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Determinants of unwanted pregnancy and abortion in Beijing, China
Xiao Yang, Hu Yukun, Bai LiJun, and Jiang Xiuhua In thepast two decades, despite an increase in the contraceptiveprevalence rate to over90per cent, the rate ofinduced abortions in China has a!so increased. Based on interviews with women this study examines the reasons from Beijing undergoing induced abortions and theirpartners, why. it finds that lack of knowledge of how to use methods correctly and/or the choice of lower efficacy methods were responsible for many pregnancies. Another key factor was the contradiction between men’s refusal to take responsibility for contraception, at the same time as they demanded the fulfilment of their sexual desires. The paper discusses the Chinese Family Planning Programme’s failure to prioritise informed choice and male responsibility, and argues that women too have a responsibility to take care of themselves, and to stop subjecting themselves to unwanted pregnancies and repeated abortions.
HINA has had an effective, nationwide Family Planning Campaign since the early 1970s and there is now a widespread service delivery network throughout the country based in two parallel systems: family planning departments at all levels of government administration and at all levels of the health service, eg. in hospitals and maternal and child health centres. These are all responsible for publicity and education, distribution of contraceptives, training of family planning workers and implementation of birth targets. There are full-time or part-time family planning staff in all neighbourhoods and work units who are responsible for contraceptive education and distribution. A variety of safe, effective and convenient contraceptives are accessible and available to married women and men without charge. Abortion is legal, and safe abortion services are widely available on request as a backup for contraceptive failure. The major objectives of the current family planning policy are ‘control of population size and improvement of population quality’. Three major strategies are advocated to achieve these aims: ?? ??
??
one child per couple marriage at later ages and delaying births, and having fewer and better quality children.
first
In China today, most married women of reproductive age (or their spouses) use one or more contraceptive methods. China’s contraceptive prevalence rate of 91 per cent (1992) is far higher than the average of 50 per cent for developing countries.1,2 Despite this, knowledge of how contraceptive methods work and use effectiveness of reversible methods of contraception such as the pill or the condom, are not very high. Further, high levels of contraceptive use do not necessarily signify willing and informed adoption of contraception. Along with an increase in contraceptive use in the last two decades, the abortion rate and ratio have also risen in China. The ratio of abortions to live births among married women aged 15-49 increased from 14 per cent in 1976 to 28 per cent in 1987, almost doubling in 12 years. Rates of induced abortion are far higher in big cities such as Shanghai and Beijing, and are primarily responsible for the lower birth rates in urban areas, despite low contraceptive effectiveness rates. The ratio of abortions to live births among married women aged 15-57 in 1991 was the highest in Shanghai (41 per cent), followed by Beijing (35 per cent) and Tianjin (27 per centL3 In contrast, the inland and remote areas are characterised by low contraceptive effectiveness, lower induced abortion, and higher birth rates.
Xiao Yang, Hu Yukun,
Bai LiJun,
and Jiang
Xiuhua
Why is it that women are unable to use contraceptives effectively? And why do women become pregnant even when they know they should not have children or do not want to have children? What obstacles do they face? These are some of the concerns that motivated this study, which explored the determinants of unwanted pregnancy in three groups of women undergoing abortions and their partners: ?? ?? ??
unmarried women married women without children married women who have already given birth to children and had at least three induced abortions.
A PROFILE OF STUDY PARTICIPANTS The study was undertaken at Beijing Maternity Hospital, one of the top municipal hospitals in China providing comprehensive reproductive health services for women. The research population were women who attended the hospital for abortions, and their partners. Data was put together from several sources. Background information came mainly from a literature review and key informant interviews. Quantitative data were compiled from a questionnaire survey. The first two women who had just had abortions in the hospital every morning, and their partners, were invited to participate. In all, 100 women and 100 men participated. The questionnaire asked about contraceptive knowledge, attitudes, behaviour and aspirations. Qualitative data were collected through indepth interviews with 61 people, including 32 women in almost equal numbers from each of the three groups who participated in the survey and their partners. Characteristics of the women participating in the in-depth interviews were broadly similar to those covered by the survey. Additional interviews were held with health and social science professionals and family planning staff from some state and municipal agencies in Beijing. Two thirds of the 100 women who answered the questionnaire survey were between 20 and 29 years old. More than half (52) had completed university education. Most (95) were economically active. There were 52 employed by the state, 36 factory workers, 4 peasants, and 3 selfemployed. There was a higher representation of
state employees and women with higher education among study participants than in the general population. All the women stated that the pregnancy they had just terminated had been unwanted or unintended. In the case of 44 of them, the abortion was their first. An analysis of the survey information, as well as the in-depth interviews, suggests that three important factors underlay non-use as well as ineffective use of contraceptives.
LACK OF ADEQUATE KNOWLEDGE ABOUT CONCEPTION AND CONTRACEPTION Irrespective of their marital or contraceptive use status, there were some women whose pregnancies were the result of a poor understanding of how conception occurs, or incorrect and inadequate information about the contraceptive methods available.
Unmet need for sex education and contraception among young people Xiao Zhang was a ZO-year-old university student, and her boyfriend Yiao Wang had just graduated from university. They were not using contraception and had no idea where to obtain contraceptives. Xiao Zhang had not menstruated for more than two months, but they did not know that this could be a sign ofpregnancy. They found out what was wrong with her when she was sent to hospital after falling down in a faint one day. By that time, she was over three months' pregnant. Xiao Zhang sought an abortion so that she could continue her studies. The doctors at Beijing Maternity Hospital told us that this story was not unusual, even for those with higher education. Newly-wed not using
Xiao Li works in an office. She was contraception and became pregnant.
