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Influence of gender equity awareness on women’s reproductive healthcare in rural areas of midwest China
International Journal of Gynecology and Obstetrics 123 (2013) 155–159
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Influence of gender equity awareness on women’s reproductive healthcare in rural areas of midwest China Lei Wang a, Ying Cui a,⁎, Li Zhang a, Chao Wang a, Yan Jiang a, Wei Shi b a b
National Management Center for 12320 Health Hotline, Chinese Center for Disease Control and Prevention, Beijing, China Department of Foreign Languages, School of Arts and Law, Beijing University of Chemical Technology, Beijing, China
a r t i c l e
i n f o
Article history: Received 28 February 2013 Received in revised form 27 May 2013 Accepted 6 August 2013 Keywords: China Gender equity awareness Reproductive health Rural areas Women
a b s t r a c t Objective: To investigate the impact of married women’s gender equity awareness on use of reproductive healthcare services in rural China. Methods: The questionnaire-based study recruited 1500 married women who were aged 15–49 years, had at least 1 pregnancy, and were living in rural Gansu, Qinghai, Shanxi, or Xinjiang, China, between October and December 2010. “Gender equity awareness” was quantified by responses to 7 statements, graded in accordance with a system scoring the strength of overall belief (≥19, strong; 15–18, moderate; and ≤14, weak). Results: Only 383 women (26.3%) demonstrated high gender equity awareness. The percentage of women who received consistent prenatal care was highest in the group scoring 15 points or more (P b 0.001); the percentage of women with hospital delivery and gynecologic examination (P b 0.001) was highest in the group scoring 19 points or more; and the percentage of women with reproductive tract infections was highest in the group with the lowest scores (P b 0.001). Conclusion: Women’s gender equity awareness is not strong in rural midwest China. There was a positive correlation between gender equity awareness and use of reproductive healthcare services. There should be an emphasis on various activities to educate women so that they can fully access reproductive healthcare. © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Gender equity means that the distribution of social and material resources and decision-making powers between men and women should be fair and just [1]. Gender inequality favoring men is apparent in numerous aspects of Chinese social life [2]. According to Chinese traditional customs, men are the dominant force in the family and women are expected to be obedient and self-sacrificing. Women always take on the critical roles of food production, childbearing, and housekeeping in rural areas. Maternal and infant mortality in rural china has declined significantly according to a marked improvement in women’s status over the past few decades [3]. Accessing good reproductive healthcare is an essential factor in improving women’s health. The Health Protection of Mothers and Infants Law approved in 1994 entitles every pregnant woman to the right to prenatal care. The services that healthcare facilities provide in some low-resource countries may differ in their distribution and quality in accordance with gender inequality awareness [4]; furthermore, the behavior of seeking reproductive healthcare is not individualistic, but is often
influenced by social problems [5–7]. These problems have hindered women’s ability to seek healthcare and have affected the quality of the healthcare service. Increasing gender equity has been found to be associated with better health for women in the United States [8]; as a result, women’s awareness of gender equity is likely to influence their access to reproductive healthcare. However, there have been few studies on reproductive health outcomes in association with gender differences in China [9–12]. The aim of the present study was to evaluate the interaction of gender equity awareness and levels of reproductive healthcare among women living in rural areas of midwest China, specifically the provinces of Gansu, Qinghai, Shanxi, and Xinjiang. Although Chinese government has paid great attention to and increased the funding budget for these 4 provinces, including increased funding in traffic, water conservancy, energy, communications, and other major infrastructure construction, the overall social and economic development of this region is behind that of east China, owing to both the remote and/or harsh physical environment and weak health awareness. As a result, the life expectancy of local residents is shorter than the national average. 2. Materials and methods
⁎ Corresponding author at: No. 27 Nanwei Road, Xicheng District, National Management Center for 12320 Health Hotline, Chinese Center for Disease Control and Prevention, Beijing 100050, China. Tel.: +86 10 83151005; fax: +86 10 83150875. E-mail address: [email protected] (Y. Cui).
The present questionnaire-based study was conducted in Gansu, Qinghai, Shanxi, and Xinjiang, China, between October 11 and December 20, 2010. Data on gender equity awareness were collected from 1500 eligible married women aged 15–49 years who had experienced at least
0020-7292/$ – see front matter © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2013.05.023
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L. Wang et al. / International Journal of Gynecology and Obstetrics 123 (2013) 155–159
1 pregnancy. The study was performed in accordance with procedures approved by the National Center for Women and Children’s Health, China Center for Disease Control and Prevention, and all participants gave written informed consent. The study region was stratified by geographic location and level of socioeconomic status, and 16 counties including 42 towns were randomly selected from the 4 following provinces: Gansu (6 towns), Qinghai (6 towns), Shanxi (9 towns), and Xinjiang (21 towns). Two villages were then randomly drawn from each town, and 25 valid households were surveyed from each village. The sampling strategy followed China’s administrative levels: province (autonomy), county, town, and village. Each participant was interviewed face-to-face by an investigator who had completed extensive training on the 12-page, double-sided questionnaire in Chinese. Experienced experts in this research field were consulted to revise the questionnaire and the same questionnaire was used in all 4 study provinces. Questionnaires were completed by the investigators in accordance with each participant’s answers. The questionnaire, which took approximately 30 minutes to complete, included women’s demographic information (e.g. age, education, and occupation), gender equity awareness, history of pregnancy, prenatal care, and delivery (place and mode). There were 7 related statements about gender equity awareness in the questionnaire [13]. (1) A wife should obey her husband on all occasions. (2) A wife should always accept her husband’s sexual demands, even if she is not willing. (3) A husband’s health and welfare are more important than his wife’s. (4) Men are more suitable to be a political leader than women. (5) It does not matter if a man has premarital sex. (6) A woman should choose to starve to death rather than losing her virginity. (7) Getting pregnant and rearing a child is the women’s sole responsibility. These 7 statements were selected to evaluate women’s awareness of gender equity on the basis of the general characteristics of gender role ideology under the background of China [14]. The participants were given the following 5 choices in response to statements: completely agree; somewhat agree; neither agree nor disagree; somewhat disagree; or completely disagree. At the end of the interview, gynecologists conducted a gynecologic check-up including a physical examination and laboratory tests. The physical examination focused mainly on the pelvic region. The laboratory examination focused mainly on analysis of vaginal discharge. If the woman had physical signs such as cervical motion tenderness, adnexal tenderness, or an abnormal discharge during the bimanual examination, pelvic inflammatory disease was diagnosed [14]. Participants who had 1 of the following clinical signs, such as mucopus, a positive swab test, or blood on the endocervical swab, were diagnosed to have endocervicitis [15]. If the microscopic examination revealed Trichomonas, trichomoniasis was diagnosed. When fungal hyphae or budding yeasts were seen on wet mount, candida was diagnosed [14]. Bacterial vaginosis was diagnosed when at least 3 of the following criteria were present: a homogeneous grayish-white vaginal discharge, a vaginal pH higher than 4.7, a positive amine odor test on addition of 10% potassium hydroxide, or the presence of clue cells (N2 high-power field) on wet mount microscopy [16]. Ultimately, the gynecologists made an overall diagnosis based on these comprehensive examination results. Diagnosed diseases included acute and chronic pelvic inflammatory disease, acute and chronic cervicitis, Trichomonas vaginitis, vulvovaginal candidiasis, and bacterial vaginosis. Any participant diagnosed with these diseases was deemed to have reproductive tract infections (RTIs). All examination results were recorded by the gynecologists. After careful checking, data from the questionnaire were recorded by double input using EpiData version 3.1 (EpiData Association, Odense, Denmark). When all of the data had been recorded, 5% were sampled and reviewed (data were reinvestigated by telephone) to ensure their accuracy and reliability.
