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Instituto Nacional de Perinatología
Isidro Espinosa de los Reyes
PERINATAL HEALTH WHERE ARE WE ?
WHERE ARE WE GOING?
Dr. Jorge Arturo Cardona Pérez Managing Director
November, 2016
Indivisible
Bond
Fetus
Neonato
Mother
Neonate
Mexico….. 1 woman dies every 10 hours 2 neonates every 60 minutes
14 14 14 14 14
25 24 23 23 22
42 42 41 39 38
59 60
48 46 44
69 66 67 66 64
2011 2012 2013 2014 2015
USA Chile Mexico Brasil Colombia
Maternal Mortality Rate per 100,000 live births
Source: Banco Mundial
Maternal Death Ratio Mexico 1990-2018*
* Information as of May 6, 2016 (epidemiological week 18) OFIC PROJECTION 2012-2018 Sources: 1990 to 2014, INEGI-SSA / DGIS, SSA / 2015 **: Preliminary information DGE. The corrected death ratio was calculated with registered births (SINAC / DGIS).
RMM reduction of 56.3% of in 24 years
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Defunciones 1,309 1,313 1,239 1,242 1,166 1,097 1,119 1,207 992 971 969 934 898 862 827 791 755 720 684 648 612 577 541 505 470 434 398 363
RMM 59.9 62.6 60.9 61.8 58.6 55.6 57.2 62.2 51.5 50.7 51.0 49.4 47.8 46.1 44.4 42.7 41.1 39.4 37.7 36.0 34.3 32.6 30.9 29.1 27.3 25.5 23.7 21.8
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
0
200
400
600
800
1,000
1,200
1,400
2029 2002 estimates
2012
Behavior of deaths and reason for maternal death Mexico, 2002 to 2029
R2 = 0.84
EUA
1970
25.3
24.9 19.1
13.1
8.2
5.6 2.3 1.4 0.1 Indirect Obstetric Causes
Hypertensive disease
Hemorragia del Embarazo
Other Direct ObstetricCausesAbortion
Other Complicationsspecially PuerperalSepsis and other PuerperalInfectionsHIV-AIDS plus Pregnancy
Non Obstetrical Causes plusPregnancy
Percentage of Causes of Maternal Death in Mexico 2014 *
Source: * 2014 Final closing, DGIS / INEGI
Teenage pregnancy: a public health problem
Teenage pregnancy rate (15-19 years) *
2009 70.9/ 1000 teenagers
2016 77/ 1000 teenagers
Teenage pregnancy rate** • With middle school and more: 60 births / 1000 adolescents
• No schooling: 180 births / 1000 adolescents
• National Survey of Demographic Dynamics (ENADID) 2009 and 2014 • ** Public Health of Mexico 2015; 57: 135-143
135 million newborns and 15 million premature babies Health system needs and human capital outcomes
Fuente: Analysis using data from Blencowe et al., 2012; Cousens et al., 2011; Liu et al., 2012
780,000 babies
< 28 weeks gestational
age
1.6 million babies 28 - 31.99 weeks gestational age
12.6 million babies 32 to 36.99 weeks
gestational age
TERM BABIES 120 million, including about
5 million term low-birthweight babies
3.1 million neonatal deaths
2.6 million stillbirths
LOSS OF HUMAN CAPITAL
Fam
ily
supp
ort
afte
r dea
th
Incr
ease
d he
alth
and
car
e lo
ad in
late
r life
Car
e fo
r chi
ldre
n w
ith d
isab
ility
, fa
mily
sup
port
Children with moderate or severe long
term disability
Children with mild long term disability eg learning or behavior
Other long term effects e.g.
higher risk of non
communicable diseases
HEALTH SYSTEM CARE NEEDED
Inte
nsiv
e ne
onat
al c
are
Esse
ntia
l mat
erna
l and
new
born
car
e
Extr
a ca
re fo
r sm
all b
abie
s
Car
e of
pre
term
bab
y w
ith c
ompl
icat
ions
STATISTICS
Mexico, 2014
8,576 < 28 weeks gestational
age
15,722 28 - 31.99 weeks gestational age
118,636 32 to 36.99 weeks
gestational age
TERM BABIES 2.3 million, including about
120,000 term low-birthweight babies
HEALTH SYSTEM CARE NEEDED
Inte
nsiv
e ne
onat
al c
are
Esse
ntia
l mat
erna
l and
new
born
car
e
Extr
a ca
re fo
r sm
all b
abie
s
Car
e of
pre
term
bab
y w
ith c
ompl
icat
ions
18,154 neonatal deaths
222,248 stillbirths
LOSS OF HUMAN CAPITAL
Fam
ily
supp
ort
afte
r dea
th
Incr
ease
d he
alth
and
car
e lo
ad in
late
r life
Car
e fo
r chi
ldre
n w
ith d
isab
ility
, fa
mily
sup
port
Children with moderate or severe long
term disability
Children with mild long term disability eg learning or behavior
Other long term effects e.g.
