(論文初稿，請勿引用)
Taiwan's Recent CS Operations, and its Gender/Medical Politics
Fu Daiwie (Institute of History, NationalTsingHuaUniversity)
Wu Chia-Ling (Department of Sociology, NationalTaiwanUniversity)
(Paper Presented for the 5thEast Asian STS Conference, Seoul National University, South Korea, Dec. 8-11, 2004)
Abstract
The point of this investigation is to discover the hidden assumption of current academic research and debates that explain the controversial high cesarean section rate in Taiwan. Most research is based on quantitative analysis of survey data and focus on the behaviors of birthing women, often assuming they could exercise individual choices between vaginal birth and cesarean delivery. The discourse of choice in such research does not mean to appreciate women’s agency but to blame them for their innocence and irrationality. This kind of research practise is actually a kind of “gendered and oriental Orientalism”, problematic in ideology and almost useless in solving the problem of high CS rate. Institution factors like National Health Insurance payment and type of medical organizations also gain much attention. By contrast, the current research seldom made efforts to examine the details of obstetric practices, such as the low rate of VBAC, the routine use of electronic fetal monitors, and the loose definition of “prolonged labor.” This explains why the public policy of reducing cesarean section rate in Taiwan has narrowed itself on educating mothers, and modification of the National Health Insurance payment, and why the cesarean section rate has not declined despite such efforts. We argue that only if we take the perspective of STS (science, technology and society studies), disclose the “inside” of obstetrics in Taiwan, rather than the “outside,” can we possibly fully explain the high cesarean rate in Taiwan. Thus treating VBAC as a medical-social technology, we study it from the perspective of medical education and training, and find problems and potentials to reform in this little discussed area. Concerning the much discussed NHI payments debates, we try to integrate these issues into the politics of medical disciplines and risk discourses, in the hope of going beyond the interests of individual obgyn doctors. Finally we study some other structural factors on two sides (in and out) of the issue of CS rate: one is how Taiwan’s state or DoH was doing in intervening Taiwan’s high CS rate, and the other is how Taiwan’s obgyn association (TAOG) was doing concerning this somewhat infamous CS rate in Taiwan’s medical sciences of obstetrics and gynecology. The historical dimension of TAOG is analized and evaluated in relation to this CS rate, and the interplay of inside and outside factors concerning CS rate is discussed from the STS perspective.
Introduction
The first international comparison of cesarean section rates was published in the New England Journal of Medicine in 1987, and the increasing trend of CS, particularly the 18% of the US, immediately aroused concerns among the international medical community to “consider the appropriateness of this continued rise.”[1] The US cesarean section rate reached its peak at 24.7% in 1988, and American College of Obstetricians and Gynecologists responded the “national epidemic” through reforming clinical practices like promoting vaginal birth after cesarean (VBAC).[2] When the editor in Lancet threw alarm on the “Caserean section on the rise” in the UK in 2000, the alarming number is 19%; the quality of care at maternity units was brought into question.[3] Overall, the medical community regards the increase in CS as controversial. Although the reasons for such increase remain to be explained, medical community efforts on improving clinical practices and reforming maternal care system.
The CS rates in Taiwan for the past decade were much higher than those “alarming” numbers (Figure 1). Since early 1990s, with the increasing availability of national data, the rocketing cesarean section rate in Taiwan became controversial. However, rather than examine the clinical practices as the medical community in the US and the UK have done, the profession and governmental awareness in Taiwan brought attention mostly on the social, cultural, and economic factors.
This paper aimed to explore how policy-makers, researchers and the medical community explained the one of the highest CS rates in the world. For the first part of the paper, we examine current academic research that has been generated after the national CS rate became available in Taiwan in 1992. What have been researched? What are the hidden assumptions of such research? Why do the clinical factors remain unexamined? Instead of treating the scientific investigation as objective efforts to seek reasons behind the high CS rate, we would like totake the view-point of science, technology and society studies (STS) to reveal how power/knowledge, intertwined with gender politics, is exercised in the politics of "medical Truth".
I. Setting Research Agenda: Surveying Women
Even since the CS rate became a controversial issue in Taiwan in early 1990s, birthing
women's behaviors have been quickly singled out as one of most popular explanations. The most discussed factors on media includes "choosing an auspicious time for the baby," "women's fear of pain," and "women's fear of loose vagina." Althoughobstetricians and governmental officials offer various explanations, birthing women’s irrational choices were almost always mentioned. With more research surveying birthing women, such explanations seemed to become evidence-based scientific findings, rather than purely speculation.
