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Perspectives of Chinese healthcare providers on medical abortion
International Journal of Gynecology and Obstetrics 114 (2011) 15–17
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o
CLINICAL ARTICLE
Perspectives of Chinese healthcare providers on medical abortion Kang Gan a,b, Yuhan Zhang a,b, Xiaomei Jiang a,b, Yucui Meng a,b, Liyan Hou a,b, Yimin Cheng b,⁎ a b
Graduate School of Peking Union Medical College, Beijing, China National Research Institute for Family Planning, Beijing, China
a r t i c l e
i n f o
Article history: Received 10 October 2010 Received in revised form 11 January 2011 Accepted 6 April 2011 Keywords: Abortion service providers Medical abortion knowledge Preference Remuneration
a b s t r a c t Objective: To evaluate Chinese healthcare providers’ knowledge regarding medical abortion, to understand provider preferences for abortion methods, and to investigate the role of remuneration on providers’ decision making. Methods: Between November 2009 and May 2010, 658 abortion service providers from familyplanning service centers and hospitals in Shenzhen and Henan, China, were surveyed via self-administered questionnaires. Results: The knowledge score (out of a maximum of 32) regarding medical abortion was 16–20 for 60.9% of the providers; 20.4% of the providers preferred medical abortion to surgical abortion, whereas 35.0% preferred surgical abortion. Overall, 72.2% of providers stated that they did not receive any commission for providing medical abortion or surgical abortion. Conclusion: Most healthcare providers believed that surgical abortion was preferable to medical abortion. Efforts should be made to overcome the perceived disadvantages of medical abortion. © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction The ratio of medical abortion to surgical abortion is very low in many areas of China, despite the wide availability of the former over the past 15 years [1,2]. There are approximately 9 million cases of induced abortion in China each year [3], but the total number of medical abortions in the 10 years preceding 2002 was 1.5 million [4]. Because healthcare providers have a major role in the process of selecting a method of abortion, it is important to understand their perspectives regarding medical abortion and the reasons for its low rate of use compared with surgical abortion. The aims of the present study were to evaluate Chinese healthcare providers’ knowledge of medical abortion, to understand their perspectives regarding the main challenges to increasing its uptake, to understand their preferences for specific abortion methods, and to investigate the role of remuneration on the decision-making process. 2. Materials and methods In the present cross-sectional study, health facility-based abortion service providers from Shenzhen (an urban area) and Henan (a rural area), China, were surveyed via a self-administered questionnaire on their knowledge of medical abortion, their perspectives regarding the main challenges to increasing its uptake, their preference in terms of abortion method, and whether remuneration affected their decision ⁎ Corresponding author at: National Research Institute for Family Planning, 12 Da Hui Si, Hai Dian District, Beijing 100081, China. Tel.: + 86 10 6212 2176; fax: + 86 10 6217 3536. E-mail address: [email protected] (Y. Cheng).
on which method to recommend. The survey was conducted from November 7, 2009, to May 29, 2010. The inclusion criteria were as follows: respondents had to be obstetricians/gynecologists, nurses, midwives, or family-planning service providers; they had to have been providing abortion services for more than 2 months; and they had to be willing to take part in the study. Family-planning service centers and hospitals (city, district, and community level in Shenzhen, and county and township level in Henan) were selected as study fields, and questionnaires were given to all eligible abortion service providers in the study fields. The questionnaire was developed by WHO experts, and a pilot study was conducted among 30 familyplanning service providers to validate it. The knowledge part of the questionnaire included items on contraindications, indications, complications, adverse effects, and regimen for medical abortion. There were 32 questions in this section; each question answered correctly was assigned 1 point, whereas those answered incorrectly were assigned 0 points. Overall knowledge scores were calculated for each questionnaire. The provider perspective section contained questions on preference for abortion method and remuneration. All respondents provided written informed consent, and approval was provided by the Ethics Review Committee of the National Research Institute for Family Planning. Data were entered twice into a computer and were checked/ corrected with EpiData 3.0 (EpiData Association, Odense, Denmark). Analysis was performed using SPSS 16.0 (SPSS, Chicago, IL, USA) and involved descriptive analysis and logistic regression. For logistic regression analysis, knowledge score was taken as the dependent variable; area, unit type, unit level, education level, abortion service experience, and training experience were considered to be independent variables. P b 0.05 was considered to be statistically significant.
