少子女化對產科醫師執業空間變遷及產婦就醫可近性之影響

Impacts of low birth rates on the geographical distribution of obstetricians and accessibility of obstetrics resources for parturient women

目標：少子女化帶來人口結構變遷，使國家發展面臨種種挑戰，健康照護產業無法自免於外，特別是與生育直接相關的產科醫師。本研究使用具代表性實證資料，分析少子女化情境下，產科市場與產科醫師執業空間的變遷，並檢視此番變遷對產婦生產就醫之影響。方法：以全民健康保險研究資料庫全國住院醫療費用清單明細檔及2005年承保抽樣歸人檔，首先分析2005-2009年間，生產件數與產科醫師服務量趨勢，再以空間分析技術，檢視研究期間產科醫師執業空間變遷與產婦就醫可近性的變化。最後透過引力模式，剖析就醫可近性與可用性於產婦就醫選擇的權衡。結果：研究期間全國生產件數減少6.7%、產科醫師減少了5.4%，全國產科醫師平均接生件數僅減少1.6%，前述指標在低都市化地區減幅大於高都市化地區。除退出市場，部分醫師選擇轉換執業地，尤其更傾向轉往區域負荷量離差高的地區執業。而醫師執業空間之變遷，使低都市化地區產婦需移動更遠距離生產就醫，也使其選擇生產地時，可近性的考量會優先於產科服務可用性。結論：少子女化將使低都市化地區產科市場先受衝擊，產科醫師則退出市場或轉換執業地以因應市場改變，進而可能造成產婦就醫可近性惡化並使其就醫選擇受限，特別是低都市化地區、就醫可近性原先即相對較差的群體。（台灣衛誌2018；37（5）：554-564）。 Low birth rates can have substantial social impacts and comprise a challenge for the health care sector, especially obstetrics. To understand their influence on obstetrics services, this study aimed to quantify the impacts of low birth rates on the geographical distribution of obstetricians and the accessibility of obstetrics services for parturient women by using representative empirical data. Methods: Using Nationwide Health Insurance Database, we observed trends in childbirth and the mean number of deliveries per obstetrician from 2005 to 2009. Theoretical frameworks and spatial analysis were employed to analyze the changes in the geographical distribution of obstetricians and the accessibility of obstetrics services for parturient women. Finally, we used a gravity model to analyze the parturient women’s trade-off of between the accessibility and availability of obstetrics services. Results: During the study period, childbirth decreased by 6.7%, and the number of obstetricians decreased by 5.4%. Meanwhile, the mean number of deliveries per obstetrician decreased by 1.6%. The changes in the aforementioned indicators were worse in rural areas than in urban areas. Some obstetricians withdrew from the market, some changed their practice location, especially to areas with a higher carrying capacity. Consequently, parturient women who lived in areas with a low urbanization level had to travel longer distances to obtain obstetrics services; thus, they preferred to obtain services in areas with better accessibility rather than better availability. Conclusions: This study demonstrated that low birth rates can lead to the geographical redistribution of obstetricians, which worsen accessibility for parturient women, particularly those living in rural areas. (Taiwan J Public Health. 2018;37(5):554-564).