June 5 in the project "Public lectures". Ru "in the framework of a series of joint lectures with the European University in St. Petersburg.
Master and doctoral student of the European University in St. Petersburg, employee of the "Gender Studies" program, expert on gender, family and parenthood Anastasia Novkunskaya delivered a lecture on the topic: "Obstetrics in Russia: Reforms and Consequences".
As Anastasia Novkunskaya noted at the beginning of the lecture, in the world now it is possible to single out various national systems of obstetrics, that is, the organization of medical care in pregnancy, childbirth and after the birth of a child. The system of the modern Netherlands is widely known, where obstetric care is autonomous and more than forty percent of births occur at home.
In contrast, in Russia, childbirth, according to the law, can only take place in a hospital. But, if it is meant that the entire system of obstetric care in Russia operates according to a single standard, in studies of concrete maternity hospitals or maternity wards it is found that in fact there are many regional and local differences. Obstetricians-gynecologists working in outpatient settings (for example, in women's clinics), and those who work in hospitals, have different views on how to take care of the health of a pregnant woman, how to give birth, and so on. Even within one large city, you can find different obstetric schools, whose adherents will criticize each other's approaches.
Anastasia Novkunskaya was studying how the system of obstetrics in Russia is being transformed since 2006. The study was conducted in maternity wards of small towns, where, as it turned out, there are many unexpected features in the work of this system.
Since the late 1980s, the USSR began to develop a model of obstetrics, which involves the establishment in each region of a large perinatal center, which will be sent to the most difficult patients in medical terms. In general, the system assumed that there will be three levels of medical care: the perinatal center in the center of the region, the maternity hospitals of the "second link" and, finally, on the periphery there will exist those maternity units where only the delivery will be accepted without any complications. This reform was not completed, but several regional perinatal centers were opened.
The introduction of market mechanisms for regulation and financing in health care after the collapse of the USSR led to the emergence of private clinics and paid services in the public health system. During this period, most of the regional features emerged in the management and financing of the obstetric service. This led, in general, to a decrease in the number of financial resources for budgetary perinatal institutions. The share of federal funding was no more than 20%.
In the mid-2000s there was a turn to the so-called static model of state policy ("statist welfare model"), in which the state declares itself to be the primary social responsibility, including health care. In the last decade, the obstetric system underwent a major reform, which was part of the overall health and social reform. In 2006 the national priority project "Health" appears, in 2011 - 2013 the project of modernization of public health services. "Generic certificates" were introduced, as an additional source of funding for maternity and childhood care.
In small cities of Russia (with a population of less than 50 thousand people) there are no autonomous maternity hospitals. The mothers are sent there to the gynecological and maternity wards of the central (inter) district hospitals (CRH). Such institutions are less autonomous in administrative and financial terms than maternity hospitals. They depend both on the general management of the hospital, and on the regional administration and federal bodies.
A consequence of this is the inadequacy of resources, from financial to administrative and social. In such maternity wards, epidural anesthesia is sometimes not done, simply because there is not an anesthesiologist in the state who could be constantly with the mother in childbirth. An anesthesiologist is usually only one for the entire district hospital. "And we have the same anesthesiologists come to us from the intensive care unit. Even on our operations. That is, we are a woman even in a cesarean, do not give her an epidural anesthesia, we have a cesarean in general under general ... [it is necessary that the anesthesiologist] know the consequences for the child and the woman, the outcomes will affect. We have none ", says the obstetrician-gynecologist of the women's consultation and the maternity department of the Central District Hospital. Not only not anaesthesiologists, but also neonatologists, nurses and other personnel.
Financing is also insufficient. Even the introduction of "maternity certificates" did not greatly alleviate the situation, since, although certificates give birth to a maternity ward for every childbirth, the chances of spending this money are severely limited. For example, these funds can not be used to purchase furniture or repairs, even a list of drugs that can be purchased, is limited. As a result, sometimes the maternity ward urgently appeals to the hospital of the neighboring district for the necessary drug, and then tries to somehow compensate the neighbors for this help.
Complicated the life of maternity wards and federal law No. 44 on public procurement. Purchased through the system of tenders and medicines and instruments should, according to law, be the cheapest of the proposed options, and in the end they often prove to be unsuitable for use in the maternity ward. Moreover, this law significantly increased the volume of bureaucratic work in supplying the hospital with everything necessary. The medical worker now has to complete the technical assignment for the purchase, then receive up to seven signatures of different officials, and eventually get the right drug only after a few months.
Since 2012, all institutions of the obstetrics system have been assigned levels coordinated between them by order No. 572n of the Ministry of Health and implemented in the form of "routing" complex cases in accordance with the degree of risk assigned to them. To each level there corresponds a certain set of services, various equipment and personnel, as well as various financing. Establishment of the first level, these are the most remote and the smallest maternity wards. They take no more than 500 births a year, and their equipment allows them to work only with deliveries without complications and pathologies. In institutions of the second level take from 500 to 1000 births per year. They are usually two to three per region. They are provided for assistance in more difficult childbirth. The third level - independent institutions located in regional centers, or perinatal centers, or maternity homes, the most equipped and secured. There can take delivery of any complexity.
If a woman has difficulties during pregnancy, she should be transferred ("routed", as doctors say) first to the institution of the second, and if necessary - to the institution of the third level. But the implementation of this order is complex. The road from the first to the third level can in some regions exceed 200-300 kilometers. Not all regions were in the presence of reanimobiles that could transport a woman with already begun birth in the center. The machine with the device for artificial ventilation and other equipment intended for transportation of parturient women and newborns may be only one per area.
Another new system increased the financial burden on district offices - the poorest in the system, as they became responsible for transportation. In addition, the unintended consequence was a reduction in the funding of such departments due to a decrease in the number of deliveries in them, since part of the parturient women is transferred to the second and third levels. "We lose a third of our births (...) A third.
That's the trouble of all the first levels; Many even, probably, also will be closed - there was such minimum. You understand, there are not enough births, economically the hospital can not support us, - very expensive service. Highly! Therefore, they always looked askance at us, that they swear on us a lot, and the output is not very big, when there is not enough birth, "says the head of obstetrics and gynecology departments of the Central District Hospital.
MAXIM RUSSO.