higher risk of non
communicable diseases
Fuente: Dirección General de Informática. SS. 2012
STATISTICS
INPer, 2014
114 < 28 weeks gestational
age
225 28 - 31.99 weeks gestational age
1,023 32 to 36.99 weeks
gestational age
TERM BABIES 3,245
HEALTH SYSTEM CARE NEEDED
Inte
nsiv
e ne
onat
al c
are
Esse
ntia
l mat
erna
l and
new
born
car
e
Extr
a ca
re fo
r sm
all b
abie
s
Car
e of
pre
term
bab
y w
ith c
ompl
icat
ions
88 neonatal deaths
234 stillbirths
LOSS OF HUMAN CAPITAL
Fam
ily
supp
ort
afte
r dea
th
Incr
ease
d he
alth
and
car
e lo
ad in
late
r life
Car
e fo
r chi
ldre
n w
ith d
isab
ility
, fa
mily
sup
port
Children with moderate or severe long
term disability
Children with mild long term disability eg learning or behavior
Other long term effects e.g.
higher risk of non
communicable diseases
Fuente: Dirección de Planeación INPer
STATISTICS
TMI (Mexico)
14.8 (2010)
11.69 (2016)
35.0
30.0
25.0
20.0
15.0
10.0
5.0
0
1
2
3
4
5
6
7
8
9
10
11
12 14
13
16
15
18
17
20
19
22
21 USA
1950 52 54 56 58
1960 62 64 66 68 72 74 76 78 82 84 86 88 92 94 96 98 02 04
1970 1980 1990 2000
Infa
nt M
orta
lity
Rate
Infant mortality rate, USA. 1950-2005
Source: US Census Bureau. Statistical Abstracts of the United States, Mini-Historial Statisties. “No. HS-13 Live Births, Death, infant Death and Maternal Deaths: 1900-2002. Wwww.census.gov/statab/hist/HS-13.pdf; World Almanac Book of Facts. “US infant Mortality Rates by Race and Sex. 1960-2005” 164.
1. Dissemination of the Apgar score 8. Introduction of parenteral nutrition in the newborn. 15. Introduction of pulse oximeters. 2. Introduction of portable Rx. 9. Introduction of CPAP (Continuous Positive Airway Pressure). 16. Use of cryosurgery in retinopathy of the premature.
3. Micromethods for the extraction of blood samples. 10. Normatization of the neutral thermal environment. 17. Approval of exogenous surfactant by Food & Drugs Administration.
4. Description of TORCH infections. 11. Indomethacin use in the ductus. 18. Standardization of the use of vasoactive drugs in the newborn.
5. Introduction of mechanical ventilation in the neonate. 12. Use of Caffeine in apnea of the newborn. 19. Introduction of the use of nitric oxide in newborn.
6. Description of neonatal hypoglycemia. 13. Interpretation of the leukocyte formula in sepsis of the newborn. 20. Standardization of the use of prenatal corticosteroids.
7. Development of cardiopulmonary monitors for neonate. 14. Introduction of brain ultrasonography in newborns. 21. Introducción de la utilización de la circulación extracorpórea.
