Our objections to Darwin

Starting next year, Ukraine is expected to see a steep rise in infant mortality. But don’t let this scare you. As The Day has already written, at issue here is not a higher number of crib deaths but a different statistical method. As of Jan. 1, 2007, the international system of determining the criteria and registration procedure for live and stillbirths will be implemented in Ukraine in keeping with the Ministry of Public Health’s Instruction No. 179 of March 29, 2006.

It is difficult to overestimate the importance of this step, which will change the attitude of our state and the public health system to the value of human life. Current statistical rules state that a baby must be registered as liveborn at a minimum of 28 weeks’ gestation, weighing at least 1 kilogram and measuring at least 35 centimeters long. The rest of the world has long followed different standards: a baby is registered as liveborn at a minimum of 22 weeks’ gestation and weighs at least 500 grams, irrespective of body length. See the difference?

This is a kind of challenge to Darwin’s law that the fittest will survive and the weak are doomed to die. H Human society has different criteria of strength. Even a physically weak life can often be intellectually strong and thus have a certain societal value. Furthermore, a humane society recognizes the value of human life as such, no matter how strong an individual may be.

Clearly, Ukrainian statistics will be considerably worsened by the new criteria during the first year. However, specialists in neonatology (a subspecialty of pediatrics that consists of medical care for newborn infants, especially sick or premature babies), who attended their third symposium on this problem a few weeks ago in the Crimean city of Sudak, say that in two or three years Ukrainian statistics will reflect a considerable improvement in the quality of medical care, especially for newborns, which will have a beneficial effect on the country’s demographic situation. With other factors at work, Ukraine’s birth rate may finally exceed the death rate, and our population will start increasing instead of dying out.

“This does not mean that in Ukraine today doctors are not fighting to save premature babies with low birth weights,” says Yelyzaveta Shunko, chief neonatologist at Ukrai ne’s Ministry of Public Health. “The question is how to make these processes much more effective; in this respect our country has its work cut out. Statistics indicate that neonatal mortality in Ukraine is only 1.2 per mill (one thousandth of one), which is 0.3 of a point lower than what it was in 2002. Still, this cannot satisfy the country in the current demographic situation.”

World practice has already confirmed the effectiveness of the new system of registration.

While deaths of newborns weighing more than 1 kilogram have risen from 8.3 to 8.9 per mill throughout Ukraine since 2002, deaths of those weighing at least 500 grams have dropped from 21.7 to 14.6 per mill. In Lithuania, which adopted the new criteria of statistical recording in 2002 and introduced up-to-date methods of intensive care, the mortality rate for underweight babies fell during the same period from 7.3 to 4.7 per mill, i.e., it is now twice as low as in Ukraine.

In the Crimea, out of six babies weighing less than 1 kg, five died in 2001, but by 2005 only 5 out of 14 low-weight babies died. Ukraine will likely experience the same process. Initially, the “tricky” statistics will show a rising mortality rate for children in this category. But in two to three years’ time new techniques and drugs will be introduced, and medical staff in hospitals will have been retrained. These changes will considerably improve the intensive care of babies, including preemies and underweight infants. The 2006 budget allocated 40 million hryvnias for this purpose, and Dr. Shunko hopes that the 2007 budget will be even more generous to these tiny infants.

Discussions at the symposium attended by neonatologists, obstetricians, pharmacists, and other medical specialists from all regions of Ukraine showed that this purely statistical question — at first glance — reflects not only medical but also economic, social, legal, moral, demographic, and other problems in Uk0rainian society. For example, statistics show that intrauterine mortality and still births have been on the rise over the past three years. Neonatal mortality has also increased from 9.7 to 10.02 per mill, while early deaths in the first hours of life are on the decline. Is the reason behind these “tricky” statistics perhaps the fact that nobody is responsible for a still birth, while somebody is sure to be blamed for a baby’s death in the first hours after birth?

In her paper Dr. Shunko emphasized that the “stillbirth rate is 1.7 times higher than the early neonatal mortality index, which runs counter to the common biological principles of prenatal statistics, according to which still births should not exceed the level of early neonatal deaths.” Therefore, the criterion for the “tricky” figure should be changed in order to set into motion positive processes in medicine, technology, and staff training. This is why Ukraine is switching to accepted criteria of birth statistics and registration.

While the five-year statistics are more or less favorable, the data for 2005 alone are shocking. Last year there was an increase in all varieties of infant mortality in Ukraine: 11 percent neonatal, 11.2 early neonatal, 10 perinatal, and 10.4 stillbirths. According to Ukraine’s Ministry of Public Health, in 2005 full-term babies predominated among newborns that died during the neonatal period. Such a statistic does not meet modern medical standards.

“PASSIVE” AND “ACTIVE” ECONOMICS OF A HUMAN BEING

Doctors are of the opinion that demographic problems, particularly the infant birth and survival level, depend on the overall health of women and socioeconomic conditions. Intensive care for low birthweight babies is only a fraction of the general state of medicine. Society should reach the point that children are born at normal gestation and healthy. But underweight and premature children will continue to be born, and both society and medicine must be prepared to help them survive.

So far, Ukraine is showing a very feeble trend towards a higher birth rate. In 2005, for every 1,000 fertile women, 33.3 bore a child, a statistic that somewhat exceeds the 2003-2004 data. In 2005, 413,850 babies were born, including 17,331 preemies (4.19 percent). The number of infants with severe problems is increasing. While 2,360 babies weighing 500 to 1,499 grams were born, in 2004, this number rose to 2,575 in 2005. At the same time, low birth-weight and premature babies are full-fledged human beings and future members of society.

