During pregnancy, childbirth, breastfeeding and postnatal care, Taiwanese women — and men — have long faced a bottleneck in the supply of medical care. Maternity care under the current system is broken and fragmented. Although it might be said to be efficient, the quality of care remains persistently low. With the system unable to meet the expected standards of healthcare in the 21st century, exclusive birth clinics for the wealthy have been popping up everywhere.
Many progressive and forward-thinking women, unwilling to suffer in silence any longer, are demanding reform to the system. Meanwhile, a small number of kindhearted and generous midwives across the nation are providing assistance to women in their homes. In hospital-based childbirth, breastfeeding and postnatal care, this type of high-quality care is rare; nevertheless, it has implanted the seed of reform in the minds of Taiwanese women.
Taiwan in the 21st century is a nation of small families. It is also a highly urbanized society in which women make up more than half of the labor force and yet are still willing to go through the ordeal of childbirth — they deserve better treatment than they now receive. In recent years, Taiwan’s birthrate has been in flux, but the long-term trend is down. In the past 30 years, the annual birthrate has declined from more than 400,000 to about 200,000 today. In 2010 — which was the Year of the Tiger and which, according to the lunar zodiac, was an inauspicious year to give birth — the birthrate fell to a record low of slightly more than 160,000.
However, the resulting savings to the National Health Insurance (NHI) budget from the falling birthrate have not been put aside to take care of the problems faced by pregnant women, nor have they been used to improve the quality of maternity care. For the past 30 years, maternity wards in NHI-funded medical centers have remained unchanged: three beds to one room, three pregnant women, three husbands and the rest of the family squashed into one tiny room, with the sound of screaming and crying ringing in one’s ears. It is a familiar scene found in hospitals across the nation.
The lack of privacy and dignity afforded to pregnant women in Taiwan is a matter of serious concern. Sometimes, pregnant women on radically different paths are forced to share the same room: a stillborn fetus or an induced abortion will sometimes occur in the same room as mothers looking forward to a healthy birth. If Taiwan is considered to be a cultured society, one only needs to spend time in an NHI maternity ward and see how the system treats postnatal women to shake one’s confidence.
The nation’s maternity care system, which is centered around doctors, is riddled with problems. There is no solution in sight for the problem of overworked and overstressed obstetricians, and staffing levels within township-level maternity departments have left them in a pitiable state. In addition, obstetricians spend far too much time and energy on low-risk childbirths. Doctors can earn a lot of money this way, but, as a consequence, hospitals are unable to improve the provision of equipment and resources for high-risk pregnancies. In the past 30 years, little change has been made to hospital delivery rooms, their aging delivery tables, the outdated ideas and the meager provision of emergency caesarean section equipment.
Talk of medical care in Taiwan as “advanced” is only a partial reflection of the true situation: It is something we like to say to ourselves to avoid confronting reality. One only has to contrast the standard of maternity wards in developed countries with those in Taiwan to see the truth.
In Taiwan, doctors are employed to deliver low-risk pregnancies. This is not just extremely costly, but also results in low-quality care since doctors usually only arrive at the very last minute, when the baby’s head is about to come out, to deliver the baby. As a result, cutting of the perineum has become standard procedure. Taiwan’s obstetricians are not taught during training to wait patiently, and if nurses call the doctor too early or too late, they usually face criticism. This behavior is understandable since throughout their training, all they see and are taught to respect and worship is those “terminator” doctors, proficient in the use of every different type of obstetric forceps, who perform miracles on the operating table and can bring a patient back from the valley of death.
As the nation’s birthrate falls, the Ministry of Health and Welfare should have used the money saved from the NHI’s budget to implement policies designed to improve the standard of maternity care in hospitals — an area that has remained stubbornly resistant to change for the past three decades. This includes reversing the practice of doctors performing low-risk deliveries. The ministry should recommend that the nation move to a more economical system of midwife-based maternity care that is able to meet the evolving physiological needs of childbirth.
Only when doctors are able to focus their attention on the expensive business of high-risk pregnancies will the medical profession be able to fulfill its noble role of saving lives. Pregnancy is a natural event. A doctor available to save the life of a baby teetering on the brink of death is infinitely more valuable than delivering 10,000 low-risk natural births.
There will of course always be an element of risk in childbirth. The Childbirth Accident Emergency Relief Regulations (生產事故救濟條例), which have been on trial for several years, will go into force on June 30. This is a small step in the right direction for improving the situation of pregnant women in Taiwan. However, the quality of maternity care should be more thoroughly inspected. The buck stops with the ministry, which should more effectively use the NHI system and a system of appraisals, in addition to other resources at its disposal, to insist that hospitals raise standards of maternity care.
Chiang Sheng is an attending physician in the Department of Obstetrics and Gynecology at Mackay Memorial Hospital.
Translated by Edward Jones
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