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Early neonatal mortality in the Russian Federation in 2010

The key to the success of perinatal care is objective knowledge about the number and causes of perinatal losses, the level and structure of which require systematic analysis, as they reflect the quality of obstetric and neonatal care. In addition, they are considered as an integral indicator of the level of socio-economic development of the country, the quality of life, the availability and quality of medical care, the effectiveness of the activities of health authorities and institutions.

The report is devoted to the analysis of early neonatal mortality, which was interpreted as the death of a child born at a gestational age of 28 weeks or more with a body weight of 1000 g or more and who died in the first 168 hours of life, and is based on an analysis of Rosstat data for 2000–2010. According to the WHO definition (ICD-10), the perinatal period begins at the 22nd completed week of pregnancy (154 days of fetal life, when the body weight normally reaches 500 g) and ends after 6 completed days (168 hours after birth). Consequently, newborns weighing less than 1000 g and who died during the 1st week of life were not registered in the state statistics bodies either as born children or as dead.

Analyzing the dynamics of perinatal mortality in the Russian Federation according to data for 2000-2010. (Table 1), , annual fluctuations in the absolute number of deaths in the perinatal period and stillbirths should be noted, with a constant decrease in the number of deaths in the early neonatal period. Indeed, the absolute number of newborn deaths and the average values ​​of the early neonatal mortality rate in the Russian Federation tend to steadily decrease.

In 2000-2010 the rate of early neonatal mortality (calculated as the number of children who died in the first 6 days after birth, per 1000 live births) decreased by 57.8%. For comparison, we indicate the following data: the perinatal mortality rate during this time decreased by 44.1%, and the stillbirth rate - by 32.1%. The most pronounced rates of reduction in early neonatal mortality are observed in 2007 and 2008.

At the same time, there is also an annual decrease in the proportion of early neonatal deaths among all cases of perinatal death (see Table 1) . If in 2000 it was 49.5%, in 2010 it was almost ¹ / ₃ (37.3%). Such facts of a progressive decline in early neonatal death objectively reflect medical advances, both in obstetrics and neonatology.

When characterizing the indicators of early neonatal mortality, one more pattern should be emphasized - a progressive decrease in the number of dead newborns with an increase in life expectancy. Thus, the largest number of dead newborns in the early neonatal period is observed on the first day: in 2010 in the Russian Federation it amounted to 29.9% of the total number of early neonatal deaths (Fig. 1). Figure 1. The indicator of early neonatal mortality in the Russian Federation in 2010 depending on the age of the deceased. The abscissa shows age (days); the ordinate shows the proportion of total early neonatal mortality. The smallest number of dead newborns was noted at the age of 6 days (5.0%). Such changes, apparently, are due to an increase in the level of the child's viability as the child's body grows and matures, and at the same time, in our opinion, indicate the urgent need for organizing a resuscitation service for newborns in an obstetric hospital.

The greatest number of reproductive losses is recorded in the earliest periods of gestation, and with increasing age of the fetus, the level of losses decreases.

In 2010, the number of deaths before 12 weeks of pregnancy was 72. 5%, at the period of 12-21 and 22-27 weeks 13.5 and 7.8%, respectively, the number of deaths in the early neonatal period was 2.3% of the total the number of prenatal (up to 28 weeks) and perinatal losses [1].

All over the Russian Federation in 2010 were born alive 1,788 948 children, 4948 children died in the first 168 hours. In accordance with this, the average value of the indicator of early neonatal mortality in the Russian Federation in 2010 was 2.75‰. At the same time, there are significant differences in its level in federal districts (Fig. 2). Figure 2. Indicators of early neonatal mortality in the federal districts of the Russian Federation in 2010 Far Eastern District. The lowest mortality rate (1.57‰) was registered in the Northwestern Federal District, the highest (6.32‰), which is 2.3 times higher than the national average, is observed in the North Caucasian Federal District.

For comparison, we point out that the highest rates of early neonatal mortality in 2000 were noted in Mauritania (52‰) and Liberia (48‰), while the lowest rates were in Austria, Germany, and Finland (2 per 1,000 live births) [2]. The average value of the early neonatal mortality rate, calculated by WHO on the basis of data for 192 countries of the world, in 2000 was 23‰.