Statistical analysis was performed via SPSS version 18.0 (IBM, Armonk, NY, USA). χ2 tests were performed to evaluate the association among women’s gender equity awareness, level of prenatal care, delivery (place and method), having a gynecologic examination or not in the past year, and diagnosis of RTIs at the time of data collection. Multivariate logistic regression was used to evaluate factors associated with reproductive healthcare. The independent variables were gender equity awareness, age, ethnicity and education level, whereas the dependent variables included receiving prenatal care, having 3 or more prenatal care visits during pregnancy, delivery in a hospital, having a gynecologic examination in past year, and presence of RTIs. Data were expressed as number (percentage) or presented as an odds ratio with 95% confidence intervals. A P value of less than 0.05 was considered to be statistically significant. 3. Results Among the 1500 participants, 1455 provided effective responses to the questionnaire, giving a recovery rate of 97.0%. The social and demographic characteristics of all women are shown in Table 1. The average age of the 1455 participants was 35.4 ± 7.7 years (range, 15 to 49 years). With regard to ethnicity, 39.0% (568) of the women were Han and 61.0% (887) were of a minority ethnicity. Education status was grouped into 3 levels: 49.9% were illiterate or educated to primary level, 39.8% were educated to junior middle school level, and 10.3% were educated to senior high school or beyond. Most of the women (91.9%) were homemakers or farmers. In terms of total family income, families with less than 5000 Renminbi (RMB) a year accounted for 51.7% of participants (Table 1). The responses of the participants to the 7 items in the questionnaire are shown in Table 2. For each item, the score was grouped into 3 grades: answers of completely agree or somewhat agree were assigned 1 point; neither agree nor disagree 2 points; and somewhat disagree or
Table 1 Social and demographic characteristics of rural women. Characteristic District Rural areas Agricultural areas Age, y 15–24 25–39 40–49 Ethnicity Han Ethnic minority Level of education Illiterate/primary school Junior middle school Senior high school or above Profession Housekeeping/farming Other Total family income, RMB per year b5000 5000–10 000 N10 000 Receive reproductive healthcare Any prenatal care during pregnancy ≥3 prenatal visits Had gynecologic examination in past year Presence of RTIs Gave birth in a hospital Priority of seeking health service Husband Son Woman herself Abbreviations: RMB, Renminbi; RTI, reproductive tract infection.
Number (percentage) of women 1012 (69.6) 443 (30.4) 156 (10.7) 803 (55.2) 496 (34.1) 568 (39.0) 887 (61.0) 726 (49.9) 579 (39.8) 150 (10.3) 1337 (91.9) 118 (8.1) 752 (51.7) 585 (40.2) 118 (8.1) 860 (59.1) 572 (39.3) 512 (35.2) 1112 (76.4) 781 (53.7) 781 (53.7) 528 (36.2) 22 (1.5)
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Table 2 Awareness of gender equity among women in rural China.a Statement
Completely agree
Somewhat agree
Neither agree nor disagree
Somewhat disagree
Completely disagree
A wife should always obey her husband A wife should always accept her husband’s sexual demands A husband’s health and welfare are more important than his wife’s Men are more suitable political leaders than women It does not matter if men have premarital sex A woman should starve rather than lose her virginity Having and rearing a child is the woman’s sole responsibility
443 (30.4) 289 (19.9) 457 (31.4) 286 (19.7) 177 (12.2) 612 (42.1) 238-(16.4)
340 (23.4) 241 (16.6) 315 (21.6) 403 (27.7) 127 (8.7) 264 (18.1) 464 (31.9)
31(2.1) 201(13.8) 142 (9.8) 127 (8.7) 317 (21.8) 96 (6.6) 216 (14.8)
414 (28.5) 357 (24.5) 333 (22.9) 345 (23.7) 438 (30.1) 274 (18.8) 249 (17.1)
227 (15.6) 367 (25.2) 207 (14.2) 294 (20.2) 396 (27.2) 209 (14.4) 288 (19.8)
a
Values are given as number (percentage).