Mexico: Demographic Indicators, 2010-2050
* Por mil ** Por cien
Nacimientos 2,239,217 2,202,237
Tasa global de fecundidad 2.18 2.10
Mortalidad infantil total 11.69 9.52
Infant and neonatal mortality rates in Mexico 2014
Infant 26,399 100.0%
Early neonatal 11,475 43.4%
Neonatal 5,304 20.0%
Postneonatal 9,620 36.4% Fuente: INEGI 2016
2006 2007 2008 2009 2010 2011* 2012*Defunciones 19,330 18,894 18,731 18,574 18,149 18,227 18,154Tasa 9.72 9.58 9.58 9.57 9.42 8.07 8.00
0
2
4
6
8
10
12
17,40017,60017,80018,00018,20018,40018,60018,80019,00019,20019,40019,600
Neonatal Mortality Rate 2006 - 2012
Fuente: DGIS:SS Tasa por 1,000 N.V.E. La tasa se calculó con nacimientos estimados por CONAPO 1990-2010 * Tasa por 1,000 N.V.R. SINAC 2011-2012
28.8%
19.5% 11.0%
22.1%
18.6%
PrematurityInfectionsHypoxia / AsphyxiaBirth defectsOther Perinatal Causes
Fuente: SS/DGIS/Cubos defunciones neonatales, 2012 INEGI-SIS
Major Causes of Neonatal Mortality in Mexico, 2012
20.3
33.5 36.5
25.1 22.3
30.9
37.1
18.6 14.4
25.0
35.5
14.1
Lactancia materna exclusiva < 6 meses
Lactancia materna predominante
< 6 meses
Lactancia materna continua al año de vida
(12 a 15 meses)
Lactancia materna continua a los 2 años
(20 a 23 meses)
Percentage of Exclusive Breastfeeding in Months
Fuente: Deterioro de la lactancia materna: dejar las fórmulas y apegarse a lo básico. Evidencia para la política pública en salud. ENSANUT 2012
ENN 1999
ENSANUT 2006
ENSANUT 2012
Infrastructure
2016 BIRTHS PREMATURE BIRTHS
……………… ………………
2,239,217 179,137
OB-GYN 5,761
MF 116
Pediatricians 10,562
Neonatologists 1,723
Nurses 928
NICUs 296
HUMAN RESOURCES
A reduction of 2.2 annual RMM points is needed of 214 vs. 2018
to achieve ODS
Prevalence of Obesity WHO 2014
Overweight and obesity in Mexico, Ensanut 2012
<5 years Overweight
9.7%
6-11 years • Overweight • 19.8%
• Obesity • 14.6%
Adolescence • Overweight • 21.6% • Obesity • 13.6%
Women > 20 years
73%
9.7% 34.4% 35.2% 73%
Increase in childhood diabetes
Guerrero-Romero Distribution of fasting plasma glucose and prevalence of impaired fasting glucose, impaired glucose tolerance and type 2 diabetes in the mexican paediatric population. Paediatr Perinatol Epidemiol 2009;23:363-9
2013 80 millions 40 millions 31.6 millions 25 millions
Population in Mexico ... 118 million Overweight and obesity Women Women of reproductive age Overweight and obesity
Numbers
Sustainable Development Goal ( SDG3 )
Maternal, Newborn and Child Health ( MNCH ) NEONATAL MORTALITY : USA 3.6. MEXICO 8.2 / 1000 livebirths. INFANT MORTALITY : OECD 3.8. MEXICO 13 / 1000 livebirths. UNDER 5 MORTALITY : USA 6.6. MEXICO 16.8 .
Non-communicable disease (NCDs) ADULT MORTALITY : 33.4% ( Diabetes and CV disease ). DIABETES PREVALENCE RATE FOR ADULTS > 20 Y….Highest en OECD. HIGHEST RATE OF OVERWEIGHT Y OBESITY
Source: Lancet Glob Health. 2016 Oct; 4(10): e714–e725.
Gross Domestic Product ( GDP ): Mexico 6.2% vs OECD Average 8.9% Public component: Mexico 3.2% vs 6.5% in OECD countries. Primary obesity related diseases: 2013 US$ 880 million to $ 1.2 billion by 2030. Diabetes and its complications acount for 2.25 of Mexico GDP
Source: Lancet Glob Health. 2016 Oct; 4(10): e714–e725.
Sustainable Development Goal ( SDG3 )
Premature deaths and death rates by cause in 1990, 2000, 2010, and three scenarios for 2030
Source: Lancet Glob Health. 2016 Oct; 4(10): e714–e725.
Sustainable Development Goal ( SDG3 )
¿WHAT ARE WE DOING ?
Red de Servicios Integrados y Regionalizados de Atención Perinatal de Calidad
Febrero, 2015
High Quality Regionalized Perinatal Centers
Community education.
Risk approach at the first level.
Enhance resolutive capacity at the second level.
Reference and contrareference program.
Perinatal data-base.
STRATEGIES
Apoyo Vital Integral del Neonato PLAN MAESTRO
INTEGRAL APPROACH
SEPSIS
ASPHYXIA HIE
RDS
STRATEGIES
Thomas Alva Edison… 1847-1931
“The doctor of the future will give no
medication, but will interest his
patients in the care of the human
frame, diet and in the cause and
prevention of disease“
Microbioma 2001 Joshua Lederberg
Biólogo Molecular
Nobel Prize 1958 Genetic Studies in Bacteria
PAUL BERG EN 1980:
WE WILL HAVE TO HAVE DOCTORS WHO DOMINATES THE MOLECULAR
ANATOMY AND THE PHYSIOLOGY OF THE CHROMOSOMES AND THE GENES, IN
THE WAY THE CARDIAC SURGEON MASTERS THE READING AND FUNCTIONING
OF THE CORONARY TREE.
Oxidative stress
OXIDATIVE STRESS
MICROBIOMA
RESEARCH PROJECT: PERINATAL IMPACT
OBESITY
What have we done?
