2003. The basis of pregnancy failure lies in impairments of the reproductive system function of women, the increase in the frequency of gestoses, the high level of abortions, and the presence of asymptomatic infections. In view of the above, the conduct of comprehensive socio-hygienic studies on this problem is highly relevant and socially significant, which served as the basis for the execution of the present research. The work was carried out in accordance with the plan of NIRS of the Military-Medical Institute of the FSB of Russia.

Goal of the Research: to develop the organizational foundations of a system of measures for the improvement of reproductive health of women in municipal health care institutions on the basis of the study of the features of reproductive-demographic indicators of the Nizhny Novgorod Region.

Tasks:

1. To analyze the dynamics and regional trends of reproductive-demographic indicators of women of reproductive age in the districts of the Nizhny Novgorod Region.

2. To provide a medical and social characterization and regional features of risk factors in women with threat of pregnancy failure and to develop a quantitative characterization of prognostic risk for this contingent.

3. To study the current patterns of reproductive behavior of youth and adolescents in the pre-marital period and the features of the formation of family-marital relations.

4. To study the features of medical and social provision of women of reproductive age during gestation, childbirth, and the postpartum period.

5. To develop an organizational model of an inter-agency system of reproductive health monitoring and a target program for the protection of maternal and child health at the regional level.

6. To conduct an organizational experiment on modeling an innovative structure of medical care for women in a restorative treatment polyclinic and a sanatorium-preventorium.

7. To calculate a short-term forecast of the dynamics of maternal and infant mortality indicators.

8. To study the medical and social and economic effectiveness of the program for improving reproductive-demographic processes in the Nizhny Novgorod Region.

Scientific Novelty. On the basis of a comprehensive medical and social and clinical-organizational study of the reproductive health of women of reproductive age in the districts of the Nizhny Novgorod Region, for the first time:

- a characterization of regional trends in reproductive-demographic indicators in the population of the region is presented;

- the features of reproductive-demographic processes and medical-statistical patterns of pregnancy failure, including the role of abortions and contraception of women of reproductive age in the regions of the Volga Federal District and the Nizhny Novgorod Region compared with data for the Russian Federation as a whole, are studied;

- a comprehensive assessment of the health status of the cohort of women with threat of pregnancy failure based on general and gynecological morbidity data is conducted;

- prognostic coefficients of the threat of pregnancy failure depending on the conditions and lifestyle of pregnant women are developed;

- a mathematical model of short-term forecasting of the dynamics of maternal and infant mortality indicators in the region is created; an organizational experiment on modeling an inter-agency system of reproductive behavior and protection of the health of women of reproductive age is conducted;

- a target comprehensive program for the protection of reproductive health in the Nizhny Novgorod Region is developed.

Scientific and Practical Significance and Implementation. The materials of the research have received wide implementation in the practice of the work of health care bodies and institutions for the protection of motherhood and childhood and obstetric-gynecological institutions in the Nizhny Novgorod Region.

The prognostic model of reproductive-demographic indicators serves as the basis for strategic planning of a complex of measures for the protection of the reproductive health of the population in the region.

The developed target comprehensive program for the protection of reproductive potential in the region ensures planned work by the health care administration regarding the protection of the health of women of reproductive age. Within the framework of the implementation of this program, the author created and tested an organizational model of medical care for the population of reproductive age in the form of a restorative treatment polyclinic and other curative-rehabilitative institutions.

The conducted inter-agency monitoring of the health of women of reproductive age in the base district ensured a positive dynamics of birth rate and relatively low indicators of natural population decline.

Results of the Research Implemented:

1. In the educational process at the Ryazan State Medical University named after I.P. Pavlov, order No. 206 dated 29.12.03

2. In the women's consultation No. 1 of the city of Ryazan, order No. 45 dated 06.05.04

3. In curative-preventive institutions of the Volga Federal District, order No. 37 dated 02.03.2004

4. In the educational process of departments: general hygiene, faculty and polyclinic pediatrics, economics and organization of health care of the Nizhny Novgorod State Medical Academy, 2004

5. At the Scientific Center of Children's Health of the Russian Academy of Medical Sciences, order dated 05.2004

6. At the Federal Scientific Center of Hygiene named after F.F. Erisman, order dated 04.2004

7. In the educational process of the Military-Medical Institute of the FSB of Russia, order No. 16 dated 28.04.03

8. In the work of the Information and Analytical Center of the Ministry of Health of the Nizhny Novgorod Region "Monitoring of the Activities of Curative-Preventive Institutions and Health of the Population of the Nizhny Novgorod Region", information bulletin No. 27, Ministry of Health of the Nizhny Novgorod Oblast, 2003.

9. Information letter "Organizational and Curative-Preventive Principles of Rehabilitation of Pregnant Women Belonging to Risk Groups on the Basis of a Sanatorium-Preventorium of an Industrial Enterprise", 2003.

