Guidelines for preconception care: from the maternal and child health perspectives of Korea

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1 DOI: /jkma pissn: eissn: Focused Issue of This Month 베이비플랜 임신전관리가이드라인개발 : 저출산시대의모자보건정책관점에서 서경 1* 김민아 2 1 연세대학교의과대학산부인과학교실, 2 강남세브란스병원건강증진센터 Guidelines for preconception care: from the maternal and child health perspectives of Korea Kyung Seo, MD 1* Min-A Kim, MD 2 1 Department of Obstetrics & Gynecology, Yonsei University College of Medicine, 2 Health Promotion Center, Gangnam Severance Hospital, Seoul, Korea *Corresponding author: Kyung Seo, kyungseo@yuhs.ac Received April 19, 2011 Accepted May 5, 2011 Korea has recorded a very low total fertility rate of 1.15 in Young Koreans tend to postpone their marriage, and as a result of late marriage, the average age of first pregnancy has been continuously increasing. Older married couples often produced multifetal pregnancies due to assisted reproduction. Elderly pregnancies and multifetal pregnancies contribute to high maternal/perinatal mortalities and morbidities. Basic maternal and child health services including prenatal, delivery, and postpartum care are covered under national health insurance in Korea. However, preconception care is not covered under national health insurance nor any other preventive service program. Many developed countries including United States and academic societies have emphasized the importance of preconception care and have proposed guidelines on preconception care. No suggested guidelines for preconception care have been developed in Korea. Evidence-based guidelines on preconception care should be developed with the cooperation of associated academic societies. In addition, the Korean government should develop a comprehensive plan for preventive services for women including preconception care. Keywords: Preconception care; Guidelines; Preventive health services; Low fertility population; Maternal-child health services 서 론 한국은 1960년합계출산력 6.0에서 2005년합계출산력 1.08까지급속하게감소하여세계적으로유래없는빠 른속도로저출산고령화시대로진입하였다. 최근한국의합 계출산력은 2005 년 1.08 로떨어진후 2009 년 1.15 로약간 회복세를보이고있으나아직도주요선진국과비교하여낮은수준이다. 따라서연간출생아는 1970년대연간약 100만명의출생아가 2009년도의경우 44만여명으로감소하였다. 이와같은저출산의영향으로한국의총인구도 2020년경약 5,000만명을정점으로하여감소하기시작하여 2050년 4,400만정도로추계된다. 또한저출산과평균수명의연장 c Korean Medical Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 대한의사협회지 845

2 Seo K Kim MA 으로인구의노령화가급격하게진행되어전체인구중 65 세 이상이차지하는노인인구의비율이 2010 년에 10.7% 에서 2050 년에 37.1% 까지급격하게증가하여한국은사상유래 없는초고령화사회가도래할것으로예측된다. 한국여성들의초혼연령은 1985 년 24.1 세에서 2005 년 27.7 세로증가하고있으며이에따라고령임신부의출산이 꾸준히증가하고있다. 고령임신부의증가는임신중고혈 압성질환, 당뇨, 조산, 사산, 태반조기박리, 전치태반등의 임신합병증이증가할가능성이있다. 실제로한국인모성사 망률은임신부의연령이증가할수록증가하는양상을보이 고있다 [1]. 고령임신부의증가는불임치료로인한다태아증가및 임신합병증의증가를초래하며이로인한저체중신생아출 생의상대적인증가를초래하고있다. 