【作者】 周英凤；

【导师】 郝模； 吕军； 李笑天； 王秋伟；

【作者基本信息】 复旦大学 ， 社会医学与卫生事业管理， 2010， 博士

【摘要】 目的孕产妇保健技术和方法众多,如何遴选出“安全、成熟、价廉、易操作、参与度高且效果明显的”孕产妇保健技术是本研究关注的重点。因此,在全面系统了解国内、外孕产妇保健现状和现有技术的基础上,遵循卫生技术评估和循证医学的原理,遴选出孕产妇保健适宜技术；结合国内社区的特点,通过孕产妇保健社区适宜技术筛选评估指标体系,遴选并论证出孕产妇保健社区适宜技术；提出被我国社区普遍接受的孕产妇孕前、产前、产时和产后等各期保健间隔周期、保健内容和保健路径,是本研究的目的。方法本研究力图对个体、技术、操作三个维度进行整合,以全流程、系统性和操作性作为总体研究思路,以结构-过程-结果模型、卫生技术评估、循证医学、项目管理及业务流程管理思路作为指导性研究方法,以文献计量分析、专家咨询、定性定量多重论证、焦点组访谈、现场调查、综合评价法为具体的研究的方法,实现孕产妇保健技术到孕产妇保健适宜技术,再到孕产妇保健社区适宜技术的遴选和论证。资料主要来自国内外文献资料和现场资料,现场资料包括北京、常州、嘉定三地的妇幼保健院及下属16个社区卫生服务中心的现场调查和专家论证。结果(一)国内外孕产妇保健现状的研究本研究第一部分主要是系统了解国内外孕产妇保健现状和技术使用情况。因此,通过对24本国内保健手册、56篇国内文献、48项国内法规政策和10本国外保健指南的国内外文献的系统评阅和来自北京、常州和嘉定三家妇幼保健院及下属16个社区卫生服务中心的40名专家和40位孕产妇的访谈的现场资料的收集,系统、全面地了解了目前国内外孕产妇保健的现状和技术使用情况。孕前保健在框架、评价方法、保健流程及实施形式上已基本完善,但国内尚未系统开展孕前保健服务；产前保健在政策支持和开展模式方面均具有一定的系统性和规范性,但国外已经形成了基于社区的孕产妇保健模式,而国内针对社区的孕产妇保健研究甚少；产时保健以住院分娩为主；产后保健基本上建立了基于社区的产后家庭访视模式。在技术方面,孕产妇保健技术和方法众多,其中,孕前保健主要包括六大类技术,67个条目；产前保健主要包括七大类技术,107个条目；产时保健主要包括四大类技术,24个条目；产后保健针对产妇的包括七大类技术,22个条目,对新生儿的包括四三大类技术,16个条目。(二)孕产妇保健适宜技术的遴选与论证在系统了解孕产妇保健现状和技术使用情况的基础上,本研究第二部分是从众多孕产妇保健技术中遴选出适宜的孕产妇保健技术。因此,本研究根据卫生技术评估和循证医学的原理和方法,对孕产妇保健技术的适宜性进行了文献遴选和现场论证,文献主要包括20篇国内期刊文献、186篇国外期刊文献和5本国外保健指南,现场论证包括北京、常州和嘉定三个保健院及下属16个社区卫生服务中心和30名专家。结果表明,孕前保健具有较好的效益和效果,孕前保健包括风险评估、孕前咨询与健康促进、知情选择与医学干预,但涉及的大部分技术均来自专家建议,缺乏系统的文献评价。产前保健也具有较好的效益和效果,产前保健包括信息采集、体格检查、产科检查、实验室检查、健康档案管理、转诊评估和健康教育与促进,涉及的大部分技术均有系统的文献评价,评价显示,部分广泛应用于临床的保健技术的效果是缺乏证据支持的。产时保健中,与分娩相关的大部分技术均有系统的文献评价,并根据技术的适宜性分为有益的技术、常用但不适宜的技术、需要进一步明确的技术和应该废除的技术四大类。产后保健具有较好的成本效果,产后保健包括针对产妇和新生儿的健康评估和健康教育与促进,产后保健服务并不涉及复杂的技术。经过文献遴选和现场论证,孕产妇保健技术中,除了已经被普遍接受的适宜技术(如采集病史、体格检查、健康教育)外,孕产妇保健方面共有27项适宜技术,其中11项技术为产时适宜技术。(三)构建孕产妇保健社区适宜技术筛选评估指标体系在明确了孕产妇保健适宜技术的基础上,为了进一步遴选出孕产妇保健社区适宜技术,本研究第三部分构建了孕产妇保健社区适宜技术筛选评估指标体系。课题组通过对417篇国内期刊文献研究和专家咨询,结合国内社区的特点,拟定了孕产妇保健社区适宜技术筛选评估指标体系的基本框架。通过对来自北京、常州和嘉定16个社区卫生服务中心的30名专家进行的两轮Delphi咨询,构建了由6个一级指标、16个二级指标和24个三级指标组成的孕产妇保健社区适宜技术筛选评估指标体系,并确定了各级指标的权重。六个一级指标的权重分别为安全性0.2710、经济性0.1737、有效性0.1796、成熟性0.1397、可操作性0.1333、参与度0.1027。(四)孕产妇保健社区适宜技术的遴选与评估本研究第四部分主要是借助指标体系实现孕产妇保健适宜技术到孕产妇保健社区适宜技术的遴选,并进一步明确所遴选出的社区适宜技术在社区机构的可操作性。因此,课题组根据构建的孕产妇保健社区适宜技术筛选评估指标体系,通过国内外文献研究及来自北京、常州、嘉定妇保院的下属16个社区机构的30名专家及40名孕产妇的现场调查,按照指标体系的评分标准和筛选流程,对课题组前期遴选出的16项孕产妇保健适宜技术进行了社区适宜性评估,按照指标体系进行评分,≥7分为社区适宜的原则,遴选并论证出了10项适宜于我国社区的孕产妇保健适宜技术。然后,通过基线调查及研究的阶段性评估,对课题组遴选出的社区适宜技术在社区机构的操作性及认可度进行了评估,评估显示,孕产妇保健社区适宜技术在社区内具有较好的可操作性,但社区发展不平衡,部分社区机构的孕产妇保健服务日趋萎缩,部分社区机构不适宜技术过度使用。同时,对我国社区开展孕产妇保健的频次、时机和内容进行了评价,为构建我国社区孕产妇保健模式提供了政策依据。结论亟需建立基于社区的孕产妇全流程保健模式,促进公共卫生服务均等化。亟需从政策、供方、需方促进孕前保健服务的系统开展,并逐步过渡到基于社区的孕前保健模式；政府需要制定政策引导和增加资源支持,促进我国社区孕产妇保健模式的建立,根据经济水平和社区服务提供能力,制定频次适宜的产前保健服务包,并制定相应的技术和管理规范,促进社区对孕产妇保健适宜技术的使用,避免非适宜技术的过度使用；加强产时保健适宜技术的使用；进一步强化基于社区的产后保健模式,促进产妇和新生儿的健康。更多还原

【Abstract】 ObjectivesHow to select the’safe, mature, cheap, easy-manipulated, high-involved and effective’maternal health care technologies is the major focus of this study. Objectives of this study are:(1) to systematically review current available international and national literatures, documents, guidelines, and policies on technologies available to maternal health care; (2) to select appropriate technologies applied in maternal health care based on concepts and principles of health technology of assessment and evidence-based medicine; (3) to apply and evaluate appropriate technologies available to maternal health care in community through an assessment model of appropriate maternal health technologies for use in community; and (4) to propose and recommend appropriate frequency, timing, pathway and contents of heath care from preconception, antenatal, intrapartum to postpartum.MethodsA comprehensive dataset was collected from literature review and field studies, and data was analyzed in individualized, technological and operational dimensions. The concept of whole process, system, and operating was applied as a framework for this study. Guided by principles of