2. Signs and mechanisms of falsification of the infant mortality rate in Russia

An analysis of the reliability of MS registration reveals significant facts of discrepancy between the registered information and the actual information.

1. The first sign of a violation of the reliability of the MS indicator is an unrealistically high rate of decline in the indicator (Fig. 7).

Rice. 7. Dynamics of annual rates of change in infant mortality rates and its components – in %

According to numerous studies conducted over many years in countries with different demographic indicators, with different levels of economic development and quality of life of the population, the level of MS is a fairly stable population indicator, the annual rate of change of which, outside of extreme situations, cannot exceed 4-5%. At the same time in Russia Lately the rate of decline in MS, neonatal and early neonatal rates reached record levels: 9.6-11.1-13.2%, respectively, in 2008. with reduction next year 2009. (4.2-4.2-6.7%) and another increase (7.9-8.7-9.1%) in 2010.

An analysis of the dynamics of MS in the regions of Russia reveals sharp year-to-year fluctuations in the indicator, reaching 40% in some regions, for example in the Republic of Kalmykia, where the MS indicator decreased from 9.5‰ in 2010. (42 babies died) to 5.7‰ in 2011. (24 children died). Equally significant progress was made in reducing the level of metabolic syndrome in 2011. compared to 2010 noted in Chuvash Republic(from 5.4 to 3.5‰), Penza region (from 7.8 to 5.7‰).

2. Violations in the registration of deceased children in Russia are evidenced by the distortion of the age structure of the MS. The latter is subject to a strict objective biological pattern: the younger the child’s age, the higher the mortality rate; As the child grows older, the level of vitality of the child increases and the likelihood of his death decreases. It is characteristic that in the EU countries early neonatal mortality in 2010. amounted to 48.5% in the MS indicator (1.97‰ with a MS level of 4.1‰) and 72.4% in neonatal mortality (1.97 out of 2.72‰), and the share of early losses is growing over time.

In Russia, early neonatal losses amounted to only 36.5% of the MS structure in 2011, having decreased in dynamics from 53.9% in 1990. – which confirms the fact of “aging” of MS. In some regions, mainly with low level MS, the share of deaths aged 0-6 days, in the structure of MS is significantly lower than the all-Russian level - in the Komi Republic (19.6%), St. Petersburg (23.7%), Khanty-Mansky Autonomous Okrug (17.4% ), in the Trans-Baikal Territory (20.0). It should be noted that an extremely low proportion of children in the first week of life with MS is registered in “good” regions - with a low rate of MS. At the same time, it is obvious that the reduction in the proportion of deaths in early age periods is an indicator of a violation in the registration of deceased children in the first week and first days of life.

A similar situation was revealed when analyzing the number of deaths in the first 24 hours of life. If in the Russian Federation as a whole, these children accounted for 12.9% of all deaths under the age of 1 year in 2011, then in some territories the figure was two or more times lower: in the Arkhangelsk region (6.8%), Kaluga (6.7%) and Tula region(3.7%). Moreover, in all these regions the level of MS (6.8-5.5-6.9‰, respectively) is lower than in Russia (7.4). An underestimation of the proportion of deaths in the first hours after birth indicates a “transfer” of deceased newborns into stillbirths.

A global sign of falsification of the MS indicator to achieve a given target MS indicator, especially clearly manifested in large numbers of children, is a distortion in the dynamics of the ratio of deceased newborns and children older than one month . As mentioned earlier, in Russia, the dynamics of infant losses is “aging” - the proportion of deaths over the age of one month is growing, while the proportion of newborn deaths is decreasing - contrary to the objective biological patterns of changes in MS and the structure of MS in the world.

Interesting data presented National Center US health statistics, according to which in the age structure of MS by racial and national origin of the mother, the share of postneonatal losses ranges from 29.5% among Cubans (1.53‰ with an MS level of 5.18) and 34.3% among the black population (4 .57‰ out of 13.31) to 50.6% among Indians and Alaska Natives (4.67‰ out of 9.22). The US average in 2007 was amounted to 34.5% (2.33‰ out of 6.75) – Fig. 8.

Rice. 8. Infant, neonatal, and postneonatal mortality in the United States in 2007: distribution by maternal race and national origin (cited in Mathews T.J. et al., 2011, www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_06.pdf .).

Unfortunately, the Russian indicator of the share of the postneonatal component in the structure of MS is 44% in 2010. with a steady upward trend in dynamics - approaching the figure for Indians and local residents of Alaska - 50.6%. This unworthy position for our country regarding the age structure of the MS is ensured due to falsification of data - under-registration of deceased newborns with a more complete accounting of deceased infants older than a month, which causes high share them in MS.

3. One of the important signs of incorrect registration of perinatal and neonatal losses is a violation of the weight structure of stillborn and deceased children: when distributing the array of deceased and stillborn children into weight groups, a so-called “statistical failure” of children weighing 1000-1499 g is observed - a decrease in their number in comparison with weight groups 500-999 g and 1500-1999 g. Such a “failure” between groups of newborns of different body weights with a high degree of probability suggests that some of the dead children and stillborns weighing 1000-1499 g are classified (due to underestimation of body weight at birth) in the group of “fetuses” weighing less than 1000 g, not subject to registration with the civil registry office – Fig.9.

Rice. 9. Distribution of stillbirths (above) and deaths at the age of 0-6 days (below) by weight categories (2010)

4. A very significant sign of the “transfer” of dead children into stillborns is a decrease in the proportion of deaths in the first 24 hours among those who died at the age of 0-6 days - Fig. 10.

Rice. 10. Proportion of deaths in the first 24 hours (% of the number of deaths at the age of 0-6 days) by weight categories in Russia

As can be seen in the figure, the proportion of deaths during the first 24 hours after birth is minimal in the weight group 1000-1499 g (36.7% of the number of deaths at the age of 0-6 days of life), despite the fact that among children of extremely low body weight (ELBW) - less than 1000 g - this figure was 50.9-63.2%, and among children weighing more than 1500 g - also higher (42.0 and 44.4%). Such a “shortage” of those who died immediately after birth in the weight category of 1000-1499 g also indicates a “transfer” of dead children into stillborns, since there are no other factors that explain the “increased survivability” of children with very low body weight, who die less often than others in the first hours of life.

It is characteristic that in some regions with a low level of MS (Komi Republic - 4.4‰ in 2011, Khanty-Mansiysk Autonomous Okrug - 5.2‰ with 7.4‰ in the Russian Federation) “children of very low body weight” (1000-1499g ) did not die at all in the first 24 hours after birth - despite the fact that in terms of the proportion of stillbirths in the structure of perinatal losses (80.8% in Komi and 79.1% in Khanty-Mansi Autonomous Okrug, with 62.8% in the Russian Federation), these regions are practically the leaders in the country , occupying second and fifth ranking places in this indicator. The level of early neonatal mortality in these regions was in 2011. 0.85‰ (Komi) and 0.90‰ (KhMAO) – i.e. five times lower than in the Russian Federation (4.49‰) and two times lower than in EU countries (1.97‰). At the same time, the level of stillbirths in these regions is very high - 4.60‰ in Komi and 3.41 in Khanty-Mansi Autonomous Okrug - with 4.49‰ in Russia (2011) and 4.03‰ in the EU countries (2010).

5. The change in the weight structure of the deceased in dynamics towards an increase in children’s physiological body weight with a decrease in the share of low birth weight in the structure of neonatal losses clearly confirms the trend of underestimation of the infant mortality rate due to the undercounting of deceased children of low body weight (Fig. 11).

Rice. 11. Comparison of the annual rate of change in the proportion of deceased newborns weighing “less than 3000g” (1000-2999g) and “3000g or more” in the dynamics of 1991-2011.

It is characteristic that an increasing disproportion in the weight structure of the deceased was noted over the last decade (2000-2009) - the years of maximum decline in the MS indicator, when the annual rate of changes in the structure of the deceased in terms of body weight increased sharply. Until 1999, there was a stable ratio of deceased children by weight group - the proportion of children with physiological body weight (“3000g or more”) fluctuated within 26-27% of the number of deaths, with a natural predominance of children weighing “less than 3000g,” whose specific weight was 73-74%, and there were no significant changes in the structure of the deceased by body weight during the 90s. Since 2000 - with the most intensive rate of decline in MS and, above all, early neonatal mortality, there is a paradoxical dynamics in the structure of deaths by weight category: the number of deaths in the physiological weight group (“3000g or more”) began to increase from 25.9% of the number of deaths in 1999 to 36.6% in 2009 - with a simultaneous decrease in the proportion of children with low and relatively low body weight (1000-2999g) from 74.1 to 63.4% over the same years.

(Children weighing 2500-2999 g, mainly with intrauterine growth retardation, although they are not considered low birth weight according to classical criteria, with regard to the dynamics of mortality and stillbirth, they behave in the same way as low birth weight children less than 2500 g - which was shown by us earlier.)

6. In direct connection with the decrease in the proportion of low birth weight newborns among all deaths is a change in the structure of early neonatal mortality by gestational age of the deceased - an increase in the proportion of full-term infants in the structure of deaths in 0-6 days from 32.2% in 1991. up to 42.6% in 2011 - with a decrease in the proportion of premature babies. The decrease in the rate of early neonatal mortality in the obstetric hospital (from 7.7‰ to 2.2‰, or 3.5 times for 1991-2011 - according to statistical form No. 32) occurred due to a primary decrease in the mortality of premature newborns (from 93 .2‰ to 23.0‰, or 4.2 times over the same years), while the mortality rate of full-term children over the same years decreased only 2.6 times - from 2.7 to 1.0‰. How plausible such dynamics are is in light of the noted disproportions raises obvious doubts and is most likely associated with under-registration of prematurely deceased children.

Thus, the decline in MS in Russia was accompanied by paradoxical dynamics in the weight and gestational structure of the deceased - i.e. a predominant reduction in the mortality of low birth weight and premature infants, which led to disproportionate changes in the structure of the metabolic syndrome.

Summarizing the information presented about the facts that raise irremovable doubts about the reliability of the registered indicators of the MS and their correspondence to the actual ones, we can present indicators of distortion and falsification of infant mortality indicators as follows.

Indicators of falsification of MS indicators:

1. fluctuations in MS indicators over the years exceeding 5%;
2. the share of dead children and stillbirths weighing 1000-1499 g is greater than their share in the weight group 500-999 g;
3. the share of stillbirths in the structure of perinatal mortality in the weight category 1000-1499 is less than in the weight category 500-999g;
4. “aging” of infant and neonatal mortality – a relative increase in older age groups (postneonatal and late neonatal) with a decrease in younger ones;
5. continued increase in the share of full-term children and children of physiological body weight in the structure of deceased newborns.

When switching to registration of births and deaths of children, a number of these indicators may lose their validity and new ones may appear. For example, underestimation of the body weight of a deceased child or stillborn ELBW by less than 500 g, i.e. classifying it as a late miscarriage. Thus, when registering children with ELBW over the last three years of detailed registration, there is a discrepancy in the number of births by gestational age and body weight. In 2011 the number of births weighing 500-999 g (15692) is less than the number of fetuses born at 22-27 weeks of pregnancy (16702, according to statistical form No. 32), that is, 1010 fetuses (6.4%) born at 22-27 weeks of pregnancy , had a body weight of less than 500g and were not registered as children. Apparently, this problem of registration, known to us from earlier times (when the fetal body weight of 1000 g was “critical” for accounting/non-accounting), will have to be faced when moving to new birth criteria - on the new threshold value fetal body weight (500g).