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2011.01.027
16
K. Gan et al. / International Journal of Gynecology and Obstetrics 114 (2011) 15–17
3. Results
Table 2 Providers’ preference of abortion method (n = 658).
Overall, 681 questionnaires were given out; 676 were returned, of which 658 were eligible for inclusion (i.e. fewer than 10 questions were left unanswered and basic information regarding area, unit type, and unit level was provided): 296 from Shenzhen and 362 from Henan. Respondents were 20–68 years of age, with an average age of 36.7 years, and the majority (278/632 [44.0%]) were in the 30–40-year group. All respondents were graduates of polytechnics/secondary schools or higher, with 438 (66.6%) having obtained college or university diplomas. In total, 353/656 (53.8%) respondents had been providing abortion services for more than 10 years, whereas 149 (22.6%) had been providing such services for fewer than 5 years. In the knowledge section of the questionnaire, the highest score obtained (out of 32) was 25 points and the lowest score was 3 points. Overall, 146 (22.2%) respondents scored 3–15 points, 401 (60.9%) scored 16–20 points, and 111 (16.9%) scored 21–25 points. In accordance with their distribution, the knowledge scores were divided into 2 groups: low (0–15 points) and high (16–32 points). Multivariate logistic regression analysis showed that area (odds ratio [OR] 1.975; 95% confidence interval [CI], 1.263–3.089; P = 0.003), education level (OR 2.297 [95% CI, 1.412–3.737]; P = 0.001), and abortion service experience (OR 1.875 [95% CI, 1.208–2.909]; P = 0.005) were significant variables (Table 1)—with providers from Henan, those with a higher level of education, and those with more than 5 years of experience providing abortions more likely to achieve higher scores. Compared with surgical abortion, providers considered the main disadvantages of medical abortion to be: greater bleeding (396 [60.2%]); longer duration of procedure (321 [48.8%]); the fact that it involves more than 1 clinic visit (230 [35.0%]); higher failure rate (325 [49.4%]); not being in control of the outcome (214 [32.5%]); provision of adequate toilet facilities at the health facility for obtaining the expelled gestational sac (286 [43.5%]); provision of adequate washing facilities (259 [39.4%]); less effective/lower success rate (246 [37.4%]); and provision of private recovery areas/beds (206 [31.3%]). When asked “do you believe that the provision of medical termination should be expanded?” 320/606 (52.8%) providers gave an affirmative answer. With regard to the “biggest challenges to expanding medical abortion,” 302/606 (49.8%) providers chose “increased complications/failures,” 242/606 (39.9%) providers chose “poor client knowledge/awareness,” and 158/606 (26.1%) providers chose “problems with drug/equipment supplies.” Overall, 294 (44.7%) providers had no preference in terms of abortion method, 230 (35.0%) preferred surgical abortion, and 134 (20.4%) preferred medical abortion. Furthermore, 275 providers (41.8%) believed that their colleagues had no preference, 288 (43.8%) thought that their colleagues preferred surgical abortion, and 94 (14.3%) thought that their colleagues preferred medical abortion (Table 2). Only 108/607 (17.8%) providers thought that economic factors were important when recommending an abortion method. Overall, 69 (10.5%) respondents considered provider income and 81 (12.3%) considered clinic income to be linked to the abortion method recommended. In
Preference
No. (%)
Own preference Medical abortion Surgical abortion No preference Perceived preference of colleagues Medical abortion Surgical abortion No preference
134 (20.4) 230 (35.0) 294 (44.7) 94 (14.3) 288 (43.8) 275 (41.8)