completely disagree 3 points. The scores were categorized into high awareness (≥19 points), moderate awareness (15–18 points), and low awareness (≤14 points). Overall, 875 women (60.1%) had 14 points or less, indicating that their gender equity awareness was relatively weak; 13.5% of women received a score of 15–18 points, indicating that their gender equity awareness was moderate; and 383 women (26.3%) had 19 points or more, indicating that they had a relatively strong belief in gender equity. Bivariate analysis showed that belief in gender equity varied with education background and family income. Among those women who scored 19 points or more, 39.9% had an elementary education or lower, whereas 60.1% had a middle school education or higher (P b 0.0001); in addition, 42.3% had a total family income of less than 5000 RMB a year, and 57.7% had a total family income of more than 5000 RMB a year (P b 0.05). Among the 1455 participants, 860 (59.1%) reported receiving prenatal care during their pregnancy, 572 (39.3%) had 3 prenatal visits or more, 512 (35.2%) had had a gynecologic examination in the past year, and 1112 (76.4%) were found to have RTIs. Furthermore, 53.7% (781) of women gave birth in a hospital: 21.5% in a county medical hospital, 72.1% in a township hospital, and 6.4% in a village or private clinic. In addition, the priority of seeking health services in a family with limited economic means was husband first, followed by son, daughter, parents, and woman herself. In total, 781 women (53.7%) reported that her husband took priority for receiving healthcare services, 528 (36.3%) reported that her son would be the first to receive healthcare services, and only 22 women (1.5%) selected themselves as being the first to receive healthcare services. The percentage of women who received prenatal care and who had 3 or more prenatal care visits was higher in the group who scored 15 points or more for gender equity awareness (P b 0.001) (Table 3). The percentage of women who had a hospital delivery and who had had a gynecologic examination in the past year was highest in the group who scored 19 points or more for gender equity awareness (P b 0.001). The percentage of women who had RTIs was highest in the group with the lowest gender equity awareness scores (P b 0.001). All comparisons achieved the statistical significance. χ2 analysis showed that receiving prenatal care, number of prenatal care visits, hospital delivery, gynecologic examination, and presence of RTIs were each related to the women’s score in gender equity awareness (P b 0.001).
Multivariate logistic regression analysis was used to assess the correlation of gender equity awareness and reproductive healthcare controlling for the factors ethnicity and family income per year (Table 4). The results indicated that gender equity awareness was correlated with receiving any professional prenatal care, the number of prenatal visits, delivery at a hospital, having gynecologic examination in the past year, and the presence of RTIs. 4. Discussion The goal of the “United Nations Millennium Declaration” in 2001 was to promote gender equity [17]. The Chinese government promised to “ensure gender equity in all policy and plans.” However, gender inequity has existed in China’s rural areas for thousands of years. The aim of the present study was to investigate the impact of gender equity awareness on women’s access to reproductive healthcare in 4 provinces. The emphasis was on the gender beliefs of women themselves; the gender beliefs of male spouses have been analyzed in a previous study, which suggested that male gender beliefs are related to women’s reproductive health [18]. Although the data collected in that and the present study were the same, the objective was different: one was the husband’s; the other was the wife’s. The present study showed that there were significantly more women with low awareness of gender equity compared with high awareness in rural China. The study also showed that gender-based cultural values inhibited women from seeking reproductive healthcare services. A “culture of obedience to husband” and “culture of husband importance,” which are deeply rooted in the inferior status of rural women, have been found to prevent many women from accessing reproductive healthcare [19,20]. In the present study, the impact of women’s low gender awareness on reproductive healthcare was evident province-wide. It influenced whether women sought reproductive healthcare and delivery in hospital. Adhering to the traditional belief that their husband’s health and well-being are of greater importance than their own may affect women’s desire to seek reproductive healthcare. This relationship was found to be significant for seeking health services such as prenatal care (χ2 = 65.758, P b 0.001) and 3 or more prenatal visits (χ2 = 48.157, P b 0.001). Government has a positive role in building a society with gender equity. To promote reproductive healthcare more effectively, the concept
Table 3 Likelihood of receiving reproductive healthcare and experiencing RTIs by awareness of gender equity. Variable
Any prenatal care ≥3 prenatal visits Delivery at a maternity facility Gynecologic examination Presence of RTIs
Total score for awareness of gender equitya ≤14 points (weak)
15–18 points (moderate)
≥19 points (strong)
417 (28.7) 272 (18.7) 123 (8.5) 92 (6.3) 769 (52.9)
132 (9.1) 88 (6.0) 92 (6.3) 105 (7.2) 133 (9.1)
311 (21.4) 213 (14.6) 297 (20.4) 315 (21.7) 209 (14.4)
Abbreviation: RTI, reproductive tract infection. a Values are given as number (percentage).
χ2 statistic
P value
129.893 68.495 484.066 633.784 175.300
b0.001 b0.001 b0.001 b0.001 b0.001
Ref. 0.627 (0.498–0.790) 0.600 (0.417–0.861)
b0.001 b0.01
Ref. 0.762 (0.587–0.989) 0.563 (0.381–0.831)
b0.05 b0.01
of gender equity should be introduced into society to build an atmosphere of “gender mainstreaming” [19]. Therefore, the government’s readiness, commitment, and concerted effort are required to improve women’s health status [20]. More policies and reforms are needed to reduce gender inequality in healthcare. Since the new health reform of the central government of China in 2010, a program for health equity has been initiated both in cities and in the countryside. Under this reform, the government pays every resident who holds citizenship 25 Yuan annually to use the 9 free basic public health services, which cover reproductive healthcare. In addition, free breast cancer screening and cervical cancer screening programs have been initiated. All of these measures have given women more opportunities to seek reproductive healthcare and give birth in a hospital, especially in rural China. Health education programs are needed to motivate women themselves to use reproductive healthcare [21]. Prenatal care and delivery in hospital can reduce the mortality of pregnant women and neonates to a large extent; however, rural women do not realize this. In the present study, more than 75% of participants were diagnosed with RTIs—common gynecologic diseases among women—but only a minority of women had sought and used reproductive health services. Obviously, awareness of women’s gender equity greatly influenced the decision of women to seek and use reproductive health services, and was also related to the presence of RTIs. In conclusion, there should be an emphasis on various activities to educate women in making decisions, to support women so that they can fully exercise their rights, and to reduce the gap between women’s and men’s access to healthcare. If equitable and sustainable progress is to be achieved, however, women’s prenatal care status must be improved, their rights must be respected, and their contributions must be recognized. With the developments in Chinese economic and living standards in the past few decades, the position of women has been promoted: more and more women have an equal opportunity to education and to participation in the paid labor force; in addition, the salary gap between men and women has decreased. Women’s awareness of gender equity should be improved accordingly such that women—especially rural women—will pay more attention to their reproductive health to enhance it. Health education programs are needed to motivate women to promote gender equity and reproductive healthcare. The gender equity awareness and reproductive health of rural women will continue to be a focus in future studies. Abbreviations: CI, confidence interval; OR, odds ratio; RTI, reproductive tract infection.