structure-process-outcome model, health technology assessment, evidence-based medicine, program administration, and work process administration, literature quantitative analysis, individual interview, group interview, qualitative and quantitative multiple demonstration, field study and comprehensive evaluation approaches were integrated in this study. Three maternal & child health care institutions in Beijing, Changzhou, and Jiaiding and 16 community health care service centers were chosen as our study fields.Outcomes1. Study on status quo of international and national maternal health careThe aim of first part of this study was to understand international and national technologies available to maternal health care. Based on a comprehensive review of literature of 24 national health care manuals,56 Chinese journal papers,48 items of national laws and regulations and 10 international health care guidelines, and the indepth interview of 40 experts and 40 pregnant women from three maternal & child health care institutions including Beijing, Changzhou, and Jiaiding and 16 community health service centers, the status quo and technologies in use have been clarified. The preconception care system was improved with the support of policy from four sides including the framework, risk-screening tool, service process and carrying pattern. The preconception care hasn’t been systematic carried out due to lacking policy and inadequate demand. The antenatal care has been systematic and normative carried out for many years with the support of policy. But a model based community of maternal health care has been formed abroad and has still been less studied internal. Childbirth in hospital has been advocated both abroad and home. And a pattern based community of family visiting postpartum has been established. As technologies as concerned, there were so many technologies available to maternal health care,6 categories including 67 items were used in preconception care,7 categories including 107 items were used in antenatal care,4 categories including 24 items were used in intrapartum care,7 categories including 22 items for mother and 4 categories including 16 items for baby were used in postpartum care.2. Selection and assessment of appropriate technologies from all technologies available to maternal health careThe second part of this study aimed to select appropriate technologies from all technologies available maternal health care. So, following the concepts and methods of health technology assessment and evidenced based medicine, appropriate technologies were picked up based on literatures including 20 pieces of Chinese journal papers,186 pieces of international journal papers and 5 pieces international health care guidelines and field studies including investigation and interview to three maternal & child health care institutions including Beijing, Changzhou, and Jiaiding and 16 community health service centers and 30 experts. The outcome showed that preconception care was a cost-effective and cost-benefit program, which includes risking assessment, consultation and health promotion, informed choice and medical intervention. But most technologies available to preconception care were from advices of expert panel. The antenatal care was also a cost-effective and cost-benefit program, which includes information collecting, physical examination, obstetrical examination, lad test, file administration, risk screening and health education. The most technologies available to prenatal care have been evaluated by systematic reviews, which indicated many technologies applied in clinical care widely had no support of evidences. Technologies related to delivery were classified four, including benefit technology, in common use but not appropriate technology, unclear technology and be abolished