Model of Management of Preventable Risk Factors of Maternal Mortality from Obstetric Hemorrhages in Modern Conditions

The dissertation is dedicated to the development of a model of management of preventable risk factors of maternal mortality from obstetric hemorrhages in modern socio-economic conditions. The research is based on a comprehensive socio-hygienic, medico-biological, and organizational analysis of the frequency of obstetric hemorrhages, the structure and causes of maternal mortality from them, conducted at the population level using data from the Ivanovo Region over a ten-year period (1994-2003). The research identified risk factors of obstetric hemorrhages, determined the role of the infectious-inflammatory factor in their determination, and conducted a comprehensive assessment of the readiness of the maternal health care service for the prevention of maternal mortality from hemorrhages according to structural, process, and result components of quality.

The scientific significance of the work consists in the substantiation of the proposed model of management of risk factors, which makes it possible to quantitatively assess the prognostic significance of modern socio-hygienic and medico-biological factors, and in the development of practical recommendations for the optimization of the prevention of obstetric hemorrhages at the territorial level. The results of the research were implemented in regional practice and used in the development of programmatic documents in the health care sphere of the Ivanovo Region.

One of the most relevant issues in obstetric science and practice is the prevention and treatment of hemorrhages. Among obstetric complications occurring during pregnancy and childbirth, hemorrhages occupy one of the leading positions, substantially affecting the level of maternal mortality, as well as contributing to the development of various diseases of the female reproductive system.

According to WHO data, annually 127 thousand women (25%) worldwide die from hemorrhages. According to a number of authors, obstetric hemorrhages as the primary cause of maternal mortality account for a net 20-25%, as a competing cause - 42%, as a background cause - up to 78% (Strizakov A.N., 2000). The frequency of obstetric hemorrhages ranges from 2.7 to 8% relative to the total number of births. Of these, 2-4% of hemorrhages are associated with uterine hypotonia in the third stage of labor and the postpartum period, and 0.8-0.9% of them occur with premature separation of a normally located placenta and placenta previa (Kulakov V.I., 1999; Serov V.N., 2005).

The problem of maternal mortality from acute massive blood loss currently exists in Russia at the same level as two decades ago - in 1986 the share of obstetric hemorrhages in the structure of maternal mortality was 25%, in 1998 - 26.8%, and in 2002 - 32% (Kulakov V.I., 1999).

One of the basic factors increasing the percentage of obstetric hemorrhages at the present stage is the increase in the percentage of abdominal delivery. The frequency of cesarean section fluctuates within wide limits and is performed in various institutions in 2-40% of all births. This indicator over the last 10 years in Russia has increased approximately threefold, and in the Ivanovo Region it stands at 19.7%. At the same time, in the FRG, Sweden, and some countries in recent years the frequency of abdominal delivery has not exceeded 10%.

Scientific research has made it possible to achieve significant positive shifts in the problem of prevention and treatment of hemorrhages. The most important of these were: the identification of features of obstetric hemorrhagic shock depending on its cause; the improvement of intensive therapy, which made it possible to increase the effectiveness of therapeutic measures in hemorrhagic shock; the widespread introduction into clinical practice of uterotonic agents, which led to certain successes in the prevention and treatment of hypotonic hemorrhages; the discovery and study of the mechanisms of development of disseminated intravascular coagulation syndrome as a component of the pathogenesis of numerous pathological states in obstetrics; new information has appeared on the mechanisms of development of the massive transfusion syndrome, the possibility of using necessary blood components and preparations in obstetric practice; pregnant women at high risk of developing hemorrhage during labor have been identified (Kulakov V.I., 1999; V. N. Serov, 2003).