When asked why she was not using contraception when she did not want a child, Xiao Li answered: ‘I read in a journal that recently married couples would not get pregnant because the successful meeting of mature sperm and egg takes over 48 hours. We are newly married, and have so+~al intercourse almost every night. I thought that with old and new sperm eating each other, none of them will survive more than 48 hours. Therefore, I thought no pregnancy would happen.
Kcproductwc
There is a growing need among unmarried or recently married young people for information on contraception and sexuality. In recent years, unwanted pregnancy among the unmarried has accounted for nearly one quarter of the total young people have in some cities.’ Although specific needs which require priority attention, existing services are limited exclusively to the married population. There is little in the way of family planning education, counselling or contraceptive services directed at young unmarried people. From what many of the interviewees said, we put together the following facts concerning sexual and contraceptive education in present day China. Few primary or secondary schools in Beijing offer these courses. Even in the schools that do, when the teachers talk about the male and female reproductive tract they feel embarrassed and ask the students to read it for themselves. At home, parents do not consider it their responsibility to provide contraceptive information to their children. In cases where children ask about it, the parents’ stance is
Women
sing the factory anthem,
People’s
usually ashamed pictures couples ample, did not spouses
Health
Matters,
No 5, May
1995
one of avoidance. Unmarried women feel to seek counselling, or even to look at in educational material. In fact, even hesitate to discuss the topic. For exone third of the participants in this study know which contraceptive method their preferred.
Lack of information methods
on contraceptive
There is a wide chasm between women’s need for information and the kind of information available. When asked if they knew about modern methods of contraception, more than a third of both women and men thought they knew about all the methods, while the rest indicated they had a very limited knowledge or none at all. Examination of the women’s sources of contraceptive knowledge showed that the information was mainly derived from books and periodicals. Of the 100 women, 65 had learned from books and periodicals, 20 from family planning staff, 19 from friends, 17 from partners and 2 each from parents, hospital or pre-marriage
Liberation
Army
Shoe Factory,
Canton
Xiao Yang, Hu Yukun,
Bai LiJun,
and Jiang
Xiuhua
health check-up division, and only 1 from school. Eight had no knowledge at all. It is worth noting that nobody got contraceptive information from TV or radio programmes or from counselling services in hospitals or health centres. At present, the popular media are not providing adequate information, yet the majority of women are relying on them. The books and periodicals women are reading contain scant information on newly developed contraceptive techniques, such as subdermal implants, or on lesser used but proven methods such as male sterilisation, let alone on how the different methods of contraception work, their effectiveness, contra-indications and side-effects. Further, even when the information is provided it is sometimes inaccurate. Of the 32 women with whom we did in-depth interviews, 27 said they needed to know more about the various contraceptive methods and how they work. There were varying preferences as to where they wanted to get such information, which included courses on physiology and health, radio and TV programmes, educational materials from the premarital health check-up division or the marriage registry division, books and periodicals, or family planning staff.
Contraceptive
use effectiveness
Twenty of the women had not used any contraceptive method prior to this abortion. Of those who had used a method, methods used were rhythm (301, condoms (151, withdrawal (14), IUD (91, the pill (8), and the diaphragm (4). Non-use of contraceptives, and the use of barrier and natural methods among the study participants, was much higher than the average for Beijing.4 A majority of the women using the rhythm method did not know when the ‘safe period’ was. According to some, it was three or five days before and after the last menstrual period, while others believed it to be seven days before and eight days after the menstrual period. One woman thought the menstrual period was the safe period. Women using the pill often did not know how many pills to take or for how long, or did not remember to take one every day. With the diaphragm, women had problems positioning it to cover the cervix, and could not anticipate when they would need it. Those using an IUD did not know what kind they were using or how it worked, and were not aware of the
need to check from time to time to see if it was still in place. Some men in the survey group did not know what size of condom fit them best, how to put them on correctly, or what to do as backup if a condom broke during intercourse. Thus, both lack of knowledge of how to use the methods correctly and/or the choice of lower efficacy methods resulted in unintended and unwanted pregnancies. Sixty-three of the 100 women in the survey had become pregnant due to incorrect use of a method, while for 17 women, pregnancy had occurred despite correct use of the method.
Inadequate attention to education and counselling Although family planning workers spend a great deal of time on publicity and information dissemination, they have tended to focus on increasing the number of new acceptors of contraception and achieving a reduction in population growth rates. Little is said about the correct use of the different methods, their relative benefits and limitations, or possible side-effects. In fact, many family planning workers themselves do not know enough about these matters. Instead, what is on offer is propaganda about the importance of birth control and of the ‘one-child’ norm, and that is mainly how family planning information is perceived. As for the health care system, a great majority of hospitals have outpatient departments for family planning, but their major duty is to terminate pregnancies, perform sterilisations or provide other clinical methods of birth control. Counselling services are grossly inadequate. Even in the Beijing Maternity Hospital, where this study was conducted, there was only one person in charge of contraceptive counselling for the many post-abortion patients.
MEN DO NOTCOOPERATE The role of men in unwanted and unintended pregnancies has largely been neglected. Eliciting information about men’s attitudes to and use of contraception could contribute greatly to an understanding of how such pregnancies may be avoided, from the perspective of the men themselves. We found that men did not take into account
Reproductive
either their wives’ health or willingness to have sex, in the satisfaction of their own sexual desires. During the in-depth interviews, women shared numerous instances of lack of support from their partners in preventing unwanted pregnancy. Some said that their partners were responsible for the pregnancy that they had just terminated, including some who had had several abortions. None of these women’s partners disagreed with this view. When we asked the women to list the major obstacles to preventing accidental pregnancy, the key issue for most of them was lack of cooperation from men.