technology. Postpartum care was also a cost-effective and cost-benefit program without intricate technologies, which including health assessment and health education for mother and baby. Besides the universal appropriate technologies (such as collecting history, physical examination and health education),27 items were chosen from technologies available to maternal health care, and 11 articles related to childbirth were involved.3. Establishment of an assessment model of appropriate maternal health technologies for use in communityThe third part of this study aimed to establish an assessment model of appropriate maternal health technologies for use in community. Through literature study of 417 pieces of journal papers and expert consultation combined with the characteristic of domestic community, a framework of the assessment model of appropriate maternal health technologies for use in community was mapped out. Then an assessment model of appropriate maternal health technologies for use in community consisting of 6 first-level indicators,16 second-level indicators and 24 third-level indicators was established through the method of Delphi involving 30 experts from 16 community service centers of Beijing, Changzhou and Jiading. Weights for each indicator were also determined, and the weights of six first-level indicators are following:safety is 0.2710, economic attribute is 0.1737, validity is 0.1796, maturity is 0.1397, convenience is 0.1333, participation is 0.1027.4. Selection and evaluation of appropriate technologies of maternal health care in communityThe Forth part of this study aimed to choose and evaluate appropriate technologies of maternal health care in community through the assessment model of appropriate maternal health technologies for use in community and to verify the feasibility of applying appropriate technologies into community. So, with the help of the assessment model, according to the grade standard and screening method, with the principle of appropriateness more than 7 score,10 items have been selected from 16 articles of appropriate technologies through literature study and field study which includes 30 experts and 40 pregnant women from 16 community service centers of Beijing, Changzhou and Jiading.Then, the feasibility and acceptance of appropriate technologies selected through the assessment model have been evaluated by baseline investigation and staged appraisal. The outcomes showed that the appropriate technologies picked up by the assessment model could be well complemented in communities and the development of maternal health care in community was unbalanced. Maternal health care services withered due to lack of resources and the demand in some communities. However, many inappropriate technologies have been excessively supplied to pregnant women in other communities. And then the appropriate frequency, timing, paths and contents of stages heath care from preconception, antenatal, intrapartum to postpartum were suggested.ConclusionsIt is strongly recommended that the promotion of preconception care should be stressed from policy, the supply and the demand level, and community-based preconception care model should be established step by step. The model of community-based perinatal health care should be built with the policy guiding and resource support from government. Community health care center should provide mother and baby package with appropriate frequency according to local economic level and the capacity of supplying. Moreover, technological and administrating norm should be formed to encourage the application of appropriate technologies and avoiding inappropriate technologies. It is also recommended to apply appropriate childbirth technologies, and strengthen community-based postpartum care, so as to improve mother and baby’s health.更多还原