Ref. 1.242 (0.995–1.551) 1.869 (1.280–2.730)
N0.05 b0.001
Ref. 1.390 (1.105–1.749) 1.469 (1.022–2.111) b0.001 b0.001 Ref. 1.663 (1.327–2.084) 2.110 (1.479–3.012)
b0.01 b0.05
Ref. 0.283 (0.197–0.407) 0.164 (0.123–0.218) b0.001 b0.001 Ref. 5.357 (3.818–7.516) 21.114 (15.540–28.687)
Belief in gender equity Weak (≤14 points) Moderate 15–18 points) Strong (≥19 points) Education Primary school or lower Junior middle school Senior high school or above
Ref. 2.230 (1.611–3.088) 4.744 (3.555–6.331)
b0.001 b0.001
Ref. 3.875 (2.795–5.372) 4.786 (3.685–6.216) b0.001 b0.001 Ref. 1.790 (1.306–2.453) 2.748 (2.147–3.519)
b0.001 b0.001
OR (95% CI)
Presence of RTIs
P value Gynecologic examination
OR (95% CI) OR (95% CI) OR (95% CI)
P value
Delivery at maternity facility
P value ≥3 prenatal visits
P value OR (95% CI)
Any prenatal care Variable
Table 4 Multivariate logistic regression for likelihood of receiving reproductive healthcare and experiencing RTIs according to gender equity awareness and education.
b0.001 b0.001
L. Wang et al. / International Journal of Gynecology and Obstetrics 123 (2013) 155–159 P value
158
Acknowledgments The present study was supported by the Kadoorie Charitable Foundation as part of the Rural Community Health Promotion program. Conflict of interest The authors have no conflicts of interest. References [1] World Health Organization. Transforming Health Systems: Gender and Rights in Reproductive Health. http://whqlibdoc.who.int/hq/2001/WHO_RHR_01.29.pdf. Published 2001. [2] Rashotte LS, Webster Jr M. Gender status beliefs. Soc Sci Res 2005;34(3):618–33. [3] Hesketh T, Zhu WX. The one child family policy: the good, the bad, and the ugly. BMJ 1997;314(7095):1685–7. [4] Bentley R, Kavanagh AM. Gender Equity and Women’s Contraception Use. Aust J Soc Issues 2008;43(1):65–80. [5] Beegle K, Frankenberg E, Thomas D. Bargaining power within couples and use of prenatal and delivery care in Indonesia. Stud Fam Plann 2001;32(2):130–46. [6] Xu KT, Borders TF. Gender, health, and physician visits among adults in the United States. Am J Public Health 2003;93(7):1076–9. [7] Price NL, Hawkins K. A conceptual framework for the social analysis of reproductive health. J Health Popul Nutr 2007;25(1):24–36. [8] Chen YY, Subramanian SV, Acevedo-Garcia D, Kawachi I. Women’s status and depressive symptoms: a multilevel analysis. Soc Sci Med 2005;60(1):49–60.
L. Wang et al. / International Journal of Gynecology and Obstetrics 123 (2013) 155–159 [9] Wong GC, Li VC, Burris MA, Xiang Y. Seeking women’s voices: setting the context for women’s health interventions in two rural counties in Yunnan, China. Soc Sci Med 1995;41(8):1147–57. [10] Li J. Gender inequality, family planning, and maternal and child care in a rural Chinese county. Soc Sci Med 2004;59(4):695–708. [11] Li X. Gender relations and reproductive decision-making in the context of rural China in the post-reform period. http://repub.eur.nl/res/pub/19028/wp284.pdf. Published January, 1999. [12] Li VC, Shaoxian W, Kunyi W, Wentao Z, Buchthal O, Wong GC, et al. Capacity building to improve women’s health in rural China. Soc Sci Med 2001;52(2):279–92. [13] Cui Y, Zhang Q, Yang L, Ye J, Lv M. Effect of married women’s beliefs about gender equity on their use of prenatal and delivery care in rural China. Int J Gynecol Obstet 2010;111(2):148–51. [14] Hawkes S, Morison L, Foster S, Gausia K, Chakraborty J, Peeling RW, et al. Reproductivetract infections in women in low-income, low-prevalence situations: assessment of syndromic management in Matlab, Bangladesh. Lancet 1999;354(9192):1776–81.
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[15] Zhang XJ, Shen Q, Wang GY, Yu YL, Sun YH, Yu GB, et al. Risk factors for reproductive tract infections among married women in rural areas of Anhui Province, China. Eur J Obstet Gynecol Reprod Biol 2009;147(2):187–91. [16] Fiorilli A, Molteni B, Milani M. Successful treatment of bacterial vaginosis with a policarbophil-carbopol acidic vaginal gel: results from a randomised double-blind, placebo-controlled trial. Eur J Obstet Gynecol Reprod Biol 2005;120(2):202–5. [17] Dickens B. The challenges of reproductive and sexual rights. Am J Public Health 2008;98(10):1738–40. [18] Ying C, Li Y, Hui H. The impact of husbands’ gender equity awareness on wives’ reproductive health in rural areas of China. Obstet Gynecol Surv 2011;66(2):103–8. [19] Keleher H. Why build a health promotion evidence base about gender? Health Promot Int 2004;19(3):277–9. [20] Tian L, Li J, Zhang K, Guest P. Women’s status, institutional barriers and reproductive health care: a case study in Yunnan, China. Health Policy 2007;84(2–3):284–97. [21] Anson O. Utilization of maternal care in rural HeBei Province, the People’s Republic of China: individual and structural characteristics. Health Policy 2004;70(2):197–206.