Table 1: Type of research on CS in Taiwan, 1993-2004
Type of research / N / %Women’s behaviors / 12 / 44%
Institutional factors (including physicians’ factors) / 10 / 37%
Clinical factors / 3 / 11%
Other / 2 / 7%
Total / 27 / 100%
We have searched 27 pieces of empirical research (including master thesis, journal articles, book chapter, and research report) that focus on the explanations and patterns of CS in Taiwan since 1993. Nearlyhalf of such studies focus on women’s attitudes and behaviors, mostly through quantitative data such as surveys, medical records and birth certificates. For the institutional factors, National Health Insurance (NHI), and characteristics of hospitals and clinicsl like ownership and accreditation levels are the major explanatory variables. Among the three journal articles that focus on the clinical factors, two evaluate whether epidural anesthesia would increase the incidence of CS, and one examines virginal birth after c-section (VBAC). Obviously, women’s behaviors gained most academic attention for explaining high CS in Taiwan. Through focusing much on birthing women’s behaviors, elective cesarean sections based on non-medical reasons gain morescrutiny than the medicine-related factors.
Table 2: Academic Backgrounds of researchers on CS in Taiwan, 1993-2004
Background of researcher / N / %Public Health / 5 / 19%
Health Care Organization Administration / 13 / 48%
Medicine / 5 / 19%
Economics / 2 / 7%
Other / 2 / 7%
Total / 27 / 100%
Why does the factor of women’s behaviors stand out? We may examine such research preference from asking who own the unchallenged legitimacy of doing research and how their academic disciplines define CS as a problem. The dominant specialty that researches on CS lies in the area of health care organization administration and public health (see Table 2). With the introduction of NHI since 1995, hospital management, especially in terms of finance and efficiency, has been deeply organized with the changing schemes of NHI. Researching CS, which has higher payment from NHI than natural birth, becomes a window to see how financial consideration might influence the obstetric practices. Governmental medical quality indicators in 2000 first includean ideal CS threshold rate (20% or lower) as one of the hospital evaluation criteria, which naturally attracts attention from the perspective of hospital management. The area of health care organization and administration therefore tends to get interested in researching CS with factors like insurance payment and management characteristics. However, in addition to these institutional factors, “health belief model” which focuses individual health literacy, cognition, and perspectives also dominates the fields of public health. Table 3 shows that those researches single out women’s behaviors as explanatory variables mainly come from the areas of public health and health care administration. In addition to women’s ideas and values on ways of birthing, women’s financial situation, health literacy on birthing, as well as other socioeconomic backgrounds, are often included in the statistical analysis. Most researchers use “the deficit model” – the lack of scientific knowledge – to present birthing women’s ideas and thoughts on birthing. Improving or correcting women’s information and viewpoints are the often-mentioned policy-implication. Obstetric knowledge itself is treated as unproblematic, and remains unexamined in these papers.
Table 3: Cross-tabulation of Researcher Background and
Background of researcher / Public Health / Health Care Org. Adm. / Medicine / Economics / Other / TotalWomen’s Behaviors / 4(15%) / 4(15%) / 1(4%) / 2(7%) / 1(4%) / 12(44%)
Institutional Factors / 1(4%) / 9(33%) / 0 / 0 / 0 / 10(37%)
Clinical Factors / 0 / 0 / 3(11%) / 0 / 0 / 3(11%)
Other / 0 / 0 / 1(4%) / 0 / 1(4%) / 2(8%)
Total / 5(19%) / 13(48%) / 5(19%) / 2(7%) / 2(7%) / 27(100%)
Comparatively, medical doctors in Taiwan seldom do research on CS. We can only find three articles done by medical doctors, and two of them are anesthetists. To our surprise, although obstetricians often express their opinions through media for their accounts on the high CS rates in Taiwan, we could only find one paper done by the leading birth attendants, obstetrician. We could not find much study experimenting on new health care model, which might show that the birthing reform did not yet happen in the clinical setting. Only one journal article experiments on a new maternal care model, done by a team composed of midwives, nurses, and obstetricians: although the evaluation shows that midwifery model does not reduce the CS rates, it has less medical intrusive procedures than the obstetrics model. With little data available on clinical data, it is harder for the society to trace whether the problem lies in the obstetric practice and knowledge. Besides, only two research projects among the 27 come from a more critical perspective – feminist and STS. The scanty of such perspectives, together with the lack of clinical reforms, the efforts to disclose the details of obstetric practices[4], such as the low rate of VBAC, the routine use of electronic fetal monitors, and the loose definition of “prolonged labor”, are mostly absent.
