Opieka ginekologiczno-położnicza w warunkach praktyki lekarza rodzinnego na Ukrainie: przegląd literatury
Oksana V. Bakun, Svitlana Y. Karatieieva, Svitlana B. Semenenko, Oksana I. Yurkiv, Ksenia V. Slobodian
Higher State Educational Institution of Ukraine “Bukovinian State Medical University”, Chernivtsi, Ukraine
Introduction: The analysis of literature on the questions of obstetrical and gynecologic care by general practitioners – family doctors in Ukraine has been presented in the article. Special attention has been paid to the actual problems of primary health care implementation on the basis of family medicine.
The aim of the study is to find out the depth of the problem “A female doctor as an obstetrician-gynecologist” by analyzing scientific relevant literature data.
Conclusions: It is evident from the review of negative demographic situation that at present topical are the issues of extension of primary care professionals’ functions concerning sexual upbringing, family planning, reproductive health promotion of the population, improvement of the qualification level of doctors on obstetric-gynecological assistance issues and creation of a motivation system for primary care physicians, which requires a decision at the national level.
Wiad Lek 2018, 71, 2 cz. II, -402
The general social and economic situation in Ukraine continue to affect negatively the demographic situation. Negative processes dominate in the sphere of the reproduction of population. Mainly this is a consequence of the social instability and fall of the living standard. The main reason of the natural decrease of population is the low birth rate compared to the high mortality rate.
The reasons of the growth of deaths and diseases lie in the changes of social and economic relations and of social stratification. These changes influence the behavior of people and their attitude to their own health. The health of children and capable-of-work adults is especially alarming. The level of professional illnesses and traumas is grows steadily. In spite of the mentioned improvement in the children mortality rate, the medical studies witness that there is a steady worsening in their physical, psychical and intellectual health. The number of inherited diseases and hereditary defects become more and more frequent.
The aim of the study is to find out the depth of the problem “A female doctor as an obstetrician-gynecologist” by analyzing scientific relevant literature data.
MATERIALS and methods
An analysis of international and national scientific literature on the problem of obstetrical and gynecologic care by general practitioners – family doctors.
Review and discussion
Modern stage of socio-economic development of Ukraine is accompanied by difficult conditions for formation of population health. Crisis phenomena in the economy, stratification of the society by standard of living, social instability, unfavorable environmental situation have led to the deterioration of public health . The deterioration of the general state of health of the population has led to the deterioration of its reproductive component. Thus, obvious manifestations of negative trends in women’s reproductive health care have been the increasing proportion of complications at labor, high maternal mortality rates (in comparison with developed countries), growth of gynecological diseases, including teenage girls [2, 3, 4].
Particular concern is caused by the growth of congenital anomalies of development, genetic diseases, chronic pathologies, that is considerably connected with the impact of adverse environmental factors and may negatively affect the reproduction of new generations .
So, questions of preservation and strengthening of reproductive health have remained an actual problem which requires a solution at the national level .
The present health care system of Ukraine is known not to meet the requirements of a modern effective health care system; it has been extensive, characterized by constant increase in the number of stationary beds and doctors .
Namely, this disproportion in the development of out-patient polyclinic and stationary, primary, secondary and tertiary care is one of the main reasons which causes reorganization of health care system .
According to the data from literary sources, the most effective form of primary health care organization is a system with general medical practice playing the lead role – that is family medicine . Today the introduction of this system into practice has already given an opportunity to put emphasis in medical provision on disease prevention and strengthening health of the population, which will enable to reduce the cost of external consultation and draw narrow specialists’ attention to complex diagnostic situations and dispensary groups of patients [8, 10, 11, 12, 13].
Leading specialists have proved that the most effective form of primary health care is general medical practice with the central figure of a general practitioner (family doctor) . Such a specialist appeared economically profitable, as he brings significantly bigger economic effect to the state by his activity . According to the qualification characteristic the range of services provided by a general practitioner (family doctor) includes preventive measures, diagnosis, treatment of most common diseases and rehabilitation of patients, emergency care, medical manipulations as well as that kind of activity which unites organizational measures [16, 17]. So, a family doctor by the essence of his professional knowledge and duties harmoniously combines preventive and therapeutic work.
Special attention in a general practitioner’s activity (family doctor’s) is focused on the provision of advisory assistance on matters of family planning, ethics, psychology of family relations, hygiene, social and medical-sexual aspects of family life, nutrition and upbringing of children . At the same time, he can’t replace completely a surgeon, an obstetrician-gynecologist, a neurologist, an ophtalmologist, and other narrow specialists .
Thus, a study of the situation related to the family support, its vitality and health status is an extraordinary important and extremely necessary stage in the optimization of a family doctor’s work and family medicine in general .
In addition, during his practical activity a family doctor has to solve not only medical, but also social problems of the family, as in the sphere of his professional work there are patients of different age and social groups. A family doctor is to come across different pathology, including genetic, extragenital and reproductive system diseases. Due to all that, specialists are required to have general medical practice and nurses with appropriate training at the undergraduate and postgraduate levels .
At present the system of training doctors in specialty “General practice – family medicine” requires extensive training for highly qualified staff at the undergraduate and postgraduate levels, using both traditional forms of teaching and innovative technologies as well as considering European recommendations [22, 23, 24].
Effective training of doctors-interns by specialty “general practice – family medicine” by profile “obstetrics and gynecology” is possible with multidisciplinary approach at the level of Family Medicine Department and Obstetrics and Gynecology Department, which enables to unify educational process at training of family doctors. In internship at training of family doctors special attention is paid to the prevention of obstetrical and gynecological pathology occurrence, early diagnosis of extragenital diseases and their peculiarities, provision of the first emergency care and questions of family planning. A knowledgeable family doctor will be able to get the most information about every patient and create a good relationship on the basis of confidence, which is important at the family doctor’s practice [ 3, 5, 25, 26, 27].
