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WOMEN'S REPRODUCTIVE HEALTH, OFFSPRING QUALITY AND ROLES OF ADVERSE ENVIRONMENTAL FACTORS E.I. Sharapova, Doctor of Sciences (Medicine), Professor, Moscow Medical Academy The International Conference on Population and Development (Cairo, 1994) and the Fourth International Women's Conference (Beijing, 1995) played a major role in enhancement of women's status and in recognition of special rights of women for protection of their reproductive health WHO defines reproductive health as a state of complete physical, mental and social well-being, not as a mere absence of diseases and health disorders pertaining to the reproductive system, its functions and processes. Notwithstanding progress in medical science and protection of maternal and children's health, some problems still remain unresolved or even become more pressing. Human activities are accompanied by permanent environmental changes. More than 60 thousand chemical compounds - industrial waste, pesticides, household chemicals, and drugs - permanently affect all living things, including human beings. The gap between the new environment and biological systems of humans, formed by the natural evolution, becomes more and more wide, resulting in growing morbidity, growth of disabilities, higher mortality and worsening of demographic situation. Many embryos are lost (the effect is manifested by subfecundity and infertility), incidence of spontaneous abortions steadily increase, birth defects still remain a rather relevant problem, incidence of somatic and reproductive diseases grows (while incidence of disorders of the reproductive system grows even more intensively), incidence of pregnancy complications steadily increases, offspring quality gets worse. Development of female reproductive system and formation of reproductive functions depend on the whole set of biological and external factors, including genetic, physiological, environmental, socio-economic, medical, lifestyle and ethnic ones. Contemporary demographic situation in Russia developed at the background of long-term negative trends, that became marked so early as in mid-1960s. At the same time, evolution of demographic processes - i.e. birth rates, mortality, natural growth, population dynamics, migration - was substantially aggravated by the economic crisis and decline of living standards of the majority of the country's population. From late 1992, population of the Russian Federation has been decreasing due to negative natural growth. In 1999, the number of the dead exceeded the number of the new-born in 1.8 times. Population reduction is not a disaster per se, it could not be assessed as a crucial phenomenon, if it occurs at the background of permanent growth of quality of life and living standards of a country's population. Unfortunately enough, in the case of Russia, population reduction (that cannot be offset even by positive net migration rates), is mainly caused by high mortality and steady decline of birth rates. As at the beginning of 2001, population of the Russian Federation reached 145.2 million people. Overall, from 1992 to 2000, the county's population decreased by 3.2 million people (or 2%). Within this period of time, fertility rates (the number of children per a women of the age group from 15 to 49 years) decreased from 2.0 to 1.2. In some regions, fertility rates decreased to critical levels - 1.0 - 0.7 (in Murmank Oblast, Leningrad Oblast, Ivanovo Oblast, Moscow Oblast, Magadan Oblast and Saint-Petersburg). Only in five republics, fertility rates exceed 2 children per a woman of reproductive age (in Kalmykia, Dagestan, Ingushetia, Tyva and Yakutia). The age profile of contemporary population of Russia was shaped by long-term decline of birth rates. Due to reduction of birth rates, the number of children under 16 decreased by 5.7 million (from 1990 to 1999)., mainly due to reduction of the age group under 5 (in the case of the latter age group, the reduction reached 5.4 million, or 47.9%). Reproductive patterns of Russian women are characterised by some specific features. Starting from early 1990s, there were substantial changes in reproductive behaviour. For example, the number of pregnancies decreased by 41.0%, while the number of abortions decreased by 43.6%. Notwithstanding substantial reduction of abortions, the ratio of abortions and deliveries remains almost unaffected - in different regions of Russia the ratio varies within the range between 1.8 and 2.0 abortions per a childbirth. Due to high reduction of fertility rates in that period of time, numbers of second, third, etc. children decreased in 1.9 times and their overall annual shares in the overall array of the new-born decreased from 51% to 41%. Demographic situation in Russia has another specific feature - the country's transition to negative population growth rates is not determined by reduction of birth rates only, it is determined by substantial decline of health status