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Study of knowledge and attitudes on medical abortion among Chinese health providers
International Journal of Gynecology and Obstetrics 118 (2012) S28–S32
Contents lists available at SciVerse ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CHINA
Study of knowledge and attitudes on medical abortion among Chinese health providers Yimin Cheng a,⁎, You Zhou b, Ying Zhang b, Xiaomei Jiang a, Maomao Xi b, Kang Gan b, Shanshan Ren a a b
Center for Social Medicine Research, National Research Institute for Family Planning (NRIFP), Beijing, China Peking Union Medical College, Beijing, China
a r t i c l e Keywords: Attitude Knowledge Medical Abortion Perspective Provider
i n f o
a b s t r a c t Objective: To investigate providers' knowledge and attitudes about medical abortion (MA) and their views regarding the main challenges to expanding the use of MA in urban and rural areas in China. Methods: A total of 658 abortion providers were surveyed from November 7, 2009, to May 29, 2010. Results: The providers' knowledge about MA was relatively poor, and most thought the risks of severe complications of MA were much higher than they are. Urban nonphysician providers were the least informed about MA. Most providers thought that the main challenges to an expanded use of MA were its lesser effectiveness in comparison to surgical abortion and women's lack of knowledge about it. In rural areas many providers thought that deficiencies of clinics, such as limited bed space and inadequate toilets and washing facilities, also posed serious obstacles to expanding MA use. Conclusion: Abortion providers, especially urban nonphysician providers, need refresher training to strengthen their knowledge of the approved protocol for providing MA in China, and also of the indications, contraindications, and safety and efficacy of the method. Deficiencies at abortion facilities should be addressed as well, and they are more numerous in rural areas. © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction About 1 in 5 pregnancies end in abortion worldwide, and the global number of induced abortions for 2003 was estimated at 42 million [1]. In China, as reported in the 2001 National Survey of Family Planning/ Reproductive Health, 27% of married women of reproductive age have had at least 1 induced abortion (the percentage among unmarried women is unknown) [2]. This high rate means that abortion is a frequent outcome for unintended pregnancies in China. China was among the first countries to test and, in 1988, approve mifepristone for early abortion. A large number of clinical trials in both China and other countries have demonstrated that medical abortion (MA) is safe and effective for terminating early pregnancies [3,4]. Over the past 20 years, MA by a combination of mifepristone and misoprostol has been made available in nearly all Chinese provinces, cities, and counties, and even in some townships. Obstetricians/gynecologists (ob-gyns), nurses, midwives, and family planning service (FPS) providers (those "special medical doctors" who mostly insert and remove IUDs and perform abortion and contraceptive sterilization) are permitted to provide MA. In urban areas, medical abortion services are provided at FPS centers, abortion clinics in hospitals, and specialized hospitals at the various administrative levels (provincial, municipal, ⁎ Corresponding author at: National Research Institute for Family Planning (NRIFP), 12 Da Hui Si, Hai Dian District, Beijing 100081, China. Tel.: + 86 10 6212 2176. E-mail address: [email protected] (Y. Cheng).
district, and neighborhood), and are available through both the private and public sectors. Despite its wide availability, MA accounts for a relatively small proportion of the abortions performed in China. Although comprehensive national data are not available, the ratio of MA to surgical abortion (SA) is about 1:6 in Shanghai city, for example [5]. Given that clinical trials have typically shown high levels of satisfaction with MA [6], it is not clear why this method is not more widely used. In China, MA is usually employed to terminate pregnancies up to 7 weeks' duration, after ruling out contraindications such as ectopic pregnancy, pregnancy while using an intrauterine device (IUD), or anemia (hemoglobin level b9.5 g/dL), among others. There are 2 approved ways of performing MA in China, which differ in the timing and dosage of mifepristone. However, both regimens require the woman to make 2 visits to the clinic, the first to be checked for eligibility and receive mifepristone and the second, on the third day, to be given misoprostol. On that day, she needs to remain at the hospital for up to 6 hours to be monitored for possible adverse effects of misoprostol, such as excessive bleeding, and for the expulsion of the gestational sac. The self-administration of misoprostol at home is not permitted in China [7]. China's policy dictates that those eligible for both MA and SA should be offered an informed and voluntary choice of method. However, women often rely on providers for information and advice, and the providers' knowledge and attitudes regarding the methods therefore greatly influence their patients' choice.
0020-7292/$ – see front matter © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2012.05.007
Y. Cheng et al. / International Journal of Gynecology and Obstetrics 118 (2012) S28–S32
This study investigates providers' knowledge and attitudes about MA in rural and urban settings in China. The specific objectives were: (1) to ascertain providers' knowledge about MA; (2) to learn about providers' attitudes toward MA; and (3) to examine differences in knowledge and attitudes between rural and urban providers. An earlier report discussed a summary measure of Chinese providers' knowledge of MA and their preferences regarding MA and SA [8]. If policymakers are to respond effectively to shortcomings in the providers' knowledge, and address the main practical problems that also affect abortion services, it is important to look more closely at specific aspects of the providers' knowledge of MA, at how the providers describe the practical problems they face when providing MA and also at how providers' knowledge and problems may differ in urban and rural settings. The present analysis examines in greater detail specific aspects of providers' knowledge and the differences in knowledge and opinions between providers in rural and urban areas of China. Generally speaking, the quality of staff, facilities, and organization is better in urban than in rural areas. For instance, staff in urban areas tend to be better educated, and this may influence their knowledge and views about providing MA or SA. In addition, when assessing the advantages and disadvantages of the 2 methods, providers are likely to take into consideration the circumstances of their patients, which differ in rural and urban areas. In particular, rural women typically need to travel farther to visit health facilities, and are thus likely to find it more difficult to make multiple visits for MA. 2. Participants and methods Abortion providers in the city of Shenzhen and in rural areas of Henan province filled out a questionnaire about their knowledge, experience, and attitudes concerning MA and SA. Family planning service centers and hospitals that provide abortion services were selected for the study through a multistage stratified cluster sampling design that ensured the inclusion of facilities belonging to the different administrative levels of the healthcare system (city, district, and neighborhood levels in Shenzhen and FPS centers and hospitals at the county and township levels in 9 rural counties in Henan Province). All eligible abortion service providers at the selected study sites were invited to participate. Eligible respondents included ob-gyns, nurses, midwives, and FPS providers who had been offering MA, SA, or both for more than 2 months at one of the selected health facilities. The survey was conducted at the facilities using a self-administered questionnaire that the providers usually completed in 20 to 30 minutes. From November 7, 2009, through May 29, 2010, 681 questionnaires were distributed, and 658 completed questionnaires were returned and are included in the study. The response rate was 96.6%. The study was approved by the Ethical Committee and the Administrative Authority of China's National Research Institute for Family Planning and by the WHO Research Ethics Review Committee. Participation was voluntary and the providers who agreed to take part signed a statement indicating their informed consent. Descriptive statistics were used to summarize characteristics and χ2 tests were used to look for differences between rural and urban respondents and between the different types of providers (ob-gyns vs other providers). 3. Results 3.1. Demographic characteristics of the abortion providers Whereas 44% of the respondents were between 30 and 39 years of age, 22% were younger than 30 years and 34% were 40 years or older. Most (96%) were women and all had graduated at least from medical vocational school. Those with college or university degrees accounted for 67% of the respondents. A majority (59%) had an average monthly income of 2000 Yuans or less (Table 1).