Nowadays a system of distance training is being introduced, a network of family medicine centers at the First Aid Center is being created, which will enable to improve practical medical skills of already working family doctors and nursing staff [28, 29].
Thus, an integral part of the improvement of family doctors’ qualification is their high-grade training at the Family Medicine Departments and Faculties. That’s exactly why very high standards should be also placed upon professorial-teaching staff of Family Medicine Faculties .
By order of the Ministry of Health from 15.07.2011 №417 “About the Organization of Outpatient Obstetrical and Gynecological Care” the family doctor’s main functions on issues providing obstetrical-gynecological care, including preventive, diagnostic and therapeutic measures within the framework of primary health care were defined .
In conformity with the defined functions ambulatory obstetric and gynecologic care at the primary level is provided in dispensaries of general practice for family medicine and includes: measures for reproductive health preservation, preventive care for pregnant women, antenatal fetal protection, prevention and treatment of obstetric-gynecological pathology, family planning. [ 3, 32, 33, 34]
Taking into account the foregoing, it should be said that the experience of providing obstetric-gynecological assistance to the female population of Ukraine hasn’t been illuminated sufficiently in literary sources. In single publications authors chiefly justify the expediency of providing certain types of medical services of this profile, mainly preventive, by the family doctor [4, 25,32, 35, 36, ].
The basic perspective form of primary health care organization in Ukraine has been determined as an outpatient clinic of general family medicine practice, which is a subsection of the therapeutic and preventive service at the First Aid Centre and can work on the basis of individual or group practice. Dispensaries of that kind have been organized for the first time in Lviv and Zhitomir Regions.
The experience of family doctors’ work at the family medicine outpatient clinics in Lviv Region has shown that they achieved an early stage of putting pregnant women on record, their timely examination, which resulted in maternal, perinatal and infant mortality reduction, home birth reduction, increase in the percentage of fertile women coverage by modern contraception methods. Family doctors actively carry out sanitary and educational work on safe sexual behavior and family planning with teenagers .
Family doctors of Zhitomir Region actively work on the issues of extragenital diseases prevention and family planning. A family doctor conducts dispensary registration of women himself. The doctor explains possible complications of extragenital and fetus pathology and introduces different types of contraception [38, 39].
Thus, not including the issues of sex education, family planning, prevention of sexually transmitted infections in the work of the first medical care doctors, that’s family doctors, it is impossible to achieve significant improvement in reproductive health, reduction in unwanted pregnancy, maternal and perinatal mortality [6,25].
So, L. F. Matyukha, N. G. Goyda believe that a family doctor has to contribute to the preservation of reproductive health by providing services while he is conducting physical pregnancy. The doctor’s role is to correct future parents’ hygienic behaviour, promote genetic counseling, prenatal care including psychoprophylaxis help and advisory assistance to pregnant women, provision of timely obstetric care, prevention of postpartum infection and also advisory services .
Deserves attention is the algorithm suggested by D. Ye. Moskvyak-Lesnyack for managing risk factors by a family doctor in the preventive activity related to the occurence of breast cancer among females. The main content of this algorithm is the introduction to practical health care of a functional model of the risk factors management system at the level of general practitioner-family doctor related to the prevention of occurence and further development of breast cancer among females as the main preventive technology in the family doctors’ practice . This algorithm is scientifically sound, but a presented by the author model of breast cancer prevention in women is only a part of the volume of medical assistance that is to be transferred to the family doctor.
V. M. Yenikeyeva proposed to expand functions of a family doctor providing rural women with medical care, namely: conducting information and education work at the family level on the issues of safe behavior and raising the culture of sexual life, training for the appearance of a newborn, preparation of a married couple to partner childbirth, carrying out work on family planning and provision of contraceptive methods, organization of advisory assistance by an obstetrician-gynecologist for women which are treated in day-care and home hospitals .
Thus, Ukraine can be stated to have a family medicine institution, its own approaches to the scope of medical care of obstetric-gynecological profile, that can be provided by family doctors and, first of all, which depends on the level of the doctor’s training, his qualification and material and technical facilities of the institution [1,43,44,45,46,47,48].
In Ukraine medical and organizational technologies for the provision of obstetric-gynecological assistance by family doctors have been illuminated insufficiently [49,50,51,52].
In addition, the authors P. G. Zhuchenko, P. G. Mazurchuk and others have proposed main regulations for general practitioners (family doctors), which determine the tactics of conducting pregnant women with extragenital diseases, at emergence of urgent states in obstetrics .
Taking into account the experience of general practitioners’ work in Ukraine, it is expedient to transfer preventive functions related to unwanted pregnancy, family planning, saving women’s health and promoting the birth of healthy children to the family doctor [52,53,54, 55]. The activities of family medicine specialists should be aimed at close cooperation with specialists and social services and basically focused on prophylaxis by evaluating the state of health [52, 56].
It is evident from the review of negative demographic situation that at present topical are the issues of extension of primary care professionals’ functions concerning sexual upbringing, family planning, reproductive health promotion of the population, improvement of the qualification level of doctors on obstetric-gynecological assistance issues and creation of a motivation system for primary care physicians, which requires a decision at the national level.
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ADDRESS FOR CORRESPONDENCE
Oksana V. Bakun
Higher State Educational Institution of Ukraine
“Bukovinian State Medical University”, Chernivtsi, Ukraine