Even more significant differences in indicators of early neonatal mortality are determined in individual subjects of the Russian Federation. The minimum level of early neonatal mortality, or rather the absence of deaths in newborns in the first 6 days of life (0‰), was noted in the Nenets Autonomous Okrug, and the maximum (9.70‰) - in the Chechen Republic. In this regard, in order to analyze the regional characteristics of the mortality rate, the available range (0–9.7) of its values ​​was divided by us into 3 parts, including 33% of the range of differences [3] and characterizing low (less than 3.23‰), medium (3 .23–6.46‰) or high (more than 6.46‰) mortality rate.

The distribution of subjects according to the level of early neonatal mortality is presented in tab. 2.

All federal districts, except for the North Caucasus and Far East, are characterized by the predominance of subjects with a low level of early neonatal mortality. In the Central Federal District, there are 15 subjects (out of 18) with a low level and 3 (Bryansk, Lipetsk and Ryazan regions) with an average level. All 11 subjects of the Northwestern and 6 subjects of the Ural Federal District are characterized by a low level of early neonatal mortality. In the Southern District (6 subjects), one part of the regions has a low level, the other has an average level. Far Eastern District (9subjects) has 1 region with a high (Chukotka Autonomous Okrug - 8.01‰) and 5 with an average rate of early neonatal mortality. The most difficult situation is observed in the North Caucasian District, where in 3 regions (the Republic of Dagestan - 7.45‰, the Republic of Ingushetia - 6.4‰, the Chechen Republic - 9.7‰) high mortality rates were registered, in 3 - medium and in one - low (Kabardino-Balkarian Republic - 2.14‰).

In general, in the Russian Federation, 59 (71.1%) subjects with low, 20 (24.1%) - with medium and 4 (4.8%) - with high levels of early neonatal mortality were noted.

An objective indicator of the assessment of the activities of health authorities and institutions is the characteristics of the causes of death. According to the regulations in force in 2010, in all cases of death of newborns born at a gestational age of at least 28 weeks and weighing at least 1000 g, medical certificates of perinatal death were drawn up (form No. 106-2 / y-98), on the basis of which the statistical form A-05 of Rosstat was formed. This form consists of cross tables, in which the main diseases and conditions of the child that caused death in the perinatal period are presented horizontally, and the diseases or conditions of the mother, complications from the placenta, umbilical cord and membranes, pathology of pregnancy and childbirth, which caused ( contributed to) the onset of death of the newborn (Table 3).

According to Rosstat, the most common cause of early neonatal death in 2010 is respiratory disorders (P22-P28 ICD-10) - 103.2 per 100,000 live births, which is 37. 3%. More than half (57.0%) of observations in this group are related to hyaline membrane disease. Moreover, hyaline membrane disease (respiratory distress syndrome), according to Rosstat, was the most common cause of early neonatal death in Russia in 2010 and accounted for 21.3%. The group of respiratory disorders also includes congenital pneumonia, which ranks second (8.8%) among all causes of death.

For the group "Congenital anomalies (malformations), deformities and chromosomal disorders" (Q00-Q99 ICD-10), the early neonatal mortality rate is 50.1 per 100,000 live births - 18.1% of all causes of death. In this regard, apparently, it is necessary to more carefully examine pregnant women and, during the perinatal consultation, evaluate the prognosis of the life of the newborn, in particular, with anencephaly, which accounts for 0.06% of all causes of death. The most common cause of death in newborns was heart disease: 35.9% of all developmental anomalies and 6.5% in the overall structure of causes of death. Congenital anomalies of the circulatory system and digestive organs as the initial cause of death account for 8.9 and 5.0% of all malformations, respectively. However, according to the literature [4], with timely diagnosis and surgical correction of congenital defects in the first hours and days of life, in 90% of cases, the life and health of the child can be saved.

The third place among the causes of death is occupied by the group “Endocrine, metabolic and other disorders specific to the perinatal period”: the mortality rate is 36.3 per 100,000 live births, which is 13.1% among the causes of death. Such a significant number of deaths in this group, in our opinion, is due to the large number of various nosologies included in it, in particular, the observations "Extreme immaturity of the fetus" and "Other disorders associated with pregnancy and fetal growth." In our opinion, in order to obtain reasonable conclusions, the group “Endocrine, metabolic and other disorders specific to the perinatal period”, allocated in the statistical form A-05 of Rosstat, should be divided into independent groups.

