Совершенствование системы охраны здоровья женщин в...
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Результаты пилотного проектаTRANSCRIPT
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РОССИЙСКАЯ ФЕДЕРАЦИЯ
СОВЕРШЕНСТВОВАНИЕСИСТЕМЫ ОХРАНЫ ЗДОРОВЬЯЖЕНЩИН В РОССИЙСКОЙФЕДЕРАЦИИРезультаты пилотного проекта
Документ Всемирного банкаИнформационный центр в России
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Improving women's health services in the Russian Federation: results of a pilot project / PatriciaStephenson...[et al].
p. cm. - (World Bank technical paper; no.404. Social challenges of transition series)Includes bibliographic references and index.ISBN 0-8213-4197-91. Maternal health services-Russia(Federation)-Statistics. 2. Women's health services-Russia
(Federation)-Statistics 3. Pregnant women-Health and hygiene-Russia (Federation)-Statistics. 4. Russia(Federation)-Statistics,Medical.1.Stephenson, Patricia,1954-.ll. Series. Ill. Series: World Bank technical paper; 404. IV. Series: WorldBank technical paper. Social Challenges of transition series.RG964. R8147 1998362.1 '982'00947-dc2l 98-14708
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* O6y4eHme cneLk4aniu4cToB, oco6eHHo B o6JaCT14 nflaHJ4pOBaHU14 ceMb1, nponaraHAbi3AOPOBoro o6pa3a )KU43HU4 U MeA"LAHHCKoro npOCBeLL4eH14R.
* PacwmpeHme ycJyr no niiaHMpOBaHMIO CeMb14, KOTOpbl8 AOnOKHbl CTaTb HeoTbeMJleMoriLacTbIo pa6oTbl no npeAOCTaBneHmio rMHeKOnor"qeCKO4 noMoLL4, npoBeAeH4lo a6opTOB Uo6cJIy)Kt1BaHmio naLA4eHTOK B nocJ1epOAOBor nep"oA.
* CoKpai4eHme 4mCna cny4aeB rocnfTanM3aLAw4 14 Bbl3OBa Ha KOHCYJ1bTa4LfIO B nePflOA6epeMeHHOcTm, a TaKoKe KOJ114eCTBa o6f3aTej1bHbix aH3an11430B u npo0LeAyp, KOTOpbieHeo6xoAi4Mo npOAT14 B LBenHx nony4eHmS nOMOLu4 no Bonpocam nnaHHPOBaHUH4 ceMbu4,a6opTa u alHTeHaTa8jbHo4 noMouL4. -
* noBblweHue Ka4eCTBa o6Cny)Kt4BaH14R, oco6eHHo yKpenneH1 e o6pa3oBaTeJIbHMx aCneKTOB,BKnKo4eHme nfLLAeBblx Ao6aBOK B paLA4OH 6epeMeHHbMx U COBepLweHCTBOBaH1e cny)K614HTeHC14BHOr Tepanf414 B aKywepCTBe A HeOHaTOJlormm.
* AKywepcK1e cjnyw6b] B 6o.nbH14Lax AOJDKHbi 6biTb npMBeAeHbi B COOTBeTCTBUe cpeKOMeHAaLAt4uM14 B03 u IOHMCED no "Apy)KOCTBeHHOMy" MeAU4LU1HCKOMy o6cJ1y)KMBaHmioMaTepe u MmnaAeHL4eB. TaKoA noAxoA BKJKO0aeT noBceMeCTHoe HaJlH4'4e naJlaT,o6opyOSBaHHbIX AnDJ COBMeCTHOrO npe6blBaHMA MaTep u14 HOBopo)KAeHHoro, nooLL4peH14erpyAHoro BCKapMjnUBaHUsH no Tpe6OBaHU1I MflaAeHLAa, a He no pe)K14My, npaKTf1KY KOHTaKTaMaTepI C HOBOpo)KAeHHbJM cpa3y nocnie pOAOB, np1MeHeHi4e yCOBepweHCTBOBaHHbIXMeTOU14K peaHmmwAtm HOBOpO)KAeHHbIX.
I
COBePpweHCTBOBaH4e CmCTeMbi OXpaHbi 3aOpOBbS xemHuH B PoccHUUcKoU Oeepawfu
3a npOBeAeHIeM 3Toro 3KcnepwMeHTa Ha6nioAaji KOHCynbTaTt'BHbir COBeT, B COCTaBKoToporo BXOAMJUn npeACTaBITeJi4 ropoAa Iio6epLbi, MMHIICTepCTBa 3ApaBooxpaHeHM4I,MOCKOBCKOU o6nacTM Ui BceMwpHoro 6aHKa. 3aTpaTbi npeAycMaTpiBsaJU o6y4eHklecneLti4anJ4CTOB, 3aKynKy o6opyAoBaHmsi, a TaioKe K0HTpa4LenTl4BOB M nl4Ln±eBblx Ao6aBoK.OCHOBHbie 3aTpaTbi npoeKTa 6bunm nPO4)MHaHCMPOBaHbl 3a C4eT rpaHTa, npeAOCTaBJ1eHHoronpaBMTeBfbCTBOM InOHMN, ynpaBneHMe KOTOPbIM ocyLLAeCTiJnmn BceMMpHbir 6aHK. Awo Ha4anapeanMmaLmMH 3KcnepMmeHTa U no ero 3aBepwQeHmL 6biw npOBeAeHbl t4ccneAosaH49, OLenbIOKOTOPbIX cTania OLAeHKa npMnemJ1MOCTL4 L43MeHeHl4u MeeA.4LAMHcKor4 npaKT&4KI4 An9/meAnepcoHana u naLAeHTOK, BbIFHCHeHme MHeHmU1 noTpe6MTeneru o MeAl4ULAHCK0Mo6ch1y)K4BaHl4M 1 oL0eHKa BII9H14R 3TUIX U3MmeHeHM Ha Ka4eCTBO OKa3aHW5I MeeAt4LA4HCKOAnOMOuAc .
2
II. PenpoAyKTUmHoe 3AopoBbe )KeHL4HH B PoccUicKoU O eA epa4nu
B 1995 r. npOAOJunK4TeJ1bHoCTb )KM3H' )KeHILLMH cocTaBiniHna 72 roAa, 4TO M3HaTenbHOHmIKe, L4eM B CTpaHaX 3anaAHoi EBponblU CWA [2]. nocne nepBbIX 3aMeTHbiX AOCTM)KeHMA BOTHoWeHi4m npOAOJ1)KL4TeJ1bHOCTM )KW3HI, OTMe4aBWMXCS B nepBou nOIOBmHe ABaA,LaToroBeKa, HacTynmna CTarHat4A [21. K 1990 r. nPOAOJDKMTeJ1bHOCTb )KM3HI4 )KeHCKorO HaceneHM4
AOCTmriia caoero nMKa, paBHoro 74,4 roAa, a 3aTeM cTania 6blCTpO CHI4)KaTbCs AOCOBpeMeHHoro ypOBHFI [2] . HawnHasi C 1985 r., POCT YPOBHI CMepTHOCTM 14 CH)KOeHMepO)KAa8MOCTt4 npmBeJnu K COKpaULLeHILio eCTeCTBeHHOrO np14pocTa HaceiIeHus (P1ucyHoK 1A, 16)[2]. 3TU TeHAeHLAMM Bbl3blBalOT 6onbWyIO TpeBory y PYKOBOACTBa pOCCMACKOrO3ApaBooxpaHeHmsi, 14 AOn)KHbl y4HTblBaTbCS B onpeAeneHm npi4Op4TeTOB An Mpa3pa6aTblBaeMbwx nporpaMM nnaHwpoBaHl4I4 ceMbI4.1
PUCYHOK l.a. 06u4He YPOBHH pOX4AaOMOCTM H CMepTHOCTh B POCCnACKOAOeAepaL4U 3a nePUOP, 1991 -1995 rr. (Ha 1000 MlTeneg)
16 -
15 151.' 4.5
14
13
12 --i|-!-o6upvR ypOBeHb11-1 f ;CMepTHOCTU
-o6u4Mii ypOseHb
10 rpOC4AeHNR
9 ~9.4 3
6 I I
1991 1992 1993 1994 1995
,AaHH1e ,eanapTaAeHTra s4pasooxpaHeHnHG H CO14fafl7HbIX c,y,W6 CIIIA, 1995r.
3
COBemmeHCTBOBaHme CHCTeMbJ OXpgHbJ 3zOpOBbR .KeHLuWH B PoccUiUCKoiU ceepauuH
PUcCYHOK 1.6. npoAon)KUiTenbHOCTb WU3HN MY)CKOrO U weHCKOrO HaCe6J1HUR BPOCCUiUCKOU OeAepamlU 3a nePUOA 1991 -1995 rr.
75
72
70 7.
65635 5 -nPOAOnKTenbHOCTb )KN3HU
2 [mce H.]
60 -nPOAOnXDICTenbHOCTb ICIU3HU, 57 1 [MY)K.]
58
55
50I I1991 1992 1993 1994 1995
roA
.4aHHble.74enapTameHTa 3ApaBooxpaHeGHHR H coL4Hrfahbx cn7yw6 CliA, 1995r.
3a nocneAHee AeCSITmfleTMe o6uAr4i YPOBeHb MaTepiHCKOU CMepTHOCTU BPOCCUUCKOU OeAepa4Mm yMeHbUi^4JCA He3HaIMTenbHO. CTaTWCTM.ieCKt.e AaHHbie,npeACTaBneHHbie B OT4eTax MMHU4CTePCTBa 3ApaBOoxpaHe8HMS, MOryT HeAoLOOeHmBaTbpeanbHYIO cmTyaLAmo - no oL0eHKaM B03 Ui IOHICECP B HaCTORUAee BpeMA B POCCUUCKOUc3eAepaLU,UU MaTeP4HCKas CMepTHOCTb COCTaBJsieT 75 CMepTeA Ha 100 TbICS4 )K4BOPO)KAeHHbIX(To eCTb B 4 - 7 pa3 BbLUe, 4eM B 3anaAHoi EBpone U CWA) [3].OCHOBHblMU4 npM4HHaMmMaTepMHCKOU CMepTHOCTU 5IBJ15IIOTCSI KpMMI4HanbHbie a6pmTbi, KpOBOTe4eHI U1 Onr-recTo3b(TOKceMmsi) (PICyHOK 2) [2].
4
CoBepuJeHCTBOBxHMe CMCT M6I Oq NeHHblLOpOBb5 KeHlUMH B POCCUUCKOU (eepau Li
PHCYHOK 2. flnpwHbI MaTepHHCKON CMePTHOCTH B POCCHiCKOA OeAepagUmm.A,aHHbie 3a 1993 r.
6epeMeIHcrTb
7%
npo- --
35%u A 111
------- -- ---
1 flfl -a6oprri i - -- 2996
- - n - C-. -0
A4aHHbie ALenapTameHTa 3ApaBooxpaHeH5q £4 coL4HiiabHbIX cn7yx~6 CLLIA,1995 r.
POCT YPOBHsR flpIMmHeHM45 KOHTpaLkelTI4B0B 6bIn He3Haqi4.TeJ1bHbIM B CBR13M C POCTOM'rncna Ao6pOBOnbHbIiX CTepM.Ju43aLAmAi (PI.CYHoK 3) [4]. CTept4nl3aLkmS~ KaK meTOA KOHTpBLJ,enLAi.Im6binua pa3peweHa B 1990 r. [nlpMKa3 MW~H3ApaBa N2 484]. OAHaKo nipMKB3 KacauiC5 TOJ1bKO)KeHLLAI4H. B npliWa3ax MAH3A,paBa Aaw He yflOML4HaeTCA B03MO)KHOCTb Ba3eKTOM1.IM (My)KCKagKOHTpaLiBflTi4BHaFi CTepmiMu3aL;mFi), B CBA3L4 C 4em 3Ta npoLAeAypa He flPOM43BOARMTCR 14OCTaeTCSI, c npaBOBOA T04IKL 3peHMS1, "(TeMHOr4 o6J1aCTbIO)) [5].
CornlaCHO CTaTl4CTI4K M MH3ALpaBa opaJIbHbie K0HTpaLiAflTLBbI (OK) i4cnolOJb3yIOTCSITon1bKo 2-4% )KeHL1I4MH penlpOAYKTM1BHorO B03paCTa, a BHYTPImmaTO'4Hbie cpeA~CTBa (BMC) -
OKO,no 20% )KeHWLI4H penP0AWKTIOBHoro so3paCTa [1,4]. OA~HaKO CTaTL4CTI14Ka MMH3ApaBa moNKeTHeA0ooLeHMBaTb YP0BeHb wcflonb3OBaHMS~ KOHTpaLAenTwBoB, T.K. )KeHI4A14HbI moryT nloKynaTbopaJIbHbie KOHTpaLAenlTIBbi 6e3 peLAenTa B meCTHbIX KIVIOCKax mnM anTeKaX mJ1m flOly'4aTb BMC4n11 A~PyrMie K0HTpaLtAflTt4Bbi no 'IaCTHbIM KaHafiam.
A60pT OCTaeTCFI OCHOBH-bIM meTOA~OM peryn1L4poBaH4MI po)KAtaeMOCT14. B 1992 r.COOTH0weHmBi a6opToB 14 )KmBbix POAOB 6bulo cnyioeLyLauL4M: Ha KawAJbie 1000 POA~OBnlPmx0AMJ1OCb 2165 a6opToB [1]. CorniaCHO oLAeHKam, cpeAtHFISl POCCMHACKaFi )KeHLLt,HHa BTBL4eHMB aceg )KM3HH A~eJaeT 6-8 a6opToB [1 ]. Ensi~ cpaBHeH14SE COOTHOweHme a6opToB 14)KmBbIx POAOB B 3aflaALHbIX CTpaHaX COCTaBJ1ieT OT 90 (ronilaHAMRn) A~o 346 (CWA) Ha 1000 [5].Eo.nbWMHCTBO a6opToB (71,4%) )KeHLLAiMHb AEen1aIOT B camom pacLABeTe penpozAyKTMBHoroBoapacTa [6]. JAeCflTb nlpoLAeHTOB a6opToB flPIXO,A14TCIA Ha nlOALPOCTKOB 14 fl4TM 19% - Ha
5
)KSeH14MH B BO3paCTe 35 nieT u cTapwe [6]. 32% npoLAeHTa a6opToB 6bio cAenaHo BO BTOPOMTPuMeCTpe 6epeMeHHoCTM, KorAa PUCK MaTePMHCKOr CMepTHOCTM uin 3a6oJieBaBMOcTM3HaU4TeQJbHO Bbiwe, L4eM pUCK, CBA3aHHblr4 c a6opTOM B nepBOM TPUMeCTpe [6].
PNCYHOK 3. YpO6eHb MCnOJ1b3OBaHHU CpOACTE KOHTPa4Lt6nL4H B POCCUACKORePeAepaiwn B nepMOA 1991-1995 rr. (Ha 100 XKeHL4MH 4*OpTHJbHoro
BO3pacTa)
40. x38.8
35 ;8- ; ' 3 t8 *37.3
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15 15.1 UCTO ", 1996 fl
4OaHbIe M3TOTrepcrHbB ,na 3fpaOOxpaeHNR U pKMeAUHCKOiB lPObWlM HTHOpTU B03. B 1996 r.
Kecapeeo CeL4eHI4 6blo flPMMBHBHO TOJ16KO B OKOI1O 10% cJiy'aeB, J1MWb B pB^KMX cJly'aRxnpMMSHsnu1Mb BBKyyMHbI6 3KcTpBKTopbI 4lI unu urflLAbI. (puc 4). JJ.jis CpaBHBHIIR, o6u4~ee 'rncnocJly'4aeB xIlpyprl9ecKoro BMKTObCTBB BO BpBMR pOBOB B CTpSNBX 3a aKHiOi Emponbl UCWA HBMHoro npesbiwaiiu pSKoMSHMoBBHHbIB cTBH;apT6I B03 no poMoBCfloMoNCSHIIo.