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Most (71%) were ob-gyns. Nurses, midwives, and FPS providers, respectively, accounted for 5%, 6%, and 18% of the respondents. Most (72%) worked at hospitals and the remaining worked at FPS centers. A higher percentage of the respondents from the city of Shenzhen were ob-gyns (and a lower percentage were FPS providers) than in rural Henan (P b 0.01). The respondents from Shenzhen were also more likely to be better educated, have higher incomes, be male, and work at hospitals than were their counterparts in Henan (Table 1).
3.2. Abortion providers' knowledge of MA The survey included a series of dichotomized (agree/disagree) questions to assess the providers' knowledge of MA and of the procedure protocol approved in China. The results show that many providers had an incorrect understanding of some of the items on the protocol (Table 2). For instance, although any woman who has experienced multiple previous surgical abortions can be offered MA if she is otherwise eligible, only 22% of the providers believed that a woman with a history of 3 surgical abortions should be offered MA. Only 34% agreed with the true statement that "the incidence of severe adverse effects (e.g. shock, coma, allergy, etc.) of medical abortion is less than 1%," and only 35% disagreed with the incorrect statement that "complications of medical abortion include endometriosis." Even though a higher percentage (54%) of providers knew that mifepristone is not to be administered sublingually, and 73% knew that the duration of vaginal bleeding is longer following MA than following SA, it appears that a substantial number of Chinese abortion providers do not know basic facts about MA and are not familiar with the approved protocol guiding its provision. Less than half of the rural and urban providers gave correct answers to 3 of the 5 questions shown in Table 2. In Shenzhen, ob-gyns were more likely than others to provide correct answers to most of the questions, and the differences were significant for 3 of the 5 questions (P b 0.05 or P b 0.01, depending on the question). There were no
Table 1 Characteristics of the providers.a Characteristics Age, y b b30 30–34 35–39 ≥40 Sex c Male Female Education level c Vocational medical Undergraduate d Graduate and higher Average monthly income, Yuans ≤2000 >2000 Type of medical provider c Ob-gyn Nurse Midwife FPS provider Type of health facility c FPS center Hospital
City of Shenzhen (n = 296)
Rural Henan (n = 362)
Total (N = 658)
26.6 21.3 17.1 35.0
19.1 27.9 20.7 32.3
22.4 25.0 19.1 33.5
8.1 91.9
0.6 99.4
4.0 96.0
11.8 63.9 24.3
31.2 68.8 0.0
22.5 66.6 10.9
12.0 88.0
97.0 3.0
59.0 41.0
80.7 6.1 4.7 8.5
63.3 4.7 6.0 26.0
71.1 5.3 5.5 18.1
16.5 83.5
38.4 61.6
28.3 71.7
c
Abbreviation: FPS, family planning service; Ob-gyn, obstetrician/gynecologist. a Values are given as percentages; P values are for the difference between rural and urban respondents. b P b 0.05. c P b 0.01. d Holding an undergraduate college or university degree.
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Y. Cheng et al. / International Journal of Gynecology and Obstetrics 118 (2012) S28–S32
Table 2 Percentages of providers giving correct answers to selected questions about medical abortion (MA), by type of area and type of provider. Question
City of Shenzhen Ob-gyns
Do you agree that: The duration of bleeding is longer with surgical abortion than with MA (incorrect statement) Mifepristone can be administered sublingually (incorrect statement) The incidence of severe adverse effects of MA (e.g., shock, coma, allergy) is less than 1% (correct statement) Complications of MA include endometriosis (incorrect statement) MA can be recommended if the woman has had 3 previous surgical abortions (correct statement) a b c d
73.4 55.0 28.8 38.9 27.9
Other providers 79.7 65.4 21.8 35.3 26.3
Rural Henan Ob-gyns b
73.2 51.9 48.1 33.9 16.7
a
Other providers 58.5 28.3 28.3 26.4 15.1
b
c d d
The statistical significance of differences in responses between ob-gyns and other providers is given within each type of area. These were nurses, midwives, and family planning service providers. P b 0.05. P b 0.01.
