| Background and Objective:Induced abortion is a remedy for contraceptive failure, and it is known to harm women’s reproductive health and can negative effects on their families and society in general, although induced abortion is very conmon and is considered a safe procedure. The patient-specific negative effects include uterine perforation,incomplete aspiration, reproductive tract infection, intrauterine adhesions, oligomenorrhea, chronic pelvic inflammation, secondary infertility, endometriosis, and mental stress.Especially repeat abortions and unmarried, adolescent abortion, will bring more damage to reproductive health, even lead to serious, irreversible injury of reproductive function and psychological trauma to various degrees.As a global public health and social issue, induced abortion has received worldwide attention. In some countries induced abortion is prohibited.Unexpected pregnancy women often can’t receive safe abortion and formal services, they had to end up seeking the illegal clinic for induced abortion, which health conditions and medical standards are very poor.Beacuse their health can’t be guaranteed, the consequences of unsafe abortion can be even more serious, as approximately 47,000 of the annual global pregnancy-related deaths are due to complications of unsafe abortions. In addition, about 500 million women lead to a variety of physical disability because of unsafe abortions,1/4 of these women needs medical treatment. Governments around the world have made extensive efforts to reduce induced abortion rate. In 2003, the World Health Organization (WHO) produced a handbook entitled "Safe Abortion:Technical and Policy Guidance for Health Systems " to guide the planning and delivery of safe abortion services. In addition, studies have demonstrated that providing contraceptive counseling and services during post abortion care (PAC) visits are critical factors for reducing the subsequent number of induced abortions.Furthermore, PAC services can reduce the number of maternal deaths and provide an opportunity to prevent future unwanted pregnancies.The current sociodemographic knowledge about women who have undergone induced abortions in China is limited by studies with a relatively small sample size or a lack of updated information. In the first part of this study, retrospective study of women who underwent induced abortion was conducted in Xiamen Maternity and Child Health Care Hospital between 2010 and 2013, and we analyzed the epidemiological tendency of induced women, and the study might provide evidence regarding how to decrease the rate of induced abortion and improve women’s reproductive health.The rate of induced abortion is high in China. Induced abortion in China has three characteristics. First, the rate of repeated abortions is high and the interpregnancy interval of repeated abortions is short. Summary of the literature data shows that more than half of induced abortion women had a history of abortion, repeated abortion was 55.9%,13.5% among the repeated abortion had three or more abortion. Second, a high proportion of the induced abortion women are young and childless, the proportion of women under 25 years old is 47.5%, the proportion of women without a child is up to 49.7%, the proportion of first pregnancy abortion is 35.8%. Third, the total number of induced abortion women is high, For example, According to Yearbook of Chinese Population and Family Planning, from 2010 to 2013, the total number of abortions in our country is more than 600 million people every year. What are the characteristics of the women who had undergone repeated abortions? What is the main reason for the repeated abortion of unplanned pregnancies? What is the difference of repeat abortions between married women and unmarried women? The second part of this study analyzed the characteristics of 733 women who undergoing repeated abortions, and compared the difference between married women and unmarried women. We expected to find out the main reason for contraceptive failure of repeat abortion women, to take action against the reason, and reduce repeated abortion rate.Induced abortion, only as a remedy for contraception failure has potential effect on reproductive health of women which should not be ignored and bring about tremendous waste in medical resources. In 2009, the Chinese Medical Association launched the PAC Service initiative, and proposed the slogan "Scientific contraception, away from induced abortion." In 2011, the same association also released a Post-Abortion Family Planning Service Guide and created a special non-profit fund to help hospitals establishing a PAC clinic (the YIAI fund). These PAC clinics are expected to reduce the rates of induced abortion by