臺灣博碩士論文加值系統

　　背景與目的：近年來，台灣地區因為少子化與醫療市場化的浪潮，導致婦產科醫師人力出現短缺與分佈不均的情況。目前更有部分的婦產科醫師僅提供婦科醫療服務，使得產檢與接生的醫師更為缺乏。在這樣產科照護不足之下，都將加劇地區孕產婦與胎兒醫療照護可近性的困難。過去研究指出，當孕產資源的可近性降低，可能導致孕產婦缺乏產前保健利用，並影響新生兒的不良出生結果，如：週產期死亡率與加護病房住院率。然而，在我國目前現行的執業醫療統計中，不但無法實質呈現產科醫師人力的困境，且綜觀國內研究也沒有深入探討產科醫師資源對於新生兒出生結果的健康影響。因此，本研究欲探討產科醫師人力資源分佈情形與年代趨勢，並進一步瞭解地區不同產科醫師資源與新生兒不良出生結果間的關係。
　　方法：使用1997-2008年全民健保資料庫特殊需求百萬抽樣檔，以及2001-2011單數年間國健署出生通報資料庫。將「產科醫師」定義為能提供婦女產前檢查與接生的醫師人力；出生人口包含出生通報內大於20週或500克以上活產與死產新生兒。以描述性統計與地理資訊系統繪圖，呈現我國產科醫師人力資源的數量趨勢與地理分佈情形。再進一步計算鄉鎮市區產科醫師資源數量，利用趨勢檢定與迴歸模型，檢視在鄉鎮市區不同產科醫師資源下，對本國籍婦女單胞胎新生兒的不良出生結果影響。
　　結果：第一，研究發現我國產科醫師人力正逐年降低，產科醫療負擔量也相同降低。第二，目前將近五成以上的鄉鎮市區缺乏產科醫師可提供醫療照護，影響出生人數約18.24~23.75%，且產科醫師多集中於高度都市化地區。第三，產科醫師資源愈低的鄉鎮市區，將影響到孕產婦女新生兒早產、低出生體重、胎兒小於妊娠週數(SGA)、死產及晚期死產的發生，產科資源距離影響顯著，且多影響到適齡與高齡婦女之新生兒。
　　結論：目前我國提供產科的醫師人力呈現地理分佈不均現況，且產科醫師資源將影響到地區間新生兒的不良出生結果增加。本研究藉由利用大型健保資料與出生通報資料在我國首次進行相關分析研究，建議衛生當局未來可針對產科醫師人力政策考量，並為地區新生兒不良出生結果的差異帶來一部分貢獻性。

　　In recent years, obstetricians / gynecologists (OB/GYN) in Taiwan has been unevenly distributed, and some of ob-gyn physicians do not provide maternity and obstetric services in particular areas. Previous researches indicated that the decreasing of accessibility of maternity care services may increase the risks of perinatal mortality and NICU hospitalization. However, the problems of human resources in obstetric care have not been indicated in current health statistics and researches in Taiwan. Therefore, the objective of this research is to investigate the number and distribution of obstetrician in Taiwan, and further explore the association between obstetrician resources and adverse birth outcomes. This research used National Health Insurance Research Databases from 1997 to 2008 and Birth Certificate Application databases of 2001, 2003, 2005, 2007, 2009 and 2011. “Obstetrician” is defined as the physician who provides prenatal cares and gives birth. All births contains both live births and stillbirths were born at more than 20 weeks or weigh over 500 grams. Descriptive statistics and geographic analysis were used to present the number and distribution of obstetrician. Trend test and multiple logistic regression model are conducted to investigate the association between obstetrician resources and adverse birth outcomes. First, this research found that Obstetricians in Taiwan present sufficiently but unevenly distributed. The number of obstetrician declines year by year, but the burden of obstetrics also declines. Besides, there is no obstetricians in over half of the towns, which affected 18.24~23.75% of the births. Second, the lack of obstetrician resources of a town increases the neonatal adverse birth outcomes, such as preterm, low birth weight, SGA, and fetal death. This is the first study in Taiwan to explore the resources of obstetricians by using large population-based database. This research expects the results can be contributed to obstetrician human resources policy and applied to decrease the differences of adverse birth outcomes.