In this regard, it should be noted that the problem of perinatal mortality in general and early neonatal mortality in particular is largely a problem of miscarriage, the main cause of which is extragenital pathology of pregnant women [5]. According to the literature [6], the survival rate among live births at 22–27 weeks does not exceed 12%.

At the same time, in the Russian Federation there is a paradoxical dynamics of perinatal and early neonatal mortality: the mortality rate of full-term newborns at the 1st week of life decreases to a lesser extent than that of preterm infants. According to L.P. Sukhanova [7], this situation indicates, first of all, the insufficient organization of perinatal care in case of timely delivery. Delivery of women with premature pregnancy is more often carried out in medical institutions that have the appropriate specialists and modern treatment and diagnostic technologies, while the vast majority of full-term fetuses and children are born in hospitals of the first and second levels, in some cases without the necessary resources to prevent and elimination of complications developing in childbirth.

"Infectious diseases" (R35-R39 ICD-10) account for 9.9% of the causes of early death of newborns.

These include congenital sepsis (21.2%). Among all causes of death, congenital sepsis is 2.1%.

Among the causes that contributed to the death of a newborn, in 22.7% of cases, maternal diseases not related to pregnancy were indicated. Of these, 24.7% are infectious and parasitic diseases, 8.6% are diseases of the kidneys and urinary tract. At the same time, toxicosis of the second half of pregnancy was registered in 12.5% ​​of cases (34.5 per 100,000 live births). However, they are noted in 39.6% of deaths from hyaline membrane disease.

Placenta pathology is indicated in 17.2% of cases. Most often it was about lesions of the placenta. At the same time, chorioamnionitis was detected only in 6.9 and 14.4% of deaths from congenital pneumonia and congenital sepsis, respectively.

According to Rosstat, in almost ¹ / ₃ cases of early neonatal death “the cause of the mother’s side has not been established”. In this case, apparently, it is about the absence of an entry in paragraph 23 of the Medical Certificate of perinatal death. It should also be noted that in 0.7% of cases, caesarean section was indicated as the condition that caused the death of the child. In our opinion, most likely we are not talking about iatrogenic, but only about ascertaining the fact of the operation in the Medical certificate of perinatal death. However, in any case, such observations must be subjected to a thorough clinical and anatomical analysis.

Thus, the analysis of the regional characteristics of early neonatal mortality indicates that in most subjects of the Russian Federation there is a positive trend in a significant decrease in its indicators. At the same time, the organization of perinatal care in Russia cannot be unified for all regions, since the high scatter of early neonatal mortality rates and the peculiarities of the structure of causes of death in the regions dictate the need for a differentiated approach to optimizing the maternal and child health service. The main task in improving the health of the next generation should be to improve basic care for every woman and every newborn child. Along with this, it is necessary to constantly analyze the causes of early neonatal death through clinical and pathological comparisons.

Infant mortality in the Russian Federation: statistics, causes, dynamics

In the last issue of Urology Digest N3-2016, we considered the issue of maternal mortality. Infant mortality has always been considered a “sensitive barometer” of the social well-being of society, according to which, as well as life expectancy, the general state of health and quality of life of the population and the level of socio-economic development and well-being of society as a whole are assessed. Together with the level of maternal mortality, it indicates the state of the reproductive health of the population, as well as the state of obstetric services and pediatrics.

Statistics

Infant mortality characterizes the mortality of children in the first year of life. Mortality under the age of 1 year is much higher than the mortality rate at most ages: its probability in this period of time is comparable to the probability of death of people who have reached 55 years of age. At the same time, according to WHO, newborns account for 40% of all deaths of children under the age of five years. The majority of all deaths in the neonatal period (75%) occur in the first week of life, and 25-45% of them occur within the first 24 hours.

According to the WHO classification, there is the following distribution of periods of infant mortality (Fig. 1):

Infant mortality characterizes the mortality of children in the first year of life. Mortality under the age of 1 year is much higher than the mortality rate at most ages: its probability in this period of time is comparable to the probability of death of people who have reached 55 years of age. At the same time, according to WHO, newborns account for 40% of all deaths of children under the age of five years. The majority of all deaths in the neonatal period (75%) occur in the first week of life, and 25-45% of them occur within the first 24 hours. According to the WHO classification, there is the following distribution of periods of infant mortality (Fig. 1): perinatal period (from 22 weeks of pregnancy to 7 days of life (including early neonatal - from the moment of live birth to 7 days - given that when calculating neonatal mortality directly, the denominator contains only born alive, and perinatal - all born, including stillborns) late neonatal period (from 8 to 28 days of life) post-neonatal period (until the end of 1 year of life)

In addition, there is a separate period from age 1 to age 5, when death is classified as “child mortality”.