In principle, there are two possible mechanisms for underestimating the infant mortality rate - the “transfer” of dead children into stillborns, which, unfortunately, are not taken into account in the nationally significant statistics of reproductive losses, or the attribution of a deceased child to “fetuses” (“miscarriages”) that are not registered in infant and perinatal mortality. However, knowing the ways and possibilities of underestimating the number of cases and the indicator of MS, it is possible to calculate its proper level using various methods . Both “mechanisms” of falsification of MS are identified based on objective data - based on the analysis of structural disproportions in the number of live births and stillbirths, on the dissociation of the weight structure of the dead - the disappearance of children of borderline body weight (1000-1499 g), “thrown over” into unregistered “fetuses”. Objective indicators of the “transfer” of live-born children into stillborns include the absence (or an inadequately small number) of deaths in the first 24 hours after birth, which is especially common in the “borderline” weight category between “fetuses” and “children” - 1000-1499g. When analyzing the nature of the distribution of deceased children by body weight, a “failure” is observed in the histogram of the corresponding unaccounted weight category of children with very low body weight. In the long-term dynamics of the structure of deceased children by body weight, there is a decrease in the number of “low weight” children with an increase in the number of children of physiological body weight, which is what we have observed in Russia after 2000.

3. Estimation of infant mortality in Russia in 2011 using the method of Dellaportas G. J.

Authoritative foreign studies use a methodology for a reasonable determination of the real indicator of metabolic syndrome, based on the natural ratio of mortality rates in different periods of the first year of a child’s life. In 1972, Dellaportas G.J. proposed a method for assessing metabolic syndrome in countries where under-registration of deaths of children in the first year of life is presumably possible. The author proceeded from the fact that at the age of 181-355 days (6 months-1 year), child mortality is registered quite completely and does not depend on differences in the registration procedure and the use of different live birth criteria. According to 16 countries in which registration by international standards has been carried out for more than 30 years, and therefore can be considered reliable, correlations have been identified between mortality rates on 1 day of life, 1-6, 7-27, 28-180 days (I-IV periods), on the one hand, and on 6- 12 months (V period), on the other. Next, the author derived a formula for determining the real level of infant mortality in the country for which an examination of the completeness of registration is being carried out:

Y=y 1 +v * (x – x 1 ) , Where

U- estimated mortality rate of I-IV age groups;
y 1- average mortality rate for 16 countries in age groups I-IV;
V- correction factor for each age group;
X-mortality rate at VI-XII months of life in the country being tested;
x 1- mortality rate in the VI-XII months of life on average in 16 countries.

Thus, to calculate MS according to Dellaportes, the following data is required: the number of children born and died (separately boys and girls) by age periods of the first year of life.

Table 3 presents all these data for the Russian Federation in 2011.

Next, mortality rates are calculated by age periods of the first year of life by dividing the number of deaths by the number of children in a given age group and multiplying by 1000. The method proposed by the author is based on calculating the indicator taking into account the sex of the child - separately for boys and girls, which makes it difficult to apply the method in practice .

Table 3 shows calculations of estimated MS indicators in the Russian Federation using the Dellaportas method. Average mortality rates for 16 countries in age groups I-IV (y 1) and the adjustment factor for each age group (c) are established constant values. The next column (RP) contains the calculated data. Next, the average indicator data (y 1) is subtracted from the calculated indicators (RP) and entered into the column (x-x 1). The OP indicator is obtained by adding y 1 + b * (x-x 1), from which the calculated indicators (RP) are subtracted. In practice, a ready-made formula for calculating indicators according to Dellaportas G. J. is used.

Table 3

MS assessment using the Dellaportas G. J. method (RF, 2011)

Table 4 shows calculations of estimated MS indicators in the Russian Federation using the Dellaportas G. J. method.

Table 4

Calculation of MS using the method of Dellaportas G. J. (RF, 2011)
Initial data for calculating MS according to Dellaportas G. J.

Table 4 shows that the undercount of mortality among boys was 8.94‰, among girls - 6.13‰, and in Russia as a whole - 7.6‰. Thus, the infant mortality rate in Russia in 2011 should be 15 per 1000 live births (instead of the registered level of 7.4‰).

In addition to the given method by Dellaportas G.J., it is possible to reproduce (reconstruct) the MS indicator: by the ratio of neonatal and postneonatal mortality; in terms of life expectancy at birth; according to the probability of dying before the age of 5 and others. We propose a method we have developed for reconstructing the MS indicator based on the level of postneonatal mortality.

4. Reconstruction of the infant mortality rate based on the postneonatal component

As is known, there are two main mechanisms for underestimating the infant mortality rate - firstly, the “transfer” of dead children into stillborns, and secondly, the attribution of a deceased child to “fetuses” not registered in the MS and perinatal mortality.

It is clear that both of these mechanisms of data falsification can be applied only to children in the first days of life, and it is thanks to this that early neonatal mortality is decreasing at an accelerated pace. (Although this contradicts the known biological patterns of changes in MS). And the steady trend of reducing infant mortality due mainly to children in the first week of life and the relative increase in late losses (“aging” of MS) ​​is nonsense in healthcare, and the factors explaining such a distortion of the structure of MS are clear and known to all participants in the process - doctors, statisticians, healthcare organizers, etc.

Since the most reliably recorded component of MS is postneonatal mortality, and its share in Russia is significantly higher than in the EU countries, and exceeds to the maximum extent the indicator in the EU compared to other components of MS, there is no reason to believe that the other component of MS - neonatal - is different from the level in European countries in a more favorable direction. Moreover, it is neonatal mortality that is more “controllable” - if it is appropriate to use this term, meaning its greater susceptibility to directive (subjective) influences - an imperative reduction to ensure positive dynamics of MS and achieve the target indicator.

Based on the fact that the level of infant and neonatal mortality in Russia is artificially underestimated due to early neonatal losses and at the same time considering the indicators of post-neonatal losses and late neonatal mortality to be more reliable, it is possible, focusing on the proper ratio of post-neonatal and neonatal losses in the EU countries as more correct, reproduce (reconstruct) the corresponding indicators of infant and neonatal mortality.

As is known, the principle of recreating the infant mortality rate, proposed by Dellaportas G.J., is based on using the most recent component of mortality of children in the first year of life at the age of 181-355 days (6-11 months) to calculate it as the most reliably recorded. Using this principle, we propose a method for verifying the infant mortality rate based on the indicator of all postneonatal mortality (28-365 days), and reconstructing neonatal mortality based on the level of late neonatal losses (7-27 days), which are the most reliable in terms of recording newborn deaths and minimally susceptible to falsification.

From our point of view, reconstructing the infant mortality rate according to the postneonatal component has an advantage over the Dellaportas G.J. method, since only 10-11.7% of children die during the second half of life out of all those who died in the first year, which undoubtedly reduces the accuracy of the obtained result, disseminated for all infant mortality. At the same time, the proportion of deaths after the first month of life (in the postneonatal period) is significantly higher - ranging from 33% in countries with low infant losses (including EU countries) to 60% in areas with a high mortality rate of MS. In Russia, the number of deaths after the first month of life increases from 37.1% in 1990. up to 43% of the number of infant deaths in 2010 (Table 5).

Distribution of the number of deceased children by month of the first year of life in 1990-2010.

the sum of the lines does not give a total due to deceased children of unknown age

Source - statistical collections of the Ministry of Health of the Russian Federation "Mortality of the population of the Russian Federation in 2000, statistical materials" M., 2001; “Medical and demographic indicators of the Russian Federation, statistical materials”, M., 2006-2011.

It is clear that this increases the reliability of the result obtained, which applies to all infant mortality. Applied Dellaportas G.J. separate calculation of deaths by gender - given the actually stable ratio of the number of dead boys and girls - is not a determining factor, while at the same time significantly complicating the application of the method in practice. And in general, that's enough complex formula author and very labor-intensive data analysis makes this method (despite its usefulness for scientific and special demographic research) difficult to access for practical purposes.

At the same time, the fundamental difference in the accuracy of registration of deceased newborns in the first week of life and the second or fourth week, as well as infants older than a month, determines the advisability of using this particular data to verify infant and neonatal mortality rates. In the postneonatal period (28-365 days) and even in the late neonatal period (7-28 days), there is practically no possibility of falsifying data on the number of deceased children - since the possibility of their “transfer” to stillbirths is completely excluded and the likelihood of underestimating the child’s body weight is minimized (i.e. e. “transferring” it to “miscarriage”) - since the baby’s body weight for seven or more days of life has already been repeatedly registered not only in the maternity ward, but also in the neonatal department, intensive care unit, by various specialists and parents, in various documents, observation cards etc.

Based on the indicators of postneonatal losses (over 27 days of age) and late neonatal losses (over 7 days, more reliable in comparison with the first week of life), and taking as a kind of “standard” the ratio of these components in the European Union countries (Tables 6, 7 ), we propose our own model for recalculating the MS indicator according to the level of postneonatal losses, and neonatal mortality - according to the indicator of late neonatal losses - by compiling the appropriate proportion.

If the postneonatal mortality rate of 1.4 in the EU corresponds to an infant mortality rate of 4.1, then with a postneonatal mortality rate in Russia of 3.3, the infant mortality rate should be 9.8, which is higher than the registered one by 28.5%. The coefficient for calculating infant mortality based on the postneonatal component is 2.96. (Coefficients and indicators in the tables were calculated with greater accuracy - up to the second digit, excluded in this table 6).

Table 6

Infant and post-neonatal mortality rates in the Russian Federation and the EU; calculation of the verified infant mortality rate in the Russian Federation

According to the corresponding calculation, the neonatal mortality rate in 2010 was not 4.2 per 1000 live births, but 5.1 (20.9% higher). The conversion factor is 3.63 for late neonatal mortality (1.4 in 2010).

It is characteristic that in the dynamics over the presented 15 years, the difference between the reconstructed and officially registered indicator tends to increase - most clearly identified in relation to neonatal mortality.

Table 7

Indicators of neonatal and late neonatal mortality in the Russian Federation and the EU; calculation of the verified neonatal mortality rate in the Russian Federation

Analysis of the dynamics of officially registered and reconstructed indicators of infant and neonatal mortality in Russia - in comparison with the corresponding data for the countries of the European Union - in 1996-2010. confirms the thesis about the increase in the level of data falsification in recent years (which was shown by the increasing rate of decline in infant and neonatal mortality rates - to unrealistic values).

Thus, to verify the indicators registered in the regions, you can use the proposed method for reconstructing the infant mortality rate (based on the ratio of the post-neonatal component in the structure of infant losses) and neonatal mortality (based on the level of late neonatal mortality).

Figure 12 shows the dynamics of officially registered and reconstructed indicators of MS in Russia - in comparison with the corresponding data for the countries of the European Union - in 1995-2010.

Rice. 12. Dynamics of infant mortality rates in the Russian Federation, EU countries (according to WHO/ERB) and the reconstructed indicator for the level of post-neonatal mortality (per 1000 live births)

As can be seen in the figure, the curves of officially registered and reconstructed indicators of MS in Russia - in comparison with the corresponding data for the countries of the European Union - in 1995-2010. “diverge” in dynamics, which confirms the thesis about the increase in the degree of data falsification in recent years (which was shown by the increasing rate of decline in MS indicators - to unrealistic values, distortion of the age and weight structure of the deceased, etc.).

Thus, to verify the indicators registered in the regions, you can use the proposed method for reconstructing the infant mortality rate (based on the ratio of the post-neonatal component in the structure of infant losses) and neonatal mortality (based on the level of late neonatal mortality).

