Contraceptive situation and Inuencing Factors in Guangdong Province: A comparative questionnaire study

The aim of our study is to describe the status of induced abortion and contraceptive use in reproductive women and make clear the correlated factors in Guangdong province. A self-administered questionnaire survey was conducted separately in 1839 individuals aged 18–49 and 900 health care providers from Guangdong province. The content of questionnaire was based on status of induced abortion and contraceptive use for the former and problems concerning contraceptive services for the latter. Systematic random sampling was used and data were analyzed using SPSS 19.0. Descriptive statistics and binary logistic regression were used in this study.

LARC and PAC should be done more research. The questionaire survey contains 50 questions including the basic demographic characteristics, the level of LARC utilization and the intention to use LARC, the situation of PAC performance and barriers to obtain free contraceptive services. In particular, the questionaire for health care providers was based on health care providers' attitudes to LARC and problems in supplying contraceptive services.
We found that 30.61% of women in reproductive age experienced the induced abortion. The rate of repeated induced abortion was high in unmarried yonger women. Older women(> 41years), having one child at least, obtaining PAC and free contraceptives services in time tended to select LARC. The rate for the use of PAC was low in our survey. Age, job types, living condition, monthly income and obtaining free contraceptives conveniently were the main factors. Free contraceptives were also helpful to promote LARC use while variety uniformity and worrying about the quality were barriers. Workplaces providing PAC services were correlated with correct attitude of regarding IUDs use in health care providers. Improving leadership management and setting up the department of family planning in hospitals may be applicable measures.

Background
Many research indicated that the absolute number of abortions world-wide increased 56·3 million per year in recent years and 27% of abortions happened in unmarried young women. In the developed world, the annual abortion rate declined signi cantly but it still maintained in 37 abortions per 1000 women in the developing world [1]. The 2018 China Health Statistical Yearbook showed that the number of induced abortions attained 9.74 million in 2018 in china [2]. 55.9% of induced abortion women experience multiple abortion, which was 43.1% in the United States [3,4]. More and more young people had more than one induced abortion experiences. High risk induced abortion presented an up-trend. Induced abortion seriously threatened the women'health. Women with induced abortion may suffer complications and adverse pregnancy outcome in pregnancies including low birthweight, preterm birth and others [5]. Some researches showed that the induced abortion increased risk of mental disorders especially in unmarried women [6]. Long-acting reversible contraceptives (LARCs) have been proved as the most cost-effective methods to prevent unintended pregnancies especially reduce the rate of repeat abortions during the post abortion period [7]. It has been recommended by the American College of Obstetricians [8]. With the loosened birth policy, contraceptive use condition has changed since 2016. Although the total contraceptive prevalence rates remain around 80% which is the highest in the world, more and more women choose the short-term and self-controlled contraceptive methods. IUD usage decreased from 20.98% in 2014 to 10.73% in 2018. Post-abortion care (PAC) counseling was rst proposed in 1991 and many reports showed that it could also induced abortions [9,10]. Although PAC had been provided in 799 hospitals since 2010, the promotion of PAC in child-bearing age people was not enough (http://www.yiaijijin.org.cn/html/xinwenzixun/1609.html). Limited understanding of LARCs and lack of high-quality post-abortion care (PAC) services are the major reasons for the largest number of induced abortion in china.
The contraceptive prevalence rate in Guangdong province was only 71.6% ranking the 27th while the rate of induced abortion was in the second place around the country. The number of internal migrants living was largest in china. Most of the migrant women were in the child-bearing age and lacked contraceptive knowledge and correct attitude. It was not easy for them to obtain the free family planning services. Free PAC services have been provided in 104 hospitals but the understanding of PAC services is not enough depth and thorough in such people of childbearing age. The objective of our study is to evaluate the present situation of contraception and abortion including the knowledge and the offering situation of LARCs and PAC services, the factors that in uenced people to obtain free contraceptive services.