significant differences by type of provider within rural areas. It should be noted that in Shenzhen, the combined percentage of nurses and midwives as providers is greater than that of FPS providers (Table 1). Nurses and midwives have a more limited medical background, with less specialization in reproductive health issues, than do FPS providers, who make up about two-thirds of the non–ob-gyn group in the rural areas. The more limited medical training received by nurses and midwives may explain why they scored lowest on some of the knowledge questions in the urban areas. All professional categories combined, the rural providers were significantly more likely than their urban counterparts to give correct answers to the questions about the mode of administration of mifepristone, and also to those about the MA eligibility of women who had multiple previous surgical abortions. However, the rural providers were less likely to know that the incidence of severe adverse effects associated with MA was less than 1% (P b 0.01). 3.3. Providers' views on the advantages and disadvantages of MA Table 3 shows the percentages of rural and urban providers citing the 8 most commonly cited advantages of MA. More than 70% in each group saw as an advantage that MA was less invasive than SA. Other advantages cited by more than 50% of the providers in each group were that MA did not require anesthesia and that it avoided physical trauma. Other advantages cited by at least 35% of the providers in each group were that MA did not involve surgery and that it was more natural, more private, less painful, and less expensive. The providers from rural areas were significantly more likely than those from urban areas to perceive avoidance of anesthesia and avoidance of pain as advantages of MA, but they were significantly less likely to cite “more natural” as an advantage. The survey also asked the providers' opinions regarding the most important disadvantages of MA in comparison to SA. The first 4 disadvantages shown in Table 4 were the most commonly mentioned in response to a general question about disadvantages, without specifying Table 3 Stated specific advantages of medical abortion.a Advantages
City of Shenzhen (n = 296)
Rural Henan (n = 362)
Total (N = 658)
Less invasive Avoids anesthesia Avoids physical trauma Avoids surgery More natural More private Avoids pain Less expensive
78.0 56.4 53.4 46.6 50.0 39.2 23.0 38.2
72.4 70.7 60.8 49.2 38.1 43.9 45.9 33.1
74.9 64.3 57.5 48.0 43.5 41.8 35.6 35.4
a
a
b
b
b
Values are given as percentages; P values are for the difference between rural and urban respondents. b P b 0.01.
whether from the patient's or the provider's point of view. The drawback the most often mentioned, by 61% of the providers, was that MA involved more bleeding. It is unclear, however, whether the response indicates that most providers thought MA involved a greater total blood loss, or had in mind the typically longer duration of bleeding with MA, or both. Approximately half of all respondents mentioned higher failure rates for MA, and a longer process duration, as important drawbacks, and 35% of the respondents perceived the need for more than 1 clinic visit as an important disadvantage. Rural providers were much more likely than urban ones to mention “more bleeding” as a drawback (77% vs 43%, P b 0.01), but they were less likely to mention higher failure rates as an important disadvantage (45% vs 55%, P b 0.05). The questionnaire contained a separate item asking about MA's disadvantages from the perspective of a provider offering the procedure. The main disadvantage, apart from perceived higher failure rates than with SA, concerned facility-related problems, such as the need for more adequate sanitary facilities and the need for private recovery areas with beds (Table 4). Rural providers were substantially more likely to cite as problems the need for toilet facilities that would allow to retrieve the expelled gestational sac (57% vs 27%, P b 0.01) and the need for adequate washing facilities (52% vs 24%, P b 0.01). It is also worth noting that the providers generally did not consider MA safer than SA. In fact, approximately the same percentage of urban and rural providers thought that causing “more serious adverse effects” was among the main disadvantages of MA (13% and 12%, respectively). Rural providers were less likely to see a higher risk of serious adverse effects as a main drawback for SA, however (9% vs 16%, P b 0.01). In addition, 15% of the rural providers cited the risk of serious adverse effects as a main disadvantage of MA, compared with the 9% who associated the same disadvantage with SA (P b 0.05). By contrast, 12% of the urban providers cited serious adverse effects as a main disadvantage of MA and 16% thought the same about SA (in their case, the difference was not significant). When asked which type of abortion they preferred to provide, 41% of the urban and 48% of the rural providers expressed no preference. However, among those who did express a preference, SA was preferred by more providers than was MA, especially in the rural areas. Specifically, 33% of the urban and 36% of the rural providers said that they preferred SA whereas 26% of the former and 16% of the latter said that they preferred MA. The difference in response distribution between the rural and urban areas was statistically significant (P b 0.01). 3.4. Providers' perspectives on obstacles to expanding the use of MA The providers were asked for their views on the greatest challenges to expanding the use of MA. The response the most often cited, by half of the 607 respondents, was that a greater use of MA would raise the rates of complications and/or failed (incomplete)
Y. Cheng et al. / International Journal of Gynecology and Obstetrics 118 (2012) S28–S32
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Table 4 Perceived disadvantages of medical abortion as given by the providers.a Disadvantages From the viewpoint of both patients and providers Greater bleeding Higher failure rate Longer procedure duration More than 1 clinic visit From the viewpoint of the providers Providing toilet facilities permitting retrieval of the expelled gestational sac Providing adequate washing facilities Providing a private recovery area and beds a b
City of Shenzhen (n = 296)
Rural Henan (n = 362)
42.6 54.7 48.0 32.4
76.6 45.0 49.4 37.0
b
27.4 24.3 33.1
56.6 51.7 29.8
b
b
b
Total (N = 658) 61.3 49.4 48.8 34.9 43.5 39.4 31.3
Values are given as percentages; P values are for the difference between rural and urban respondents. P b 0.01.
