PERINATAL AND INFANT MORTALITY TRENDS AND DEATH’S CAUSES IN CROATIA

Abstract

Među najvažnijim pokazateljima kojima mjerimo ostvarenje Milenijskih razvojnih ciljeva broj 4. i 5. su perinatalni i dojenački pomor. Budući da je rani neonatalni pomor sastavni dio perinatalnog i dojenačkog pomora te da stanja iz perinatalnog razdoblja značajno utječu na rast i razvoj dojenčeta, analizirano je kretanje perinatalnog i dojenačkog pomora u Hrvatskoj u zadnjih 10 godina te uzroka smrti u 2009. godini. U razdoblju 2000.–2009. godine perinatalno je umrlo 3755 djece i prosječna stopa perinatalnog pomora je 8,9/1.000 ukupno rođenih porodne težine (PT) 500 grama, a prema kriteriju za međunarodne usporedbe, za ukupno rođene PT1000 grama, je 6,1‰. Prema ukupnom broju i strukturi perinatalno umrlih u 10-godišnjem razdoblju je umrlo najviše djece PT 500–999 grama i njihov je udjel u svim smrtima 31,9%. Među rano neonatalno umrlima je najviši udjel (39,3%) u skupini PT 500–999 grama. U fetalnim smrtima je najviši udjel (30,4%) umrlih PT 2500 grama. U istom razdoblju je umrlo 2538 dojenčadi i prosječna stopa dojenačke smrtnosti je 6,1/1.000 živorođenih. Najviši je bilo ranih neonatalnih smrti (59,1%), kasnih neonatalih smrti (15,6%) te postneonatalnih 25,3%. U 2009. godini 53% od svih ranih neonatalnih smrti je bilo u dobi trudnoće 22–27 tjedana, a uzroci su najčešće vezani uz komplikacije višeplodovih trudnoća i posljedičnu nezrelost s respiracijskim distresom i/ili intrakranijalnim krvarenjem, a nakon 27. navršenog tjedna perinatalna stanja čine svega 17% ranih neonatalnih smrti. U dobi trudnoće od 32–36 tjedana i ročnim trudnoćama najčešći uzroci ranih neonatalnih smrti su kongenitalne malformacije s udjelom od 10% odnosno 15% svih ranih neonatalnih smrti. Mrtvorođenja su u 92,2% uzrokovana stanjima iz perinatalnog razdoblja te u 7,8% kongenitalnih malformacija. Stanja iz perinatalnog razdoblja kao uzroci mrtvorođenja su otprilike podjednako zastupljeni udjelom iznad 20% u dobi trudnoće od 22–27, 28–31, 32–36 i 37 navršenih tjedana, a kongenitalne malformacije s udjelom od 3,1% u dobi trudnoće 22–27 i 32–36 tjedana, s 0,5% u dobi trudnoće 28–31 tjedan i s 1,1% u ročnim trudnoćama. U dojenačkim smrtima najčešći su uzroci (52%) komplikacije trudnoće i posljedična nezrelost te kongenitalne malformacije (36,6%). Sniženje perinatalnog i dojenačkog pomora u Hrvatskoj može se postići primjenom mjera, nakon poroda vezanih uz bolju organizaciju i uvjete intenzivnog neonatalnog liječenja te prije poroda antenatalnom dijagnostikom i intervencijskim mjerama. Hrvatska ima nižu stopu perinatalnog pomora u djece PT 1000 grama, nego je prosjek zemalja Europske unije i zemalja SZO Eur-A, s dobrim zdravstvenim pokazateljima, ali više stope rane neonatalne i ukupne dojenačke smrtnosti. U većini europskih zemalja s niskim stopama perinatalnog, dojenačkog i ranog neonatalnog pomora je, za razliku od Hrvatske, provedena regionalizacija perinatalne zaštite te su ovakve organizacijske mjere doprinijele značajnom smanjenju perinatalnog i dojenačkog pomora.Among the most important indicators to appreciate the achievement of Millennium Development Goals No. 4 and 5 are perinatal and infant mortality. As early neonatal mortality is an integral part of the overall perinatal and infant mortality, and since perinatal conditions significantly affect the growth and development of infants and young children, a study was made of the Croatian trends of perinatal and infant mortality over the last 10 years and causes of death in 2009 as well. Between 2000 and 2009, 3755 perinatal deaths occurred. The average perinatal mortality rate was 8.9/1,000 in all births with birth-weight 500 grams, while, according to the criteria for international comparison, the equivalent rate in all births with BW 1000 grams was 6.1‰. According to the total number and structure of perinatal deaths in the 10-year period, among all births the highest mortality rate was with BW of 500–999 grams – 31.9% of perinatal deaths. Among early neonatal deaths, the equivalent mortality rate was also highest in the 500–999 g BW group, with a share of 39.3% in overall early neonatal deaths. In fetal mortality, the highest rate (30.4%) was at BW 2500 grams. In the same period, 2538 infants died, while the average infant mortality rate was 6.1/1,000 live-births. Early neonatal deaths had the highest share – 59.1%, and were followed by late neonatal (15.6%) and postneonatal deaths (25.3%). In 2009, 53% of total early neonatal deaths belonged to the gestational age of 22–27 weeks; the causes of death were most commonly related to complications of multiple pregnancies and consequent immaturity with respiratory distress and/or intracranial hemorrhage. Deaths caused by perinatal conditions after completed 27 weeks of pregnancy accounted for 17% in overall early neonatal deaths. At the gestational age of 32–36 weeks and in term pregnancies, the most common cause of early neonatal deaths were congenital malformations with respective shares of 10% and 15%. Stillbirths were caused by conditions from the perinatal period in 92.2% of all cases, and by congenital malformations in 7.8%. Perinatal conditions as causes of stillbirth were more or less equally represented in a share of over 20% of mortality at the gestational ages of 22–27, 28–31, 32–36 and > 37 weeks. Congenital malformations, however, occurred in 3.1% of the cases at the gestational ages of 22–27 and 32–36 weeks, 0.5% at the gestational age of 28–31 weeks and 1.1% in term pregnancies. The predominant causes of infant mortality were pregnancy-related complications and consequent immaturity in 52% of the cases, and congenital malformations in 36.6% of all infant deaths. A reduction in perinatal and infant mortality in Croatia can be achieved by introducing the measures of improving the organization and conditions of neonatal intensive care after birth, and antenatal diagnostic and intervention prior to delivery. Croatia has lower perinatal mortality in total births with BW >1000 grams than is the average of the EU and WHO Eur-A countries with good health indicators, but has considerably higher rates of early neonatal and overall infant mortality. Most of European countries with low perinatal, infant and early neonatal mortality have, unlike Croatia, implemented regionalization of perinatal health care, which has led to a significant decrease in perinatal and infant mortality