作者 ｜
曾家琳(台灣大學附設醫院家庭醫學部)、張玨(台灣大學衛生政策與管理研究所)
摘要 ｜
國外婦女自然產曾在五Ｏ年代醫療化的生產概念底下，發展出一套關於會陰切開術必要性的醫學論述，但經過八Ｏ年代質疑和九Ｏ年代實證研究後，逐漸形成醫界內部共識與規範；然而這個知識與信念的翻轉並沒有影響國內高會陰切開術的使用與產科醫界的信念。本研究企圖分析國內婦產科界會陰切開術使用的歷史以及關於會陰切開術的論述的。
本研究以歷史比較、科技與社會研究以及女性主義的觀點，分析國內關於自然產會陰切開術「醫療介入」的論述，包括國內報紙期刊相關內容、歷年常用醫學及護理產科學教科書、近年醫學生共同筆記以及醫學界內部通訊，並以台北一區域醫院的產房變革作為會陰切開術施行的個案研究。
研究發現台灣會陰切開術運用可以分為五個時期：日治時期新式產婆會陰保護與舊式產婆會陰切開的對照期；戰後至七Ｏ年代美援對台灣醫界的影響期，威廉氏產科學可以視為會陰切開重要的論述來源；八Ｏ年代現代助產技術的宣稱，產科醫師佔據主要的發言位置；九Ｏ年代技術蓬勃期，產科醫師對於會陰切開術的肯定與堅持立場，出現在大眾期刊相關的文章中；2000 年以後會陰切開質疑期，助產學界人性化生產的訴求連結到對常規會陰切開的質疑。然而台灣產科醫界則有不同的看法，醫學院內醫學生婦產科教學上，並未採取實證結果，僅有少數邊緣的個案發展出與主流不同的自然產模型與生產概念。
台灣生產技術專科化，生產環境機構化以及生產過程病理化與醫療化的因素，使得台灣的婦女生產處境，缺少專業對話的對象與機會，國內自然產與技術掌握於婦產科醫師。雖然近年實證醫學的發展以及產科教科書的改寫，但是低科技助產技術的操作並未獲得產科醫界的重視，除了自然產的醫學典範並未受到來自醫界內部，也沒有受到外部的挑戰。而醫學典範一如科學典範，可以被挑戰。作為行動主體的婦女，才逐步進入這個自然產運動的領域。未來婦女健康政策，除了評估生產時母嬰親善醫院、應鼓勵本土的生產經驗研究、與生產資訊的公開；產前與產後的社會與醫療支持體系，也是婦女生育健康的議題。如此，婦女生產環境中，才有親善支持條件的可能性。
關鍵字 ｜
會陰切開術、自然產、典範轉移、醫學史、醫學論述、婦產科
Title ｜
Discourse Analysis of the Episiotomy Dispute in Taiwan’s Obstetrics Practice
Author ｜
Chia-Lin Tseng( Department of Family MedicineNational Taiwan University Hospital)、Chueh Chang( Institute of Health Policy and Management National Taiwan University)
Abstract ｜
The origins of medical discourses about the benefits of episiotomy can be traced back to the 1920s, when episiotomy slowly gained a wider acceptance in different societies. However, the 1990s saw a transformation of the debate, including the view that episiotomy should have been regarded as an important parameter for evaluating the quality of perinatal care. Yet, this concept has not been accepted by Taiwanese obstetricians. This paper therefore strives to shed some light on the evolution of episiotomy use in Taiwan through an analysis of the existing medical discourses.
In carrying out this research, the following methods and materials were utilized: archival analysis, examination of recent notes from medical school lectures, textual analysis of medical textbooks, newspapers, and public journals, review of communication in the obstetrics community, and a field study of a Taipei regional hospital. Compared with some other countries, it appears that majority of Taiwanese obstetricians are not affected by the latest obstetric transformation, partly due to the dominance of male obstetricians, institutionalization of childbirth, and delayed childbirth movement. The “high tech” values shared by a large number of physicians make them ignore the importance of restricted use of episiotomy, which is regarded as “low tech,” but “high art” procedure.
When reviewing the history of the formation and transformation of the episiotomy discourse, it is clear that the medical paradigm of childbirth continues to be medically centered. In sum, the obstetrical practice in Taiwan needs further scientific and psychosocial assessments, in order to allow for stronger focus of the medical community on women’s health and well-being.
Keywords ｜
episiotomy, childbirth, obstetrics, medical history, medical discourse, paradigm shi