6
COBepWeHCTBOBaHMe CfCTeMbl OXp8Hbi 3AO=OBb9 )KXeHWH B POCCUUiCKOUl bePaUUU
PHCYHOK 4. K03S¢NL%IIHT aKyW.pCKoro BMetuaTJlbCTBa npHpOAOBCnOMO)KeHUM B PNO (Ha 100 pOAOB), 1991-1995 rr.
12
10 10.1
8
_ 6 +KecapeBo ce4eHN
4 -BariHanbHble
onepaTHUHbieBMeWaTenbCToa
2
0.5
1991 1992 1993 1994 1995
roA
AiaHHble MiUHUCTepCTBa 3aPaBOOXpBHeHIqR U MeCAl4NHCKOKf flpOMMbIWJIeHHoCT;b, 1996 r.
C 1990 no 1993 rr. 3a6oJleBaeMoCTb rOHopee B0Oapocna Ha 78% (Co 128,0 CnY4aeB HaKa,KAbIe 100 TbICs'4 4eqoseK Ao 228,1 cny4aeB Ha Ka)KAbie 100 TbICsH LienoBeK), a cuMA4pMcoM -B nfTb paB (c 5,3 cIly4aeB Ha Ka)KAbie 100 TbICF14 4enoBeK Ao 33,8 cny4aeB Ha Ka)KAbie 100TbICF14 4enoBeK) [2]. 3a6oneBaeMOCTb renaTUTOM A U B CHU3U4JnaCb (c 226,7 CJly4aeB HaKa)KAbie 100 TbICM4 4eAoseK B 1990 r. Ao 136,2 Ciy4aeB Ha KawAble 100 TbIC^H 4enJoBeK a 1992r.), HO OHa no-npe)KHeMy HaMHOro BbSieW, 4eM B 3anaAHor EBpone 14 CWA. [2]. O4)MLA4aJbHO3apermCTpupoBaHHble cny4a 3Bapa)KeHm1i B4L/CnlloAoM B PoccuM HeyKJ1OHHO pacTyT - c 581cny4aq no COCTOSHUIO Ha 30 CeHTm6ps 1992 r. Ao 717 cnyLiaeB no COCTOSIHUIO Ha 1 anpens1994 roAa [2]. OKOAo nOJ1OB&lHb6 Bcex BbISBi1eHHbIX cjiyHaeB - 3TO AeTm AO 15 AeT [2].
7
Ill. CHCTeMa OxpaHbI penpOAyKTHBHoro 3AOpOBbSg B POCCUACKOUOVeAepaiuu
PoCC14UCKoe npaBUTenJbCTBO TpaA3U14OHHO yAe11Fino 6OrnbWoe BHUMaHMe oxpaHe
3AOpOBbSP )K8HLLkMH 14 AeTeA. C14CTeMa MmeeT MHo)KeCTBO Ba3)KHblx npe1mMyL4eCTB, T.K. OHaco3AaBaniacb no npMHL14ny cnpaBeAnJBoCT1 u AOcTynHOCT1I. OAHaKo Co BpeMeHeM u no mepeCOKpaLL4eHUP peCypCOB C14CTeMa MeA4LkHCKOA nOMOLLl4 )KeHLW4HaM penpOAyKTIIBHoroB03paCTa cTaiia He30eKTUMBHOR: Ay6nmpo3aHme 4yHKLM4A, qpe3mepHoe MHBeCTMpOBaHMe
CpeACTB B CTaL14OHapHOe o6CJly)KMBaHme u npeHe6pe)KeHme TaKuMu Ba>KHHbIMM ycilyraMm, KaK
nepBM4Han MeAML4LHCKai nOMOLU.b, nponaraHAa 3AOPOBoro o6pa3a )KU3HU U CaHuTapHo-
MeAM4LkHCKoe npoCBeLl4eHue.
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pQo 1992 r. pa3pa6oTKa CTaHAaPTOB MeA14mLHCKOi npaKTMKM u KOHTponb 3a mx
co6rnKoAeHmeM 6bri4n npeporaTrBoB MMH3ApaBa. BnocneAcTBVIM OTBeTCTBeHHOCTb 3a
o6ecne4eHme u 4)1HaHCMPOBaHme 3ApaBooxpaHeHFiP 6bLnm nepegaHbi c LteHTpanbHOrO YPOBHI
Ha o6J1acTHoA (permoHanbHbIM BJ1aCTRM). B 3TO wKe BpeMH roCyAapCTBeHHbig KOMUTeTcaHuTapHoro U 3n1Aem4olorH4eCKorO KOHTPOJnIX (roccaH3n"AeMHaA3op) 6bu1 BbiBeAeH m3-noA
KOHTpOJn1 MMMH3ApaBa. B 1996 r. roccaHanwAeMHaA3op 6bin Bo3BpaLLUeH nOA KOHTPOJ1b
MMH3ApaBa, B BeAeH14e nepBorO 3aMeCTMTenjiF MMHMCTpa.
roccaH3nmAeMHaA3op o6Ina,aeT WLIPOKUMU nonHoMoq4uM1M B o6JnaCTM CaHTapMm,
rmrmeHbIl, 3nfAeMmonJorm1 MH4)eKLA4OHHbIX 3a6oneBaHMr4, a TaioKe HeKOTOpblx acneKTOB3aLLA4Tbl oKpy)KaiouAer cpeAbt. KoM1TeT YCTaHaBniBaeT CTaHAapTbI MH4eKO4OHHorO KOHTPOJ15I
B 6w1bH14Lax (MHorUe 13 KOTOPhLX B 3HaBMTeBJbHO1 CTeneHM ycTapeiiM nuw60 He34)4)eKTMBHbl),
ocyXueCTBn1eT KOHTPOIb 3a q)yHKLA4OHmpoBaHmeM 6onbHM4L, MmeeT nOJ1HOMOI14Sl HanaraTb
WTpaq)bl U npecneAOBaTb B yrOIIOBHOM nOpRAKe TeX MeAUmL14HCKMX pa6oTHMKoB, KOTOpbleHapywaloT YCTaHOBneHHbie npaBt4na. CTpax nepeA HaKw3aHueM 3a AeCiCTBRl, MAyLUm4e Bpa3pe3
yCTaHoBjneHHbIM cTaHAapTaM, 3aqacTyio CTaHOBFITCFI OCHOBHbIM KaMHeM npeTKHOBeH4S1 Ha nflT1
npOBeAeHu14 pe4opM.
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o6nacTHor4 poAJnbHblA AOM U nOAOTqeTHbIe emy nOnflKJ114H1K1 41u )KeHCKi4e KOHCyJibTaL14U4. BKa)KAoM paroHe o6nacT. o6bl4Ho eCTb CBOA POA4flbHbIU AOM, paCOHHbie 6o01bHU4Lbi (B KOTOPbIX
HeCKOJ1bKO KoeK MoryT 6biTb 3ape3epBMPOBaHbl AnPR naLk4eHTOK aKywepcKoro LirMHeKOnor1MecKoro npo4muii), oAHa 14Jnu HeCKOnbKo nOfl1KJI1H1K, rAe MO)KHO nOJIy4i4Tb
nOMOU4b cnel ai4unCTa, u OAHa unu1 HeCKOJ1bKO )KeHCKMX KoHCyJ1bTaLrnA, rAe OKa3blBaeTCR
aKywepCKasi Li r14HeKOJlOrm4eCKasi nOMOLLtb. KpoMe Toro, B paAoHax, oco6eHHo B CeJbCKOUMeCTHOCTu, MoryT 6blTb 4enbAwepCK4e CTaHLAM4.
CoxpaHeHme CeTM cneuLAmaj143HPOBaHHblx 6onbH14L U KOHCynbTaLAL4U Ami OKa3aHmsi
aKywepCKOA U rMHeKOnorumeCKOA nOMOL41 BMeCTO ux o6beA14HeHwI c 6o11bHH4iaML4 14
no.nmKnuHWKaMw o6u.ero Ha3HaqeHMS co3AaeT napanneAbHyIo CMCTeMy MeAULL14HCKoroo6ch1yKMBaHi4s HaceneHM5, KOTOpyiO nPfXOAMTCP coAep)KaTb B YCJ1OB1RIX o6LLero COKpaLLuAeH"
rocyAapCTBeHHbIX peCypCOB. ,D,a)Ke BHyTPU CaM14X pOAUnbHbIX AOMOB cyU4eCTByIOLu.14e
CaHMTapHbie npasu4na Tpe6ylOT Haniw4i cne4falJbHbix naJlaT-1430,n1iTopoB u oTTgejbHoronepcoHana AnP )KeHLA4MH C KaK1Mm4-Jn6o MH4peKLA4%1MM He3aBMCMMO OT Toro, npeACTaBJ1RIQT J114
OHM onaCHOCTb AnA Apyrux naL14eHToK. E,onee Toro, poAL4nbHbie AOMa Aon)KHbi 2 pa3a B roA
3aKpblBaTbCfl - Ka,KAbA pa3 He MeHee, qeM Ha ABOe HeAeiiu - Ha Ae3MH4)eKLkMIO U
8
CoBepueHcTBOBaHHe ct4cTeMbi oxaHbi 3,UOPOBbR mmHutfH B POCCH1LCKOa 0enepa=uu
4HcneKT4pOBaHIe CO CTOPOHbl FoccaH3n"AeMHaL3opa. Bce 3TU 4aKTOpbl o6ycJlaBnlMBaIoTAy6nHpoBaHme ycnyr, HeAOCTaTO4HYIO 4HTeHCL4BHOCTb mCnonb3OBaHMA Koe4Horo qpOHAa 1yBejulqeHue 3aTpaT.
CooTHoweHle BpaqeVi-aKywepoB U )KeHLL,UH B Poccww npm6n1M3MTenbHo CoCTaBnJeT 510000 [2]. B nepmog C 1990 no 1993 rr. o6LLee q"Ccno (4enb,LwepoB m aKywepoK 3HaqmTenbHOCOKpaT.lIOCb [2]. CoKpaLueH1e I1Cj1eHHOCT1 cpegHero MeAg4LHcKoro nepCOHana, B03MO)KHO,o6ibcHseTcR H43KWM YPOBHeM aapnnaTbi no CpaBHeHL4O C TeM, 4TO MO)KeT npeAnO)Ki4Tbpac4BeTaiomuumA HaCTHbli ceKTop. BonpoCbl 3apnJiaTbl, 6e3yCnoBHo, oqeHb CwJbHO BJU4KoT HaB03MO)KHOCTUi npMBneqeHM14 U yjep)KaHL4 MemeLL4UHCKMX pa6OTHMKOB.
HeAaBHo 6b1na BBeAeHa CICTeMa MeAi4U4HCKOrO CTpaxOBaHSI [9]. CeMac pa3peweHoqacTHoe npeAoCTaBneHi4e MeAML4UHCKWX ycjiyr, Ha KOTOpbIe, OAHaKO, np1XOA1TCP MeeHee 5% OTo6uAero o6beMa pacxogoB Ha 3ApaBooxpaHeHL4e [2]. PacnpegeneHle peCypcoB,npeAHa3HaqeHHbIX AnP 3ApaBOoxpaHeHwi, opmeHT1pOBaHO, riJaBHbIM o6pa3oM, Ha 6OnbHl4Ikbl UApyrme BUAbi CTaIwoHapoB. B 1991 r. 6onbHM4bi nony4uwnu 69% Bcex pecypcoB, BbiAeneHHbXHa 3ApaBooxpaHeHme, a ocTaBwasacR qaCTb pecypcoB 6bina noAeneHa MeWKAy yqpe)KAeHMummOXpaHbi o6LUJeCTBeHHorO 3AopoBbS], aM6ynaTopHoVi nOMOLL,u, o6pa3oBaHwl, HaYKL4 U T.A. [9].
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9
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10
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11
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12
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13
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nomoraMoLti1e B 6onbwel 3. BBeCTm npaKTrKy KOHTaKTa MmaTepU C 2. PacwmpeHme npaicr1K1 rpyAHoroCTeneHU Y414TblBaTb UHTepeCbI HOBOpO)KAeHHbIM cpa3y nociie pOAOB. BCKapMJ1UBaHU4I.
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POAAOM. 2. Yny4wOeHme noKa3aTen, 30p, yMeAt4LtMHcKMX pa6oTHMKoB, 6onee6.naronpt4RTHoe OTHoweH1e CO CTOpOHbiMeApa6oTHMKoB K np1cyTCTB4IO 4neHOBCeMbU npl poAax.
14
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flio6epeLkKt4r par4OH HaxOAuTCA B 4ace e3Abi OT LAeHTpa MOCKBbl. HaceJieHme papioHaCOCTaBnsJeT 302000 qenoBeK. 4mcno )KeHLLAt4H B penpOAyKTMBHOM Bo3pacTe paBHReTCR 77200.AKywepcKme u rMHeKOnorH4ecKWe ycjiyru 6onbHMwHoro xapaKTepa Ha TeppUTOpuU paRoHao6ecneqMBaIoTcH, rnaBHbIM o6pa3oM, OAHMM pOLA14JbHblM AOMOM Ha 220 KOAKo-MecT(wecTbAecsT u3 HMX npeAHa3Ha4eHbi Ang nocnepoAoBoro nepmoAa). POAAOM HaxOAmTCm BropoAe Jlio6epAbi, OH Ke MBnsieTCA LteHTpOM no yXoAy 3a powKeHMLAaMm, CTpaAaiOu.i4MmcepAe'4HO-COcyACTbIM14 3a6oneBaHMRMN. CIOAa ice nocTynaloT naLr4eHTK14 MocKoBcKoroo6nacTHoro HayqHo-ccA1eAOBaTenbcKoro MHCTMTyTa aKywepcTBa u rWHeKOflormm, KorAa14HCT14TyT 3aKpblBaKOT Ha Ae3&1H4)eKLl4io. B 1994 roAy B 3TOM POAmnbHOM AOMe 6buio npl4HS1TOnptM4epHO 1600 poAoB. flpu pOA,MJbHOM AoMe pa6oTaloT ABe )KeHCK4e KOHCyJ1bTaLA414, OHUnpeAnaraioT WL4pOKL4i cneKTp ycinyr, CB93aHHbIX C penpOAyKTWBHor (&yHKL14erl 3AOPOBbA,HanpMmep, KOHCynbTaLAm4 no McfnolOb3oBaHMIO KOHTpatAenTMBHbIx cpeACTB, npOBeAeH4eM4Hma6OpToB, ocyu4ecTBJleHi4e npeApOAOBoro yXoAa, OKw3aHme rAHeKOnormuecKWx ycnyr,npOBeAeHme na6opaTopHbIx aHlanN3OB u AmarHOCTUKM, oKa3aHme ~fr3MOTepaneBTN4ecKNx ucTOMaToJlorfrqecKMx ycnIyr.