Professor Oleksandr Zahorulko, a department head at Crimean Medical University, compared life value levels in Ukraine and the rest of the world. In a US clinic 20 newborns are cared for by 104 nurses and 14 specialists, who have at their disposal all sorts of cutting-edge equipment and funding. Where a human being is regarded as society’s greatest value, it is considered normal to spend $1,000 a day on caring for a baby in the first days of its life. An average of $50,000 spent on health care for an individual until age 20 is cost- effective. So a newborn is already useful to society by the very fact that s/he is economically effective in a passive manner: together with other peers, they create jobs: for obstetric hospital doctors, then kindergarten teachers, and later, schoolteachers.

They will also need transport, trade, consumer services, and other infrastructures. Thus, by the age of 20 every individual brings society 50 million dollars of passive economic effect and then, after gaining employment, s/he brings society countless sums of active economic effect. In our country, however, very few people think about such problems — perhaps poets and philosophers do, but not MPs or ministers. Therefore, the children to whom the new statistics will apply account for a mere four or five percent of all newborns. But if most of them survive and grow up, this will mean a similar growth in the birth rate, which will have a great impact on our country’s demographic situation.

EMERGENCY NEONATOLOGY

Caring for fragile infants is a very complex task. When an effective technique is the decisive factor in a life-or-death situation, this gives rise to a conflict in ethical values between the newborn’s self-sufficiency and its uncertain survival and the interests of society, family members, and professionals when the new technique for saving the newborn’s life is too expensive for society. A large group of Ukrainian neonatologists, both theoreticians and practitioners, are active members of the European Association of Pediatricians and other European medical associations. An association of neonatologists has already been established in Ukraine, and the first congress of Ukrainian neonatologists will be held in October. Although society, particularly the public health sector, is supposed to focus on protecting women’s health and creating conditions for full-term gestation and normal childbirth, neonatology is now concentrated not so much on mothers (other specialists will take care of them) as on infants — from conception to raising a viable organism without major risks to life.

Unfortunately, not all babies can be saved. According to Ministry of Public Health statistics, in 2005 most neonatal deaths (42 percent) occurred because of abnormalities that developed in the mother’s womb: 8 percent were due to congenital developmental abnormalities, 12.2 percent, to various diseases, and 8.1 percent, to external influences causing diseases, of which 4.5 percent were infectious and parasitic diseases and an equal number of respiratory diseases. In Ukraine only one-third of all low birthweight babies survive compared to 90 percent in Canada. A high mortality rate among premature babies weighing 500 to 999 or even 1,499 grams is attributed to underdeveloped lungs preventing these infants from breathing on their own.

Statistics indicate that in 2005 respiratory dysfunction was the cause of death of more than 28 percent of low birthweight babies, while in the rest of the world this figure is much lower. Science has found an effective method for helping such children: they are given so-called surfactants, which purify lungs and facilitate breathing. In most cases, this measure saves the baby, who has been kept for several weeks in a special incubator that provides warmth and makes it easier to breathe.

Our birthing facilities use various surfactants, often imported, such as the Italian-made Curosurf, which can cost more than 1,000 euros. American and German medications are even more expensive. At the same time, the Ministry of Public Health has provided Ukrainian birthing facilities with a domestically produced medication called Sukrim, which is made from pig’s lungs, like the Italian medicine, but one vial costs about 700 hryvnias. The medication was invented by a group of Crimean scientists and is produced in the Crimea by Dokfarm.

This field illustrates the principle “we can if we want to.” In 2005 there was a considerable drop in neonatal mortality in the Crimea; Mykolaiv, Kyiv, Lviv and Ternopil oblasts; and the city of Sevastopol. According to Dr. Shunko, this achievement was made possible by the so- called regionalization of perinatal assistance: pregnant and child-bearing women, as well as newborns, receive high-quality assistance at the level of a maternity ward, obstetric in-patient hospital, or regional general hospital. Pregnant women, especially those in risk groups, are closely monitored, which helps to establish timely diagnoses of congenital abnormalities and provide special treatment in complicated cases. What also helps is the cooperation of gynecologists, obstetricians, and neonatologists in diagnosing the health of mother and child and administering aid in a baby’s first minutes of life.

High rates of early and post- neonatal mortality have been recorded in Sumy, Donetsk, Zaporizhia, Luhansk, and Chernivtsi oblasts. In Dr. Shunko’s view, these rates can be reduced if neonatal intensive care units in Ukraine are better furnished with special beds and equipment, if mothers are allowed to stay with newborns in such units and encouraged to breastfeed even premature babies, etc. Specialized wards should be equipped with state-of-the-art devices for cardio- respiratory monitoring and ultrasonography, and other modern techniques should be used.

Also very important is the introduction of health ministry-approved protocols on medical care of newborns, including clinical protocols on neonatal jaundice, the care of low birthweight babies, primary resuscitation, post-resuscitation care of newborns, and neonatal infections. These documents are now being drawn up. Also expected to reduce still births and early mortality is the introduction of the fetus distress record, which will help diagnose a baby’s health, starting from the time it is in utero. All this will considerably increase newborns’ chances of surviving if all the protocol requirements are met. At the same time these protocols will also greatly increase the responsibility of doctors who fail to meet them.

The speakers at the recent symposium said that in no other country are clinical protocols subject to ministerial endorsement — the case in Ukraine — which means that they are professional-advisory in nature instead of administrative and compulsory. In some cases a doctor has the right to depart from protocol in the interests of the family and their child if this means providing more effective assistance to the child. Accordingly, the new work pattern of birthing facilities, which will be in force from 2007, will require a revision of the curriculum in educational institutions. In the view of Mykola Ariaiev, Corresponding Member of Ukraine’s Academy of Medical Sciences, these facts confirm Ukraine’s participation in the beneficial globalization of medicine, which makes it imperative to standardize terms and integrate higher medical education into the Europe-wide Bologna Process.