Infant mortalIty In russIan federatIon and Influence on Its dynamIc factors

снижение младенческой смертности (Мс) — важная государственная задача. Цель: анализ показателей Мс, выявление факторов, влияющих на ее динамику путем изучения уровня ведущих региональных индикаторов социально-экономического развития, обеспеченности врачами и стационарными койками и сопоставление показателей российской Федерации с зарубежными. Материалы: официальные и оперативные отчеты росстата за 2011–2016 гг. Результаты. Коэффициент Мс в 2016 г. составил 6,0 на 1000 живорожденных и варьировал в федеральных округах от 4,8 до 9,2. в связи с переходом на новую систему регистрации новорожденных показатель увеличился к 2012 г. К 2016 г. наблюдалось его устойчивое снижение. выявлена отрицательная корреляция величины валового регионального продукта и коэффициента Мс и положительная корреляция указанного показателя и абсолютного показателя Мс. Не выявлено зависимости между показателями Мс и площадью территории, плотностью автодорог с твердым покрытием, количеством человек на 1 койку/1 врача. Выводы. Мс в российской Федерации выше, чем в развитых странах мира, имеет устойчивую тенденцию к снижению, коррелирует с величиной валового регионального продукта, не зависит от транспортной доступности и обеспеченности врачами и стационарными койками, определяется организацией и качеством оказания медицинской помощи.


BACKGROUND
Reduction of childhood mortality is one of the most important government public health care goals. The majority of child deaths occur during the first year of life: 40% in the early neonatal period and 30% in the postneonatal period [18]. Approximately 55%-65% of all deaths in the age group 0-14 years are registered among children below the age of one year [7]. The significance of infant mortality (IM) is underlined by its high contribution to overall childhood mortality [4,9,14]. IM rate (IMR) is one of the main health indicators that reflect healthcare priorities and performance of social insurance programs [3].
Aim. This study was undertaken to analyze the rate of IM in the Russian Federation and identify the factors that affect its dynamics through an assessment of the main regional indicators of socio-economic development and sufficiency of physicians and hospital beds. A comparison of the evaluated parameters with those in other countries is also conducted and relevant inferences have been drawn.

MATERIAL S
We used official statistical reports and publications of the Russian Federal Statistics Service for 2011-2016.

STATISTIC AL ANALYSIS
We conducted a population-based study. Data analysis was performed using the Statistica 10.0 software package (Statsoft Inc., USA). Correspondence of data to normal distribution was not checked. Categorical variables were compared using the Pearson's test, chisquare test, and Fisher's exact test, if one of the values in the contingency table was < 5. Spearman's correlation coefficient was calculated to examine the correlation between variables. Differences associated with р values ≤ 0.05 were considered statistically significant.

RESU LT S
Overall IMR in Russia in 2016 was 6.0 per 1,000 live births; IMR ranged from 4.8 in the Northwestern Federal District to 9.2 in the North Caucasian Federal District ( Figure 1). An increase in IM was observed during    A statistically significant correlation was observed between the value of gross regional product and IM: negative correlation between IMR and gross national product and a positive correlation between the absolute number of infant deaths and gross national product (Tables 2 and 3).
In the Russian Federation, patients are primarily transported to the in-patient dpts by ambulance cars. Therefore, we used the density of paved roads as a proxy indicator of inpatient care availability. We found no correlation of IM with inpatient care availability or the size of the region.    Gross regional product Size of the area Density of paved roads Gross regional product Size of the area Density of paved roads Gross regional product Size of the area Density of paved roads Gross regional product Size of the area Density of paved roads Gross regional product Size of the area Density of paved roads Gross regional product Size of the area Density of paved roads Gross regional product Size of the area Density of paved roads Gross regional product Size of the area Density of paved roads Gross regional product    Congenital and chromosomal abnormalities were the most frequent causes of deaths during the perinatal period ( Figure 4). We observed an increase in the number of perinatal deaths in 2012 and a decline by 2016. The speed of changes in IM associated with congenital and chromosomal abnormalities was significantly higher compared to changes in IM owing to other reasons.
Among the countries of the Commonwealth of Independent States (CIS), the lowest IMR in 2015 was observed in Belarus, 3 per 1,000 live births. Other CIS countries had implemented the system of birth registration recommended by WHO prior to 2012. IM in Russia was higher than that in other post-Soviet states: >1.5-fold higher than that in Poland and Hungary, 2.2-fold higher than that in Finland (for 2014), 1.5-fold higher than that in Germany and Austria, and 22% higher than that in the USA.
The sufficiency of medical care was estimated by the number of doctors and hospital bed for 1 person. None of the countries used for comparative analysis reported a correlation between the IM and the sufficiency of medical care (with the exception of USA due to lack of data). In Finland (which has the lowest IMR), the provision with physicians during 2011-2013 varied between 331 and 335, whereas in Russia during 2011-2015 their number varied between 195 and 218; the provision with hospital beds varied from 181-221 and 106-120 per person in Finland and Russia respectively. In Kazakhstan and Azerbaijan the number of physicians in 2011-2015 was 253-266 and 290-295 respectively; the provision with hospital beds was 142-172 and 204-215, i. e., these parameters were similar to those in Russia, while the IMR was significantly higher in these countries. These data seem to suggest that the availability of medical personnel and hospital beds does not affect the level of IM in the country.