Numerous studies have proven that the best ways of preventing massive blood loss are careful observation during the prenatal period, modern diagnostic methods, and the availability of qualified personnel proficient in intensive therapy techniques and knowledgeable about the specifics of obstetric clinical practice (Bakhsheev N.S., 1970; Burduly G.M., 1994; Abubakirova A.M., Baranov I.I., 1996; Arekat Hulud Jamal, 1996; V. N. Serov, 2003; Frolova O.G., 2003).

At the same time, there are extremely few works concerning the study of regional features in the dynamics of changes in obstetric hemorrhage and maternal mortality indicators over the period of socio-economic transformations in the country; the medico-social and medico-organizational aspects of obstetric hemorrhages are insufficiently studied; studies on the assessment of the quality of obstetric services with account of the realization of their properties have not been conducted; there is insufficient information on the role of the material and technical base and the quality of the staff of maternity care institutions in ensuring the effectiveness of the prevention of obstetric hemorrhages; clear standards for ensuring the readiness of maternity care institutions for the prevention of hemorrhages are absent; risk factors of obstetric hemorrhages require clarification taking into account the stages of pregnant woman observation, as well as algorithms for the observation of women at risk of hemorrhage by obstetrician-gynecologists of women's clinics. The nature of the influence of infectious diseases of the reproductive system on the development of hemorrhages in labor, which affect the course, outcome, and complications of labor and determine the state of the reproductive function of a woman in the future, has been insufficiently studied.

The above determined the goal of the research: on the basis of a comprehensive socio-hygienic study of obstetric hemorrhages and maternal mortality from them, to develop proposals for the optimization of management of the factors determining them.

In order to achieve the goal, the following tasks were resolved:

1. To study the frequency and structure of obstetric hemorrhages, maternal mortality from them over the last ten years (1994-2003) at the territorial level.

2. To study the socio-hygienic and medico-social factors determining the development of obstetric hemorrhages in modern conditions, their prevalence in the population of pregnant women and trends over the last ten years.

3. To clarify the role of the infectious-inflammatory factor in the determination of the occurrence of obstetric hemorrhages.

4. To assess the quality of the prevention of obstetric hemorrhages and maternal mortality from them based on expert evaluation of the base, medical personnel, expert review of provided cases of medical care, and satisfaction of women.

5. To substantiate and develop recommendations for the optimization of management of factors determining the quality of prevention of obstetric hemorrhages, as a cause of maternal mortality, in modern conditions at the territorial level.

The scientific novelty of the research lies in the fact that:

- for the first time new data on the level and structure of obstetric hemorrhages in the population of pregnant women, as a cause of maternal mortality, and their trends in dynamics over 10 years of monitoring observation of populations of pregnant women have been obtained;

- risk factors of obstetric hemorrhages in modern crisis socio-economic conditions have been identified, differences in their volume and prognostic significance, prevalence in the population of pregnant women compared with the pre-crisis period based on monitoring of pregnant women have been established;

- the role of the infectious-inflammatory factor in the determination of the occurrence of obstetric hemorrhages has been determined;

- for the first time a comprehensive assessment of the structural, process, and result components of the quality of prevention of obstetric hemorrhages at the territorial level, based on the opinions of experts and women as consumers of obstetric-gynecological medical services, has been provided.

- scientific grounds have been developed and recommendations for the optimization of management of factors determining the quality of prevention of obstetric hemorrhages, as a cause of maternal mortality, in modern conditions at the territorial level have been elaborated.

The practical significance of the research results lies in the fact that health care management bodies of the region are presented with scientifically substantiated data of epidemiological analysis of the maternal mortality indicator in the Ivanovo Region, obstetric hemorrhages, the state of readiness of the material and technical base and personnel for ensuring the prevention of obstetric hemorrhages and maternal mortality from them, the quality of its performance in the conditions of the obstetric-gynecological service, factors influencing the effectiveness of this activity, and a risk prognosis scale for obstetric hemorrhages for the modern socio-economic situation, which will contribute to the timely and substantiated adoption of management decisions on the improvement of the service; proposed test-cards for assessing the level of preparedness of obstetrician-gynecologists for the prevention of maternal mortality from hemorrhages, questionnaires for studying the awareness of women on issues of preserving reproductive health, scales for group prognosis of reduction in the effectiveness of prevention of maternal mortality from hemorrhages can be used in other territories of the country for the optimization of the maternal health care system.