II. Building Causal Links: Directing the Arrow
“Choosing auspicious time” is one of the most researched women’s behaviors. Since early 1990s, several physicians in media reports list women’s choosing auspicious time as one of the main reasons, a unique Taiwanese culture, for explaining high CS rate in Taiwan. Such belief reached its peak in 1995, whenChina Times Evening had a feature report with such a beginning: "The most important factor for the Taiwanese birthing women to choose cesarean section is that: half of c-sections were for choosing the auspicious time." After this report, various media discussions on c-sections refer to women's preference of auspicious time.[5] Sinorama magazine, published by Government Information Office, publishes an analysis of cesarean sections in Taiwan with a title "C-section for Dragon Baby Boys and Phoenix Baby Girls?" The story begins: "[a]ccording to one survey, up to half of the mothers who chose to give birth by Cesarean section at the NationalTaiwanUniversityMedicalCenter did so in order to make sure their child was born at a propitious moment."[6]
What the media cites is based on a conference paper, and the reporters misread the original findings. In Huang's paper that he presented in the conference, it writes: “Non-medical reasons that influence women for choosing c-section -- women of c-section in the sample are influenced by non-medical factors are as follows: 1. "choosing the auspicious time" (45.1%)…”[7] The media reports neglect that these reasons are "non-medical reasons" only. If the journalists had read Huang's original thesis, it would be very clear that all of these women had medical reasons to do so, and medical reasons were the foremost determining factors. It seems that by and large, this medical center did not perform a c-section for women to choosing an auspicious time without any medical reasons. Other large hospitals have similar policies.[8] Official statistics show that elective c-section without any medical reasons were only 1.85 percent, 2.48 percent, and 0.9 percent in July, August, and October of 1995 of the total c-section for those months.[9]
It would be unfair if we sorely blame the media for misinterpretation of the original survey results. The research itself did emphasize the finding that "those who believe fortune telling can change your fate are 7.10 times more likely than those who do not believe so to have c-sections." Thus, the author suggests the medical institutions and women's groups should educate women, because "women are influenced by their beliefs and some non-medical factors which increase the c-section rate; this shows women's inadequate and biased conception on c-section."
The cross-sectional statistical analysis here cannot offer direct evidence on the causal link between this cultural belief and CS. We would call such a causal link a spurious relationship. We argue that it is the design of the survey questions and the belief of the researchers that contribute to such a causal link. In Huang's study, birthing women were given a questionnaire with fixed categories. These women were asked "in addition to medical reasons, list the degree of importance (important, OK, not important, no opinion) of the following items that influence why you adopt a c-section: (1) preference of good time...." These are hypothetical questions. Even these birthing women had medical reasons for c-sections, they had to answer these questions on "non-medical reasons" which probably did not exist in the first place. Women may have misinterpreted the questions as asking the possible by-products of c-section. Such questionnaire designs cannot show their real decision-making processes. Other fieldwork shows that most of the time, picking an auspicious time is only a side-"benefit" of an unavoidable elective c-section situation, rather than the decisive reason for having a CS. Thus, it is the elective c-section that brings the possibility of choosing a good time, rather than the other way around. The researchers did not infer in this direction possibly due to their emphasis on the non-clinical reasons.
III. Focusing Specific Attitudes: Gendered & Oriental Orientalism
Even in 2000s, “choosing auspicious time” still dominates some of the research agenda. Utilizing birth certificate data, Lo shows that C-Sections are more commonly performed on auspicious days than non-auspicious days.[10] Still, the claim that “pregnant women generally prefer to have deliveries on auspicious days and not on inauspicious days” cannot prove that such cultural preference leads to the high c-section rate in Taiwan. More reasonably, choosing an auspicious day is the efforts made after having CS is determined by doctors. However, women’s attitudes and behaviors gained so much attention that in a DOH-sponsored project to reduce the unnecessary c-sections, questions regarding “choosing auspicious time” were asked three times (with slightly different ways).[11] By contrast, for example, there is no single question about whether women receive sufficient information regarding “choosing” the mode of deliveries. The intention of the questionnaire to find women’s faults is obvious. Ironically, the survey findings show no evidence that women have c-section purely due to their preference over the birthing time. For those survey questions that could clarify whether healthy women “choose” c-section due to time preference, the researchers did not show the statistical results. It is highly suspicious that such finding that may contradict the past research finding is suppressed in the final report. Even worse, the researchers still put “choosing auspicious time” on the top of women’s attitudes section, only because “75-80% of birthing women feel that choosing the auspicious time is common in Taiwan.” This could at most show surveyed women’s social observation, far away from being an explanatory reason for their (own) mode of delivery. Unfortunately, ten years after the misread of research findings by China Times Evening in 1995, media continued to distort the finding, claiming that the explanation of high c-section again could be attributed to superstitious women. Such enthusiasm of media and research to support the specific culture as the leading cause of high CS, despite its shaking data, demonstrates an attitude of gendered and oriental orientalism(G.O.O.)– Taiwanese to view the women of our culture, or our women’s culture, from the viewpoint of an orientalist’s West, and to single out this “oriental women’s culture” of ours as the dominant factor in explaining problematic social characteristics of our society.
Blaming women for causing high c-section rate in Taiwan is so prevalent that in a survey of 535 obstetricians-gynecologists in 2002, more than 90% of interviewees agreed that the main cause for the unnecessary CS was “the request from the patients.”[12] We would like to emphasize that those distorted research designs and shaking inferential processes help strengthen such belief. Birthing women are not only overly researched, but also are “forced” to reveal their particular attitudes that might prove their ignorance and irrationality. For example, when physicians are surveyed, they are often asked their explanations for the high c-section rate, and their observation of patients.[13] By contrast, when birthing women are surveyed, they are often not given the chance to make explanations of their own c-section, as well as their observation of the obstetric system and physicians’behaviors. Their viewpoints and observations for the explaining high CS are not treated as legitimate knowledge.