C-section rate……23% Nosocomial infections………51% LOS …………….2.1 days Rationale use of antibiotics
Breastfeeding Rooming in Father involvement Milk Bank
O-W/Obesity
CONCEPTION
WEIGHT GAIN METABOLIC
ALTERATIONS
C-Section Prematurity
FASTING
Gestational
Diabetes
Antibiótics
Pre-eclampsia
METABÓLIC DISRUPTION Fórmula
NICU O2
NEXT STEPS ……………………
MATERNAL MORTALITY INFANT MORTALITY MATERNAL AND NEONATAL MORBILITY STILLBIRTHS CHRONIC DISEASE ( DoHaD ) REGIONALIZATION ADOLESCENTS PREGNANCY
COMPLEX AGENDA……We have to deal with underdevelopment
And at the same time face the challenge of the future
PUBLIC HEALTH STRATEGY
Modelo de intervención para prevenir alteraciones en el neurodesarrollo y constantes metabólicas durante los primeros tres
años de vida en el hijo de madre diabética
Ensayo clínico aleatorizado
Subdirección de Neonatología: Dra. Alejandra Coronado Zarco Colaboradores Dra. Gabriela Arreola Dr. Saúl Garza Morales Dra. Gisela Villalobos Alcázar Dra. Otilia Perichart Dra. Ivonne Alvarez
Seguimiento Pediátrico Dra. Gloria López Dra. Patricia García Alonso Dra. Martina Guido C Dr. Carlos Martínez Cruz Dra. Mayra N. Ramírez Vargas Lic. Alma Ramírez Maya Lic. Angeles Quiroz Cristo Mtra. Pilar Ibarra Reyes Psicol. Rosalía Jiménez Quiroz Psicol. Mary Paz Conde TS. Elizabeth Luján TS: María Elena Magaña
Anticipated double expense in 2017 Obesity will cost $202 billions
IDF Diabetes Atlas 2015
Nov 14, 2016
Nov 14, 2016
Evaluar el epigenotipo de pacientes embarazadas con peso pregestacional
normal, con sobrepeso y con obesidad y correlacionarlo con la cuantificación de
marcadores funcionales del tejido adiposo, inflamatorios y metabólicos, así
como con la presencia de disruptores endócrinos, nivel de neurodesarrollo y con
la composición corporal del binomio madre-hijo con seguimiento de 3 años
posparto.
Objetivo General
AVIN (Definición)
Es un curso de capacitación nacional dirigido al personal de salud responsable de la atención neonatal para fortalecer sus
habilidades y capacidades en la patología de mayor impacto en el periodo neonatal precoz
Mexico's potential to converge in life expectancy by 2030
Source: Lancet Glob Health. 2016 Oct; 4(10): e714–e725.
Japan and USA estimates are based on UNPD data. Mexico's inertial forecast takes into account linear projections of trends in cause-specific mortality rates and United Nations population projections. Mexico's SDG 40 × 30 scenario considers an overall reduction of 40% in premature mortality (for individuals aged 0-69 years) by 2030.
Life
exp
ecta
ncy
at b
irth
(num
ber o
f yea
rs)
Sustainable Development Goal ( SDG3 )
Mexico's potential to converge in mortality by age group, 1990, 2010, and 2030
Source: Lancet Glob Health. 2016 Oct; 4(10): e714–e725.
Own estimates using data from: United Nations, Department of Economic and Social Affairs, Population Division, World Population Prospects, 2015 Revision. Pr
obab
ility
of d
eath
at e
ach
age
Age group (years)
Sustainable Development Goal ( SDG3 )
Deaths and death rates by age group in 1990, 2000, 2010, and three scenarios for 2030
Source: Lancet Glob Health. 2016 Oct; 4(10): e714–e725.
Sustainable Development Goal ( SDG3 )
*
*
* p≤0.001
Complicaciones Maternas
Complicaciones Fetales y Neonatales
*
* p≤0.001
Infraestructura
Equipamiento
Recursos Humanos
Regionalización
Enfermedades Crónicas no Transmisibles Mortalidad Materna y Perinatal
AVIN OBESO
QUE SIGUE…………………………………………………
Medical salary tab, paramedic and related group
DESCRIPCIÓN DEL PUESTO TOTAL PERCEPCIONES BRUTAS
TOTAL DEDUCCIONES NETO
MEDICO ESPECIALISTA "A" 35,702.00 8,771.10 26,930.90
MEDICO ESPECIALISTA "B" 37,433.00 9,357.98 28,075.02
MEDICO ESPECIALISTA "C" 41,066.00 10,712.44 30,353.56
ENFERMERA ESPECIALISTA "A" 20,695.00 4,378.69 16,316.31
ENFERMERA ESPECIALISTA "B" 22,784.00 4,936.50 17,847.50
ENFERMERA ESPECIALISTA "C" 26,204.00 6,032.23 20,171.77