of the population and growing mortality rates. These factors are reflected by such parameters as life expectancy and mortality rates, associated with some groups of diseases (including reproductive ones). For example, in many regions of Russia, pregnancy/delivery complications belong now to six main death causes of women of the early reproductive age (from 15 to 34 years). These developments are characteristic to such regions as Sakha Republic (Yakutia), Chita Oblast, Buriatia, Tyva, Kemerovo Oblast - in these regions mortality rates of women of early reproductive age exceed Russian national averages in 2.4 - 2.8 times. The situation demands urgent actions to protect vital interests of the population - it is necessary to maintain population levels and to ensure improvement of living standards, focusing on women, who play the decisive role for health of future generations. Analysis of reproductive morbidity is of major relevance to review of health status of women, children and adolescents. The most high growth of gynaecological morbidity is observed among young and adolescent girls. The phenomenon causes serious concerns, because reproductive health of future mothers is formed in these periods of life. For example, from 1991 to 1999, incidence of menstrual disorders among young girls increased in 5.6 times (relevant figures for adolescent girls and adult women reached 4.7 and 2.8 times, respectively). The growth of menstrual disorders is associated inter alia with higher nervous and information loads, stresses, inadequate nutrition - all these factors were further aggravated by the socio-economic crisis. 60% of girls, who stay in environmentally unhealthy areas with heavy chemical pollution, were found to experience some deviations of the menstrual function. Later on, these disfunctions may result in higher levels of endocrine infertility, delayed foetal development syndrome, gestosa. It is necessary to note substantial growth of inflammatory diseases of female reproductive organs, which negatively affect the reproductive function later. According to research study findings, incidence of acute inflammatory diseases among adolescent girls increased in 5.4 times, while the relevant increase among adult women reached 1.3 times. Besides that, it is necessary to note permanently high incidence of infertility and diseases of cervix uteri. In environmentally unhealthy areas, pathologies of cervix uteri are registered in 2.7 times higher than in cleaner areas (relevant excess factors for inflammatory diseases of adnexa of the uterus, myoma of the uterus, and ovarian cysts reach 2.1, 1.6 and 4.3, respectively). Growth of cancer incidence among women substantially affects their reproductive health. These effects are especially serious in the case of malignant tumours of the mammary gland, uterus, cervix uteri and ovaries. The share of tumours of these localisations among female patients with initially diagnosed malignant tumours exceeds 40%. Breast cancer belongs to the most common forms of cancer from the above list (51.7%). Substantial increase of patients with initially diagnosed breast cancer and uterus cancer of 3rd and 4th stages causes especially serious concerns, because these facts reflect poor diagnostics and lack of prevention-oriented measures. It is worth to note, that in environmentally unhealthy regions these pathologies are diagnosed substantially more often. Health status of pregnant women is also alarming. The share of pregnant women with different health disorders reaches 91.3%. From 1990 to 1999, morbidity levels among pregnant women increased: incidence of anaemia cases increased in 2.8 times, incidence of urogenital disorders and pregnancy/delivery complications increased in 3 - 4.8 times. As a result, the share of normal deliveries steadily decreases, in early 1999 it reached 31.3% of all deliveries, in parallel, incidence of complicated deliveries increased in 2.6 times in 7 recent years.
In order to assess dependencies between health status of children and their mothers and specific environmental parameters of their places of residence, we selected the following territories for the study: regions of the Volga basin (where oil and gas, metallurgy and manufacturing industries operate), North Russia regions and other areas of similar status (in these regions, local residents are under permanent impacts of adverse geographic, socio-economic and environmental factors).
Findings of the analysis demonstrate that the regions under study are characterised by especially high excess incidence (comparatively to the national averages) of spontaneous abortions (by 18%), anaemia of the pregnant (by 46.2%), and gestosa (by 28.6%). The following chronic diseases were the most often encountered of the mothers surveyed: diseases of cardiovascular system, urogenital organs and thyroid gland pathologies (morbidity levels for these diseases exceeded Russian national averages by 42.9%; 39.3% and 39.3%, respectively).