nOCKOnbKy LAenbbO 3KcnepMmeHTa 6bilna anpo6aLu,s npOTOKOnOB, npeAnojiaraBwiMxH3MeHeHme o6uLenpl4H5IToA npaKTHKL4, 6bin cAej1aH BbIBOA 0 TOM, qTO y npoeKTa 6yAeT 6onbweWaHCOB Ha ycnex, ecAM cHa4aJia OH 6yAeT npOBeAeH B )KM3Hb B ycj1OB145X, 6
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COTpyAH1KM 3Toro pOA14nbHoro AoMa npO%BWJN 6onbWoe wKenaHme u 3HTy3ua3M no noBoAyy4aCT14S B 3TOM npoeKTe. CoCToSIHme 3AOPOBbS HaceneHfg, KOTOpOMy OKa3bIBaIOTCSI ycJyri4, a
15
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BMAHMOCTM, oTpa)KaeT o6U4ylO TeHAeHLA14UO pocTa 6e3pa6oT4Lkbi cpeAM )KeHu.LkH. MonoAeIKb BBo3paCTe OT 17 AO 19 neT COCTasBJI5A1M 13% nauL,eHTOK nOCTHaTanbHoro nepMOAa, 6%naLiMeHTOK, pe6WBW1X cAejiaTb a6opT M MuHuia6opT U 13% naLMeHTOK, o6paTMBWMXCSl 3a
rMHeKOAorM4eCKuMM ycnyraMu. qwcno Kyp&4J1bLLA&4LA CO BpeMeHeM yBeJu'I'*IJ1oCb B rpynnenOCTHaTa.nbHoro nepMoAa (c 5% Ao 23% p<0,001) A B rpynne naLAmeHTOK, cAeJ1aBw1xMuHua6opTbl (c 22% Ao 56% p<0,001), u OCTaFOwCb HeM3MeHHblM B Apyrux noArpynnax HaYPOBHe OKOno 20% OT o6uAero 'ucna o6cJieAoBaHHbIx.
pepT&4nbHOcTb, KaK U O)IK&AanOCb, 6bina HL43KOU, OAHaKO AOBOj1bHO 6onbwoeKOn4IeCTBO )KeHU4AMH B Ka)KAoA noArpynne coo6wA&nj11i o TOM, ITO OHM ywe Aenanm TpU unum
6OAbwe a6opToB (PMCYHOK 5). aianee, OT 7% Ao 22% )KeHUL4UH B KaA,gOU noArpynnecoo6uLLMjun, LITO B TeqeHMe npoweAWWx ABeHaA3LaT1 MecS1LeB OHM nu46o yKe poKan, 1n16o yweAenanu a6opT (npwio)KeHi4e E, Ta6n&4LAa V). 13 3TUX AaHHbIX cJieAyeT, 'TO )KeHULAMHblpaccMaTPMBaKOT a6opT, KaK BseCbMa cepbe3Hoe cpeCTBO KOHTPOJIn1 3a po)KAaeMocTbio, awcnonb3OBaHwe nnaHMPOBaHMKO KOHTpaBLenTUTBHbIX CpeACTB HaXOAUTC5I Ha HeAOCTaTOIHOM
ypOBHe. 3Ta TeHAeHLHL4S1 OCTanaCb HeM3MeHHOA U nocne npOBeAeH14I MeponpMATHR no ceMbM(CM. npi4lo)KeHHe B, Ta6.nmu.a VI)
16
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Bce Oa4eHTKw nocnePOAoBoro nepmoga coo6L4mm o TOM, 0To nOu2y430 5npeHaTanbHblu yXOA, npu 3TOM 6on1bW1HCTBO 43 HUX o6cny)KMBafOCb OAHWMH U TeMw KeMeAmLA14HCKWMW pa6OTHMKaMt4 B Te4eHle Bcero nepwoAa 6epeMeHHOcT4, 4TO qBnsmTCmCyL4eCTBeHHbiM AOCTW)KeHmeM B cq)epe Me[u4LHcKoro o6cfy)KI4BaHw4. OAHaKO o6beM ycnyr,npeAOCTaBneHHbIM )KeHLL4AHaM B nep1oi0 6epeMeHHocT1, ecnu UCXOAUTb 143 4UcnlaKOHcy.nbTa4mr1, nonyL4eHHbIX B npeApOAOBoA nepuOA, u U3 KOA14qeCTBa rocnllTamU3aL~4 BnepuoA 6epeMeHHOCTU CyLL4eCTBeHHO npeBbIwan CTaHAapT Apyrtx eBponeuiCKux CTpaH(PU4CYHOK 6; npfnox(eHme E, Ta6n14Lka Vila). npoLAeHT coo6L4wBW14x o TOM, LITO B nepwoA6epeMeHHocT1 OHm 6b1n14 rocnfTanJ3NpoBaHbl XOTi 6bl OAHa)KAbl, HeCKOnbKO yMeHbW14j1Cs nomepe ocyLLeCTBaneHus npoeKTa, HO pa3HWLY 3Ty HeJIb35 C'I1TaTb CTaTWCT14'IeCKCyL4eCTBeHHOu. B cpeAHeM B4CnO nOnyIeHHbIX B npeApOAOBOU nepmoA KOHCynlbTaLA14U no mepeocyLLteCTBneHu4 npoeKTa Aa)Ke yBenJAW)OCb, 6onee 50% noArpynnbl (noCT-TecTupoBaHiue),Coo6Lu41j1 0 TOM, 'TO UMm nOJIyqeHo 20 uMn 6onee KOHcynbTaLxu.. CpeAHee KOJ1M4eCTBOKOHcy)nbTauLMr B npeApOAOBoA nepmoA (15,6 - B nOArpynne nPeABapmTenbHOrO TeCTmPOBaHms,19,4 - B noArpynne nOCT- TecT1poBaHwl; p<0,001) He uMeno OTHOweHMU K AeMorpacM144ecKHMxapaKTepUCTHKam AaHHOU nOArpynnbI, HanmmBiO XpOHUqeCKUX MeAI4LA14HcKMx 3a6oneBaH149,OCJIO)KHeHMI B xoAe npe)KHerl 6epeMeHHocT4 14unu gaae OCnO)KHeHL4r B xoAe TeKYL4Ae6epeMeHHOCTL4.
17
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no mepe npOBeAeH4si npOeKTa B )KW3Hb B COAep)KaHme aHTeHaTa)lbHoro yxoAa 6bl)oBHeCeHO HeCKOJbKO CyLLteCTBeHHbIX N3MeHeHH1 (nlpmno,KeHme 5, Ta6nuu,La Vila). YBej1i44L4JoCbWC=lO naL\meHToK, coo6u.LL4BWMx 0 TOM, BTO B xoAe 6epeMeHHOCTU MM AaBaj1mCb CBeAeHmfl o
nOArOTOBKe K po)KAeHM4o pe6eHKa, o6 yxoAe 3a HOBopo)KAeHHbIM, 0 AOCTOMHCTBaxMaTepuHCTsa, o nnJaHMPOBsaHM ceMbW. K cowKaneHmio, no mepe peBwfaLAIW npoeicraCHH31JAOCb BHMmaHme K KOHCynlbTaLAmsiM no noeoAy nNTaHNS u npeAynpe)KAaIoLu4x npH3HaKOBOCJ1O)KHeHMI4 BO BpeMA 6epeMeHHocTM. 1l13y4eHme pe3ynbTaTOB He BbISBLU1O CTaTNCTU44eCKfrBa)KHbIX M3MeHeHMi B 4aCTOTHOCTm flpOBeAeHI4U KOHCYJnbTaLmA O BpeAe KypeHMH (npu TOM, 4TO4MCJO KyPu1nbLL4MLA Bo3paCTaJio), BpeAe ynOTpe6feHWl alKorojlsl, 0 BaWKHOCTN oTAbixa 144fl3H4eCKNX ynpa)KHeHI4M.
C ApyroA CTOPOHbi, cyLLAeCTBeHHO YJ1y4WMJlOCb coAep)KaHme yxoAa BO BpeM% poAoB,poAopa3peLleHuf 14 B nocnePOAOBoA nep"OA (nlpMno,KeHme 6, Ta6nuiu,a Vlla).flpeABapMTenbHoe TeCTPOBaHMe B Ha4ane npOBeAeHm5 npoeKTa nOKa3anO, 4TO TOJlbKO 2%)KeHLLtUH 4Menm B03MO)KHOCTb HaXOAMTbCF B OAHOA naiiaTe CO CBOUMM HOBOpo)KAeHHbIMI4. K3aaepweHuio npoeKTa 3Ta LAL44ppa so3pocina Ao 57%, noBbicCmiaCb TamKe 4aCTOTHOCTbKOHTaKTOB C HoBopo)KAeHHbIM4 Ha paHHeM 3Tane. Bo3pocno 04nCJ1O OTLAOB, nOny44rBWlMXB03MO)KHOCTb nPL4CYTCTBOBaTb npm pOAax, XOTI YPOBeHb OTLtOBCKOrO y4aCTMSl OCTanCSI HU3KU4M.
nlocKonbKy B nePHOA nOCT-TecTMpoBaHL4$ 6onbWMHcTBo po)KeHMu, HaxOAHn,L4Cb B OAHOAnanaTe Co CBOUMM HOBOpo)KAeHHbIMM, y cecTep U aKyLwepOK 6uino 6onbwe BpeMeHM AnsI Toro,
18
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21
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22
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23
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MeCTHbIe opraHM3aOLAmt IU KoMLTeT no caH3nLIAeMHaA3opy. Eu.e Ba)KHee TO, qTO He 6biulo4eTKOA B3amMOCBF13H Me)KAy TeopueU L npaKTUKOUi C OAHOA CTOPOHbI L perynSYTOPHbIMM
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24
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BbiBonbl u nocneyvioulie warm
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(1) B AojirocpoqHom nAaHe cJieAyeT BeCT4 pa6OTy no yTOqHeHMIO A coBepweHcTBoBaHu1oHOBbIX HOpMaTMBOB LI CTaHAapTOB B o6JnaCTu oxpaHbl MaTeP1HCTBa L nnaHmpoBaHms ceMb1.KpoMe Toro, AOJnKHa 6bITb pa3pa6oTaHa CMCTeMa MOHt4Top14Hra U oL4eHKM, BKJIIoLaioLLua5inOKa3aTe6J14 nOBbiwBeHR ponu1 npo(4nJ1aKTL4KM U ynyJ1YeHu45 Ka4eCTBa OKa3aHAsi nomoLU14.CoAeicTB1e B peaBA3mM41 KpynHoMacWTa6Horo npoeKTa no pe(copMe 3,paBooxpaHeHwRMo)KeT BKJ1IO4aTb B ce6R npeAocTaBneH1e TeXHM4eCKOV1 nOMOWLI MUH14CTepCTBy3ApaBooxpaHeHN14 U o6n1aCTPIM B Bonpocax 6onee qeTKOrO pa3rpaHM4eHwl poieu 14OTBeTCTBeHHOCT14 3a pa3pa6oTKy Li npoBeAeHL4e rocyAapcTBeHHoC nOJ1lTUKU, B qaCTHOCT14B c()epe CAep)KHBaHl4R pacXoAoB, KOHTpOJ1F 3a KaqeCTBOM Ul MOHL4TOp14Hra. CoBepweHHooqeB1IAHo, 'To rocKoM1TeT no caH3nMAeMHaA30py TaKwe goJI)KeH y'4aCTBoBaTb B 3TOMnpoLAecce.
(2) BO3MO)KHO OKa3aHme TeXHmqeCKOr4 nOMOLLA14 B pa3pa6oTKe 6onee 3dIxjeKmMBHoroMexaH143Ma KOHTpoJ1sF 3a Ka4eCTBOM Li Co61nOAeHMS1 yCTaHOBJneHHbiX nloJ1o)KeiiU4. Knp14Mepy, B HacToRt4ee BpeMS He npOBOA1TCI aHaan3 3(pXeKTHBHoCTM 3aTpaT ycnyr 14TeXHo.norm4 U npoAojnKaeTCF OKa3aHme MHor1x U3 3aBeAOMO HM3K03C1deKTMBHbIX yCjnyr.pto CU4X nop He cyLLAeCTByeT CUCTeM KOHTpOJn Ka4ecTea (3a McKJ1ioL4eHi4eM aHaAM3anoKa3aTeJneri MaTepU4HCKOu CMepTHOcTU U KOHTpOnIl 3a MH(ceK4MOHHbUMM 3a6oJleBaHMRM14),OAHaKO 3Ha4eHme TaK1X C1CTeM 6yAeT Bo3pacTaTb no mepe CTaHOBneHmFi 6o0eenfmopaulMcTw'iecKoA CL4CTeMbl 3ApaBooXpaHeHL4R. HbiHeWHwe noJ1o)KeHMIR, CBFi3aHHbIe CKOHTponeM 3a 14H(BeKLA4M1M U4 co6nIo'AeHi4eM caHLTapHbIx Tpe6oBaHL4i, cepbe3Ho YCTapeni4U BeAyT K 'ipe3MepHo cTporou perflaMeHTaLmL AeRTenbHoCT1 POJAOMOB, Ay6n14poBaHM1oyCnyr (Hanpi4Mep, oTAenbHbie MHq)eKLA14oHHbie nanlaTbI), HeHy)KHblM npoBepKam Ha HianwuiqeMHO)eKLAM4 B xoAe 6epeMeHHocTr U nepeA a6opToM. C Apyrovi CTOpOHbl, Meponp4RmTs1,AeUCTB1TenbHo npeAoTBpaLuaioLum4e 1HHJeKL14oHHbie 3a6oneBaHMR y HoBopoKKAeHHbIx, Boco6eHHOCTM HaXoKxteHme MaTepm 14 HOBopo)KAeHHorO B OgHHOU nanaTe U KOpMIleH4eHoBopo)KAeHHoro no Tpe6oBaHM1o, He npaKTL4Ky0oTCSI, U FOCKOMLTeT no caH3n"AeMHaA30pyHe npI43HaeT MX Ba,KHOCT14.
(3) B xoAe AaHHoro mccneAoBaHL4s 6b1.na BblsumeHa npaKTLKa OKa3aHLIR LI36blTO4Hblx ycnyr nooxpaHe 3AOpOBbsH MaTepw 14 Apyrt4M BUAaM oXpaHbi penpogyKTLIBHoro 3AOpOBbR.CheACTBseM 3TOrO CTaHOB1TC5 'pe3MepHo BbICOKasl CTOLIMOCTb C14CTeMbI3ApaBooxpaHeHHR AnH rocyAapCTsa, npo6neMa HL43KOrO YPOBHR lonnaTb4 TpyAaMeA"uLAHcKHx pa6oTHt4KoB, HeAocTaToK cpeACTB Ha BHeApeHLe HoBoro o6opyAoBaHM9 Upa3BMTme uHclpaCTpyKTypbl, a TaKwKe orpaHwMeHHocTb pecypcoB Ha npoBeAeHIe 6oneeW14pOKoMacWTa6HbIx MeponpHIT149 B o6nacTL4 nepBlI4Hoii npo(pInaKTUKU no TaKUM
25
COBepWgeHCTBOBaHHe CiCTeMbI OgpaHbi 3IIOPOBbq XeHLKW4H
BonpocaM KaK nAaHipoBaHme ceMbu, paLuAoHanbHoe nluTaHUe U4 nponaraHAa 3AOPOBoroo6pa3a )KW3H14. B qaCTHoCT14, MHoroq4CJ1eHHbie noceLAeHM9 Bpaqa B neptoA6epeMeHHOCTU U M36blToqHas rocnl4Tanw3aLklFi CB93aHbl CO 3HatMTeJ1bHblMM 3aTpaTaM4.flpo6neMa eu.Ae 6o0nee o6oCTpFieTcs 3a CqeT 1436blToqHoro KoeqHoro (4OHAa, Ay6rnipOBaHI4Ryciyr BHYTPM CMCTeMbi, HanJ11qj4S4 CTporu4x rocyAapCTBeHHblX perJlaMeHTaLrMA, OTHOweH1451 K
Ae,ny MeAu4LuHCKoro nepCoHana. B xoAe npoAon)KeH14 u pacnpocTpaHeH1 pe3ynbTaTOB3Kcnepi4MeHTa B Jlio6epLAax nepBooqepeAHbIM MeponpHSTmeM AOJO)KHa CTaTb opraHM3aAi4u5o6cy)KAeHs' AaflbHer4weu rocyAaPCTBeHHO nOJuT14K14, B TOM &4uCne B03MO)KHOCTM B6yAyLLAeM, B LienRx nOBblweH14F 3KOHOMt4eCKOr4 3c"4>eKTABHOCTM, MHTerp1poBaTb ceTbMeAB4Lk14HCKMX yqpe)KAeHlIg no oxpaHe 3AOPOBbS maTepl U no OKa3aH¶IO ycnyr, CBfl3aHHbIXC nPO143BOACTBoM a6opToB, B ceTb 6OnbH14U, non1L4Kn1HWK o6uIero npo(14jlsi.
