产后妇女高血压社区管理的需要与实施模式的可行性分析

Needs and feasibility analysis of community management for postpartum women with hypertension

目的了解产后妇女高血压的患病情况和相关因素,探讨产后保健与社区高血压管理链接的可行模式。方法选取2021年6月—2022年12月上海市徐汇区分娩的3297例产妇为研究对象,选取其中产后1个月内上门访视时采用非同日3次血压测量值均收缩压≥140和(或)舒张压≥90 mmHg(1 mmHg=0.133 kPa)的产妇,或产后服用降压药且血压控制在140/90 mmHg以下的产妇,共计86例为病例组;以年龄是否超过35岁作为匹配条件,按1∶1匹配血压测量正常或未服用降压药的下一位访视产妇作为对照组。收集一般人口学特征、疾病史、孕产史、心理健康及社会支持等因素探讨产后高血压的相关因素;选取区级和社区基层妇幼保健管理者,慢性病管理者、产后访视人员、家庭医生及其他慢性病相关服务人员,以及高血压产妇共计20名,开展个人访谈,从卫生系统角度分析产后保健与社区慢病管理链接的内部优势和劣势、外部机遇和挑战。结果产后高血压的患病率为2.60%[(86/3297),95%CI=0.020~0.031],多因素条件logistic回归分析结果显示,有焦虑情绪(OR=3.619,95%CI=1.283~10.210,P=0.015)、有高血压家族史(OR=5.180,95%CI=2.514~10.673,P<0.001)和孕前BMI越高(OR=3.634,95%CI=1.280~10.621,P=0.018)的产妇发生高血压的风险增加。受访者均认为对产后高血压有必要进行长期管理,社区基层完善的妇幼保健和高血压管理工作及家医团队的参与为社区产后保健服务与社区高血压管理链接的新模式奠定了基础,其中2类服务的链接点是社区预防保健科,兼具产后保健和高血压管理职能;但产后保健服务对象的社区卫生服务签约率低、依从性不高是整合服务模式的阻力。当前,上海市慢性病健康管理支持中心的建设和重点人群签约政策的落实有利于新服务模式的实施;但社区妇幼保健与高血压管理在业务上隶属于2个不同的上级部门,且信息系统不互通及基层医务人员激励机制不健全给新模式的链接和实施带来了挑战。结论产后妇女高血压问题值得关注,在现有卫生资源条件下,社区卫生服务中心具备开展产后妇女高血压管理新模式的可行性,但具体的实施机制还需进一步改革与完善。

Objective To understand the prevalence and correlation factors of hypertension in postpartum women and explore feasible models for linking postpartum care with community hypertension management.Methods A total of 3,297 postpartum women who gave birth in Xuhui District,Shanghai from June 2021 to December 2022 were selected as the study participants.Among them,86 cases were included in the case group,which consisted of women who had a systolic blood pressure≥140 mmHg and/or diastolic blood pressure≥90 mmHg(measured on three different days during home visits within one month postpartum)or women who were taking antihypertensive medication and had blood pressure controlled below 140/90 mmHg.The control group was matched 1:1 based on whether the age exceeded 35 years,and consisted of the next visiting postpartum women with normal blood pressure measurements or those who did not take antihypertensive medication.General demographic characteristics,medical history,obstetric history,psychological health,and social support were collected to explore the correlation factors of postpartum hypertension.Twenty personnel,including district-level and community-level maternal and child health directors,chronic disease directors,postpartum visit personnel,family doctors,and other personnel related to chronic disease services,as well as hypertensive postpartum women,were selected for individual interviews.The internal strengths and weaknesses,external opportunities and challenges of linking postpartum care with community chronic disease management were analyzed from the perspective of the healthcare system.Results The prevalence of postpartum hypertension was 2.60%(86/3297,95%CI=0.020~0.031).The results of multivariate logistic regression analysis showed that women with anxiety(OR=3.619,95%CI=1.283~10.210,P=0.015),a family history of hypertension(OR=5.180,95%CI=2.514~10.673,P<0.001),and higher pre-pregnancy BMI(OR=3.634,95%CI=1.280~10.621,P=0.018)had an increased risk of developing hypertension.The interviewees all believed that long-term management of postpartum hypertension is necessary.The well-established maternal and child health and hypertension management work at the community level,as well as the participation of family doctor teams,laid the foundation for the linkage between community postpartum care services and community hyper-tension management.The two types of services are linked through the community preventive healthcare department,which combines postpartum care and hypertension management functions.However,the low rate of community health service contracts and poor compliance of postpartum care service recipients pose challenges to the integrated service model.Currently,the construction of the Chronic Disease Management Center in Shanghai and the implementation of the key population contract policy are conducive to the implementation of the new service model.However,community maternal and child health care and hypertension management belong to two different higher-level departments in terms of business,and the lack of interoperability of information systems and inadequate incentive mechanisms for grassroots medical personnel pose challenges to the linkage and implementation of the new model.Conclusion The issue of hypertension in postpartum women deserves attention.Under the existing healthcare resource conditions,community health service centers have the feasibility to implement new models for postpartum hypertension management.However,further reforms and improvements are needed for the specific implementation mechanisms.