When comparing the officially registered indicator of MS and the reconstructed one, it was revealed that in Russia as a whole in 2010 the indicator instead of 7.5‰ reaches the level of 9.7‰ (i.e. 28.9% higher). At the same time, in some regions the level of MS according to the reconstructed indicator exceeds the officially registered one by 50-80% (Irkutsk and Kemerovo regions, Trans-Baikal Territory, Republic of Buryatia) and reaches 14-20‰, exceeding the level in Russia by 1.5-2 times (Table .8).

Table 8

Regions with the highest reconstructed infant mortality rates compared to those officially recorded in 2010.

At comparative analysis The degree to which the reconstructed MS indicator exceeded the officially registered one revealed regions where the difference in indicators reached a double value - for example, in the Chuvash Republic - 10.8‰ according to the reconstructed indicator, while 5.4‰ according to the officially registered one in 2010 (Table 9).

Table 9

Regions with the maximum excess of the reconstructed infant mortality rate over the officially registered one in 2010.

At the same time, in all analyzed regions (except for the Irkutsk region), the officially registered level of metabolic syndrome was lower than the national level, mainly due to low neonatal mortality, while post-neonatal mortality in 7 out of 12 regions exceeded the figure in Russia.

The second feature of regions with incorrect registration of MS is that in 10 regions (except for the Trans-Baikal Territory and Tyumen region) in 2010 there was a decrease in the officially registered MS indicator compared to 2009. (most pronounced in the Kaliningrad region, where there was a decrease in the indicator by 1.6 times in one year - from 7.1‰ in 2009 to 4.5 in 2010).

Thus, analysis of MS using the reconstructed indicator allows us to identify signs of incorrect registration of MS.

5. Methodology for calculating infant mortality in accordance with the criteria for live births and stillbirths recommended by WHO

Russia's transition to the criteria for live births and stillbirths recommended by WHO is accompanied by a change in the methodology for calculating infant mortality rates and its components (neonatal, early and late, as well as postneonatal).

As is known, until March 2012, in the registry office and in state statistics, children with a body weight at birth of 1000 g or more (or, if the weight is unknown, a body length of 35 cm or more, or those born at a gestational age of 28 weeks or more) were taken into account among those born alive. ), including live births weighing less than 1000 g in multiple births. At the same time, all births weighing from 500 to 999 g were subject to registration with the civil registry office in cases where they lived after birth for more than 168 hours (7 days).

In accordance with the Order of the Ministry of Health No. 1687 of December 27, 2011, “On medical criteria for birth, the form of the birth document and the procedure for its issuance,” which came into force on March 15, 2012 (after registration of the Order with the Ministry of Justice, No. 23490), new medical criteria for birth have been approved, which include: 1) gestational age of 22 weeks or more; 2) the child’s body weight at birth is 500 grams or more (or less than 500 grams in case of multiple births); 3) the child’s body length at birth is 25 cm or more (if the child’s body weight at birth is unknown).

In accordance with the new criteria for live births and stillbirths, all births with a body weight of 500 g or more (or less than 500 g in case of multiple births) with a body length at birth of 25 cm or more (if the child’s body weight at birth is unknown) must be registered with the civil registry office. or if your pregnancy is 22 weeks or more.

When calculating infant mortality rates for all age periods of a child’s life in the first year, the numerator takes into account the number of deaths of children of the corresponding age, including those born weighing 500 g or more. The denominator takes into account the number of live births, also taking into account live-born children weighing 500 g or more.

In 2011, 1,796,629 children weighing “1000 g or more” and 5,106 children with extremely low body weight (ELBW) 500-999 g were born alive, which amounted to a total of 1,801,735 live births. 13,168 children with a body weight of “1000 g or more” died before the age of one year, in addition to those born with ELBW (500-999 g) who lived for more than 168 hours (7 days).

Of the 5,106 EMT children born alive, only 2,753 died (of which 2,371 were in obstetric hospitals and 382 in children’s hospitals), including 2,251 children who died at the age of 168 hours (0-6 days) (2,106 in obstetric hospitals and 145 in children’s hospitals ), and it was they (and only they) that were not taken into account in the MS indicator - according to the previous criteria for recording births and deaths. The number of deceased EMT children who “survived” 7 days after birth was (2753-2251=502 children), who were already included in the 13168 as those who survived perinatal age, accounting for 3.8% of the number of deaths according to the old accounting criteria.

Consequently, the number of all deaths under one year of age today should increase from 13,168 (according to the old accounting criteria) by 2,251 deaths of ENMT children who died at the age of 0-6 days of life, not included in the previous MS indicator. The sum of all deceased infants according to the new accounting rules will be 15419 (i.e. 13168+2251) children. The number of deceased EMT children (2,753 children) will account for 17.8% of all deaths (15,419).

The infant mortality rate, taking into account the deaths of EMT children, will be 8.56 per 1000 live births, which is higher than the previous indicator (7.33‰ according to the given calculation data - 13,168 deaths per 1,796,629 live births) by 16.8%.

The early neonatal mortality rate will be: 4811 (the number of deaths weighing “1000g or more” according to form A05) plus 2251 children who died at the age of 0-6 days weighing “500-999g” (2106 in obstetric hospitals, according to form GSN No. 32, and 145 children - in children's hospitals, according to GSN form No. 14), i.e. 7062 children. The indicator of early neonatal mortality will be the quotient of 7062 divided by 1801735, multiplied by 1000 = 3.92‰ (i.e., it will increase by 46.3% compared to the indicator of 2.68 when taking into account only children weighing “1000 g or more "). Neonatal mortality will increase from 4.25‰ to 5.48‰, or by 29.0%.

It is clear that the rate of early neonatal mortality increases the most (by 46.3%), to a lesser extent - neonatal (by 29.0%) and to an even lesser extent - infant mortality (by 16.8%).

Late and postneonatal mortality rates will not change, since they previously included the number of deaths of children weighing less than 1000 g who survived the perinatal period (168 hours).

The stillbirth rate will increase to the maximum - more than twice - since the number of stillbirths weighing 500-999g (10,586 in 2011 - according to the GSN form No. 32) exceeds the number of stillbirths weighing “1000g or more” - 8181 according to Form No. 32 and 8109 according to form A05. (The discrepancy between departmental and state statistics regarding the number of stillbirths is due to incomplete registration of stillbirths in the registry office.) At the same time, it is obvious that in conditions of increased control over the reliability of registration of signs of live birth, a decrease in the number of stillbirths is possible with a simultaneous increase in deaths in the early neonatal period.

And it is not for nothing that an indicator of “fetoinfantile losses” was proposed abroad, including the sum of stillbirths and deaths in the first year of life . Unfortunately, this indicator is not widely used in Russia and is used only in scientific research.

Thus, summing up the given data, we can formulate an algorithm for assessing the reliability of MS registration as follows.

Algorithm for assessing the reliability of registration and calculating the MS level

1. Analysis of the overall MS indicator: fluctuations over the years no more than 5%; ratio of shares of early neonatal, neonatal and postneonatal mortality; proportion of deaths in the first 24 hours after birth.
2. Analysis of child mortality by weight groups: the proportion of live and stillborn births weighing 500-999g and 1000-1499g among all newborns; the proportion of children of these weight groups among those born alive; among stillborns; ratio of living and dead; the share of “low birth weight” children in the structure of MS; proportion of children who died in the first 24 hours; proportion of children who died in the first 168 hours.
3. Analysis of the structure and level of perinatal losses: ratio of early neonatal mortality and stillbirths by weight groups; the ratio of full-term and premature infants in perinatal mortality.
4. Calculation of the proper MS level using various methods: taking into account the “transfer” of deaths under the age of 0-6 days into the category of stillbirths; taking into account the proper number of deaths by weight group; taking into account deceased children ENMT; according to the method of Dellaportas G.J.; calculation of infant mortality based on the postneonatal level.

Conclusion

In total for the post-Soviet period 1991-2011. in Russia - according to Rosstat, 31,162,646 children were born alive, or a fifth (21.8%) of the total population of today's Russia. 420,389 children died during the first year of life. The number of stillbirths over these years amounted to 202,894. Fetoinfantile losses (those born still and those who died before one year old) amounted to 623,283 children - 20.3 per 1000 births (or 2.0%). Those. We have lost every 50th person over the past 20 years - due to those who died in the first year of life or were stillborn. From the perspective of potential demography - taking into account “failed births in subsequent generations” - this is an unacceptably high, irreversible loss of the country’s reproductive potential, and in the overwhelming majority of cases, death was preventable. Of all 420,389 children who died before one year of age, 186,259 children (44.3%) died in the first week of life, and this determines the particular importance of obstetric services in reducing infant mortality.

It is clear that in order to identify true reserves for improving the situation and developing a strategy for actually reducing MS, an objective assessment of the situation with an analysis of the structure and causes of death of children and viable fetuses is necessary. At the same time, at present, we regret to note the imperfection of statistics on perinatal and infant mortality, as well as the unreliability of the information provided on both the number of children who died and the causes of their death. The results of monitoring infant mortality indicate the unreliability of the information provided, and the degree of unreliability of the data is increasing over time.

Observed during 1991-2010. the predominant decrease in early neonatal mortality by 68.5% with a decrease in neonatal mortality by 61.8% and infant mortality by 57.9% is accompanied by a disproportion in the mortality structure by age of deceased children, gestational age (increase in the proportion of full-term ones), body weight of newborns (relative growth of children with physiological body weight with a decrease in low birth weight), which indicates significant violations in the registration of deceased children.

At the same time, there are quite objective and clearly detectable signs of violations in the registration of infant deaths - according to the age, weight, nosological, gestational structure of child mortality, the rate of change in indicators, the ratio of different components, as well as the degree of correspondence of the dynamics of reproductive losses to their structure. The most important sign of the unreliability of the recorded MS level is the unrealistic rate of decline in the indicator. In this regard, it should be noted the importance of ensuring proper control of the reliability of MS indicators as a vital fact that determines the prospects for the development and effectiveness of the maternal and child health service.

And today, with the transition to new criteria for recording live births, that very “hour-X”, or moment of Truth, arises when it is possible and should be converted to recording real indicators of reproductive losses and MS. And the relevance of the problem of reliable registration and control of records of deceased children does not disappear in the new conditions.

It must be borne in mind that the unreliability of statistical data is always obvious - due to indirect signs, structural disproportions in the number of live and stillborns, disturbances in the distribution of deceased children by age, dissociation in the weight structure of the deceased, etc. And those “improved” indicators that are provided by incorrect registration of the dead to achieve target indicators are in fact always visible, just as the methods of data falsification used are also obvious.

As is known, the level of infant and neonatal mortality in Russia is artificially lowered at the expense of children 0-6 days of life - due to their “transfer” either into stillborns or into unaccounted “fetuses” (“miscarriages”), and the indicator of post-neonatal losses is more reliable, than the neonatal mortality rate.

And it is on the basis of using the postneonatal component as the most reliably recorded that the proposed method for reconstructing the true level of infant mortality is based. The mechanism presented in this work for monitoring the reliability of the information provided on infant mortality can be used to realistically assess the completeness and quality of recording of infant deaths.