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Influence of gender equity awareness on women’s reproductive healthcare in rural areas of midwest China Lei Wang a, Ying Cui a,⁎, Li Zhang a, Chao Wang a, Yan Jiang a, Wei Shi b a b
National Management Center for 12320 Health Hotline, Chinese Center for Disease Control and Prevention, Beijing, China Department of Foreign Languages, School of Arts and Law, Beijing University of Chemical Technology, Beijing, China
a r t i c l e
i n f o
Article history: Received 28 February 2013 Received in revised form 27 May 2013 Accepted 6 August 2013 Keywords: China Gender equity awareness Reproductive health Rural areas Women
a b s t r a c t Objective: To investigate the impact of married women’s gender equity awareness on use of reproductive healthcare services in rural China. Methods: The questionnaire-based study recruited 1500 married women who were aged 15–49 years, had at least 1 pregnancy, and were living in rural Gansu, Qinghai, Shanxi, or Xinjiang, China, between October and December 2010. “Gender equity awareness” was quantified by responses to 7 statements, graded in accordance with a system scoring the strength of overall belief (≥19, strong; 15–18, moderate; and ≤14, weak). Results: Only 383 women (26.3%) demonstrated high gender equity awareness. The percentage of women who received consistent prenatal care was highest in the group scoring 15 points or more (P b 0.001); the percentage of women with hospital delivery and gynecologic examination (P b 0.001) was highest in the group scoring 19 points or more; and the percentage of women with reproductive tract infections was highest in the group with the lowest scores (P b 0.001). Conclusion: Women’s gender equity awareness is not strong in rural midwest China. There was a positive correlation between gender equity awareness and use of reproductive healthcare services. There should be an emphasis on various activities to educate women so that they can fully access reproductive healthcare. © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Gender equity means that the distribution of social and material resources and decision-making powers between men and women should be fair and just [1]. Gender inequality favoring men is apparent in numerous aspects of Chinese social life [2]. According to Chinese traditional customs, men are the dominant force in the family and women are expected to be obedient and self-sacrificing. Women always take on the critical roles of food production, childbearing, and housekeeping in rural areas. Maternal and infant mortality in rural china has declined significantly according to a marked improvement in women’s status over the past few decades [3]. Accessing good reproductive healthcare is an essential factor in improving women’s health. The Health Protection of Mothers and Infants Law approved in 1994 entitles every pregnant woman to the right to prenatal care. The services that healthcare facilities provide in some low-resource countries may differ in their distribution and quality in accordance with gender inequality awareness [4]; furthermore, the behavior of seeking reproductive healthcare is not individualistic, but is often
influenced by social problems [5–7]. These problems have hindered women’s ability to seek healthcare and have affected the quality of the healthcare service. Increasing gender equity has been found to be associated with better health for women in the United States [8]; as a result, women’s awareness of gender equity is likely to influence their access to reproductive healthcare. However, there have been few studies on reproductive health outcomes in association with gender differences in China [9–12]. The aim of the present study was to evaluate the interaction of gender equity awareness and levels of reproductive healthcare among women living in rural areas of midwest China, specifically the provinces of Gansu, Qinghai, Shanxi, and Xinjiang. Although Chinese government has paid great attention to and increased the funding budget for these 4 provinces, including increased funding in traffic, water conservancy, energy, communications, and other major infrastructure construction, the overall social and economic development of this region is behind that of east China, owing to both the remote and/or harsh physical environment and weak health awareness. As a result, the life expectancy of local residents is shorter than the national average. 2. Materials and methods
⁎ Corresponding author at: No. 27 Nanwei Road, Xicheng District, National Management Center for 12320 Health Hotline, Chinese Center for Disease Control and Prevention, Beijing 100050, China. Tel.: +86 10 83151005; fax: +86 10 83150875. E-mail address: [email protected] (Y. Cui).
The present questionnaire-based study was conducted in Gansu, Qinghai, Shanxi, and Xinjiang, China, between October 11 and December 20, 2010. Data on gender equity awareness were collected from 1500 eligible married women aged 15–49 years who had experienced at least
0020-7292/$ – see front matter © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2013.05.023
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L. Wang et al. / International Journal of Gynecology and Obstetrics 123 (2013) 155–159
1 pregnancy. The study was performed in accordance with procedures approved by the National Center for Women and Children’s Health, China Center for Disease Control and Prevention, and all participants gave written informed consent. The study region was stratified by geographic location and level of socioeconomic status, and 16 counties including 42 towns were randomly selected from the 4 following provinces: Gansu (6 towns), Qinghai (6 towns), Shanxi (9 towns), and Xinjiang (21 towns). Two villages were then randomly drawn from each town, and 25 valid households were surveyed from each village. The sampling strategy followed China’s administrative levels: province (autonomy), county, town, and village. Each participant was interviewed face-to-face by an investigator who had completed extensive training on the 12-page, double-sided questionnaire in Chinese. Experienced experts in this research field were consulted to revise the questionnaire and the same questionnaire was used in all 4 study provinces. Questionnaires were completed by the investigators in accordance with each participant’s answers. The questionnaire, which took approximately 30 minutes to complete, included women’s demographic information (e.g. age, education, and occupation), gender equity awareness, history of pregnancy, prenatal care, and delivery (place and mode). There were 7 related statements about gender equity awareness in the questionnaire [13]. (1) A wife should obey her husband on all occasions. (2) A wife should always accept her husband’s sexual demands, even if she is not willing. (3) A husband’s health and welfare are more important than his wife’s. (4) Men are more suitable to be a political leader than women. (5) It does not matter if a man has premarital sex. (6) A woman should choose to starve to death rather than losing her virginity. (7) Getting pregnant and rearing a child is the women’s sole responsibility. These 7 statements were selected to evaluate women’s awareness of gender equity on the basis of the general characteristics of gender role ideology under the background of China [14]. The participants were given the following 5 choices in response to statements: completely agree; somewhat agree; neither agree nor disagree; somewhat disagree; or completely disagree. At the end of the interview, gynecologists conducted a gynecologic check-up including a physical examination and laboratory tests. The physical examination focused mainly on the pelvic region. The laboratory examination focused mainly on analysis of vaginal discharge. If the woman had physical signs such as cervical motion tenderness, adnexal tenderness, or an abnormal discharge during the bimanual examination, pelvic inflammatory disease was diagnosed [14]. Participants who had 1 of the following clinical signs, such as mucopus, a positive swab test, or blood on the endocervical swab, were diagnosed to have endocervicitis [15]. If the microscopic examination revealed Trichomonas, trichomoniasis was diagnosed. When fungal hyphae or budding yeasts were seen on wet mount, candida was diagnosed [14]. Bacterial vaginosis was diagnosed when at least 3 of the following criteria were present: a homogeneous grayish-white vaginal discharge, a vaginal pH higher than 4.7, a positive amine odor test on addition of 10% potassium hydroxide, or the presence of clue cells (N2 high-power field) on wet mount microscopy [16]. Ultimately, the gynecologists made an overall diagnosis based on these comprehensive examination results. Diagnosed diseases included acute and chronic pelvic inflammatory disease, acute and chronic cervicitis, Trichomonas vaginitis, vulvovaginal candidiasis, and bacterial vaginosis. Any participant diagnosed with these diseases was deemed to have reproductive tract infections (RTIs). All examination results were recorded by the gynecologists. After careful checking, data from the questionnaire were recorded by double input using EpiData version 3.1 (EpiData Association, Odense, Denmark). When all of the data had been recorded, 5% were sampled and reviewed (data were reinvestigated by telephone) to ensure their accuracy and reliability.