Study design and setting
We designed the questionnaire using an APP to collect data. Participants with 18-49-year-old who had sexual life in Guangdong province were recruited in our study. This study observed the voluntary participation principle and was approved by Guangzhou Women & Children Medical Center's ethics committee. The questionnaire included questions on: (1)basic demographics; (2)occupation; (3)marriage and fertility status; (4)contraceptive use; (5)history of abortion; (6)contraceptive status; (7) di culties in receiving free contraceptive and PAC services; and (8) knowledge and acceptance of LARCs and PAC. We also recruited 900 health care providers to reveal problems encountered with in providing the contraceptive services and attitudes towards LARCs and PAC use in abortion or postpartum women. The questions were close-ended. In order to ensure all participants to easily understand the questionnaire, we used simple language and conducted a pre-survey. We excluded cases with incomplete data and reviewed the questionnaire by experienced obstetricians. SPSS 19.0 was utilized to analyze the data. A chi-Square test and logistic regression analysis were performed to analyze factors in uencing the status of induced abortion, the choice of contraceptive methods and knowledge of LARCs and PAC. Chi square analysis, descriptive statistics and binary logistic regression were employed in our study. We also chose Odds ratios (ORs) and 95% con dence intervals (CIs) to calculate. A p-value of less than 0.05 was regarded as statistically signi cant.

Results
Socio-demographic characteristics of all participants 93.26% of 1839 participants were of Han ancestry, the average age of which were 33.5 ± 8.17 years. Among them, 69.01% had a college education and approximately half (52.04%) had individual income per month over 5000 RMB. 83.14% of those persons were married. 78.47% had one child at least. 93.2% of those 1839 persons were employed. Table 1 showed all the demographic information for 1839 common participants. All those 900 health care providers came from hospitals(80.33%) or family planning organizations(19.67%). 93.88% of them were obstetrics and gynecology physicians and others were family planning practitioners. In those obstetrics and gynecology physicians, 21.02% served in the department of family planning in hospitals. teachers or medical staffs more frequently used PAC services(OR:6.971, 95%CI: 1.580-30.76). We pointed out the person with monthly income lower than 10000 (p < 0.01) and the person obtaining free contraceptives inconveniently (p = 0.000) was main in uencing factors for the acceptability of PAC services (Table 2). In our investment for 900 health care providers, 66.11% of their work units provided PAC services. PAC services were carried out mainly in 3-A-grade General Hospitals and maternal and child health institutions The application of PAC services was only 12.4% in primary hospitals. There was signi cant difference in rates of supplying PAC services between their workplaces with and without the department of family planning. Factors associated with applications of free Contraceptives In our study, 51.22% (942/1839) of people did not obtain contraceptives free of charge from the government. Worrying about the quality of contraceptives, being unsatis ed with models and types and feeling embarrassed were main reasons for them to refuse free contraceptives. All those in uence factors were described in Fig. 1. Family planning departments, self-service terminal for free contraceptives and department of gynecology in public hospitals are main sources of which people at reproductive age to obtain free contraceptives(88.4%). The satisfaction with those approachs was only 57.44%(874/1839). Youger women(20-40 years old) had a lower incidence of using free contraceptives comparing to women being over 40 year-old. The participants'monthly income lower than 3000 or between 3000-5000 had higher odds of using free contraceptives(OR: 2.119, 95%CI:1.125-3.991 and OR: 2.014, 95%CI:1.260-3.221 respectively) The higher income people, the population living in urban and suburb, and the persons being self-employed or without working did not intend to obtain free contraceptives(p < 0.05)( Table 3). We also analyzed the in uence factors for betimes of obtaining free contraceptives.The major factors were also associated with intention to use free contraceptives. Another factor that the women had more than one boy was also strongly associated with timeliness(OR:2.066, 95%CI:1.265-3.374) ( Table 4).  Our survey showed that the contraceptives free of charge were provided in 87.22% of the 900 health care providers' work units. Obtaining from self-service terminal for free contraceptives(35.84%) and having prescriptions of free contraceptives after counselling (21.74%) were main approaches. The staff faced many di culties in promoting contraceptive service provision, which were showed in Fig. 2.
Knowledge and performance of LARC and in our study In this study, only 46.80% of 1839 people know exactly about types of LARC. Few (9.74% had used IUDs, 1.53% had used implants and 6.96% had used vasoligation or female ligation) used LARC. 27.80% participant took regard condom as LARC and 50.49% of them took the condom as the main contraceptive method. 29.8% of the women had the intention to use IUDs or implants during the post abortion period. By using binary logistic regression, the following factors for LARC use were identi ed as risk factors for age, job, educational level, monthly income, the use of PAC services. (Table 5). We also used binary logistic regression logistic regression to analyze variables that had the signi cant correlation with a woman's intention to use a LARC after abortion or after childbirth. The result showed that the women who had less than one boy, used PAC services, obtained free contraceptives and were between 30-40 years old were more likely to use a LARC (Table 6).