providing PAC services for all women who have had induced abortions. These services include counseling(e.g. information regarding post-abortion complications and contraceptives) and free access to contraceptives.The Xiamen Maternity and Child Health Care Hospital is a tertiary teaching hospital with a PAC clinic that was established in 2010. The medical staff received formal training in PAC, which led to our clinic being named a demonstration hospital with high-quality PAC services in 2011. High quality PAC service required to be contacted regular follow-up such as erery one month, three months, six months, one year a time after induced abortion. Currently PAC is mainly followed up through telephone interviews. Most of the abortion women is in a passive position, and don’t want to response to the telephone interviews. With the passage of time after the abortion, post-abortion women significantly reduced the need for follow-up services, post-abortion 6 months and 1 year women willing to accept the follow-up services is less, which affects the effect of PAC services. The third part of this study was to adopt a new way of follow-up services(network follow-up services). Taking the advantage of Internet, we contacted the repeat abortion women for six months through QQ or WeChat. It would provide more methods for post abortion follow-up services and it would show the differences in network follow-up and telephone follow-up.Method:Chapter One:A cross-sectional epidemiological study was used.Research subjects were taken routine preoperative examination after they come to hospital. If everything was normal they would fill out the questionnaire in detail.The investigators were selected with medical background (some doctors and some senior nurses). The detailed investigation contents included:age, marital status, number of pregnancy, number of delivery, number of abortion, the date and high risk factors of abortion, telephone number. When any of the required information was missing in the record, the record was not selected.The study was approved by the Hospital Institution, and all patients signed an informed consent before surgery.Collected data were exported and analyzed using the SPSS version 16 program after randomly rechecked by independent supervisors. Data Qualitative data were presented in frequency and percentage while quantitative data were presented in mean and standard deviation. Trend analysis was used to identify independent factors related to induced abortions between 2010 and 2013. The statistical tests—chi-square for percentage comparisons or t-test for means comparisons were carried out,P<0.05 was considered statistically significant.Chapter TwoThe patients entered into the PAC service process when they came to hospital. Doctor would ask the illness history of the patients immediately, then found out the repeated abortion women(induced abortion 2 or more times). If the patient agreed to participate in the survey, they would get the questionnaire with homemade number. The investigators involved uniform training (mostly senior nurses) investigated face to face and provide one to one counseling services after the patients reserved induced abortion surgery and signed an informed consent. The respondents filled the questionnaire in relatively closed space at any time.The investigators would check the integrity of questionnaire at the same time, try to avoid invalid questionnaires because of missing questionnaire data. The questionnaire included:age, marital status, number and method of births, education, number of pregnancy, number of abortion, contraception method caused contraceptive failure, reason and situation of the non-contraception, selection of the style of follow-up services.The investigators checked the questionnaire in detail, and build the database with EXCEL.The researcher and an independent person entered the same data separately, then swap entry results and made sure to get the same results.Logical examination performed after the completion of data entry.lt should be corrected according to the raw data if there were logical errors.Collected data were exported and analyzed using the SPSS version 16 program.Data Qualitative data were presented in frequency and percentage while quantitative data were presented in constituent ratio. Quantitative data comparison were checked with t-test.Compare the number of repeated abortion, education, contraceptive failure reason and non-contraceptive reasons between unmarried and married women using Chi-square test,the differences were considered significant at a=0.05 and p≤0.05.Chapter ThreeAccording to the process of chapter two,sending questionnaire with homemade numberto 733 repeated abortion women.The investigators checked