Statistical analysis was performed via SPSS version 18.0 (IBM, Armonk, NY, USA). χ2 tests were performed to evaluate the association among women’s gender equity awareness, level of prenatal care, delivery (place and method), having a gynecologic examination or not in the past year, and diagnosis of RTIs at the time of data collection. Multivariate logistic regression was used to evaluate factors associated with reproductive healthcare. The independent variables were gender equity awareness, age, ethnicity and education level, whereas the dependent variables included receiving prenatal care, having 3 or more prenatal care visits during pregnancy, delivery in a hospital, having a gynecologic examination in past year, and presence of RTIs. Data were expressed as number (percentage) or presented as an odds ratio with 95% confidence intervals. A P value of less than 0.05 was considered to be statistically significant. 3. Results Among the 1500 participants, 1455 provided effective responses to the questionnaire, giving a recovery rate of 97.0%. The social and demographic characteristics of all women are shown in Table 1. The average age of the 1455 participants was 35.4 ± 7.7 years (range, 15 to 49 years). With regard to ethnicity, 39.0% (568) of the women were Han and 61.0% (887) were of a minority ethnicity. Education status was grouped into 3 levels: 49.9% were illiterate or educated to primary level, 39.8% were educated to junior middle school level, and 10.3% were educated to senior high school or beyond. Most of the women (91.9%) were homemakers or farmers. In terms of total family income, families with less than 5000 Renminbi (RMB) a year accounted for 51.7% of participants (Table 1). The responses of the participants to the 7 items in the questionnaire are shown in Table 2. For each item, the score was grouped into 3 grades: answers of completely agree or somewhat agree were assigned 1 point; neither agree nor disagree 2 points; and somewhat disagree or
Table 1 Social and demographic characteristics of rural women. Characteristic District Rural areas Agricultural areas Age, y 15–24 25–39 40–49 Ethnicity Han Ethnic minority Level of education Illiterate/primary school Junior middle school Senior high school or above Profession Housekeeping/farming Other Total family income, RMB per year b5000 5000–10 000 N10 000 Receive reproductive healthcare Any prenatal care during pregnancy ≥3 prenatal visits Had gynecologic examination in past year Presence of RTIs Gave birth in a hospital Priority of seeking health service Husband Son Woman herself Abbreviations: RMB, Renminbi; RTI, reproductive tract infection.
Number (percentage) of women 1012 (69.6) 443 (30.4) 156 (10.7) 803 (55.2) 496 (34.1) 568 (39.0) 887 (61.0) 726 (49.9) 579 (39.8) 150 (10.3) 1337 (91.9) 118 (8.1) 752 (51.7) 585 (40.2) 118 (8.1) 860 (59.1) 572 (39.3) 512 (35.2) 1112 (76.4) 781 (53.7) 781 (53.7) 528 (36.2) 22 (1.5)
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Table 2 Awareness of gender equity among women in rural China.a Statement
Completely agree
Somewhat agree
Neither agree nor disagree
Somewhat disagree
Completely disagree
A wife should always obey her husband A wife should always accept her husband’s sexual demands A husband’s health and welfare are more important than his wife’s Men are more suitable political leaders than women It does not matter if men have premarital sex A woman should starve rather than lose her virginity Having and rearing a child is the woman’s sole responsibility
443 (30.4) 289 (19.9) 457 (31.4) 286 (19.7) 177 (12.2) 612 (42.1) 238-(16.4)
340 (23.4) 241 (16.6) 315 (21.6) 403 (27.7) 127 (8.7) 264 (18.1) 464 (31.9)
31(2.1) 201(13.8) 142 (9.8) 127 (8.7) 317 (21.8) 96 (6.6) 216 (14.8)
414 (28.5) 357 (24.5) 333 (22.9) 345 (23.7) 438 (30.1) 274 (18.8) 249 (17.1)
227 (15.6) 367 (25.2) 207 (14.2) 294 (20.2) 396 (27.2) 209 (14.4) 288 (19.8)
a
Values are given as number (percentage).