37 (5.6%) cases, the abortion clinic charged for abortion counseling, and in 72 (10.9%) cases it charged for abortion follow-up. One hundred and fifteen (17.5%) healthcare providers stated that their income was related to the number of abortions they performed, and 475 (72.2%) reported that they did not receive any commission for providing medical or surgical abortion (Table 3). 4. Discussion In the present study, provider knowledge scores regarding medical abortion were at a moderate level—consistent with previous findings [5]. The results indicated that provider knowledge of the method is still inadequate, meaning that further studies and training are needed. Particularly in urban areas, among providers who are less educated, and those with less working experience, attention should be paid to the improvement of medical abortion knowledge. Training, communication, periodic evaluation, merit pay, and open competition may facilitate the achievement of this goal. In China, rural practitioners engage in only 4 family-planning procedures (inserting and removing intrauterine devices, induced abortion, and sterilization), whereas urban practitioners deal with many obstetric and gynecologic conditions. Therefore, rural practitioners are relatively more specialized and may be more familiar with medical abortion. Providers often focus on the problem of bleeding associated with medical abortion, but recent studies have found that traditional Chinese medicine can effectively reduce the amount of bleeding and shorten its duration [6,7]. However, owing to individual differences, women's sensitivity to the medicines used can vary, so further investigation is required. Significant improvements in duration and amount of bleeding are observed when compound mifepristone is used in conjunction with misoprostol for medical abortion [8,9], so this regimen can be recommended to abortion clinics throughout China. Resource limitation was also mentioned by providers as a disadvantage of medical abortion, especially in remote areas—implying that the Chinese government and authorities should allocate more medical resources for this method, increase investment, provide healthcare facilities with the necessary equipment and with sufficient recovery room for resting, and increase human resources. Furthermore, additional
Table 1 Multivariate logistic analysis of abortion knowledge scores.a Variable
Comparison group
Control group
B value
OR (95% CI)
P value
Area Unit type Unit level
Henan (rural area) Hospital City District/county University or higher N5 Yes
Shenzhen (urban area) FPSC Community/township Community/township Secondary school or lower b5 No
0.681 0.247 –0.291 0.311 0.832 0.628 1.581
1.975 1.281 0.748 1.365 2.297 1.875 4.858
0.003 0.308 0.399 0.168 0.001 0.005 0.051
Education level Experience, y Training
(1.263–3.089) (0.796–2.060) (0.380–1.470) (0.877–2.122) (1.412–3.737) (1.208–2.909) (0.995–23.727)
Abbreviations: FPSC, family-planning service center; CI, confidence interval; OR, odds ratio. a In accordance with their distribution, knowledge scores (out of 32) were divided into 2 groups: low (0–15 points) and high (16–32 points). The low group was used as the reference group.
K. Gan et al. / International Journal of Gynecology and Obstetrics 114 (2011) 15–17 Table 3 Provider perspective on relationship between abortion service and remuneration (n = 658). Views on financial remuneration
In the present study, most healthcare providers believed that surgical abortion was preferable to medical abortion. Efforts should be made to overcome the perceived disadvantages of medical abortion.
No. (%)
Importance of economic factors in provider recommending an abortion method a Very important 108 (17.8) Somewhat important 325 (53.5) Not important 174 (28.7) Provider income related to abortion method recommended 69 (10.5) Clinic income related to abortion method recommended 81 (12.3) Abortion clinic charges for abortion counseling 37 (5.6) Abortion clinic charges for abortion follow-up 72 (10.9) Provider income related to number of abortions performed 115 (17.5) Commission obtained by providers for performing medical abortion or surgical abortion No commission 475 (72.2) Medical abortion 11 (1.7) Surgical abortion 57 (8.7) Don't know 115 (17.5) a
17
Fifty-one responses missing.
