NTDs发生的相关因素和预防措施对其发生影响的研究
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摘要
目的：神经管畸形(neural tube defects, NTDs)是造成婴儿死亡、致残的主要原因,给社会、家庭乃至个人带来巨大痛苦,严重威胁着人类健康和人口素质。在叶酸作为NTDs有效干预措施的情况下,筛选出目前NTDs发生的主要影响因素,了解产妇接受健康教育情况、遗传优生咨询情况、叶酸的服用情况、产妇所做孕期检情况和比较她们预防NTDs知识的异同,对孕期卫生费用给她们造成的经济负担作出评价,为提出NTDs综合干预模式提供科学依据。
方法：采取1：1匹配的病例对照研究,在山西省随机抽取平遥、介休、祁县、和顺、离石、中阳六县(市)作为现场。将抽取的县市中从2006年1月-2008年12月的监测报告资料中所有生育过NTDs患儿的产妇组成病例组,按同地区、同年份、同医院分娩、1：1匹配的原则选取相应的对照。在统一培训调查员后,采取入户或通过一定的联系方式将研究对象召集到医院进行面对面访谈,填写事先设计好的调查表。用SAS8.0和SPSS13.0软件对数据进行统计分析,采用的分析方法有：t检验、x2检验、条件Logistic回归分析、秩和检验等。
结果：(1) NTDs影响因素的多因素条件Logistic回归分析：分析结果显示共有8个变量进入回归模型：服用叶酸、孕早期调整膳食、计划怀孕、孕期精神状态、孕早期坚果摄入频率、孕期被动吸烟、孕前产妇配偶接触有毒有害物质、孕期患病的OR值分别为0.131、0.254、0.265、0.444、0.549、8.413、3.804、7.087,且坚果摄入频率与NTDs存在剂量反应关系。孕妇在怀孕前3个月服用叶酸、孕期开始服用的月份、孕期服用的时间差异有统计学意义,x2值和P值分别为25.543、17.161、8.318和0.000、0.001、0.016,而孕期的前3个月服用叶酸、孕前开始服用叶酸的月份、孕前服用叶酸的时间在两组间差别无统计学意义。在孕早期调整过膳食的人群中分析了调整食物的种类,发现增加肉类、增加蛋类、增加蔬菜、增加海产品、减少泡菜经x2检验差异有统计学意义,x2值和P值分别为5.420、4.655、8.741、6.611、5.042和0.020、0.031、0.003、0.010、0.025。
(2)接受健康教育、遗传优生咨询情况：接受健康教育、遗传优生咨询虽未进入最终的多因素回归分析模型,但对接受健康教育方式经检验发现通过杂志或书籍(x2=8.419,P=0.004)、宣传单张或宣传手册(x2=6.956,P=0.008)在两组间差异有统计学意义,同时对两组人群中进行和未进行遗传优生咨询的原因进行分析,经x2检验发现两组间差异有统计学意义(x28.230、11.969和,P=0.041、0.018)。两组接受健康教育的地点、遗传优生咨询的时间、机构级别的差异均无统计学意义,且对遗传优生咨询作用的认识差异亦无统计学意义。
(3)预防NTDs的知识：产妇预防NTDs知识得分未进入多因素回归模型,但对照组产妇的预防NTDs知识得分高于病例组,且听说过叶酸、知道食物中含有叶酸、NTDs与接触环境有害因素有关、知道服用叶酸的作用、服用叶酸可以预防NTDs、遗传优生咨询可以预防NTDs、产前检查可以预防NTDs、知道产前筛查NTDs的时间、知道服用叶酸的时间、知道生过NTDs孩子的妇女还会生这样的孩子等经x2检验发现差异有统计学意义,x2值和P值分别为25.476、11.074、11.466、21.979、13.590、7.803、9.128、20.882、15.445、7.766和0.000、0.001、0.009、0.000、0.000、0.005、0.003、0.000、0.004、0.021。
(4)孕期检查和卫生费用：产前检查的时间、孕期产妇第二次、第三次超声检查经x2检验发现两组间差异有统计学意义(x2=16.712,23.458和P=0.000、0.000),孕期超声检查和门诊检查的次数经秩和检验亦有统计学意义(Z=-7.550,-7.059和P=0.000,0.000)。孕期总卫生费用占家庭收入的比例在两组间差别无统计学意义(Z=0.388,P=0.698)。门诊直接卫生费用、门诊间接卫生费用、住院直接卫生费用、住院间接卫生费、总卫生费用经x2检验只发现门诊直接卫生费用在两组间差异有统计学意义(x2=38.849,P=0.000)。
结论：(1)孕妇在孕前有计划怀孕、孕期有较好的精神状态、孕早期坚果摄入频率高、服用叶酸、孕早期调整膳食是NTDs的保护因素,尤其是在孕前和孕期坚持服用叶酸,服用叶酸的种类对其预防NTDs的作用可能影响较小；而其配偶在孕前接触有毒有害物质、孕期被动吸烟、孕期患病则是NTDs发生的危险因素。
(2)通过听医生当面讲解、听专题讲座或授课、广播、电视、电影、报纸、杂志或书籍、标语或板报、互联网等方式接受健康教育的比例还较低,可以加大通过这些方式进行相关保健知识的健康教育。在医院、妇幼保健院、计划生育部门、社区或居住的村庄、家中等地方均宜开展健康教育。
(3)对照组产妇的预防NTDs的知识水平较病例组高,病例组产妇的相关知识水平还有待进一步提高。
(4)产妇在孕期做产前检查并未给其造成更多的经济负担,产妇在孕期去做产前检查从经济学的角度考虑是可行的。