(4) Pe3ynbTaTbl 3KcnepwMeHTa HarnlR;HO nOKa3ajl14, KaK14X pe3yDbTaTOB B o6naCTHnnJaHMPOBsaH14 CeMbU MO)KHO AOCT14qb, ecnu yAenji$Tb 3TOMy HanpasBJeH1io nepB4'4HOUinpO0mj1aKT14KMi nOBb1weHHOe BHUMaHue. no-npe,KHeMy y3KWM MeCTOM OCTaeTCsi npo6neManepe6oeB c o6ecne4eHmeM u AOpOrOBM3Hbl CpeACTB opanJbHOu KOHTpa4LenLAi4t4 uMaTept4aAOB Ans AN1HOR CTepl4nW3aLA4w4. KpoMe Toro, Heo6xoALMo OpFaHU3oBaTb CWCTeMynOArOTOBK1 U nepenOArOTOBKu MeAU4ULHCKoro nepcoHajia c L4enbIo nOBblWeHU1I YPOBH1 UX
3HaHNA U CO3AaH145 AonOj1HuTe6JbHbIX CTmMynOB K pa6oTe. BceMLpHoMy 6aHKy UMHHMCTePCTBY 3ApaBooxpaHeHHA cAeAyeT paCCMOTpeTb B03MO)KHOCTL4 qaCTHoro ceKTopano 4)WHaHCWpOBaHI4o U4 pacw1peH&1K0 ceT&4 OKa3aHWl ycjiyr no oxpaHe penpOAYKTMBHoro3AOPOBbSi. M14CHCTePCTBO 3ApaBooxpaHeHW9 U opraHbl 3ApaBOoxpaHeHM9 Ha MeCTaxAOf)KHbl cnoco6CTBOBaTb TOMy, 4To6bl BOnpOCbi nniaH&lpoBaHMFI CeMbW CTani
HeOTheM,neMbiM KOMnOHeHTOM npeHaTanbH0A U nOCTHaTanbHOrU noMou14, a TaKwKe ycjiyr noa6opTaM U ML4H&4-a6opTaM. CneAyeT cepbe3Ho paccMOTpeTb B03MO)KHOCTb BBeAeHNApernameHTaLuu no noaogy Toro, qTo6bi a6opTbl B nepBOM Tp&4MeCTpe 6epeMeHHocTunpOM3BOAHRHCb TOJ1bKO BaKYYMHbIM cnoco6oM, KOTOpblU 3aMeH1i1n 6bI BO BCeX cnyL.aRxBbICKa6Jl14BaH&4e. nOBblweHHoe BHMmaH1e Heo6XoA1Mo yAent4Tb npo6JleMaM KOHTPOnn 3apacnpOCTpaHeH1eM 3flfln (HanpiMep, c nOMOLbIO Ab POCBoeT1TenbCKOm geJTenbHOCT1 1nponaraHAbi l4cnOJ1b3OBaH&i;i npe3epBaTMB0o3), oco6eHHO cpeA& noApOCTKOB.
no &4ToraM 3KcnepwMeHTa MO)KHO cAejiaTb BbIBOA, 'ITO pOnb My)KYWH B COXpaHeHI4&1penpOAYKTi4BHOrO 3AOpOBbS U B nnaH&lpoBaHWW ceMbL oL,eHMBaeTC COBepweHHOHeAOCTaTO4HO KaK CaMUM HaceJIeH&4eM, TaK U Me,OAU4UHCK14MM pa6OTHIKaM&4, 14 noHaAo6i4TCmeLu.e MHoro BpeMeH&4, 4To6bl 3Ta cmTymas4i &13MeHt4jiaCb. nlJaH&4pyg AaaJbHer414e warm,none3Ho 6bino 6bl BK1IO'4&Tb B HUX opraHW3aLXkmO AL4CKYCC&1&1, KOTOpas BbISBI4J1a 6bi, no4eMyBa3eKTOM14S AO cuMx nop 3aKOHOAaTenbHO He npW3HaHa, HecMOTP1 Ha TO, 4TO 3T0 6onee6e3onacHaX, MeHee AoporocToALLAasi u 6onee npocTasi onepa4msi no CpaBHeHO410 c nepeBH3KOr4MaTo'HbIX Tpy6. Pacw4pHsi c4epy peanu43aLL4uu npoeKTa, HeO6XOAmMO B KaSeCTBenp14Op&4TeTHb1X CTaB14Tb 3aAa'4 pacCw&peH&lS] B03MO)KHOCTH Bbi6opa CpeACTB KoHTpaLAenLAi4&1,
yBeH4teHme OTBeTCTBeHHOCT&4 My)K'4H, 6onee aKTHBHa; pa6oTa c noApoCTKaMl4. CyuL4ecTByeTTpaAWL145, LITO pa6oTa no nflaHJUpOBaH11O CeMb&4 Haqk4HaeTCR B )KeHCKMX KOHCyJ1bTaLt&45lX.nnaHIipysi aKTc4BN3aL#4io pa6oTbI C My)K'4HaM&4, cneAyeT noAyMaTb o6 OpraHU3a14UU OMyKCK14kXKOHcyj1bTaLk4m1 cunaM1 Bpat4er o6uAeA npaKT1K1, yponoroB unu xupyproB, pa6oTaIoLL4mx B
nonmKnMHHKaX.
26
nlpJloxKeHHe A
MeToAo.normsl oL0eHKU pe3yJlbTaTOB 3KcnepIMeHTa B illo6ep4ax
MeTon: npu oi4eHKe pe3ynbTaTOB nio6epeLkKOro 3KcnepIMeHTa 6bin mcnofJb3oBaHMeTOA oAHopa30ooro rpynnoBoro o6cneAOBaHMA c npeABapUTenbHbIM U 3aKJIOLii4TeOJbHbIM(nocT-) TecT1pOBaH1eM. lpeABapuTenbHoe TeCTupOBaHue COCTORnOCb B nepwoA c 6 4)eBpanAno 3 MapTa 1995 roAa. nOCT-TeCT4poBaHwe COCTOSJ1OCb B nepwoA c 13 MapTa no 9 anpen;i1996 roAa. Ha Ka)KAoe U3 o6c11eAoBaHmA nOTpe6OBaJlOCb 20 nOnHblX AHeiA, B Te4eHMe KOTOpbIXnPOBOA1nOCb Ha6ftoAeHme 3a onpawLuBaeMbIMu U npMBneqeHme na4UeHTOB B nOArpynnbi.1QaHHbie o6cneAoBaHwsi nOAKpenneHbi co6eceAOBaHwrM14 C KlKOqeBblMH HOCMTeSJWMMMH4PopMaLAmm, a TaKwoe C FoKyc-rpynnamm, B KOTOpbie BOWJIL MeAmLUwHCKK1X pa6OTHK14u UnaL,UeHTbi.
Bbi6opKa: B TeCTMPOBaHMM Morliw npMHS;Tb y4acTme Bce naLAmeHTKL OT 16 neT U CTapwe,Ae.naawme a6opT, MMHma6opT U nonyLiaBiue rMHeKonorumeCKMe ycnyrM, npoxoAMewHenie4eHme B pOoAOMe nu160 o6pau4aBw1ecsi B )KeHCKYIO KOHCynbTaLk4io. PecnoHAeHTKM AOR)KHbl6bin rOBOPMTb Ha PYCCKOM 5l3blKe U AaTb corilacue Ha yLacTme B o6cneAOBaHMM. npuonpeAeneHi* pa3mepa Bbl6opKU KaK Ans npeABapMTenbHoro, TaK U gnsw nOcT-TecTMpOBaHMSl,mcnOJlb3OBaJIMCb cpeAHeMec5lqHbie CTaTMCTM4eCKwe noKa3aTeinLu AJnR AaHHoro peruoHa uYL4TblBaCSlR TOT c?aKT, qTO AflSl c6opa MH(jopMammL OTBOAw1nOCb LieTbipe HeAenA (Ta6&nu4a I).FOTOBHOCTb OTBe4aTb Ha BonpOCbl BO Bcex noArpynnax 6blina o4eHb BblCOKOU (Ta6nu4a II).CpeAm noArpynn naULAeHTOK He 6b611O OTMeL4eHO HUKaKUX KpynHblX A3MeHeH14u B CMblCJ1ecoLA4anbHo-AeMorpad)pM4ecKMx xapaKTepUCTUK, UCTOpUU penpOAyKTWBHOu (tYHKLJ.4 3AOpOBbS11n1 MHAMKaTOpOB COCTOFIHL451 3AOpOBbSi, XOT1 HeKOTOpbie I13MeHeHW1 B cocTaBe noArpynn Ha
3Tanax npeABapuTenbHoro u nOCT-TecTupoBaHwl 6b6AW (Ta6fut,bl III-IV). 3TU m43MeHeHMA HeOKa3blBanJI BnM'sHMFI Ha pe3ynbTaT npoBeAeHHbIX 4CcneAOBaHM0. XapaKTepMCcTM14KMeA14LkHCKMX pa6oTHMKoB o6o6uLeHbl B Ta6iniLAe XI.
npaKTtcrwecKwe xefRCTB14r: BOnpOCHLIKM Ha aHlrnUlUCKOM Il3biKe 6blnu nepeaeAeHbi HapYCCKUUA, 3aTeM AnH1 nPOBepKm npaB4JlbHOcT4 6b6IJ BbinOJ1HeH o6paTHbIi nepeBoA. 4HneHblKOHCynbTaUL,OHHOA rpynnbi O3HaKOMMJInCb C cOAep)KaH4eM BOnpOCHuKa, nocne qero 6bimJonpOM3BeAeHO ero unMAOTHoeD TeCTUpoBaHue. flocne 3Toro B BOnpOCHUK 6biJu1 BHeCeHbiHeo6xOAmMble u3MeHeHMFl, OH 6bin nepeneqaTaH U nepeAaH JnJJ O3HaKOMneHMH1 rpynne,npOBOAslLLAeul o6cneAOBaHme, nocne 4ero 6bl1no npoBeAeHo ("nMnOTHoe") TeCTMPOBaHMe HaMecTe, U 6binM BHeceHbI OKOHHaTenbHbie M3MeHeHWS;.
KoMaHAa U3 4eTbipex MHTepBbiOepOB npowuna TpexAHeBHylo nOArOTOBKy: MeTOAMKao6cneAOBaHM4, TeXHuKa onpoca, 3aTparMlaH4e LUAeKOTnl4BblX TeM, MeTOAUKa pa6oTbl CAaHHbIMu U rapaHTupOBaHUe KOHcmgeHL4UanbHOCTU, TeXHUKa pa6OTbl C Bbi6OpKOUi,opraHM3aLAms pa6oTbl B pOAAOMe VI KnJH4Ke, ynpaBneHL4e nO0JyqeHHblMw AaHHblM14,KOAMpOBaHUe U aAMUH1CTpaTMBHbie BOnpOCbl. Onpoc naLLUeHTOK npOM3BaOA4ncF KaK MO)KHO6nm)Ke KO BpeMeHM BbinfCKM, 4To6bi nony'eHHbIA yxOA OHM MornJ o4eHWTb B nOnHOA Mepe.nlaLAmeHTKu nocAepoAoBoro nepmoAa TaK)Ke onpaw14BanlCb KaK MO)KHO 6nmwKe KO BpeMeH1npeAno11araeMor4 BbinfCKM, )KeHLLA14H, Aenaaiwwx a6opT uJnI MUHU a6opT, onpawmBanJ HeMeHee qeM 3a ABa 4aca nociie OKa3aHlMS mM MeAM4LAHCKWX yCnyr, nauLMeHTKw, o6pauLtaBw1ecsi3a rMHeKOJlorm4ecK1MM yclyraMM, onpawL.BanICb cpaay nocne nocew,eHMFl UMM Bpa4a(onpoCbl npu BbixoAe). lOcKOnbKy naLJmeHTKaM, npflPweALwIM nfOJly4Tb rHeKOnorHMecK14eyCnyrM, npMXOAmnOCb 3aAep)K1BaTbCg nocne BL43UTa, XOTFI OHM, CKOpee Bcero, cnefwMAAOMOA, 6bilo peweieHO AenaTb MM He6O11bWoo nOAapOK (KycoK AyWwcToro Mbina) 3a y4acTMe Bonpoce. 3anonHeHMe OnpOCHbIX JICTOB An1 MeAm4L,HCKWX pa6oTHAKoB nocAeAHMeKOHTpOnMpoBa111 caM1. Bce IHTepBbio 6b61114 aHOHuMHbIMu. HMKaKOu onO3HaBaTenbHOA
27
CoBepLueHCTBOBaHse CtiCTeMbi 3,QOpOBbq xKeHLLUH B POCCHUlCKOa OeUeoawu
MH4)opMaLA4I4 Ha onpOCHbIX n1CTaX He 6bino, nocne o6o6u.eHMrn M4HopMauL4L4 Bce onpocmblenuICTbi 6binu yH4ITo)KeHbI. YqacTTie a onpoce 6bino nOnHOCTblO Ao6poBonbHbIM.
nlepeMeHHble BeJ14uIuHbi 4 noKa3aTenl4: nyHKTbi onpOCHoro JMCTa 3aTparMBanMpa3A1WHbie aCneKTbi M3MeHeHML KJ1MHm4eCKOrl ,eSTenbHOCTM u peaKL,ulo Ha HMX naLJi4eHTOK 14MeAu4uLHCKuX pa6oTHI4KoB. B OCHOBHOM uCTOYHu4KaMu AaHHbIX AnFi oLAeHKt4 npoeKTa 6bmuicaMooT4eTbi, KJIMHMqeCKaB CTaTt4CTWKa ku LHTepBbIo C KnioqeBbiMW HOCLTen1m1M H 4H()opMaLA4m.CaMooTmeTbi no aonpocaM, Hanpu4Mep, COCTOSHMWI 3AOpOBbsi, 4mcna noceUAeHHr4 Bpasa 14rocnMTa.n3aLUU B npeApoAoBoA nepMoA He conOCTaBAn1L4Cb C 3anfcsCML, cAenaHHbIMM BMeAl4lAMHCKkiX yqpe)KIeHHslx, 14 o4eHwBai1Cb, KaK TaKOBbIe. XOTR CBeAeHge 1 B TaKl4XcaMoOTqeTaX UHOrAa MornU 6bITb npeAB35ITbIMi, mCnnb3OB=Hme aanuceu MeAL41HCK14Xyqpe)KAeHmA 6bino 6bl YpeBaTO CB01M1M npo6neMaMm, oco6eHHo B cny-aSIx, KorAa 3anu4cuBeAyTcsl He nOApo6HO 14 He no onpeAeneHHoMy CTaHAapTy. 06bitHO caMOOTBeTbi KacaT8nbHOycnyr B o6naCTU4 3ApaBooxpaHeHt4FC conOCTaB1Mbi c MaTept4aiaM4, COAepwauAimics B 3anucsixMeAi4LI14HCKHX yqpe)KAeHu1u. Ecnu 4Ke BO3HWKaIOT npoTWBope41SI, ICHOCTW no noBoAy Toro,KaKO14 UCT04HUK WH(pOpMa4wm1 Cq4TaTb 3OJ1OTbIM CTaHgapTOM", HeT.
