Scientific Justification of Modern Organizational Forms for Improving the Reproductive Health of Women (Based on the Material of the Republic of Kazakhstan)

The dissertation is devoted to the scientific justification of modern organizational forms for the improvement of reproductive health of women based on the material of the Republic of Kazakhstan. The research is conducted from medical-social, organizational, legal, ethical, clinico-statistical, and economic perspectives and covers a complex of issues: the formation of reproductive health and reproductive behavior of women in various age periods, the prevalence of gynecological morbidity, the health status of pregnant women and women in labor, maternal mortality, and medical activity of women. Special attention is given to female infertility as a medical-social problem affecting the demographic situation in the country, as well as to the clinico-statistical, legal, ethical, and economic assessment of the application of assisted reproductive technologies, including IVF programs. The research analyzes the existing state of the service for the protection of reproductive health of Kazakhstan and develops directions for its optimization.

The Relevance of the Problem. It is difficult to overestimate the role of women in modern society. Being the most numerous group of the population, they constitute more than half of all specialists with higher and secondary education, dominate in healthcare, education, the service sector, and in a number of industrial sectors. However, the most important is the reproductive function of women. Under conditions of mass participation of the female population in modern production, a contradiction arises between women's professional activity and their role as wives and mothers. In eliminating the negative consequences of this contradiction, a significant role belongs to a rational system of health protection, and first and foremost — reproductive health (Kuchenko V.A., 2002; Kulakov V.I., 2003; Denisov I.N., 2000).

This problem acquires particular acuteness against the backdrop of the complex demographic situation that took shape at the end of the past — beginning of the present century, largely attributable to declining birth rates. The emerging trend toward an increase in the number of pregnancy and childbirth complications, as well as the deterioration of neonatal health indicators, is to a significant extent associated with low health indicators among women of reproductive age. To resolve these problems, governing bodies and authorities must possess reliable information on women's health status, which is necessary for the development of measures to optimize management and planning of the entire healthcare system for the female population (Medik V.A., Yuryev V.K., 2003; Petrenko A.A., 2003).

The World Health Organization considers the protection of reproductive health a priority direction of its activities (WHO Resolution 48.10) and calls upon all countries to further develop programs for the strengthening of reproductive health, for which it recommends assessing their needs for its improvement, developing medium- and long-term guiding principles in accordance with the directions elaborated by WHO, paying special attention to equality, prospects, and participation of those in need of assistance, in accordance with internationally recognized principles of human rights. WHO proposes to regularly monitor and evaluate the achievements, quality, and effectiveness of reproductive health programs. Reproductive health constitutes an important and relevant component of the European Strategy "Health 21" (Shchepin O.I.Kh., 2004; Friedman H.L., 1994; Benderbay O.S.M., 2001).

At the same time, at present, there exists a disparity in the level of reproductive health across Western, Central, and Eastern Europe. Kazakhstan, having experienced a profound economic downturn during the period of state formation, carried out a serious optimization in the social sphere, including the healthcare system, where the cumbersome network of medical organizations established during the Soviet era was, for the most part, oriented toward quantitative performance indicators. In recent years, the country has achieved significant economic growth, which has made it possible to substantially increase sectoral financing and opened prospects for its further growth. Being socially oriented, the state at present attaches serious attention to the protection of reproductive health of citizens (Sharmann T.Sh. et al., 2000; Westoff C.F. et al., 1998; Kayupova N.A., 2000; Abdiyev K., 2004).

Achieving positive parameters in demographic development as a whole and in reproductive health in particular is one of the most significant tasks of the Republic of Kazakhstan. The national strategy for the protection of reproductive health in the country is based on a legal foundation. On June 16, 2004, the Law of the Republic of Kazakhstan No. 551-II "On Reproductive Rights of Human Beings and Guarantees of Their Realization" was adopted, which regulates public relations in the area of protection of reproductive health of citizens, as well as establishes state guarantees and the basic principles of state policy in the sphere of reproductive rights of citizens. A number of articles of the Law "On Protection of Health of Citizens of the Republic of Kazakhstan" are devoted to this problem; a whole block of questions on this issue was included in the State Program for the Reforming and Development of Healthcare of the Republic of Kazakhstan for 2005–2010, and so forth.

At the same time, a number of programmatic documents on the basis of which the service for the protection of reproductive health is currently developing were adequate at the time of their development and now lag behind the pace of change. Individual measures designated in these documents were not oriented toward achieving a final result, and structural transformations did not always follow a consistent character. Today it cannot be asserted that the state of the system for the protection of reproductive health and its level fully satisfy society and the state, which is why the time has come to change the existing situation. There has arisen a necessity for conducting scientific research that would allow an objective assessment of the state of reproductive health and, on their basis, to develop a unified program for the purposeful, consistent activity of society aimed at the improvement and preservation of the reproductive potential and reproductive health of citizens.

Objective of the Research. On the basis of a comprehensive assessment of the process of formation, the state of reproductive health, and behavior of women of the Republic of Kazakhstan, to develop a complex of scientifically substantiated organizational and medical-social recommendations aimed at improving indicators of reproductive health, optimizing reproductive behavior of women, and improving obstetric and gynecological care.