Mrs Guan, a 42-year-old accountant, had come to the hospital for her fourth abortion. With tears streaming down her face, she said: /My husband cares a great deal for me except when it comes to sex. 1 am less interested in love-making since the birth of my children, while his desire for sex is still strong and he will not agree to use condoms. I often get angry with his insistence on having sex without contraception. However, 1 still give in sometimes. I’m afraid if I always refuse, it will cause emotional stress between us. During the last year alone, 1 have had an abortion twice. Now I have become frightened and nervous about having sex.. One of my colleagues suffers even more than me. She is frequently forced by her husband to have sex when she doesn’t want it. As a result, she has had to have three abortions in just one year. Whenever she tries to argue with her husband, he always answers back that he only took a wife for sex. She is now attempting to get a divorce from him. Why is it that women have to bear the burden alone, giving birth or having abortions? It’s too unfair.’ Like Mrs Guan’s colleague, some of the women we interviewed also expressed the wish to divorce their husbands and non-cooperation with contraception was one of the reasons they mentioned. Some confessed that if only they had firmly rejected their husbands’ demand for sex, this unintentional pregnancy would never have happened, but that this would have had a bad effect on their relationships. When men in the survey group were asked what method of contraception they intended to use after their wives’ abortions, 11 of the 100 said that they had not thought about it. More than
Health
Matters,
No 5, May 1995
half said they did not concern themselves with it because it was ‘women’s business’ and women should undertake the responsibility. Eight planned to use the rhythm method. Only 18 men said that they themselves intended to adopt contraception henceforth. Men in the interview group made similar remarks. The contradiction between men’s refusal to take responsibility for contraception, at the same time as they demand the fulfilment of their sexual desires, inevitably increases the incidence of unwanted pregnancy. Over a decade of publicity by the Chinese family planning programme ‘Husband has a responsibility for family planin changing male ning’ - has not succeeded attitudes and Chinese men of reproductive age have not rid themselves of the traditional values of male domination. A few men who were using condoms did not admit to it (we only learnt this from their partners); they even said they would not accept education on contraception if it were offered.
Mr. Cheng is 38 years old and a worker. This was the third time his wife was coming for an abortion. Talking about using contraception in the future, Mr. Cheng said: ‘My wife has had abortions several times and suffered greatly from repeated pregnancies. I can understand why I should be practising contraception, but I can’t explain why, when thinking about using contraceptives, I invariably feel terribly uncomfortable. It seems like a loss of face for a man to use contraceptives. Although the condom is safe and has no harmful health effects, I still feel resistant to using it. People always say it isn’t easy to be a woman. Nowadays, it is not easy being a man either. What man would even have considered practising contraception in the past?’ To some extent, male indifference in matters related to fertility control is a consequence of the family planning programme’s exclusive attention to women, and the non-availability of contraceptive services directed at men. The great majority of women and men in the survey reported that family planning services for men were not available within their communities. Even malespecific methods such as the condom are usually supplied to women at their work units. Nearly everyone who works in family planning and nearly everyone \\ho attends farnil)
Xlao
Yang, Hu Yukun,
Bai LiJun,
Compulsory
and Jiang
Xiuhua
15 minute rest, People’s
planning conferences is a woman, particularly at the grassroots level. The success of targets such as a decline in the incidence of unwanted pregnancies or a rise in contraceptive use is also measured in relation to women. Furthermore, women alone are punished for not keeping within the birth targets. A striking example that came out in our survey was an instance where the wife had experienced repeated abortions, while the husband won a prize for family planning. Such practices on the part of the family planning programme inevitably strengthen the notion that contraception is women’s responsibility, and help to absolve men of playing their part in preventing unwanted pregnancies. Just over half of the women and men in the survey suggested that publicity, education, and counselling for family planning should also be directed at men and that men should be able to obtain contraceptives; this would help to make the prevention of unwanted pregnancy a joint responsibility.
Liberation
Army Shoe Factory, Canton
WOMEN HAVE TO TAKE RESPONSIBILITY TOO! Women in urban areas generally enjoy a high status within the family in present day China, and they too have a responsibility to take care of themselves, instead of subjecting themselves to unwanted pregnancies and repeated abortions. If they did, they would refuse their partners, they would practice contraception or insist that their partners did so, and they would accord due priority to regular screening and check-ups at the same time. For example, women with IUDs were told to return for screening every six months, but none of the women who had an IUD failure had ever come for screening or even carried out selfexamination to ensure that the IUD was still in place, despite the lapse of one to five years since the insertion. They had never thought about it, and said they did not have the time to attend to the matter, or that it was too much trouble to return to the hospital for regular screening. Further, women have to rid themselves of
Reproductive
notions such as that it is their duty to meet their husbands’ demands for sex or that women are destined to suffer more than men in matters related to sexuality and reproduction because of physiological differences. Instead, because safe abortion services are widely available in China and ending a pregnancy is not life-threatening, women are taking the soft option of terminating unwanted pregnancies. In-depth interviews with women revealed that women’s concerns about the consequences of induced abortion centred not around themselves, but around possible implications for future sexuality and fertility. Women without any children were concerned that an induced abortion might lead to spontaneous abortions or infertility, whereas women who were already mothers were anxious that repeat abortions should not impair their ability to keep up with their husbands’ demands for sex. Few cared about their own health. Thus, among the 300 million women of reproductive age in China and the 3 million women living in Beijing, if there were a lack of awareness and lack of self-care in practising contraception among even one percent, it would lead to millions of abortions every year.
ROLE OF
THE ALL CHINA WOMEN’S FEDERATION The All China Women’s Federation, the largest nationwide women’s organisation in China, can play an important role. The Federation has over 90,000 staff working at all levels of women’s federations, whose aim is to improve the status and wellbeing of Chinese women. All branches countrywide should take the leadership in raising women’s awareness and ability to take better care of their health. The most pressing task facing them is wider dissemination of information on sexuality, reproduction and contraception. There are more than 30 women’s magazines run by branches at the central and provincial levels, and to date these have paid insufficient attention to these issues. Local branches might find it worthwhile to integrate the ‘Five Periods Protection’ into in-service training courses for their staff. This refers to protecting women at the onset of menstruation, during pregnancy, childbirth and
tfealth
Matters. No 5, Mdk
19%
puerperium, and during the menopause. The All China Women’s Federation has initiated several education and research projects on women’s health, such as a nationwide competition for women on knowledge of women’s health care, and a competition inviting proposals for research on reproductive health. Such initiatives should continue, and further research on women’s health needs and health-seeking behaviour carried out.