28
npmnoweH"e E
noApo6Hbie Ta6J1HL4bi
Ta6nmLta I. O)KU,AaeMbie H pLeACTBI4TeJlbHbie pa3Mepbl Bbi6opOK B noArpynnax;P03JIbTaTbi npeAiapBlTeJIbHoro TeCTWpOBaH4si U nOCT-TeCTt4pOBaHw5lnoarpynna oLLeHKa npenB. nocT-TecTWPOBaHme
TeCTLpOBaHme
nocnepojA. 80-100 94 100a6opT 200 96 95MIHma6opT 80-100 87 99rIHeKoJn. 200 155 110MeA. pa6OTHMK 136 103 132A4aHHbIe nmo6epeL(Koro 3KKcnep4MeHTa
-Ta5uli4a IL. PeaKicw,s onpaw IBaeMbIx no nOArpynnaM, npeABapHTenbHoeTeCTHPoBaHue U nOCT-TeCTHpOBaHUe (B CKo6Kax)rloArp. nlpeMneM. HenpueMn. OTKa3 FloTepHbI He paccm. % OTBeT.nocnepoA 100 [1001 0 [0] 0 [0] 0 [0] 6 [0] 94%[100%]a6opT 98 [102] 3 [2] 0 [0] 0 [4] 2 [3] 98% [93%]MmHMa6opT 94 [103] 0 [0] 2 [3] 0 [1] 5 [01 93% [96%]rMHeKon. 167 [116] 7 [0] 8 [3] 0 [0] 4 [3] 93% [95%]MeA. 136 [136] 0 [0] 33 [3] 0 [0] 0 [1] 76% [97%]pa6OTHMKAlaHHbie nho6epeLKoro 9KcnepFiMeHTa
noTepRHbl = npH npoBeAeHmm nOCT-TeCTHpOBaHNrP pecnOHAeHTbi 6binH yTepRHbI u3 BUAy.He paccm. = He paccmaTPMBan1MCb Te BonpOCHu4Ku, KOTOpbIe mcnOnb3oBanMCb B nunOTHOM TeCTIPOBaHHHAnR nOArOTOBKH UHTepBbioepOB (npeABapHTenbHoe TecTHpoBaHi4e), nocne 4ero HeKOTOpbie i43UeHeH&lR6binU CAAleaHbl B TeKCTe BonpocHHKoB. TaKwKe He paccmaTpmaanMCb Te BonpocHuKu, B KOTOpbIX He 6binAaH OTBeT Ha MHOrme BOnpOCbl - TaKme clyq4am paCCMaTpHBanfCb KaK OTKa3.
29
COBCpWeHCTBoaHMe CHCTeMbi OXpaHbi 3,OPOBbH .KeHLW4H B POCC14cKoa oenepaLuu
Ta6n4ia IlIl. CoULjanbHo-AeMorpaaO1IecKme xapaKTepl4cTMKM naLtmeHToK (nocnepoAosoIq nepmoA, a6opTb,MHHma6opThi, rmHeKonorMs), npeABapwTenbHoe TecTU4poBaHiue tU nocT-TecT14poBaHt4e
nocneponopok nePOLM A60pT
npeAf. TecT nOCT TecT p npeAE. TeCT n=96 noOT TecT pn=94 n=100 n=95
Bo3PacT (cp.) 25,2 25,2 CH 28,8 28,0 CHrpaxAaHCKoe COCTToHUe(%)3aMyxeM 83,0 85,0 CH 82,3 85,3 CHCOBMeCTH. npOIcUBaH1e 8,5 3,0 4,2 7,4pa3seAeHa 0,0 1,0 6,3 2.1He3aMY)K 6,4 11,0 7,3 5,3BAOBa 0,0 0,0 0,0 0,0OTCyTCTB. 2,1 0,0 0,0 0,006pa3oBaHue (%)Ha8anbHoe 6,4 8,0 CH 1,0 1,1 CHcpeAHee 19,1 33,0 13,5 13,7y4wnwuAe 42,6 34,0 43,8 43,2TeXHuKyM 7,4 5,0 18,8 18,9YHMBePCcTeT 24,5 20,0 22,9 23,7
pa6oTa (%)nOJnHas unuW qacTwqHas 61,7 57,0 CH 62,5 46,3 *3aHRTOCTbcTyAeHTKa 12,8 14,0 CH 9,4 8,4 CH
MuHMa600T rMHeKo orms
npe- nocT- p npe- nocT- pn=94 n=100 n=96 n=95
Bo3paCT (Cp) 30,4 29,3 CH 29,5 27,8 CHrpa)KAaHcKoe CocToRHIe
(%)3aMy)KeM 78,2 58,2 * 72,3 78,2 CHCosMeCTH. npO)KIBaHNe 9,2 18,4 15,5 16,4pa3BeAeHa 8,0 11,2 7,7 2,7He3aMy)K 2,3 12,2 2,6 1,8BAoBa 2,3 0,0 1,9 0,9OTCyTCTB. 0,0 0,0 0,0 0,0
o6pa3oaaHSe (%)Ha4anbHoe 1.1 7.1 * 1.9 0,9 CHcpeAHee 22,9 29,3 21,9 21,0yqnA1LLte 34,5 16,2 38,1 41,8TeXHu4KYM 12,6 18,2 9,7 13,6yHusePCu4TeT 28,7 29,3 28,4 22,7pa6oTa (%)noJIHaR 4nu 4aCT14qHas 60,9 71,7 CH 58,7 42,7 *3aHRTOCTbCTyAeHTKa 9,2 22,2 * 14,2 13,6 CH
cH=cTaTHcTM'ecKI He3Ha4MT.* p<0,05 p<0,01 p<0,001
,aaHHbie nio6epeuKoro 3Kcnepi7 meH7Ha
30
COBepWueHCTBOBaHUe CUCrembi OX8HbJ 311OpOBbSw XeHLUH B POCCUUcKOUl Peepau=U
Ta5,Hnu,a IV. lICTOPUR penpOAyKTHUBHOuI 4yHK4Hm l8auLeHTOK (nocnepOAOBoA nlepHOA,a6opT, MHHHaBOpT, rHHeKonorHfi), npeABapHTe6IbHoe TeCTHpOBaHHe H nOCT-TeCTHPOBaHUH
noCnepOAOBOU nepHoA aGOPT
npeABapUT. nOCT-TeCT p npeABapHT. nOcT- pTeCT n=100 TeCT TeCTn=94 n=96 n=95
BO3paCT nepBoi 21,9 21,3 CH 20,0 19,6 CH6epeMSHHOCTH (Cp)
>KHBOpO)KAeHHbie (%)HeT 0,0 0,0 CH 12,5 7,4 CH1-2 94,7 96,0 85,4 91,6>2 5,3 4,0 2,1 1,1MepTBOpONcAeHHbie
(%)HeT 96,8 98,0 CH 100,0 98,9 CH1 nnn 6onbwe 3,2 2,0 0,0 1,1BbIKMAbIWHI (%)HeT 88,3 87,0 CH 92,7 93,7 CH1 mnM 6onbwe 11,7 13,0 7,3 6,3HCKyCCTB a6opT (%)HeT 74,5 57,0 HK HK1 16,0 22,0 40,6 30,52 5,3 11,0 37,5 26,33 MnM 6onbwe 4,3 10,0 21,9 43,2
MHHH-860PT rHHeKOnOrMRnpeaBapHT. nOCT TeCT p npeABapHT. nOCT pTeCT TeCT TecT
BO3p8CT nepBoI 20,4 20,3 CH 20,9 20,7 CH6epeMeHHOCTH (Cp)
WKHBOpOX(AeHHbie (%)HeT 12,6 22,2 * 31,0 28,2 CH1-2 82,8 65,7 67,1 69,1>2 4,6 12,1 1,9 2,7MSPTBOPO)KASHHble
(%)HeT 98,9 90,9 99,4 98,2 CHI nmn 6onbwe 1,1 9q1 0,6 1,8BbiKMiAbIWH (%)HeT 78,2 83,8 CH 85,8 82,7 CH1 mnm 6onbwe 21,8 16,2 14,2 17,3HCKyCCTB a6OpT (%)HeT HK HK 39,4 38,21 28,7 23,2 * 23,2 29,1 CH2 25,3 45,5 12,9 18,23 MnM 6onbwe 46,0 31,3 24,5 14,5
cH=cTaTMcTM4ecKM He3HaI4MO* p<O,O5 ** p<O0O1 *** p<o,oo. AaHHble nO6epe4Koro3KcnepuiMeHTa
31
CoBepweHcTBoBaHme cHcTeMbi oxgaHbi 3DAODOBbR .weHLu4H B POCCUUCKOU Oeepauu
Ta6nuua V. CocTosule 3AopOBbHf naui4eHTOK (nocneponoBoru nepmon. a6OpT. MNHMa6opT.rmHeKonormsI), npefx3apulTenbHoe TeCTIpoBaHUe U nOCT-TeCTIpOBaHU
nocnePoAOBo0 nepuoA a6opTnpeABapUT.TeCT nOCT-TeCT p npeABapulT. nOCT- pn=94 n=100 TeCT TeCT
n=96 n=95npo6neMbl 3AOPOBbSI
(%)HeT 74,5 53,0 90,6 85,3 CH1 iu.nm 6onbwe 25,5 47,0 9,4 14,7OCnONCHeHi1si npu
6epeMeHHOCTm(AaHHoA/nio6oA Apyroui -
HeT 28,7 21,0 CH HK HK1 unu1 6onbwe 71,3 79,0 HK HKoCnoMHeHmR npm
6epeMeHHOCT4
(npeAb'AyLek -%)
HeT 71,7 44,6 * 92,7 98,9 *1 unu 6olbwe 28,3 55,4 7,3 1,1KypeHue (Aa - %) 5,3 23,0 30,2 20,0 CHB Te4eHme npownoro
roAa (Aa -%)
poauana HK HK 18,8 16,8 CHAenana a6opT HK HK 13,5 15,8 CH
M14HM-a6opT rWHeKonormsnpeABapHT.TeCT nOCT-TeCT p npeABapMT. nOCT- pn=87 n=99 TeCT TecT
n=155 n=110npo6neMbli 3AOPOBbS
(%)HeT 46,0 52,5 CH 29,0 31,8 CH1 u 6onbwe 54,0 47,5 71,0 68,2OCJ1o)KHeHMS
6epeMeHHOCTU1
(HacTofuu4eA
/nio6ogi) -%
HeT HK HK HK HK1 U 6onee HK HK HK HKOCnO)KHeHU414
6epeMeHHOCTTU
(npeAblAyu4eg) -%
HeT 27,6 28,3 CH 46,2 50,0 CH1 U 6o0nee 72,4 71,7 53,8 50,0
KypeHue (Aa -%) 21,8 55,6 ... 23,2 19,1 CH
B Te4eHwe nocneAHHX
12 MecsLIeB (Aa-%)
powKana 8,0 10,1 CH 7,1 8,2 CH
Aenana a6opT 13,8 22,2 CH 11,6 12,7 CH
CH=cTaTMcTH4ecKH He3HaL4Mo* p<O,05 p<0,O1 p<0,001; /aHHbIe nio6epeliKoro3KCn6plfMeHTa
32
COBCpLLJeHCTaOBaHHe CbfCTeMbi OXMaHbi 3JOJBb51 )eHWl4H B POCCkUUCKOa Veepaukim
Ta6nuL4a VI. Mcnonb3oBaHme KOHTpaLIenTLBOB (naUmeHTKH nocnepoaOBoro nepHoAa, a6opT,MmKma6opT, rMHeKoJ1orMsl, npeABaprTenbHoe U nocT-TecT14poBaHl4enocnepoooiq nept4oa a6opTnpeAB.TeCT nOCT- p npeAjB. nOCT-TeCT pn=94 n=100 n=96 n=95iqcnOJnb3OBaHme unui nony4eHme 0,0 65,0 ** 39,5 60,0 **COBpeMeHHbIX KOHTPa8LenTMBOB
*B HaCTOSUtee BpeMs (%)
MeTOA(bi) KOHTpaL4enl4IImcnOnb3OBaH (bi) unuino.ny4eH(bi) (%)OK 16,0 21,0 5,2 17,9Apyrme ropMOHanJbHbIe 0,0 1,0 0,0 0,0cp-BaBMC 6,4 21,0 4,2 0,0TOJnbKo npe3epBaTMBbl 4,5 32,0 28,6 42,1npe3epBaTMBbl + cnepMaL&4Abl 10,6 3,0 0,0 0,0TOJnbKO cnepMaLIuAbi 0,0 0,0 0,0 0,0Apyrme nperpaAbi 0,0 1,0 0.0 0,0
CTepH3mAaJuLk 0,0 0,0 0,0 0,0
M4Ht-a6opT rLHeKorioriSnpeAB. TeCT nOCT p npeAB. nOCT TeCT pn=87 TeCT TeCT n=110
n=99 n=155mcnOflb3oBaHme mun nony4eHme 52,9 69,7 60,0 72,7 *coBpeMeHHbIX KOHTpa4fenTuBOBB HaCTORULee BpeMs (%)
MeTOA(bl) KOHTpa4enlp4lmcnonb3oBaH (bl) uanunony4eH(bl) (%)OK 9,2 35,3 12,3 22,7Apyrne ropMoHanbHble cpeCGTBa 0,0 1,0 0,0 1,8BMC 14,9 15,2 19,4 22,7TOnbKo npe3epBaTWBbl 24,1 6,1 24,5 25,5npe3epBaTHBbl+ 2,3 8,1 0,6 0,0cnepMaLMAb'TOJnbKO cnepMa4L,AbI 1,2 2,0 1,9 0,0Apyrme 6apbepbl 1,2 2,0 0,6 0,0CTepMn03a4UP 0,0 0,0 0,6 0,0
CH = CTaTWCTM4eCK14 He3HaLBMop<O,05 ** p<O,O1 * p<0,001 cTaTL4CT14Ka TeCTVIpOBaHL45 X2
# An nocnlepo,QoBbix naLAIeHTOB paccmaTpUBaeTCR Icnonb3QBaHme TOQJbKO npeAblayWLX MeToAOB
.4aNHHIe ilo6epeAlKoro YKcnepieHrTa
33
CoBepWeHcTBoBaHme CmCTeMbl OXQaHbi 3AODOBbH .weHLUH 8 POCCoaCKOL cezepaUUU
Ta6nmua Vila MenwKo-caHUT. nPoceuUieHUe U YxoO U poAnoMax U NKeHCKHX KOHCYJ1bTaUUHX. naU*OHTKInocJIeDOR,lbUrO neD a nDeasaDmTeabHoe u nOCT-TeCTHDOBaHMOTeMbi 6.cn O 3Dopobe (KKOHCJbTaUUMU) % naUmeHTOK. nOny4M8. HHP-UUIO
npe- (n=94) nOCT- (n=100) pKYPeHme 37,2 45,0 CHanKOrOJlb 40,4 28,0 CHnUTaHUe 92,6 62,0AUCKOM(POpT npw 6epeMeHHOcTm 71,3 80,0 CHOTAbiX U YnPa)KHeHMS1 62,8 54,0 CHYXOA 3a HOBOPO)KAeHHbIM 25,5 60,0rpyAHoe BCKaPMJU4BaHte 23,4 36,0 CHnOArOTOBKa K POAaM 25,5 58,0PUCKH He6e3onaCHbix a6opTOB 29,8 42,0 CHnbrOTbi MaTePHHCTBa 47,9 73,0KOHTPaLAenLtL4U 17,0 54,0MHTepeaJn Me)KAy poAaM/BpeMFi POAOB 13,8 43,0CHrHanbw onacHocTtl:KPOBOTeYeHUe 74,5 73,0 CHCU.nbHbie rOnOBHbie 6onU 43,6 27,0 *CUnbHa9 PBOTa 50,0 25,0BbICOKa9 TemnepaTypa 58,5 34,0nOTepU C03HaHU9/KOHBynbCUU 43,6 21,0Pa3pSiB nnOAHbIX o6onoBeK 63,8 50,0 CH6biCTpbie onyxaHH9 KOHe6HOCTeA 74,5 43,0pe6eHOK BHYTPU nepecTaeT weBenUTbC9 72,3 60,0 CHToMb 6.eCn O SalOpobe IDO*AOM)KypeHUe 8,5 58,0anJKOrOnb 9,6 39,0nUTaHeL4 76,6 80,0 CHYXOA 3a Co6oU 35,1 82,0YXOA 3a pe6eHKOM 21,3 91,0rpyAHoe BCKaPMJUBaHIe 39,4 81,0KOHTpaL4enLrn9 7,4 38,0L4HTePBan Me)KAY poAaaM4/BpeMA POAOB 5,3 37,0nfOJwaeMshm yOx (KOHCYnBTaUUm) % naUUieHTOK, OTBOTUBWUIX "al"nOnyB4UnU nPeHaTanbHbiU YXOA 100,0 100,0 CHnony4Ujn npeHaT. yxoA 6Oiee 4eM U3 OAHOrO I,CTOqHHKa 41,5 6,0Bce npeHaT. KOHC-LAmm/6O,nbWYIO 4aCTb Y OAHoro BpaBa 73,4 65,0 CHrOCnUTanlU3alAUU BO 6 peM9 6epeMeHHOCTUnoceUXeHme KYPCOB MOnOAbiX maTepeU B npeAPOA. nepwoA 60,6 54,0 CHnOnyHeHUe BMTaMHHOB/MMH. BeU4eCTB BO BPeM9 6epem-Tr 17,0 9,0 CHnfOnYaeMb; VXOn (DOAAOM) 79,8 83,0 CHHaxo)KAeHme B OAHOU nanaTe C HOBOpO)KAeHHbIM 2,1 57,0KOHTaKT C HOBopoKAeHHbIM Cpa3y nocne POAOB 8,5 50,0rpyAHoe BCKaPMJ1BBaHLe 63,8 78,0 *AOnOnHMTenbHOe nUTaHUe An9, HOBOPO)KAeHHoro 69,4 99,0AeTCK. nfTaHLe MOWKHO MO)KHO nocie BinUCKt B39Tb AOrMOU 0,0 0,0 CHnPmCyTcTBi4e naPTHePa npf CXBaTKaX H POAaX 2,1 16,0BU3UTbl OTL4a B nanaTy 3,2 4,0 CHBbiAa4a CpeACTB KOHTPa4Len4LUU A Fi niaHHPOBaHH9 CeMbU 0,0 65,0nonyBeHUe BmTaMUHOB/MMH. BeXLLecTB 0,0 45,0CH=CTaTMCT. He3Ha94MO* p<0,05 ** p<0,01 *** p<O,OO1 cTaT-Ka TeCT-Ht4VI X2.4aH.bIe nlo5epewKoro s9cK7epuueHra