To achieve the stated objective, the following tasks were set: 1. To present a medical-social assessment of the state of reproductive health and behavior of women in the republic, and to study the patterns of their formation. 2. To consider the medical-social aspects of female infertility. 3. To provide a medical-social, legal, ethical, clinico-statistical, and economic assessment of the use of assisted reproductive technologies. 4. To analyze the quality and assess the state of the service for the protection of reproductive health. 5. To develop an organizational and legal substantiation of measures for the protection of reproductive health of women in Kazakhstan.

The scientific novelty of the research consists in the fact that, for the first time in the conditions of the Republic of Kazakhstan, through comprehensive research from medical-social and organizational positions, the problems of the formation of reproductive health and behavior (productive, marital, contraceptive, and abortion) of women in different age periods have been resolved, in particular, the prevalence of pathology of the reproductive system, the course of pregnancy and childbirth, maternal mortality, medical activity of women, and female infertility. For the first time, a medical-social, legal, ethical, clinico-statistical, and economic analysis of the use of modern assisted reproductive technologies (ART) in healthcare has been conducted. For the first time, in contemporary socio-economic conditions, a detailed comprehensive characterization of the state of the service for the protection of reproductive health of women of the Republic of Kazakhstan and possible directions for its optimization has been provided.

The scientific-practical significance of the research is determined by its results, which have made it possible to present to government authorities and management, as well as to institutions of practical healthcare, objective, scientifically substantiated information on the state of reproductive health of women in Kazakhstan. The implementation of the set tasks made it possible to develop scientifically substantiated recommendations aimed at improving indicators of reproductive health of women in the republic, optimizing their reproductive behavior, and eliminating or mitigating the negative impact of risk factors of disorders in the formation of reproductive health. A complex of measures has been proposed for the improvement of obstetric and gynecological care, for the broader and more effective introduction into practice of modern assisted reproductive technologies, an algorithm for the management of pregnancy occurring within ART programs has been developed, and an economic justification of ART programs has been provided. On the basis of the data obtained in the course of the research, proposals have been developed and presented for the draft "National Strategy of Kazakhstan on Reproductive Health until 2010," the Law of the Republic of Kazakhstan "On Reproductive Rights of Human Beings and Guarantees of Their Realization," and protocols on the protection of reproductive health have been introduced in the United Nations Population Fund in the Republic of Kazakhstan.

The materials of the dissertation have been introduced into practical activity of the United Nations Population Fund (development of clinical protocols on the protection of reproductive health — approved by orders of the Ministry of Health of the Republic of Kazakhstan No. 116 dated 01.02.02 and No. 176 dated 16.02.02; letter signed by the representative of the Fund A. Alzhanova), the Ministry of Health of the Republic of Kazakhstan (on the basis of the research materials, methodological recommendations have been prepared, approved on 18.05.05 by the Director of the Department N. Khamzina, and introduced into practical activity: "Features of the Course of Pregnancy Occurring in Programs of Assisted Reproductive Technologies. Principles of Management"; "Application of Methods of Assisted Reproductive Technologies in Gynecology. Organization of the Work of the IVF Center"), the Reproductive Health Center of Tbilisi (order No. 375 dated 30.04.05, approved by the head T.T. Tugushi), the Institute of Human Reproduction named after I. Jordania (Tbilisi) (order No. 03101-56 dated 13.05.05, approved by the head of the IVF Department G. Tsagarashvili), the IVF Center of Tashkent (order No. 413-05 dated 23.04.05, approved by the director Kh.D. Asadov), the Research Institute of Obstetrics and Gynecology of the Republic of Uzbekistan (order No. 244/13 dated 11.04.05, approved by the director D.D. Kurbanov), the Research Institute of Obstetrics, Gynecology, and Pediatrics of the Ministry of Health of the Republic of Tajikistan; Departments of Healthcare of the Akimats of the city of Almaty (order No. 1176 dated 10.05.05, approved by the deputy chief T.M. Dzhusubalieva), Kostanay Oblast (order No. 633 dated 27.05.05, approved by the chief obstetrician-gynecologist I.A. Yantsen), Karaganda Oblast (order No. 875 dated 15.06.05, approved by the chief obstetrician-gynecologist K.A. Medeubaeva), and East Kazakhstan Oblast (order No. 514 dated 07.06.05, approved by the chief obstetrician-gynecologist G.K. Raysov), the Perinatal Center of South Kazakhstan Oblast (order No. 548 dated 18.04.05, approved by the chief physician G.Zh. Zadina), the National Research Center for Maternal and Child Health Protection of the Ministry of Health of the Republic of Kazakhstan (order No. 143/15 dated 14.02.05, approved by the director N.M. Mamedalieva), the Novgorod Scientific Center of the Ministry of Health of the Russian Academy of Medical Sciences (order No. 248 dated 20.06.05, approved by the deputy director V.R. Weber), the Committee on Population Health Protection of Novgorod Oblast (order No. 1136 dated 14.06.05, approved by the first deputy chairman T.E. Kotova), the Novgorod Regional Clinical Hospital (order No. 114-e dated 23.05.05, approved by the head of the obstetric-gynecological clinic I.O. Marina), the Institute of Medical Education of Novgorod State University named after Yaroslav the Wise (order No. 12-k dated 13.06.05, approved by the vice-rector of NSU V.E. Gantmakher), the Novgorod State Medical Academy (order No. 212/85 dated 30.05.05, approved by the head of the department I.O. Marina).