RECOMMENDATIONS The time has come for the Chinese Family Planning Programme to shift its efforts from publicising the one-child policy and implementing birth targets, to putting a greater focus on women’s health needs. For this purpose, it is essential to enhance the professional skills and sense of commitment to this goal on the part of family planning staff. Women’s reproductive health concerns should become an integral part of the Family Planning Programme, and indicators for assessing programme performance should include women’s ability to control their sexuality and fertility: level of contraceptive knowledge, access to information and services, and ability to prevent unwanted pregnancies. Education and services for young people should become a high priority, eg. education on sexuality, physiology and reproduction, telephone hotlines for contraceptive advice, vending machines for contraceptives, and programmes about sexuality, contraception and reproduction on radio and TV. All these efforts would go a long way towards meeting the needs of young unmarried couples who feel too embarrassed to seek advice, or to buy or borrow books on contraception. In addition, the pre-marital health check-up division and the marriage registry division should provide contraceptive knowledge and guidance for prospective couples, both the man and the woman. Lastly, contraceptive services should be available to unmarried people at all service delivery points. Schools for newly-wed couples have emerged in some places in recent years, whose aim is helping young people, particularly newlyweds, with starting their life together. The curriculum includes information on economic nlanagcmci~i,
Xiao
Yang,Hu Yukun, Bai LiJun, and Jiang Xiuhua
inter-personal and family relationships; maternal health care; the care and education of babies and children; and sexuality, reproduction and contraception. Many more such schools are needed. Existing family planning services need to be improved. Contraceptive supply alone cannot create sustained contraceptive use. Informed choice is currently lacking and should become an important component of propaganda, education and counselling. State Family Planning Committees could establish expert panels to develop pamphlets on contraception and sexuality with comprehensive and accurate information for different age groups. More male staff and administrators should be recruited for family planning service delivery. Short-term workshops could be organised for men at their work sites. Men accompanying their partners undergoing abortions should be given information on the health risks of repeated abortion, and on male contraceptive methods, eg. through pamphlets or videos while they wait. Hospitals need to prioritise counselling on contraception and sexuality for women, particularly for those
seeking
abortions
-to
to select more suitable
methods of contraception and understand the factors responsible for their unwanted pregnancies. Better coordination between health professionals and family planning service providers in providing information and counselling would be a welcome development. Promotion of male sterilisation should become a priority. There is a successful model in Sichuan Province, which demonstrates that it is possible to increase acceptance of male sterilisation. Moreover, the Family Planning Programme should regard its accomplishments with men as an integral part of the evaluation of its programme performance. The male contraceptive prevalence rate should be as important an indicator as contraceptive prevalence rates among women. Note The research project on which this paper is based was one of 20 projects prepared for the Reproductive Health Research Competition, funded by the Ford Foundation. Translated from Chinese by Hu Yukun.
help them
References 1.
China Population Statistics (Year Book), 1993. State Statistics
Bureau, Beijing, 1993. 2. Fathalla MF, 1992. Reproductive health in the worlds: Two decades of progress and the challenge ahead. Research in Human Reproduction, Biennial Report 7990-91. World Health
Organization,
Geneva.
3 Kang Xiaoping, 1991. The trend and determinating factors of induced abortion for married women in China. China Demographic
Sciences.
2:48.
4 In 1992, only 10 per cent of women of reproductive age or their spouses did not use a method of contraception in Beijing. Choice of contraceptive
methods for the city as a whole, was as follows: IUD (62 per cent), condom (15 per cent), female sterilisation (11 per cent), pill (9 per cent), diaphragm and other methods (2 per cent) and male sterilisation (0.4 per cent).
Reproductive
RBSUMB Ces vingt dernieres
an&es, bien que le taux de prevalence contraceptive se soit eleve audessus de 90%, le taux d’avortements provoques a augmente lui aussi en Chine. Se fondant sur des entretiens avec des femmes de Beijing subissant une interruption de grossesse et avec leurs partenaires, cette etude recherche la raison d’une telle situation. Elle a constate que le mangue de connaissances sur l’utilisation correcte des methodes et/au le choix de methodes d’efficacite moindre etaient a I’origine de nombreuses grossesses. Un autre point important est que les hommes se refusent a assumer une quelconque responsabilite dans la contraception, en m&me temps qu’ils exigent la satisfaction de leurs desirs sexuels. Les auteurs discutent de l’echec du programme chinois de planification familiale a mettre au premier rang le choix Cclaire ainsi que la responsabilite masculine, et fait valoir qu’il incombe aux femmes aussi de prendre soin d’elles-memes, et de cesser de se soumettre aux grossesses non desirees et aux avortements a repetition.
Health
Matters,
No 5, May 1995
RESUMEN En las ultimas dos decadas, a pesar de1 incremento a mas del 90 por ciento en la tasa de prevalencia anticonceptiva en China, la tasa de abortos provocados tambien se ha visto incrementada. Basado en entrevistas con mujeres en proceso de hacerse un abort0 y con sus compaiieros, este trabajo analiza la razon de estas cifras. El estudio seiiala que detras de muchos embarazos esta la falta de conocimientos sobre la utilization adecuada de 10s metodos y/o la escogencia de metodos de menor eficacia. Otro element0 clave es la contradiction entre el rechazo, por parte de1 hombre, a aceptar su responsabilidad en el proceso de control de natalidad, a la vez que exige plena satisfaction de sus deseos sexuales. El trabajo examina coma el Programa de Planificiacion Familiar de la China no ha dado prioridad a la posibilidad de tomar decisiones basadas en buena information, ni al aspect0 de la responsabilidad masculina. Plantea, ademas, que la mujer tambien tiene la responsabilidad de cuidarse a si misma y de impedir el verse sometida a embarazos no deseados y a repetidos abortos.