research into taking misoprostol at home should be conducted because home administration not only keeps clinic recovery rooms free but also reduces the duration of clinic visits. Overseas studies [10–12] have indicated that, given the option, approximately 90% of women would choose to take misoprostol at home, of whom only 10% would return to the clinic because of failure of medical abortion [10,11]. Thus, time and resources could be spared for both providers and patients. At present in China, women are required to take misoprostol at clinics, where they must subsequently remain for more than 6 hours before going home. However, many high-income countries—in addition to some lowresource areas such as India, Nepal, and Cuba [10–12]—have implemented programs for taking misoprostol at home [13,14], indicating that home administration would be feasible and worthwhile in China. Most providers stated that remuneration was not associated with recommending an abortion service. In the rural area, there was not much difference in cost between medical abortion and surgical abortion, and both methods were very cheap. In the urban area, even if there was a difference in cost between the 2 methods, the income associated with abortion was low compared with that for other services (e.g. obstetric and gynecologic surgeries), and therefore it was not necessary for the providers to consider remuneration when recommending an abortion method. Most providers stated that they recommended a method based mainly on the situation of the women.
Acknowledgments Financial assistance was provided by WHO. Conflict of interest The authors have no conflicts of interest. References [1] Gong D, Zhu X. Factors of early abortion methods choice. Med Innov Res 2008;5(2): 83. [2] Zhu W, Chen H. Investigation of influential factors of choice if early induced abortion. Matern Child Health Care China 2005;20(12):1532–3. [3] Sedgh G, Henshaw S, Singh S, Ahman E, Shah IH. Induced abortion: estimated rates and trends worldwide. Lancet 2007;370(9595):1338–45. [4] Zhou R, Elul B, Winikoff B. Medical Abortion in China: Results of a Fact-finding Mission. Critical Issues in Reproductive Health. New York: Population Council; 2002. [5] Zhang P, Jin H, Xu X, Hu S, Chang M, Zhang X, et al. Situation of health providers offering service after abortion. Matern Child Health Care China 2007;22(27): 3839–43. [6] Chen L, Zhou L. Clinical application of Gong xuening capsules used to reduce bleeding after medical abortion. China Pract Med 2009;4(20):129–30. [7] Zhao H. Biochemical decoction treats 77 cases of bleeding after medical abortion. Tradit Chin Med Res 2006;19(8):32–3. [8] Liu F. Clinical study of compound mifepristone on medical abortion. Asia Pac Tradit Med 2009;5(9):81–2. [9] Zhao A. Effectiveness observation on compound mifepristone on medical abortion. J Reprod Med 2008;17(2):142–3. [10] Karki C, Pokharel H, Kushwaha A, Manandhar D, Bracken H, Winikoff B. Acceptability and feasibility of medical abortion in Nepal. Int J Gynecol Obstet 2009;106(1):39–42. [11] Winikoff B, Sivin I, Coyaji KJ, Cabezas E, Xiao B, Gu S, et al. Safety, efficacy, and acceptability of medical abortion in China, Cuba, and India: a comparative trial of mifepristone–misoprostol versus surgical abortion. Am J Obstet Gynecol 1997;176(2): 431–7. [12] Bracken H, Family Planning Association of India (FPAI)/Gynuity Health Projects Research Group for Simplifying Medical Abortion in India. Home administration of misoprostol for early medical abortion in India. Int J Gynecol Obstet 2010;108(3): 228–32. [13] Lohr PA, Wade J, Riley L, Fitzgibbon A, Furedi A. Women's opinions on the home management of early medical abortion in the UK. J Fam Plann Reprod Health Care 2010;36(1):21–5. [14] Clark WH, Hassoun D, Gemzell-Danielsson K, Fiala C, Winikoff B. Home use of two doses of misoprostol after mifepristone for medical abortion: a pilot study in Sweden and France. Eur J Contracept Reprod Health Care 2005;10(3):184–91.