Fig. 1. Terminology for classifying deaths during pregnancy and early childhood

Calculation of indicators

Algorithms for calculating the infant mortality rate:

The formula adopted by the state statistics bodies in the Russian Federation (Fig. 2):

However, due to the fact that a child can be born in one calendar year (for example, in December 2015) and die in another calendar year (for example, in January 2016), the following calculation method is also used to determine the indicator: .3): By order of the Ministry of Health and Social Development of the Russian Federation of December 26, 2008 N 782n "On the approval and procedure for maintaining medical records certifying cases of birth and death", documents for registering infant mortality were approved by the "Medical death certificate" (f. 106 /u-08) and "Medical certificate of perinatal death" (f. 106-2/u-08).

Fig. 2. Algorithm for calculating the infant mortality rate adopted by the state statistics authorities of the Russian Federation

Fig. 3. WHO algorithm for calculating the infant mortality rate using the Rats formula

Dynamics in Russia

According to the latest data, in the first half of 2015 the infant mortality rate in Russia reached 6. 6 per 1,000 live births. Considering that this indicator is only semi-annual, the coefficient is really high. As Eduard Gavrilov, head of the Health Foundation, notes, “... such an increase in infant mortality was not even during the economic crisis of 2008 and in subsequent years.”

It should be noted that the dynamics of changes in the infant mortality rate in the Russian Federation is still not stable. In various periods of time, the Federal State Statistics Service of the Russian Federation notes both its decrease and increase (Fig. 4).

Fig. 4. Dynamics of changes in the infant mortality rate in the Russian Federation in the period 2008-2014

For example, in 2014 the infant mortality rate was 7.4 per 1000, which is lower than in 2013 – 8.2 per 1000 live births. At the same time, as the Deputy Director for Research of the Federal State Budgetary Institution Scientific Center for Obstetrics, Gynecology and Perinatology named after V. I. IN AND. Kulakova Dmitry Degtyarev, the decline in infant mortality is never synchronous in all regions. Thus, in the first half of 2013, infant mortality rates above the national average were observed in 25 regions (30.11%), in the first half of 2014 - in 16 (18.8%), and in the first half of 2015 an increase in infant mortality mortality rates were higher than the national average in 20 out of 85 regions, amounting to 23.5%.

Fig. 5. Distribution by indicators of infant mortality in the Russian Federation depending on the place of residence

The infant mortality rate also differs depending on whether the woman in labor lives in the city or in the countryside (Fig. 5). As in the case of the statistics of the Federal State Statistics Service of the Russian Federation on maternal mortality, mortality rates among the rural population exceed those among the urban population.

Infant mortality by regions of the Russian Federation

As noted above, infant mortality rates vary by region as well. According to the Federal State Statistics Service of the Russian Federation on infant mortality in the constituent entities of the Russian Federation for the period January-December 2015, the districts with the highest infant mortality rate are the North Caucasian Federal (11.9‰ in 2014 and 10.3‰ in 2015) and Far Eastern Federal (9.1‰ in 2014 and 7.6‰ in 2015). Districts by the lowest indicator are Privolzhsky Federal (7.2‰ in 2014 and 6.1‰ in 2015) and Northwestern Federal - (5.8‰ in 2014 and 5.3‰ in 2015) ( Fig. 6)

Fig. 6. Infant mortality by constituent entities of the Russian Federation in 2014 and 2015

Periods of infant mortality

Within the framework of the first year of human life, which considers the infant mortality rate, three periods are distinguished, differing both in the probability of death and in the structure of the dominant pathology.