the integrity of questionnaire and certify the questionnaire true,then choose the women of repeated abortion who would like to accept follow-up services, with also QQ (or WebChat) and phone contact methods.Explained the questionnaire to the respondents and promised that survey data is limited to scientific research, the investigation would not disclose to anyone without the permission of themselves.The numbered questionnaires were randomly divided into two groupsand informed the patients which group she belongs to. Group of even numbers will adopt follow-up mode with the telephone, Group of odd numbers will adopt follow-up mode with the network. At the same time, informed the patients the QQ group number or WebChat name, help them to join successfully and told them to modify nickname by number.If needed, patients could use free WiFi offered by the hospital. The patients can leave messages to the QQ group manager at any time or make an appointment to communicate in real-time.Provided the follow-up services with telephone or internet to patients and record the results at regular time (one month, three months and six months after the surgery), according to the operation time and the questionnaire number of patients. Patients of network group would be classified as lost if they withdrawal from QQ or WebChat or did not respond to follow-up questions over 15 days.Patients of telephone group would be classified as lost if the phone number is disabled,or the patients refused to answer the phone or short message, or didn’t answering the questions on the phone.The questionnaire included:Age, marital status, number and method of births, education, number of pregnancy, number of abortion, contraception method caused contraceptive failure, reason and situation of the non-contraception, choice of contraception methods immediately after the abortion,choice of contraception methods after one month,three months and six months.Collected data were exported and analyzed using the SPSS version 16 program. Data Qualitative data were presented in frequency and percentage while quantitative data were presented in constituent ratio. Qualitative data comparison were checked with Chi-square test. Compare the number of repeated abortion, education(ranked data) between unmarried and married women using Wilcoxon, analysis of Logistic regression model were used for screening the significant risk factors of repeated abortion, the differences were considered significant at a=0.05 and p<0.05.Result:Chapter One1.1 Demographic characteristics of induced abortion women:The mean age of the 19655 induced abortion cases was 27.21 (SD±5.65), with a range of 15-48 years. 891(4.5%) of the women were under the age of 20,Majority,12658(64.4%) were between 20 and 29 years old,7846 (39.9%) were unmarried,5803(29.5%) were first-time pregnant,9797(49.8%)were nulliparity,2576(13.1%) had a history of cesarean section.Of the 19655 women,9300(47.3%) were undergoing a first induced abortion,6173(31.4%) a second abortion, and 4182 (21.3%) a third or more abortion, the highest is 15 times. Induced abortion Women with IUD,or in breastfeeding period or with the space between current pregnancy and the previous in half a year,or women with uterus malformation were considered as high-risk abortions,so 959 women (4.9%) had undergone high-risk abortions,349 (1.8%) women of pregnancy with IUD, the rate of breastfeeding period or the interval between current pregnancy and the previous in half a year or uterus malformation was 159(0.8%),391(2.0%)and 77(0.4%).There are 10 cases within six months of pregnancy abortion who are in breastfeeding period,2 cases of women with uterus malformation who are in breastfeeding period.1.2 we analyzed the ages, marital status, pregnant times, delivery times, and induced abortion times, abortion in high-risk of 16955 abortion women between 2010-2013 and observe the changing tendency over the four-year period.1.2.1 age The average age of induced abortion women increased between 2010 and 2013,from 26.71 (SD ±0.092) in 2010 to 27.70 (SD ±0.076) in 2013. The rate of women in the group aged 15-24 years declined every year, from 42.5% in 2010 to 33.1% in 2013, and the percent of women between 25 and 48 increased accordingly.1.2.2 Marital status The unmarried rate of induce abortion was 44.8% in 2010 and 36.1% in 2013, declining year by year. The married rate of induce abortion increased over 4 years accordingly.1.2.3 Rate of induced abortion women in their first known pregnancy:the rate of induced abortion women in their first known pregnancy was 33.9% in 2010,31.6% in 2011,27.4% in 2012 and 26.5% in 2013, gradually declining during 4 years.1.2.4 Rate of women without history of delivery:the rate of women without