Bibliography

1. Albitsky V.Yu., Nikolskaya L.A., Abrosimova M.Yu. Fetoinfantile losses. Kazan. 1997. 168 p.
2. Baranov A.A., Albitsky V.Yu. Mortality of the Russian child population. M.: Literra; 2007. 328 p.
3. Baranov A.A., Ignatieva R.K. The problem of underestimation of perinatal losses / Mortality of the child population of Russia. Series "Social Pediatrics". Issue 1. M.: Literra; 2007. pp. 45-59.
4. Goryainova I.L. Medical and social problems of infant mortality, ways to reduce and prevent it. Author's abstract. dis. Ph.D. M. 2010. 24 p.
5. Order of the Ministry of Health and Social Development of Russia No. 1687 of December 27, 2011. (registered with the Ministry of Justice of the Russian Federation on March 15, 2012 No. 23490) On the medical criteria for birth, the form of the birth document and the procedure for its issuance [Internet]. URL: http://www.minzdravsoc.ru/docs/mzsr/orders/1245. Date of visit November 12, 2012.
6. Order of the Ministry of Health of the Russian Federation dated December 4, 1992. No. 318 "On the transition to the criteria for live birth and stillbirth recommended by the World Health Organization." [Internet]. URL: http://base.consultant.ru/cons/cgi/online.cgi?req=doc;base=MED;n=1971 (Date of visit November 12, 2012).
7. Sorokina Z.H. Problems of transition of domestic healthcare to international criteria for registering children with extreme body weight // Problems of healthcare management. 2010. No. 5. pp. 35-40.
8. Starodubov V.I., Sukhanova L.P., Sychenkov Yu.G. Reproductive losses as a medical and social problem of demographic development of Russia // Social aspects of population health [Electronic scientific journal]. 2011. No. 6..)
9. Starodubov V.I., Tsybulskaya I.S., Sukhanova L.P. Maternal and child health protection as a priority issue modern Russia//Modern medical technologies. 2009. No. 2. pp. 11-16.
10. Sukhanova L.P. Optimizing perinatal care as most important factor Preserving the health of the population of Russia: Dis. ...Dr. med. Sci. M. 2006. 335 p.
11. Sukhanova L.P., Sklyar M.S. Child and perinatal mortality in Russia: trends, structure, risk factors // Social aspects of population health [Electronic scientific journal]. 2007. No. 4. [Internet]..
12. Decree of the President of the Russian Federation No. 825 of June 28, 2007. (as amended on April 28, 2008 and May 13, 2010-No. 579) “On assessing the effectiveness of the activities of executive authorities of the constituent entities of the Russian Federation.” [Internet]. URL: http://www.referent.ru/1/120081 (Date of visit November 12, 2012).
13. Pediatric 1990;(12):34-56.
14. 1977;125(6):674.
15. Health Services Reports 1972;87(3):275-281.

References

1. Albitskiy V.Yu., Nikolskaya L.A., Abrosimova M.Yu. Fetoinfantilnyye poteri. Kazan. 1997. 168 p.
2. Baranov A.A., Albitskiy V.Yu. Smertnost children's naseleniya Rossii. Moscow: Literra; 2007. 328 p.
3. Baranov A.A., Ignatyeva R.K. Problema nedoucheta perinatalnykh poter. In: Smertnost children's naseleniya Rossii. Seriya "Sotsialnaya pediatriya". Vypusk 1. Moscow: Literra; 2007. P. 45-59.
4. Goryainova I.L. Mediko-sotsialnyye problemy mladencheskoy deathnosti, puti eye snizheniya i profilaktiki. . Moscow. 2010. 24 p.
5. Prikaz Minzdravsotsrazvitiya Rossii No. 1687 from December 27, 2011. (zaregistrirovan v Minyuste RF March 15, 2012 No. 23490) "O meditsinskikh kriteriyakh rozhdeniya, forme dokumenta o rozhdenii i poryadke eye vydachi" ["On health criteria of the childbirth, the form of the birth certificate and the order of its registration" , the Regulation of the MoH&SD of the RF No. 1687 of December 27 2011]. . 2011. Available from: http://www.minzdravsoc.ru/docs/mzsr/orders/1245
6. Prikaz Ministerstva zdravookhraneniya RF from 04 December 1992 g. No. 318 "O perekhode na rekomendovannyye Vsemirnoy Organizatsiyey Zdravookhraneniya kriterii zhivorozhdeniya i mertvorozhdeniya." . 1992. Available from: http://base.consultant.ru/cons/cgi/online.cgi?req=doc;base=MED;n=1971
7. Sorokina Z.Kh. Problemy perekhoda otechestvennogo zdravookhraneniya na mezhdunarodnyye kriterii registratsii detey ekstremalnoy massy tela. Problemy upravleniya zdravookhraneniyem 2010;(5):35-40.
8. Starodubov V.I., Sukhanova L.P., Sychenkov Yu.G. Reproduktivnyye poteri kak mediko-sotsialnaya problema demograficheskogo razvitiya Rossii. Sotsialnyye aspekty zdorovya naseleniya. 2011;(6). . Available from: http://site/content/view/367/27/lang,ru/
9. Starodubov V.I., Tsybulskaya I.S., Sukhanova L.P. Okhrana zdorovya materi i rebenka kak prioritetnaya problema sovremennoy Rossii. Sovremennyye meditsinskiye tekhnologii 2009;(2):11-16.
10. Sukhanova L.P. Optimizatsiya perinatalnoy pomoshchi kak vazhneyshiy faktor sokhraneniya zdorovya naseleniya Rossii. Moscow. 2006. 335 p.
11. Sukhanova L.P., Sklyar M.S. Detskaya i perinatalnaya smertnost v Rossii: tendentsii, struktura, faktory riska. Sotsialnyye aspekty zdorovya naseleniya. 2007;(4) . Available from: http://site/content/view/46/30/
12. Ukaz President RF No. 825 dated June 28, 2007. (v redaktsii from 04/28/2008 i 05/13/2010-No. 579) "Ob otsenke effektivnosti deyatelnosti organov ispolnitelnoy vlasti subyektov RF" ["On assessment of efficiency of executive bodies activity in the subjects of the Russian Federation", the Regulation of the President of the RF No. 825 of June 28, 2007]. . 2007. Available from: http://www.referent.ru/1/120081
13. Blondel B., Breart G. Mortalite feto-infantile. Evolution, causes et methods d’analyse. Encycl. Med. Chir. (Paris-Franct). Pediatric 1990;(12):34-56.
14. Ewerbeck H. Neue Definition bei der Saulingssterblichkeit. Monatsschrift fur Kinderheilkunde 1977;125(6):674.
15. Dellaportas G. J. Correlation-based estimation of early infant mortality. Health Services Reports 1972;87(3):275-281.
16. Mathews TJ, MacDorman MF. Infant mortality statistics from the 2007 period linked birth/infant death data set. National vital statistics reports. . 2011;59(6). . Available from: www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_06.pdf.

“Infant mortality in Russia is outrageous. The number of children in our country is declining every year, and in terms of child life expectancy we rank 150th out of 250 countries in the world” - Larisa Nikovskaya, expert at the Institute of Sociology of the Russian Academy of Sciences (1)

1. Official government statistics show infant mortality rates in Russian Federation between 2001 and 2005

From Letter of the Ministry of Health and Social Development of the Russian Federation dated February 14, 2007 N 1065-ВС “ON INFANT MORTALITY IN THE RUSSIAN FEDERATION in 2001-2006”:

“For the analyzed period 2001-2005. infant mortality in the Russian Federation decreased by 25%, from 14.6 in 2001 to 11.0 per 1000 live births in 2005. The number of deaths of children under 1 year from 2001 to 2005 decreased by 3031 - in 2001 19,104 children died, in 2005 - 16,073.
...The process of reducing infant mortality occurred more intensively in the Ural Federal District - by 35%, in the rest federal districts infant mortality decreased by 23-27%.
In the context of the constituent entities of the Russian Federation, the most significant decrease in infant mortality for the period 2001-2005. took place in the Chita region by 52%, the Republic of Kalmykia - by 51%, the Saratov region and the Karachay-Cherkess Republic - by 46%, in the Tambov, Kirov, Yaroslavl regions and the Chuvash Republic - by 45%.
...High infant mortality rates in 2005 in the Siberian and Far Eastern Federal Districts - 12.3 and 15.5 cases per 1000 live births, respectively - were due to high infant mortality rates in the Sakhalin region - 14.4, Amur region - 18.7, the Republic Tyva - 19.3, the Republic of Khakassia - 17.5, the Altai Republic - 14.3 per 1000 live births.
...The most pronounced dispersion of infant mortality rates across territories occurs in the Southern Federal District - from the lowest rate of 7.6 in the Republic of Kalmykia to the highest - 25.7 per 1000 live births in the Republic of Ingushetia.
...In most constituent entities of the Russian Federation from 2001 to 2005, infant mortality rates did not have a stable trend and fluctuated significantly from year to year, exceeding the annual increase or decrease by more than 15%.
...The age factor is of decisive importance in the mortality of children under 1 year of age.
...At the age of 0-3 months. 76.4% of children die between 3-6 months. - 12.7%, from 6-9 months. - 6.7%, from 9-12 months. - 4.2% (of all children who died under the age of 1 year).
...The first place in the causes of death of children under 1 year of age in all constituent entities of the Russian Federation is occupied by certain conditions that arise in the perinatal period; the second is congenital anomalies (defects).
...Certain conditions that arise in the perinatal period not only occupy a leading place in the causes of infant mortality, but are also at the origins of most childhood diseases and disabilities.
...In 2005, 44.7% of all children under the age of 1 year died from “conditions of the perinatal period”; the infant mortality rate was 49.1 per 10,000 live births...
...For the period 2002-2005. in all federal districts there was a decrease in infant mortality from conditions arising in the perinatal period. In the context of constituent entities of the Russian Federation, the spread of indicators is quite significant, from 27.0-28.0 in the Oryol, Yaroslavl regions and St. Petersburg to 71.0-74.0 per 10,000 live births in the Amur, Nizhny Novgorod and Rostov regions and up to 185. 9 in the Republic of Ingushetia.
...The reason for such a difference in infant mortality rates from “perinatal causes” can be partially explained by a subjective approach to assessing the causes of death due to the low percentage of autopsies of deceased children from 7 days to 1 year or the “lumping” of deaths from respiratory diseases, digestive diseases, and infectious diseases into the group causes of death from conditions arising in the perinatal period.
... Among the conditions that arise in the perinatal period and are the cause of death in children under 1 year of age, the first place is occupied by respiratory disorders of newborns - 9.6 per 10,000 births ..., the second place is hypoxia and asphyxia during childbirth - 5.4 per 10,000 births.” (2)

2. Member of the Public Chamber Leonid Roshal in his speech in July 2006 at a meeting of the Russian government, i.e. before the above letter appeared, stated the following:

“Infant mortality rates in Russia are underestimated by approximately two times... To put it mildly, infant mortality rates are inaccurate, and the Ministry of Health knows this,” Interfax reports.
Leonid Roshal noted that low birth weight children - up to 500 grams - are not registered in Russia. “If they were registered, as in the West, the mortality rates would double – to 20, and not to 11 (died babies per thousand born),” the doctor emphasized. According to Roshal, such incorrect information is presented to the country's leadership while the whole world knows about this problem in Russia.
Roshal said that the presented draft of the federal target program “Children of Russia” will not be able to radically change the situation. “It’s not enough to give birth, you need to prevent the child from dying, and to save the child, maternity hospitals need a well-functioning resuscitation service,” he emphasized. At the same time, there are supposed to be four intensive care beds per thousand births, while in Russia there are half as many of them. The cost of creating such a bed is 675 thousand rubles, now there are 3.5 thousand beds missing.” (3)

Doctor Leonid Roshal’s doubts are confirmed by calculations presented in comparison with Western countries: the number of deaths of infants under the age of 1 year is 25.7 per 1 thousand live births, in contrast to the officially stated 11:

“...Despite the fairly steady decline in infant mortality occurring in Russia (that is, the mortality rate of children under 1 year of age), it remains significantly higher than in Western countries. Number of deaths of children under 1 year of age per 10,000 live births:
Russia -257.2; EU countries - 97.2; USA - 145; Japan-67.7..."
[Note: Russia - 2002, other countries - 1999. Calculated by E. Andreev for Russia according to state statistics, for foreign countries based on the WHO Mortality Data Base] (4)