completely disagree 3 points. The scores were categorized into high awareness (≥19 points), moderate awareness (15–18 points), and low awareness (≤14 points). Overall, 875 women (60.1%) had 14 points or less, indicating that their gender equity awareness was relatively weak; 13.5% of women received a score of 15–18 points, indicating that their gender equity awareness was moderate; and 383 women (26.3%) had 19 points or more, indicating that they had a relatively strong belief in gender equity. Bivariate analysis showed that belief in gender equity varied with education background and family income. Among those women who scored 19 points or more, 39.9% had an elementary education or lower, whereas 60.1% had a middle school education or higher (P b 0.0001); in addition, 42.3% had a total family income of less than 5000 RMB a year, and 57.7% had a total family income of more than 5000 RMB a year (P b 0.05). Among the 1455 participants, 860 (59.1%) reported receiving prenatal care during their pregnancy, 572 (39.3%) had 3 prenatal visits or more, 512 (35.2%) had had a gynecologic examination in the past year, and 1112 (76.4%) were found to have RTIs. Furthermore, 53.7% (781) of women gave birth in a hospital: 21.5% in a county medical hospital, 72.1% in a township hospital, and 6.4% in a village or private clinic. In addition, the priority of seeking health services in a family with limited economic means was husband first, followed by son, daughter, parents, and woman herself. In total, 781 women (53.7%) reported that her husband took priority for receiving healthcare services, 528 (36.3%) reported that her son would be the first to receive healthcare services, and only 22 women (1.5%) selected themselves as being the first to receive healthcare services. The percentage of women who received prenatal care and who had 3 or more prenatal care visits was higher in the group who scored 15 points or more for gender equity awareness (P b 0.001) (Table 3). The percentage of women who had a hospital delivery and who had had a gynecologic examination in the past year was highest in the group who scored 19 points or more for gender equity awareness (P b 0.001). The percentage of women who had RTIs was highest in the group with the lowest gender equity awareness scores (P b 0.001). All comparisons achieved the statistical significance. χ2 analysis showed that receiving prenatal care, number of prenatal care visits, hospital delivery, gynecologic examination, and presence of RTIs were each related to the women’s score in gender equity awareness (P b 0.001).
Multivariate logistic regression analysis was used to assess the correlation of gender equity awareness and reproductive healthcare controlling for the factors ethnicity and family income per year (Table 4). The results indicated that gender equity awareness was correlated with receiving any professional prenatal care, the number of prenatal visits, delivery at a hospital, having gynecologic examination in the past year, and the presence of RTIs. 4. Discussion The goal of the “United Nations Millennium Declaration” in 2001 was to promote gender equity [17]. The Chinese government promised to “ensure gender equity in all policy and plans.” However, gender inequity has existed in China’s rural areas for thousands of years. The aim of the present study was to investigate the impact of gender equity awareness on women’s access to reproductive healthcare in 4 provinces. The emphasis was on the gender beliefs of women themselves; the gender beliefs of male spouses have been analyzed in a previous study, which suggested that male gender beliefs are related to women’s reproductive health [18]. Although the data collected in that and the present study were the same, the objective was different: one was the husband’s; the other was the wife’s. The present study showed that there were significantly more women with low awareness of gender equity compared with high awareness in rural China. The study also showed that gender-based cultural values inhibited women from seeking reproductive healthcare services. A “culture of obedience to husband” and “culture of husband importance,” which are deeply rooted in the inferior status of rural women, have been found to prevent many women from accessing reproductive healthcare [19,20]. In the present study, the impact of women’s low gender awareness on reproductive healthcare was evident province-wide. It influenced whether women sought reproductive healthcare and delivery in hospital. Adhering to the traditional belief that their husband’s health and well-being are of greater importance than their own may affect women’s desire to seek reproductive healthcare. This relationship was found to be significant for seeking health services such as prenatal care (χ2 = 65.758, P b 0.001) and 3 or more prenatal visits (χ2 = 48.157, P b 0.001). Government has a positive role in building a society with gender equity. To promote reproductive healthcare more effectively, the concept
Table 3 Likelihood of receiving reproductive healthcare and experiencing RTIs by awareness of gender equity. Variable
Any prenatal care ≥3 prenatal visits Delivery at a maternity facility Gynecologic examination Presence of RTIs
Total score for awareness of gender equitya ≤14 points (weak)
15–18 points (moderate)
≥19 points (strong)
417 (28.7) 272 (18.7) 123 (8.5) 92 (6.3) 769 (52.9)
132 (9.1) 88 (6.0) 92 (6.3) 105 (7.2) 133 (9.1)
311 (21.4) 213 (14.6) 297 (20.4) 315 (21.7) 209 (14.4)
Abbreviation: RTI, reproductive tract infection. a Values are given as number (percentage).
χ2 statistic
P value
129.893 68.495 484.066 633.784 175.300
b0.001 b0.001 b0.001 b0.001 b0.001
Ref. 0.627 (0.498–0.790) 0.600 (0.417–0.861)
b0.001 b0.01
Ref. 0.762 (0.587–0.989) 0.563 (0.381–0.831)
b0.05 b0.01
of gender equity should be introduced into society to build an atmosphere of “gender mainstreaming” [19]. Therefore, the government’s readiness, commitment, and concerted effort are required to improve women’s health status [20]. More policies and reforms are needed to reduce gender inequality in healthcare. Since the new health reform of the central government of China in 2010, a program for health equity has been initiated both in cities and in the countryside. Under this reform, the government pays every resident who holds citizenship 25 Yuan annually to use the 9 free basic public health services, which cover reproductive healthcare. In addition, free breast cancer screening and cervical cancer screening programs have been initiated. All of these measures have given women more opportunities to seek reproductive healthcare and give birth in a hospital, especially in rural China. Health education programs are needed to motivate women themselves to use reproductive healthcare [21]. Prenatal care and delivery in hospital can reduce the mortality of pregnant women and neonates to a large extent; however, rural women do not realize this. In the present study, more than 75% of participants were diagnosed with RTIs—common gynecologic diseases among women—but only a minority of women had sought and used reproductive health services. Obviously, awareness of women’s gender equity greatly influenced the decision of women to seek and use reproductive health services, and was also related to the presence of RTIs. In conclusion, there should be an emphasis on various activities to educate women in making decisions, to support women so that they can fully exercise their rights, and to reduce the gap between women’s and men’s access to healthcare. If equitable and sustainable progress is to be achieved, however, women’s prenatal care status must be improved, their rights must be respected, and their contributions must be recognized. With the developments in Chinese economic and living standards in the past few decades, the position of women has been promoted: more and more women have an equal opportunity to education and to participation in the paid labor force; in addition, the salary gap between men and women has decreased. Women’s awareness of gender equity should be improved accordingly such that women—especially rural women—will pay more attention to their reproductive health to enhance it. Health education programs are needed to motivate women to promote gender equity and reproductive healthcare. The gender equity awareness and reproductive health of rural women will continue to be a focus in future studies. Abbreviations: CI, confidence interval; OR, odds ratio; RTI, reproductive tract infection.