Objectives:Neural tube defects resulted in mortality and disability of infants, brought great suffering to society, families and individuals, became serious threat to human health and the quality of population. we wanted to understand the state of receiving health education, receiving genetic eugenics counseling, taking folic acid, screening the influential factors which may be related to the occurrence of NTDs and assess the economic burden which is caused by health expenditure of lying-in woman during pregnancy and the knowledge of lying-in woman preventing NTDs to provide a model of scientific and comprehensive intervention for NTDs.
Methods:This study adopted 1:1 matched case-control study and selected Pingyao, Jiexiu, Qixian, Heshun, Lingshi, Zhongyang as research site.The cases who were selected from Jan 2006 to Dec 2008 in monitoring report were all lying-in mother who had children of NTDs.The year of birth, region of Residence, the puerperal hospital of the control was the same with the case.Then the investigators who had received unified training went into each the study object's house or summoned them to the hospital for face-to-face interviews to complete pre-designed questionnaire. t test,x2 test, conditional Logistic regression analysis, rank sum test and so on. were used for statistical analysis of collected data with SAS8.0 and SPSS 13.0 software.
Results:(1) 34 variables which were statistically significant by single-factor conditional Logistic regression and some suspectable factors were inducted into multiple conditional Logistic regression analysis.And eight variables were entered into the final regression model: planning pregnancy, mental state during pregnancy, passive smoking during pregnancy, Husband of the lying-in woman exposed to toxic hazardous substances during progestation, sickness during pregnancy, adjusting diet during pregnancy, high frequency of intaking nuts during early pregnancy, taking folic acid. And their OR values were respectively 0.265,0.444,8.413,3.804,7.087,0.254,0.549,0.131. The lying-in woman intaking folic acid 3 months before pregnancy, started month of intaking folic acid during pregnancy, time of intaking folic acid during pregnancy were statistically significant between two groups.Their x2 values and P values were respectively 25.543,17.161,8.318 and 0.000,0.001,0.016.
(2) Reading the magazines or books and publicity leaflets or brochures which were the ways of receiving health education was statistically significant by x2 test between two groups.Reasons of receiving and unreceiving Genetic eugenics counseling between two groups were statistically significant by x2 test (x2=8.230、11.969和, P=0.041、0.018). The location of receiving health education, time, institution of eugenics counseling and effect of eugenics counseling were no statistically significant between two groups.