3. Opinion of Doctor of Medical Sciences, professor, head of the laboratory of the Scientific Center for Children's Health of the Russian Academy of Medical Sciences Rimma Ignatieva on stillbirth statistics:

“...It was only in 1992 that we finally recognized that the heartbeat, pulsation of the umbilical cord and movements of the voluntary muscles of the child, along with breathing, are signs of life. But that, unfortunately, is where it all ends. The current order of the Ministry of Health of the Russian Federation No. 318 actually legitimizes the possibility of juggling the most important demographic indicators. Unlike the rest of the world, in Russia the perinatal period begins not from the 22nd week of pregnancy and the fetal weight of 500 g, but from the 28th and 1000 g.”
“A child weighing up to 1000 g who died in the first week of life is not registered in the registry office, he is not included in the statistics. There is not even a law obliging doctors to fight for the lives of such children. Nobody really struggles, with the exception of perinatal centers. Now let's look at the statistics. According to official data in 2000 in Russia, 14,743 out of 18,111 children weighing from 500 to 1000 g, that is, 81.4%, were allegedly born without signs of life. Let me doubt this! It has been proven that childbirth at 22-28 weeks of pregnancy is most often caused by a pathology that does not lead to intrauterine fetal death. And his future fate depends on nursing.”
“I think that at least 10 thousand children were born with signs of life and required intensive resuscitation measures in the delivery room. However, due to the lack modern equipment they were simply recorded as stillborn so as not to spoil the statistics.”
“Now let’s take another “interesting” indicator. During the year, 18,111 children were born weighing from 500 to 1000 g, 7,686 children weighing 100-1500 g and 19,163 - from 1500 to 2000. Are you not surprised by the failure in the second category? Let me explain: obstetricians-gynecologists simply underestimate the weight of premature babies... According to the laws in force in Russia, children born from 22 to 28 weeks of pregnancy and weighing less than 1000g are considered late miscarriages. No one is responsible for their lives... Therefore, doctors quietly “transfer” children from the borderline group of 1000 - 1200 g to the lower category without rights... Our very premature children do not have basic civil rights, even the right to medical care. As part of compulsory health insurance, funds are allocated only to registered citizens... And an unregistered child “de jure” simply does not exist...” “Moskovskaya Pravda” November 9, 10 and 14, 2006 (5)

So, the official data presented indicate that 16,073 babies died in Russia in 2005, i.e. 11 babies for every thousand born alive. Including “from conditions of the perinatal period,” 44.7% of children died from all deaths of children under the age of 1 year. And this means that compared to 1998, the mortality rate of children from perinatal causes has increased:

“Among the causes of infant mortality in 1998, the leading causes were perinatal causes (42.4%) and congenital malformations (24.6%).” (6)

4. HELP (7)

“...PERINATAL PERIOD (synonymous with perinatal period) - the period from the 28th week of pregnancy, including the period of childbirth and ending 168 hours after birth. According to the WHO classification, adopted in a number of countries, P. p. begins at the 22nd week of pregnancy (when the fetal weight reaches 500 g or more).
Duration P.p. varies and depends on a number of factors that determine the onset of labor. For example, in case of premature birth in a child born at 28 weeks of pregnancy, P. is made up of the period of childbirth and the first seven days of life. The longest duration of P. p. is observed during postterm pregnancy. P. p. is the most important stage that determines the further physical, neuropsychic and intellectual development of the child.
In the perinatal period, the maturation of functions necessary for the independent existence of the newborn’s body occurs. According to P.K. Anokhin, in the fetus by the 28th week of intrauterine development, scattered local reactions (see Fetus) are combined into functional systems (digestive, respiratory, cardiovascular, etc.).
The likelihood of developing serious neurological and somatic disorders in the fetus and newborn in P.p. significantly greater than in other periods. During the 28th to 40th week of pregnancy, the fetus is prepared for childbirth and extrauterine life. Its functional systems at the time of birth, although imperfect, are sufficient to ensure viability during childbirth, when the fetus experiences the effects of the expelling forces of the uterus and a lack of oxygen. During physiological labor, there is a pronounced activation of the pituitary-adrenal system of the woman in labor and the endocrine glands of the fetus, which is manifested by an increase in the concentration of cortasol and growth hormones, especially pronounced during fetal hypoxia.
Childbirth has a significant impact on the state of the fetal functional systems and is a kind of test of their biological reliability. The nature of labor and the method of delivery determine the degree and nature of adaptation reactions of the fetus and newborn. Thus, during vaginal delivery, the fetus experiences consistent activation of the functions of the adrenal cortex, thyroid gland and pituitary gland. In newborns delivered by cesarean section, there is simultaneous activation of the functions of the adrenal cortex and thyroid gland, increased release of red blood cells and leukocytes into the blood vessels in the first minutes after birth. In cases where the fetus does not experience the effects of physiological labor (with a caesarean section before the onset of labor), the respiratory system does not turn on in a timely manner; the formation of breathing occurs without straining the function of external respiration, as a result of which it becomes adequate only at the end of the first hour of life. When the fetus experiences particularly intense effects during childbirth (during rapid labor, acute short-term hypoxia), the adaptive and compensatory reactions of the respiratory system, hematopoiesis and endocrine system are most pronounced. Mild and short-term hypoxia promotes an earlier development of fetal adaptation reactions. Severe and prolonged hypoxia, on the contrary, leads to inhibition of adaptation reactions. Primary adaptation to the environment is vital important systems in a full-term newborn it ends in the first 168 hours of life. In premature babies, the processes of adaptation to the environment proceed more slowly: they are less perfect, the less mature the fetus is at the time of birth. In children with low birth weight (1000-1500 g), the adaptation period is extended to 3-4 weeks.
The pathology of P. p. is associated with unfavorable factors affecting the period of intrauterine development of the fetus, starting from the 28th week of pregnancy, the pathology of childbirth, as well as with adverse environmental influences in the first 168 hours of life ... "

5. “Indeed, today (October 2004) half of all child deaths occur in the first year of life,” a leading specialist at one of the Moscow Centers for the Protection of Maternal and Child Health told RBC daily. – At the same time, in the structure of perinatal (up to one year of age) losses, stillbirth is 51.5%, and 48.5% of the number of children who die under 1 year of age die in the first days of life. In the first hours after birth – 71.4% of all children lost by doctors in the first days of life”... According to doctors, the leading causes of infant mortality remain difficult childbirth, which provokes illnesses during the infancy period and congenital developmental anomalies.
Collectively, these causes account for almost 87.1% of all infant deaths.” (8)

6. An alarming picture is observed in the obstetric service:

“... At the end of 2004, the number of normal births in Russia was 32.3%, while the rest occurred with any complications.
“Negative trends are noted in the health of newborns,” notes the materials of the Ministry of Health and Social Development. The overall incidence among newborns has increased by 32% over the decade.
Over the past decade, there has also been a threefold increase in cancer incidence among children. The number of children with diabetes has also increased at the beginning current year amounted to 17 thousand children.” (9)

So, the number of complicated births in Russia is more than 60%, and in the first hours after birth, 71.4% of all children lost by doctors in the first days of life die, 48.5% of the number of children who died before 1 year of life die in the first days of life, in In the first three months, 76.4% of children die from all deaths under the age of one year. In addition, “in the structure of perinatal losses, stillbirth is 51.5%.”

IT IS OBVIOUS THAT COMPLICATED BIRTH, INFANT AND MATERNAL MORTALITY, AND STILLBIRTH RATES ARE RELATED. THE WORST THING IS THAT ALL THIS IS HAPPENING IN PUBLIC MATERNITY HOSPITALS.

7. “...Doctors clearly call the main reason for the persistence of high infant mortality a catastrophic deterioration in the health of the mothers themselves... According to doctors, there is a constant increase in inflammatory and endocrine diseases, an increasing number of women of childbearing age are being registered with diseases of the cardiovascular system... Most women in labor need serious medical support during childbirth to preserve your health and the life of newborns" (10)

Candidate economic sciences Victoria Ivanovna SAKEVICH answers the question whether all mothers survive complicated births:
“Maternal deaths are divided into two groups: 1) directly related to obstetric causes; 2) indirectly related to obstetric causes... Maternal mortality is a problem primarily in developing countries. Russia is not one of them; However, according to this indicator, it can only be classified among developed countries with great reserve. In 2003, 463 cases of maternal death were recorded in Russia, or 31.3 per 100 thousand live births, while in the countries of the European Union this figure averaged 4.9 per 100 thousand. Of the 1,280 maternal deaths reported in 2001 in the WHO European Region (41 countries), about 40 percent occurred in the Russian Federation. Russia is “ahead” of all countries of geographical Europe. Higher level maternal mortality only in the states of Central Asia and Turkey" (11)

8. From a letter from the Ministry of Health of the Russian Federation dated October 31, 2002. No. N 2510/10836-02-32 “ON MATERNAL MORTALITY IN THE RUSSIAN FEDERATION IN 2001”:

“...In 2001, the mortality rate of pregnant women (all gestational ages), parturients and postpartum women (BPP) amounted to 362 cases - 67.3% (379 cases 66.2%, 2000). As before, more than 3/4 of all maternal losses are determined four reasons: bleeding, toxicosis of pregnancy, septic complications, extragenital diseases. In 2001, pregnant women over 28 weeks of gestation, women in labor and postpartum died - 335, of which every fourth or fifth died from bleeding (22.4% - 75 cases), every fifth - from an extragenital disease (21.4% - 72 cases ), every eighth - from a purulent-septic process (12.5% ​​- 42 cases).
...In general, in the country's obstetric hospitals, only every third birth is normal (31.2% in 2001, 31.1% in 2000). At the same time, the share of normal births ranges from 10.8% in the Belgorod region, to 61.0% in the Koryak Autonomous Okrug, to 54.8% in the Ryazan region.
..The proportion of births by cesarean section is growing every year (1.2 times over the last 5 years) and amounted to 150.4 per 1000 births in 2001 (121.5 in 1997), ranging from 56.0 (every twentieth ) in the Evenki Autonomous Okrug to 223.5 (every fourth) in the Komi Republic.
... An alarming point is the simultaneous increase in delivery using vacuum fetal extraction - from 0.25 in 2000 to 0.34 in 2001 per 1000 births (315 cases and 434 cases, respectively).
...An important characteristic of the quality of childbirth care is the indicator “hysterectomy during and after childbirth.” This figure is growing annually and amounted to 1.96 per 1000 births in 1999, 2.02 in 2000 and 2.38 in 2001 (3067 operations were performed - one in every 500 births). In some territories this figure exceeds the Russian average by 5 or more times (Irkutsk region - 13.0, i.e. one operation for 77 births, Perm region -12.3), which requires special analysis on site. Mortality after hysterectomy during and after childbirth exceeds mortality after cesarean section in 2001 by more than 30 times (2.31 and 0.07, respectively
...The number of postpartum mothers who died from postpartum purulent-septic complications is not decreasing (42 cases - 12.5%), their share in the structure of maternal mortality is increasing. At the same time, there is a growing underreporting of cases of purulent-septic diseases (PSD) of postpartum women in obstetric hospitals. Thus, in 2001, 0.14% of cases of postpartum infection in postpartum women were registered in obstetric hospitals (0.18% in 2000), while according to sample studies it is 5.0% or more.” (12)

9. REFERENCE: ACTIVE MANAGEMENT OF CHILDREN IN RUSSIA (13)

“Russian medical institutions adhere to the tactics of expectant-active management of labor, and not just watchful observation. The concept is not based on the idea of ​​normal childbirth, but on the idea of ​​minimal risk of childbirth. Normal labor can be judged retrospectively after it is completed.