abortions (Table 5). The next most common response was that women's poor awareness and poorer knowledge of MA posed an obstacle. Although those 2 challenges were the most commonly mentioned by both urban and rural providers, the prospect of higher complication and failure rates was mentioned by a significantly greater percentage of urban providers (55% vs 46%, P b 0.05). Inadequate facilities or equipment and/or problems with the supply of drugs were mentioned by 36% of the rural but only 12% of the urban providers (P b 0.01). In addition, 30% of the rural and 8% of the urban providers thought that there were national or local legal barriers to expanding the use of MA (P b 0.01). Many of the rural providers may have had in mind the regulation forbidding the home administration of misoprostol, as traveling a second time to a hospital or clinic to receive the drug can be a major barrier for rural women. About 1 in 5 providers also thought that expanding MA would overburden emergency services, obviously an important obstacle. Most providers did not consider lack of skilled clinical staff, objections from clinic staff, lack of demand from women, or lack of guidelines as serious obstacles to expanding the use of MA. 4. Discussion Even though SA is generally available in China under medically safe conditions, MA provides a low-cost, very low-risk alternative with other advantages that include avoidance of surgery and anesthesia. Moreover, because the indications and contraindications of the 2 approaches do not always overlap, MA and SA can be seen as complementary. However, although MA has become widely available in China over the past 20 years, SA continues to account for the large majority of abortions carried out in this country. The present study aimed to assess the current knowledge and perceptions of Chinese abortion providers about MA, and also their views about the prospects for expanding its use. Abortion providers' knowledge about MA was found to be relatively poor, which is consistent with the finding of other studies that many MA providers are not well informed about contraindications to the procedure [9–11]. In the
present study, for example, high percentages of providers gave wrong answers to questions concerning eligibility criteria for MA and the approved way of administering mifepristone. The present study also found that most abortion providers believe MA to pose greater health risks than clinical studies show that it does. Since MA avoids the risks associated with surgery, it may be safer than SA . However, only about one-third of the surveyed providers knew that the incidence of very serious adverse events due to MA, such as anaphylactic shock, was less than 1%. In fact, a review of the safety of MA in China found that the incidence of adverse events of such severity was only 0.06% [12]. Rural providers were especially likely to think that the risk of serious complications was greater than 1%. They were also more likely to believe that the risk of serious adverse effects was a major drawback for MA and a lesser drawback for SA. When asked which method of abortion they preferred to provide, many expressed no preference. More chose SA, however, and the percentage of those preferring MA was less in the Henan rural areas than it was in Shenzhen city. Studies in China [13] and elsewhere have published higher incomplete abortion rates with MA than with SA, and many providers in the present study saw these higher rates as an important obstacle to expanding MA use. But in China the rate of complications and/or incomplete abortion is less than 10% with MA, and clinically acceptable. Still, incomplete abortion means that the woman must undergo curettage, and this second procedure increases the providers' workload while adding an extra burden to emergency services. Many providers see those issues as important. Many rural providers also pointed to facility-related issues as obstacles to a wider use of MA. Accommodating women while they wait for abortion completion entails a need for more beds, more privacy, and more adequate washing and sanitation facilities. Addressing those problems might lead to a wider use of MA, especially in rural areas. The rural abortion providers were significantly more likely than those from urban areas to perceive the avoidance of anesthesia and pain as important advantages of MA. Those advantages are more
Table 5 Providers' perspectives on the challenges of expanding the use of medical abortion.a Challenge
b
Higher complication/abortion failure rate than with SA Women's poor related knowledge and cognition Problem with facility/drug supply inadequacies Legal barriers Strain on emergency medical services
City of Shenzhen (n = 263) 54.8 38.8 12.5 8.0 23.2
Abbreviation: SA, surgical abortion. a Values are given as percentages; P values are for the difference between rural and urban respondents. b Multiple answers were allowed. c Data were not available for 51 respondents. d P b 0.05. e P b 0.01.
Rural Henan (n = 344) 45.9 40.7 36.3 29.7 16.9
d
e e
Total (N = 607) 49.8 39.9 26.0 20.3 19.6
c
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obvious for rural providers, who often perform surgical abortions without anesthesia because of their fear of anesthesia-related accidents. The rural providers were also somewhat less likely to say that the higher complication and/or failure rate was an important disadvantage of MA or an important obstacle to expanding its use. At the same time, the rural providers were more likely to think that MA carries a substantial risk of severe complications, and they were much more likely to cite “more bleeding” as an important drawback of MA. Rural providers were also much more likely to mention inadequate facilities, insufficient drug supplies, or legal issues as important barriers to expanding the use of MA. These findings first point to the need to better educate providers on the factual aspects of MA, and this need can be met through refresher training as well as the distribution of well-designed informational materials. The need is greatest among urban providers other than obgyns, but all types of providers would benefit from a program designed to allay their unfounded concerns about MA safety and to strengthen their knowledge of the indications and contraindications for the method and the approved protocol for its provision. Second, if the providers are to become active supporters of a greater use of MA, issues such as shortage of beds and poor sanitation facilities, and concerns about straining emergency services, also need to be addressed. Providers' knowledge of and attitudes toward MA play a key role in promoting access to MA and ensuring that it is delivered according to protocol. However, other factors are also important, including women's knowledge and attitudes toward MA, and their opportunity for choice at healthcare facilities. Expanding access, improving acceptability, and providing high-quality MA services will require attention on the following fronts: improving providers' knowledge and addressing their concerns about MA and its safety; improving women's knowledge and addressing their own concerns; and overcoming deficiencies at the facilities. In conclusion, abortion providers, especially urban, nonphysician providers, need accurate information about MA (including practical refresher training) to strengthen their knowledge of the approved protocol, improve their knowledge of MA indications and contraindications, and allay unfounded concerns about MA safety. Deficiencies at abortion facilities should also be addressed, especially in rural areas.
Acknowledgments The authors acknowledge the financial and technical assistance provided by the Special Programme in Human Reproduction of the World Health Organization, and thank all those who participated in the project for their hard work and important contributions. Conflict of interest The authors have no conflicts of interest to declare.