(4) Knowing folic acid before or during pregnancy, the food containing folic acid, relation between NTDs and environmental harmful factors, knowing effect of intaking folic acid during pregnancy, intaking folic acid to prevent NTDs, knowing eugenic genetic counseling to prevent NTDs, prenatal check prevent NTDs, knowing prenatal time of screening NTDs, knowing the time of taking folic acid, and knowing whether women who had children of NTDs had a child like this were statistically significant by x2 test. And their x2 values and P values were respectively 25.476,11.074,11.466,21.979,13.590,7.803,9.128, 20.882,15.445,7.766,and 0.000,0.001,0.009,0.000,0.000,0.005,0.003,0.000,0.004,0.021.
(5) The time of prenatal examinations, second time, third time of ultrasonic inspection between two groups was statistically significant by x2 test. The times of examinations in clinic service and times of ultrasonographic during pregnancy between two groups was statistically significant by rank sum test, Z values and P values were respectively-7.059 and 0.OOO.The percentage that health expendifure hold the proportion of household income was no significant difference between two groups, Z value and P value were respectively-0.388 and 0.698. The direct health expendifure in clinic service, the indirect health expendifure in clinic service, the direct health expendifure in hospital, the indirect health expendifure in hospital were detected by byx2 test, but only found that the direct health expendifure in clinic service had statistically difference (x2=38.849, P=0.000).
Conclusions:(1) Our study found that planning pregnancy, good mental state during pregnancy, high frequency of intaking nuts during early pregnancy, persistently intaking folic acid during progestation and early pregnancy, adjusting the diet during early pregnancy were protective factors of NTDs.while the passive smoking during pregnancy, husband of lying-in woman exposure to toxic hazardous substances during progestation, sickness during pregnancy were risk factors of NTDs.
(2) The proportion of receiving health education through going to hospital and listening to doctors, listening to lectures or radio, watching television or movies, reading newspapers, magazines or books, posters or blackboard newspaper, leaflets or brochures etc were fairly low. And the health education could be received in the hospital, department of birth control, community or villages and at home and so on to improve their knowledge of preventing NTDs.
(3) The lying-in woman knowledge of preventing NTDs in the control group was higher than that of the case group. The lying-in woman knowledge of preventing NTDs in the case group needed to be further improved.