10. Certificate of the Ministry of Health of the Russian Federation No. 202 dated 04.07.96 "Identification of Risk Groups of Pregnant Women with Respect to the Development of Intrauterine Pathology"

11. Certificate of the Ministry of Health of the Russian Federation No. 237 dated 24.06.97 Comprehensive Program "Automation of Statistical Accounting and Reporting of Polyclinic Institutions, Management of Pharmaceutical Supply of a Hospital, Management of Medical Personnel"

12. In the work of curative-preventive institutions and the Territorial Fund of Mandatory Medical Insurance of the Nizhny Novgorod Region "Automation of Statistical Accounting and Reporting of Ambulatory-Polyclinic Institutions", order dated 20.07.2002.

13. In the work of curative-preventive institutions of the city of Nizhny Novgorod and the Territorial Fund of Mandatory Medical Insurance of the Nizhny Novgorod Region "Automation of Statistical Accounting and Reporting of Ambulatory-Polyclinic Institutions", order dated 27.12.2002.

14. Monograph: A.N. Lavrov "Reproductive-Demographic Processes in the Population of a Region and Protection of the Health of Women of Reproductive Age", Moscow, 2004, p. 180.

15. Methodological Recommendations "Restorative Treatment Polyclinic as an Organizational Model of Medical and Social Provision and Rehabilitation of the Population", approved by the Ministry of Health of the Russian Federation, 2004.

16. Methodological Recommendations "Organization of the Nursing Process in the Work of a Neurological Hospital for Patients with Cerebrovascular Disorders", approved by the Ministry of Health of the Russian Federation, 2003.

Presentation. The results of the work were reported at: the Scientific and Practical Conference "Applied Statistics in Socio-Economic Problems" (Nizhny Novgorod, 1988); the All-Russian Scientific and Practical Conference "Nursing at the Turn of the Centuries" (Arzamas, 2000); the Scientific and Practical Conference "Introduction of New Scientific Developments into the Practice of Medical Provision of Bodies, Troops, and Organizations" (Nizhny Novgorod, 2001); "Socio-Hygienic and Epidemiological Problems of the Health of Military Personnel and the Population" (Nizhny Novgorod, 2002); the Scientific and Practical Conference "Main Problems and Directions of Rehabilitation and Restorative Treatment of Veterans of Armed Local Conflicts" (Dzerzhinsk, 2002); the Road Jubilee Scientific and Practical Conference of the Gorky Railway (Nizhny Novgorod, 2002); the Scientific and Practical Conference of the Military-Medical Institute (Nizhny Novgorod, 2002); the International Conference "Applied Statistics in Socio-Economic Problems" (Nizhny Novgorod, 2003); the Russian National Congress of Cardiologists (Moscow, 2003); the Scientific and Practical Conference of the Federal Administration "Medbioextrem" (Moscow, 2003); "Fundamental Research and Progress in Cardiology" (St. Petersburg, 2003); the Russian Congress "Week of Women's Health" (Nizhny Novgorod, 2002, 2003); the Republican Scientific and Practical Conference with International Participation (Ryazan, 2003); the First Russian Congress "Rehabilitative Assistance to the Population in the Russian Federation" (Moscow, 2003); the Inter-Regional Scientific and Practical Conference "Urgent Problems of Municipal Health Care" (Arzamas, 2003); the Scientific and Practical Conference "Urgent Problems of Medical Provision of Troops of the North-Caucasian Regional Administration of the Border Service in the Counter-Terrorist Operation" (Stavropol, 2003); the Scientific and Practical Conference "Socio-Hygienic and Epidemiological Problems of the Health of the Population" (Nizhny Novgorod, 2004).

MAIN PROVISIONS SUBMITTED FOR DEFENSE:

1. Reproductive-demographic health indicators ensuring the reproduction and development of the nation have acquired a clearly expressed negative trend in contemporary conditions, which inflicts substantial damage on further economic development and national security of the country.

2. Pregnancy failure is the main type of obstetric pathology substantially affecting the reproductive health of women and perinatal pathology. In the Nizhny Novgorod Region, screening for pregnancy failure has been conducted and a system for evaluating the effectiveness of measures aimed at the health improvement of women of reproductive age has been modeled.

3. The organization of medical and social assistance and the protection of reproductive health, as well as the family planning system, at the municipal level require reorganization and must be of a comprehensive character. An organizational model of an inter-agency system of reproductive health monitoring and a target program for the protection of maternal and child health at the regional level have been developed, tested, and implemented.

4. An organizational model of a system of measures for the protection of reproductive health can be realized provided coordinated joint inter-agency actions with the leading role of the Regional Administration. The implementation of this model has yielded a substantial medical and social and economic effect.