history of delivery decreased from 56.35% in 2010 and 45.2% in 2013 respectively.1.2.5 Rate of induced abortion women history of cesarean section.the rate of women with history of cesarean section were found to increased yearly,form 9.5% in 2010 to 17.7% in 2013.1.2.6 Rate of induced women with high-risk abortions:the rate of lactating women and women whose current pregnancy were in half an year from last pregnancy were found to increased yearly,from 0.59% to 1.02% and 1.09% to 2.79% respectively over 4 years.A slow downward trend in the women with IUD existed from 2.20% in 2010 to1.45% in 2012,however,1.67% of the women experienced IUD failure.Smilar to the women with IUD,the rate of uterus malformation falling from 0.44% in 2010 to 0.24% in 2012, but the rate increased 0.57% in 2013.1.2.7 Ratio of induced abortion and live birth:the total number of induced abortions increases from 3906 in 2010 to 5403 in 2013, however, the ratio of induced abortion and live birth showed a steady decline from 48.8% in 2010 to 42.3% in 2013.Chapter Two2.1 Demographic characteristics of the 733 repeated and sexual partner as follows:2.1.1 age:The average age of married repeated abortion women was 30.00 ± 5.55, with a range of 18-45years.60.2% were between 25 and 34 years old, The average age of sexual partner was 32.17 ± 5.83,58.9% were between 25 and 34 years old2.1.2 hukou and birthplace.There were two kinds of hukou,one was in xiamen city,the other was not in xiamen city.The hukou of 61.9% repeated abortion women and 61.5% sexual partner was not in xiamen city. We divided birthplace into urban and city,The birthplace of 63.2% repeated abortion women and 56.8% sexual partner was in urban.2.1.3 level of education and mean monthly income.Most of the repeated abortion women and their sexual partner were below the Junior or senior middle school level,only a small proportion(33.2%and19.5%) received higher educational. Most of the repeated abortion women had a monthly income of 1001-3000 and 3001-5000 yuan,while Most of their sexual partner had a monthly income of over 3000 yuan.2.1.4 The distance of previous abortion time,the abortion method and area. The distance previous abortion time of 70.4% was over one year,12.1% was less half year, the percentage of painless induced abortion was highest (57.2%),48.7% of repeated abortion women operated in city hospital.2.1.5 sexual frequency and the reason of unexpected pregnancy.Most of the subjects (56.3%) resumed 1-2 times sexual intercourse once a week.The main reason of unexpected was unprotected intercourse(34.2%),the failure of rhythm(28.1%) and emergency contraception(19.6%) followed.2.1.6 multi-factor analysis.The analysis of more factors suggested that the first five high risk factors were level of education of sexual partner, age, parity,the distance of previous abortion time and the way of abortion.2.1.7 analysis of abortion and contraceptive knowledge.69.2% subjects know curettage of incomplete abortion,the pain during abortion is 81.3% subjects greatest fear,69.2% subjects worry about infertility, awarenesss of IUD,COC and subdermal implant is 45.2%,15.0% and 7.5%. The knowledge of most research subjects derived from books/newspapers, the second and the third is from television networks and medical workers.82.5% bought contraceptives from stores/hospital/pharmacy.49.6% hoped getting contraceptive knowledge by with a qualified medical professional consultation,7.5% hoped school can distribute contraception information.43.2% thought painless abortion was best way of induced abortion,70.9% thought Side effects of IUD was high.76.7% think COC should not be taken for long periods.2.2 qualitative interviews.The contraceptive knowledge of repeated induced abortion was not satisfactory,post abortion and follow could improve their awareness of contraceptive.The hospital could not provide induced abortion women with detailed counseling because of lacked medical workers, post abortion care needed the whole society to support.2.3 Of the 733 repeated induced abortion cases 548 were married and 185 were unmarried.2.3.1 Age:The average age of married repeated abortion women was 31.87±4.87. It was older than the average age of unmarried repeated abortion women, which was 24.55±3.44 (t=-18.812, P<0.05). Repeated abortion and married women aged mainly from 25 to 34. Repeat abortion and unmarried women aged in two significant proportion,one from 15 to 24 and one from 25 to 34.2.3.2 The number of induced abortions:The largest proportion of the patients was undergoing 2 times induced repeated abortions, respectively the married women was 57.5% and the unmarried women was 64.5%.The minimum proportion of the patients was undergoing 4 times induced abortions, respectively the married women was 17.9% and the unmarried women was 14.1%.There is no significant difference in two group patients of abortions.