34
COBepW=eHCTBOBaHMe C54CTeMbi OXpHbi 311OpoBbq xeHLUUH B POCCrniCKOLU OeeaMu
Ta6nmua V116. MeanNKO-CaHT. npoCoBLueHme U yXoA. nauMeHTKU. npmWefWme AenaTb a6ODT. MmHua6opT i3a rKHOKOROErMOCKNMN ycnyraMH. npepBapHTeJlbHOe U nOCT-TeCTMpOBaaHeTeMh % naLtHOeTOK, nony4aoutwx MH4)OpMatmio OT MeA.pa6OTHNKM
A6opT MUHH-a6opT rMHoKOJ1ormNn=96 n=95 n=87 n=99 n=155 n=110npeAB. nocT- p npeAn. nOCT- p npeA4. nOCT p
KoHTpaL,enT. cp-Ba (KC) 38,5 40,0 CH 28,7 69,7 ... 56,8 90,0
nO6OqH.S1Bn-JI 37,5 34,7 CH 23,0 56,6 49,7 65,5 *nniocbI OT HeCnonOb3OB. 28,1 34,7 CH 19,5 59,6 43,9 55,5 CHKCKaK mCnOnb3OBaTb KC 32,3 26,3 CH 52,9 85,9 *** 56,1 30,9 **KOrAa HaL4lHaTb UX 1,0 3,2 CH 21,8 87,9 HK HK HKmcnonb3OBaHme
qaCTOTa 6epeMeHHOCTm 7,3 1,1 5,7 48,5 41,3 32,7 CHnUlTepaTypa o KC 2,1 4,2 CH 5,7 40,4 11,6 3,6nPOCMOTP BUAeO O 28,1 7,4 17,2 23,2 CH 6,5 0,0 *nnaHMpOBaHu14 CeMbU
6e3onacHbIA ceKc 15,6 17,9 CH 29,9 43,4 CH 63,9 17,3 *
npo4*PnaKT OCnO)KHeHLUU 16,7 18,9 CH 96,6 84,8 * HK HKnpw a6opTelICTOpUR6one3HH/KOHCyubT-UU
MeA. U4CTOpUi 66,7 54,7 CH 81,6 56,6 HK HKpenpoAqyKT.mcTopwFi 43,8 88,4 85,1 62,6 HK HKanneprL451 Ha MeAl4KaM- 88,5 82,1 CH 93,1 73,7 HK HKTbl/aHecTe3Mlo
oTHoweHL4e K 12,5 15,8 CH 19,5 34,3 * HK HK6epeMeHHOCTr
OTHoweHMe Ka6opTy 11,5 7,4 CH 10,3 66,7 HK HKT.3peHws napTHepa 10,4 5,3 CH 12,6 19,2 CH HK HKnilaHbi Ha 6yAyIoauAe 17,7 8,4 CH 19,5 46,5 HK HK4To o)KUAgaTb/KaK 6yAeT 15,6 18,9 CH 25,3 85,9 HK HKnposeAeHa npoLeAypa
YxOA % pecnOHAeHTOK, nOny4aioLLtx ycnYrUI43MepeHMe Kp. AaBfleHWF1 54,5 100,0 98,9 3,0 HK HKL43MepeHL4e Beca 1,0 1,1 CH 0,0 6,1 ** HK HKo6uui OCMOTP 16,7 89,5 1,1 7,1 HK HKOCMOTp Bnarant1uAa 99,0 98,9 CH 100,0 99,0 CH HK HKaHlanM3 Ha cnf,1 99,0 100,0 CH 98,9 88,9 * HK HKaHaJn13 KPOBM ((cW4)Wnlc) 100,0 100,0 CH 0,0 81,8 HK HKaHaJnU3 MO04 81,3 87,4 CH 0,0 8,1 ** HK HKOCMOTP Ha npegmeT 99,0 100,0 CH 100,0 88,9 *** HK HKMH4)eKI4Lu anaranunay,nbTpa3ByK 49,0 42,1 CH 18,4 39,4 HK HKaHa.fW3 Ha 6epeMeH. 9,4 14,7 CH 5,7 32,3 HK HKKC nony4eHO 0,0 0,0 CH 1,1 43,4 HK HKTUn a6OPTaBaKyyM 1,0 0,0 CH 100,0 100,0 CH HK HKBbiCKa6n4BaHt4e 99,0 100,0 CH 0,0 0,0 CH HK HKnpOAOnIXHT.68pOM-TH 99,0 HK HK6onee 12 HeAenlb 99,0 100,0 CH 100,0 100,0 CH HK HKMeHee 12 HeAenb 1,0 0,0 CH 0,0 0,0 CH HK HK
CH=CTaTU4CTWUeCKlU He3Ha4iUMO* p<O,O5 ** P<0,O1 * P<O,OO1 CTaTl4CTKa TeCTPO8saHMfIX2; 4aHHble IodVepet4Koro SKc7ephMMeHTa
35
QoaWwleHcTBoBaHU4e cUCTem4 OX=Hbi 321oposbg weHLUUH B POCC14rcKoU oePenmuu
Ta6AmHga Vill. OTHOUeH140 K nlOJlY4HHOMY YXOAY; UHH4OpMaIA. UHAUKaTOpbi no noBoAy nOnri4oHHbix ycAyr:nloCeopoAoB. nlepmoA, a6opT H mmHma60pT, rUH8KOnormn, npeAB. U nOCT-TeCTMpoeaHme
nocAepoAosoo nepuoA a6OPT
npeAB.TeCT nOCT- p npeAB. nOCT-TOCT p
n=94 n=100 n=96 n=95HeyAO6HbI6 4acbi o6cny)KmeaHHA(% 10,6 7,0 CH 9,4 7,4 CHTpyAHO Ha3HaBHTb Bpem-m npmema ()4,3 12,0 * 2,1 5,3 CHHa Aopory YXOANT 6OAbwle 30 MHH. 20,2 12,0 CH 5,2 4,2 CHMHoroO PeMeHN yXOAHT Ha O)KUAaHUG B 56,4 40,0 * 60,4 37,9 *0O"PGAN K RPA4Y(%)3OTpATbI (%)
KOHCYnlbTa411B, aHlanB3bl HK HK 7,3 89,5 **neKaPCTBa HK HK 3,1 12,6 *TpaHcnopT U YxOA 3a HoBopo)KAeHHbIM HK HK 21,9 2,1 **nOTePBi goxoAa HK HK 0,0 3,2*1UHAeKC YAOBn@TBOpOHUfl (KOHCYJlbTaL4UU)
TeopeT"q.3Ha4eHme 15,0 15,0 16,5 16,5npalCrM. 3HaHeHBe 16,1 17,4 CHi 13,4 17,0 **NHAOKC YAOBSeTBOpOHUR (PO;AOM)
TeopeTBH.3HaqeHBe 15,0 15,0 16,5 16,5npaKTWq. 3HaqeHme 15,9 15,8 CH 12,8 15,0 **NHAeKc nOIy4HeHNS UH4)opmagm (aKOHCYAbTaL4uu unu rAe-nm6o eu4e)
TeopeTiq. 3HaHeHme 6,0 6,0 8,5 8,5npaumx. 3HaHeHme 4,9 6,4 ** 4,7 5,2 CH
KHAeKc nOAY48HI4l NH4)opmaL4H (BPOAAoMO)TeopeTUA4.3Ha4eHme 4,0 4,0 HK HK
npaKTM4. 3HaseHBe 2,0 5,1 ** HK HK
MUHHH-a60PT rUHeKoniormsnpeA'3. TeCT nOCT p npjeAB. nOCT TecT p
n=87 n=99 n=155 n=110HOyA06HbIO 4acbi o6cny)KmeaHMA (%) 3,4 14,1 ** 0,6 0,9*TpyAHO Ha3Ha4HTb BPeMM (%) 2,3 7,1 CH 1,3 3,6 CH
Ha Aopory yXOAMT 6Onbwle 30 MU4H. 20,7 38,4 ** 5,8 3,6 CH
MHorO BpeMOHu yXOAHT Ha O*KuAaHHO B 47,3 75,8 * 66,5 74,5 CH
0OHPeAU K NPa4Y (%)3aTPOTbI (%)KOHCY.nbTaLAMM, allanM3bl 97,7 64,6 39,4 22,7 *nieKapcTBa 31,0 11,1 * 65,8 39,1 **TpaHcnOpT U yx0A 3a HOBopo>qAeHHblM 73,6 41,4 *nOTePs' AoXoaa 25,3 12,1 * 7,1 0,0UHHAKC YAOBneTOOPeHMS1 (KOHC-4UUM)
TeopeTUH.3HaYeHHe 16,5 16,5 15,0 15,0npaKTL4q. 3Ha4eHm4e 17,8 13,1 -* 12,7 13,3 CH
mHAeKc nony4eHmsl NH4)opmaLtm (BKOHCYAbTaL%mm unu rAe-nm6o eu4e)
TeopeTLUH.3Ha4eHme 8,5 8,5 5,0 5,0npaicrm4.3HaHeHL1e 6,7 10,5 -* 6,4 6,2 CH
CHI=CTaTt14eCKM HesHaqMT..*p<0.005 **p<0.001 ***p<0.00
,4aHHble lvo6epewKoro 3KcnepGMeHTa
36
COBepWeHCTBOBaHoHe C&fCTeMbl OXpaHbi 3SllOpBbR .WeHlUIH B POCCHlfCKOf 0eAepanuMl
TaG6nma IX. OTHOW6H.e naL4MHTOK K OTASJ1bHbIM 3neMeHTaM yxoAa (nocnepoAoBoU nepmOA, a6opTm,M4HNa6OPTbI, ruHeKonormsi), np6ABaPUTeJbHOO U nocr-TOCTMpOBaHUO
% pecnoHAeHToK, OTBUTHBUwXx"ocerAa" Mnu "0o6iBHo"nocnepo4oAoio nepuoA a6opTnpeAB. noCT. p nPeAB. nocT. pn=94 n=100 n=96 n=95
KoHCynbTa4gmaBexnUBoe OTHOweHUe 88,3 94,0 CH 93,8 97,9 CHyAejiniiocb AoCTaTo4Ho BpeMeHu 77,7 88,0 CH 90,6 95,8 CHYBa)KUTenlbHOe OTHOw6eHUe 60,6 96,0 ... 99,0 98,9 CHK U4HTUMHbIM BonpocamHanUPUe Bi6opa 54,2 53,0 CH 100,0 96,8 CHXOpOWWUU KoHTaIcr 86,1 96,0 * 97,9 98,9 CHnooLiApFJn1Cb Bonpocbi 71,3 35,0 86,5 63,2gaBanUCb OTBeTbI Ha BOnPOCbI 80,8 96,0 89,6 86,3 CHyBa)KMTe,nbHoe OTHOwLeHLe K 64,9 95,0 93,8 96,8 CHBbICKa3blBaeMbiM MHeHV1PM
3a6oTa O naLAmeHTe 81,9 98,0 99,0 98,9 CHXOPOWwU yxoa 81,9 100,0 95,8 92,6 CHHe pa3rOBap4BalOT C To60U CBbICoKa HK HK 87,5 2,1
PoggoMBe)KnJ4Boe OTHOweHUe 96,8 87,0 99,0 100,0 CHyAejnipjoCb AoCTaTo4Ho BpeMeHu 63,8 88,0 92,7 97,9 CHyBaX>(TenbHOe 30,9 97,0 99,0 100,0 CHOTHOwBeHAe K UHTLUMHbIM BonpocaMHaJniM4e Bbi6opa 26,6 63,0 99,0 100,0 CHXOPOWl.11 KOHTaKT 90,4 97,0 CH 97,9 100,0 CHnOOuApFi,nmCb BOnPOCbI 86,1 38,0 88,5 81,1 CHgaBanJCb OTBeTbl Ha Bonpocbi 93,6 94,0 CH 81,7 98,9 *yBa)KOTefJbHoe OTHoweHLe K 49,0 96,0 93,8 98,9 *BbICKa3blBaeMbIM MHeHUPM
3a6oTa o naLtmeHTe 84,0 96,0 * 100,0 100,0 CHXOPOwUJU YXOa 94,6 100,0 * 99,0 97,9 CHHe pa3rOBapuBaKOT C To6oA CBbicoKa HK HK 88,5 9,5
MmHH-a6OpT rUHeKOnorUnnpeAB. noCT. p npeAB. nOCT. pn=87 n=99 n=155 n=110
KOHCynb rTaqIu
Be,KnUBoe OTHoweHWe 88,5 100,0 ... 95,5 98,2 CHyje.nnOCb aOCTaTO4HO BpeMeHU 86,2 97,0 ** 94,8 99,1 *YBa)KUTe,nbHOe OTHoweHHe 80,5 88,9 CH 89,7 100,0K HTWMHbIM BonpocaM
HanM4we Bbl6opa 75,5 96,0 84,5 100,0XOPOWkl' KOHTaKT 83,9 83,8 CH 93,5 99,1 *nOOflAtSI.VnCb BOnpOCbI 9,2 70,7 67,7 94,5AaBani1Cb OTBeTbi Ha BOnpOcbd 77,0 92,9 92,9 97,3 CHyBa)KMTeBJbHoe OTHOwBeHLe K 70,1 89,9 88,4 99,1BNCKa3bIBaeMbiM MHeHuPM
3a6oTa o naLmeHTe 690 87,9 89,7 99,1xOpOwUJU yxoA 62,1 99,0 90,4 74,5He Pa3rOBaPUBalOT C To6oU CBbICOKa 36,7 90,9 HK HK
CH=CTaTUPeCKU He3Ha4T.,* p<0,005 **p<00O1 ***p<0,001.4aHble n7to6epei4Koro 3KcnepmmeHra
37
COBepweHCTBOBaHme CHCTCMbi O92Hbi 3aOpOBbR .KeHwbf H B POCC&UUCKOU 0eepaUNN
Ta6niuua X. B3rnRnMb noTpe6lTeneg Ha noIly4eHHbIi yxona nauMeHTKm nocnepo0o.oroneDfloDa. nfDsapMTeOJbHoe u nOCT-TeCThpOBaHUe
npoUeHT OTDaBBWfX npefLnO4TSHNenpeAB.TeCT. nOCT-TeCT. p
n=94 n=100
KTO AOmKeH o6ecne4HBaTb YXOA B npeApoAoBoAnepUOA
Bpa4 o6uLJeu nPaKTUKU 3,2 26,0aKywepKa 1,1 4,0aKywep-rwHeKOJ1or 92,6 65,0MHeHL4F HeT 3.2 5,0
KTO AOJ1)KeH nPUHUMaTb POAblBpa4 o6LLAeA npaKTMK&. 2,1 0,0 CHaKywepKa 6,4 14,0aKywep-rHHeKOJlor 91,5 85,0MHeHMR HeT 0,0 1,0
KaK nfl8TMTb 3a MeAM4LAHCKoe o6cnymlcBaHmeBce pacxoAbl 143 CBoero KapMaHa 6,4 31,0Hamlorm + U3 cBoero KapmaHa 41,5 16,0TOJnbKO HanorU 23.4 49,0MHeHMR HeT 28,7 4,0
AoflxcHbi nM )KeHCl4lHbl MmeTb npaBo Bbi6opaBpa4a? 94,7 98,0 CH
AOnfKHbl nm xceHU4MHbl MmeTb npaBo Bbi6opa 97,9 100,0 CHne4e6Horo 3aBeAeHMH?