HINA has had an effective, nationwide Family Planning Campaign since the early 1970s and there is now a widespread service delivery network throughout the country based in two parallel systems: family planning departments at all levels of government administration and at all levels of the health service, eg. in hospitals and maternal and child health centres. These are all responsible for publicity and education, distribution of contraceptives, training of family planning workers and implementation of birth targets. There are full-time or part-time family planning staff in all neighbourhoods and work units who are responsible for contraceptive education and distribution. A variety of safe, effective and convenient contraceptives are accessible and available to married women and men without charge. Abortion is legal, and safe abortion services are widely available on request as a backup for contraceptive failure. The major objectives of the current family planning policy are ‘control of population size and improvement of population quality’. Three major strategies are advocated to achieve these aims: ?? ??
??
one child per couple marriage at later ages and delaying births, and having fewer and better quality children.
first
In China today, most married women of reproductive age (or their spouses) use one or more contraceptive methods. China’s contraceptive prevalence rate of 91 per cent (1992) is far higher than the average of 50 per cent for developing countries.1,2 Despite this, knowledge of how contraceptive methods work and use effectiveness of reversible methods of contraception such as the pill or the condom, are not very high. Further, high levels of contraceptive use do not necessarily signify willing and informed adoption of contraception. Along with an increase in contraceptive use in the last two decades, the abortion rate and ratio have also risen in China. The ratio of abortions to live births among married women aged 15-49 increased from 14 per cent in 1976 to 28 per cent in 1987, almost doubling in 12 years. Rates of induced abortion are far higher in big cities such as Shanghai and Beijing, and are primarily responsible for the lower birth rates in urban areas, despite low contraceptive effectiveness rates. The ratio of abortions to live births among married women aged 15-57 in 1991 was the highest in Shanghai (41 per cent), followed by Beijing (35 per cent) and Tianjin (27 per centL3 In contrast, the inland and remote areas are characterised by low contraceptive effectiveness, lower induced abortion, and higher birth rates.
Xiao Yang, Hu Yukun,
Bai LiJun,
and Jiang
Xiuhua
Why is it that women are unable to use contraceptives effectively? And why do women become pregnant even when they know they should not have children or do not want to have children? What obstacles do they face? These are some of the concerns that motivated this study, which explored the determinants of unwanted pregnancy in three groups of women undergoing abortions and their partners: ?? ?? ??
unmarried women married women without children married women who have already given birth to children and had at least three induced abortions.
A PROFILE OF STUDY PARTICIPANTS The study was undertaken at Beijing Maternity Hospital, one of the top municipal hospitals in China providing comprehensive reproductive health services for women. The research population were women who attended the hospital for abortions, and their partners. Data was put together from several sources. Background information came mainly from a literature review and key informant interviews. Quantitative data were compiled from a questionnaire survey. The first two women who had just had abortions in the hospital every morning, and their partners, were invited to participate. In all, 100 women and 100 men participated. The questionnaire asked about contraceptive knowledge, attitudes, behaviour and aspirations. Qualitative data were collected through indepth interviews with 61 people, including 32 women in almost equal numbers from each of the three groups who participated in the survey and their partners. Characteristics of the women participating in the in-depth interviews were broadly similar to those covered by the survey. Additional interviews were held with health and social science professionals and family planning staff from some state and municipal agencies in Beijing. Two thirds of the 100 women who answered the questionnaire survey were between 20 and 29 years old. More than half (52) had completed university education. Most (95) were economically active. There were 52 employed by the state, 36 factory workers, 4 peasants, and 3 selfemployed. There was a higher representation of
state employees and women with higher education among study participants than in the general population. All the women stated that the pregnancy they had just terminated had been unwanted or unintended. In the case of 44 of them, the abortion was their first. An analysis of the survey information, as well as the in-depth interviews, suggests that three important factors underlay non-use as well as ineffective use of contraceptives.
LACK OF ADEQUATE KNOWLEDGE ABOUT CONCEPTION AND CONTRACEPTION Irrespective of their marital or contraceptive use status, there were some women whose pregnancies were the result of a poor understanding of how conception occurs, or incorrect and inadequate information about the contraceptive methods available.
Unmet need for sex education and contraception among young people Xiao Zhang was a ZO-year-old university student, and her boyfriend Yiao Wang had just graduated from university. They were not using contraception and had no idea where to obtain contraceptives. Xiao Zhang had not menstruated for more than two months, but they did not know that this could be a sign ofpregnancy. They found out what was wrong with her when she was sent to hospital after falling down in a faint one day. By that time, she was over three months' pregnant. Xiao Zhang sought an abortion so that she could continue her studies. The doctors at Beijing Maternity Hospital told us that this story was not unusual, even for those with higher education. Newly-wed not using
Xiao Li works in an office. She was contraception and became pregnant.
When asked why she was not using contraception when she did not want a child, Xiao Li answered: ‘I read in a journal that recently married couples would not get pregnant because the successful meeting of mature sperm and egg takes over 48 hours. We are newly married, and have so+~al intercourse almost every night. I thought that with old and new sperm eating each other, none of them will survive more than 48 hours. Therefore, I thought no pregnancy would happen.