(4) The times of check in the control group were much higher than the case group's. while the prenatal examinations during pregnancy didn't cause more economic burden to lying-in woman. It is feasible to do prenatal examinations during pregnancy.
方法：采取1：1匹配的病例对照研究,在山西省随机抽取平遥、介休、祁县、和顺、离石、中阳六县(市)作为现场。将抽取的县市中从2006年1月-2008年12月的监测报告资料中所有生育过NTDs患儿的产妇组成病例组,按同地区、同年份、同医院分娩、1：1匹配的原则选取相应的对照。在统一培训调查员后,采取入户或通过一定的联系方式将研究对象召集到医院进行面对面访谈,填写事先设计好的调查表。用SAS8.0和SPSS13.0软件对数据进行统计分析,采用的分析方法有：t检验、x2检验、条件Logistic回归分析、秩和检验等。
结果：(1) NTDs影响因素的多因素条件Logistic回归分析：分析结果显示共有8个变量进入回归模型：服用叶酸、孕早期调整膳食、计划怀孕、孕期精神状态、孕早期坚果摄入频率、孕期被动吸烟、孕前产妇配偶接触有毒有害物质、孕期患病的OR值分别为0.131、0.254、0.265、0.444、0.549、8.413、3.804、7.087,且坚果摄入频率与NTDs存在剂量反应关系。孕妇在怀孕前3个月服用叶酸、孕期开始服用的月份、孕期服用的时间差异有统计学意义,x2值和P值分别为25.543、17.161、8.318和0.000、0.001、0.016,而孕期的前3个月服用叶酸、孕前开始服用叶酸的月份、孕前服用叶酸的时间在两组间差别无统计学意义。在孕早期调整过膳食的人群中分析了调整食物的种类,发现增加肉类、增加蛋类、增加蔬菜、增加海产品、减少泡菜经x2检验差异有统计学意义,x2值和P值分别为5.420、4.655、8.741、6.611、5.042和0.020、0.031、0.003、0.010、0.025。
(2)接受健康教育、遗传优生咨询情况：接受健康教育、遗传优生咨询虽未进入最终的多因素回归分析模型,但对接受健康教育方式经检验发现通过杂志或书籍(x2=8.419,P=0.004)、宣传单张或宣传手册(x2=6.956,P=0.008)在两组间差异有统计学意义,同时对两组人群中进行和未进行遗传优生咨询的原因进行分析,经x2检验发现两组间差异有统计学意义(x28.230、11.969和,P=0.041、0.018)。两组接受健康教育的地点、遗传优生咨询的时间、机构级别的差异均无统计学意义,且对遗传优生咨询作用的认识差异亦无统计学意义。
(3)预防NTDs的知识：产妇预防NTDs知识得分未进入多因素回归模型,但对照组产妇的预防NTDs知识得分高于病例组,且听说过叶酸、知道食物中含有叶酸、NTDs与接触环境有害因素有关、知道服用叶酸的作用、服用叶酸可以预防NTDs、遗传优生咨询可以预防NTDs、产前检查可以预防NTDs、知道产前筛查NTDs的时间、知道服用叶酸的时间、知道生过NTDs孩子的妇女还会生这样的孩子等经x2检验发现差异有统计学意义,x2值和P值分别为25.476、11.074、11.466、21.979、13.590、7.803、9.128、20.882、15.445、7.766和0.000、0.001、0.009、0.000、0.000、0.005、0.003、0.000、0.004、0.021。
(4)孕期检查和卫生费用：产前检查的时间、孕期产妇第二次、第三次超声检查经x2检验发现两组间差异有统计学意义(x2=16.712,23.458和P=0.000、0.000),孕期超声检查和门诊检查的次数经秩和检验亦有统计学意义(Z=-7.550,-7.059和P=0.000,0.000)。孕期总卫生费用占家庭收入的比例在两组间差别无统计学意义(Z=0.388,P=0.698)。门诊直接卫生费用、门诊间接卫生费用、住院直接卫生费用、住院间接卫生费、总卫生费用经x2检验只发现门诊直接卫生费用在两组间差异有统计学意义(x2=38.849,P=0.000)。
结论：(1)孕妇在孕前有计划怀孕、孕期有较好的精神状态、孕早期坚果摄入频率高、服用叶酸、孕早期调整膳食是NTDs的保护因素,尤其是在孕前和孕期坚持服用叶酸,服用叶酸的种类对其预防NTDs的作用可能影响较小；而其配偶在孕前接触有毒有害物质、孕期被动吸烟、孕期患病则是NTDs发生的危险因素。
(2)通过听医生当面讲解、听专题讲座或授课、广播、电视、电影、报纸、杂志或书籍、标语或板报、互联网等方式接受健康教育的比例还较低,可以加大通过这些方式进行相关保健知识的健康教育。在医院、妇幼保健院、计划生育部门、社区或居住的村庄、家中等地方均宜开展健康教育。
(3)对照组产妇的预防NTDs的知识水平较病例组高,病例组产妇的相关知识水平还有待进一步提高。
(4)产妇在孕期做产前检查并未给其造成更多的经济负担,产妇在孕期去做产前检查从经济学的角度考虑是可行的。
Objectives:Neural tube defects resulted in mortality and disability of infants, brought great suffering to society, families and individuals, became serious threat to human health and the quality of population. we wanted to understand the state of receiving health education, receiving genetic eugenics counseling, taking folic acid, screening the influential factors which may be related to the occurrence of NTDs and assess the economic burden which is caused by health expenditure of lying-in woman during pregnancy and the knowledge of lying-in woman preventing NTDs to provide a model of scientific and comprehensive intervention for NTDs.