References [1] In Brief: Fact Sheet: Facts on Induced Abortion Worldwide. Guttmacher Institute Web site. www.guttmacher.org/pubs/fb_IAW.html. [2] Pang L, Sun Y, Zheng X. Comparison and analysis of the induced abortion level and factors of married women in China. Theses Collection of the 2001 National Family Planning and Reproductive Health Survey. Beijing, China: Population Press of China; 2004. p. 204–15. [3] Shang X. Investigating the safety and efficacy of medication abortion in terminating risk pregnancy. China Pharmaceuticals 2009;18(1):57. [4] Nguyen N, Winikoff B, Clark S. Safety, efficacy and acceptability of mifepristone medical abortion in Vietnam. Int Fam Plan Perspect 1999;25(1):10–4. [5] Chen A, Gao E, Yuan W. Medical abortion and surgical abortion history among women attending antenatal care. Reprod Contracept 2002;22(3):164–8. [6] Winikoff B, Sivin I, Coyaji KJ, Cabezas E, Xiao B, Gu S. Safety, efficacy, and acceptability of medical abortion in China, Cuba, and India: a comparative trial of mifepristonemisoprostol versus surgical abortion. Am J Obstet Gynecol 1997;176(2):431–7. [7] Chinese Medical Association. Clinical Technology Operational Standard in Family Planning Volume. Beijing, China: People's Military Medical Press; 2004. p. 40–3. [8] Kang G, Yuhan Z, Xiaomei J, Meng Y, Hou L, Cheng Y. Perspectives of Chinese healthcare providers on medical abortion. Int J Gynecol Obstet 2011;114(1):15–7. [9] Shangchun W, Bilian X, Yunrong L. Survey of mifepristone utilization in medical abortion. Fam Plan J China 1999;5:205–10. [10] Zhang PY, Jin H, Xu X, Hu SZ, Chang MX, Zhang XJ, et al. Situation of health providers offering post-abortion care. Matern Child Health Care China 2007;22(27): 3839–43. [11] Zou Y, Liang Y, Wu S. Meta analysis of comparing acceptability of medical abortion and surgical abortion. Chin J Epidemiol 2006;27(1):68–71. [12] Zhang D, Zhou Y. Safety analysis of medical abortion. Fam Plan J China 2008;3: 188–90. [13] Zou Y, Youping LI, Changping Y. Evaluation of the effectiveness of mifepristone matching misoprostol medical abortion at early pregnancy. Chin J Evid Based Med 2005;5(8):619–31.
Contents lists available at SciVerse ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CHINA
Study of knowledge and attitudes on medical abortion among Chinese health providers Yimin Cheng a,⁎, You Zhou b, Ying Zhang b, Xiaomei Jiang a, Maomao Xi b, Kang Gan b, Shanshan Ren a a b
Center for Social Medicine Research, National Research Institute for Family Planning (NRIFP), Beijing, China Peking Union Medical College, Beijing, China
a r t i c l e Keywords: Attitude Knowledge Medical Abortion Perspective Provider
i n f o
a b s t r a c t Objective: To investigate providers' knowledge and attitudes about medical abortion (MA) and their views regarding the main challenges to expanding the use of MA in urban and rural areas in China. Methods: A total of 658 abortion providers were surveyed from November 7, 2009, to May 29, 2010. Results: The providers' knowledge about MA was relatively poor, and most thought the risks of severe complications of MA were much higher than they are. Urban nonphysician providers were the least informed about MA. Most providers thought that the main challenges to an expanded use of MA were its lesser effectiveness in comparison to surgical abortion and women's lack of knowledge about it. In rural areas many providers thought that deficiencies of clinics, such as limited bed space and inadequate toilets and washing facilities, also posed serious obstacles to expanding MA use. Conclusion: Abortion providers, especially urban nonphysician providers, need refresher training to strengthen their knowledge of the approved protocol for providing MA in China, and also of the indications, contraindications, and safety and efficacy of the method. Deficiencies at abortion facilities should be addressed as well, and they are more numerous in rural areas. © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction About 1 in 5 pregnancies end in abortion worldwide, and the global number of induced abortions for 2003 was estimated at 42 million [1]. In China, as reported in the 2001 National Survey of Family Planning/ Reproductive Health, 27% of married women of reproductive age have had at least 1 induced abortion (the percentage among unmarried women is unknown) [2]. This high rate means that abortion is a frequent outcome for unintended pregnancies in China. China was among the first countries to test and, in 1988, approve mifepristone for early abortion. A large number of clinical trials in both China and other countries have demonstrated that medical abortion (MA) is safe and effective for terminating early pregnancies [3,4]. Over the past 20 years, MA by a combination of mifepristone and misoprostol has been made available in nearly all Chinese provinces, cities, and counties, and even in some townships. Obstetricians/gynecologists (ob-gyns), nurses, midwives, and family planning service (FPS) providers (those "special medical doctors" who mostly insert and remove IUDs and perform abortion and contraceptive sterilization) are permitted to provide MA. In urban areas, medical abortion services are provided at FPS centers, abortion clinics in hospitals, and specialized hospitals at the various administrative levels (provincial, municipal, ⁎ Corresponding author at: National Research Institute for Family Planning (NRIFP), 12 Da Hui Si, Hai Dian District, Beijing 100081, China. Tel.: + 86 10 6212 2176. E-mail address: [email protected] (Y. Cheng).
district, and neighborhood), and are available through both the private and public sectors. Despite its wide availability, MA accounts for a relatively small proportion of the abortions performed in China. Although comprehensive national data are not available, the ratio of MA to surgical abortion (SA) is about 1:6 in Shanghai city, for example [5]. Given that clinical trials have typically shown high levels of satisfaction with MA [6], it is not clear why this method is not more widely used. In China, MA is usually employed to terminate pregnancies up to 7 weeks' duration, after ruling out contraindications such as ectopic pregnancy, pregnancy while using an intrauterine device (IUD), or anemia (hemoglobin level b9.5 g/dL), among others. There are 2 approved ways of performing MA in China, which differ in the timing and dosage of mifepristone. However, both regimens require the woman to make 2 visits to the clinic, the first to be checked for eligibility and receive mifepristone and the second, on the third day, to be given misoprostol. On that day, she needs to remain at the hospital for up to 6 hours to be monitored for possible adverse effects of misoprostol, such as excessive bleeding, and for the expulsion of the gestational sac. The self-administration of misoprostol at home is not permitted in China [7]. China's policy dictates that those eligible for both MA and SA should be offered an informed and voluntary choice of method. However, women often rely on providers for information and advice, and the providers' knowledge and attitudes regarding the methods therefore greatly influence their patients' choice.