Kcproductwc
There is a growing need among unmarried or recently married young people for information on contraception and sexuality. In recent years, unwanted pregnancy among the unmarried has accounted for nearly one quarter of the total young people have in some cities.’ Although specific needs which require priority attention, existing services are limited exclusively to the married population. There is little in the way of family planning education, counselling or contraceptive services directed at young unmarried people. From what many of the interviewees said, we put together the following facts concerning sexual and contraceptive education in present day China. Few primary or secondary schools in Beijing offer these courses. Even in the schools that do, when the teachers talk about the male and female reproductive tract they feel embarrassed and ask the students to read it for themselves. At home, parents do not consider it their responsibility to provide contraceptive information to their children. In cases where children ask about it, the parents’ stance is
Women
sing the factory anthem,
People’s
usually ashamed pictures couples ample, did not spouses
Health
Matters,
No 5, May
1995
one of avoidance. Unmarried women feel to seek counselling, or even to look at in educational material. In fact, even hesitate to discuss the topic. For exone third of the participants in this study know which contraceptive method their preferred.
Lack of information methods
on contraceptive
There is a wide chasm between women’s need for information and the kind of information available. When asked if they knew about modern methods of contraception, more than a third of both women and men thought they knew about all the methods, while the rest indicated they had a very limited knowledge or none at all. Examination of the women’s sources of contraceptive knowledge showed that the information was mainly derived from books and periodicals. Of the 100 women, 65 had learned from books and periodicals, 20 from family planning staff, 19 from friends, 17 from partners and 2 each from parents, hospital or pre-marriage
Liberation
Army
Shoe Factory,
Canton
Xiao Yang, Hu Yukun,
Bai LiJun,
and Jiang
Xiuhua
health check-up division, and only 1 from school. Eight had no knowledge at all. It is worth noting that nobody got contraceptive information from TV or radio programmes or from counselling services in hospitals or health centres. At present, the popular media are not providing adequate information, yet the majority of women are relying on them. The books and periodicals women are reading contain scant information on newly developed contraceptive techniques, such as subdermal implants, or on lesser used but proven methods such as male sterilisation, let alone on how the different methods of contraception work, their effectiveness, contra-indications and side-effects. Further, even when the information is provided it is sometimes inaccurate. Of the 32 women with whom we did in-depth interviews, 27 said they needed to know more about the various contraceptive methods and how they work. There were varying preferences as to where they wanted to get such information, which included courses on physiology and health, radio and TV programmes, educational materials from the premarital health check-up division or the marriage registry division, books and periodicals, or family planning staff.
Contraceptive
use effectiveness
Twenty of the women had not used any contraceptive method prior to this abortion. Of those who had used a method, methods used were rhythm (301, condoms (151, withdrawal (14), IUD (91, the pill (8), and the diaphragm (4). Non-use of contraceptives, and the use of barrier and natural methods among the study participants, was much higher than the average for Beijing.4 A majority of the women using the rhythm method did not know when the ‘safe period’ was. According to some, it was three or five days before and after the last menstrual period, while others believed it to be seven days before and eight days after the menstrual period. One woman thought the menstrual period was the safe period. Women using the pill often did not know how many pills to take or for how long, or did not remember to take one every day. With the diaphragm, women had problems positioning it to cover the cervix, and could not anticipate when they would need it. Those using an IUD did not know what kind they were using or how it worked, and were not aware of the
need to check from time to time to see if it was still in place. Some men in the survey group did not know what size of condom fit them best, how to put them on correctly, or what to do as backup if a condom broke during intercourse. Thus, both lack of knowledge of how to use the methods correctly and/or the choice of lower efficacy methods resulted in unintended and unwanted pregnancies. Sixty-three of the 100 women in the survey had become pregnant due to incorrect use of a method, while for 17 women, pregnancy had occurred despite correct use of the method.
Inadequate attention to education and counselling Although family planning workers spend a great deal of time on publicity and information dissemination, they have tended to focus on increasing the number of new acceptors of contraception and achieving a reduction in population growth rates. Little is said about the correct use of the different methods, their relative benefits and limitations, or possible side-effects. In fact, many family planning workers themselves do not know enough about these matters. Instead, what is on offer is propaganda about the importance of birth control and of the ‘one-child’ norm, and that is mainly how family planning information is perceived. As for the health care system, a great majority of hospitals have outpatient departments for family planning, but their major duty is to terminate pregnancies, perform sterilisations or provide other clinical methods of birth control. Counselling services are grossly inadequate. Even in the Beijing Maternity Hospital, where this study was conducted, there was only one person in charge of contraceptive counselling for the many post-abortion patients.
MEN DO NOTCOOPERATE The role of men in unwanted and unintended pregnancies has largely been neglected. Eliciting information about men’s attitudes to and use of contraception could contribute greatly to an understanding of how such pregnancies may be avoided, from the perspective of the men themselves. We found that men did not take into account
Reproductive
either their wives’ health or willingness to have sex, in the satisfaction of their own sexual desires. During the in-depth interviews, women shared numerous instances of lack of support from their partners in preventing unwanted pregnancy. Some said that their partners were responsible for the pregnancy that they had just terminated, including some who had had several abortions. None of these women’s partners disagreed with this view. When we asked the women to list the major obstacles to preventing accidental pregnancy, the key issue for most of them was lack of cooperation from men.