Methods:This study adopted 1:1 matched case-control study and selected Pingyao, Jiexiu, Qixian, Heshun, Lingshi, Zhongyang as research site.The cases who were selected from Jan 2006 to Dec 2008 in monitoring report were all lying-in mother who had children of NTDs.The year of birth, region of Residence, the puerperal hospital of the control was the same with the case.Then the investigators who had received unified training went into each the study object's house or summoned them to the hospital for face-to-face interviews to complete pre-designed questionnaire. t test,x2 test, conditional Logistic regression analysis, rank sum test and so on. were used for statistical analysis of collected data with SAS8.0 and SPSS 13.0 software.
Results:(1) 34 variables which were statistically significant by single-factor conditional Logistic regression and some suspectable factors were inducted into multiple conditional Logistic regression analysis.And eight variables were entered into the final regression model: planning pregnancy, mental state during pregnancy, passive smoking during pregnancy, Husband of the lying-in woman exposed to toxic hazardous substances during progestation, sickness during pregnancy, adjusting diet during pregnancy, high frequency of intaking nuts during early pregnancy, taking folic acid. And their OR values were respectively 0.265,0.444,8.413,3.804,7.087,0.254,0.549,0.131. The lying-in woman intaking folic acid 3 months before pregnancy, started month of intaking folic acid during pregnancy, time of intaking folic acid during pregnancy were statistically significant between two groups.Their x2 values and P values were respectively 25.543,17.161,8.318 and 0.000,0.001,0.016.
(2) Reading the magazines or books and publicity leaflets or brochures which were the ways of receiving health education was statistically significant by x2 test between two groups.Reasons of receiving and unreceiving Genetic eugenics counseling between two groups were statistically significant by x2 test (x2=8.230、11.969和, P=0.041、0.018). The location of receiving health education, time, institution of eugenics counseling and effect of eugenics counseling were no statistically significant between two groups.
(4) Knowing folic acid before or during pregnancy, the food containing folic acid, relation between NTDs and environmental harmful factors, knowing effect of intaking folic acid during pregnancy, intaking folic acid to prevent NTDs, knowing eugenic genetic counseling to prevent NTDs, prenatal check prevent NTDs, knowing prenatal time of screening NTDs, knowing the time of taking folic acid, and knowing whether women who had children of NTDs had a child like this were statistically significant by x2 test. And their x2 values and P values were respectively 25.476,11.074,11.466,21.979,13.590,7.803,9.128, 20.882,15.445,7.766,and 0.000,0.001,0.009,0.000,0.000,0.005,0.003,0.000,0.004,0.021.
(5) The time of prenatal examinations, second time, third time of ultrasonic inspection between two groups was statistically significant by x2 test. The times of examinations in clinic service and times of ultrasonographic during pregnancy between two groups was statistically significant by rank sum test, Z values and P values were respectively-7.059 and 0.OOO.The percentage that health expendifure hold the proportion of household income was no significant difference between two groups, Z value and P value were respectively-0.388 and 0.698. The direct health expendifure in clinic service, the indirect health expendifure in clinic service, the direct health expendifure in hospital, the indirect health expendifure in hospital were detected by byx2 test, but only found that the direct health expendifure in clinic service had statistically difference (x2=38.849, P=0.000).
Conclusions:(1) Our study found that planning pregnancy, good mental state during pregnancy, high frequency of intaking nuts during early pregnancy, persistently intaking folic acid during progestation and early pregnancy, adjusting the diet during early pregnancy were protective factors of NTDs.while the passive smoking during pregnancy, husband of lying-in woman exposure to toxic hazardous substances during progestation, sickness during pregnancy were risk factors of NTDs.
(2) The proportion of receiving health education through going to hospital and listening to doctors, listening to lectures or radio, watching television or movies, reading newspapers, magazines or books, posters or blackboard newspaper, leaflets or brochures etc were fairly low. And the health education could be received in the hospital, department of birth control, community or villages and at home and so on to improve their knowledge of preventing NTDs.
(3) The lying-in woman knowledge of preventing NTDs in the control group was higher than that of the case group. The lying-in woman knowledge of preventing NTDs in the case group needed to be further improved.
(4) The times of check in the control group were much higher than the case group's. while the prenatal examinations during pregnancy didn't cause more economic burden to lying-in woman. It is feasible to do prenatal examinations during pregnancy.
引文
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