0020-7292/$ – see front matter © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2012.05.007
Y. Cheng et al. / International Journal of Gynecology and Obstetrics 118 (2012) S28–S32
This study investigates providers' knowledge and attitudes about MA in rural and urban settings in China. The specific objectives were: (1) to ascertain providers' knowledge about MA; (2) to learn about providers' attitudes toward MA; and (3) to examine differences in knowledge and attitudes between rural and urban providers. An earlier report discussed a summary measure of Chinese providers' knowledge of MA and their preferences regarding MA and SA [8]. If policymakers are to respond effectively to shortcomings in the providers' knowledge, and address the main practical problems that also affect abortion services, it is important to look more closely at specific aspects of the providers' knowledge of MA, at how the providers describe the practical problems they face when providing MA and also at how providers' knowledge and problems may differ in urban and rural settings. The present analysis examines in greater detail specific aspects of providers' knowledge and the differences in knowledge and opinions between providers in rural and urban areas of China. Generally speaking, the quality of staff, facilities, and organization is better in urban than in rural areas. For instance, staff in urban areas tend to be better educated, and this may influence their knowledge and views about providing MA or SA. In addition, when assessing the advantages and disadvantages of the 2 methods, providers are likely to take into consideration the circumstances of their patients, which differ in rural and urban areas. In particular, rural women typically need to travel farther to visit health facilities, and are thus likely to find it more difficult to make multiple visits for MA. 2. Participants and methods Abortion providers in the city of Shenzhen and in rural areas of Henan province filled out a questionnaire about their knowledge, experience, and attitudes concerning MA and SA. Family planning service centers and hospitals that provide abortion services were selected for the study through a multistage stratified cluster sampling design that ensured the inclusion of facilities belonging to the different administrative levels of the healthcare system (city, district, and neighborhood levels in Shenzhen and FPS centers and hospitals at the county and township levels in 9 rural counties in Henan Province). All eligible abortion service providers at the selected study sites were invited to participate. Eligible respondents included ob-gyns, nurses, midwives, and FPS providers who had been offering MA, SA, or both for more than 2 months at one of the selected health facilities. The survey was conducted at the facilities using a self-administered questionnaire that the providers usually completed in 20 to 30 minutes. From November 7, 2009, through May 29, 2010, 681 questionnaires were distributed, and 658 completed questionnaires were returned and are included in the study. The response rate was 96.6%. The study was approved by the Ethical Committee and the Administrative Authority of China's National Research Institute for Family Planning and by the WHO Research Ethics Review Committee. Participation was voluntary and the providers who agreed to take part signed a statement indicating their informed consent. Descriptive statistics were used to summarize characteristics and χ2 tests were used to look for differences between rural and urban respondents and between the different types of providers (ob-gyns vs other providers). 3. Results 3.1. Demographic characteristics of the abortion providers Whereas 44% of the respondents were between 30 and 39 years of age, 22% were younger than 30 years and 34% were 40 years or older. Most (96%) were women and all had graduated at least from medical vocational school. Those with college or university degrees accounted for 67% of the respondents. A majority (59%) had an average monthly income of 2000 Yuans or less (Table 1).
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Most (71%) were ob-gyns. Nurses, midwives, and FPS providers, respectively, accounted for 5%, 6%, and 18% of the respondents. Most (72%) worked at hospitals and the remaining worked at FPS centers. A higher percentage of the respondents from the city of Shenzhen were ob-gyns (and a lower percentage were FPS providers) than in rural Henan (P b 0.01). The respondents from Shenzhen were also more likely to be better educated, have higher incomes, be male, and work at hospitals than were their counterparts in Henan (Table 1).
3.2. Abortion providers' knowledge of MA The survey included a series of dichotomized (agree/disagree) questions to assess the providers' knowledge of MA and of the procedure protocol approved in China. The results show that many providers had an incorrect understanding of some of the items on the protocol (Table 2). For instance, although any woman who has experienced multiple previous surgical abortions can be offered MA if she is otherwise eligible, only 22% of the providers believed that a woman with a history of 3 surgical abortions should be offered MA. Only 34% agreed with the true statement that "the incidence of severe adverse effects (e.g. shock, coma, allergy, etc.) of medical abortion is less than 1%," and only 35% disagreed with the incorrect statement that "complications of medical abortion include endometriosis." Even though a higher percentage (54%) of providers knew that mifepristone is not to be administered sublingually, and 73% knew that the duration of vaginal bleeding is longer following MA than following SA, it appears that a substantial number of Chinese abortion providers do not know basic facts about MA and are not familiar with the approved protocol guiding its provision. Less than half of the rural and urban providers gave correct answers to 3 of the 5 questions shown in Table 2. In Shenzhen, ob-gyns were more likely than others to provide correct answers to most of the questions, and the differences were significant for 3 of the 5 questions (P b 0.05 or P b 0.01, depending on the question). There were no
Table 1 Characteristics of the providers.a Characteristics Age, y b b30 30–34 35–39 ≥40 Sex c Male Female Education level c Vocational medical Undergraduate d Graduate and higher Average monthly income, Yuans ≤2000 >2000 Type of medical provider c Ob-gyn Nurse Midwife FPS provider Type of health facility c FPS center Hospital
City of Shenzhen (n = 296)
Rural Henan (n = 362)
Total (N = 658)
26.6 21.3 17.1 35.0
19.1 27.9 20.7 32.3
22.4 25.0 19.1 33.5
8.1 91.9
0.6 99.4
4.0 96.0
11.8 63.9 24.3
31.2 68.8 0.0
22.5 66.6 10.9
12.0 88.0
97.0 3.0
59.0 41.0
80.7 6.1 4.7 8.5
63.3 4.7 6.0 26.0
71.1 5.3 5.5 18.1
16.5 83.5
38.4 61.6
28.3 71.7
c
Abbreviation: FPS, family planning service; Ob-gyn, obstetrician/gynecologist. a Values are given as percentages; P values are for the difference between rural and urban respondents. b P b 0.05. c P b 0.01. d Holding an undergraduate college or university degree.