npeAno4TuTenbHbl 3annaHMPoBaHHbie BCTpem4l C 13,8 65,0Bpa4oM B npeAPOAOBoA nepmoA
npeAno4TiITeJnbHa )KeHCKaSi KoHCyJ1bTaL4si, 21,3 30,0 CHpa6oTaiouLaS B Be4epHee opeMs
nlpeAno4TMTenbHo HaxoxKAeHme B OAHOA nanaTe c 87,2 79,0 CH
HOBOpO)KAeHHbIM
npeAnoTHmTenbHo rpyAHoe BCKapMJnUBaHuie no 43,6 47,0 CH
Tpe6oBaHuKo HOBOpoXKAeHHoro
npeAnOTUiTeneH AOcTyn noceTUTeneU 79,8 84,0 CH
npeAno'4THTenbHo npUCYTCTBme napTHepa npu4 40,4 44,0 CH
poAax34,0 41,0 CH
npeAno4T4Te.nbHo npMCYTCTBme napTHepa npmpoAopa3peLueHM
79,8 76,0nlPeAno4TITenbHa P8HH5R BbinICKa U3 pOAAOMa
CH=CTaTmCTm4eCKM He3Ha'*iMo* p<O,O5 ** p<O,01 *** p<O,001 cTaTICTMKa TecTwPOBaH&i4l X24aNHbHe moeGpe6LKoro 3KaKlBepiueHTa
38
COBep weHCTBOBaHbe CUCTeMbi OXpaHbI 34lOpOBbH )KeHCllIH B PoCcoa1CKoa1 (1enepau
TaOfnuua XI AaHHbie o MeAHLLHHCKHX pa8OTHHKax, npeABapITenbHoe u noCT-TOCTMpOEaHHSnpe- nOCT- p
B03paCT cpeAH,U 35,6 37,3 CHSD 12,2 11,6Amanla3OH 19,66 19,67
non )KeHCKMI 98,1% 97,7% CHMy)KCKOA 1,9% 2,3W.
M9CTO pa6OTbi pOAAOM 78,6% 75,2% cHKOHCYTIbTaBLLmF 19,4% 24,1%
3aHmMaOMan 3aB.OTAerleHmeM 9,7% 7,5% CHAOnl)KHOCTb cneLtmaniCT 18,4% 18,8%
Bpa'4-npaKTMKaHT 2,9% 6,8%cTapwaFi aKywepKa 4,9% 3,8%aKywepKa 50,5% 54,1%MfiaAwlaFi aKywepKa 4,9% 3,8%npo4me (rnaBHbIM o6pa3oM MegceCTpbl) 0,0% 5,3%
cH=cTaTHcTM4ecKH He3HaqMmo* p<O,05 ** p<0,01 *** p<O,001 CTaTWCTuKa TeCTupo0saHMX2,4aHHble .7/o6epeKoroP 3KcnepfMeMHTa
39
CoaepuweHcBoBaHme CMCTeMbi OXpBHbi 3nOpOBbR )weHLUfH B POCClCKOa Oenepaumu
Ta6nu4a Xii. YpomeHb 3HlaHU4A U OTHOweHIe MeAHL414HCKLIX pa6oTHHKOB K OTAe@JbHbIMacneKTaM npeAoCTaoneHun ycnyr, npeABapuTenbiHoe u nocT-TecTupoBaHme
flpoqeHT cornacUmnuixcs
npeAB. nOCT p
MuHHa6opTbil npeAnO4TOTebHee o6bl4Hblx a6opTOB 93,2 92,4 CH
BceM naLA[4eHTKaM, nP"weA1w8 M AenaTb a6OpT, cnegyeT AasaTb 99,0 99,6 CHKOHCynbTa4LM1 B o6naCTu KOHTpaL,enL,lUU U nOMOraTb MMBbl6paTb MeTOA KOHTpaLnLk,14
Bce naLm4eHTKM nocilepoAoBoro nepHoAa AOJn)KHbi noi1y4aTb 99,1 99,2 CHKOHCynbTaSL1O U 14H4)OpMaLAt4iO no BOnpOCaM KOHTpaLkenLAmm AOBbinfCK14 U3 popAoma
Bce ,KeHu14HblI, An0 3AOPOBbSl KOTOPblX 6epeMeHHocTb Mo)KeT 99,1 99,6 CHnpeACTaBJnISTb yrpo3y, AOn)KHbi nonyJLaTb Heo6xoAmmyio14H4)OpMaLUUIO U KOHCynbTaL1414 B o6nacTM KOHTpa4enLU,U
)KeHuALHbl, KOTOPbIX 14HTepeCyKOT BOnpOCbi nnaHMPOBaHMS 94,2 95,3 CHCeMbM, AOnfKHbl MmeTb B03MO)KHOCTb npOATU Bce Heo6xogwMbieo6cneAoBaHMA U cAaTb na6opaTOpHbie aHlanJ43bl 3a OAHOnoceLLOeH1e
Bce )KSHUAMHbl, KOTOpbie 6onbwe He )KenalOT MmeTb AeTeW, 93,2 92,4 CHAOJDKHbl UMeTb npasO Ha xmpypri4eCKYKo CTepwnw3aLukmo
Bce My)K414Hbl, KOTOpbie 60nbWe He *enaiOT UMeTb AeTeA, 80,6 87,7 **AOOJ)KHbl MmeTb npaBO Ha XmpyprMIIeCKyiO CTept4nI43a,41io
A,ni Toro, 4To6bl HaceJeHme oTAaBano npeAnoLcTeHme He 99,1 98,7 CHa6opTaM, a KOHTpaLUenL,UU, Heo6xoAL1Mo npOBOAUTbnpOCBeTUTenbCK1e KaMnaHUU c mcnOnb308aHmeM CpegCTBMaccOBOA 14H4)opMaaLA4
CnegyeT CTpeM1TbC5I K TOMy, 4To6bl My)K4HHbl Aenmnm 6peMs 100,0 99,2 CHOTBeTCTBeHHOCTU B Bonpocax ninaH1poBaH145 ceMbL
npm )KeHCKWX KOHCynbTaLkm5X 1 pO0AmnbHblX AOmax AOn)KHbl 99,0 98,3 CHpa6OTaTb rpynnbi npeApoAoBor0 o6yL;eHHuI u rpynninOArOTOBK14 K poAaM
Bo BpeMn poAos u poAopa3peweHWsl )KeHuHI4Ha Aon)KHa 66,0 64,8 CHHaXOATbCSI B oTAeJ1bHOri nanaTe
AInJ KOHTPOnJ 3a xoAoM poAos cneAyeT nOnb3OBaTbCFI 84,5 91,9napTorpa4)oM
B pOA14flbHOM AoMe BO BpeMsi CXBaTOK p5AOM C pO)KeHinLaMm 62,1 63,1 CHAOOn)KHbI HaXOAUTbCR MX napTHepbi
B POAMJ1bHOM AoMe BO BspeM5 pOgOB pRAOM c pO)KHeHLMam 45,6 47,5 CHAOJVKHbl HaXOAUTbC51 mX napTHepbl
40
COBepagMeHCTBOBaHme CHCTeMbl OXpaHbi 3IIO2OBbq weHLUH B POCC&UCKOi CeaeDuu
Ta6nmu4a XIl. YpomeHb 3HaHUM U OTHOwleHme MeAI4I4HCKUX pa6oTHMKOB K OTAOnbHblMacneKTam npeAoCTasBneHu ycnyr, npeABa PTeJbHoe n focT-TecTNpomaHue(npoAonxKeHMe)
nlpoLAeHT cornacumwuxcu
npeAB. nOCT p
CJSeAyeT CTpeMWTbCA K TOMY, HTO6bi MY)KBUHbl OKa3blBanJ1 88,4 87,7 CHnOMOUb no yXoAy 3a HOBOpo)KAeHHbIMM
nO4TM BCeM naLAmeHTKaM noCAiepOAOBOrO nepmoAa cneeAyeT 73,8 79,7 *pa3pewaTb HaxOAUTbCsI B OAHOU naniaTe Co CBOUMHOBOPO)KAeHHbIM
locuie pOAOB KeHLU4MHe cJ1eAyeT nO3EOn;1Tb BCKapMnmBaTb 62,1 76,3 CHrpyAbio no Tpe6oBaHMIo HOBOpo)KAeHHoro
Eciui HOBOpO)KAeHHbi4 6oJleH, pOAMTeJUi AO)lKHbi nlOJ1yqaTb 83,4 89,4MH(IOpMaL4kmo 0 COCTOsHmm ero 3AOpOBbR, 4MeTb B03MO)KHOCTbHaBeLi.aTb ero U OKa3b[BaTb MaKC14MaJlbHO B03MO)KHbIA yXOA
Ecnu4 )KeHWu14Hbl B penpOAYKT14BHOM 1o3pacTe HeAonony4aloT 97,1 98,7Heo6xOAUMoro fllTaHM4 (BKnio4aA MOnOAe)Kb AO ABaALaTM neT),TO mM CJ2eAyeT AaBaTb nfTaTenJbHbie Ao6aBK1M, B oco6eHHocTM,)KeBJe3O u conm 4)ojimeBo4 KMCJnOTbl
6epeMeHHbIM )KeHLL4MHaM nflTaTeClbHbie Ao6aBKM cn1eAyeT AaBaTb 85,4 88,6 CHHa perynnPHou OCHOBe
KOPMsL4UmM MaTepRM nMTaTenbHbie Ao6aBKM cneAyeT AaBaTb Ha 82,5 88,1 *peryn51pHoO OCHOBe
BblSJ1eHUe U nle4eHMe 3a6oj1eBaHL4r, nepeAaiaoLU4xci llO)lOBbIM 99,0 99,2 CHnyTeM, AOJ1)KHO OCYL4eCTBI15TbCA B )KeHCKMX KOHCyn1bTaLA4lx
CBeAeHl51 AAA MOnoAe)Km, CBA3aHHbie C CeKCOM U 94,2 95,8 CHpenpOAyKTMBHOU OYHKLA4eri 3AOpOBbA, AO)1)KHbl npeAnaraTbc; B)KeHCKMX KOHCynbTaiA4mX
npeAoTBpau2eHue 6ecnnoAu14, ero ne'eHie U KOHCynbTL4poBaHme 96,1 98,3 *AOJDKHO ocyLieCTBR51TbC51 B )KeHCKMX KoHcyJIbTai451x
41
COBepweHCTBOBaHHe CHCTeMbi OXDBHbi 3JlOpOBbq YeHLUIH B POCCUU1CKOU Oeneauuu
Ta6mnua XII. YposeHb 3HaHmA U OTHOwUeH1e MeA4ULHCKUX pa6oTHmKOB K OTAellbHbiMacneKTaM npeAOCTasJ1eHII ycinyr, npeABapiTenbHoe i nocT-TeCTUpoBaHMe(npoAoncKeHMe)
npoLAeHT cornacnmwuxcu
npeAB. nOCT- p
)KXeHLLHbl, Haxo,AEsmeC B nOCT-KnuMaKTepw4ecKoM nepuoAe, 95,1 97,0 CH
A,oJKHbl i4MeTb BO3MO)KHOCTb nOny'4Tb ropMoHanibHylO Tepanuio B
)KeHCKOu4 KOHCYJ1bTaLAt41
npOBepKa Ha paK rpyA, 1 weAKM MaTKU AOJDKHa oCyu,eCTB)1%STbCs B 94,2 97,0 *
)KeHCK1IX KOHCYJ1bTa"m4X
ropMoHanbHble KoHTpaLJenT4BbI (MMHw-nwulonm) He npeAcTaBnsmoT 28,1 45,3onaCHOCT1 AnFl KOpMsU.L4UX maTepeA
npOCBeTNTenbCKas pa6oTa B Bonpocax ceKca u KOHTpa4LenLU14 He 82,5 83,5 CH
BeAeT K nOBbiweHI4o ceKcyanbHoA aKTMBHOCTM u Hepa36opq4BocTM
B CB53RX cpeAu4 MOnOAe1)K
YPOBHU BTop1qHoro 6ecnhioAM1 BbIWe y )KeHLLk1H, KOTOpbie npu 88,3 92,4 *
nh1aHmpoBaHI414 CeMbI4 OTAaIOT npegnoITeHme a6opTaM, a He
KOHTpaL1enI,41
nloBTopHbie a6opTbi nOBbIWalOT 6eposTHOCTb po)4AeHLuH pe6eHKa c 70,8 75,0 CH
4pe3MepHO Manb1M BeCOM
npu a6opTe PUCK HaMHorO BbIwe, L9eM npu MCnOnb3OBaHMM 91,3 94,9 *
ropMOHanbHbMX KOHTpaBLenT1BOB U cnupanieu
A6opT cJneAyeT paccMaTpMBaTb, KaK nepawqHoe cpeACTBO KOHTpoj1n1 68,0 72,5 CH
HaA po)KAaeMocTbIO, a TaK)Ke BCnlOMOraTeJlbHoe cpeACTBO B cnyqae,
ecJui KOHTpagLen1fL1 He cpa6oTaJla
OTHoweHme K KOHTpaLAenTMBaM ynyIWWTcS;, ecnu ycnyrm no 94,2 95,8 CHKOHTpauLen1LA4i4 6yAyT AeWeBbIMm u 6onee AOCTynHbIMu
KoHTpaL.enL.msi cpa6aTblBaeT LiaLA4e, ecnu )KeHLlUHbi nonyqatOT 95,2 95,8 CH
OCHoBaTenbHYIO KOHCYJ1bTaLI4io no noBoAy npaBWJbHOCTW
wcnOnb3OBaHwfl AaHHoro KOHTpa4LenTHBHoro cpeAcTBa u ecni OHM3HaIOT, 9TO HeKOTOpbie nO6OqHbie RBJ1eHM9 CqUTalOTC9HoPManJbHbIMu U H14KaKoro BpeAa 3AOpOBblO He npMHeCYT
42
COBeUpLueHCTBOBaHke CHCTeMbi OXpaHbi 3J2OPOBbI )eHLUkWH B PoccUUcKoU (PeaeDaub
Ta6nmLla XII. YpOBeHb 3HaHIA U OTHOLueHme MeA"LULHCKtIX pa60THMKOB K OTASJebHbiMacneKTam npeAocTasneHu. ycnyr, npeABapuITenbHoe u nocT-TecTupoBaHue (npo4oJDKeHwe)
npo4eHT cornacsuBmxcnnpeAB. nocT- p
KoHTpaLAenLAmw cpa6aTblBaeT qau,e, ecnu KOHTpauenTLlBbl U 95,1 95,3 CHCOOTBeTCTBYIOLLOee o6opyAoBaHme nOCTynalOT Ha aAeKBaTHOU UperyjspHoA OCHOBe
OTHoweHme K KOHTpaLBenTIBaM nyqwe, ecjin Bce HeO6xOAmMbie 92,2 96,6 **o6c,neAoBaHwq, alHanM3bl A KOHCYJ1bTaBLJ, MO)KHO OCyLLkeCTBUTb B xoAeOAHoro noceLLAeHUIi MeAL;4UHCKOro yqpe)KAeHMS1
)KeHLLiMH cneAyeT AH(pOPMMPOBaTb 0 TOM, B qeM 3aKJlio4alOTCS 91,2 94,9 *noJno)KuTenJbHbie CTOPOHbl HeL4Cnonb3OBaHL4L KOHTpauLenTLBOB
nepmOA pOAOB B cpeAHeM KOpoqe, ecnu pSLAOM c poKeHmkeO 37,9 44,5 CH