DISCUSSION
The increase in IM observed in the Russian Federation in 2012 is associated with the implementation of a new birth registration system comparable to the international one, which was a significant breakthrough for the national health care [3].
We identified a negative correlation (from mild to moderate) between IMR and the value of the gross regional product, which may indicate relatively small impact of the economic level on IM. However, from 2011 to 2015, the correlation coefficient showed a gradual increase from |0.262| to |0.351|, which suggests a growing impact of economic factors on the IMR. The moderate positive correlation between the absolute number of infant deaths and the gross re-gional product observed in the study is likely attributable to the larger number of young people who tend to reside in the economically prosperous regions, and therefore, to a larger amount of births eventually. High frequency of deaths indicates relatively "low quality" of the product of conception. Thus, IM is considered a medico-social, rather than just a medical problem [5,6,10].
"The decrease in IM is associated with improved availability of medical equipment in obstetric hospitals, development of neonatologic services, implementation of internationally-accepted treatment protocols, and the establishment of regional perinatal networks. However, the rate of reduction in postneonatal mortality is slower; during 2011-2016 the perinatal mortality associated with congenital and chromosomal abnormalities demonstrated the most rapid decrease, whereas the mortality associated with respiratory system disorders and infections in children over 1 month of age showed a significantly slower decline. Such dissonance is probably attributable to existing differences in the pace of development of neonatal and pediatric services, which contributes to delayed mortality, when critically ill newborns undergo prolonged, costly treatment in neonatal units and eventually die in pediatric facilities due to improper emergency medical care. In 2014, this problem encouraged the authorities of the Rostov region to start a project entitled 'Audit of children's hospitals' coordinated by the Ministry of Health of the Russian Federation and administrative bodies of Rostov region with the involvement of experts from WHO, Scientific Center of Children's Health (Moscow), medical institutions of the region, and specialists from the Rostov State Medical University. The project had the following objectives: assessment of the existing status of children's emergency care and readiness of medical facilities; analysis of pediatricians' adherence to Federal Clinical Guidelines (treatment protocols); identification of the main 'hot points' and planning for immediate and longterm actions to address these. Off-site analysis of patient medical records, quarterly on-site monitoring of changes in the quality of diagnosis made and treatment, improving the skills of doctors and nurses by providing regular one-day trainings using mannequin simulators and subsequent monitoring of performance were some of the key activities undertaken as part of the project.
In addition to this project, the regional government implemented various measures to improve pediatric intensive care, including compulsory rapid (within 2 hours) reporting of all hospitalized children aged 1 month-18 years to the specialists of the Intensive Care and Advisory Centre (ICAC), joint decisionmaking on the management of such patients and organization of an ICAC specialists visit to a hospital when necessary. As a result the proportion of children who died in primary healthcare units showed a significant decrease: from 52.9% ( It is essential that the results were achieved using only the internal resources of healthcare institutions and with no significant additional expenditures. These internal resources were saved by optimizing the system of drug administration, discouraging the use of expensive medications with unproven efficacy and unnecessary investigations (tests with low diagnostic value), ensuring comprehensive control of children in reanimation units, and provision of timely intensive/ emergency care with the involvement of specialized healthcare facilities [8,12,13,15]. Establishment of an effective intensive/emergency care is a powerful tool to reduce the number of deaths in children [1,2,16,17].