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o
CLINICAL ARTICLE
Perspectives of Chinese healthcare providers on medical abortion Kang Gan a,b, Yuhan Zhang a,b, Xiaomei Jiang a,b, Yucui Meng a,b, Liyan Hou a,b, Yimin Cheng b,⁎ a b
Graduate School of Peking Union Medical College, Beijing, China National Research Institute for Family Planning, Beijing, China
a r t i c l e
i n f o
Article history: Received 10 October 2010 Received in revised form 11 January 2011 Accepted 6 April 2011 Keywords: Abortion service providers Medical abortion knowledge Preference Remuneration
a b s t r a c t Objective: To evaluate Chinese healthcare providers’ knowledge regarding medical abortion, to understand provider preferences for abortion methods, and to investigate the role of remuneration on providers’ decision making. Methods: Between November 2009 and May 2010, 658 abortion service providers from familyplanning service centers and hospitals in Shenzhen and Henan, China, were surveyed via self-administered questionnaires. Results: The knowledge score (out of a maximum of 32) regarding medical abortion was 16–20 for 60.9% of the providers; 20.4% of the providers preferred medical abortion to surgical abortion, whereas 35.0% preferred surgical abortion. Overall, 72.2% of providers stated that they did not receive any commission for providing medical abortion or surgical abortion. Conclusion: Most healthcare providers believed that surgical abortion was preferable to medical abortion. Efforts should be made to overcome the perceived disadvantages of medical abortion. © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction The ratio of medical abortion to surgical abortion is very low in many areas of China, despite the wide availability of the former over the past 15 years [1,2]. There are approximately 9 million cases of induced abortion in China each year [3], but the total number of medical abortions in the 10 years preceding 2002 was 1.5 million [4]. Because healthcare providers have a major role in the process of selecting a method of abortion, it is important to understand their perspectives regarding medical abortion and the reasons for its low rate of use compared with surgical abortion. The aims of the present study were to evaluate Chinese healthcare providers’ knowledge of medical abortion, to understand their perspectives regarding the main challenges to increasing its uptake, to understand their preferences for specific abortion methods, and to investigate the role of remuneration on the decision-making process. 2. Materials and methods In the present cross-sectional study, health facility-based abortion service providers from Shenzhen (an urban area) and Henan (a rural area), China, were surveyed via a self-administered questionnaire on their knowledge of medical abortion, their perspectives regarding the main challenges to increasing its uptake, their preference in terms of abortion method, and whether remuneration affected their decision ⁎ Corresponding author at: National Research Institute for Family Planning, 12 Da Hui Si, Hai Dian District, Beijing 100081, China. Tel.: + 86 10 6212 2176; fax: + 86 10 6217 3536. E-mail address: [email protected] (Y. Cheng).
on which method to recommend. The survey was conducted from November 7, 2009, to May 29, 2010. The inclusion criteria were as follows: respondents had to be obstetricians/gynecologists, nurses, midwives, or family-planning service providers; they had to have been providing abortion services for more than 2 months; and they had to be willing to take part in the study. Family-planning service centers and hospitals (city, district, and community level in Shenzhen, and county and township level in Henan) were selected as study fields, and questionnaires were given to all eligible abortion service providers in the study fields. The questionnaire was developed by WHO experts, and a pilot study was conducted among 30 familyplanning service providers to validate it. The knowledge part of the questionnaire included items on contraindications, indications, complications, adverse effects, and regimen for medical abortion. There were 32 questions in this section; each question answered correctly was assigned 1 point, whereas those answered incorrectly were assigned 0 points. Overall knowledge scores were calculated for each questionnaire. The provider perspective section contained questions on preference for abortion method and remuneration. All respondents provided written informed consent, and approval was provided by the Ethics Review Committee of the National Research Institute for Family Planning. Data were entered twice into a computer and were checked/ corrected with EpiData 3.0 (EpiData Association, Odense, Denmark). Analysis was performed using SPSS 16.0 (SPSS, Chicago, IL, USA) and involved descriptive analysis and logistic regression. For logistic regression analysis, knowledge score was taken as the dependent variable; area, unit type, unit level, education level, abortion service experience, and training experience were considered to be independent variables. P b 0.05 was considered to be statistically significant.
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2011.01.027
16
K. Gan et al. / International Journal of Gynecology and Obstetrics 114 (2011) 15–17
3. Results
Table 2 Providers’ preference of abortion method (n = 658).