(χ2=3.641,P>0.05)2.3.3 Education:the largest proportion of education degree was senior middle school and technical secondary school, respectively the married women was 61.5% and the unmarried women was 59.5%.The minimum proportion of education degree was under primary school and illiteracy, respectively the married women was 1.3% and the unmarried women was 2.7%. There is no significant difference in two group patients of abortions. (χ2=1.862,P>0.05)2.3.4 Reason of unplanned pregnancies:Contraception methods of unmarried women before repeated abortions and unplanned pregnancies:not or poorly using any means of contraception 60 (32.4%),emergency contraception 59 (31.9%),rhythm 39 (21.1%),withdrawa 15 (8.1%),condoms 11 (5.9%),IUD 1 (0.5%).Contraception methods of married women from high to low:not or poorly using any means of contraception 191 (34.9%), rhythm 167 (30.5%), emergency contraception85 (15.5%), withdraw 158 (10.6%), condoms 34 (6.2%), IUD 13 (2.4%).There is significant difference in two group patients of abortions. (χ2=26.767.64,P<0.05).2.3.5 Implementation of contraception immediately after abortion:according to PAC, suggested the abortion women to choose contraceptive methods,based on the wishes of themselves.The choice of contraception for married women was:short-acting contraceptives248 (45.3%),IUD 169 (30.8%), condoms 129 (23.5%),norplant 2 (0.4%).The choice of contraception for unmarried women was:short-acting contraceptives156 (84.3%),condoms 169 (30.8%),IUD 2(1.1%),norplant 2(1.1%). There is significant difference in two group patients of abortions (χ2=98.723, P<0.05).2.3.6 The investigation result of non-contraceptive reason:The non-contraceptive reason of married repeated abortion women:56.0% had not prepared contraceptives, 22% did not want to contraception,12% did not know how to contraception,9.9% had not agreement with male partners. The non-contraceptive reason of unmarried repeated abortion women:did not know how to contraception 18 (30.0%), had not prepared contraceptives 22 (26.7%), did not want to contraception 10 (16.7%), had not agreement with male partners 10 (16.7%).There is significant difference in two group patients of abortions (χ2=14.75,P=0.002).Chapter ThreeFrom January to March,2014, there were 486 cases of repeated abortions women according to standard, accounting for 66.3% of all repeated abortions women. 239 cases (49.2%) accepted network follow-up services,247 cases (50.8%) accepted telephone follow-up services.3.1 The average age before surgery,stratified age, the number of abortions, education and implementation of contraception immediately after abortion had no significant difference in two group patients of abortions.3.2 Follow-up services after 1 month of abortion:In the network group, implementation of contraception after one month of abortion:short-acting contraceptives114(50.9%),ICU 65 (29.0%),condoms 41 (18.3%),norplant 1 (0.4%), lost contact 15 (6.3%). In the telephone group:short-acting contraceptives 117 (52.9%),condoms 47 (21.3%), ICU 51 (23.1%), norplant 1 (0.4%), lost contact 26 (10.6%). Although the efficient contraception (short-acting contraceptives and ICU) of network group is higher than telephone group, the lost contact of network group is lower than telephone group, there was no significant difference in two group patients of abortions (χ2=2.618, P>0.05).3.3 Follow-up services after 3 months of abortion:The lost rate was gradually increased after three months of abortion, lost contact of network group was 21 (8.8%), successful contact of network was 91.2%, lost contact of telephone was 71 (28.7%), successful contact of telephone was 71.3%. In the network group, implementation of contraception after three months of abortion:short-acting contraceptives 103 (47.2%),ICU 71(32.60%), condoms 39 (17.9%),norplant 1 (0.5%), rhythm /emergency contraception/withdrawal 2 (0.9%), unplanned pregnancies 2 (0.9%). In the telephone group,implementation of contraception after three months of abortion:short-acting contraceptives 54 (30.7%),condoms 59 (33.5%),ICU 54 (30.7%),norplant 1 (0.6%),rhythm/emergency contraception/withdrawal 4 (1.6%), unplanned pregnancies 4 (2.3%).There was significant difference in two group patients of abortions (χ2=18.756, P<0.05).3.4 Follow-up services after 6 months of abortion:The lost rate was increased significantly after six months of abortion, lost contact of network was 27 (11.3%), successful contact of network was 89.7%, lost contact of telephone was 105 (42.5%), successful contact of telephone was 57.5%. In the network group, implementation of contraception