또한고령임신은염 색체이상을포함한선천성기형의상대적발생이증가하기 때문에이들기형으로인한사산, 신생아의질병, 사망및잔 존장애가증가할것으로예측된다 년우리나라영아 사망의사인분포를보면전체사망의 58% 가미숙아와관련 된주산기질환이고 21.7% 가선천성기형과관련된사인으 로보고되고있어우리나라도이미영아사망양상이선진국 형저출산시대의사망양상으로접어들고있음을보여주고 있다 [2]. 저출산시대의만혼및유배우부인의출산연기는고령임 신을증가시키고이로인한미숙아및선천성기형아출생을 상대적으로증가시켜서출생인구의양이감소할뿐만아니 라그질도낮아지는이중의부담을초래하게된다. 이러한 이유때문에저출산시대의모자보건관리특히산전관리및 임신전관리가더욱중요하게대두된다. 저출산시대의한국모자보건정책현황및문제점 한국은 1960 년대이후범국가적인가족계획사업을실시 하여 1960 년대합계출산력 6 에서 1970 년대합계출산력 4 이하로낮추는데성공하였으며이시기의모자보건사업 은가족계획사업의부수사업정도로인식되는정도였다. 그 이후 1970년대후반급격한경제성장과동시에전국민건강보험이도입됨에따라산전관리및분만관리의대부분을건강보험체제내에서민간병의원이담당하게되어한국의모자보건실태가급속도로향상되었으며합계출산력도지속적으로감소하였다. 이와같은가족계획사업은 80년대초합계출산력 2에도달하였을때일부학자들의우려에도불구하고지속하다가 1997년금융위기이후합계출산력이 1.4에도달하자저출산의문제가본격적으로제기되고이후한국은그방향을 180도전환하여가족계획과관련된정부프로그램을중지시키고그반대로불임부부지원을비롯한적극적인출산장려정책으로돌아서게되었다. 따라서정부는 2000년대에이르러피임과관련된정부지원사업을단계적으로축소하거나폐지하여현재는정부지원의가족계획사업은전무한실정이다. 또한최근에는그동안암묵적으로용인되어왔던인공임신중절을금지하거나그단속을강화하는방안들이논의되고있다. 한편임신및출산과관련된임산부의대책으로는기본적인임신부의산전관리, 분만관리및산후관리는건강보험에포함되어있으며그이외정부의저출산대책과관련된임산부지원사업으로는 1) 난임부부지원, 2) 임신출산진료비지원확대, 3) 임산부철분제지원, 4) 의료기관외출산시출산비지급, 5) 임산부영유아영양플러스, 6) 산모도우미서비스, 7) 출산양육정보및상담서비스, 8) 모유수유지원등이있다. 이와같은정부모자보건지원사업정책은인구의생식보건향상이라는궁극적인모자보건목표를지양하기보다는출산력증가라는인구학적목표에초점을맞추고있기때문에임신전관리내용이포함되지못하고있으며가족계획사업의중지및인공임신중절의단속강화정책으로인하여원하지않는임신및안전하지못한임신중절수술이증가할위험이있으며, 또한난임부부지원으로인하여고령고위험임신및다태임신이증가할가능성이있다. 임신전관리가이드라인 모자보건관리에있어서산전관리의중요성은항상강조 846 임신전관리가이드라인개발 : 저출산시대의모자보건정책관점에서

3 Guidelines for preconception care: from the maternal and child health perspectives of Korea 특 집 Table 1. Recommendations and the quality of the evidence for preconception clinical intervention Potential component of preconception care Strength a) Quality b) Health promotion Family planning and reproduction life plan A Ⅲ Physical activity C Ⅱ-2 Weight status A Ⅲ Nutrient intake A Ⅲ Folate A Ⅰ-a Immunizations A Ⅲ Substance use A Ⅱ-2 (tobacco) Ⅲ (alcohol) Sexually transmitted infections A Ⅲ Immunization Human papillomavirus B Ⅱ-2 Hepatitis A Ⅲ Varicella B Ⅲ Measles, mumps, and rubella A Ⅱ-3 Influenza C Ⅲ Diphtheria-tetanus pertussis vaccination B Ⅲ Infectious diseas Human immunodeficiency virus A Ⅰ-b Hepatitis C C Ⅲ Tuberculosis B Ⅱ-2 Toxoplasmosis C Ⅲ Cytomegalovirus C Ⅱ-2 Listerosis C Ⅲ Parvovirus E Ⅲ Malaria C Ⅲ Gonorrhea B Ⅱ-2 Chlamydia A Ⅰ-a Syphilis A Ⅱ-1 Herpes simplex virus B Ⅱ-1 Asymptomatic bacteruria E Ⅱ-1 Periodontal disease C Ⅰ-b Bacterial vaginosis D Ⅰ-b Group B Streptococcus E Ⅰ-2 Medical conditions Diabetes mellitus A Ⅰ B (overweight Ⅱ-2 and obese adults) Thyroid disease A Ⅱ-1 Phenylketonuria A Ⅱ-1 Seizure disorders A Ⅱ-2 Hypertension A Ⅱ-2 Rheumatoid arthritis A Ⅲ Lupus B Ⅱ-2 되어왔다. 그러나건강한어린이를출생하기위해서는원하는임신이어야하며, 여성이정신적육체적으로건강한상태에서임신하여야한다. 미리계획하지못한임신의경우는출산및육아환경이적절히준비되지못한상태에서임신을지속하거나최악의경우에는인공임신중절로종결될위험이있다. 또한계획하지못했던임신의경우흔히뒤늦게임신을확인한이후에야산전관리를시작하게되므로태아에가장중요하게영향을미치는임신초기배아시기및초기태아시기에유해환경에노출될위험이있다. 따라서보다완전한산전관리를위해서는부부가임신이전에미리임신전관리를통하여상담한이후음주, 흡연, 약물복용등을포함한유해요인제거, 예방접종, 여성및가족들의건강상태평가및질병치료, 기타교육및상담을통하여임신에적합한육체적, 정신적건강수준을확보해야한다. 미국의경우산부인과학회와소아과학회가공동발간한주산기관리지침에서임신전관리의내용으로 maternal assessment, vaccination, screening, counselling을포함하고있으며 [3], 2008년미국질병관리본부가전문가그룹을조직하여광범위한문헌고찰을통하여임신전관리의각내용별과학적근거들을검토하여권고수준을마련한바있다 (Table 1) [4]. 임신전관리의내용으로는임신전여성의일차예방관리 (primary preventive care) 의내용을포함하고있으며따라서임신전관리는여성의포괄 대한의사협회지 847