Overall, 681 questionnaires were given out; 676 were returned, of which 658 were eligible for inclusion (i.e. fewer than 10 questions were left unanswered and basic information regarding area, unit type, and unit level was provided): 296 from Shenzhen and 362 from Henan. Respondents were 20–68 years of age, with an average age of 36.7 years, and the majority (278/632 [44.0%]) were in the 30–40-year group. All respondents were graduates of polytechnics/secondary schools or higher, with 438 (66.6%) having obtained college or university diplomas. In total, 353/656 (53.8%) respondents had been providing abortion services for more than 10 years, whereas 149 (22.6%) had been providing such services for fewer than 5 years. In the knowledge section of the questionnaire, the highest score obtained (out of 32) was 25 points and the lowest score was 3 points. Overall, 146 (22.2%) respondents scored 3–15 points, 401 (60.9%) scored 16–20 points, and 111 (16.9%) scored 21–25 points. In accordance with their distribution, the knowledge scores were divided into 2 groups: low (0–15 points) and high (16–32 points). Multivariate logistic regression analysis showed that area (odds ratio [OR] 1.975; 95% confidence interval [CI], 1.263–3.089; P = 0.003), education level (OR 2.297 [95% CI, 1.412–3.737]; P = 0.001), and abortion service experience (OR 1.875 [95% CI, 1.208–2.909]; P = 0.005) were significant variables (Table 1)—with providers from Henan, those with a higher level of education, and those with more than 5 years of experience providing abortions more likely to achieve higher scores. Compared with surgical abortion, providers considered the main disadvantages of medical abortion to be: greater bleeding (396 [60.2%]); longer duration of procedure (321 [48.8%]); the fact that it involves more than 1 clinic visit (230 [35.0%]); higher failure rate (325 [49.4%]); not being in control of the outcome (214 [32.5%]); provision of adequate toilet facilities at the health facility for obtaining the expelled gestational sac (286 [43.5%]); provision of adequate washing facilities (259 [39.4%]); less effective/lower success rate (246 [37.4%]); and provision of private recovery areas/beds (206 [31.3%]). When asked “do you believe that the provision of medical termination should be expanded?” 320/606 (52.8%) providers gave an affirmative answer. With regard to the “biggest challenges to expanding medical abortion,” 302/606 (49.8%) providers chose “increased complications/failures,” 242/606 (39.9%) providers chose “poor client knowledge/awareness,” and 158/606 (26.1%) providers chose “problems with drug/equipment supplies.” Overall, 294 (44.7%) providers had no preference in terms of abortion method, 230 (35.0%) preferred surgical abortion, and 134 (20.4%) preferred medical abortion. Furthermore, 275 providers (41.8%) believed that their colleagues had no preference, 288 (43.8%) thought that their colleagues preferred surgical abortion, and 94 (14.3%) thought that their colleagues preferred medical abortion (Table 2). Only 108/607 (17.8%) providers thought that economic factors were important when recommending an abortion method. Overall, 69 (10.5%) respondents considered provider income and 81 (12.3%) considered clinic income to be linked to the abortion method recommended. In
Preference
No. (%)
Own preference Medical abortion Surgical abortion No preference Perceived preference of colleagues Medical abortion Surgical abortion No preference
134 (20.4) 230 (35.0) 294 (44.7) 94 (14.3) 288 (43.8) 275 (41.8)
37 (5.6%) cases, the abortion clinic charged for abortion counseling, and in 72 (10.9%) cases it charged for abortion follow-up. One hundred and fifteen (17.5%) healthcare providers stated that their income was related to the number of abortions they performed, and 475 (72.2%) reported that they did not receive any commission for providing medical or surgical abortion (Table 3). 4. Discussion In the present study, provider knowledge scores regarding medical abortion were at a moderate level—consistent with previous findings [5]. The results indicated that provider knowledge of the method is still inadequate, meaning that further studies and training are needed. Particularly in urban areas, among providers who are less educated, and those with less working experience, attention should be paid to the improvement of medical abortion knowledge. Training, communication, periodic evaluation, merit pay, and open competition may facilitate the achievement of this goal. In China, rural practitioners engage in only 4 family-planning procedures (inserting and removing intrauterine devices, induced abortion, and sterilization), whereas urban practitioners deal with many obstetric and