Opinions about feeding during labor vary in many countries. In developed countries, due to the fear of aspiration of gastric contents during general anesthesia (Mendelssohn syndrome), they abstain from taking food and liquids during childbirth. In our country, especially in high-risk pregnant women, they abstain from taking liquids and food during childbirth, and for energy supply The body is administered intravenously glucose with vitamins, calcium gluconate, etc. Refusal of oral food intake leads to dehydration (dehydration) and ketosis (acid-base imbalance), and intravenous administration of glucose and fluid is usually used for treatment. But at the same time, a rise in glucose levels in the blood serum was established, which is accompanied by a rise in insulin levels (and a decrease in the level of 3-hydroxybutyrate). This also leads to an increase in the level of glucose in the baby's plasma and, as a result, to a decrease in pH in the arterial blood of the umbilical cord. Hyperinsulism can occur in the fetus when a pregnant woman receives more than 25 grams of intravenous glucose during labor. This can lead to neonatal hypoglycemia, an increase in blood lactate levels. Excessive intravenous administration of sodium-free solutions may lead to hyponatremia in mother and child.

Management of childbirth. Currently, there is an acceleration in the duration of labor. In our country's obstetric institutions, active expectant tactics for childbirth management have been adopted, that is, labor management. This is expressed...in the prescription of antispasmodic and analgesic drugs, timely use of effective uterotonic drugs (oxytocin, prostaglandin, etc.).

1) In order to speed up labor, intravenous administration of oxytocin is carried out, which leads to a decrease in the duration of labor, but hyperstimulation of the uterus can be observed, leading to intrauterine suffering of the fetus, the number of neonatal disorders and jaundice of newborns increases.
To prevent bleeding, intravenous and less often intramuscular administration of oxytotic agents (oxytocin, ergometrine, methylergometrine, syntometrine, syntocinon) is recommended after the birth of the anterior shoulder or after the birth of the fetus
Oxytocin has an antidiuretic effect and can cause water intoxication in large doses. Routine administration of oxytotic agents may increase the risk of placental retention. Complications associated with the administration of oxytotic agents include nausea, vomiting, headache, and hypertension. These complications are more often observed with the administration of ergometrine. Among the severe complications following the administration of ergometrine, it should be noted: cardiac arrest, intracranial hemorrhage, myocardial infarction, postpartum eclampsia and pulmonary edema.

2) Caesarean section is currently the most common delivery operation. Expansion of indications for this operation is one of the features of modern obstetrics
It is known that the expansion of indications for cesarean section leads to a decrease in professionalism in terms of management of vaginal birth. According to the Russian Federation, the frequency of cesarean sections has increased approximately 3 times in the last decade and in 1995 amounted to 11.0% and continues to grow. At the same time, there is no decrease in perinatal mortality, which requires finding ways to solve this problem.
In many clinical institutions in Russia, which are collectors of various pathologies, the rate of cesarean section exceeds 30%. Expanding the indications for cesarean section in order to reduce perinatal mortality can only be justified up to a certain limit of 10-15%.

3) In the third stage of labor, placental abruption occurs and the placenta is released, which, according to our data, during normal labor is 10 minutes
Stimulation of the mother's nipples in the third stage of labor to prevent bleeding was as effective as intravenous oxytocin (5 units) and ergometrine.
The combined action of oxytotic drugs and control traction on the umbilical cord is called "active management of the third stage" as opposed to expectant or physiological management of labor.
If there are no signs of placenta separation 10-15 minutes after the birth of the child, even if methylergometrine was administered intravenously for prophylactic purposes, drip intravenous administration of oxytocin is indicated, and if, despite the administration of oxytocin, there are no signs of placenta separation and there is no external bleeding, then after 30 -40 minutes after the birth of the fetus, manual separation of the placenta and release of the placenta are indicated.

Pain relief for childbirth.
Medications are widely used to relieve labor pain, but it should be remembered that there is not a single sedative or hypnotic, not a single analgesic that does not penetrate the placenta and does not affect the fetus to some extent.
The administration of analgesic substances causes monotony in the fetal rhythm; they often cause respiratory depression in the newborn and neonatal disorders, including aspiration.
Promedol easily penetrates the placenta and depresses the respiratory center of the mother and fetus. Orthostatic hypotension, nausea, vomiting, and dizziness may occur following the administration of pethidine.
Droperidol reaches the child within 1 minute. May cause sudden and severe respiratory depression.
Diazepam can cause neonatal respiratory depression, hypotension, lethargy and hypothermia, and enhances the inhibitory effect of narcotic analgesics on the child's breathing.
Lidocaine easily crosses the placenta. Such intense anesthesia leads to inhibition of the oxytocin release reflex in response to cervical stretching, therefore the strength of contractions decreases, the duration of the 1st and 2nd stages of labor increases, and the percentage of spontaneous birth decreases. In the mother's body it undergoes biotransformation (combines with glycine), which reduces the excitability and strength of CV, blood pressure, and can cause convulsions.
Epidural anesthesia. Possible complications: lack of pushing, headaches, back pain, hypotension, respiratory failure, dysfunction of the bladder, signs of toxic effects of the anesthetic (convulsions, amnesia), entry of the anesthetic into the subarachnoid space and the development of a spinal block (respiratory arrest, paralysis of the intercostal and diaphragmatic nerves, as well as sympathetic fibers, leading to a serious condition).
Local anesthesia. Local anesthetics reduce blood pressure, resulting in the child being in a state of hypoxia, which contributes to the development of acidosis, as a result - anesthetic molecules bind to cell proteins and are retained in tissues, creating high concentrations in the liver, brain and heart, which can cause convulsions and cessation of blood circulation (especially lidocaine). All local anesthetics can cause vasoconstriction of the uterus, as a result of which fetoplacental blood flow may be disrupted and hypoxia may occur in the child."

10. RESEARCH RESULTS OF HOME AND MEDICAL BIRTH are presented by the following authors: Khasanov A.A., Maltseva L.I., Khamitova G.V. (Kazan State Medical Academy, Kazan State Medical University):

“Having convinced ourselves of the traumatic nature of some generally accepted obstetric procedures, we became interested in the condition of children born not only without any obstetric manipulations, but also without medical care at all - at home, without a doctor or midwife.
To clarify this issue, 110 so-called home births were analyzed. The control group included the performance indicators of the maternity ward of the Department of Obstetrics and Gynecology No. 21 of KSMA.
..During home births, no bleeding was observed due to premature abruption or placenta previa; in the control group, the frequency of this pathology was 2.7%.
Bleeding in the postpartum period occurred in 1.8% after home birth (blood loss did not exceed 600 ml) and in 8.3% of the control group.
... Injuries to the soft tissues of the birth canal were noted in 9.4% of postpartum women after home birth and in 32.11% in the control group, including 22.3% and 36.7% of primigravidas, respectively.
...Symptoms of neurological pathology were found in 11 (10%) children born at home. In the control group, signs of birth damage to the nervous system were found in 168 (30.48%) of 551 newborns.
... Having compared the results obtained, we discovered an unexpected pattern: where women in labor are deprived of obstetric care, there is not a deterioration (logically expected), but an improvement in the outcome of childbirth for the mother and fetus
...This analysis allows us to assert that excessive reliance on manual and instrumental techniques adopted in physiological obstetrics can often cause more harm than non-interference in the natural multi-thousand-year process of childbirth.
...Deliverance of women at minimal risk during the normal course of pregnancy and childbirth in the comfort of home, surrounded by close relatives and in the presence of an obstetric team, with patient, careful management of labor and rational non-interference in the physiological process is one of the desirable and promising areas for the development of modern obstetric care.” (14)

11. In order to change the current demographic situation against the backdrop of rising infant mortality and a general decline in the birth rate, decisions are made at the state level.
In October 2005, the Minister of Health proposed to solve this problem as follows:

“It is possible to reduce the infant mortality rate in Russia by issuing future mothers a certificate for the birth of a child, which will be equal in monetary equivalent to five thousand
rubles About this October 19, 2005 in Moscow, at an online press conference in Moscow, the Minister of Health and social development Mikhail Zurabov.
“...It is necessary to prepare a woman for childbirth differently: firstly, she should have free access to medicines and vitamins, and there should also be a clearer diagnosis... For this purpose, we will allocate two thousand rubles to antenatal clinics,” he emphasized .
In addition, the minister believes, “...It is important to examine the child after birth for three types of pathology.” According to him, in 2006, each newborn will be checked for five types of pathology, then this figure will be increased to seven types." (15)

12. The State Duma in December 2006 adopted a law on maternity capital, which should help increase the birth rate:

“The State Duma on Friday adopted the law on maternity capital in the third and final reading. It provides for payment maternity capital in the amount of 250 thousand rubles to women who gave birth to or adopted a second or subsequent children, starting from January 1, 2007, reminds RIA Novosti.

The document also stipulates that the right to receive 250 thousand rubles is given to men who are the sole adoptive parents of the second, third or subsequent children, if the court decision on adoption entered into legal force starting from January 1, 2007.

It is provided that maternity capital will be provided no earlier than when the child reaches three years of age, or after 3 years have passed from the date of his adoption.

Maternity capital funds in in full or partially can be aimed at obtaining education, and for any child in the family, purchasing housing, as well as forming the funded part of the mother’s labor pension. The amount of maternity capital will be reviewed annually taking into account the growth rate of inflation.” (16)

In the current situation, even if we assume that all these material measures will lead to an increase in the birth rate, we need to understand that the number of deaths will also increase:
- because the state loses its newborn citizens in the first hours after their birth;
- because the early pediatrics service is not able to preserve and protect already born babies;
- because in institutions called maternity hospitals, everything remains unchanged: medication and surgical management of childbirth, which is traumatic for both the woman and the child;
- because vaccination of newborns is carried out during the perinatal period, in fact, in the first hours of their life.

In the media and on numerous Internet sites, there are discussions about natural childbirth, in which both mother and child experience the least interference in the physiological process of childbirth, and, as a result, the birth itself most often proceeds without any complications, both for the mother and for a child. But home births are still considered “criminal”.
There is absolutely ambiguous information about the traumatic effect on a child’s immune system in the first hours of life when he is given a vaccine against hepatitis B (created using a genetic engineering method). The issue of administering a live vaccine against tuberculosis to an infant during the first 3-4 days of life, which is a factor of additional impact on the immune system in one of the most important periods of a newborn’s life, remains controversial.
Isn’t this also one of the reasons for the horrific mortality of children in the first hours and days after birth, that is, in the perinatal period, when only “primary adaptation to the environment of the vital systems of a full-term newborn occurs” and which “is completed in the first 168 hours of life "?

It would seem that the task of reducing infant mortality should be solved simply:

1. Return to natural childbirth, without massive drug intervention.
2. Introduce home births into practice for women with an uncomplicated medical history.
3. Stop vaccinating children in maternity hospitals.

Should we expect a decrease in infant and maternal mortality in the near future in the context of drug-induced labor, an increasing number of births by cesarean section, and powerful drug effects on the mother and baby?
It seems that if the current state of affairs in maternity hospitals continues, a progressive decrease in infant and maternal mortality will not follow in the near future...