HaxOALTCS cnyTHLK, eciul cnyTHLKa HeT, POAbI AJ19TCSI AOflbwe
)KeHaWuHbl, npowejeAuwe Kypc nOArOTOBKL K pOgaM, mCnlblTblBwIOT 92,3 94,5 CH
MeHbWMA CTpax nepeA pOAaMm, B pe3ynbTaTe qero poAbi y HUX HeTaKle AnUTeAbHbIe
HoBopo)KAeHHblI cKopee nOnyqWT WHc1¢eKLKIO OT MewL4tuHCKoro 19,4 26,3 *pa6oTH4Ka, qeM OT Co6CTBeHHOu MaTepw
3nmAeMms meH*HrwTa y HOBopo)KAeHHbix 6onee 3epoSTHa, ecnu Bce 56,3 62,7 CH
MJiaAeHL,bl cOAep)KaTCFI B OAHOU nanaTe, a He CO CBOUMm MaTepsiM4
Pa3AeneHme maTepek U mnaAeHikeB nocAe pOAOB BeAeT K TOMy, qTO 51,5 58,5 CH
MaTb B nocnepoAoBou nepHoA He qyBCTByeT ce6e cIacT1lMBOVi
Ecnu AaBaTb HoBOpo)KAeHHblM AeTcKoe nHTaHiIe uJnl BOAy C rnlOKO301, 72,8 72,9 CHnOBblwaeTCI BepOHTHOCTb TOrO, 4TO MaTb He CMO)KeT KOpMLUTb rpyAbKO
pLa)Ke MaTepL, KOTOpbIe nnoxo nL4TalOTCR, CnOCo6Hbl BCKapMn1HBaTb 78,6 84,3 *rpyAblo
PaHuuii nepexOA Ha KOpMneHHe KOPOBbUM MOJ1OKOM MO)KeT npwaBeCTr K 59,3 75,4HeXBaTKe )Kenie3a B opraHU3Me HoBopO)KAeHHOrO U alHeMLi
Ecnui MnaAeHL4eB BCKapMjIWBaTb rpyAbio pa3 B TpL-qeTbipe qaca, 46,6 58,9BePOHTHOCTb pa3BWTMl1 y HUX r4nep6wlwpy6MHeMMI Bblwe, qeM yMj1aAeHLAeB, KOTOpbIX BCKapMnWBalOT rpyAbio no Tpe6oBaHWLo
Tpe6oBaHme K po)KeHuL4e np4HS]Tb npu nOCTynneHl'4 B pOAAOM 71,9 83,1Ae3NH(0MrWnpyKIU.14t AYW He MmeeT noA co6o0 HayqHoro o6oCHoBaHwi
HeT HNKaKWX HayqHbIX nOATBep)KAeHL4V TOMy, qTO ecnu cgenaTb 74,4 71,1 CHpO)KeHNiLe KJlU3My, CH143L4TCA BePOITHOCTb MHJfeKLLM4 unu 3TO gaCTKaKile-TO Apyriie nlOJO)Ki4TeJlbHbie pe3yJi bTaTbICH=CTaTMCTH4ecKK He3HaqI4Mo* p<0,05 P<0,0I p<0,001 CTaTMCTiiKa TeCTLpoBaHMR X24aaHmble n/o6epelmro 3KcnepHmeHTa
43
COBWepeHCTBOBaHme CUCTMem OXPHbi 3I0p0Bb YWeHdLU4H B POCCHaCKO9 OeIe6UML
Ta6nNua XiII. OTHOweHUle Men&iUIHCKt4X pa60THuIKOB K OTAOeJbHbIM *CnelKTaMgOnqecnoMo2KSHRMN npeAsapMTenbHoe U nOCT-TeCTHDosaHme
nlpoAeHT BblCKa3aBUwx MHOHSe O TOM,4TO B HaCTORI4uO EPeMs CyuIOCThyeT'nepe6op" no cneAyiou4um nomulmnM:
npeAB. noCT- p
nfpoTsonoKa3aHMA An npiMeHeHwa BMC 18,4 18,0 CH
flpoTuBonoKa3aHWA Ana np&MmeHeHmA ropMOHanbHbIX 23,3 12,0 *KOHTpaB0enTHBOB
nlepeA a6opToM Tpe6yioTC aHauii3U, KpOBM 14,6 11,3 CH
AnA KOHTpatAenLU4M Tpe6yIoTcA aHanM3bl KpOBU 12,6 7,5 CH
nlepeA a6opToM Tpe6yIoTc alHanju3bU Ha 6aKTepIw 6,8 12,0 CH
An,n KOHTpai4enLtL4M Tpe6yIOTcA alHlanj13b Ha 6aKTept4II 10,7 4,5 CH
nlepeA a6opToM Tpe6yloTcA alHanMb3 Ha BOLA t1 CnM, 8,7 3,8 CH
AJ.ng KOHTpatAenLkl4M Tpe6ylOTCa alHanM3bi Ha BM4 m cnMA, 7,8 4,5 CH
O653aTenbHMe KOHCyJ1bTaW.14 4Ans nonb30saTejIew 2,9 6,0 CHKOHTpa4LenTOMBHIX CpeACTB
PeKoMeHAosaHHhie noceLu.eH4g MmeA"LuMHCK4X y4pegKAeH4 8,7 6,8 CHB nPOAPOAOBoM nepflOA
rocnUTaJ1I.3aau,A* B nept4oA 6epeMeHHOcTkl 11,7 6,8 CH
Kypcbu B npeApoAoBou nepmoA, npM3BaHHbie noAroToBBTb 0,0 0,8 CHPOAMTenef4 K POAaM
06paaosaTenbHbie maTepuanumi Ann 6epeMeHHbIx )KeHu.AL4H 3,9 2,3 CH
0DaKTopbl, B COOTBeTCTB.14 C KOTOpblMU 6epeMeHHOCTb 9,6 3,8 CHnonaAaeT B KaTeropmio 'pl4CKoBaHHo0V4
npaBi3na no MICTOTe U4 Ae3.MH4eKLHM4 15,5 12,8 CH
VIHCTPYKLk4U4, onpeAenKioLuLe AeriCTBM4A B 4pe3Bbl4aruHbIX 3,9 8,3 CHciTyaw4ax npIu poAax
cH=CTaTHCTM4eCKfr He3Ha4uMO* p<005 * p<001 p<O,OO1 CTaTMCTILKa TeCTI4pOBaHMRX2,4aHHwme n7ioepeUKoro 3Kcnep(HMeHTa
44
COue8iWeHCTBOBaHlfe CbfCTeMbi OXDHbl 3,aOpOBbq YXeHLJLH B POCCi4rfCKOA OeaeauuM
Taf6lnuua XIV, YpOBeHlb non3rOToBKu me6,U4HCKX 4a60THuKoB, 21ena,1 nonYHTa6nOJ1HeTeBnba yO noaroTonKye npeeapHTenbHoe u nOCT-TeCTBpeaaHae
meAHL4NHCKme pa60THINK1, meMe^UNHICne pa60THNKU4,nonyO4BMuee nOArOTOMK KoKeCnaioL.e nonyINTb(%) nOArOTOBKY (%)npeAn. nOCT- p npeA4 . nOCT- p
Tema
flpeAOTBpaL.eH4e cnnOAa Ui 63,1 68,4 CH 24,3 21,1 CH3a6oneBaHMu, nepeAaBaembixnOHYoBblm nyrem, KOHCynbTa1' 4
KoNcynbTa4i& no 4onpocam 17,5 31,6 * 31,1 34,6 CHceKca u penpOAYKTHBHOr4
flOpYHKL, 3AOTOBb K
KoHcynbTaI4m U ycnyru no 14,6 42,9 ** 45,6 36,8 CHKOHTpa4eniAmw
nlp8AOTBpauAeHme 6ecnnlOAMS1, 15,5 30,1 *41,7 31,6 *KOHCynbTaLAm4 u ne4eHme
06y4eHMe B npeApOAOBOU 47,6 52,6 CH 22,3 26,2 CHnePNOA, noAroToBKa K POAam
I]oAAep)KKa rpyAHoro 42,7 48,1 CH 29,1 27,1 CHBCKapMjnuBaH14R Li KOHCYJ1bTai&414
CH=CTaTHCTIqeCKH He3HaL4MMO* p<0,05 ** p<0,01 p<0,001 CTaTUCTUKa TeCTMpOBaHMR X2,4aHHbe nlo6epewKoro 3Kcnepi7MeHTa
45
VI. CHOCK14
[1 ] AaHHer (D. 3AopoBbe MaTepL m pe6eHKa B POCCWV4CKOPi cIeAepaLu.(Maternal and Child Health in the Russian Federation). pooKnaAKOHCynbTaHTa (pyKonMCb), 1994.
[2] pQenapTaMeHT 3ApaBooxpaHeHWP m CoLAaJabHb]X cily)K6, Cu1y)K6ao6u.ecTBeHHoro 3AOpOBbS, LteHTp no npomilnaKTLKe LI KOHTpOnio 3a
pacnpocTpaHeHmeM 3a6oneBaHv1P, HaLkWoHanbHbIV1 L,eHTp no MeALALJHCKOMCTaTWCTMKe CIWA. OcHoBHasi L4 MeAmLAWHCKas CTaTMCTIKa: POCCOACKaS
OeAepaiLts m CoeAWHeHHbie WJTaTbi AMepMKL: Bbl6opoqHo no roAam 1980-1993. (Vital and Health Statistics: Russian Federation and United States:Selected Years 1980-1993. DHHS Publication No. (PHS) 95-1485.Hyattsville, MD: DHHS. June 1995).
[3] BCeMVApHaR OpraHL43aULAi5i 3ApaBOoxpaHeHwsi/,eeTCKW1 c1OHA OOH.nepecMoTpeHHble pac4eTbi noKa3aTeneO MaTepWHCKo0 cMepTHOCTI, 1990r.: HoBbtm noAxoA B03 L lOHlCE0 (Revised 1990 Estimates of MaternalMortality: A New Approach by WHO and UNICEF. Geneva: WHO, 1996.)
[4] BceMLpHas OpraHMw3aLm 3gpaBooxpaHeHwR/J&eTcKLA0 VOHA OOH.nepecMoTpeHHble paCqeTbi noKa3areneL1 MaTepLHCKOLA cMepTHOCTI, 1990r.: HOBbu noAxoA B03 m KOHLCEO (Revised 1990 Estimates of MaternalMortality: A New Approach by WHO and UNICEF. Geneva: WHO, 1996.)
[5] XeHWo C.K., Moppoy C. K. CTWMynvlpoBaHwe a6opToB: MApOBOA o630p,
1990. (Henshaw S. K., Morrow E. Induced Abortion: A World Review,1990 Supplement. New York: Alan Guttmacher Institute, 1990).
[6] nonOB A.A. fnaHLIpoBaHme m CTV1MynJ1pOBaHLAe a6OpTOB B nocT-coBeTcKOlr
Poccuuv B Haqahle 90-x rOAOB: HeyAOBfleTBOpeHHbIe nOTpe6HOCTH BnonyIeHAI WHLHopMaLtAm (Popov A. A. Family Planning and InducedAbortion in the Post Soviet Russia of the Early 1990s: The Unmet Needs inInformation Supply. Moscow: Center for Demography and Human EcologyWorking Papers. Vol. 16, 1994.)
(7] BceMwpHas OpraHM3aL.mq 3ApaBooxpaHeHMi5. CornacHTernbHanKo4)epeHi*ms B03 no Bonpocam COOTBeTCTByMW1X TeXHO1OAr pOAOB.(WHO Concensus Conference on Appropriate Technology for Birth,Forteleza Brazil, 22-26 April 1995. Copenhagen: WHO, 1985.)
[8] CTUBeHCOH n. Me)KAyHapOAHbie pa3nWW9A B wCnOJ1b30BaHwm aKywepCKL4XBMewaTe.rbcTB.,Q0oKnaA o6 MccneAoBaHAL4. (Stephenson P. InternationalDifferences in the Use of Obstetrical Interventions. Report on a Study.Copenhagen: WHO, 1992.)
46
CoBepweHcrTBoaHue CUCTrMbI 3AiOpOBb? xeHHLUPH B POCCUaCKOa Oeneouu
[9] BceMHpHhfi 5aHK. flwnoTHbI0 npoeKT no pec)OpMe 3ApaBooxpaHeHUP BPOCCU>CKOA 0PeAepaL,i4w. )J,oKnaA o6 3KcnepTW3e npoeKTa. (World Bank.Russian Federation Health Reform Pilot Project, Staff Appraisal Report No.15585-RU. Washington, D.C.: World Bank. 1997).
[10] Buccep A.ll., BpyriHWKc H., PeMeHH-K H. nlnaHMpoBaHwe ceMb6 B Pocci*:onbiT M MHeH51" BpaqePi-rMHeKonoroB. (Visser A. P., Bruyniks N., RemennickL., Family planning in Russia: experience and attitudes of gynecologists.Advances in Contraception 1993; 9: 94-104.)
[11] Bmccep A. n., nlaBneHKo IA. , PeMeHHMK fl., Bpyv1H1Kc H. JlerepT fl.npaKTwKa u OTHoLueHLe 6b6muLAwxxCOeTCKiX >KeHULUH K KoHTpaLAenTMBaM.(Visser A. P., Pavlenko I., Remmenick L., Bruyniks N., Lehert P.Contraceptive Practice and Attitudes in Former Soviet Women. Advances inContraception 1993; 9: 13-23.)
[12] BceMwpHas OpraHw3aLws 3ApaBooxpaHHeHme. 3auWTa, cTLMynMpoBaHMe uno,Aep)KKa rpyAHoro KopmneHvI^: Oco6as ponb cny><6 no oxpaHeMaTepuHcTBa. CoBMecTHoe 3asBjieHLe B03/lOHVI CEc. (World HealthOrganization. Protecting, Promoting and Supporting Breast-feeding. TheSpecial Role of Maternity Services. A Joint WHO/UNICEF Statement.Geneva: WHO, 1989).
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