The obtained results can be used in the compilation of comprehensive regional programs for the health protection of mothers and children, prevention and reduction of maternal and infant mortality.

Implementation of the results of the work into practice - The materials of the research were used in the development of the "Concept of Health Care Development of the Ivanovo Region until 2008". The proposed set of measures was implemented in the regional target program "Safe Motherhood", and also found reflection in the orders of the Health Care Administration of the Ivanovo Region: No. 75 dated 26.07.99 "On measures to reduce maternal mortality in the Ivanovo Region in 1999", No. 51 dated 27.04.2000 "On the state of maternal mortality in the region and operational measures for its prevention", No. 84 dated 13.06.2001 "On maternal mortality in the Ivanovo Region and measures for its prevention"; No. 82 dated 27.05.02 "On the improvement of the provision of emergency obstetric-gynecological care in the Ivanovo Region"; No. 112 dated 23.07.2002 "On the state and measures to reduce maternal mortality in the Ivanovo Region", No. 355 dated 27.08.2003 "On the introduction of autodonation in surgical and obstetric practice", No. 39/4 dated 29.01.2003 "On the state and urgent measures to reduce maternal and infant mortality in the Ivanovo Region". Based on the research materials, an informational letter of the Health Care Administration of the Ivanovo Region for obstetrician-gynecologists, anesthesiologists-resuscitators, and health care organizers "Medico-organizational aspects of the prevention of maternal mortality from obstetric hemorrhages at the regional level" (2006) was issued. The generalized results of the conducted research, as well as prepared methodological documents, were applied in conducting practical sessions with cadets of the Department of Obstetrics and Gynecology of FDPPO, as well as with students of the Department of Public Health and Health Care, Law, Medical Informatics, and History of Medicine of the State Educational Institution of Higher Professional Education "Ivanovo State Medical Academy" of the Ministry of Health of Russia (GOU VPO IvGMA MZ RF) and were introduced in a number of maternity care institutions of the city of Ivanovo and the Ivanovo Region.

Validation of the work

The materials of the dissertation were reported and discussed at the scientific-practical conference "Critical States in Obstetrics/Gynecology" (Moscow, 2004), Regional Scientific-Practical Conferences "Prevention of Maternal Mortality from Hemorrhages", "Infusion-Transfusion Therapy in Obstetric Hemorrhages" (Ivanovo, 2004, 2005), at the interdepartmental conference of the Department of Obstetrics and Gynecology of FDPPO, as well as with students of the Department of Public Health and Health Care, Law, Medical Informatics, and History of Medicine of GOU VPO "Ivanovo State Medical Academy" of the Ministry of Health of Russia (2006).

Five scientific works and two informational letters have been published on the topic of the dissertation.

Propositions to be defended:

1. The basis for forecasting obstetric hemorrhages and maternal mortality from them is a complex of socio-hygienic, medico-biological risk factors, different from the pre-crisis period, whose prognostic significance in modern conditions can be quantitatively assessed using the proposed prognosis scale.

2. The basis for the optimization of the prevention of obstetric hemorrhages and maternal mortality from them at the territorial level should be the proposed model of management of risk factors of obstetric hemorrhages, based on the identified degree of their manageability and the dynamics of the frequency of registration in the population of pregnant women.

Personal participation of the author. The author took personal and direct part in the performance of research in all sections of the dissertation, conducted the collection, processing, and analysis of data, and implemented the proposals into the practice of health care institutions of the obstetric-gynecological profile in the Ivanovo Region. The author's share in the accumulation, processing of information, generalization, and analysis of the material is 100%.