(1) http://novosti.tmb.ru/i/FrontShowNewsItem/rubric5/id3849

(2) http://base.consultant.ru/

(3) http://www.nr2.ru/75680.html

(4) http://www.polit.ru/research/2003/11/21/629809.html

(5) http://www.sultanov.org/life_82.html

(6) http://www.antibiotic.ru/index.php?article=466

(7) http://medarticle24.moslek.ru/articles/30866.htm

(8) http://www.mercana.ru/lenta/2004/10/21/29/31817.html

(9) http://beon.ru/news-politics-society/

(10) http://www.mercana.ru/lenta/2004/10/21/29/31817.html

(11) http://www.demoscope.ru/weekly/2005/0199/reprod01.php

(12) http://base300.consultant.ru/

(13) http://ladabirth.ur.ru/activ.php

(14) http://www.midwifery.ru/st/home_birth2.htm

(15) http://mednovosti.ru/news/2005/10/20/sertificat/

(16) http://www.vesti.ru/news.html?id=105116&tid=41451

A UNICEF report notes that in 2011, 9.7 million children under the age of five died worldwide. This figure is 3.3 million less than the 1990 figure. Back in 2000, at a joint summit in New York, world leaders pledged to reduce child mortality by two-thirds by 2015.

Previous research conducted by the Foundation shows that of the 9.7 million children dying, 3.1 million are in South Asia and 4.8 million in sub-Saharan Africa.

In 1990, the figure was 13 million, and the infant mortality rate was 93 out of 1,000 live births. In 2000, the rate dropped to 72 children per 1,000 live births. In Western industrialized countries, an average of 6 out of 1,000 children die before the age of 5. IN developing countries– 186 out of 1000.

In countries of Central and Eastern Europe, as well as in countries former USSR On average, 27 children die out of 1000. In 1990, there were 55 deaths for every thousand. The same indicators in Latin America and the Caribbean.

In 2011, 10 thousand babies died in Russia, or 7 children out of every thousand born.

Child mortality is one of the leading indicators characterizing the health status of the population. It is a kind of barometer, an “indicator” of the levels of socio-economic development of the country, the material and sanitary well-being of the people, the state of medical care for the population, especially children and mothers, and the effectiveness of preventive and sanitary and anti-epidemiological measures. Analysis of the level, dynamics and causes of child mortality equips health authorities with the necessary information for a targeted struggle to improve the health of the younger generation.

Reducing child mortality is one of the reserves in the fight to reduce overall mortality, extend people's life expectancy, as well as population reproduction, i.e. is considered as an important socio-economic criterion.

In 2012, 65 children aged 0 to 14 years inclusive died in the Kamchatka Territory. The share of children in the total number of deaths in the region in 2012 was 1.7%, which is 0.3 percentage points higher than the previous year. The mortality rate among boys is, as a rule, always higher than among girls. 2012 was no exception - one and a half times more boys died than girls (39 and 26 people, respectively).

The mortality rate for children under 14 years of age was 1.2 per thousand, that is, one child died out of every thousand children. In the structure of causes of death, about half is the mortality of children from certain conditions arising in the perinatal period and from congenital developmental anomalies.

When analyzing the age-specific mortality of children, a pattern is observed - the number of deaths decreases as the age of the children increases. The maximum number of children die immediately after birth; with age, the level of losses decreases, which is an objective biological pattern and is due to an increase in the level of vitality of the child as the child’s body grows and matures.

Most high level Mortality among children is recorded annually in infants under the age of 1 year, the so-called “infant mortality”. The number of children who died under the age of 1 year in 2012 was 47 people or 72.3% of the total number of children who died in the region. The growth compared to 2011 was 17.5%. Compared to the 80s of the last century, infant mortality in the region decreased by half, compared to the 90s - by one and a half times.

Of the total number of babies who died in the first year of life, 28 were boys and 19 were girls. Compared to the previous year, 1.6 times more boys died, and 17.4% fewer girls.

Out of every thousand babies born in 2012, 11 died before reaching the age of one year. IN rural areas 10 infants died, 37 children died in the city, infant mortality rates were 11.2 and 11.8 ppm, respectively.

In 2012, out of 47 children who died in the first year of life (infant mortality), 32 children (68.1%) died in the neonatal period (up to the 28th day of life), of which 15 children (46) died in the first week of life (perinatal mortality). .9% of the number of deaths during the neonatal period and 31.9% of the number of deaths in the first year of life). From the data presented it follows that the infant mortality rate is largely determined by the number of deaths in the neonatal period. The neonatal mortality rate in the region was 7.7 ppm, the perinatal mortality rate was 6.7 ppm.

In the structure of causes of infant mortality, the leading place is occupied by mortality from certain conditions arising in the perinatal period (55.3%). In second place are congenital anomalies (27.7%).

Among the districts Kamchatka region the highest infant mortality rates in 2012 were recorded in Karaginsky (70.5 ppm) and Milkovsky (16.8 ppm) districts. The lowest are in the Elizovsky district (11.1 ppm) and the city of Petropavlovsk-Kamchatsky (11.3 ppm).

The mortality rate of children aged 1 to 14 years during 2012 increased from 3.9 to 4.8 ppm. The absolute number of deaths compared to the previous year increased by 20% and amounted to 18 cases (11 boys, 7 girls).

More than half of children (61.1%) in 2012 aged 1-14 years died from external causes (accidents, poisoning and injuries). In 2012 absolute indicator Mortality from external causes increased by 10% and amounted to 11 cases (7 boys and 4 girls). Among the dead, five were poisoned by gas, two were accidentally suffocated, one drowned, and another died in an accident.

Infant mortality in Russia in the 20th century

Infant mortality is one of the demographic factors that most clearly reflects the level of development of a country and the economic and social change. In the 20th century, the infant mortality rate in Russia decreased by almost 20 times. Its share in the overall mortality rate has also changed. But behind these positive achievements lie trends that are of grave concern. Let's consider the dynamics and features of this process.

At the beginning of the 20th century, Russia was characterized by extremely high mortality rates for children under 1 year of age (infant mortality), which was one of the main reasons for the high mortality rate in the country as a whole. In 1901, the proportion of deaths at this age in the total number was 40.5%. By the end of the first decade it began to decline slowly and by 1910 it had dropped to 38%. During this period, Russian data exceeded the corresponding indicators in developed countries by 1.5-3 times (Figure 1). In 1901, the infant mortality rate in Russia was 298.8 per 1000, while in Norway it was 93 per 1000.

Figure 1. Infant mortality in the first half of the 20th century in a number of countries
(on years)

The main causes of death of children in the first year of life at the beginning of the 20th century were gastrointestinal and infectious diseases, and respiratory diseases. Thus, of the 11,786 children who died in 1907 in Petrograd, 35.8% died from gastrointestinal disorders, 21.1% from congenital weakness, 18.1% from catarrhal inflammation of the lungs and respiratory tract, infectious diseases accounted for 11. 0%

Russian doctors and social hygienists largely associated the extremely high level of infant mortality with the peculiarities of feeding infants in Orthodox, that is, mostly Russian families, where it was traditional to give the child complementary foods almost from the first days of life or to deprive him of breast milk altogether. , leaving motherless children in the care of older teenage children or old people, food was left for the whole day. Representatives of other religions often lived in worse conditions, but due to the fact that they continued breastfeeding their children for quite a long time, the mortality rate of children in these families was much lower. So, I.I. Tezyakov noted that in the Saratov province the mortality rate of children in the first year of life (per 1000 births) was 270.2 cases, among Orthodox Christians - 286.8%, among schismatics - 241.8%, among Lutherans and Catholics - 163.5% , among the Mohammedans - 118.4%. Other authors have also written about the connection between mortality rates and religion.

Another reason for the high mortality rate, including maternal mortality, was the underdevelopment of the system of medical care and obstetrics, as well as the difficult sanitary conditions of work, life and living conditions, lack of hygiene knowledge, low literacy of the population. In Russia there was no legislation on the protection of motherhood and childhood, which had existed in many European countries for quite a long time.

In the first decade of the 20th century, the infant mortality rate declined consistently, reaching 259.6 per 1000 in 1909. However, it grew significantly during the First World War and the Civil War.

There are several stages in the dynamics of infant mortality in Europe at the beginning of the 20th century. 1). From the beginning of the century until 1910, there was a period of decline at different rates in the mortality rate of children under 1 year of age; at the same time, there is a convergence of infant mortality rates in different countries; 2). The period of rises and falls in infant mortality rates under the influence of the 1st World War, which ends in 1919 with a sharp decrease in these indicators; 3). Since 1920, the process of reducing infant mortality has been restored.

Adoption and gradual implementation of legislative acts and decrees on the protection of motherhood and childhood, including labor protection for pregnant women, providing them with leave before and after childbirth, breaks from work for breastfeeding; development of the system of obstetrics and medical care for mothers and children; development of issues related to the construction unified system protection of maternal and child health, and then the creation of child care infrastructure (dairy kitchens, nurseries, patronage system, shelters for infants), carrying out sanitary educational work as an integral part of the cultural revolution in Russia; the positive impact on the economic and social life of the NEP - all these measures, dictated by the October changes, led to a noticeable decrease in infant mortality in Russia. By 1927, its rate reached 205 per 1000.

Subsequently, its level fluctuated under the influence of economic and social cataclysms accompanying the transformation of the new government. The collapse of the NEP, the beginning of industrialization and especially collectivization Agriculture led to an increase in the infant mortality rate (to the level of the first decade of the 20th century). It reached its peak in 1933 (295.1 per 1000), the year of the worst famine. It is not without interest that the share of deaths under the age of 1 year in the total number of deaths in 1933 was 24.3%, which is lower than in 1932 - 37.3% and 1934 - 30.9%. Only towards the end of the 30s did the infant mortality rate in Russia begin to decline steadily. The main reason for this decline can be considered the implementation of measures to protect motherhood and childhood, the increase in sanitary literacy of the population, and improvement in the quality of medical care.

For industrialized countries and European countries, these two decades were, in general, years of decreasing infant mortality rates and their convergence between countries. In some of them it was quite large (in Austria it decreased by 2.1 times, in the Netherlands - by 2.2, Switzerland - by 2.0, the USA - 1.8 times), in other countries - less noticeable (Bulgaria - by 5%, Ireland - 18%, Spain - 17%, Romania - 26%).

A new fundamental decrease in infant mortality in Russia occurred at the end of the Second World War as a result of a number of factors. Basically, this is the introduction of antibiotics and sulfonamides into medical practice, which led to a reduction in infant mortality from respiratory diseases, most infectious diseases, as well as a decrease in the birth rate in conjunction with the implementation of measures aimed at restoring and improving the system of care for mothers and children. In 1946, the infant mortality rate in Russia reached 92 per 1000, which was 74% lower than it was in 1940.
Infant mortality in the second half of the 20th century

Figure 2. Infant mortality in the second half of the 20th century in a number of countries
(on years)

Table 1. Infant mortality rates in Russia by cause of death in the period from 1960 to 2000 (per 100,000 live births)

As a result, by the end of the 20th century, the infant mortality rate in Russia was 2-5 times higher than in developed countries of the world (2000: Russia - 15.3 per 1000; Sweden - 3.4 per 1000; and Iceland 3.0 per 1000). 1000), that is, with an absolute decrease, the relative lag has become even greater than it was at the beginning of the 20th century. The figures were higher than in Russia only in Romania and some republics of the former USSR. At the same time, the share of deaths under 1 year of age in the total number of deaths was 0.87% in 2000.

There are several countries that in the early 70s had even worse infant mortality rates than Russia: Greece, Italy, Portugal, Hungary, Poland, Bulgaria. But now they have all moved forward, sometimes very far. Figure 2 shows what the ratio of infant mortality rates was in Italy, Hungary and Russia in the 60s-70s and what it became at the end of the 20th century. But the most eloquent example of our missed opportunities is the example of Portugal, where in 1960 infant mortality was more than twice that of Russia, but over 40 years it has decreased by more than ten times and is now 2.78 times lower (2000: 5.5 per 1000 - Portugal and 15.3 per 1000 - Russia).

