Kakovost v zdravstvu/Quality of health service
KAKOVOST PERINATALNEGA VARSTVA V SLOVENIJI OD LETA 2003 DO 2008
QUALITY OF PERINATAL CARE IN SLOVENIA 2003-2008
Tanja Premru-Sršen, Ivan Verdenik Ginekološka klinika, Univerzitetni klinični center Ljubljana, Šlajmerjeva 3, 1000 Ljubljana
Izvleček
Izhodišča
Metode
Rezultati
Zaključki
Namen raziskave je bil ugotoviti, ali se kazalci kakovostiperinatalnega varstva v Sloveniji spreminjajo.
Izbrali smo kazalce kakovosti, s katerimi Europeristat1 primerja kakovost perinatalnega varstva v državah Evropske unije. Izbrali smo dve petletni obdobji, od 1998 do 2002 in od 2003 do 2008. Podatke za perinatalne kazalce kakovosti smo zajeli iz Nacionalnega perinatalnega informacijskega sistema Slovenije.2 Statistično značilnost smo ugotavljali s Pearsonovim testom hi-kvadrat.
V	letih od 1998 do 2002je bilo 87.679porodov, rodilo se je 88.678 otrok. V letih od 2003 do 2008je bilo 90.662porodov in rodilo seje 91.736 otrok. V obdobju od 2003 do 2008 so bile ženske statistično značilno bolj izobražene in več nosečnic je prišlo na prvi pregled v nosečnosti do 12. tedna (84,0 % proti 75,3 %). Večjih je zanosilo po postopkih asistirane reprodukcije (2,0 % proti 1,7 %) in večje bilo mnogoplodnih nosečnosti (1,7 % proti 1,6 %). Porodov brez medicinskih posegov je bilo značilno manj (34,7 % proti 41,9 %). Manj porodov seje pričelo spontano (74,0 % proti 92,6 %). Zelo seje povečal tako odstotek sproženih porodov (20,1 % proti 6,6 %) kot načrtovanih carskih rezov (6,0 % proti 0,9 %). Odstotek carskih rezov se je povečal v celoti (14,8 % proti 11,0 %), predvsem zaradi povečanja načrtovanih carskih rezov, povečal pa se je tudi odstotek s posegom dokončanih vaginalnih porodov (3,1 % proti 2,6 %). Epiziotomij je bilo manj (48,7 % proti 51,0 %), manj je bilo tudi poškodb presredka druge stopnje (4,5 % proti 5,4 %), medtem koje bilo poškodb tretje do četrte stopnje več (0,3 % proti 0,2 %). Transfuzij je bilo manj (0,3 % proti 1,0 %), zato pa je bilo narejenih več histerektomij (0,1 % proti 0,03 %). Odstotek eklampsij je bil v obeh obdobjih enak (0,1 %). Med prezgodnjimi porodi je bil večji odstotek porodov med 32. in 36. tednom nosečnosti (5,9 % proti 5,5 %), medtem ko ni bilo razlik med porodi med 22. in 31. tednom nosečnosti. Mrtvorojenost nad 22. tednom nosečnosti je bila v obeh obdobjih enaka - 5 na 1000 vseh rojenih, zgodnja (2 na 1000proti 3 na 1000) in pozna (0,04 na 1000proti 0,4 na 1000) neonatalna umrljivost pa sta bili manjši. V obeh obdobjih so bile usodne malformacije vzrok za tretjino mrtvorojenosti in neonatalnih smrti.
V	zadnjih letih v Sloveniji opažamo porast porodov s posegom in upad porodov brez medicinskega poseganja. Kljub temu, da nosečnice prihajajo na prvi pregled bolj zgodaj v nosečnosti in so bolj izobražene, kar pomeni tudi boljši socialno-ekonomski položaj, prezgodnji porodi naraščajo, medtem ko se zdravje nosečnic in mrtvorojenost nista pomembno spremenila. Zmanjšala pa seje neonatalna umrljivost.
Ključne besede nosečnost;porod; kazalci kakovosti
Abstract
Background	The purpose of this analysis was to find whether the quality indicators of perinatal care in
Slovenia change.
Methods	We used the same quality indicators which are used in the European project Europeristat1
to compare the quality of perinatal care among the countries of the European Union. We
used two 5-year periods, from 1998 to 2002 (reference period) and from 2003 to 2008 (observed period). Data for perinatal quality were collected from the National Perinatal Information System of the Republic of Slovenia.2 Statistical significance was tested using the Pearson's chi-square test.
Results	Between 1998 and2002, there were 87.679 labours ending in the delivery of88.678 new-
borns, and between 2003 and 2008, there were 90.662 labours ending in the delivery of 91.736babies. In the observed period (2003 do 2008) mothers had statistically significantly higher educational level, a higher percentage came to their first pregnancy examination before the 12th week of gestation (84.0 % vs. 75.3 %), a higher percentage conceived after assisted reproductive techniques (2.0 % vs. 1.7 %), and the incidence of multiple pregnancies was higher (1.7 % vs. 1.6 %). Significantly lower were the percentages of labours without medical interventions (34.7 % vs. 41.9 %) and of spontaneous onset of labour (74.0 % vs. 92.6 %). The percentages of induced labours and of elective cesarean sections increased dramatically (20.1 % vs. 6.6 % and 6.0 % vs. 0.9 %). The increase in the overall percentage of cesarean sections (14.8 % vs. 11.0 %) is mainly due to increased incidence of elective cesarean sections, but the percentage of operative termination of vaginal labour increased as well (3.1 % vs. 2.6 %). The incidence of episiotomies was lower (48.7 % vs. 51.0 %) and so was the incidence of 2nd degree perineal lacerations (4.5 % vs. 5.4 %), while the incidence of 3rd-4th degree lacerations was higher (0.3 % vs. 0.2 %). Transfusion was required in a lower percentage (0.3 % vs. 1.0 %), but the percentage of hysterectomies increased (0.1 % vs. 0.03 %). The incidence of eclampsia was the same in the two time periods (0.1 %). Among preterm deliveries, the higher percentage occurred between 32 and 36 gestational weeks (5.9 % vs. 5.5 %), while there were no differences among the deliveries between the 22nd and 31stgestational week. Stillbirths after the 22ndgestational week was the same in both periods, 5 per 1000 of all newborns, whereas early (2 per 1000 vs. 3 per 1000) and late (0.04 per 1000 vs. 0.4 per 1000) neonatal mortality rates were lower. In both time periods lethal malformations were the cause of death in 1/3 of stillborn babies 1/3 of neonates.
Conclusions	Over the last years, an increase in operative deliveries and a decrease in deliveries without
medical interventions have been observed in Slovenia. Despite the fact that mothers come to their firstprenatal examination earlier in pregnancy than before and that they are more educated, i.e. they have a better socio-economic status, the incidence of preterm deliveries increases, while the mother's health and the incidence of stillbirths have not changed significantly. The decrease in neonatal mortality rate should be highlighted.
Key words	pregnancy; labour/delivery; quality indicators
Literatura
1.	Zeitlin J, Mohangoo A ed. European perinatal health report. EURO-PERISTAT Project, SCPE, EUROCAT, EURONEOSTAT; 2008.
2.	Perinatalni informacijski sistem RS (podatkovna zbirka 2003-2008). Ljubljana: Inštitut za varovanje zdravja R Slovenije.
Prispelo 2009-09-03, sprejeto 2009-10-01