4 Seo K Kim MA Table 1. (Continued) Renal disease B Ⅱ-2 Cardiovascular disease B Ⅲ-3 Thrombophilia C (women not Ⅲ using warfarin); B (women using Ⅱ-3 warfarin) Asthm B Ⅱ-3 Psychiatric condition Depression/anxiety B Ⅲ Bipolar disease B Ⅲ Schizophrenia B Ⅲ Parental exposure Alcohol B Ⅰ-a Tobacco A Ⅰ-a Illicit substance C Ⅲ Family and genetic history All individuals B Ⅲ Ethnicity-based B Ⅱ-3 Family history B Ⅱ-3 Previous pregnancies C Ⅲ Known genetic conditions B Ⅱ-3 Nutrition Dietary supplements C Ⅲ Vitamin A B Ⅲ Folic acid A Ⅰ-a Multivitamins A Ⅱ-2 Vitamin D B Ⅱ-3 Calcium A Ⅰ-b Iron A Ⅰ-b Essential fatty acids B Ⅰ-b Iodine A Ⅱ-2 Overweight A Ⅰ-b Underweight A Ⅲ Eating disorders A Ⅲ Environmental exposure Mercury B Ⅲ Lead C Ⅱ-2 Soil and water hazards B Ⅲ B (BPA Ⅱ avoidance) Workplace exposure B Ⅲ Household exposure A Ⅲ Psychosocial risk Inadequate financial resource C Ⅲ Access to care C Ⅲ Physical/sexual abuse C Ⅲ Medication Prescription A Ⅱ-2 Over-the-counter medication A Ⅲ 적인일차예방관리와분리하여생각할수없다. 미국산부인과학회는여성의생애주기에따른일차적예방관리가이드라인을연령대에따라 13-18세, 19-39세, 40-64세, 65+ 세으로나누어 screening, evaluation & counseling, immunization 가이드라인을발표한바있다 [5]. 한국의경우생애주기에따른일차적예방관리에관한가이드라인은없으며국내산부인과및관련학회에서임신전관리에관한종합적인가이드라인을발표한바없다. 현재정부가추진하는예방적관리로는국민건강보험공단에서실시하는일반검진, 생애전환기검진, 구강검진, 영유아검진, 암검진정도이다. 이들검진은주로질병선별검사에초점이맞추어져있으며상담및교육부분은형식적이거나미흡한수준이다. 국가필수예방접종사업도주로영유아를대상으로하는예방접종사업으로, 성인예방접종은질병관리본부의 역학과관리 라는책자를통하여기준을제시하고있는정도이다 [6]. 한국의예방적관리의많은부분은민간의료기관이건강검진의형태로실시하고있다. 이와같은건강검진서비스는주로암을비롯한성인병선별검사에초점이맞추어져있으며최근검진항목으로근거가부족한검사항목들이많이포함되었거나노화방지등근거가부족한내용들이강조된고급호텔타입의서비스가강조된형태로제공되고있어개선이필요한부분이다. 848 임신전관리가이드라인개발 : 저출산시대의모자보건정책관점에서

5 Guidelines for preconception care: from the maternal and child health perspectives of Korea 특 집 Table 1. (Continued) Dietary supplements A Ⅱ-c Reproductive history Prior preterm birth infant A Ⅰ-a Prior cesarean delivery A Ⅱ-2 Prior miscarriage A Ⅰ-a Prior stillbirth B Ⅱ-2 Uterine anomalies B Ⅱ-3 Special populations Women with disabilities B Ⅲ Immigrant and refugee populations B Ⅲ Cancer A Ⅲ Men B Ⅲ From Jack BW, et al. Am J Obstet Gynecol 2008;199(6 Suppl 2):S266-S279, with permission from Elsevier [4]. BPA, bisphkenol A. a) Level A, Recommendations are based on good and consistent scientific evidence; Level B, Recommendations are based on limited or inconsistent scientific evidence; Level C, Recommendations are based primarily on consensus and expert opinion. b) I, Evidence obtained from at least one properly designed randomized controlled trial (RCT); I-a, Systematic review (with