Changes in infant mortality components

Russia's lag behind economically developed countries in terms of infant mortality is primarily due to its archaic structure. As is known, infant mortality consists of neonatal (at the age of 0-27 days of life) and post-neonatal (from 28 days to the end of the first year). Neonatal mortality, in turn, is divided into early neonatal (the first 7 days of life, more precisely 168 hours) and late (the next three weeks of life).

This division is important because reducing mortality at different stages of the first year of life are tasks of varying degrees of complexity. A newborn is most vulnerable in the first days after birth, then his vulnerability weakens, and the body’s defenses strengthen. The older the baby, the easier it is, with other equal conditions, save his life. That is why the first decisive successes were achieved in the fight against postneonatal mortality - they ensured a rapid decline in infant mortality in many countries in the first half of the 20th century.

In the early 60s, in the group of countries with the lowest infant mortality (then it was 17 per thousand births in Sweden, 18 in the Netherlands, 21 in Denmark, Finland and Switzerland), neonatal mortality was 13-16 per 1000, and only 3-4 babies out of every thousand born died after they reached the age of one month. Gradually, the rest joined the leading countries.

By the end of the 20th century, in economically developed countries, as a result of socio-economic development, advances in medical science (including the emergence of the ability to determine the state of health and pathology of the fetus at different stages of pregnancy), in methods of diagnosing, treating and caring for children, reducing to a minimum the influence of exogenous factors of death, with regard to infant mortality, a situation has developed in which the main part of the deceased children under the age of 1 year is concentrated in the neonatal period, and in it - in the 1st week. The lower the infant mortality rate in a country, the higher the proportion of deaths occurring during the first month of a child's life. In recent years, the neonatal period in the countries with the lowest rates accounted for approximately 65-75% of all infant mortality (50-60% occurred in the 1st week of life). For example, in Italy in 1996 this proportion was 74.5% (early neonatal 56.1%).

All this allows us to talk about approaching in these countries to the minimum possible at the present stage of socio-economic and medical development infant mortality rate. In Russia, as well as in some former socialist countries (Romania, Bulgaria), with an increase in the proportion of deaths occurring in the neonatal and early neonatal period, these shares are relatively small (in 2000 in Russia it was 59.6%, moreover, early neonatal - 43.1%), which is quite natural given the existing general level of infant mortality, the contribution to its level of causes of an exogenous nature, the socio-economic and cultural level, and the degree of development of the health care system in the country.

Today in Russia the neonatal mortality rate is approximately the same as it was in the early 70s (Figure 3). While in developed countries the neonatal mortality rate decreased by 2-4 times during this period. This decline was one of the components of the second epidemiological transition. And it is precisely with the level of neonatal, mainly early neonatal mortality from causes arising in the perinatal period and congenital anomalies, and with the relatively high post-neonatal mortality that Russia lags behind in terms of infant mortality. As already noted, the reduction in infant mortality in developed countries was based on effective systems for preventing the pathology of pregnancy and nursing a newborn and the general development of the health care system.

Rice. 3. Dynamics of three components of infant mortality in Russia (number of deaths at the corresponding age per 1000 live births)

As far as can be judged from data on infant mortality and its components, Russian system By the end of the 20th century, healthcare in terms of mother and child health was at least 30-40 years behind the EU countries, the USA, and Japan, even if we do not take into account that government statistics are actually based on an outdated definition of live birth. Table 2 shows how long this backlog has been.

Table 2. Years in which the EU countries, the USA and Japan reached the current Russian level of infant mortality

Causes of infant mortality

Another factor behind Russia’s infant mortality rate compared to developed countries lies in the structure of its causes. Let us compare the structure of mortality of children under 1 year of age by cause of death in Russia and in a number of other countries (see Table 3). A comparison shows that we still have a very high mortality rate from exogenous causes, which, as already noted, are the main ones in the postneonatal period. As a rule, completely viable children die from them. In Russia, the mortality rate of children from infectious diseases, accidents, and respiratory diseases is sometimes tens of times higher than in the most developed countries. At the same time, in Russia, not everything is in order with endogenous causes - congenital anomalies or conditions that arise in the perinatal period. They usually kill children with reduced vitality, they are more difficult to fight, they claim the most children's lives in Europe, America, and Japan. But still, as already noted, there have been considerable successes both in the prevention and treatment of this kind of pathology, but we are far behind. The mortality rate from perinatal causes in Russia has remained almost unchanged since the mid-60s (see Table 1), while in the West it has been steadily declining.

Table 3. Infant mortality by cause of death in selected countries (per 100,000 live births)

Even more striking are the differences in the level and trend of mortality from congenital anomalies, mortality from which is steadily increasing in Russia, while in the West it is also decreasing. If in the mid-60s this level in Russia was lower than in the UK, USA, France or Sweden, now it is 2-3 times higher. We are paying for all these lags and unfavorable trends with 2-4 times higher infant mortality. The gap is “many times” smaller than, say, in the case of infectious diseases, but in absolute numbers, the greatest losses that determine the difference in infant mortality levels between Russia and most developed countries are associated precisely with these reasons.

Comparisons not only with developed countries are useful for understanding Russian specifics. industrial countries, but also with less developed Romania. Russian and Romanian infant mortality rates from various causes of death are extremely close - with one exception: in Romania, mortality from respiratory diseases is three times higher. It is the leading cause of infant death there. Among the countries with high mortality from respiratory diseases are Bulgaria and the Republic of Moldova.

Since the 1960s, mortality from diseases of the digestive system has also sharply decreased in Russia. They have lost their role as one of the main sources of danger to the lives of infants, and today it is about the same as it was in the mid-90s in the United States, and less than three times higher than it is now in the EU and Japan. Unfortunately, the same cannot be said about infectious diseases, the mortality dynamics from them have been less consistent, and now they still pose a significant threat to children's lives.

Respiratory diseases are the leading cause of death for young children in the late 50s. It decreased almost continuously and decreased by more than 8 times by the end of the 20th century. This is one of our main achievements in the field of infant mortality over the past 40 years. True, even now, as can be seen from Table 2, it is 10-40 times higher than in the EU countries, the USA and Japan. But still lower than in Romania, Bulgaria and the Republic of Moldova.

Seasonality of infant mortality

One of characteristic features changes in infant mortality in the 20th century - a weakening of its dependence on the season. In the past, especially in the 19th and early 20th centuries, the most dangerous period was the summer months, when mortality from gastric diseases increased markedly. Over time, when mortality from them was brought under control, the winter peak in infant mortality, associated with the rise of colds in infants, began to come to the fore. Establishing control over this cause of death has created conditions for the almost complete disappearance of seasonal fluctuations in mortality. At the same time, for many economically developed countries, already by the 60s, it became typical that there was either a winter seasonality in infant mortality or no seasonality at all.

For Russia, by the beginning of the 50s, seasonality continued to remain characteristic with the greatest peak in the summer months, although, compared with the pre-war, and especially pre-revolutionary, years, the proportion of deaths in children under 1 year of age occurring in the summer months became smaller. The height of the summer peak continued to decrease, and by the mid-60s it had almost disappeared (Figure 4). But the winter seasonality began to manifest itself more and more clearly, which became especially noticeable since the late 60s, which reflects a change in the structure of causes of death in children under 1 year of age, in particular, a changing ratio of mortality from diseases of the digestive and respiratory organs. Gradually weakening, winter seasonality still persists, indicating the role of exogenous causes of death.

Rice. 4. Seasonality of infant mortality in Russia in the second half of the 20th century

Both summer and winter seasonality in infant mortality are largely due to fluctuations in the postneonatal period. It is at this age that the majority of deaths from exogenous causes, in particular from respiratory diseases, including pneumonia, occur. As neonatal mortality, caused primarily by endogenous causes of death, comes into first place, the experience of other countries shows that seasonality should weaken and gradually disappear, but this has not yet happened in Russia.

Instead of a conclusion

Why has Russia over the course of a century, with all its progressive development in relation to infant mortality (a 19.5-fold decrease over the 20th century), not only not reduced, but also increased the gap with the economically developed countries of the world in this socially and economically important indicator? The reasons are most likely the same as at the beginning of the century. This is the socio-economic development and cultural level in the country, as well as stratification according to these characteristics. An important role is also played by the existing predetermined ways of caring for a child and state assistance in this area (where a lot is decided for the woman and child).

Another factor that influenced the relative stabilization in the late 60s and the increase in the early 70s, and then the small rate of decline in the subsequent period, of the infant mortality rate was what had previously been the reason for its rather strong decline: the development of the healthcare in the 50-60s, the introduction of new medications, the increase in the number of medical personnel (that is, a system aimed at combating exogenous causes), the established nature of child care, hygienic culture, customs and traditions, that is, all that which is determined by the general cultural and material level of the family at this stage. These factors more or less fulfilled their task and, under other prevailing conditions, could not influence the reduction in infant mortality to the same extent as before.

The combination of these factors suggests that a transition to another level of healthcare is necessary (and not only in terms of financing), capable of combating not only exogenous, but also endogenous causes of neonatal mortality, and introducing into widespread practice methods that prevent infant death (including including on the basis of determining fetal pathologies and genetic examinations of future parents). WITH modern system health care, we won’t be able to go far. In addition to its restructuring, it is also important to reconsider the views of people (women, pregnant women, mothers, families), that is, change the mentality of people regarding the state of their health and attitude towards it, which again brings us back to the level of culture in the country.

1 - Recalculations of infant mortality rates for the period 1901-1926 were made by E.M. Andreev
2 - See: Kurkin P.I. Mortality of infants. M., 1925. P. 18
3 - Calculated according to: Medovikov P.S. Causes of child mortality. Petrograd, 1916. pp. 30-31
4 - Tezyakov I.I. Materials on the study of infant mortality in the Saratov province from 1897 to 1901. Saratov, 1904. P. 78-79
5 - See: Ershov S. Experience in comparative demographic characteristics of the Russian and Tatar nationalities. St. Petersburg, 1888; Grokhav D.E. Social significance, causes of child mortality and the fight against it. M., 1912; Gubert V.O. The current state of the issue of child mortality in Russia and the fight against it. Journal of the Russian Society for the Protection of Public Health. 1911. No. 9-10
6 - See: Kurkin P.I. Fertility and mortality in the capitalist states of Europe. M., 1938. pp. 34-35
7 - Infant mortality in Russia for the period 1927-1958 is taken from: Andreev E.M., Darsky L.E., Kharkova T. L. Demographic history of Russia: 1927-1959. M., 1998. pp. 164-165
8 - See: Sifman R.I. On the question of the reasons for the decline in child mortality during the Great Patriotic War Patriotic War. Lifespan: analysis and modeling. M., 1979. P. 50-60; Aminova RJ. Decrease in morbidity and mortality of children in Kazan during the Great Patriotic War. Kazan medical collection. Kazan, 1947
9 - See: Zakharov S.V. The Second World War as a turning point of infant mortality decline in Russia. // Sante et mortalite des enfants en Europe: Inegalites sociales d"hier et d"aujourd"hui. Chaire Quetelet 1994. Ed. par Masuy-Stroobant G., Gourbin C. et Buekens P. Academia-Bruylant/L"Harmattan, Louvain-la-Neuve, 1996. S. 325-328
10 - Infant mortality in Russia for 1959 was calculated based on statistical forms. For the period 1960-2000. Demographic Yearbook of Russia. Statistical collection. M., 2001. P. 190
11 - Data on European countries for the period since 1960 taken from Recent demographic developments in Europe 2001
12 - Sakamoto-Momiyama M. Seasonality and human mortality. M., 1980. P. 70-80