Personal contribution of the author to the conducted research. The author independently conducted an analytical review of domestic and foreign literature on the studied problem, performed a content analysis of official documents, carried out research planning, compiled its program, developed statistical recording forms, and conducted the collection of factual data. The program for mathematical-statistical processing of the material was developed and the processing itself was carried out with the participation of the author. The analysis, interpretation, presentation of the obtained data, and formulation of conclusions and practical recommendations were mainly performed personally by the author. The author's share in the collection and processing of accumulated data exceeds 80%, and in the generalization and analysis of the research material reaches up to 100%.

Principal Propositions to Be Defended:

1. The process of formation of reproductive health in adolescence occurs under the influence of a complex of medical-social risk factors and depends on ethnic affiliation and region of residence. Young women in Almaty have positive marital but low reproductive orientations; among them, gynecological diseases are widely prevalent. Teenage girls have a low level of knowledge on issues of sexual relations, and the majority would like to supplement their existing knowledge.

2. In recent years, Kazakhstan has registered a positive trend in the reproductive behavior of women; however, the majority have low reproductive orientations. Despite the fact that gynecological morbidity has a tendency toward decline, a deterioration is noted in a number of indicators characterizing the health status of pregnant women, and the frequency of complications in labor and the postpartum period is increasing. The maternal mortality ratio in the republic is declining, but its level remains high, and many cases of maternal mortality are the consequence of organizational errors.

3. Female infertility in the Republic of Kazakhstan is an important medical-social problem negatively affecting the demographic situation. Women suffering from infertility have specific medical-social characteristics. In the republic, the use of assisted reproductive technologies is legally permitted, but they are not included in the guaranteed volume of free medical care. ART constitute an expensive but effective method of infertility treatment. Pregnancy occurring within IVF programs carries a high risk of complications, is often multiple, and frequently results in the birth of a premature infant.

4. The existing system for the protection of reproductive health does not fully cope with the tasks assigned to it, which indicates the necessity of developing and introducing new organizational forms of work. Women have a low assessment of the activity of both district and inpatient obstetric and gynecological services. The practical recommendations developed as a result of this research will contribute to the improvement of reproductive health of women and the optimization of the organization of activities for its protection.

Validation of the Research. The principal propositions of the dissertation were heard, discussed, and approved at the sessions of: Russian Scientific and Practical Congresses "Man and Medicine" (Moscow, 1998; 2000); the International Congress of Obstetricians and Gynecologists (Almaty, 1999); the VII Congress of Obstetrics and Gynecology of the Baltic States (Saint Petersburg, 1999); the symposium with international participation "Infertility: Assisted Reproductive Technologies 2000" (Kyiv, 1999); the VI Congress of Obstetricians and Gynecologists of Kazakhstan (Almaty, 2000); the International Symposium "Diferelin — A Step into the New Millennium" (Kyiv, 2001); the X Congress of the European Society of Gynecological Endoscopy (Moscow, 2001); the Scientific and Practical Conference "Current Problems of Healthcare at the Present Stage" (Almaty, 2001); the Republican Conference "Current Trends and Current Problems of Neonatology" (Tashkent, 2001); the First Conference of Young Scientists "Progress in Oncology" (2002); the City Society of Obstetricians and Gynecologists of the city of Almaty (2002, 2003, 2004); the International Scientific and Practical Conference "Strategy for the Development of Healthcare of the Republic of Kazakhstan" (Almaty, 2003); the VI Congress of Obstetricians and Gynecologists of Uzbekistan (Tashkent, 2003); the V Russian Forum "Mother and Child" (Moscow, 2003); the II International Congress of ART (Moscow, 2005); Scientific and Practical Conferences "Current Problems of Infertility Treatment" (Kostanay, 2004, Chimkent, 2004); the All-Russian Scientific and Practical Conference "Current Problems of Regional Healthcare" (Saransk, 2004); the International Conference "Kazakhstan, Medicine of the 21st Century" (Almaty, 2004); the Anniversary Scientific and Practical Conference Dedicated to the 100th Anniversary of the Clinic of SPbGMA and the 80th Anniversary of the Academy (Saint Petersburg, 2005); the XXXVIII Scientific Conference — Khlopin Readings "Environment, Lifestyle, and Health" (Saint Petersburg, 2005); the Scientific and Practical Conference "Assisted Reproductive Technologies in the Treatment of Infertility" (Almaty, 2005).

68 scientific works have been published on the topic of the dissertation.