題目：Flexible Standardization or Mandatory Regulation?The Effects of Guideline and Law on Limiting Clinical Practices of Assisted Reproduction in Taiwan
Abstract：What are the most effective measures to regulate clinical practices to generate a better quality of care? The flexible standardization approach, such as voluntary guidelines, integrates recommended procedures and medical autonomy. On the other hand, the mandatory regulation binds the clinical procedures with legal enforcement. This paper examines the effects of two approaches using the case of regulating the number of embryos being transferred during in-vitro fertilization (IVF) to reduce the incidence of multiple pregnancies, the leading complication of health risk. While US and Japan issue voluntary guidelines, Germany and Belgium stipulate the specific number by law. Taiwan offers both, serving as a telling site for evaluating two approaches. The data for analysis are 159,742 IVF cycles from the National Registry of Assisted Reproduction Database between 1998-2016.
First, we found that Taiwan’s voluntary guidelines, issued by the Taiwan Society of Reproductive Medicine (TSRM) in 2005 and 2012, only slightly changed the clinical practices. For example, in the transfer cycles for women under 35 years old, the procedures which did not follow the guideline dropped from 50% to 30% two years after the 2005 guidelines were published. Although the guidelines are one of the most lenient in the world, 34 % of IVF cycles have not followed the guidelines in the following years.
Secondly, the Assisted Reproduction Act, stipulating “no more than four” embryos to transfer in 2007, only eliminates the practice of implanting five or more embryos without changing much of the typical clinical patterns. Moreover, the cap of four even encourages some clinical behaviors to implant the upper limit of four for women of younger age, despite that single and double embryo transfer has been proposed by evidence-based medicine in the mid-2000s.
Thirdly, we argue that with the lenient regulation and high medical autonomy it endows, medical practitioners would tend to prioritize success rates rather than reducing health risks. The data show that the pregnancy rate remains high after making guidelines and statutes. The health risk indicators caused by multiple pregnancies – miscarriage, premature birth, and low birthweight -- have not been reduced significantly after the regulation. Reaching a high success rate at the expense of creating multiple pregnancies appears to be the main guiding principle. Both regulation approaches fail to reach the goal of safety.
We conclude that no matter which regulatory approach, the implementation of guidelines or laws cannot lead to the goal of good quality of care if the content is too lenient. Factors such as market competition and medical professionalism might need to be considered to explain the failure of regulatory interventions in Taiwan.
Key Words: Assisted Reproduction Technology, IVF, TSRM guidelines, embryo transfer, reproduction outcomes．
題目：Moving Beyond Fertility/Infertility: Taiwanese Women’s Experience of Ambiguity and Loss of Control in Miscarriage
Abstract：Pregnancy does not always lead to a childbirth. Many early miscarriages occur for unknown reasons. 10-30% of pregnancies worldwide end in miscarriage, and in Taiwan, those numbers are 10%-18% of pregnancies. However, despite the high miscarriage rate and its severe impacts, few social science or feminist studies have addressed miscarriage; I consider this “studied silence” (Layne 1997) as an “undone reproduction study.” This paper aims to open up a discussion of women’s experience of miscarriage in order to extend the discussion of reproduction - particularly by moving beyond the concept of fertility/infertility. Existing reproductive studies either focus on fertility, the capacity of giving birth to a child, or infertility, having difficulty with conceiving or giving birth to a child. The concept of fertility limits and ignores other processes of reproduction. Those limits are especially clear in the biomedical discourse depicting reproduction as a linear progress where the outcome is a live birth, and where miscarriage is failed pregnancy. As I will discuss in this paper, reproduction is more than the division of fertility and infertility. Particularly, miscarriage does not fit well to the understanding of women as either fertile or infertile. How do women experience miscarriage, and how do their experiences lead us into an anticipatable reproductive future? Based on 23 interviews with women who have experienced miscarriage and 20 participant drawings depicting the experience of miscarriage, this paper aims to provide another version of miscarriage different from the mainstream biomedical narrative. Particularly, as I will argue, from unfolding women’s experience of ambiguity and loss of control when anticipating their reproductive future, the paper will help us to move beyond a discussion of, and get out of the maze of (in)fertility (Franklin 2022).
Keywords:Fertility/infertility, reproduction, miscarriage, liminality．
摘要：台灣是全世界人口轉型的經典案例，在不到百年的時間從高出生與死亡率轉型到低出生與低死亡率的平衡，學界普遍認為自1960年代實施的家庭計畫對加速生育率下降有顯著的貢獻。本文以此認識為基礎，以STS學者Michel Callon在新經濟社會學的概念展演性（performativity），探討家庭計畫在推行盛期（1965-1975）如何在人口轉型模型的指引下，集結各種條件之部署（dispositif）將人口轉型展演出來。本文主張至少有三種部署：（一）專家部署：在二戰後全球人口控制的脈絡下，紐約人口局（Population Council）派駐台灣的美國人口科學家如何將人口調查的理論知識（如KAP調查）引入台灣，將台灣置於全球人口轉型的模型，並培育了一批執行人口調查的研究者；（二）統計部署：為配合省衛生處的五年計畫裝置六十萬樂普目標數，家庭計畫研究者建置評價系統（Coupon System），透過個案紀錄聯將原本與國家節育政策無關的各個行動者予以連結；（三）身體部署：家庭計畫如何建立樂普與婦女身體的關聯，使婦女如其所願地成為「接受者」，貢獻到全球在地家庭計畫的統計資料中。本文利用家庭計畫的歷史研究、檔案資料、曾參與家庭計畫的行動者的口述訪談，對前述三種部署進行描述，試圖主張台灣人口轉型並非一種自然發生的現象，而是集體展演的結果。
摘要：本文探討台灣獨居者的就醫行為因素，除了人口特徵和個人健康外，統合社會因素和資源便利性，以社會網絡、醫療和交通資源便利性綜合分析在全民健康的醫療去商品化效果下，獨居行為會否對就醫行為造成障礙，從而擴大健康不平等。本文以醫療社會學的社會建構論出發，Health Power Resource觀點強調健康應為群體權力的一種重要資源，透過重分配（stratification）、歧視（discrimination）、商品化（commodification）和去生機化（devitalization）機制對健康資源產生影響。本文運用台灣社會變遷基本調查計畫2019第七期第五次：科技與風險組資料，合併衛福部公佈的醫事機構及人員統計和中研院社會所整理之交通資源數據庫，探索就醫行為與人口特徵、個人健康、社會網絡、醫療資源便利性和交通資源便利性間的影響機制。從多項式邏輯對數分析中發現，獨居並非台灣民眾就醫行為的障礙，在控制醫療及交通資源情況下，台灣的健康不平等原因是城鄉差距，符合過往文獻發現，但本文的結果特顯偏鄉人口的健康弱勢不單來自於醫療資源不均，而是社會對偏鄉人口的生活習性的歧視及偏鄉人口的非正式社會支援缺乏有關。