Study design and sampling
This cross-sectional study was conducted in Hunan Province in cooperation with the Women's Federation of Hunan Provincial Government between May 30 and September 16, 2019. Hunan Province is in central China and has a population of 68.6 million. We selected one county each in the eastern (Loudi), western (Huaihua), southern (Chenzhou), and northern (Changde) regions of Hunan Province that we believed to be typical for each region in economics and demographics, then selected one city in each county. Next, multistage cluster sampling was used to recruit samples from these four selected cities. We randomly selected one township per city and one village from each township for a total of four villages.
We determined the sample size using the equation of the random sampling method. According to a study for the floating population, the utilization rate of RH services in China was approximately 40% . We chose an approximate value of 40% for the calculation of the sample size. The formula we used for the sample size calculation was n=μ2α×P（1-P）/δ2, where α=0.05，μα=1.96, P means the overall rate of RH services and δ=3.3%. The sample size was calculated to be 847. To reduce the sampling error and increase the study power, we arbitrarily made a rough estimation by multiplying the calculated sample size by 15%, which led to a sample size of 974. Finally, a total of 980 women who met the requirements were recruited in this study, and 978 (99.8%) participants completed the questionnaire as requested.
An analysis of dynamic population monitoring data based on Hunan Province demonstrated that the fertility rate of women over 40 years was lower than 2.0% . Thus, our study selected women aged 20–39 years to investigate the utilization of and demand for RH services. The inclusion criteria were (1) females who were between 20 and 39 years old; (2) females who registered residences (hukou) in rural Hunan or lived in the investigated area for more than 6 months; and (3) females who provided oral informed consent. The exclusion criteria were cognitive impairment and the inability to complete the questionnaire independently.
Measurements and data collection
A Women’s Reproductive Health Questionnaire (WRH-Q) was developed by the researchers after an extensive literature review and revised by a panel of 10 experts from Central South University, affiliated hospitals, and the Hunan Women's Federation. We recruited women through direct door to door visits. When the three door-to-door investigations were failure, the household was abandoned and supplemented in sequence from the alternate households.
The Women's Federation of Hunan Provincial Government trained the community health workers, who were local familiarity. The training contents included the content and purpose of the current study and the steps to collect questionnaires. Well-trained investigators conducted interviews with the eligible subjects and explained the purpose and procedures of the study. The anonymous questionnaires were either completed by the subjects themselves or with the help of the investigators in cases of subjects with limited literacy. Investigators checked the completeness and accuracy of each questionnaire on the spot.
Socio-demographic and gestation data
This part was developed to collect participant information for items related to the region, age, marital status, employment, monthly household income, education level, spouse education level, sexual behavior, artificial abortion history, pregnancy history, and delivery history.
Utilization of RH services
RH services for women of childbearing age in China mainly include consulting, premarital checkups, preconception care, antenatal examination, postpartum visits, and general gynecological investigation . Depending on China's RH service content, this part of the questionnaire included: 1) Access to RH counseling. Participants would answer questions about whether she had gotten contraception counseling and pregnancy counseling. 2) Awareness of the free birth policy. Participants would answer the following questions: whether she had known about the basic public health service policy, free folic acid supplement policy, and free AIDS, syphilis, and hepatitis B testing. 3) Access to RH-related examinations or services. Participants would answer the following questions: whether she had received free folic acid supplements, free AIDS, syphilis and hepatitis B testing, free antenatal examinations, free preconception care, free postpartum visits, cervical cancer screening, and breast cancer screening.
Demand for RH services
The questionnaire also asked about the women’s needs for RH services. 1) What type of RH services do you want to get? (Answers: prevention of cervical/breast cancer, child health care, reproductive tract infection/sexually transmitted disease treatment, psychological health care, pregnant/prenatal care, contraception climacteric hygiene, and others). 2) Which way do you most want to get RH-related information? (Answers: medical staff, Internet, WeChat/Micro-blogs, radio and television, friends and family, books/newspapers/magazines, and brochures).
All data were independently double-entered and validated using EpiData (Version 3.0, The EpiData Association, Odense, Denmark). Data were analyzed with SPSS software (Version 18.0, Chicago: SPSS Inc.). Descriptive statistics were used to examine the socio-demographic factors and the statutes of the reproductive health services offering the samples. Logistic regression analyses were performed to examine the correlation factors of the utilization of RH services. Statistical significance was defined as a two-sided P value of less than 0.05. If more than 20% of the items had missing values, the questionnaire would be excluded as invalid.
The study was approved by the Ethical Committee of the Xiang Ya Nursing School, Central South University. Written consent was obtained from all respondents before the interviews.