Discussion
Guangdong was the most populous province of china. O cial data indicated that the induced abortion incidence has maintained more than 50‰ in this province(http://www.gdhealth.net.cn/html/tongjishuju/tongjiziliao/). China's a two-child policy has been implemented since 2015. It means that people can have their preferred number of children. IUD was nearly received by all women after the birth of their rst child due to the one-child policy [11]. The rate of LARCs use decreased because women could make their own choices. In fact, LARC devices should be rst-line contraceptive methods for adolescents [7]. The data showed that the rate of IUD use among married women has reduced in half in Guangdong province since 2015. Problems in contraceptives and in uence factors for induced abortion in Guangdong province are still lack of relevant reports.
The abortion rate in our study was close to that reported in three major cities in china [12]. The percentage of married women and unmarried women experiencing one induced abortion was about 32.78% and 17.18% respectively, and 11.72% of unmarried women and 21.28% of married women experienced the repeated induced abortion. A review based on nine studies showed that the average value of abortion rates was about 28%, the range of which was from 11-55% in china [2,13]. A recent survey showed that the proportion of repeat induced abortion was high and veried different among 30 provinces in china [14]. The abortion rate in Guangdong province was inside this range. The women in the 40-49 age group had a much higher percentage of induced abortion(38.12%) and repeated abortion(28.15%). It was consistent with the ndings of other studies due to the experience undergoing the one-child policy during their reproductive age [12,14,15].Although the proportion of induced abortion in women under 20 was lower than that in women over 20-years of age(12.5% vs 30.9%), the proportion of repeated induced abortion was higher in the the former group(25% vs 20.45%). In particular, 66.7% of them were unmarried. It meant that reducing unintended pregnancy in unmarried younger women were grim in Guangdong province. LARC program has been recommended for adults espercially nulliparous and adolescent patients since 2008. It also was identi ed as a very effective method for adolescents [16][17][18]. In our study, the rate of IUD use in participants was 14.5%. 75% of women with age less than 20 did not use LARC such as IUD as the common conceptive methods. The rate of IUD use among unmarried women was only 7.74% in this study. The data were consistent with what were reported in china before [19]. We found that the women with age less than 30 years old or nulliparous women seldom chose IUD as the main contraceptive method due to attempting pregnancy for them. Most of them feared that LARC would cause infertility.
Fear of infertility was a major factor for young women's contraceptive decision in the world all along [10,20,21]. Out study indicated that the women who had two children often seek LARC. With increase of the education cost and work pressure, many families do not choose to have more children in china. The rst consideration for contraception method was e ciency.
Other in uencial factors included the provision of PAC services and free contraceptive services. PAC services were rst proposed since 1994 and described as the effective method to reduce repeat induced abortion [9]. Providing contraceptive services was one of the important parts. Our questionaire showed that the individual who never used PAC services was signi cantly less likely to use LARC. It meant that PAC services were very useful to promote LARC use in reproductive age women. In fact, only 14.18% of persons accepted PAC services in our survey. It was much lower in unmarried women(7.03%, 18/256). The correlation between the rate of LARC use and provision of PAC services was seldom described before. Other in uence factors for PAC services use including living conditions, occupation and monthly income. People have seldom opportunities to obtain PAC services including living in rural areas, with lower income, being self-employed or without jobs. We should pay more attention to those high-risk groups.
The survey in 900 health care providers showed that PAC services not supplied in the staff' workplaces were correlated with their negative attitudes of regarding IUDs use for unmarried and childless women.