第一章　前言 1
第一節　背景與動機 1
第二節　研究目的 2
第三節　研究問題 3
第四節　研究假設 3
第二章　文獻探討 4
第一節　產科醫師人力資源 4
一、產科醫師的角色 5
二、國外產科或婦產科資源評估 5
三、國內產科或婦產科資源評估 7
第二節　產科醫師資源對孕產婦及新生兒出生結果影響 9
一、產科醫師資源與孕婦產檢利用 9
二、孕婦產檢利用與新生兒出生結果 11
三、產科醫師資源與新生兒出生結果 13
第三節　新生兒出生結果之其他影響因素 17
第四節　小結 19
第三章　研究方法與材料 20
第一節　資料來源 20
第二節　變項定義 21
第三節　分析策略 25
第四節　統計軟體 30
第四章　研究結果 31
第一節　產科醫師人力趨勢分析 31
第二節　產科醫師地理分佈情形 38
第三節　不良出生結果趨勢分析 46
第四節　產科醫師資源與出生結果相關分析 49
第五章　討論 80
第六章　參考文獻 86

表目錄
表4-1　1997-2008年產科醫師數之變化與佔執照登記數比例 33
表4-2　1997-2008年非婦產專科醫師數之科別分佈 34
表4-3　1997-2008年產科醫師平均產科負擔量 35
表4-4　1997~2008年所有產科醫師之鄉鎮市區數、醫師數量分布 40
表4-5　1997~2008年所有產科醫師之鄉鎮市區數與出生人數分佈 41
表4-6　1997~2008年所有產科醫師之鄉鎮市區數與出生人數分佈-都市化別 42
表4-7　2001-2011年間單數年之新生兒不良出生結果趨勢 47
表4-8　2001、2003、2005年不同產科醫師資源地區之新生兒及母親人口學特性 54
表4-9　2007、2009、2011年不同產科醫師資源地區之新生兒及母親人口學特性 56
表4-10　2001、2003、2005年不同產科醫師資源地區之新生兒不良出生結果 58
表4-11　2007、2009、2011年不同產科醫師資源地區之新生兒不良出生結果 60
表4-12　不同產科醫師資源地區不良出生結果之迴歸分析-早產（醫師密度） 62
表4-13　不同產科醫師資源地區不良出生結果之迴歸分析-早產（醫師距離） 63
表4-14　不同產科醫師資源地區不良出生結果之迴歸分析-低出生體重（醫師密度） 64
表4-15　不同產科醫師資源地區不良出生結果之迴歸分析-低出生體重（醫師距離） 65
表4-16　不同產科醫師資源地區不良出生結果之迴歸分析-SGA（醫師密度） 66
表4-17　不同產科醫師資源地區不良出生結果之迴歸分析-SGA（醫師距離） 67
表4-18　不同產科醫師資源地區不良出生結果之迴歸分析-先天性缺陷（醫師密度） 68
表4-19　不同產科醫師資源地區不良出生結果之迴歸分析-先天性缺陷（醫師距離） 69
表4-20　不同產科醫師資源地區不良出生結果之迴歸分析-死產（醫師密度） 70
表4-21　不同產科醫師資源地區不良出生結果之迴歸分析-死產（醫師距離） 71
表4-22　不同產科醫師資源地區不良出生結果之迴歸分析-早期死產（醫師密度） 72
表4-23　不同產科醫師資源地區不良出生結果之迴歸分析-早期死產（醫師距離） 73
表4-24　不同產科醫師資源地區不良出生結果之迴歸分析-晚期死產（醫師密度） 74
表4-25　不同產科醫師資源地區不良出生結果之迴歸分析-晚期死產（醫師距離） 75

圖目錄
圖3-1　全民健保資料庫選樣流程 26
圖3-2　出生通報資料庫選樣流程 28
圖3-3　健保資料庫與出生通報檔研究階段連結 29
圖3-4　研究架構圖 30
圖4-1　1997-2008年執行產科照護醫師數之變化與佔執業登記數比例 36
圖4-2　1997-2008年婦產科醫師與其他科醫師平均產科負擔量 37
圖4-3　1997-2008年產科醫師數之鄉鎮數 44
圖4-4　臺灣地區執行產科照護醫師數分佈(以2006-2008年為例) 45
圖4-5　2001-2011年間單數年之新生兒不良出生結果率趨勢 48
圖4-6　2001、2003、2005年不同產科醫師資源地區之新生兒不良出生結果 76
圖4-7　2007、2009、2011年不同產科醫師資源地區之新生兒不良出生結果 78

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