[[alternative]]The Impact of Informed Variation for Pregnant Women on the Utilization of Prenatal care、mode of delivery and Neonatal Health status

[[abstract]]背景：資訊不對等會有醫療服務選擇性的差異，身為知情消費者的醫師其專業優勢也會影響本身及親眷醫療行為，過去雖有研究但結論不一致。一般消費者則因認知或新移民女性語言、文化差異等之醫療弱勢而有利用之差異，惟以往的研究缺乏以整合性的觀點研究探討，因此，爲填補此一缺口，值得利用大型資料庫進一步探討資訊不對等對知情與不知情消費者之醫療行為。 目的：探討女醫師及醫師配偶身為知情消費者時，對產前檢查利用之充足性、選擇之生產方式及新生兒健康狀況與本國籍及新移民女性之差異。材料及方法：採病例對照研究，以全民健康保險2005年7月1日至2006年6月30日資料庫住院生產(自然生產與剖腹生產)個案為研究對象。並使用住院醫療費用醫令清單檔(PBD)、醫務管理醫師檔(MHA)、門診處方治療明細檔(PBC) (案件類別為預防保健A3者)等檔案分析。採用階層羅吉斯迴歸模式統計方法分析。結果：1、 知情消費者與一般消費者在產前檢查利用無顯著差異，但新移民女性(OR=1.142，95% CI: 1.073-1.215)與本國孕婦間達統計上顯著差異水準，女醫師及新移民女性之產檢利用不足。2、 知情消費者與一般消費者在生產方式上無顯著差異，但本國產婦與新移民女性(OR=0.778，95%CI：0.712-0.850)呈統計上顯著差異水準；女醫師剖腹產率最高(41.25%)，本國產婦次之(35.47%)、新移民女性最低(25.99%)。3、 知情消費者與一般消費者在新生兒健康狀況無顯著差異，但本國產婦與新移民女性之新生兒間 (OR=0.306，95% CI：0.247-0.379)達統計上顯著差異水準，新移民女性之新生兒較少住院；另本國產婦的新生兒亦較知情消費者中女醫師與醫師配偶之新生兒健康狀況為差(OR=0.225，95% CI：0.031-1.642；OR=0.966，95% CI：0.534-1.745)。結論：知情消費者中女醫師有尋求非正式的諮詢來取代產檢之自我醫療行為，而工作機會成本高、高齡、害怕疼痛及對剖腹產手術風險有較佳的認知，選擇剖腹產者多；另因具醫療專業背景新生兒健康照護較佳；男醫師配偶則因醫師先生支持系統之專業客觀意見剖腹產率低。因此在資訊不對稱的醫療環境中，醫療資訊應用能力較佳之知情消費者與一般消費者仍有醫療利用差異。新移民女性有產檢充足性不足、剖腹產率低及新生兒健康風險低之結果；應是新移民女性受健保法規限制有初次產檢時程及次數延遲及減少現象，但因年輕且身體健康故剖腹產率低，相較於本國產婦其新生兒健康狀況亦有較好的結果。基層診所及私立機構有以剖腹生產取代自然生產之風險規避行為及醫療給付誘因；此亦證實醫療市場仍由醫師主導，且在醫師與病患間存在資訊不對等及保險介入之差異。限制：本研究資料來源為次級資料有排除較多不符合者情形及跨健保分局轄區就醫而無法勾稽之憾。其次新移民女性國籍變更時身分證號即由原居留證號轉換為台灣身分証號，及國建局新生兒出生檔之新生兒或母親ID資料鍵錄錯誤率高，致產生勾稽無法對應之情形。另社經地位分類係依據健保局承保檔的投保薪資，可能有低估實際收入所得。關鍵字：資訊不對等、知情消費者、新移民女性、剖腹生產、自然生產、產前檢查充足性、新生兒健康、周產期病態。[[abstract]]Background: The information asymmetry may result in the difference in choosing medical services. Physician’s expertise influences their own as well as their spouses’ choices of medical care. Although some studies had explored this issue, their findings varied from one paper to another. On the other hand, because of language barriers and cultural differences, lay consumers and immigrant women have relatively less medical information. Whether they could have different medical choices or not is worth to study. Most of the previous studies focused on one single-issue, integrated perspectives and empirical evidence addressed on these two issues is lack. Objectives: To bridge the existing gap, this study examined the differences concerning the adequacy of prenatal care, the mode of delivery, and neonatal health status of their infants between medically informed consumers (female physicians and male physicians’ spouses) and lay consumers (domestic and immigrant women). Materials & Methods: A cross-sectional correctional study design was employed. Data were obtained from the Bureau of National Health Insurance Inpatient Case File, and the observation period is from July 1, 2005 to June 30, 2006. Hierarchical logistic regression analysis was applied. Results: 1. The adequacy of prenatal care was not found to be insignificantly different between informed consumer and lay consumer groups. But compared to domestic pregnant women, immigrants pregnant women tendered to under utilize prenatal care (OR=1.142, 95% CI：1.073-1.215).2. There was no significant difference in the mode of delivery between informed consumers and lay consumers. But compared to domestic pregnant women, immigrants pregnant women was less likely to undergo cesarean section (OR=0.778, 95% CI：0.712-0.850). While, female physicians themselves were in higher likelihood to use cesarean section as the mode of delivery (OR=1.700, 95% CI：0.871-3.316). 3. The health status for the neonates born by informed or lay mothers was not found to be statistically significant. Nevertheless, neonates born by immigrant mothers tended to be healthier and less likely being admitted to hospital (OR=0.306, CI：0.247-0.379)than those neonates born by domestic mothers. In addition, those neonates born by domestic lay mothers tended to be less healthy and in a higher likelihood of being admitted to hospital, compared to those bore by the medically informed mothers (OR=0.225, 95% CI：0.031-1.6420).Conclusions: Compare to lay domestic women, medically informed consumer group tended to use less prenatal care, it could because they seek informal consultations for substitute. A higher cesarean section rate of female physicians could due to their higher working opportunity costs, higher ages, afraid of pain, and better perception concerning the risk of cesarean operation. Additionally, because of their professional advantages, informed consumers’ usually have better neonatal care, consequently they are more likely to have healthier neonates. In contrast, the inadequacy of prenatal care for immigrant women might result from the under coverage of insurance. A significantly lower cesarean section rate might reflect the social-economical and cultural differences for immigrant women. Neonates born by immigrant mothers tended to be healthier and have a lower risk of inpatient care could because mothers were younger and in better health status. Limitations: Because the inherent constraints with secondary data, when female immigrants change their nationalities, and become residents/citizens of Taiwan, their original identification changed. This identification change could make them categorized as domestic lay women. Another limitation was that the classification of a subject‘s social economic status was based on the insured’ premium, which would lead to less precise measure of this variable.Key words: information asymmetry, informed consumers, immigrant women, cesarean section, normal spontaneous delivery, utilization of prenatal care, neonatal health status, perinatal period disease