Ref. 1.242 (0.995–1.551) 1.869 (1.280–2.730)
N0.05 b0.001
Ref. 1.390 (1.105–1.749) 1.469 (1.022–2.111) b0.001 b0.001 Ref. 1.663 (1.327–2.084) 2.110 (1.479–3.012)
b0.01 b0.05
Ref. 0.283 (0.197–0.407) 0.164 (0.123–0.218) b0.001 b0.001 Ref. 5.357 (3.818–7.516) 21.114 (15.540–28.687)
Belief in gender equity Weak (≤14 points) Moderate 15–18 points) Strong (≥19 points) Education Primary school or lower Junior middle school Senior high school or above
Ref. 2.230 (1.611–3.088) 4.744 (3.555–6.331)
b0.001 b0.001
Ref. 3.875 (2.795–5.372) 4.786 (3.685–6.216) b0.001 b0.001 Ref. 1.790 (1.306–2.453) 2.748 (2.147–3.519)
b0.001 b0.001
OR (95% CI)
Presence of RTIs
P value Gynecologic examination
OR (95% CI) OR (95% CI) OR (95% CI)
P value
Delivery at maternity facility
P value ≥3 prenatal visits
P value OR (95% CI)
Any prenatal care Variable
Table 4 Multivariate logistic regression for likelihood of receiving reproductive healthcare and experiencing RTIs according to gender equity awareness and education.
b0.001 b0.001
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Acknowledgments The present study was supported by the Kadoorie Charitable Foundation as part of the Rural Community Health Promotion program. Conflict of interest The authors have no conflicts of interest. References [1] World Health Organization. Transforming Health Systems: Gender and Rights in Reproductive Health. http://whqlibdoc.who.int/hq/2001/WHO_RHR_01.29.pdf. Published 2001. [2] Rashotte LS, Webster Jr M. Gender status beliefs. Soc Sci Res 2005;34(3):618–33. [3] Hesketh T, Zhu WX. The one child family policy: the good, the bad, and the ugly. BMJ 1997;314(7095):1685–7. [4] Bentley R, Kavanagh AM. Gender Equity and Women’s Contraception Use. Aust J Soc Issues 2008;43(1):65–80. [5] Beegle K, Frankenberg E, Thomas D. Bargaining power within couples and use of prenatal and delivery care in Indonesia. Stud Fam Plann 2001;32(2):130–46. [6] Xu KT, Borders TF. Gender, health, and physician visits among adults in the United States. Am J Public Health 2003;93(7):1076–9. [7] Price NL, Hawkins K. A conceptual framework for the social analysis of reproductive health. J Health Popul Nutr 2007;25(1):24–36. [8] Chen YY, Subramanian SV, Acevedo-Garcia D, Kawachi I. Women’s status and depressive symptoms: a multilevel analysis. Soc Sci Med 2005;60(1):49–60.
L. Wang et al. / International Journal of Gynecology and Obstetrics 123 (2013) 155–159 [9] Wong GC, Li VC, Burris MA, Xiang Y. Seeking women’s voices: setting the context for women’s health interventions in two rural counties in Yunnan, China. Soc Sci Med 1995;41(8):1147–57. [10] Li J. Gender inequality, family planning, and maternal and child care in a rural Chinese county. Soc Sci Med 2004;59(4):695–708. [11] Li X. Gender relations and reproductive decision-making in the context of rural China in the post-reform period. http://repub.eur.nl/res/pub/19028/wp284.pdf. Published January, 1999. [12] Li VC, Shaoxian W, Kunyi W, Wentao Z, Buchthal O, Wong GC, et al. Capacity building to improve women’s health in rural China. Soc Sci Med 2001;52(2):279–92. [13] Cui Y, Zhang Q, Yang L, Ye J, Lv M. Effect of married women’s beliefs about gender equity on their use of prenatal and delivery care in rural China. Int J Gynecol Obstet 2010;111(2):148–51. [14] Hawkes S, Morison L, Foster S, Gausia K, Chakraborty J, Peeling RW, et al. Reproductivetract infections in women in low-income, low-prevalence situations: assessment of syndromic management in Matlab, Bangladesh. Lancet 1999;354(9192):1776–81.
159
[15] Zhang XJ, Shen Q, Wang GY, Yu YL, Sun YH, Yu GB, et al. Risk factors for reproductive tract infections among married women in rural areas of Anhui Province, China. Eur J Obstet Gynecol Reprod Biol 2009;147(2):187–91. [16] Fiorilli A, Molteni B, Milani M. Successful treatment of bacterial vaginosis with a policarbophil-carbopol acidic vaginal gel: results from a randomised double-blind, placebo-controlled trial. Eur J Obstet Gynecol Reprod Biol 2005;120(2):202–5. [17] Dickens B. The challenges of reproductive and sexual rights. Am J Public Health 2008;98(10):1738–40. [18] Ying C, Li Y, Hui H. The impact of husbands’ gender equity awareness on wives’ reproductive health in rural areas of China. Obstet Gynecol Surv 2011;66(2):103–8. [19] Keleher H. Why build a health promotion evidence base about gender? Health Promot Int 2004;19(3):277–9. [20] Tian L, Li J, Zhang K, Guest P. Women’s status, institutional barriers and reproductive health care: a case study in Yunnan, China. Health Policy 2007;84(2–3):284–97. [21] Anson O. Utilization of maternal care in rural HeBei Province, the People’s Republic of China: individual and structural characteristics. Health Policy 2004;70(2):197–206.