The perinatal period is the period from the 22nd week of pregnancy to the end of the 7th day of extrauterine life. Separately, intranatal (from the time of the appearance of regular labor pains to the moment of ligation of the umbilical cord - 6-8 hours) and early neonatal periods (from the moment of live birth to 7 days of life) are distinguished in it. Difference: when calculating neonatal mortality, the denominator is only those born alive, when calculating perinatal - including stillborns. This period is the most important time in the life of the fetus and newborn, characterized by the highest risk of death (taking into account the fact that it includes children born prematurely). It accounts for up to 75% of deaths in the first year of life and up to 40% of all infant deaths under 5 years of age. The value of this indicator, especially in interregional and interstate comparisons, characterizes the level of a mother's reproductive health, her quality of life, the state of obstetric care, and many other aspects of medical and social development. It is also believed that with sharp fluctuations in the indicator, the dynamics of perinatal mortality indicates distortions in the statistics of infant mortality, since the number of deaths during this period correlates with the total number of births, both alive and dead.

Since 2012, the Russian Federation switched to birth registration according to the WHO criteria (gestation period of 22 weeks or more, body weight at birth of a child of 500 g or more or less than 500 g in case of multiple births; body length of a child at birth of 25 cm or more - in if the birth weight of the child is unknown). Caring for these children represents a challenge of a new level of complexity and guides the search for solutions to reduce fetal loss, neonatal disability and infant mortality.

Causes of infant mortality in the perinatal period are usually divided into two groups:

1. diseases or conditions of the mother or placenta, pathology of pregnancy and childbirth;
2. diseases and condition of the fetus

The first group of causes includes complications from the placenta, umbilical cord and membranes - premature detachment of the placenta, pathology of the umbilical cord, etc.; such complications of pregnancy as toxicosis of the second half of pregnancy, premature rupture of amniotic fluid; directly complications of childbirth and delivery.

Causes of perinatal death by a child in developing countries are: 22.5% each - asphyxia and birth trauma, 12.7% - congenital malformations, 1.4% - infections. Developed countries have a higher proportion of congenital anomalies and a lower proportion of intrapartum causes and infections.

The neonatal period is the period of a child's life from the moment of birth to the age of 28 days. Within the framework of the neonatal period, two are distinguished: early (1st week of life) and late (2nd - 4th weeks), which correspond to the concepts and indicators of early and late neonatal mortality.

The main causes of neonatal mortality are: congenital malformations, birth trauma, neonatal pneumonia (excluding congenital). The ratio of these causes varies depending on the standard of living and the state of healthcare in terms of obstetric care. The fundamental feature of infant mortality in Russia, which qualitatively distinguishes it from the EU indicators, is a steady trend towards a decrease in the share of neonatal mortality in favor of an increase in postneonatal mortality. This feature of the dynamics of the indicator is due to the so-called. "underregistration" of dead newborns. The main ways to underestimate the infant mortality rate are the “transfer” of dead children to stillbirths that are not taken into account in state statistics, or the assignment of a deceased child to “fetuses” unregistered in the registry office (“miscarriages”, which in domestic medicine - up to 2011 inclusive - included termination of pregnancy up to 27 completed weeks). In practice, these two "mechanisms" are identified on the basis of obvious structural disproportions in the number of live and stillborns, as well as on the dissociation of the weight structure of the dead - the disappearance of children of borderline body weight (1000-1499d), "thrown" into unregistered "fruits".

The third period, which is allocated within the framework of the first year of life, is postneonatal - starting from the 29th day of life and until reaching 1 year, for which the corresponding indicator of postneonatal mortality is calculated. Among the main causes of postneonatal mortality are congenital anomalies, respiratory diseases, and external causes. The latter include the quality of care and nutrition, the timeliness of pediatric care, and injuries.

Dynamics - historical facts

The past century has been marked by a significant decline in infant mortality throughout the world. If at the beginning of the twentieth century in Norway, every twelfth-thirteenth newborn died before reaching the age of one, in France - every seventh, in Germany - every fifth, in Russia - every fourth, then in the period from the middle to the end of the twentieth century. the infant mortality rate has fallen unprecedentedly.

However, changes have taken place with varying degrees of success. At the beginning of the XX century. infant mortality rates in Russia were extremely high: at 19In 01, the proportion of deaths at this age was 40.5%, gradually decreasing to 38% in 1910. During this period, Russian indicators exceeded the corresponding data in developed countries by 1. 5-3 times. The main causes of infant mortality in the early XX century. were gastrointestinal and infectious diseases, respiratory diseases. In many ways, such a high level was associated with the peculiarities of feeding infants in Russian families, where it was traditionally accepted almost from the first days of life to give a child complementary foods or completely deprive him of breast milk, leave him without a mother in the care of adolescent children or the elderly. .