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Table 2 Percentages of providers giving correct answers to selected questions about medical abortion (MA), by type of area and type of provider. Question
City of Shenzhen Ob-gyns
Do you agree that: The duration of bleeding is longer with surgical abortion than with MA (incorrect statement) Mifepristone can be administered sublingually (incorrect statement) The incidence of severe adverse effects of MA (e.g., shock, coma, allergy) is less than 1% (correct statement) Complications of MA include endometriosis (incorrect statement) MA can be recommended if the woman has had 3 previous surgical abortions (correct statement) a b c d
73.4 55.0 28.8 38.9 27.9
Other providers 79.7 65.4 21.8 35.3 26.3
Rural Henan Ob-gyns b
73.2 51.9 48.1 33.9 16.7
a
Other providers 58.5 28.3 28.3 26.4 15.1
b
c d d
The statistical significance of differences in responses between ob-gyns and other providers is given within each type of area. These were nurses, midwives, and family planning service providers. P b 0.05. P b 0.01.
significant differences by type of provider within rural areas. It should be noted that in Shenzhen, the combined percentage of nurses and midwives as providers is greater than that of FPS providers (Table 1). Nurses and midwives have a more limited medical background, with less specialization in reproductive health issues, than do FPS providers, who make up about two-thirds of the non–ob-gyn group in the rural areas. The more limited medical training received by nurses and midwives may explain why they scored lowest on some of the knowledge questions in the urban areas. All professional categories combined, the rural providers were significantly more likely than their urban counterparts to give correct answers to the questions about the mode of administration of mifepristone, and also to those about the MA eligibility of women who had multiple previous surgical abortions. However, the rural providers were less likely to know that the incidence of severe adverse effects associated with MA was less than 1% (P b 0.01). 3.3. Providers' views on the advantages and disadvantages of MA Table 3 shows the percentages of rural and urban providers citing the 8 most commonly cited advantages of MA. More than 70% in each group saw as an advantage that MA was less invasive than SA. Other advantages cited by more than 50% of the providers in each group were that MA did not require anesthesia and that it avoided physical trauma. Other advantages cited by at least 35% of the providers in each group were that MA did not involve surgery and that it was more natural, more private, less painful, and less expensive. The providers from rural areas were significantly more likely than those from urban areas to perceive avoidance of anesthesia and avoidance of pain as advantages of MA, but they were significantly less likely to cite “more natural” as an advantage. The survey also asked the providers' opinions regarding the most important disadvantages of MA in comparison to SA. The first 4 disadvantages shown in Table 4 were the most commonly mentioned in response to a general question about disadvantages, without specifying Table 3 Stated specific advantages of medical abortion.a Advantages
City of Shenzhen (n = 296)
Rural Henan (n = 362)
Total (N = 658)
Less invasive Avoids anesthesia Avoids physical trauma Avoids surgery More natural More private Avoids pain Less expensive
78.0 56.4 53.4 46.6 50.0 39.2 23.0 38.2
72.4 70.7 60.8 49.2 38.1 43.9 45.9 33.1
74.9 64.3 57.5 48.0 43.5 41.8 35.6 35.4
a
a
b
b
b
Values are given as percentages; P values are for the difference between rural and urban respondents. b P b 0.01.
whether from the patient's or the provider's point of view. The drawback the most often mentioned, by 61% of the providers, was that MA involved more bleeding. It is unclear, however, whether the response indicates that most providers thought MA involved a greater total blood loss, or had in mind the typically longer duration of bleeding with MA, or both. Approximately half of all respondents mentioned higher failure rates for MA, and a longer process duration, as important drawbacks, and 35% of the respondents perceived the need for more than 1 clinic visit as an important disadvantage. Rural providers were much more likely than urban ones to mention “more bleeding” as a drawback (77% vs 43%, P b 0.01), but they were less likely to mention higher failure rates as an important disadvantage (45% vs 55%, P b 0.05). The questionnaire contained a separate item asking about MA's disadvantages from the perspective of a provider offering the procedure. The main disadvantage, apart from perceived higher failure rates than with SA, concerned facility-related problems, such as the need for more adequate sanitary facilities and the need for private recovery areas with beds (Table 4). Rural providers were substantially more likely to cite as problems the need for toilet facilities that would allow to retrieve the expelled gestational sac (57% vs 27%, P b 0.01) and the need for adequate washing facilities (52% vs 24%, P b 0.01). It is also worth noting that the providers generally did not consider MA safer than SA. In fact, approximately the same percentage of urban and rural providers thought that causing “more serious adverse effects” was among the main disadvantages of MA (13% and 12%, respectively). Rural providers were less likely to see a higher risk of serious adverse effects as a main drawback for SA, however (9% vs 16%, P b 0.01). In addition, 15% of the rural providers cited the risk of serious adverse effects as a main disadvantage of MA, compared with the 9% who associated the same disadvantage with SA (P b 0.05). By contrast, 12% of the urban providers cited serious adverse effects as a main disadvantage of MA and 16% thought the same about SA (in their case, the difference was not significant). When asked which type of abortion they preferred to provide, 41% of the urban and 48% of the rural providers expressed no preference. However, among those who did express a preference, SA was preferred by more providers than was MA, especially in the rural areas. Specifically, 33% of the urban and 36% of the rural providers said that they preferred SA whereas 26% of the former and 16% of the latter said that they preferred MA. The difference in response distribution between the rural and urban areas was statistically significant (P b 0.01). 3.4. Providers' perspectives on obstacles to expanding the use of MA The providers were asked for their views on the greatest challenges to expanding the use of MA. The response the most often cited, by half of the 607 respondents, was that a greater use of MA would raise the rates of complications and/or failed (incomplete)
Y. Cheng et al. / International Journal of Gynecology and Obstetrics 118 (2012) S28–S32
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Table 4 Perceived disadvantages of medical abortion as given by the providers.a Disadvantages From the viewpoint of both patients and providers Greater bleeding Higher failure rate Longer procedure duration More than 1 clinic visit From the viewpoint of the providers Providing toilet facilities permitting retrieval of the expelled gestational sac Providing adequate washing facilities Providing a private recovery area and beds a b
City of Shenzhen (n = 296)
Rural Henan (n = 362)
42.6 54.7 48.0 32.4
76.6 45.0 49.4 37.0
b
27.4 24.3 33.1
56.6 51.7 29.8
b
b
b
Total (N = 658) 61.3 49.4 48.8 34.9 43.5 39.4 31.3
Values are given as percentages; P values are for the difference between rural and urban respondents. P b 0.01.