Female residents of Northern Russia were found to have shorter reproductive periods. For example, 18.9% were found to have delayed menarche (in 15-19 years), early climax was observed for 46.3% of the women surveyed.
Nizny Novgorod Oblast may serve as an example of marked health impacts of environmental factors. There, according to statistical data, the highest incidence of pregnancy/delivery pathologies is observed. For example, incidence of cardiovascular diseases exceeds Russian national averages by 53.8%; incidence of urogenital diseases - by 32%; incidence of thyroid gland disfunctions - by 64%; incidence of anaemia of the pregnant - by 21.5%; incidence of gestosis - by 44.3%.
Maternal health status is the decisive determining factor of offspring quality and perinatal losses. Low health status of mothers results in high shares of ill new-born children. It is necessary to note maximal rates of proliferation of respiratory diseases among full-term children, suggesting their morhpo-functional underdevelopment as a consequence of adverse impacts of poor health of their mothers and pregnancy complications. Special attention should be paid to high growth of annual rates of incidence of hypoxia, infections, development retardation, malnutrition and birth defects among children of these mothers.
Impacts of adverse environmental factors, aggravated by other adverse impacts on maternal health, were diagnosed for 59.5% women, whose new-born children had inherited development defects. Among the whole array of factors, which induce birth defects, it is necessary to pay special attention to growth of extragenital and gynaecological pathologies and impacts of environmental factors of anthropogenous origin.
Shares of underweight new-born (the share of new-born with weight lower than 2500g among all live new-born and stillborn children) exceeded Russian national averages in the majority of environmentally unhealthy areas. The phenomenon was mainly determined by trophic impairments of foetal development, rather than by the fact of premature birth per se.
Besides that, it is necessary to note higher incidence of overweight (in excess of 3500g) new-born in these regions (excess by 39.3%). So high differentiation of biological parameters (higher incidence of both overweight and underweight new-born) suggests existence of serious morpho-functional offspring impairments under impact of unhealthy environment.
In 14 areas of the Volga region, incidence of inherited development anomalies among live new-born and stillborn children with weigh over 1000g exceeded Russian national averages (by 50.0%). In the case of stillborn children only, the excess incidence reached 53.6%.
Besides than, incidence of inherited development anomalies exceeded Russian national average in Northern Russia, especially in the Republic of Buriatia and Kamchatka Oblast (in 3.5 and 1.22 times, respectively), In Magadan Oblast and Murmansk Oblast (in 2.9 and 1.35 times, respectively).
Therefore, analysis of obstetric data has allowed us to identify impairments of main biologic functions of women (reproductive capacity) and children (foetal growth and development). The first conclusion is supported by higher incidence of spontaneous abortions, while the second one is supported by higher incidence of overweight and underweight new-born and development anomalies.
In environmentally unhealthy regions, incidence of environment-determined diseases was found to be substantially higher for both women and children.
Decline of biologic capacity of women and children is confirmed also by higher incidence (comparatively to Russian national averages) of decompensation phenomena among women (severe forms of gestosis, anaemia, hypotonic postpartum haemorrhages) and children (higher incidence of foetal hypoxia and vulnerability at birth, anaemia, rachitis and pathologies of the nervous system within the first year of life) and higher incidence of chronic health disorders.
The above particular features correlate also with unfavourable socio-economic conditions and quality of health care and social services, that substantially declined in recent years.
The majority of the above nosologies belong to controlled and socially-determined ones. For example, foetal growth retardation and trophic impairments, morpho-functional underdevelopment of foetuses and the new-born - all these disorders correlate with higher incidence of anaemia and chronic diseases of pregnant women and mothers. From the medical point of view, birth defects belong to the most easily controlled nosologies. From the one hand, their relative growth may be associated with adverse impacts of environmental and occupational factors, while from the other hand, these pathologies may be easily identified by prenatal diagnostics. Therefore, timely health improvement measures for women, proactive measures to prepare the young ones to the reproductive age, taken together with improvement of quality of health care and diagnostic services - all these actions may promote enhancement of health status of women and their children. |