Out study also indicated that the stuff' age was not the in uencing factor. It different from the studies before [22]. The possibility was that most health care providers were obstetrics and gynecology physicians and having medicine background. We also found that setting up the department of family planning was important to perform LARC use. The reason may be that PAC services have been one part of works in abortion clinics of some public hospitals since 2010 [23]. The doctors who work in the department of family planning mainly provide contraceptive services and induced abortion. Comparing to obstetricians or gynecologists in obstetrics and gynecology, they have relatively enough time to obtain the knowledge of PAC services and performance. The questionnaire revealed that the department of family planning was only set up in 66.22% of hospitals. This was a common problem that the leadership did not pay attention to this work.
It's worth noting that people who received free contraceptive in time were easier to choose LARC(OR = 1.609, CI:1.135-2.282). This was the rst time to describe the relationship between free contraceptive and LARC use. In china, free contraceptive counselling and reproductive health materials were provided to married women by a government-run Family Planning system in 2004 [24]. Free contraceptive use has been identi ed to be an effective policy in family planning and the reduction of unintended pregnancy [25,26]. Our study showed that less than half of persons accept contraceptives free of charge and the satisfaction was only 57.1%. We analyzed the in uence factors. Variety uniformity, quality and feeling embarrassed were the main reasons. The options for contraceptive pill, intrauterine device and condom free of charge were not plentiful. People who want to obtain free contraceptive services in family planning departments or hospitals will spend spare time. Although they could obtain contraceptives from selfservice terminal at any time, the self-service terminal could not be seen everywhere. Most importantly, they could not obtain consulting service from self-service terminal. Interestingly, the lower income people and the people living in rural areas had more chance to obtain free contraceptives. The people living in rural areas accepted free contraceptives easily because the family planning work was part of the villagelevel leaders' works and it was easily to manage and perform and the leaders pay more attention to those things. Comparing to people with higher income who paid more attention to the quality and types of free contraceptives, low-income groups would consider the price. This result identi ed that free contraceptive services were apt to some high risk group for PAC services use. Freelance staff or persons without work could also accept free contraceptive services easily. The main reason is that it is di cult to manage and follow up. They could not receive the relevant information from health care providers in time except that they want to know more about those things by themselves. Those people were the concerned objects.
There were some limitations in our study. First, most participants were of Han ancestry and the local residents. Second, we did not study deeply to evaluate how well reproductive aged women master the PAC knowledge and the level of post-abortion care services. Third, we did not distinguish the health care providers based on their education degree. The samples not homogeneously distributing in Guangdong province was also a limitation.

Conclusion
Page 18/22 Our ndings rst gave a detailed account of the current situation of contraception and induced abortion in Guangdong province. The rate of induced abortion was high especially in unmarried women and younger women. LARC use was not widely accepted espercially in nulliparous women. Some health care providers had negative attitudes regarding IUDs use for nulliparous women or unmarried women. The attentions paid by leaders and setting up the department of family planning were important to improve providers' accurate knowledge of LARC use. Free contraceptive services provided by the government were very useful but there were some limitations. Finding more channels to supply free contraceptive and PAC services for different populations should be performed.
Abbreviations LARC: Long-acting Reversible Contraceptives; PAC: Post-abortion Care; OR: Odds Ratio; 95%CI: 95% Con dence Intervals; IUDs: Intra Uterine Device Declarations Figure 1 The in uence factors for people refusing free contraceptive services Figure 2