Mrs Guan, a 42-year-old accountant, had come to the hospital for her fourth abortion. With tears streaming down her face, she said: /My husband cares a great deal for me except when it comes to sex. 1 am less interested in love-making since the birth of my children, while his desire for sex is still strong and he will not agree to use condoms. I often get angry with his insistence on having sex without contraception. However, 1 still give in sometimes. I’m afraid if I always refuse, it will cause emotional stress between us. During the last year alone, 1 have had an abortion twice. Now I have become frightened and nervous about having sex.. One of my colleagues suffers even more than me. She is frequently forced by her husband to have sex when she doesn’t want it. As a result, she has had to have three abortions in just one year. Whenever she tries to argue with her husband, he always answers back that he only took a wife for sex. She is now attempting to get a divorce from him. Why is it that women have to bear the burden alone, giving birth or having abortions? It’s too unfair.’ Like Mrs Guan’s colleague, some of the women we interviewed also expressed the wish to divorce their husbands and non-cooperation with contraception was one of the reasons they mentioned. Some confessed that if only they had firmly rejected their husbands’ demand for sex, this unintentional pregnancy would never have happened, but that this would have had a bad effect on their relationships. When men in the survey group were asked what method of contraception they intended to use after their wives’ abortions, 11 of the 100 said that they had not thought about it. More than
Health
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No 5, May 1995
half said they did not concern themselves with it because it was ‘women’s business’ and women should undertake the responsibility. Eight planned to use the rhythm method. Only 18 men said that they themselves intended to adopt contraception henceforth. Men in the interview group made similar remarks. The contradiction between men’s refusal to take responsibility for contraception, at the same time as they demand the fulfilment of their sexual desires, inevitably increases the incidence of unwanted pregnancy. Over a decade of publicity by the Chinese family planning programme ‘Husband has a responsibility for family planin changing male ning’ - has not succeeded attitudes and Chinese men of reproductive age have not rid themselves of the traditional values of male domination. A few men who were using condoms did not admit to it (we only learnt this from their partners); they even said they would not accept education on contraception if it were offered.
Mr. Cheng is 38 years old and a worker. This was the third time his wife was coming for an abortion. Talking about using contraception in the future, Mr. Cheng said: ‘My wife has had abortions several times and suffered greatly from repeated pregnancies. I can understand why I should be practising contraception, but I can’t explain why, when thinking about using contraceptives, I invariably feel terribly uncomfortable. It seems like a loss of face for a man to use contraceptives. Although the condom is safe and has no harmful health effects, I still feel resistant to using it. People always say it isn’t easy to be a woman. Nowadays, it is not easy being a man either. What man would even have considered practising contraception in the past?’ To some extent, male indifference in matters related to fertility control is a consequence of the family planning programme’s exclusive attention to women, and the non-availability of contraceptive services directed at men. The great majority of women and men in the survey reported that family planning services for men were not available within their communities. Even malespecific methods such as the condom are usually supplied to women at their work units. Nearly everyone who works in family planning and nearly everyone \\ho attends farnil)
Xlao
Yang, Hu Yukun,
Bai LiJun,
Compulsory
and Jiang
Xiuhua
15 minute rest, People’s
planning conferences is a woman, particularly at the grassroots level. The success of targets such as a decline in the incidence of unwanted pregnancies or a rise in contraceptive use is also measured in relation to women. Furthermore, women alone are punished for not keeping within the birth targets. A striking example that came out in our survey was an instance where the wife had experienced repeated abortions, while the husband won a prize for family planning. Such practices on the part of the family planning programme inevitably strengthen the notion that contraception is women’s responsibility, and help to absolve men of playing their part in preventing unwanted pregnancies. Just over half of the women and men in the survey suggested that publicity, education, and counselling for family planning should also be directed at men and that men should be able to obtain contraceptives; this would help to make the prevention of unwanted pregnancy a joint responsibility.
Liberation
Army Shoe Factory, Canton
WOMEN HAVE TO TAKE RESPONSIBILITY TOO! Women in urban areas generally enjoy a high status within the family in present day China, and they too have a responsibility to take care of themselves, instead of subjecting themselves to unwanted pregnancies and repeated abortions. If they did, they would refuse their partners, they would practice contraception or insist that their partners did so, and they would accord due priority to regular screening and check-ups at the same time. For example, women with IUDs were told to return for screening every six months, but none of the women who had an IUD failure had ever come for screening or even carried out selfexamination to ensure that the IUD was still in place, despite the lapse of one to five years since the insertion. They had never thought about it, and said they did not have the time to attend to the matter, or that it was too much trouble to return to the hospital for regular screening. Further, women have to rid themselves of
Reproductive
notions such as that it is their duty to meet their husbands’ demands for sex or that women are destined to suffer more than men in matters related to sexuality and reproduction because of physiological differences. Instead, because safe abortion services are widely available in China and ending a pregnancy is not life-threatening, women are taking the soft option of terminating unwanted pregnancies. In-depth interviews with women revealed that women’s concerns about the consequences of induced abortion centred not around themselves, but around possible implications for future sexuality and fertility. Women without any children were concerned that an induced abortion might lead to spontaneous abortions or infertility, whereas women who were already mothers were anxious that repeat abortions should not impair their ability to keep up with their husbands’ demands for sex. Few cared about their own health. Thus, among the 300 million women of reproductive age in China and the 3 million women living in Beijing, if there were a lack of awareness and lack of self-care in practising contraception among even one percent, it would lead to millions of abortions every year.
ROLE OF
THE ALL CHINA WOMEN’S FEDERATION The All China Women’s Federation, the largest nationwide women’s organisation in China, can play an important role. The Federation has over 90,000 staff working at all levels of women’s federations, whose aim is to improve the status and wellbeing of Chinese women. All branches countrywide should take the leadership in raising women’s awareness and ability to take better care of their health. The most pressing task facing them is wider dissemination of information on sexuality, reproduction and contraception. There are more than 30 women’s magazines run by branches at the central and provincial levels, and to date these have paid insufficient attention to these issues. Local branches might find it worthwhile to integrate the ‘Five Periods Protection’ into in-service training courses for their staff. This refers to protecting women at the onset of menstruation, during pregnancy, childbirth and
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puerperium, and during the menopause. The All China Women’s Federation has initiated several education and research projects on women’s health, such as a nationwide competition for women on knowledge of women’s health care, and a competition inviting proposals for research on reproductive health. Such initiatives should continue, and further research on women’s health needs and health-seeking behaviour carried out.
