剖腹產後自然生產之成效及其影響因素之探討; The Effect and Associated Factors of Vaginal Birth After Cesarean Section

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Title:	剖腹產後自然生產之成效及其影響因素之探討;The Effect and Associated Factors of Vaginal Birth After Cesarean Section
Authors:	林春米;Chun-Mi Lin
Contributors:	中國醫藥大學醫務管理研究所
Keywords:	剖腹產;自然產;陰道生產;剖腹產後陰道生產;剖腹產後自然生產;cesarean section;normal spontaneous delivery;vaginal birth after cesarean section;normal spontaneous delivery after cesarean section
Date:	2004
Issue Date:	2010-01-20 16:50:49 (UTC+8)
Abstract:	摘要目的：台灣地區的剖腹產率在1995至2003年一直維持在32%~34%，呈現居高不下的趨勢。本研究希望瞭解剖腹產後自然生產之成效、影響剖腹產後自然生產之相關因素，並探討醫師對健保給付獎勵制度的看法及其是否鼓勵產婦剖腹產後採自然生產，從中分析醫師對產婦選擇生產方式的影響。方法：本研究採用結構式問卷，於2004年10月至2005年3月，以中部地區15家醫院之住院產婦與婦產科醫師為收案對象。在產婦方面，凡前一胎是剖腹生產者，此次不論其為自然生產或再次剖腹產均為研究的對象，共收集有效問卷318份（27份自然生產、291份再次剖腹產）；在醫師方面，以前述15家醫院的婦產科醫師為研究的對象，共收集有效問卷52份。利用羅吉斯迴歸分析（Logistic regression analysis），探討影響產婦剖腹產後是否採自然生產之相關因素。結果：前一次剖腹產的原因多為「胎位不正」（35.53%）；而前次剖腹生產者，本次再次剖腹生產的比率高達91.5%，其原因為「前一胎為剖腹產，經醫師建議」之比率最高(41.58%)，次要的原因為「前一胎為剖腹產，而自己要求」(28.87%)。有過自然生產經驗者，採剖腹產後自然生產機率較高。在無產科禁忌症的情況下，醫師認為剖腹產後自然生產是安全的佔73.08%，會鼓勵產婦剖腹產後自然生產者有50%。在產檢期間經醫護人員鼓勵自然生產者比未經鼓勵者，採剖腹產後自然生產的機率較高(勝算比22.86)。有致力推動剖腹產後自然生產政策的機構，其接生之產婦採剖腹產後自然生產的機率較高(勝算比15.02)。私立醫院及財團法人醫院相對於公立醫院而言，產婦會剖腹產後自然生產的機率低很多，勝算比分別是0.004及0.001。依據參與TQIP之醫院，健保局2003年4月增訂「前胎剖腹產之陰道生產」醫療費用支付項目，似乎達到提高「剖腹產後自然產比率」之目的。結論：「剖腹產後自然產比率」有上升之趨勢，但是其真正的成效仍有待持續追蹤。在影響產婦剖腹產後自然生產的因素方面，以「醫護人員是否鼓勵剖腹產後自然生產」及「醫療機構是否致力推動剖腹產後自然生產之政策」為兩大重要影響因素。因此，要降低剖腹產率，宜加強民眾衛教宣導、加強醫護人員對剖腹產後自然生產的認知與態度、鼓勵醫院推動剖腹產後自然生產的政策、建立良好的醫療保險及醫療糾紛處理模式，方能達到降低總剖腹產率之目的。關鍵詞：剖腹產、自然產、陰道生產、剖腹產後陰道生產、剖腹產後自然生產; Abstract Objectives: The cesarean section rate in Taiwan during 1995-2003 kept in a high level between 32% and 34%. This research investigated the effectiveness of VBAC, the factors associated with VBAC, the gynecologists’ views on health insurance rewarding system and VBAC, and analyzed the impact of gynecologists on maternity’s choices. Method: The structured questionnaires were administrated to maternities and gynecologists in 15 hospitals in central Taiwan during October 2004 to March 2005. Maternities who previously experienced cesarean were included in this study. This study collected 318 effective questionnaires, including 27 of vaginal birth and 291 of repeat cesarean section. This study also collected 52 effective questionnaires from gynecologists. Logistic regression analysis was conducted to find out the factors related to VBAC. Results: Malposition was the most common reason for the cesarean section (35.53%). About 91.5% of the maternities chose cesarean section if they previously experienced cesarean section; the reasons were gynecologist’s advice (41.58%) and self request (28.87%). Maternities who previously experienced vaginal birth tended to choose VBAC. About 73.08% of the gynecologists agreed that VBAC is safe, and 50% of them recommended it if no contraindication occurs. Maternities were more likely to choose VBAC if they were recommended to do so during the examination (odds ratio 22.86). Hospitals with units promoting VBAC were more likely to choose VBAC (odds ratio 15.02). Private and foundational hospitals were less likely to choose VBAC than public hospitals (odds ratio 0.004, 0.001). In April 2003, the Bureau of National Health Insurance (BNHI) revised and augmented the health care reimbursement on VBAC and this seems to reach the goal of increasing the rate of VBAC. Conclusions: The rate of VBAC is increasing, but the further investigation of its effectiveness is needed. With respect to the factors associated with VBAC, the promotion of VBAC by gynecologists and medical organizations were two major factors associated with maternities’ choices. Therefore, in order to reduce the cesarean section rate, it is suggested to strengthen the propaganda of VBAC, to reinforce gynecologists’ knowledge and attitudes, to encourage the hospitals to promote VBAC, and to establish an adequate model for medical insurance and medical dissension. Keywords: cesarean section, normal spontaneous delivery, vaginal birth after cesarean section, normal spontaneous delivery after cesarean section
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