新北市與其他縣市新生兒死亡率與證明書填寫行為之比較

Comparing neonatal mortality rates and certification behaviors between New Taipei City and other cities/counties in Taiwan

目標：比較新北市與其他縣市新生兒死亡率與證明書填寫行為。方法：首先分析2002至2022年各縣市新生兒（<28天）與出生當天（0天）死亡率趨勢，以連結回歸模型檢定趨勢改變是否顯著差異。接著連結2018至2021年五個資料庫，計算不同縣市產科醫師開具死亡證明書佔0天死亡者的比例與相關特徵差異。最後分析2021年50位新北市出生當天死亡個案母親生產當日病歷與訪談醫院管理者，瞭解影響填寫行為相關因素。結果：只有新北市與高雄市出現0天死亡率先降後升轉折趨勢型態。新北市是在2012年開始出現每年11.4%上升趨勢，高雄市是在2006年開始出現每年8.1%上升趨勢。2018至2021年合計台灣0天死亡數為778名，產科醫師開具死亡證明書404名（52%）。新北市72%遠高於其他縣市（約55%），而且出現逐年上升趨勢：2018至2021年分別是63%，73%，74%與78%。2019至2021年懷孕週數<24週比例超過九成，主要是人工流產個案增加。訪談醫院表示在2014與2020年有相關決議，會影響開具出生證明書與死亡證明書行為。結論：新北市新生兒死亡率增加與高於其他縣市，有相當部份受到證明書開具行為影響。要正確比較新生兒死亡率高低，必須排除這些行為因素。

Objectives: This study compared the neonatal mortality rates (NMRs) and certification behaviors between New Taipei City (NTC) and other cities/counties in Taiwan. Methods: We first examined the NMR trends for days <28 and day 0 for each city or county for the years 2002 to 2022. Joinpoint regression was performed to identify significant changes in the trends. We then linked five population-based data sets to calculate the proportion of day-0 deaths for which the death certificate was issued by an obstetrician and to examine the related characteristics. Finally, we reviewed the charts for 50 day-0 deaths in NTC in 2021 and interviewed hospital managers regarding the regulation of certification behaviors. Results: Only the day 0 NMR trends for NTC and Kaohsiung City (KC) exhibited a decline-and-rise pattern. The annual percent change was 11.4% since 2012 for NTC and 8.1% since 2006 for KC. In total, 788 day-0 deaths occurred between 2018 and 2021, and the death certificates of 404 (52%) were issued by obstetricians. The percentage of day-0 deaths with obstetrician-issued death certificates was 72% in NTC, which was higher than those of other cities/counties (approximately 55%), and a rising trend was also identified (63% in 2018, 73% in 2019, 74% in 2020, and 78% in 2022). More than nine-tenths of these deaths involved a gestational age of <24 weeks, and most of them were the result of artificial abortions. The interviewed hospital managers indicated that various regulations for certification behaviors have been introduced. Conclusions: The higher NMRs and rising NMR trend in NTC compared with other cities/counties were partially due to certification-related behavioral artifacts. To properly interpret the regional variations in NMRs we should first remove this behavioral artifact.