abortions (Table 5). The next most common response was that women's poor awareness and poorer knowledge of MA posed an obstacle. Although those 2 challenges were the most commonly mentioned by both urban and rural providers, the prospect of higher complication and failure rates was mentioned by a significantly greater percentage of urban providers (55% vs 46%, P b 0.05). Inadequate facilities or equipment and/or problems with the supply of drugs were mentioned by 36% of the rural but only 12% of the urban providers (P b 0.01). In addition, 30% of the rural and 8% of the urban providers thought that there were national or local legal barriers to expanding the use of MA (P b 0.01). Many of the rural providers may have had in mind the regulation forbidding the home administration of misoprostol, as traveling a second time to a hospital or clinic to receive the drug can be a major barrier for rural women. About 1 in 5 providers also thought that expanding MA would overburden emergency services, obviously an important obstacle. Most providers did not consider lack of skilled clinical staff, objections from clinic staff, lack of demand from women, or lack of guidelines as serious obstacles to expanding the use of MA. 4. Discussion Even though SA is generally available in China under medically safe conditions, MA provides a low-cost, very low-risk alternative with other advantages that include avoidance of surgery and anesthesia. Moreover, because the indications and contraindications of the 2 approaches do not always overlap, MA and SA can be seen as complementary. However, although MA has become widely available in China over the past 20 years, SA continues to account for the large majority of abortions carried out in this country. The present study aimed to assess the current knowledge and perceptions of Chinese abortion providers about MA, and also their views about the prospects for expanding its use. Abortion providers' knowledge about MA was found to be relatively poor, which is consistent with the finding of other studies that many MA providers are not well informed about contraindications to the procedure [9–11]. In the
present study, for example, high percentages of providers gave wrong answers to questions concerning eligibility criteria for MA and the approved way of administering mifepristone. The present study also found that most abortion providers believe MA to pose greater health risks than clinical studies show that it does. Since MA avoids the risks associated with surgery, it may be safer than SA . However, only about one-third of the surveyed providers knew that the incidence of very serious adverse events due to MA, such as anaphylactic shock, was less than 1%. In fact, a review of the safety of MA in China found that the incidence of adverse events of such severity was only 0.06% [12]. Rural providers were especially likely to think that the risk of serious complications was greater than 1%. They were also more likely to believe that the risk of serious adverse effects was a major drawback for MA and a lesser drawback for SA. When asked which method of abortion they preferred to provide, many expressed no preference. More chose SA, however, and the percentage of those preferring MA was less in the Henan rural areas than it was in Shenzhen city. Studies in China [13] and elsewhere have published higher incomplete abortion rates with MA than with SA, and many providers in the present study saw these higher rates as an important obstacle to expanding MA use. But in China the rate of complications and/or incomplete abortion is less than 10% with MA, and clinically acceptable. Still, incomplete abortion means that the woman must undergo curettage, and this second procedure increases the providers' workload while adding an extra burden to emergency services. Many providers see those issues as important. Many rural providers also pointed to facility-related issues as obstacles to a wider use of MA. Accommodating women while they wait for abortion completion entails a need for more beds, more privacy, and more adequate washing and sanitation facilities. Addressing those problems might lead to a wider use of MA, especially in rural areas. The rural abortion providers were significantly more likely than those from urban areas to perceive the avoidance of anesthesia and pain as important advantages of MA. Those advantages are more
Table 5 Providers' perspectives on the challenges of expanding the use of medical abortion.a Challenge
b
Higher complication/abortion failure rate than with SA Women's poor related knowledge and cognition Problem with facility/drug supply inadequacies Legal barriers Strain on emergency medical services
City of Shenzhen (n = 263) 54.8 38.8 12.5 8.0 23.2
Abbreviation: SA, surgical abortion. a Values are given as percentages; P values are for the difference between rural and urban respondents. b Multiple answers were allowed. c Data were not available for 51 respondents. d P b 0.05. e P b 0.01.
Rural Henan (n = 344) 45.9 40.7 36.3 29.7 16.9
d
e e
Total (N = 607) 49.8 39.9 26.0 20.3 19.6
c
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obvious for rural providers, who often perform surgical abortions without anesthesia because of their fear of anesthesia-related accidents. The rural providers were also somewhat less likely to say that the higher complication and/or failure rate was an important disadvantage of MA or an important obstacle to expanding its use. At the same time, the rural providers were more likely to think that MA carries a substantial risk of severe complications, and they were much more likely to cite “more bleeding” as an important drawback of MA. Rural providers were also much more likely to mention inadequate facilities, insufficient drug supplies, or legal issues as important barriers to expanding the use of MA. These findings first point to the need to better educate providers on the factual aspects of MA, and this need can be met through refresher training as well as the distribution of well-designed informational materials. The need is greatest among urban providers other than obgyns, but all types of providers would benefit from a program designed to allay their unfounded concerns about MA safety and to strengthen their knowledge of the indications and contraindications for the method and the approved protocol for its provision. Second, if the providers are to become active supporters of a greater use of MA, issues such as shortage of beds and poor sanitation facilities, and concerns about straining emergency services, also need to be addressed. Providers' knowledge of and attitudes toward MA play a key role in promoting access to MA and ensuring that it is delivered according to protocol. However, other factors are also important, including women's knowledge and attitudes toward MA, and their opportunity for choice at healthcare facilities. Expanding access, improving acceptability, and providing high-quality MA services will require attention on the following fronts: improving providers' knowledge and addressing their concerns about MA and its safety; improving women's knowledge and addressing their own concerns; and overcoming deficiencies at the facilities. In conclusion, abortion providers, especially urban, nonphysician providers, need accurate information about MA (including practical refresher training) to strengthen their knowledge of the approved protocol, improve their knowledge of MA indications and contraindications, and allay unfounded concerns about MA safety. Deficiencies at abortion facilities should also be addressed, especially in rural areas.
Acknowledgments The authors acknowledge the financial and technical assistance provided by the Special Programme in Human Reproduction of the World Health Organization, and thank all those who participated in the project for their hard work and important contributions. Conflict of interest The authors have no conflicts of interest to declare.
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