Also, the causes of high mortality were the underdevelopment of the system of medical care and obstetrics, the difficult sanitary conditions of work, life and living conditions, lack of knowledge of hygiene, low literacy of the population. In Russia, there was no legislation on the protection of motherhood and childhood, which has existed in many European countries for a long time. In the 1920s as a result of health care reforms on the adoption and implementation of legislative acts and decrees on the protection of motherhood and childhood, on the development of the system of obstetrics and medical care for mother and child, on the creation of infrastructure for caring for children (dairy kitchens, nurseries, patronage system, shelters for infants) , to carry out health education as an integral part of the cultural revolution, a reduction in infant and maternal mortality was achieved. At 1926, the Russian mortality rate for children under 1 year old was 188 per 1,000 births, i.e., for the first quarter of the 20th century, having decreased by almost a third.

1930s characterized again by fluctuations in the level of infant mortality due to influencing economic and social causes. There was a curtailment of the NEP, the process of industrialization and collectivization of agriculture began, which contributed to the growth of indicators to the level of the first decade of the 20th century. In 1933, the highest level of infant mortality was reached - 295.1‰ - largely due to the mass starvation of the population, and only by the end of the 1930s. began to decline again. The main reason for this was the implementation of measures to protect motherhood and childhood, the growth of sanitary literacy of the population, and the improvement in the quality of medical care.

After the Great Patriotic War, there were again improvements in performance. First of all, this is due to the appearance and use of antibiotics and sulfanilamide drugs in the treatment of gastrointestinal infections and pneumonia, which led to a significant reduction in the mortality of children under 1 year of age from respiratory diseases and infectious diseases. As a result, at 1946, the infant mortality rate in Russia was 124.0‰ compared to 205.2‰ in 1940. And by the mid-1960s. mortality in the first year of life decreased in the country by another 5 times: to 26.6‰ in 1965

The reduction in infant mortality continued in the future. From the 1960s to the end of the twentieth century. its level decreased by 2.5 times. However, this decline was repeatedly interrupted by periods of increase: in 1971-1976, 1984, 1987, 1990-1993 and 1999. Significant was the growth of the indicator in 1990−1993 from 17.4 to 19.9‰, which is associated with the transition from January 1, 1993 to the definitions of live birth recommended by WHO.

At the World Summit for Children, held in 1990, the first agreed goal was to substantially reduce infant and under-5 mortality. Subsequently, significant emphasis was placed on this in the commitments made in the outcome document "A world fit for children" during the special session of the UN General Assembly on children in 2002. In addition, since 2000, reducing child mortality by 2/3 by 2015 was included in the list of the UN Millennium Development Goals. And, according to the 2015 MDG report, the under-five mortality rate worldwide has more than halved, falling from 90 to 43 deaths per 1,000 live births over the period 1990–2015

Currently, as mentioned at the beginning of this work, infant mortality rates are not stable, but compared to the 20th century. the dynamics are definitely positive. According to the Federal State Statistics Service of the Russian Federation in 2014, the infant mortality rate will be 7.4, although the figures for 2015, judging by the data for the first half of the year, are likely to be higher. In accordance with the analysis of existing problems to reduce infant mortality, which is one of the goals of the "Strategy for the development of healthcare in the Russian Federation until 2020", the following provisions can be put forward:

• ensuring equal access to highly qualified specialized care regardless of residence in urban or rural areas through the regionalization of care;
• tiered perinatal care system
• expanding the network of perinatal centers with the ability to provide optimal care for seriously ill and extremely immature premature babies
• providing equitable high-tech care for pregnant women and high-risk women in childbirth;
• ensuring a full examination of potential parents for congenital diseases and possible pathologies of the unborn fetus;
• improving the quality and regularity of observation of pregnant women for timely referral to institutions of the required functional level, corresponding to the state of health of the woman, the condition of the fetus, the nature of the course of pregnancy and the expected timing of delivery;
• monitoring the effectiveness and timeliness of hospitalization in compliance with the principles of regionalization; development of an emergency transport service for pregnant women, women in labor and newborns;
• providing conditions for continuous medical education and advanced training of personnel;
• a comprehensive analysis of the causes of perinatal mortality (including stillbirths) separately for full-term and preterm infants in order to identify existing reserves to reduce perinatal losses;
• improving the reproductive education of Russian youth and the development of the appropriate mentality of future parents, based on a responsible attitude to their own health.

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