homogeneity) of RCTs and of prospective cohort studies; I-b, Individual RCT with narrow confidence interval, prospective cohort study with; II-1, Evidence obtained from well-designed controlled trials without randomization; II-2, Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group; II-3, Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence; III, Opinions of respected authorities, based on clinical experience, descriptive stud ies, or reports of expert committees. 임신전관리의경우산전, 분만및산후관리, 영유아관 리와달리국가차원의예방적관리사업은없으며국민건강 보험공단에서실시하는일반검진이나생애전환기검진이외 에는전액그비용을본인이부담하여야한다. 관리에관한프로그램및가이드라인의 제정이필요하다. 구체적정책대안으로는첫째, 임신 에관한여성들의권리를보호해야한 다. 임신하기를원하는여성의불임치료 지원과동등하게임신을원하지않는여 성의피임을지원해야한다. 둘째, 여성 의임신전관리에대한최소한의제도 적보장장치가필요하다. 임신전관리 를국민건강보험의검진에포함하거나 또는국가모자보건정책에반영하여임 신을계획하고원하는여성의임신전 관리를국가가제공해주어야한다. 셋 째, 임신전관리는여성의생애주기에 따른예방적건강관리의일부분이므로 여성의생애주기에따른예방적건강관 리를강화해야한다. 넷째, 임신전관리 는여성뿐만아니라남편및전가족구 성원의건강관리와밀접하게연관되므 로궁극적으로남녀를통틀어일반국민 을대상으로한생애주기별예방적건강 관리를강화해야한다. 다섯째, 임신전관리의내용은여성의 건강평가및검진, 상담및교육, 예방접종등의포괄적예방서 비스가되어야하며그내용및가이드라인은관련전문가들 에의하여과학적근거에입각하여제정되어야한다. 결 론 핵심용어 : 임신전관리 ; 가이드라인 ; 예방적건강관리 ; 저출산 ; 모자보건 대한민국은저출산시대를맞이하여비록출생아수의감소를피할수없다하더라도인구의질적수준을제고하여이에대처하는정책을수립할수밖에없다. 그간한국의모자보건수준은국민건강보험이도입됨에따라민간병의원을중심으로산전관리, 분만관리, 산후관리가강화되어많은향상이있었다. 그러나최근의만혼및청소년임신등의생식보건문제는임신이후의건강관리만으로는불충분하다. 따라서범국가적차원에서저출산환경에대비한계획임신및임신전 REFERENCES 21. Choi JS, Seo K, Yee NH, Lee SW, Lee SW, Shin CW, Boo YK. Infant and maternal mortality survey in Seoul: Ministry for Health, Welfare and Family Affairs, Korea Institute for Health and Social Affairs; Han YJ, Seo K, Lee SW, Hong YJ, Shin SM, Shin CW, Yee NH. Infant mortality and causes of death. Seoul: Ministry for Health, Welfare and Family Affairs, Korea Institute for Health and Social Affairs; Amercian Academy of Pediatrics; the American College of 대한의사협회지 849

6 Seo K Kim MA Ob-stetricians and Gynecologists. Guideline for perinatal care. 6th ed. Elk Grove Village (IL): American Academy of Pediatrics; Jack BW, Atrash H, Coonrod DV, Moos MK, O Donnell J, Johnson K. The clinical content of preconception care: an overview and preparation of this supplement. Am J Obstet Gynecol 2008;199(6 Suppl 2):S266-S American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Committee opinion no. 483: primary and preventive care: periodic assessments. Obstet Gynecol 2011;117: Korea Centers for Disease Control and Prevention; Korean Medical Association; Advisory Committee on Immunization Practice. Epidemiology and prevention of vaccine-preventable disease. Seoul: Korea Centers for Disease Control and Prevention; 2006 Peer Reviewers Commentary 본논문은우리나라와같은저출산환경에서임신전관리의중요성을환기하면서, 저출산고령화사회를극복하고자하는정부의모자보건정책의현황과문제점을짚고있다. 특히임신전가이드라인의개발과관련된외국의여러자료들을제시함으로써향후우리나라에서임신전가이드라인을개발할경우, 그기초자료로서의가치가인정된다. 다만우리나라환경에맞는임신전가이드라인을개발하기위해서는본논문에서언급된자료외에보다광범위한자료조사및연구가필요하다고생각된다. [ 정리 : 편집위원회 ] 850 임신전관리가이드라인개발 : 저출산시대의모자보건정책관점에서