RECOMMENDATIONS The time has come for the Chinese Family Planning Programme to shift its efforts from publicising the one-child policy and implementing birth targets, to putting a greater focus on women’s health needs. For this purpose, it is essential to enhance the professional skills and sense of commitment to this goal on the part of family planning staff. Women’s reproductive health concerns should become an integral part of the Family Planning Programme, and indicators for assessing programme performance should include women’s ability to control their sexuality and fertility: level of contraceptive knowledge, access to information and services, and ability to prevent unwanted pregnancies. Education and services for young people should become a high priority, eg. education on sexuality, physiology and reproduction, telephone hotlines for contraceptive advice, vending machines for contraceptives, and programmes about sexuality, contraception and reproduction on radio and TV. All these efforts would go a long way towards meeting the needs of young unmarried couples who feel too embarrassed to seek advice, or to buy or borrow books on contraception. In addition, the pre-marital health check-up division and the marriage registry division should provide contraceptive knowledge and guidance for prospective couples, both the man and the woman. Lastly, contraceptive services should be available to unmarried people at all service delivery points. Schools for newly-wed couples have emerged in some places in recent years, whose aim is helping young people, particularly newlyweds, with starting their life together. The curriculum includes information on economic nlanagcmci~i,
Xiao
Yang,Hu Yukun, Bai LiJun, and Jiang Xiuhua
inter-personal and family relationships; maternal health care; the care and education of babies and children; and sexuality, reproduction and contraception. Many more such schools are needed. Existing family planning services need to be improved. Contraceptive supply alone cannot create sustained contraceptive use. Informed choice is currently lacking and should become an important component of propaganda, education and counselling. State Family Planning Committees could establish expert panels to develop pamphlets on contraception and sexuality with comprehensive and accurate information for different age groups. More male staff and administrators should be recruited for family planning service delivery. Short-term workshops could be organised for men at their work sites. Men accompanying their partners undergoing abortions should be given information on the health risks of repeated abortion, and on male contraceptive methods, eg. through pamphlets or videos while they wait. Hospitals need to prioritise counselling on contraception and sexuality for women, particularly for those
seeking
abortions
-to
to select more suitable
methods of contraception and understand the factors responsible for their unwanted pregnancies. Better coordination between health professionals and family planning service providers in providing information and counselling would be a welcome development. Promotion of male sterilisation should become a priority. There is a successful model in Sichuan Province, which demonstrates that it is possible to increase acceptance of male sterilisation. Moreover, the Family Planning Programme should regard its accomplishments with men as an integral part of the evaluation of its programme performance. The male contraceptive prevalence rate should be as important an indicator as contraceptive prevalence rates among women. Note The research project on which this paper is based was one of 20 projects prepared for the Reproductive Health Research Competition, funded by the Ford Foundation. Translated from Chinese by Hu Yukun.
help them
References 1.
China Population Statistics (Year Book), 1993. State Statistics
Bureau, Beijing, 1993. 2. Fathalla MF, 1992. Reproductive health in the worlds: Two decades of progress and the challenge ahead. Research in Human Reproduction, Biennial Report 7990-91. World Health
Organization,
Geneva.
3 Kang Xiaoping, 1991. The trend and determinating factors of induced abortion for married women in China. China Demographic
Sciences.
2:48.
4 In 1992, only 10 per cent of women of reproductive age or their spouses did not use a method of contraception in Beijing. Choice of contraceptive
methods for the city as a whole, was as follows: IUD (62 per cent), condom (15 per cent), female sterilisation (11 per cent), pill (9 per cent), diaphragm and other methods (2 per cent) and male sterilisation (0.4 per cent).
Reproductive
RBSUMB Ces vingt dernieres
an&es, bien que le taux de prevalence contraceptive se soit eleve audessus de 90%, le taux d’avortements provoques a augmente lui aussi en Chine. Se fondant sur des entretiens avec des femmes de Beijing subissant une interruption de grossesse et avec leurs partenaires, cette etude recherche la raison d’une telle situation. Elle a constate que le mangue de connaissances sur l’utilisation correcte des methodes et/au le choix de methodes d’efficacite moindre etaient a I’origine de nombreuses grossesses. Un autre point important est que les hommes se refusent a assumer une quelconque responsabilite dans la contraception, en m&me temps qu’ils exigent la satisfaction de leurs desirs sexuels. Les auteurs discutent de l’echec du programme chinois de planification familiale a mettre au premier rang le choix Cclaire ainsi que la responsabilite masculine, et fait valoir qu’il incombe aux femmes aussi de prendre soin d’elles-memes, et de cesser de se soumettre aux grossesses non desirees et aux avortements a repetition.
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RESUMEN En las ultimas dos decadas, a pesar de1 incremento a mas del 90 por ciento en la tasa de prevalencia anticonceptiva en China, la tasa de abortos provocados tambien se ha visto incrementada. Basado en entrevistas con mujeres en proceso de hacerse un abort0 y con sus compaiieros, este trabajo analiza la razon de estas cifras. El estudio seiiala que detras de muchos embarazos esta la falta de conocimientos sobre la utilization adecuada de 10s metodos y/o la escogencia de metodos de menor eficacia. Otro element0 clave es la contradiction entre el rechazo, por parte de1 hombre, a aceptar su responsabilidad en el proceso de control de natalidad, a la vez que exige plena satisfaction de sus deseos sexuales. El trabajo examina coma el Programa de Planificiacion Familiar de la China no ha dado prioridad a la posibilidad de tomar decisiones basadas en buena information, ni al aspect0 de la responsabilidad masculina. Plantea, ademas, que la mujer tambien tiene la responsabilidad de cuidarse a si misma y de impedir el verse sometida a embarazos no deseados y a repetidos abortos.