gynecologic conditions. Therefore, rural practitioners are relatively more specialized and may be more familiar with medical abortion. Providers often focus on the problem of bleeding associated with medical abortion, but recent studies have found that traditional Chinese medicine can effectively reduce the amount of bleeding and shorten its duration [6,7]. However, owing to individual differences, women's sensitivity to the medicines used can vary, so further investigation is required. Significant improvements in duration and amount of bleeding are observed when compound mifepristone is used in conjunction with misoprostol for medical abortion [8,9], so this regimen can be recommended to abortion clinics throughout China. Resource limitation was also mentioned by providers as a disadvantage of medical abortion, especially in remote areas—implying that the Chinese government and authorities should allocate more medical resources for this method, increase investment, provide healthcare facilities with the necessary equipment and with sufficient recovery room for resting, and increase human resources. Furthermore, additional
Table 1 Multivariate logistic analysis of abortion knowledge scores.a Variable
Comparison group
Control group
B value
OR (95% CI)
P value
Area Unit type Unit level
Henan (rural area) Hospital City District/county University or higher N5 Yes
Shenzhen (urban area) FPSC Community/township Community/township Secondary school or lower b5 No
0.681 0.247 –0.291 0.311 0.832 0.628 1.581
1.975 1.281 0.748 1.365 2.297 1.875 4.858
0.003 0.308 0.399 0.168 0.001 0.005 0.051
Education level Experience, y Training
(1.263–3.089) (0.796–2.060) (0.380–1.470) (0.877–2.122) (1.412–3.737) (1.208–2.909) (0.995–23.727)
Abbreviations: FPSC, family-planning service center; CI, confidence interval; OR, odds ratio. a In accordance with their distribution, knowledge scores (out of 32) were divided into 2 groups: low (0–15 points) and high (16–32 points). The low group was used as the reference group.
K. Gan et al. / International Journal of Gynecology and Obstetrics 114 (2011) 15–17 Table 3 Provider perspective on relationship between abortion service and remuneration (n = 658). Views on financial remuneration
In the present study, most healthcare providers believed that surgical abortion was preferable to medical abortion. Efforts should be made to overcome the perceived disadvantages of medical abortion.
No. (%)
Importance of economic factors in provider recommending an abortion method a Very important 108 (17.8) Somewhat important 325 (53.5) Not important 174 (28.7) Provider income related to abortion method recommended 69 (10.5) Clinic income related to abortion method recommended 81 (12.3) Abortion clinic charges for abortion counseling 37 (5.6) Abortion clinic charges for abortion follow-up 72 (10.9) Provider income related to number of abortions performed 115 (17.5) Commission obtained by providers for performing medical abortion or surgical abortion No commission 475 (72.2) Medical abortion 11 (1.7) Surgical abortion 57 (8.7) Don't know 115 (17.5) a
17
Fifty-one responses missing.
research into taking misoprostol at home should be conducted because home administration not only keeps clinic recovery rooms free but also reduces the duration of clinic visits. Overseas studies [10–12] have indicated that, given the option, approximately 90% of women would choose to take misoprostol at home, of whom only 10% would return to the clinic because of failure of medical abortion [10,11]. Thus, time and resources could be spared for both providers and patients. At present in China, women are required to take misoprostol at clinics, where they must subsequently remain for more than 6 hours before going home. However, many high-income countries—in addition to some lowresource areas such as India, Nepal, and Cuba [10–12]—have implemented programs for taking misoprostol at home [13,14], indicating that home administration would be feasible and worthwhile in China. Most providers stated that remuneration was not associated with recommending an abortion service. In the rural area, there was not much difference in cost between medical abortion and surgical abortion, and both methods were very cheap. In the urban area, even if there was a difference in cost between the 2 methods, the income associated with abortion was low compared with that for other services (e.g. obstetric and gynecologic surgeries), and therefore it was not necessary for the providers to consider remuneration when recommending an abortion method. Most providers stated that they recommended a method based mainly on the situation of the women.
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