after six months of abortion:short-acting contraceptives 95 (44.8%),IUD 71(33.5%),condoms 41 (19.3%),norplant 1 (0.5%), rhythm /emergency contraception/withdrawal 2 (0.9%), unplanned pregnancies 2 (0.9%).In the telephone group,implementation of contraception after six months of abortion: short-acting contraceptives 31 (21.8%),condoms 54 (31.7%),IUD 53 (37.3%),norplant 1 (0.7%), rhythm/emergency contraception/withdrawal 7 (4.9%), unplanned pregnancies 5 (3.5.6%). There was significant difference in two group patients of abortions (χ2=26.567, P<0.05).3.5 The difference of lost contact between network and telephone follow-up services: The successful contact cases of telephone group was decreased significantly with time. There was only 142 successful cases responding the follow-up services, which was 57.4%. The lost rate of network group was higher significantly than the lost rate of telephone group.There was significant difference in two group patients after 3 months and after 6 months of abortions.Conclusion:1 In this study,although the number of induced abortions increased,declines were observed in the ratio of induced abortions to livebirths,the proportion of induced abortions among women of 15-24 years, those who were unmarried, had their first pregnancy, or had no history of delivery. This suggested the status of abortion seemed to getting better. Postabortion care (PAC) was a major measure to reduce induced abortion. However,the rates of induced abortions increased among women who were repeated aortion,had a history of caesarian section, or had risks such as their interpregnancy interval of<6months.We should carry out more research aimed at those women.2 The analysis of more factors suggested that the first five high risk factors were level of education of sexual partner, age, parity,the distance of previous abortion time and the way of abortion. The most of repeat abortion women is still the married women with one-child birth. Unmarried and married women terminate pregnancy for different reasons.The PAC services of hospitals could promote some women of childbearing age to choose efficient contraception, but it has limited effort.Induced abortion women could not get detailed consultation for shortage of medical staff, telephone follow-up keep increasing medical worker’s workloads and the effect was not ideal.3 PAC follow-up services was the key measures to guide women insist on the proper use of contraceptive methods.At present,the telephone follow-up service had limitations in most surgery institutions.However, the network of follow-up service was advantage of economical, convenient and without time and space constraints, which greatly improved the success rate of follow-up services and facilitate follow-up services and receive counseling with post abortion women.Only based on the actual situation and the wishes of abortion women, combined the network and telephone follow-up, the PAC follow-up services would be effective. Then, post abortion women would gradually take effective contraceptive measures,developed good habits of contraception and reduced the incidence of repeated abortions.Reducing induced abortion rate require the joint efforts of the government and the whole society,and it will not be an overnight change.We should further improve PAC by propagating knowledge of sexual health and contraceptive.So that women of childbearing age can successfully facilitate access to contraceptives for their own and reduce unexpected pregnancy.Research features and limitationThe current sociodemographic knowledge about women who had undergone induced abortions in China is limited by studies with a relatively small sample size or a lack of updated information. The study supported by the Development Foundation of women of China was large and continuous samples data, and all of the data was form the same hospital,so the heterogeneity level of our data was low.The study investigated the characteristics of women who underwent induced abortion during 4 years and made an analysis for repeated abortion women by quantitative method and qualitative method. The comprehensive data objectively revealed true formation of induced women and post abortion care,and tried to improve the effect by network follow up.The sample may not be an accurate reflection of the Chinese population because the population of patients attending a tertiary center may not be representative of the entire population.Howerve,the hospital is the largest medical centres which perform abortions in xiamen,and xiamen has developed commercial economy, thriving culture and open ideals in China,so the study can reflect the status of induced abortion in Chian to some extent. |
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